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August 9, 2015

2015/2016 Flu: Forward Thinking for the next Epidemic

Its difficult to think about seasonal influenza and the potential of a seasonal epidemic when you're bathed in summer weather. Its difficult to research and write about it at this time of year, too. Believe me. Still, after last flu season, if we learned nothing (and maybe we did learn nothing) we learned to get prepared early.

The 2014/2015 flu season was particularly difficult. The vaccine was poorly matched and resulted in ~23% vaccine effectiveness (VE) overall with a ~18% VE for the (drifted) H3N2 strain. And it was worse for children. Add to that the particularly long season of 20 weeks as compared to the usual 13 week flu season and it becomes easy to see why we had such a difficult time last flu season. Thats why we need to get into gear now.

Epidemic on the horizon

We don't often get a lot of warning before a natural disaster strikes. Seasonal influenza gives us a bit of a break on that fact. We know seasonal influenza is coming every year. We know what it did last year, and the year before that and the year before that. We know what it can do to our emergency response systems, our emergency departments, intensive care units, walk-in clinics, and doctors offices. There remains a lot to learn and apply from Dark Winter and Atlantic Storm.

We have an awful lot of data and we need to use it, along with this time of relative quiet, to ramp up for the coming epidemic.

Plan for it

Drag out your biologic plans and review them with all members of your staff. Anyone who works in your facility (medical providers, secretarial support, food service, and environmental service) should be made aware of their responsibilities (and they all have them) during a biologic event. Remember, seasonal influenza is a naturally occurring biologic event. Treat it like one. Surge capacity and mass fatality plans are two additional plans you should be looking at.

Take a hard look at your staffing patterns 

Influenza-like illness (ILI) can result in an absentee rate greater than 20%. Now is a good time to review your call back procedures and evaluate who will be available/willing to come back to work. Keep in mind that the best way to keep people coming back to work is to keep them safe. Medical staff who feel they (and their families) are protected are more likely to report to work during a biologic event. The flip side of this is, of course, reminding sick staff to stay home.

Review triage 

In this case, triage of specialty medical resources such as ventilators and intensive care unit bed. At the height of a biologic event is not the time to decide who does or does not get the last bed or ventilator.

Points of Distribution

Points of distribution (POD) planning is critical to any successful pharmaceutical countermeasure program. Public (open POD) and closed POD plans need to be reviewed, updated and practiced. They will not run themselves and your organizations health, safety, and public image may hang in the balance. Make sure you POD system works!

Practice the non-pharmaceutical countermeasures

Hand washing, respiratory etiquette, and appropriate social distancing (staying home if you're ill) will go a long way towards keeping your staff and facility safe and functional. Endorse it, live it, practice it.

Forward thinking: Whats in store for the 2015/2016 flu season? 

The predicted strains included in this season are A H1N1, A H3N2, and two strains of B influenza. Go here for additional details on flu strains. Estimates are that between 164 million and 175 million doses of flu vaccine will be available between August and October, 2015. Sanofi Pasteur released their first flu vaccine shipment of the season in July, 2015.

A trivalent and quadrivalent vaccine will again be available for the 2015/2016 season. Intramuscular, nasal spray will be available. New this season is the Jet Injector that delivers vaccine by a high pressure stream rather than a needle.

June 12, 2013

MJ 252: A Unique Perspective on Secret Spying

A Unique Perspective on Secret Spying on Mitigation Journal - keeping the use of tin foil to a minimum. 
This edition is all about the revelation that the United States Government has been collecting data from various sources on each and every one of us. The situation is breaking news and unnerving but should we be surprised? 
In this edition we discuss how the changes in technology have made it possible for secret spying on the American pubic to take place. In the name of “stoping terrorism” we’re collecting cellular, internet, and email data on everyone...just in case we find something worth investigating. 
WIll this type of surveillance work? No. It didn’t work during the Civil War and World War Two and it won’t work now. 
At the end of it all, we have to ask it now is the time to unplug? 

Check out this episode!

May 21, 2013

When Can We Stop Training for Terrorism?

Time to focus on what we're the threats we're seeing today

This posting was originally written in 2005 and reflected my views on how expenditures of time and money were being wasted in the name of terrorism training. Not much has changed over the eight years since I originally published this article' except for a decrease in preparedness funding, of course. We've seen several assaults on civilian soft targets resulting in mass casualties during this time as well. Some have been labeled "terrorism" some have not. While we can debate the usefulness of terrorism as a descriptor of what we face, we can't ignore the fact that our responses to these events are not much improved from the pre-9/11 days.

