THIS IS AN EXERCISE. IT IS NOT REAL.
The pandemic flu has hit hard in Southeastern Idaho. Attack rates and death rates are close to expected, with an attack rate of 30%, meaning 30% of people get sick, and a death rate of 2%, meaning 2% of people who get sick die. Vaccinations are not available because of the long lead time required to identify the strain and create vaccines from eggs; research and development on faster production of vaccines was not completed in time, although it began in 2006. This year’s annual flu vaccine may provide some help by minimizing the affects of the pandemic flu strain, but it will not provide immunity. Local hospitals are providing drugs to people who are already sick, but these pills are not available to the public as a method to prevent the flu.
| July 29 | Population | Absenteeism Rate | Attack Rate | Number of people who have presented to the hospital with flu-like symptoms | Fatalities past 24 hours |
| Bannock | 75,565 | 35.00% | 35.00% | 970 | 19 |
| Bear Lake | 6,411 | 35.00% | 35.00% | 82 | 2 |
| Bingham | 41,735 | 35.00% | 35.00% | 536 | 11 |
| Butte | 2,899 | 35.00% | 35.00% | 37 | 1 |
| Caribou | 7,304 | 35.00% | 35.00% | 94 | 2 |
| Franklin | 11,329 | 35.00% | 35.00% | 145 | 3 |
| Ft Hall | 3500 | 35.00% | 35.00% | 45 | 1 |
| Oneida | 4,125 | 35.00% | 35.00% | 53 | 1 |
| Power | 7,538 | 35.00% | 35.00% | 97 | 2 |
Supply shortages are already happening. Grocery store shelves are near bare because of runs on basic food items and inability to get resupplied because there are not enough trucks operating (lack of gas and repairs). Many Automated Teller Machines (ATMs) are out of cash and have not been resupplied for several days.
SDHD is recommending that citizens continue voluntary isolation. This means that you should stay away from large gatherings to keep from getting infected. Mandatory quarantine and isolation is not expected but is legally possible.
SDHD is again telling the public that they should STAY HOME if sick with influenza.
Here is another mock news clip provided by the CDC.
The flu in this scenario is a Category 5 flu. The categories are created by CDC, who used the hurricane categories as a model.
Here are a couple of newspaper clips from the 1918 pandemic flu.
What happens if the business you work for closes its doors and you are out of a job? This situation will cause a problem for a majority of Americans.
Government personnel should consider: How to provide services via the internet.
Business personnel should consider: How to provide services via the internet. Should you and can you shutdown operations? Do you have the finances to see your way through 6-8 weeks of very slow business? Have you cross-trained enough people and the right people to keep operating with low attendance rates?
Private Citizens should consider: Voluntary isolation measures: How will you stay away from large gatherings? Do you have enough food in your house so you won’t have to go to a grocery store (which has empty shelves)? What will you do if your employer closes its doors as a method to stay in business, meaning you are out of a job and paycheck for about six weeks?
Pandemic Flu could seriously jeopardize your family income. The slide above shows results from a poll in 2006 concerning household income if businesses close for pandemic flu.
All readers are encouraged to leave a comment about the how this exercise scenario
might impact your lives.
THIS IS AN EXERCISE. IT IS NOT REAL.
SDHD PanFlu BlogEx 
The historical information gives us perspective. Our experience here (Lewiston) is summarized by Dr. Daniel Miller, MD, in his book “Little Patch of Idaho.” Extracting from pages 155 and 156…
“The worldwide influenza pandemic that began in France during World War I struck Lewiston and vicinity. Health services reported 774 cases of flu in Lewiston in November, 1918. This strain of influenza was particularly toxic and dangerous, causing hemorrhage into the lung tissue and death by asphyxiation. During the winter months of 1918-1919, Dr. Susan Bruce, the county health officer, forbade public gatherings; schools were closed; lodge meetings and church services were banned. Quarantine signs were pasted on homes all over town. Fifty-three Lewiston residents died. In 1974, Dr. Al Cochrane of Lewiston recalled that death was rampant and ‘the bodies were stacked up behind the hospital like cordwood.’ Seven sisters of St. Joseph [hospital] died in the line of duty, tending to the sick.”
Now lets use the current CFR of H5N1…….. 60%+
SDHDTRaining,
Very good posting asking people and business what would they do. We can ask people to train but not make them.
I hope people see others, professional and non professional, take h5N1 to heart and act. Lead by example.
