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Wednesday

Commonn Sense Influenza

Prevention of transmission of flu sometimes takes on a life of its own. The media hype and hysteria can easily overwhelm the facts. We need to remember that the flu virus is one of the most infectious pathogens we know of and that Type A influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza. Knowledge and common sense can keep us safe.

The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

There are several types of influenza viruses and  influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.


During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.



Tuesday

DHS Fires Back with Active Shooter Preparedness

The Department of Homeland Security is hosting an Active Shooter Preparedness site loaded with a variety of interactive, web-based tools and instructional aids.

Poster from DHS Active Shooter Preparedness



The Active Shooter Preparedness site offers the following resources 
  • Active Shooter: What Can You Do Course
  • Active Shooter Webinar
  • Active Shooter Workshop Series
  • Active Shooter: How to Respond Resource Materials
  • Options for Consideration Active Shooter Training Video
  • U.S. Secret Service (USSS) Active Shooter Related Research
  • Active Shooter Resources for Law Enforcement and Trainers: Request for Access to Joint Countering Violent Extremism (CVE) Portal
  •  




Most of the material hosted by DHS is ready-to-use or self-study format. This site is ideal for in-service training. According to the DHS Active Shooter Preparedness site:
The Department of Homeland Security (DHS) aims to enhance preparedness through a ”whole community” approach by providing training, products, and resources to a broad range of stakeholders on issues such as active shooter awareness, incident response, and workplace violence. In many cases, there is no pattern or method to the selection of victims by an active shooter, and these situations are by their very nature are unpredictable and evolve quickly. DHS offers free courses, materials, and workshops to better prepare you to deal with an active shooter situation and to raise awareness of behaviors that represent pre-incident indicators and characteristics of active shooters.
For more, see prior MJ postings Soft Targets Attractive to Active Shooter Events and MJ Podcast #187: Inside Look at Net Talon. Also recommended: Net Talon

 

Highlights

Active Shooter: How to Respond Resource Materials provides quick and easy reading materials for businesses, offices and schools in preparing for an active shooter event. Print materials available include: active shooter booklet, active shooter poster and active shooter pocket card.

The Active Shooter Training Video gives simple and easy to follow recommendations for personal safety during a shooter event. This video is crisp and to the point and would be ideal for introducing the topic to a workforce and supporting training already in progress.

For those interested in case study, the United States Secret Service has provided several research papers related to active shooter events.

Monday

The Best Disease Prevention is Action

More than vaccine, personal protection requires personal action


Personal protection equipment (PPE) can protect us from everything from anthrax to influenza but use of such equipment is unrealized as is the value of a good infection control program until someone gets sick.  Our personal protection is more than  a “thing” we put on, our best personal protection is our action.

No matter which side of the mandated vaccine debate you happen to be on, vaccine is a top preventive measure. Vaccines are proven to be safe and effective. Not only do they provide the individual with protection from specific diseases, vaccination also provides herd immunity to a given population. A community that is vaccinated and protected against disease also protects those who have not developed immunity. Herd immunity is vital to those with compromised immune systems and even to some healthy groups such as schoolchildren.

CDC photo
Pharmacological measures such as vaccine are fantastic at preventing disease. However, the downfall is that they are not always readily available and pharmaceutical shortages have become frequent. Deployment of vaccine and oral medications can be challenging. It's important to understand the role of non-pharmaceutical interventions in disease spread control. The non- pharmaceutical interventions include; hand washing, respiratory etiquette, appropriate social isolation.

Hand hygiene, the simple act of washing your hands, is rated as the number one means for preventing the spread of disease. The use of warm water and soap for washing hands for between 15 and 30 seconds is a major component in effectively stopping disease spread in any population.

Respiratory etiquette means covering your cough and your sneeze and limiting other secretions you discharge from your mouth or nose. Covering your cough and sneeze is a mainstay of respiratory etiquette and helps prevent droplet transmission of disease. Droplet transmission is a major mode of transmission for Type A influenza. Don't be afraid to put a mask on yourself or patients exhibiting signs of influenza-like illness. Placing a mask on the patient goes a long way to containing the source of the droplets and respiratory secretions at the source and placing a mask on you significantly decreases your intake potential of those droplets and respiratory secretions. The Centers for Disease Control and Prevention noted that standard surgical masks were sufficient to prevent droplet transmission in the setting of many respiratory illnesses including Type A influenza.