From 2005...
Our language reflects how we think and act. When we place a term on an issue, that term becomes face or imprint in our mind for that given issue. Terrorism and weapons of mass destruction (WMD) are two terms arisen out of the September 11, 2001 attacks that have been imprinted on us. Although not entirely new terms for many in the traditional response group of emergency medical service (EMS), fire service, and law enforcement; terrorism and WMD became the language defining events of National crisis. These and several other terms have taken on a center stage appearance since 9-1-1. Highly paid “experts” have become obligatory content in any number of trade journals and conferences. Emergency service organizations have received millions of grant dollars to purchase training/education, equipment, and supply all to be brought to defend against terrorism/WMD. 

Most of the training that has been conducted is next to meaningless. A majority of the training conducted lacks context to what is encountered and managed every day. That is to say; we need to take the all-hazards approach to training and relate the material to the bread-and-butter jobs paramedics, EMT’s and firefighters respond to. Doing so will keep the skills and knowledge fresh and usable. If we continue to wrap this material up and say “don’t open ‘till terrorist attack” we will not be able to use it properly. We must take the message given by intentional event training and project it across routine, every day events. I believe the terms terrorism and WMD should be replaced with intentional events.

A good example would be to apply the all-hazards approach to triage. Ask any group of emergency medical technicians or firefighters, veterans or rookies, if they’ve ever worked an event that they’ve needed to do triage. You might get one or two that have, but the majority will claim to have never needed their triage skills. In reality we all have. The fact is that we do triage on each and every call we’re on. Triage means to sort and prioritize. We do that with every patient, looking at injuries and complaints, making decisions about what to treat first and how. Firefighters triage the situation, the building and the fire…only it’s called size-up, and we’ve been doing it for years. Educators who can describe intentional event preparedness in this format will be giving the student the tools to truly be prepared.

"If we continue to wrap this material up and say “don’t open ‘till terrorist attack” we will not be able to use it properly."

I’ve found numerous training officers who would come to me after a lecture and buoyantly declare “this WMD stuff is all well and good, but my guys need to get back to basics”. I usually ask those officers if they believe the “basics” include training on poisons and toxics like organophosphate materials. Or, might we be able to find time in our zealous training schedule to include basics of mass casualty management. Oh, the irony of it all! For these same training officers do not hesitate to defend the need for hazardous materials or mass casualty training yet miss the more than obvious relationship between intentional events and the hazardous materials event or bus crash. I guess if we call it haz-mat they’re OK with it, but; terrorism…hell, terrorism can’t happen here, right? Not to mention the probability of a natural event impacting any community.

The point here is this; we have to blend what we’ve come to know as terrorism/WMD training into the “basics” of EMS and fire service. To do so is simple because of the similarities between the intentional (terrorist/WMD) event and haz-mat accidents, mass casualty events, and natural disasters.

What do accidents, man-made events (human initiated to be politically correct), and natural disasters (ice storms, hurricanes, earth quakes, floods) have in common? The short list of examples include:

  • Little or no warning
  • potential for large numbers of civilians needing assistance
  • multiple casualties and fatalities
  • protracted operations
  • limited resources

The all-hazards approach looks at preparing us for a multitude of potentials. Not everyone has to be ready for a blizzard or a wildland fire, but we should all be cognizant of the need for self-protection, working within the incident management systems, triage and the like. We also must take advantage of our existing knowledge and skill base by putting them to use in the context of terrorism/WMD events.

The labels of terrorism and WMD may have been a great disservice to our responders and citizens. Those terms imply an event that most people don’t believe will ever happen to them. However, the principles, tactics, and added knowledge that training for intentional events advocate can traverse a multitude of disciplines and events.

Let’s try to change our thinking...when will it happen here?

May 14, 2013

Why "Terrorism" is Obsolete

Words that no longer matter in todays preparedness world

I'm disappointed by recent reports of the Mothers Day shootings that took place in New Orleans for several reasons. My obvious disappointment, because the shooting happened during a celebratory parade (civilian soft target). The not-so-obvious disappointment; local government officials snapping out the "its not terrorism" phrase almost as bold as the headlines. It seems we're quick to ensure whats not terrorism, quick to define whats not a threat as if to tell the public to go back to sleep, nothing to see here.

The lines and definitions of what is and what is not have become too blurred to be meaningful.

19 people shot during a parade in New Orleans is not terrorism. Its gang violence. Would the presence of an elected official or religious leader at the parade make the shooting an act of terrorism? Perhaps.

In January, 2011 an individual opens fire at an outdoor gathering in Tucson, Arizona, hitting 18 people including U.S. Representative Giffords and killing 6 others. The incident was initially describes as "terrorism" by numerous officials.

Regardless of the title bestowed, the outcomes remain the same.

Another term thats outlived its usefulness is Homegrown Terrorism. We started using that little waste of text after some freshly re-worded, politically corrected preparedness documents were published. We're supposed to use Homegrown in place of Domestic Terrorism. According to WikiPedia Homegrown Terrorism is the
 “use, planned use, or threatened use of force or violence by a group or individual born, raised, or based and operating primarily within the United States or any possession of the United States to intimidate or coerce the United States government, the civilian population of the United States, or any segment thereof, in furtherance of political or social objectives.”
To understand how moronic this is, realize that, according to this definition, the attacks of 9/11 were Homegrown Terrorism.

