1. Community Challenge of Pandemic Influenza Michael P. Dailey, M.D., FACP North Fulton Regional Hospital Roswell, GA

2. Pandemic Influenza

3. Bird Flu Strikes Florida

4. The Question Why worry about pandemic influenza?

5. The Answer

6. Flu Terms Seasonal flu – influenza like illness year to year Avian flu (AI) – low pathogenicity in birds is common H5N1 – highly pathogenic AI, deadly to domestic fowl and transmissible to humans Pandemic flu – virulent human flu that causes global outbreak with little natural immunity

7. Diagnosis During influenza season, influenza like illness with cough and fever can be presumed to be influenza Monto et al Arch Int Med 2000;160:3243-3247

8. H5N1 Hong Kong 1997 -cluster of human cases associated with poultry Claas et al Lancet 1998;351:472 Southeast Asia 2003 -outbreaks in 8 Asian countries Ungchusak et al NEJM 2005;352:333 Indonesia 2005 -human clustering Kandun et al NEJM 2006;355:2186

9. H5N1 Turkey 2006 Great Britain 2007 As of February 6, 2007 Total human cases272 Deaths166 Mortality61%

10. MAA Initiative 2006 John Harvey, M.D. Matt Gwynne, M.D. Radio Sandy Springs Interviews September 11, 2006 – December 18, 2006 Archived www.radiosandysprings.com 7pm Monday MAA Pandemic Flu Report, January 24, 2007

11. Summary of Findings Medical Care Groups Critical A Patients with respiratory failure due to viral or bacterial pneumonia Critical B Identical patients for whom no ventilator support is available Urgent Patients requiring hydration or IV antibiotics and anti- emetics who could be sent home Basic Uncomplicated influenza needing advice and/or antivirals, but neither critical nor urgent care

12. Summary of Findings The central issue for pandemic healthcare is how to respond to the loss of our most critical asset, the hospital. How do we evaluate care needs in such a circumstance?

13. Statistics and Comparisons YearPopulationDeaths%Severity Index 1860 Civil war 31,000,000620,000234 1918100,000,000750,000352 1957170,000,00070,0000.152.6 1968200,000,00035,0000.0581.0 Pan 1.0300,000,000900,0001.017

14. Summary of Findings Evaluation of Roswell/Alpharetta Population 150,000 Mortality 1% Infected patients 45,000 Deaths 450

15. Summary of Findings Evaluation of Roswell/Alpharetta Deaths 450 Critical care pts. 450 x 2 = 900 Potential hospitalized 450 (50%) Ventilator needs 450 (over 3 mos.) Ventilators available 50 Patients saved by critical care 25

16. Hydration and Influenza Dehydration common due to poor fluid intake, fever and rapid mouth breathing Hosker et al BMJ 1994; 308:701 Dehydration and GI dysfunction VanNieuwenhoven et al Eur J App Phys 2000;83:578 Airway dehydration and asthma Maloney et al Chest 2002;121:1806 Dehydration related abdominal pain Shah et al J Coll Physicians Surg Pak 2004;14:14 Dehydration and/or renal dysfunction occurs on 24 to 35% of hospital admissions for influenza

17. Summary of Findings Evaluation of Roswell/Alpharetta Urgent care pts. = 1% of infected 450 Mortality in urgent care 20% Potential urgent care save = 360 Save 360 with urgent care vs. 25 by critical care (i.e. > 10:1)

18. Summary and Conclusions Fulton County plan is based on hospital being open – the reality is otherwise The hospital will experience 30-50% staff deficiencies during pandemic We will need a voluntary plan to provide urgent care at off campus sites We will need a community committee to develop urgent care plans including MD, hospital, EMS, and city government input

19. Pandemic Urgent Care Fluids – 1 liter of NS IV antibiotics Ceftriaxone 2 Gm (Rocephin) Ertapenem 1 Gm (Invanz) if Pen allergic Antiemetic Phenergan 12.5 mg Allergy Kit Antihistamine Steroid Epipen Pulse Oximetry

20. Problems Where will my neighborhood get care? How will they know where to go? Who will give it to them? Who will provide logistic support?

21. Vaccine “Barricade vaccine” “Rampart vaccine” ED Kilbourne Viral Immunol 2004;17:350 H5N1 Clade 1 H5N1 Clade 2 – 3 subclades Cross protection against death in ferrets Govorkova et al JID 2006;194:159

22. Call to Action We will need a community committee to develop urgent care plans including MD, hospital, EMS, and city government representation We will need you to provide the care in your community that will make the most difference It will not be in the hospital