Social distancing means staying home when you're sick and includes staying out of public areas when you're ill. It does us no good to have someone stay home from work and/or school only to go to the local shopping mall or otherwise be out in public. I realize this is not a popular topic with many employers but the fact remains that people who are ill with gastrointestinal problems or respiratory illness should not be in a position to spread that disease whenever possible.

Simply wiping down flat surfaces in your work environment will go a long way to preventing your exposure to disease and the spread of many illnesses. Many commercial products are available for this purpose and a quick wipe on telephones and computer keyboards will help prevent disease spread.

Sunday

2012/2013 Flu Update #6

Update #6 for the week of January 20, 2013

This weeks Mitigation Journal Flu Update includes publicly available data from the CDC FluView, Google Flu Trends, Sickweather and other media sources.

This report contains data from the Centers for Disease Control and Prevention 2012/2013 Influenza season week 1 for the period ending January 12, 2013. In this reporting period (January 6 - 12, 2013) all flu data sources report continued high rates of flu activity with forty-eight states demonstrating widespread activity as compared to forty-seven states reporting widespread flu in week 1 (see Flu Update #5). Many healthcare facilities have implemented some form of visitation limits in effort to reduce the spread of influenza within the patient population.

Viral surveillance results for week 2, 2013 shows 29.4% (3,638) of the 12,360 samples tested positive for flu, down slightly from week 1 (29.9%) and down significantly from week 51, 2012 (38.2%) with the proportion of deaths related to influenza and pneumonia remaining above epidemic threshold. Those older than 65 years old account for 49.6% of influenza hospitalizations.

In the News 
Could influenza virus actually know when to attack you? According to an article published published by BBC News the answer is yes. The article cites studies that indicate influenza can detect how long it takes to produce enough copies of itself to be effective prior to leaving the host cell. Understanding how this timing process work may allow reserachers to prevent infection. 
See BBC News: Flu virus 'knows when to attack'

Is a "good match" meaningful? We've been given the impression that a good match between circulating influenza strains and vaccine makes for a mild flu season. Current data reported on by Global News suggests the "good match" theory may not hold up. 
See Global News The Canadian Press: Flu studies suggest vaccine 'match' not super predictor of effectiveness

Flu data graphic displays

Latest map from CDC Flu Interactive



Data from Google Flu Trends


 Map from Sickweather




See also:
Mitigation Journal
Writing your biologic plan
Web Tools
CDC FluView
CDC Flu App
Google Flu Trends
Sickweather

Thursday

Stay Flu Informed with these three apps

CDC and Sickweather provide quick access to flu data

The Centers for Disease Control and Prevention's Influenza and FluView apps provide quick access to the latest influenza data. Both apps are feature-rich and offer concise flu information on the go. They are appropriate for teaching/informing in the workplace or classroom. 

The Influenza app targets information to health care professional and easily accesses flu updates on your iOS device.  

 The main page displays flu topics included in the app. While the design is for health care providers, the content is appropriate and useful for Paramedics and RN's. I've also used this app as a public awareness teaching tool. Students have commented that the app was a great too for self education and weeding out hype from the mainstream media. I've also had civilians tell me they felt comfortable getting information (on flu vaccine) from the app and using it helped them make health care decisions or initiate conversation with their health care provider.

According to the iTunes description, you can:
  • obtain information on diagnosis, treatment and lab testing
  • view updated CDC recommendations
  • view videos from subject matter experts
  • order official CDC print products



One of my favorite features of this app is the ability to customize with text size and notes. Highlight, notation, and bookmarking functions like most eBook readers and ePub files making it easy to enter your information as you work with the app. I've found these functions are extremely useful when using the Influenza app in the classroom

 




The FluView app provides the same graphic representation of influenza activity that is found on the CDC FluView webpage. The map data is limited to the current weeks and two weeks immediately prior.

Sickweather.com is an on-line forecasting tool that utilizes social media entries for indication of illness.
According to the Sickweather website:
"Everyday thousands of people around the globe update social media sites like Facebook and Twitter when they (or someone close to them) get sick. Posts like "I'm sick," "the doc says I have bronchitis" and "My son has chickenpox." When this information is made publicly available by the user and contains location information, we are able to track and map this data using our patent-pending algorithm. "
"Sickweather allows its members to report directly to our map and forecast anonymously via the input field under "How Are You Feeling Today?" Simply tell us how you feel and we’ll do our best to match it to our most relevant forecasts. If you report symptoms or illnesses that we aren't tracking, that information will be processed by our algorithm to automatically make suggestions for expanding our tracking capabilities. "
I'm impressed with the concept of crowdsourcing data for disease prediction models. One of the most intriguing functions on the Sickweather website is the video/graphic representation. I've been so happy with the data that I've included information from Sickweather for Mitigation Journals Flu Updates.