Why not retire terms like terrorism and homegrown terrorism? They taint our thinking, planning and response. Instead why not embrace Rule of Outcomes Thinking that prepares us for a variety of outcomes from events...regardless of the motive. Rule of Outcomes Thinking leads to preparedness based on what we can expect the outcomes of a given event to be. Its a close cousin to all-hazards. We don't need to stress over who's in charge if its a terrorist event or not. Manage the situation based on the outcomes or anticipated outcomes.

May 13, 2013

MJ 250: Focusing on New Flu and NCoV

Why wait? The writing is on the wall indicating N7N9 and Novel Corona Virus situations could follow similar paths that Avian Flu and SARS did. Those subtle warnings should be calling us to action now. 
On Mitigation Journal Podcast this week: 
Editorial changes: We’re attempting to publish blog topics on regular days (by reader request). Go to for details.
University of Pittsburgh Medical Center Center for Health Security (formerly center for biosecurity) Follow them on Twitter @UPMC_CHS
Pandemic on the horizon? Maybe two. This is our reminder that pandemics and biologic events usually start small with subtle warnings. Those warnings are there now. We should be paying attention. MERS-CoV is gaining momentum and the future of H7N9 is unclear. Now’s the time to become engaged in “Determined Awareness” and educate yourself - get in tune with the CDC by visiting their website, visit your local health department website and coordinate with responder groups. 
Action now will pay off. 
See Related MJ topics:

Check out this episode!

May 3, 2013

Acute Radiation Sickness

Overview of biologic effects of radiation, acute radiation sickness

Biological effects of radiation are dependent upon the type of exposure a person has with the duration of the exposure and intensity of the material playing a key role. We also have to include the role of personal protection such as time, distance and shielding.

Acute Radiation Sickness (sometimes called Acute Radiation Syndrome or ARS), occurs when an individual is exposed to a large amount of radiation in a short period time or a total doses greater than 100 REM (100 RAD  for gamma radiation).  Acute radiation sickness has a variety of clinical features; some are obvious, some not.In general, the clinical manifestations of acute radiation sickness include the following:
  • changes in blood cell count, specifically lymphocytes decrease
  • vascular permeability changes
  • gastrointestinal irritation; nausea, vomiting, and diarrhea
  • fever
  • hair loss, in uneven patterns
  • skin rash, skin burns, in general skin irritation
  • vague symptoms such as flu-like symptoms
The appearance of these symptoms may begin within minutes after exposure or may not appear for several days. Symptoms may disappear after a few days and resurface with severe illness. Individual unique response to radiation is variable that has to be accounted for as well as age and pre-existing medical condition.

Acute radiation sickness has four phases and may manifest with four separate syndromes.
The four syndromes of acute radiation sickness  are:
  • Hematopoietic Syndrome
  • gastrointestinal syndrome
  • cardiovascular syndrome
  • and central nervous system syndrome
The four phases of acute radiation sickness are:
  • prodromal phase
  • latent phase
  • manifest phase (sometimes called the period of illness)
  • and recovery or death
From: REMM
 Hematopoietic Syndrome  effect the blood cells and platelet counts. The lymphocyte count begins to drop and is seen is the earliest marker or indicator of the degree of severity of exposure and subsequent acute radiation sickness.  Complications associated with Hematopoietic Syndrome  including infection and internal hemorrhage. Changes in lymphocyte counts are detected or measured on a Andrews Curve. The Andrews curve graphs the lymphocyte count for the first 48 hours. In addition to being a marker for severity of exposure to radiation,  decreasing lymphocytes are also all marker for treatment and prognosis. In many cases red blood cells and red blood cell production remains fairly normal after radiation exposure. Neutrophils decline in a gradual rate, while platelets may decrease slightly over time. Again, lymphocytes and lymphocyte counts are critical for determining the degree of severity of acute radiation sickness.

Gastrointestinal syndrome is a condition in which the epithelial lining of the G.I. system is gradually destroyed. Epithelial cells decline in results in nausea, vomiting, diarrhea, and sepsis. Sepsis is a result  of the loss of protective barrier that separates normal bacteria from the bloodstream. Gastrointestinal syndrome may impact the lower G.I. or upper G.I. tract, or both. In the lower G.I. system bloody diarrhea (frank in nature) is most common.

Large doses of whole body radiation can cause Central Nervous System and Cardiovascular syndrome. Both are caused by a destruction of blood vessels and an increase in capillary permeability. Symptoms usually appear fairly rapidly and take the form of cerebral edema, pulmonary edema, cardiogenic shock, and death. Victims exposed to large amounts of whole body radiation may often die within 72 to 80 hours, often before the symptoms of G.I. syndrome or hematopoietic  develop.

