This presentation was developed in 2006 and delivered to EMS providers in Connecticut.

1. Pandemic Response
for Rural EMS
Nick Nudell, MS, NRP

2. • Prepared for and presented to EMS
providers in Connecticut in 2006.
• Data has not been reevaluated for the
2009 Swine outbreak.
PrioriHealth Partners, LLP

3. Pandemics are not a new threat!

4. Pandemics Influenza
• Influenza Pandemics are believed to have
occurred for at least 300 years at
unpredictable intervals.
The 1918 Spanish flu pandemic National Museum of Health and Medicine, Armed Forces Institute of Pathology

5. 20th
Century Influenza Pandemics
• 1918 Spanish Flu A (H1N1)
20-40 mill Deaths 675,000 US Deaths
• 1957 Asian Flu A(H2N2)
1-4 mill Deaths 70,000 US Deaths
• 1968 Hong Kong Flu A(H3N2)
1-4 mill Deaths 34,000 US Deaths
• Swine Flu 1976 emphasized need for pandemic flu
planning.

7. 20th
Century Influenza Pandemics
(Cont’d)
• Avian Flu 1997 (AH5N1)
“chicken flu” – 18 cases
including 6 deaths,
more than 1 million
chickens were killed in
Hong Kong
• Avian Flu 2003 (AH5N1)
2 persons with
confirmed infection,
two deaths.
• (H7N7) Over 80 cases of
mild disease and 1
death in the
Netherlands

8. CT Avian Industry

9. CT Avian Industry
• 240 Poultry Farms
• 1st
in New England for
– Density of Egg Laying Poultry
– Chickens Sold
– Egg Production and value (per sq/mile)
• 2nd
in New England Egg Production with
230 eggs per person/year

10. Pandemic Influenza
• The nature and severity for the next
Pandemic cannot be predicted with any
certainty.
• Preparedness Planning is imperative to
lessen the impact of a Pandemic

11. Influenza Pandemic Requirements
For A Health System
• Adequate staffing
– EMS Providers
– Infectious Disease
– Health Care
Epidemiologists
– ED Nursing
– Respiratory Therapists
– X-Ray techs
– Infection Control
Professionals
– Occupational Health
Professionals
– Environmental Services
Personnel
– Clinical Microbiology
Technologist

12. Influenza Pandemic Requirements
For Health System (Cont’d)
• Adequate staffing should not be assumed!
– Only 32.5% of Florida’s licensed
community healthcare providers are
willing and able to respond to a high risk
event, such as the Avian Flu
(n=2,279, MD- 34.6%, RN-38.4% , RPh-17.4%)
Reference - Crane, Jeffrey S. Assessment of the Community Healthcare Providers' Ability and
Willingness to Respond to a Bioterrorism Attack in Florida. 1 ed. UMI Publishing, Ann
Arbor, MI. 2005. Report located at http://www.jscrane.com/index-7.html

13. Pandemic Requirements For A Health System
(Cont’d)
• Training
– Initial
– Just-in-time
• Protective equipment
– Surgical masks, Disposable long-sleeve gowns
and gloves, eye protection
– N-95 or PAPRS
• Training
• Fit testing
• Battery maintenance
• Storage

14. Pandemic Requirements For A Health System
(Cont’d)
• Hand hygiene and cough etiquette
– Signage
– Soap, alcohol hand rubs, paper towels,
tissue and containers, waste baskets,
and surgical masks
– Ambulance contamination and
decontamination procedures

15. Pandemic Requirements For A Health System
(Cont’d)
• X-Ray Equipment
• Mechanical ventilation
– Transport Ventilators
– Respiratory circuits (adult & pediatric)
– Oxygen Supply
– Scope of Practice
– Dedicated facility for disinfecting, cleaning
ventilators

16. Pandemic Requirements For A Health System
(Cont’d)
• Pharmaceuticals and Diagnostic
Testing
– Oseltamivir and Amantadine
– Influenza and Pneumococcal Vaccine
– Rapid Viral Antigen Tests
– Respiratory Viral Cultures

17. Pandemic Requirements For A Health System
(Cont’d)
• Specific resources & destinations for
cohorting patients
– Triage
– Multi-patient transport
– Designated transport units
– In-patients Pediatric and Adult
• ICU
• Intermediate Care
• Wards

18. Federal Pandemic Influenza Plan
• Pandemic “Influenza Plan” US
Department of Health and Human
Services released November 2005
• 396 Page Plan with 8 Page Executive
Summary

19. Executive Summary of HHS
Pandemic Influenza Plan
• Influenza Pandemic has potential to cause
more deaths and illness then any other
Public Health Threat
• If pandemic occurs with similar virulence of
1918 strain, 1.9 million Americans could die
and 10 million could be hospitalized over the
pandemic course which may evolve over a
year or more.

