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2020 unit 9 pandemics
This document discusses the key roles and challenges for EMS during a pandemic. It notes that EMS is not just on the front lines, but surrounded by the pandemic as they enter homes and communities. It then discusses how pandemics have occurred historically and the unpredictability. It outlines WHO phases and discusses non-pharmacological interventions like social distancing that can help slow spread. EMS roles include preparing for increased demand and risk while potentially having reduced staffing, and following specific protocols for PPE, destinations and treating in place when possible. Public health agencies are also key partners for EMS in pandemic response and mitigation efforts.
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2020 unit 9 pandemics
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- 2. EMS is noton the front lines of any pandemic, EMS is surrounded by the pandemic. EMS, as it’s core function, leaves the safety of the healthcare system to go into the the community, homes of the afflicted, into the living spaces, into the sphere of the virus itself. Why is this Important?
- 3. Pandemics are notnew Influenza Pandemics are believed to have occurred for at least 300 years at unpredictable intervals. • 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 The 1918 Spanish flu pandemic National Museum of Health and Medicine, Armed Forces Institute of Pathology Pandemic has potential to cause more deaths and illness then any other Public Health Threat.
- 4. Pandemics are notnew • The nature and severity for the next Pandemic cannot be predicted with any certainty. • Past Pandemics have spread worldwide within months • Are expected to spread even more quickly today given modern travel patterns • Preparedness Planning is imperative to lessen the impact of a Pandemic In 2012, Middle Eastern Respiratory Syndrome (MERS) emerged in Saudi Arabia during the annual pilgrimage to Mecca. While not as widespread as SARS, it has a 32% CVR
- 5. Major Outbreaks Pandemic Influenza •1918 Pandemic (H1N1 virus) • 1957-1958 Pandemic (H2N2 virus) • 1968 Pandemic (H3N2 virus) • 2009 H1N1 Pandemic (H1N1pdm09 virus) Other • 2002 – 2003 SARS coronavirus (SARS-CoV) • 2012-Present Middle East respiratory syndrome coronavirus (MERS-CoV) • 2014–2016 Ebola
- 6. If the “SpanishFlu” were to happen today… • Multiple Waves over 3+ years • 350 million US Population • 30% illness • 105 Million • 50% of those ill will require outpatient care: • 52.5 Million • 10% of those ill will require hospitalization: • 10 Million Hospitalized • 1-2% Case Fatality Rate • 1-2 million Deaths
- 7. Key Point • EMSspecifically reaches out to some of the most vulnerable. • This means we are in a great position to help… • Surveillance • Community Measures • This means we are in a great position to harm… • Vector for transmission
- 9. "Although people oftenthink of prisons and jails as closed environments, they are not. Medical staff, correctional staff, and visitors come from the community into the facilities every day and then return home," wrote Morris in an op-ed. "There is ample opportunity for a virus to enter a prison or jail, and for it to go back out into the community."