Acute radiation sickness may present within four distinct stages: prodromal, latent, manifest, and recovery/death. In the prodromal phase (approximately 48 hours after exposure) victims may present with:
  • nausea and vomiting, diarrhea
  • fatigue and headache
  • fluid shifts due to  increased permeability and electrolyte losses
 In the latent phase the victim may show signs of improvement. Depending upon the unique variables of the person and the dose/rate/body surface area of exposure. Symptoms may return in 24 hours to several days with greater severity.  The manifest illness stage produces compromise to the immune system and can present with symptoms of any one or all of the syndromes  (hematopooietic, GI, CV/CNS) discussed earlier. Symptoms may also be seen in major organ systems; particularly in the integument, neurovascular and G.I. systems of the body. The final stage of acute radiation sickness is the recovery or death stage. Unfortunately, treatment at this point is supportive in nature and the outcome is determined by the dose of radiation exposure and the body surface area along with the other variables we discussed. It should be noted that after a lethal dose of radiation, victims may progress through each of the four phases rapidly with a quick decline in status.

April 19, 2013

Biologic Effects of Radiation

Radiation Exposure Phases and Syndromes

The biological effects of radiation are dependent upon the type of exposure a person actually has. Duration of the exposure as well as the intensity of the material play a role. Factors of personal protection such as time, distance, and shielding need to be included.

Biologic effects can be categorized generically as acute or chronic. Acute exposure may be for a very short period of time to a higher level radiation source while chronic exposure can either be in extended exposure to low-level source or repetitive exposures to a variety of sources of radiation.

 Individual biological differences must be considered. Each person is different and will respond differently to radiation exposure.  Extremely high-level radiation exposure is an exception.

In general, radiation causes three major problems in our bodies.
  • Radiation can damage DNA and other cellular structures
  • Radiation exposure results in cell death immediately or shortly after exposure
  • Radiation exposure results in incorrect cellular repair and mutations that can cause cancer and other disease
The effects of radiation on each person differs in their biologic response to any given dose of radiation. The factors that influence radiological impact on the body include:
  • age- Younger patients and those with a higher metabolism and cell turnover rate are more susceptible.
  • sex
  • diet
  • body temperature and overall health
Acute radiation sickness can occur when an individual is exposed to a large amount of radiation in a short period of time (acute exposure). This level of exposure may be defined that radiation doses greater than 100 REM which is equivalent to 100 RAD for gamma ray exposure. The signs and symptoms of acute radiation sickness vary by the dose received and by the unique biologic factors of each individual. Symptoms can be as subtle as “flu-like” symptoms or as dramatic as rapid changes in blood cells. In general acute radiation sickness generates the following:
  • nonspecific (flu-like symptoms)
  • hair loss
  • fever
  • skin irritation
  • vascular changes
  • blood cell changes
While the initial symptoms may seem minor such as with G.I. upset, the sooner a person vomits or loses consciousness after cute exposure indicates severe exposure. Severity and course of treatment depend on how much total doses been received as well as how much of the body has been exposed taking into account individual susceptibility as a variable. Acute radiation sickness is not an all-or-nothing situation. The symptoms may appear shortly after exposure only to disappear after a few days. Symptoms may also reappear in a much more severe illness later on.

Acute radiation sickness has four phases and may manifest with four separate syndromes.
The four phases of acute radiation sickness are:
  • prodromal phase
  • latent phase
  • manifest phase (sometimes called the period of illness)
  • and recovery or death
The four syndromes of acute radiation sickness  are:
  • Hematopoietic Syndrome
  • gastrointestinal syndrome
  • cardiovascular syndrome
  • and central nervous system syndrome

April 12, 2013

Radiation Basics Demystified

Making Sense of Radiation

The threat or potential of harmful radiation can be expected from a variety of sources.
  • Nuclear weapon
  • Nuclear power plan accidents
  • Transportation and waste storage accidents
  • Military accidents
  • Vandalism
  • Terrorism

Rules for Radiosensitivity...made easy

“The sensitivity of cells to irradiation is in direct proportion to their reproductive activity and inversely proportional to their degree of differentiation.”                                          (Bergonie and Trubondeau)
What this means is:
  • The faster turnover rate (reproduction rate) a cell has the greater radiation exposure will effect it.
  • Unborn children and young children are affected more.
  • Effects can be terotgenic or mutagenic
Dose Rate Effects

From: REMM
Dose RATE is a significant factor. As the dose rate is decreased and the exposure time is increased, the biological effect for a given dose is decreased.

What this means is:

At lower dose rates more subleathal damage to the cell can repair and cell populations have time to reproduce and repopulate.