20. • Novel Influenza virus could emerge from
anywhere in world at any time
• Particular concern is about Avian (H5N1) virus
currently circulating in Asia and parts of
Europe
• Outbreaks of Influenza H5N1 have occurred
among poultry in several countries in Asia
Since 1997
Executive Summary of HHS
Pandemic Influenza Plan
Cont’d

21. Avian Influenza In Humans
• More than 100 confirmed cases of Human
Infection with Avian Influenza Viruses have
been reported since 1997
• Most of these cases are thought to have
resulted from direct contact with infected
poultry or contaminated surfaces
• To date human infections with Avian
Influenza a viruses detected since 1997 have
not resulted in sustained human to human
transmission

22. Avian Influenza Viruses Infecting
Humans
• Hong Kong 2003 one child infected
recovered.
• New York 2003  One patient
recovered.
• Canada 2004  Mild eye infection
following poultry outbreak.
• Thailand and Vietnam 2004 and other
parts of Asia in 2004-2005.

23. • Sustained Human to
Human transmission
anywhere in the world
will be the triggering
event to initiate a
Pandemic Response
by US
Only a matter of… time!

24. Characteristic Moderate (1958/68-like) Severe (1918-like)
Illness 100 Million (30%) 100 million (30%)
Outpatient
Medical Care
50 Million (50%) 50 Million (50%)
Hospitalization 865,000 9,900,000
ICU Care 128,750 1,485,000
Mechanical
Ventilation
64,875 742,500
Deaths 209,000 1,903,000
* Estimates based on extrapolation from past pandemics in the United States. Note that these estimates do not
include the potential impact of interventions not available during the 20th
century pandemics.
Number of Episodes of Illness, Healthcare Utilization, and Death
Associated with Moderate and Severe Pandemic Influenza Scenarios*

25. Connecticut
• 2004 Population of 3.5 mill (1.2% of US)
• 21% of CT population is “rural”
Characteristic Moderate (1958/68-like) Severe (1918-like)
Illness 1,050,000 (30%) 1,050,000 (30%)
Outpatient
Medical Care
525,000 (50%)
110,250
525,000 (50%)
110,250
Hospitalization
10,090
2,120
115,500
24,255
ICU Care
1,500
315
17,325
3,650
Mechanical
Ventilation
750
160
8,660
1,850
Deaths
2,450
515
22,200
4,700

26. • Past Pandemics have spread worldwide
within months
• Are expected to spread even more quickly
today given modern travel patterns

27. Rural Connecticut

29. CT Influenza Pandemic Plan
• Pandemic Period (cases in the U.S.)
– Governor will declare a “Public Health
Emergency.”
– Governor will work with:
• DPH,
• Office of Public Affairs, and
• Department of Emergency Management and
Homeland Security (DEMHS)

30. CT Influenza Pandemic Plan
• DPH Emergency Command Center (ECC) and DPH ICS activated.
• State Epidemiologist will manage the epidemiologic and
immunization in collaboration with local health departments,
hospitals and other key response partners.
• DPH will provide assistance to the pandemic response as needed:
– Epidemiology Program,
– Immunizations Program,
– Environmental Health Section,
– Health Care Systems Regulation Branch,
– Laboratory Branch,
– Local Health Administration Branch,
– Regulatory Services Branch,
– Office of Communications,
– Office of Emergency Medical Services, and
– Office of Public Health Preparedness (OPHP).

31. CT Influenza Pandemic Plan
• Each hospital and medical care provider should
develop or update its own pandemic response
plan to be consistent with the National and CT
Pandemic Influenza Response Plans
• Each hospital and medical care provider should
participate in development of a regional
pandemic influenza response plan

32. CT Influenza Pandemic Plan
• Each hospital and major medical care provider will
establish its own EOC and be prepared to participate
collaboratively with DPH as needed to:
– collect information to monitor the pandemic,
– provide information and respond to patient inquiry,
– isolate patients and enforce quarantine of employees and
patients as needed,
– vaccinate employees and patients and/or
– provide antiviral agents to health care providers and patients in
accordance with DPH recommendations, and
– conduct and enforce other activities as may be declared
necessary by the Governor and Commissioner of Public Health.

33. CT Influenza Pandemic Plan
• Licensed health care workers (DPH 5/03)
– Physicians 10,805
– Registered Nurses 40,080
– Licensed Practical Nurses 9,640
– Paramedics 1,380
– Emergency Medical Technicians 8,980
• Essential service providers (DPH 1/06)
– Medical Response Technician (MRT) 5,871
– Emergency Medical Technician (EMT) 9,686
– EMT – Intermediate 843
– Paramedic 1,586
– Firefighters (est. from CT Fire Academy) 21,000
– Local Law Enforcement 7,522
– State Law Enforcement 1,200
– Air National Guard (as of 01/23/06) 1,020
– Army National Guard (as of 01/23/06) 3,212
– State Public Health workforce (as of 5/05) 848
– Local Public Health workforce (as of 2004) 1,802
• Correctional population 19,216

34. Need to be actively involved!
• Feb 2006 GAO report
identifies lack of
transport resources for
nursing home
evacuations
• Planners under/over
estimate EMS transport
capabilities
• PAPRS and decon
training/equipment are
expensive

35. Thank you!
Information Systems, Security, & Technology
Management – Clinical, Operations, & Quality
Management – Contract Oversight – Provider &
Patient Safety
PrioriHealth Partners, LLP
Voice (760) 405-6869
http://www.priorihealth.com/
nick@priorihealth.com