- 10. The Homeless "A lotof lung disease and heart disease, a lot of people are living with cancer while they're homeless, so I'm really worried about their susceptibility to the severe complications of coronavirus," said Dr. Margot Kushel, director of the UCSF Center for Vulnerable Populations. -https://abc7news.com/5980956/
- 11. Healthcare Staffing is Uncertain •Adequate staffing should not be assumed! • (2005 Study) – 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 • Modern estimates suggest up to 40% of healthcare workforce may be unavailable • Self Quarantine • Actual Illness • Family Illness • Other
- 12. Basic Concepts Got to understandthe basics “ “
- 13. Inter-pandemic flu andpandemic flu
- 14. Potential Impacts of an Influenza Pandemic •Impacts • Rapid Spread World Wide • Healthcare System Overload • Medical Supplies and Resources inadequate • Economic and Social Disruption
- 15. WHO 6 Phasesof a Pandemic 1– Interpandemic Period – Everyday operations • Training, Planning, Preparation, pre-pandemic detection 2 – Potential Pandemic identified in Animals • Surveillance and detection 3- Human Infection Detected, limited spread to close contacts • Identification, Containment, Increased Surveillance 4- Human Infection – Small clusters • Containment, delaying spread 5- Human Infection - Large clusters in small areas 25-50 cases over 2-4 weeks • Containment, Delaying Spread 6- Human Infection – Worldwide spread, Sustained community infections • Mitigation • Contingency Plans • Mass Public Health Measures
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- 18. Case Fatality Rateand Mortality Rate • Case fatality rate is calculated by dividing the number of deaths from a specified disease over a defined period of time by the number of individuals diagnosed with the disease during that time; the resulting ratio is then multiplied by 100 to yield a percentage. • Measures incidence of death for the sick patients • Mortality rate is calculated by dividing the number of deaths by the population at risk during a certain time frame. • Measures the incidence of death for entire population
- 19. CFR can veryby age, location, demographic, etc
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- 22. R naught • R0: Pronounced “R naught.” It’s a mathematical term that indicates how contagious an infectious disease is. • It’s also referred to as the reproduction number. As an infection spreads to new people, it reproduces itself. • Three possibilities exist for the potential spread or decline of a disease, depending on its R0 value: • If R0 is less than 1, each existing infection causes less than one new infection. In this case, the disease will decline and eventually die out. • If R0 equals 1, each existing infection causes one new infection. The disease will stay alive and stable, but there won’t be an outbreak or an epidemic. • If R0 is more than 1, each existing infection causes more than one new infection. The disease will spread between people, and there may be an outbreak or epidemic. • The R0 of the 1918 Spanish Flu Pandemic was estimated to be 1.4-1.6
- 23. R naught Can varyby: location and population Mode of Transmission Vaccination Immunity Control Measures
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- 26. WHO are the majorplayers? Public / Community Health organizations are as much responsible for the prevention of pandemics, as they are for the response to pandemics. “ “
- 27. World Health Organization's (WHO) TheWorld Health is a specialized agency of the United Nations that is concerned with world public health. It was established on 7 April 1948, and is headquartered in Geneva, Switzerland. The WHO is a member of the United Nations Development Group.
- 28. Major Campaigns • Maternaland Neonatal healthcare • West Nile Virus • Ebola • HIV/AIDS • Pandemic Influenzas • Small Pox Erradication By United States Mission Geneva - Flickr: World Health Organization Headquarters and Flag, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=18609 992
- 30. 4 Don’t forgetNGOs, local health districts and resources
- 31. Public Health Measures Work! “Weare treating it right now like any infectious disease that’s a virus” - Mike McCabe. CEO Bayonne EMS “ “
- 32. Major Measures • Pharmacological •Vaccinations • Non-Pharmacological • Personal Protective Measures • Environmental Measures • “Social Distancing” • Travel Related Measures