Units of radioactivity measurements

The three units of activity that are of concern to patient care are:
  • Units of activity.
  • Units of radiation dose or deposited energy
  • Units of biological dose equivalent.
  • Units of activity
From: REMM
Radioactive materials are classified by activity or rate of decay. Knowing radiation unit conversion is also helpful. The units of radioactive decay are:
  • The Becquerel (Bq) or disintegrations per second:
    • 1Bq = 1 disintegration per second
  • The Curie (Ci)
    • 1 Ci = 3.7 x 1010 Bq

Units of radiation dose

Units of radiation that is absorbed by the body is the dose.  The units of absorbed dose are:
  • The radiation absorbed dose (rad)
    • 1 rad = 0.01 Gy
    • 1 Gray (Gy) = 100 rad

April 10, 2013

EMS NOW: Future of EMS

EMS NOW - a weekly highlight of emergency medical services

EMS NOW: The Future of EMS
By Matt Comer, EMTP

"... if we hope to have a cutting edge provider as the future of EMS we need cutting edge clinical educators now..."
How does your agency/department select, train, and maintain its field training officers (FTOs)?  If your agency is anything like the ones I have worked for over the years, the process probably goes something like; “Hey you’re a good EMT or Paramedic , you’re going to be an FTO.”  FTOs are typically then sent out with little to no direction or continued education.  Unfortunately, this has been the model for FTO programs throughout EMS over the years.  In order to produce better EMTs and paramedics in the future we have to shift our model to view FTOs as educators.

As mentioned, typically the selection process for choosing FTOs has been picking our best    EMTs / Paramedics.  This selection process is based on the quality of the provider’s clinical care and perhaps whether or not they are a friendly person.  The selection process often does not take into account the future FTOs teaching style, personality type, or perhaps most importantly their passion to teach.  As EMS leaders looking to further our profession we must create a more comprehensive FTO selection process.  EMS leaders should place a strong emphasis on a provider’s passion to teach and become a FTO.  The future FTO will have to balance being a solid provider, a constant learner, as well as a passionate and skilled clinical educator.  The future FTO will become more than a trainer, they must become educators.

What is an educator?  According to Merriam-Webster it is:  one trained in teaching, a specialist in the theory and practice of education. “One trained in teaching”, that assumes some type of training specific to the science / art of teaching.  Rarely do FTOs receive any training on how to teach and may not ever receive any such training.  EMS training departments must develop and implement a comprehensive FTO training program in which the EMT/Paramedic can make the transition from clinician to clinical educator.  Our future FTOs are already experts in their field we must make them specialists in the theory and practice of education.  An additional challenge faces the FTO and that is being an effective clinical educator.  Over and above being an educator the clinical educator must teach their students in the clinical environment which offers many challenges.  The primary challenge we must prepare the new FTO for is how to balance appropriately treating their patients while allowing for a rich learning environment for the student.

So what does this new FTO program look like?  It begins with recruiting, seeking out, and selecting solid providers who are passionate about teaching.  Providers must be solid in their own practice as much of the additional training they receive will be on the theory and practice of clinical education.  The provider should be passionate about teaching as they now have to commit much of their time to teaching, guiding and mentoring students.  An FTO program must now offer initial and ongoing training on how to become and improve as a clinical instructor.  The program must place a strong emphasis on the education of the FTOs.  FTOs should be offered consistent and regular educational opportunities which give them a greater knowledge base not only as providers, but as educators.

The logic is fairly simple; if we hope to have a cutting edge provider as the future of EMS we need cutting edge clinical educators now. 

April 5, 2013

Where has our little SARS gone?

A decade later is SARS ready to come home?

2003: Severe Acute Respiratory Syndrome (SARS) rips around the globe causing serious illness and death. In many ways, we’re still dealing with the preparedness aftermath of the SARS situation as we struggle to maintain some level of sustainable preparedness for biological events.

SARS was contained in the summer of 2003 after it mysteriously vanished from the environment. Few cases of SARS-like infections were seen in late 2003/early 2004, but it seems that SARS, in an uncharacteristic move for a virus, had died off. Or did it?

According to an article in, we can’t be sure SARS wont come back despite evidence that the previous novel corona virus that causes SARS is indeed dead.

The reason, according the those quoted in the article, is that animals can still transmit a SARS-type virus to humans. The Civet has been long believed to be the vector between bats and humans, allowing SARS to make the leap between species.

According to the article:

“While the precise sequence of events that resulted in the 2003 SARS virus can never be traced, it's clear that the factors that led to its emergence still exist. Bats still carry SARS-like viruses. Small carnivores still eat dead bats. People in some parts of the world still trap small carnivores and sell them as food in markets crowded with other mammals...”