As the graph shows 2% is just the beginning, the arrow goes up from there.
One thing I would add for business – what if your supplier failed? How many alternates do you have and can you afford to use them?
Mel,
Lodge meetings – thanks. I forgot that one. From Rutarians to masons meetings may be cut short.
They description of dying by asphyxiation applies. Cytosine (sp?) storm is the term they use. The lungs fill up with mucous. Forced ventilation is recommended I am told.
Regards,
Kobie
“Liberty is rendered even more precious by the recollection of servitude.” Marcus Tullius
Cytokine Storm
http://en.wikipedia.org/wiki/Cytokine_storm
SDHDT Training…
Help please…given the symptoms of the 1918 pandemic, I would appreciate a “pros and cons” on ventlators in the pandemic flu context if the info is available. For example…
1. How effective are they (lives saved by ventilators for confirmed H5N1 patients)
2. What is the staffing requirement per ventilator?
3. How much do they cost?
Thanks.
heres a better on…
http://www.cytokinestorm.com/
CYTOKINE STORM and the INFLUENZA PANDEMIC
Mel: I wish that was an easy answer, but it is not; there are several types of ventilators. The most important thing to know about mechanical ventilators is that the staffing is the hardest part. You can have all the mechanical ventilators you want, but without the technical staff they do you no good, and the just in time training is more involved than the average Just In Time training. Cost depends on type: bag vs mechanical. I’ll find you an answer. As for the effectiveness, I’ll e-mail an answer when I get it.
There are probably less than 100 ventilators in SE Idaho so how do we decide who gets to be on one? The triaging wold actually be a nightmare…. yuk
Katy: the ventilator triage will likely be a county decision because they are county asset. In any case, you are right about the triage being a nightmare. And there are indeed less than 100 in SE Idaho. We discuss this type of ethical issue in most of the meetings to ensure that during the pandemic is not the first time it is thought through. The health district can provide recommendations, but ultimately it is the County Commissioners and their staff and voters responsible for what happens in their county.
For example: if a 64 year old retired man is on the ventilator and the prognosis is not good, do you take him off the ventilator to put a 24 year old lady on the ventilator. If so, when do you do that?
Do elected officials have some sort of “priority” for ventilators over regulaar citizens? If a county commissioner gets the flu, does he “bump” someone from a ventilator?
The questions continue………
Thanks for the feedback Darin. Reading Katy’s comment about triage, the effectiveness issue (lives saved by ventilators for confirmed H5N1 patients) may be more important than I thought.
i think only one person H5N1 positive in Indonesia survived on a vent.
I kept seeing the large number ill,
knowing that he/she/they were contaminated but not symptomatic.
At many points persons are going to have to go for food, supplies, some reason to get out of their private area.
Surely there is a health quranteen,
Legal implications and curfew hours, persons to enforce . compensation, for persons.
Thinking about staff, those persons that able to work, that have no symptoms
such as the persons to take care of those on ventalators. The most 24 hr rotation of 12 hr shifts would have minim. 3 skilled nurses per 5 vent pts , at the most.
I began to think about the time needed to make sure that persons would need to be cleared when going from one point or station to another.
Ill go ahead and include this. Possibly old news to every one, but I found it interesting to re think:
(http://www.who.int/csr/disease/avian_influenza/avianinfluenza_factsheetJan2006/en/index.html)
The incubation period for H5N1 avian influenza may be longer than that for normal seasonal influenza, which is around 2 to 3 days. Current data for H5N1 infection indicate an incubation period ranging from 2 to 8 days and possibly as long as 17 days. However, the possibility of multiple exposure to the virus makes it difficult to define the incubation period precisely. WHO currently recommends that an incubation period of 7 days be used for field investigations and the monitoring of patient contacts.
lll
Resources absent, persons anxious and fear of dying people will be trying to leave the area.
lllll
On the other hand there are those rambunxous persons that have no fear or have the drive to take care of the shop no matter what, and or the fear of losing even more money, perhaps venders seeing opportunity. and chancing contamination.
Below is an article that I read this am. I think it pertnate to think about as contaminated persons will break the barriers spreading the illness:
[[[[[
Why Do Sick People Go To Work? Unhealthy Fear
by Joanne Silberner
“The fact that so many people feel they can’t stay at home for economic reasons is not the best way to go. … You want them to feel that if they’re sick, the best option is to stay home without serious financial penalties.”