- 33. Non-pharmacological interventions • “NPIs(also known as non-pharmacological interventions) include all measures or actions, other than the use of vaccines or medicines, that can be implemented to slow the spread of influenza in a population. “ • May be used to delay the start of an epidemic for the distribution of medications/vaccines • May be used to slow or lesson the “PEAK” of an epidemic to allow for to allow time for surge capacity to increase. • NPIs outside of health care settings usually focus on reducing transmission by personal protective or environmental measures (e.g. hand hygiene); reducing the spread in the community (e.g. isolating and treating patients, closing schools and cancelling mass gatherings); limiting the international spread (e.g. traveler screening); and improving risk communication with the public
- 35. Personal Protective Measures • Hand hygiene •Respiratory etiquette • Face masks
- 36. Environmental Measures • Surfaceand object cleaning • • Other environmental measures • Increased ventilation • Unclear or ineffective • Modifying humidity • UV Light
- 37. Social Distancing • Contacttracing • Isolation of sick individuals • Quarantine of exposed individuals • School measures and closures • Workplace measures and closures • Avoiding crowding
- 38. Travel Related Measures • Traveladvice • Entry and exit screening • Internal travel restrictions • Border closure
- 39. EMS ROLES During aPANDEMIC “Care and transports by EMS present unique challenges because of the nature of the setting, enclosed space during transport, frequent need for rapid medical decision-making, interventions with limited information, and a varying range of patient acuity and jurisdictional healthcare resources.” - CDC.gov During a Pandemic, EMS operations are changed. These factors include factors may include: • Increased Demand for Services • Increased risk to providers and patients • Reduction of EMS/Dispatch Workforce • Healthcare Facility Bed Availability
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- 49. Post Response • Cleaningand Decon • Notification of public health agencies • Documentation
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Editor's Notes
- #6 An influenza pandemic is a global outbreak of a new influenza A virus. Pandemics happen when new (novel) influenza A viruses emerge which are able to infect people easily and spread from person to person in an efficient and sustained way. Currently, no areas of the world are reporting transmission of SARS. Since the end of the global epidemic in July 2003, SARS has reappeared four times – three times from laboratory accidents (Singapore and Chinese Taipei), and once in southern China where the source of infection remains undetermined although there is circumstantial evidence of animal-to-human transmission.
- #9 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
- #10 https://www.commondreams.org/news/2020/03/10/nightmare-waiting-happen-advocates-warn-us-prison-conditions-risks-intense "Although people often think of prisons and jails as closed environments, they are not. Medical staff, correctional staff, and visitors come from the community into the facilities every day and then return home," wrote Morris in an op-ed. "There is ample opportunity for a virus to enter a prison or jail, and for it to go back out into the community.“ https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2011/04/04/california-shrinks-its-prisons-but-overcrowding-persists
- #11 https://idahonews.com/news/local/four-members-of-boises-homeless-community-found-dead-in-the-past-week
- #12 https://www.ems1.com/medical-clinical/articles/study-responders-reluctant-to-work-in-pandemic-EcKWczqVs96ua0Fo/
- #14 There were three major pandemics in the 20th century, commonly referred to as the “Spanish flu” in 1918–1919, the “Asian flu” in 1957–1958 and the “Hong Kong flu” in 1968–1969 (Table 3). The most serious of these was the pandemic caused by the A(H1N1) virus in 1918–1919, which resulted in 20–50 million deaths, and had a particularly notable impact on mortality in young adults (17). The A(H2N2) pandemic in 1957–1958 and the A(H3N2) pandemic in 1968–1969 each caused around 1 million deaths worldwide, with the greatest impact on mortality being in older adults (18). The first influenza pandemic in the 21st century, which occurred in 2009–2010, was caused by a new strain of influenza A(H1N1) virus that was antigenically shifted from the seasonal influenza A(H1N1) strains circulating at the time, but antigenically similar to A(H1N1) strains that had circulated before 1950 (19). The virus is thought to have emerged in central America shortly before it