Meanwhile, Saudi Arabia has confirmed cases of infection with a novel corona virus (nCoV) according a World Health Organization (WHO) update. Of the 15 reported cases of infection with this nCoV, 9 of those have died.

World Health Organization defines cases of nCoV infection as confirmed or probable. Confirmed cases are those with laboratory confirmation of infection. According to the WHO Revised Interim Case Definition nCoV, a probable case is defined as:
"A person with an acute respiratory infection with clinical, radiological, or histopathological evidence of pulmonary parenchymal disease (e.g. pneumonia or Acute Respiratory Distress Syndrome, (ARDS); AND no possibility of laboratory confirmation for novel corona virus either because the patient or samples are not available for testing; AND close contact with a laboratory-confirmed case."

Close contact is defined by WHO as:
"...anyone who provided care for the patient, including a health care worker or family member, or who had other similarly close physical contact;
anyone who stayed at the same place (e.g. lived with, visited) as a probable or confirmed case while the case was symptomatic."

Are we seeing the start of SARS, the next generation? If so, planning for biologic events is more important than ever.

March 29, 2013

CDC: 90% of Pediatric Deaths Not Vaccinated Against Flu

Pediatric vaccination rate low, but same as other years

The Centers for Disease Control and Prevention believe that 90% of pediatric deaths from influenza this season were not vaccinated. There have been 105 pediatric deaths attributed to influenza-like-illness (ILI) to date this flu season. The CDC defines pediatric cases as those less than 18 years of age.

The report also indicates that 60% of these cases were in pediatrics who are considered “high risk” while the remainder had no known chronic health or medical problems. Conditions such as asthma/respiratory pathology, heart conditions, or neurological problems along with anyone who has a weak or compromised immune system put children at high risk for complications or severe cases of influenza.

The CDC also points out that these numbers are consistent with experience from previous flu seasons. See the latest 2012/2013 Flu Update for additional flu data.

According to the CDC:
"CDC began tracking flu-associated pediatric deaths after the 2003-2004 flu season – a season that, like the current flu season, started early and was intense. In addition, it took a high toll on children. In the 2003-2004 season, 153 pediatric deaths were reported to CDC from 40 states. Flu-associated pediatric deaths became nationally reportable the following season. Since that time, reported pediatric deaths during regular influenza seasons have ranged from 34 deaths (during 2011-2012) to 122 deaths (during 2010-2011). However, during the 2009 H1N1 influenza pandemic, which lasted from April 15, 2009 to October 2, 2010, 348 pediatric deaths were reported to CDC."

Despite recommending vaccination of children aged 6 months to 18 years, and subsequently adults, pediatric vaccination rates have remained low. The CDC claims this years vaccine was estimated 60% effective against flu with slightly lower effectiveness in those over 65 years old.

Vaccination continues to be the first-line of defense in preventing influenza followed by antiviral treatment for those at high risk.

March 27, 2013

POD Sites of the Future - Public Health Preparedness Summit

How we respond to biologic events continues to evolve. 

Points of Distribution, or POD's, are critical parts of public health emergency management during a biologic event. In this conference segment from Mitigation Journal, we hear from Wesley McDermott, Public Health Adviser and Garrett Simonsen, Regional Public Health Preparedness Planner, while covering the Public Health Preparedness Summit 2013 in Atlanta, Georgia, on the topic of POD sites of the future.

The Summit is sponsored by the National Association of City and County Health Officials. Special thanks to Jamie Davis, RN, EMTP, (MedicCast Productions and Promed Network) for his expertise in the creation of this video segment. 

March 26, 2013

MJ Podcast #246: Smallpox, SARS, Flu

Mitigation Journal Podcast #246
This week:
Flu Update - Influenza B causing majority of problems
CDC Report: 90% of Peds deaths from flu were not vaccinated
SARS 10 Years Later - Where has our little SARS Gone? Will it be back?
Smallpox Vaccine Buy Out: US stockpiles for 2 million people, $410 million

Hosted by Rick Russotti, RN, Paramedic
Please visit Mitigation Journal at

Check out this episode!

March 22, 2013

Jack Herrmann at Public Health Preparedness Summit 2013

Jack Herrmann at Public Health Preparedness Summit 2013
with Jamie Davis of the MedicCast

 From MedicCast.TV

MedicCast host Jamie Davis, the Podmedic is joined by Jack Herrmann, Senior Advisor and Chief of Public Health Preparedness at NACCHO. Jack is the chairman of the Public Health Preparedness Summit and shares his views on this incredibly successful conference. Find more videos from this conference at

March 20, 2013

Education and Technology at Public Health Preparedness Summit 2013

Education and Technology at Public Health Preparedness Summit 2013
with Jamie Davis of the MedicCast

Technology needs proper education and training to make it work and attendees got both at Public Health Preparedness Summit 2013.

A special thank-you to Jamie Davis of The MedicCast for his efforts in the production of these video segment.