Wednesday

Flu Emergency. How prepared are we?

NYS, Boston declare public health emergency as widespread flu remains "intense"

New York State joined Boston, MA by declaring a public health emergency as a result of seasonal influenza. Boston Mayor Thomas Menino made the emergency declaration on January 9, 2013, New York followed with its own emergency declaration at the direction Governor Cuomo on January 12.

The NYS declaration includes an Executive Order that allows pharmacists to administer flu vaccination to people six-months and older. Governor Cuomo strongly urged all New Yorkers to get a flu shot and directed the NYS Health Department to "to marshal all needed resources to address this public health emergency and remove all barriers to ensure that all New Yorkers - children and adults alike - have access to critically needed flu vaccines." Mayor Menino included statements urging people to remain home when sick in addition to getting a flu vaccine. Mayor Menino further stated that "This is not only a health concern, but also an economic concern for families..."

Could we see flu coming?
The public health emergencies in Boston and New York State were issued during week 2 (January) 2013 while influenza had been identified as "high" or "widespread" in some states since week 46 (November) 2012. According to the Centers for Disease Control and Prevention,  Mississippi was experiencing high or widespread flu activity in November (week 46) and by week 47, flu was identified as high or widespread in Tennessee, Alabama, Louisiana, and Texas. By week 52 there were 30 states, including New York and Boston, that made the list of states experiencing high or widespread flu.

By comparison, Google Flu Trends identified NY and Massachusetts as having "high" flu activity on December 12, 2012. Flu activity was identified as "intense" in  NY and in Boston on December 23, 2012.

Both the NY and Boston public health officials encourage vaccination and have opened flu vaccine clinics and since the declarations of emergencies, mainstream media attention has expanded. Looking back, we haven't seen the flu awareness campaign as we did in response to the 2009 Swine flu situation.

Are public health and local health care systems prepared to deal with unexpected biologic situations? The answer is not reassuring.  According to Trust for Americas Health 10th annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report, 35 states and Washington, D.C. scored a six or lower on 10 key indicators of public health preparedness. See also States Lagging in Emergency Preparedness by Healthday News.

While the 2012/2013 Flu Season continues, the question on the minds of many is: why is flu so bad this year?  While this question will be studied and debated, an easy answer may be that people simply did not get vaccinated and were unprepared for an early start to the flu season. The CDC states that its too early to define peak of flu season. However, the Washington Post is reporting that over 60% of Americans have not been vaccinated as of November 2012. Meanwhile, an interesting side story is developing...despite low vaccination rates, retail and healthcare systems are reporting dwindling vaccine supply. If vaccine supply is drying up when 60% of the population didn't get the shot, how ready were we in the first place?

Tuesday

No vaccine, no mask? No job

Healthcare providers fired over flu vaccine mandate

ABC is reporting the firing of eight hospital Indiana hospital employees, three of them nurses, for failure to comply with influenza vaccination program. USA Today is running a story about a registered nurse who has been fired for not wearing a mask after declining flu vaccine. These reports indicate a growing trend in healthcare: comply with flu vaccine mandates or risk loosing your job.

Mandate the shot or not? We may have an answer to that question.
There are indications that mandated participation in flu vaccine programs have become normal. Notice the term flu vaccination program, meaning that there is more than just vaccine involved. Flu programs typically give the healthcare employee a choice to be vaccinated or, decline the vaccine and wear a mask while at work. Having reviewed a number of policies, we've noticed a growing number of healthcare agencies (including non-hospital facilities) have begun to require "participation" in a flu program. The meaning of the word "participation" changes frequently between facilities and can indicate a vaccine requirement, receipt of vaccine or signed declination, or vaccine/decline and wear a mask.

As noted in the USA Today piece, some healthcare providers feel stigmatized by being requiered to wear a mask. Some may consider their privacy has been eroded as they feel compelled to explain why they have to wear a mask.


Monday

2012/2013 Flu Update #5

Update #5 for the week of January 13, 2013

This weeks Mitigation Journal Flu Update includes publicly available data from the CDC FluView, Google Flu Trends, Sickweather and other media sources.