Robert Blendon, Harvard School of Public Health
Morning Edition, July 28, 2008 • A lot of people come to work sick, according to a new poll conducted by NPR, the Kaiser Family Foundation and the Harvard School of Public Health.
You know the scene: The guy in the next cubicle is sneezing and coughing. And you’re afraid to breathe.
In a survey of people in Florida and Ohio — two swing states in the upcoming presidential election — NPR asked people about their work habits.
“What we found,” says Robert Blendon, of the Harvard School of Public Health, “is about half the people reported that in at least a number of cases they go to work when they’re sick and believe they should stay at home because of the financial issues that are involved.”
Employers are offering sick leave. Among those polled in Florida, about 67 percent of people with jobs said they had sick leave. For Ohio, it was 60 percent.
Employees Under Pressure
Blendon says the poll suggests there are two main reasons people go to work sick: There is no paid sick leave, or they feel pressure from their employer to be on the job, regardless of whether they are ill.
There is no information proving this trend of going to work sick is increasing. This appears to be the first time pollsters have asked this question.
But other parts of the poll by NPR, Kaiser and Harvard suggest more workers are going to work sick. Many people said their financial situation has gotten worse over the last year. More than a third said they’ve had problems getting a good-paying job or a raise because of the economy.
Going to work sick isn’t a good idea, Blendon says.
“The fact that so many people feel they can’t stay at home for economic reasons is not the best way to go in terms of the best health of families,” he says. “You want them to feel that if they’re sick, the best option is to stay home without serious financial penalties.”
Easing The Burden On Workers
That’s why San Francisco and Washington, D.C., have recently required many employers to offer sick leave. And federal legislation has been proposed.
But that’s not the cure, says Marc Burgat. He’s the vice president of government relations for the California Chamber of Commerce, and he fought against the San Francisco law. He says in this economy, businesses can’t afford it.
“If we start mandating these benefits, some of those entry-level positions will either find reduced benefits, reduced pay or simply find the jobs eliminated,” Burgat says.
The best way to deal with sick leave? Leave it up to the marketplace, Burgat says. Employers compete among one another for good workers.
“When an employee comes in to look for a job — whether it’s an entry-level job or a higher job — they’re not looking at just the salary, but the entire benefits package,” he says. “Sick leave and medical insurance and those sorts of things are part of that total package, and that’s what allows one business to attract employees over another business.”
Whether that will work in a struggling economy remains to be seen. Still, Burgat says, he doesn’t want his workers to come in sick. When they’re ill, he tells them to stay home
(http://www.npr.org/templates/story/story.php?storyId=92762761)
THANK YOU, Laqueta
Mel,
There are several types of vents. Making them is not as hard as having trained medical people. Here is a story from India about how they got Nebulisers and have not used them because of power and personnel.
Story is Cached from Google:
http://64.233.169.104/search?q=cache:OaKtWcYSMaQJ:www.thestatesman.org/page.news.php%3Fclid%3D23%26theme%3D%26usrsess%3D1%26id%3D215712+Nebulisers+kept+unused&hl=en&ct=clnk&cd=1&gl=us
Yes people are looking at building their own.
Like Goju and SDHDTraining I wish there was more on the role of ventilators. The article on cytokine storm Goju cited is good. Yes there are secondary complications from cytokine storm. Also the use of pure Ox is required. Because the avioli of the lungs are full they are less effective – like breathing on one lung or less.
Kathy,
You bring up a good point. So far the hardest thing was helping edit the N.Y. vent triage document. It is necessary to have guidelines and legal protection in place, reviewed and understood *before* they are needed.
I hope your hospital / care facility has one.
Some points are 1) those on ventilator or partial ventilator support will not have their ventilators removed to aid others. 2) Legal recourse for when the parents do not agree with treatment change. 3) Security 4) Counseling. 5) councilling for staff.
Kathy note: if under a 1.5% CFR a hospital with 5 free vents gets 50 patients, 45 will not get treatment but palliative care to make their last hours as comfortable as possible. Why? Recovery on a vent takes days. Time those waiting for a vent may not have.
Please correct me if I am wrong.
It does not have to be this way. In 1850 we did not have ventilators. In 1918 we did not have ventilators. This is the 21st century. Please look at this youtube high school project vent http://www.youtube.com/watch?v=liOQ9P2urOM
This high school ventilator is not a solution but shows what can be done.