March 17, 2013

International Attendees and High-Tech at Summit at Public Health Preparedness Summit 2013

International Attendees and High-Tech at Summit at Public Health Preparedness Summit 2013
with Jamie Davis of the MedicCast

The Public Health Preparedness Summit 2013 was host to an large domestic and international audience along with a wide variety of high-tech products and services geared to enhance public health efforts during a crisis.

Summit 2013 in Atlanta, Georgia, gathered over 1600 dedicated public health experts under one roof for education and sharing of information. Every state in the United States was represented this year. We were also joined by public health colleagues from Canada, China, Cuba, Guam, Kenya, the American Samoa, the US Virgin Islands, and Vietnam.

March 16, 2013

Opening the Doors at Public Health Preparedness Summit 2013

Opening comments on Public Health Preparedness Summit 2013
with Jamie Davis of the MedicCast

After getting  the podcast studio set up we were able to recon the exhibit hall floor and take note of the  offerings at the Public Health Preparedness Summit. Many of the governmental services including several branches of the Centers for Disease Control and Prevention.

In addition to highlights from the Summit, Mitigation Journal along with The MedicCast, conducted a variety of interviews with Summit presenters on a variety of topics. Those interviews will be posted in the near future.

March 15, 2013

JAMA Busts Flu Vaccine Myths

Worthy of Myth Busters, JAMA debunks common influenza vaccine myths

The 2012/2013 influenza season may be winding down, but the excuses for not being vaccinated against seasonal flu continue. Vaccination rates seem to be low despite an early and ferocious flu season and healthcare workers seem to be on the lower end of the vaccine numbers. In response to the reluctance of many to get the flu shot, JAMA recently published a paper outlining (and debunking) common arguments against flu vaccination.

MYTH: The Vaccine does not work.
JAMA Response: Busted! Notes the flue vaccine is not as effective as common vaccines, but "not as effective" does not mean "not effective". They go on to state that this years influenza vaccine was estimated at 62% effective by mid-season. According to the article:
"A prevention measure that reduced the risk of a serious outcome by 60% in most in- stances would be a noted achievement; yet for influenza vaccine, it is seen as a “failure.” JAMA.
Myth: The vaccine causes the flu.
JAMA Response: Busted!
"...people may develop an influenza-like illness or even laboratory-confirmed influenza after vaccination. This does not mean the illness was vaccine induced but rather was likely due to a noninfluenza viral infection" and "exposure to influenza before immunity from the vaccine had time to develop, or the fact that the vaccine is not 100% effective."
Myth: I have an allergy to eggs.
JAMA Response: Busted! The article states that those with severe allergic reactions or anyphylaxis after exposure to eggs should avoid flu vaccine. Those with such a reaction should consult an allergist for detailed assessment. They further state:
"...recent evidence-based guidance advises that all other egg-allergic patients should receive influenza vaccination based on the rationale that the risks of not vaccinating outweigh the risks of vaccinating these individuals as long as basic precautions are followed."
Myth: I cannot get the vaccine because I am pregnant or have an underlying medical condition or because I live with an immunocompromised person.
JAMA Response: Busted! This may be the most important flu vaccine myth to bust as it directly impacts those who need the vaccine (or protection from flu) the most. Those with comorbid conditions or underlying medical problems are at most risk of complications from seasonal influenza. According to JAMA -
"...these groups have been specifically recommended for influenza vaccination because the vaccine is safe in these persons and can prevent serious morbidity and mortality." and "it is important for clinicians to recognize the individual’s desire to prevent harm in close contacts but to redirect this good intention by emphasizing the morbidity due to transmitted influenza."
Myth: I never get the flu/I am healthy.
JAMA Response: Busted! This excuse sounds a lot like Optimism Bias from the It Wont Happen to Me crowd. According to the JAMA article:
"Refusing vaccination because of a perceived low risk ignores the potential risk to close contacts, especially those who cannot get vaccinated or who will not mount a strong immune response to the vaccine and rely on herd immunity for protection."

Influenza Prevention Update, JAMA. 2013;309(9):881-882. doi:10.1001/jama.2013.453. Examining Common Arguments Against Influenza Vaccination

NYS Nurses Association Opposes Mandates for Vaccine 
No Vaccine? No Mask? No Job. 
Influenza Vaccine Overrated? 
Best Disease Prevention is Action

March 12, 2013

MJ#246 Live from the Public Health Preparedness Summit

Welcome to Mitigation Journal / We're podcasting live from the Public Health Preparedness Summit 2013 in Atlanta GA. / / Please visit and follow me on Twitter @rickrussotti for the latest / / Today Mitigation Journal joined over 1600 summit attendees as we set up the Promed podcast studio and made final preparation for live social media coverage of the event.
Check out this episode!