was first detected in North America in April 2009, and subsequently spread rapidly to other parts of the world (20). Because of the similarity with older A(H1N1) viruses, older adults had some immunity, reducing the impact of A(H1N1)pdm09 in this age group (21). Globally, the pandemic was estimated to have caused 123 000–203 000 respiratory deaths in 2009 (22). Influenza pandemics typically occur in epidemic waves. For example, in 2009 the United States of America (USA) experienced a spring epidemic of A(H1N1)pdm09 that had a limited impact; the spring epidemic was followed by a much larger autumn epidemic that had a major health impact (24). Subsequent epidemics of A(H1N1)pdm09 have occurred every 2–3 years since 2009, with similar epidemiological characteristics to other seasonal influenza epidemics
- #15 Rapid Worldwide Spread: When a pandemic influenza virus emerges, its global spread is likely inevitable. Preparedness activities should assume that the entire world population will be affected by the virus. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but would not be able to stop it. Health Care Systems Overloaded: Most people have little or no immunity to a pandemic virus. Infection and illness rates will be very high. A substantial percentage of the world’s population will require some form of medical care. Nations are unlikely to have the staff, facilities, equipment and hospital beds needed to cope with large numbers of people who suddenly fall ill. Death rates may be high, depending on four factors: the number of people who become infected, the virulence of the virus, the underlying characteristics and vulnerability of affected populations and the effectiveness of preventive measures. Medical Supplies Inadequate: The need for vaccine and antiviral medications is likely to outstrip supply early in a pandemic period. In addition, a pandemic may create a shortage of hospital beds, ventilators and other supplies. Surge capacity at non-traditional sites such as schools may be created to cope with demand. Shortages may result in the need for difficult decisions regarding who should get antiviral Pandemic Influenza in History drugs and vaccines. Historically, the 20th century has seen • Economic and Social Disruption: Travel bans, three pandemics of influenza: closings of schools and businesses and • 1918 influenza pandemic caused at least 675,000 U.S. deaths and up to cancellations of events could have major impact 50 million deaths worldwide on communities and citizens. Care for sick • 1957 influenza pandemic caused at family members and fear of exposure can result least 70,000 U.S. deaths and 1-2 in significant worker absenteeism.
- #23 Three possibilities exist for the potential spread or decline of a disease, depending on its R0 value: If R0 is less than 1, each existing infection causes less than one new infection. In this case, the disease will decline and eventually die out. If R0 equals 1, each existing infection causes one new infection. The disease will stay alive and stable, but there won’t be an outbreak or an epidemic. If R0 is more than 1, each existing infection causes more than one new infection. The disease will spread between people, and there may be an outbreak or epidemic. Importantly, a disease’s R0 value only applies when everyone in a population is completely vulnerable to the disease. This means: no one has been vaccinated no one has had the disease before there’s no way to control the spread of the disease This combination of conditions is rare nowadays thanks to advances in medicine. Many diseases that were deadly in the past can now be contained and sometimes cured. For example, in 1918 there was a worldwide outbreak of the swine flu that killed 50 million people. According to a review article published in BMC Medicine, the R0 value of the 1918 pandemic was estimated to be between 1.4 and 2.8. But when the swine flu, or H1N1 virus, came back in 2009, its R0 value was between 1.4 and 1.6, report researchers in the journal Science. The existence of vaccines and antiviral drugs made the 2009 outbreak much less deadly.
- #25 https://www.vox.com/2020/2/18/21142009/coronavirus-covid19-china-wuhan-deaths-pandemic
- #26 https://www.vox.com/2020/2/18/21142009/coronavirus-covid19-china-wuhan-deaths-pandemic
- #28 Just this week : 20 - 26 May 2019 Anthrax outbreak in Guinea Ebola virus disease outbreak in the Democratic Republic of the Congo Humanitarian crisis in Central African Republic Humanitarian crisis in Nigeria Yellow fever in Uganda.