This report contains data from the Centers for Disease Control and Prevention 2012/2013 Influenza season week 1 for the period ending January 5, 2013. In this reporting period (December 30, 2012 to January 5, 2013) all flu data sources report increased flu activity with many areas reporting hospital surge capacity nearing maximum and emergency departments "flooded" with flu cases. Boston, Massachusetts, has declared a public health emergency related to seasonal influenza and has opened public vaccination centers.

According to the CDC flu activity is still elevated, but may be on the decline in some places. As of last report, 29.6% of influenza samples (1,846) were positive for influenza (see 2012/2013 Flu Update #4 week 51). Latest data for week 1 shows 12,876 specimens tested and reported by WHO with 32.8% positive (4,222) for influenza. As a result, the CDC now states pneumonia and influenza mortality is above epidemic threshold. There were no new infections with H3N2 variant/novel influenza A during week 1.

Forty-seven states continue to report widespread flu activity with circulating strains of virus continuing to be susceptible to neuraminidase inhibitor antiviral medications (Tamiflu). Supply of Tamiflu has been a concern and reports indicate that a shortage of the antiviral/neuraminidase inhibitor could occur. Reserves of Tamiflu has been released from the Canadian National Stockpile  to ease shortages. 

CDC FluView Map for Week 1, 2013




As noted above, Boston declared a public health emergency due to seasonal influenza and the mainstream media seems to have jumped on the preparedness bandwagon. Boston officials have described ten-times normal amount of flu cases, 25% of those requiring hospitalization and resulting in over burdening of healthcare systems. Boston has now established fee flu clinics to promote vaccine. Meanwhile the CDC and some public health officials believe the intense flu situation may have reached its peak.

Google Flu Trends continue to gauge flu activity throughout the United States as "intense".

Google Flu Trend as of January 6, 2013


New to the MJ Flu Update this week is Sickweather. This service scans social media networks for indicators of illness. Sickweather may be among the most promising use of social media for identification of adverse health situations. A full review of Sickweather will be posted shortly. In the meantime, visit www.sickweather.com for more information on this important tool. 

Sickweather map data as of January 8, 2013



See also:
Mitigation Journal
Writing your biologic plan
In the News
RN fired for declining flu vaccine and refusing  to wear a mask (USAToday)
Eight hospital employees fired for declining flu vaccine
Web Tools
CDC FluView
CDC Flu App
Google Flu Trends
Sickweather

Saturday

Mitigation Journal Podcast #242

2012/2013 Flu season labeled a public health emergency


Welcome to 2013 and thank you for joining us on Mitigation Journal as we enter our eighth year of emergency preparedness blogging and podcasting.

Publication Note: Mitigation Journal will publish a blog posting three times each week. We'll also return to a weekly podcast. We encourage you to join over 100,000 emergency service providers, healthcare workers, agency leaders, and domestic preparedness experts by subscribing to the blog and podcast feeds. Link to these feeds can be found at www.mitigationjournal.org.



Edition 242 Recorded on January 12, 2013: 2012/2013 Flu Season - public health emergency

Join us as we discuss important issues surrounding the current flu situation. Click the player below to listen now.



This week Boston declared a public health emergency due to seasonal influenza and the mainstream media seems to have jumped on the preparedness bandwagon. Boston officials have described ten-times normal amount of flu cases, 25% of those requiring hospitalization and resulting in over burdening of healthcare systems. Boston has now established fee flu clinics to promote vaccine. Meanwhile the CDC and some public health officials believe the intense flu situation may have reached its peak.



Writing your biologic plan
In the News
RN fired for declining flu vaccine and refusing  to wear a mask (USAToday)
Eight hospital employees fired for declining flu vaccine
Web Tools
CDC FluView
CDC Flu App
Google Flu Trends
Sickweather
Mitigation Journal is:
Hosted by Rick Russotti, RN, Paramedic
Co Host Matt Comer, Paramedic

Thursday

No shelter for you! In case of emergency, go some place else

Identifying where not to shelter is becoming popular. 
The reason should be no surprise.


People may evacuate or shelter in place during a disaster situation. Evacuees often find themselves seeking refuge in an established shelter of one type or another. Shelters are typically preplanned and established within the framework of a disaster plan that includes a system of public information. Those who don't evacuate to a shelter, didn't receive shelter information, or are unfamiliar with their current location, may find themselves seeking safe haven at locations of perceived safety. Public locations such as schools and libraries may be thought of as "places to go" during a crisis. Similarly, other installations may represent a location of service or place to go for help. Fire stations and healthcare facilities are often understood to be locations were the public can go for help in times of crisis. But are these locations suitable and prepared to become shelters during disaster or crisis situations?