Laqueta,
You bring up a lot of good points. I’m not sure in what percentage they will play out. In 1918 people sank back into their homes as kids watched the funeral carts pick up neighbors. School was a time to see who was left. In 1917 life expectancy was 48.4 for women, 54.0 for men. In 1918 this dropped to 36.6 for women and 42.2 for men.
Yes Influenza did more damage than the World War I on life expectancy.
Source: http://www.demog.berkeley.edu/~andrew/1918/figure2.html
Hence because we are used to a safe world where death is far less common and doctors cure people I’m not sure how your thoughts will play out but agree with you. Keep thinking.
I hope you all keep thinking and asking questions.
Please remember “The whole is greater than the sum of its parts” – Gestalt
Regards
Kobie
“United we stand – divided we fall”
Katy, Mel,
I you are interested in a discussion on ventilator Triage here is the N.Y. vent thread from April 2007
http://www.newfluwiki2.com/showDiary.do?diaryId=1081
Note, the comments may seem flippant at times for these folks get along and some levity keeps things from falling apart.
Side issues are often brought up because things do not happen in a vacume and so there are guidlines explaining what else need be done; what else need not be done.
Laqueta,
You are quite right about people possibly shedding virus before showing symptoms. In a hospital environment the patient is already sick so cross contamination is to other staff and visitors / family. This brings up issues.
In my *opinion* if people believe there is nothing they can do they will either fight to do something, leave adn run away or give up and “party like there is no tomorrow”
H5N1 is not the end of the world, not even close. So having the public see adn believe they can get through H5N1 even though help will not arrive (calvery is calling in sick with H5N1) is beneficial. Just my *opinion*
Regards,
Kobie
“If you think you can or you think you can not – you will be right” Henry Ford, US inventor
Ventilators…
Thanks Goju and Kobie for the supplemental ventilator information. The survival rate in Indonesia gets me thinking along these lines…
1. Survival rate on a ventilator could be less than, say 5 percent. I’m assuming that you are on a ventilator because you have advanced (respiratory distress) symptoms.
2. Those who do survive have significant health issues (perhaps for the rest of their lives)
3. Properly using ventilators is a skilled task, and is manpower intensive
Are they worth it???
One analogy is the use of CERT teams in a large-scale disaster. We teach them to NOT initiate CPR during a mass casualty/injury event. Why? Once CPR is initiated, there is a legal and moral obligation to continue CPR until the responder(s) is either exhausted or relieved. The cost is other victims NOT being treated on the slight chance that someone whose heart has stopped will be saved, when they can finally be brought to definitive care. So, you do the most good for the most people.
Please don’t construe this as meaning we shouldn’t use ventilators for pandemic flu victims. Rather, two things for consideration:
1. If there is a shortage of healthcare professionals, there may be cases where the most good for the most people is realized, for example, by taking care of those showing early symptoms, and a good chance of recovery.
2. If the survival rate of ventilator patients holds true, the cost/benefit ratio can’t be very good…implying that we should have a very large (and adequate) supply of N95 masks BEFORE we spend scare dollars on ventilators.
Just thinking, and would appreciate thoughts from the healthcare perspective.
Mel,
I have not found any numbers. Ventilators help but are not a cure.
“Are they worth it?” – Like you I argue yes. Air may not cure you but no one wants their breathing cut off. We have one doctor who watched her daughter die of ARDS so I deffer to her very real description.
Can a state affored 35,000 vents that cost $10k each and total 350 million? They can affored 350 million dollar building or highway so why not something that will save lives. They may get a bulk discount.
As a nation will we pay for vents that will most likely only be used once? This is a deeper question that McCain and Obamma should answer as our next leader. So far both have dodged the requests.
Some do argue no as ventilators are not a cure and may only prolong suffering and false hope while expending large sums of scarece monies. Their argument is sound in some respects.
Yes – “an ounce of prevention is worth a pound of cure” and the N-95 masks are but one possible bit of prevention. Technicaly masks have not been proven to be effective.
Regards,
Kobie
“The only winning move is not to play” – The Whopper computer from the movie “War Games”
Thanks for the thoughtful response, Kobie, and yes, there are no clear answers. One of the important parts of this exercise is the many views from the participants, that we can each take back and discuss further locally – thanks also, Darin.
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July 28: First Wave of Pandemic Flu peaking in Southeast Idaho | SDHD PanFlu BlogEx