- #32 https://hudsonreporter.com/2020/03/05/ems-prepare-for-coronavirus-in-bayonne/
- #35 https://apps.who.int/iris/bitstream/handle/10665/329438/9789241516839-eng.pdf?ua=1
- #36 Personal protective measures 20 4.1. Hand hygiene 20 4.2. Respiratory etiquette 24 4.3. Face masks Hand hygiene is recommended as part of general hygiene and infection prevention, including during periods of seasonal or pandemic influenza. Although RCTs have not found that hand hygiene is effective in reducing transmission of laboratory-confirmed influenza specifically, mechanistic studies have shown that hand hygiene can remove influenza virus from the hands, and hand hygiene has been shown to reduce the risk of respiratory infections in general. Respiratory etiquette is recommended at all times during influenza epidemics and pandemics. Although there is no evidence that this is effective in reducing influenza transmission, there is mechanistic plausibility for the potential effectiveness of this measure Face masks worn by asymptomatic people are conditionally recommended in severe epidemics or pandemics, to reduce transmission in the community. Although there is no evidence that this is effective in reducing transmission, there is mechanistic plausibility for the potential effectiveness of this measure. A disposable surgical mask is recommended to be worn at all times by symptomatic individuals when in contact with other individuals. Although there is no evidence that this is effective in reducing transmission, there is mechanistic plausibility for the potential effectiveness of this measure
- #37 Environmental measures 28 5.1. Surface and object cleaning 28 5.2. Other environmental measures 31 5.2.1. Ultraviolet light 31 5.2.2. Increased ventilation 33 5.2.3. Modifying humidity Surface and object cleaning measures with safe cleaning products are recommended as a public health intervention in all settings in order to reduce influenza transmission. Although there is no evidence that this is effective in reducing transmission, there is mechanistic plausibility for the potential effectiveness of this measure. Installing UV light in enclosed and crowded places (e.g. educational institutions and workplaces) is not recommended for reasons of feasibility and safety. Increasing ventilation is recommended in all settings to reduce the transmission of influenza virus. Although there is no evidence that this is effective in reducing transmission, there is mechanistic plausibility for the potential effectiveness of this measure. There is no evidence that modifying humidity (either increasing humidity in dry climates, or reducing humidity in hot and humid climates) is an effective intervention, and this is not recommended because of concerns about cost, feasibility and safety.
- #38 Social distancing accepts or acknowledges that the coronavirus is likely widespread, community transmission is already occurring https://apps.who.int/iris/bitstream/handle/10665/329438/9789241516839-eng.pdf?ua=1 The most effective strategy to mitigate the impact of a pandemic is to reduce contacts between infected and uninfected persons, thereby reducing the spread of infection, the peak demand for hospital beds, and the total number of infections, hospitalizations and deaths. The most effective strategy to mitigate the impact of a pandemic is to reduce contacts between infected and uninfected persons, thereby reducing the spread of infection, the peak demand for hospital beds, and the total number of infections, hospitalizations and deaths.
- #39 Travel-related measures 79 7.1. Travel advice 60 7.2. Entry and exit screening 62 7.3. Internal travel restrictions 64 7.4. Border closure
- #40 Emergency medical services (EMS) play a vital role in responding to requests for assistance, triaging patients, and providing emergency medical treatment and transport for ill persons. However, unlike patient care in the controlled environment of a healthcare facility, care and transports by EMS present unique challenges because of the nature of the setting, enclosed space during transport, frequent need for rapid medical decision-making, interventions with limited information, and a varying range of patient acuity and jurisdictional healthcare resources.
- #42 Municipalities and local EMS authorities should coordinate with state and local public health, PSAPs, and other emergency call centers to determine need for modified caller queries about COVID-19, outlined below. Development of these modified caller queries should be closely coordinated with an EMS medical director and informed by local, state, and federal public health authorities, including the city or county health department(s), state health department(s), and CDC.
- #46 The “Sample Pandemic Influenza EMS Dispatch Protocol” is for illustrative purposes only. It is one example of how resources may be reallocated within the system during an influenza pandemic utilizing the Pandemic Severity Index. EMS planners should consider other factors, including community mitigation strategies, that will impact how resources will be used. These factors may include: Increased Demand for Services Reduction of EMS/Dispatch Workforce Healthcare Facility BedAvailability
- #50 Cleaning EMS Transport Vehicles After Transporting PUI or Patient Don PPE for cleaning with disposable gown and gloves, facemask, and goggles or face shield if splashes are anticipated Routine cleaning and infection procedures should follow organizational standard operating procedures Use protect use products with EPA-approved emergent viral pathogens claims Once transport is complete, organizations should notify state or local public health authorities for follow up. Additionally agencies should (if not done already) develop policies for assessing exposure risk and management of EMS personnel, report any potential exposure to the chain of command, and watch for fever or respiratory symptoms amongst staff.