What happens when public expectation is not met?
Photo credit: Michael Ehrman
We discussed this topic in the aftermath of hurricane Katrina and the Tenet health decision. Tenet Health, owners of  a New Orleans hospital, were sued by the people who sought shelter at the hospital during and after hurricane Katrina. The suit alleged that the hospital was not prepared to deal with the disaster situation and provide for the needs of those who sought shelter at the hospital. It'd be important to to note that those who came to the hospital during Katrina were not patients. Since the public had never been told not to shelter there, it was a reasonable expectation that the hospital was a shelter and, therefore, liable. At the time of publication, we called the Tenet decision the biggest healthcare preparedness ruling that no one is talking about. While the monetary impact of the suit may not have been impressive, the implications of the outcome were president setting. More and more we're seeing signs posted telling the public that this place "is not a shelter". It seems a little creepy to find a sign on the door of your local school or hospital or Moose Lodge reminding you to go someplace else in the event of an emergency.

Michael Ehrman, retired emergency manager and long time MJ follower, sent in the above photo taken at a school in his area. What locations in your ares might be considered to be a safe haven or shelter by the public? Is your agency prepared to take in refugees during a disaster? Finally, are you aware of public perceptions concerning sheltering in your area? In the wake of natural disasters like Hurricane Katrina and more recently, Super Storm Sandy, this would be a good time to explore those questions and include the proper information in your public education and preparedness efforts.

Related posts:
Forward thinking: Bringing the Katrina Healthcare Decision Home
Message from Katrina: Hospitals, be ready

Wednesday

Mitigation Journal Podcast #241

Active shooters: killing children, assassination of firefighters

Welcome to 2013 and thank you for joining us on Mitigation Journal as we enter our eighth year of emergency preparedness blogging and podcasting.

Publication Note: Mitigation Journal will publish a blog posting three times each week. We'll also return to a weekly podcast. We encourage you to join over 100,000 emergency service providers, healthcare workers, agency leaders, and domestic preparedness experts by subscribing to the blog and podcast feeds. Link to these feeds can be found at www.mitigationjournal.org.

This weeks podcast focuses on active shooter assassination events. Sadly, we have to start off 2013 with tragedy as Matt and I discuss the Sandy Hook Elementary School shooting and the wounding and killing of West Webster, NY firefighters.

Click the player below to listen here.



Thursday

2012/2013 Flu Update #4

Update #4 for the week of January 3, 2013

This weeks Mitigation Journal Flu Update includes publicly available data from the CDC FluView, Google Flu Trends, and other media sources.

Data reported by the CDC for week 51 of 2012 (December 16-22) continues to reflect increased influenza activity throughout the United States. 6,234 specimens were tested by the World Health Organization during this period. Of those tested, 29.6% of samples (1,846) were positive for influenza. Current report indicate a decrease in samples tested by WHO from week 50 (December 9-15) with 9,560 samples tested resulted in 28.3% or 2,709 cases positive for influenza. The decrease in samples tested between weeks 50 and 51 my indicate a decline in influenza-like-illness and trending down of cases or may simply reflect cases being treated without testing.

The CDC also reports that pediatric flu related deaths continued to climb during week 51 with eight deaths reported. Three cases attributed to influenza B viruses, three cases from influenza A (H3) viruses, and two cases influenza A with no subtype identified.

Despite widespread influenza, CDC reports that the proportion of deaths attributed to pneumonia and influenza remains below the limits to be declared and epidemic.

Video compilation of flu maps from Centers for Disease Control and Prevention FluView as reported for 2012 week 51/ending December 22, 2012.


Google Flu Trends data reports "intense" flu activity as of December 30, 2012



In the news
Many hospitals and healthcare facilities have begun restricting visitation based on influenza-like-illness (ILI) symptoms.  Duke University Health System has outlined the following temporary restrictions on visitation (from Duke University Health System news):

•Patients may receive no more than two adult visitors at one time. 

•Children under 18 are not permitted to visit hospitals or wards without prior approval from healthcare providers and for special circumstances. 

•Visitors are urged to perform hand washing frequently, including when entering and leaving the building. Foam dispensers are available throughout the buildings, and are effective against influenza virus. 

•Visitors with fever, cough or other flu-like symptoms should remain home.

•Emergency rooms, urgent care centers and clinics will seek opportunities to physically segregate potential flu patients if facility designs allow.