March 11, 2013

MJ# 245: BioTerror Lessons for Today, CDC Defines Bio Agents, DAWN Report on Synthetic Drugs

Please visit for compete show notes and features

Edition 245 Recorded on March 5, 2013

This week on Mitigation Journal:

Bio Terror: How do we measure up?

CDC Defines Bio Threats

DAWN Report on Synthetic Drugs

Mitigation Journal is:

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at

Check out this episode!

March 7, 2013

MJ#244: Are we prepared for Flu?, Act to prevent disease, and Great Flu Apps

Please visit for compete show notes and features

Edition 244 Recorded on February 25, 2013

This week on Mitigation Journal:

Flu Emergency. How prepared are we?

Personal Action for Disease Prevention

Flu Informed with 3 Great Apps

Mitigation Journal is:

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at

Check out this episode!

March 6, 2013

FDA: 2013-2014 Influenza Vaccine Composition

Quadrivalent Vaccines for Add Influenza B Protection Recommended

The strains of influenza virus to be included in next years seasonal flu vaccine have been determined. the 2013-2014 vaccine will provide options for both trivalent and quadrivalent  vaccines and include flu strains from the 2012-2013 vaccine plus addition strains. The typical flu vaccine contains three flu strains (trivalent) two Influenza A and one Influenza B. For the first time, a vaccine containing protection against four strains of influenza, a quadrivalent vaccine, will be an option.

The World Health Organization (WHO) has recommended vaccine viruses for the 2013-2014 Northern Hemisphere vaccines, and the Food and Drug Administration’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) has made recommendations for the composition of the 2013-2014 influenza vaccines to be used in the United States. Both agencies recommend that trivalent vaccines contain an A/California/7/2009-like (2009 H1N1) virus, an A(H3N2) virus antigenically like the cell-propagated, or cell-grown, virus A/Victoria/361/2011 (A/Texas/50/2012), and a B/Massachusetts/2/2012-like (B/Yamagata lineage) virus. It is recommended that quadrivalent vaccines containing an additional influenza B virus contain a B/Brisbane/60/2008-like (B/Victoria lineage) virus in addition to the viruses recommended for the trivalent vaccines. These recommendations were based on global influenza virus surveillance data related to epidemiology and antigenic characteristics, serological responses to 2012-2013 seasonal vaccines, and the availability of candidate strains and reagents.
Additional Commons Sense Influenza

 The inclusion of an additional influenza B virus ("It is recommended that quadrivalent vaccines containing an additional influenza B addition to the viruses recommended for the trivalent vaccines") appears to be a result of the 2012-2013 flu season. As the CDC notes they have characterized 1,340  influenza viruses since October, 2012. Of those influenza viruses, 105 have been H1N1 2009, 827 N3N2 influenza A and 408 influenza B. Also, according to the CDC:
"Since the start of the season, influenza A (H3N2) viruses have predominated nationally, however in recent weeks, the proportion of influenza B viruses has been increasing. During week 8, 53% of all influenza positive specimens reported were influenza B viruses."
made the final recomendation at their meeting in February, 2013. According to the FDA website, the Vaccicnes and Related Biological Products Advisory Committee "reviews and evaluates data concerning the safety, effectiveness, and appropriate use of vaccines and related biological products..."

The FDA committee recommended next years influenza vaccine should retain the current influenza A H1N1 strain and replace the influenza A H3N2 component with an A H3N2 virus. They also recommend replacement of the current influenza B strain, the B/Victoria lineage strain. 

March 5, 2013

MJ Podcast #243: Active shooters, PODs and Jobs

Please visit for compete show notes and features
Edition 243 Recorded on February 4, 2013
This week on Mitigation Journal:
DHS Active Shooter Page
Will your POD work when you need it?
No Mask? No Vaccine? No Job!
Mitigation Journal is:
Hosted by Rick Russotti, RN, Paramedic
Co Host Matt Comer, Paramedic
Please visit Mitigation Journal at

Check out this episode!

February 27, 2013

SAMHSA: Synthetic Marijuana linked to thousands of Emergency Department Visits

First report on Synthetic Marijuana use highlights dangers, healthcare impact

The Substance Abuse and mental Health Services Administration (SAMHSA) has released a study highlighting the impact of synthetic marijuana use. Drug Related Emergency Department Visits Involving Synthetic Cannabinoids appears in the December, 2012 issue of The Drug Awareness Warning Network (DAWN) Report.

Synthetic drugs are generally considered to include synthetic Bath Salts (sBS) and synthetic marijuana (sM). Both sBS and sM are sold under a variety of names and are made up of any number of chemical compositions. Both classifications of drugs have been linked to thousands of emergency department visits and hospital admissions as well as a variety of medical and psychiatric outcomes. The exact composition of synthetic cannabis and bath salts may change with manufacturer. For more on chemical composition and effects on the body, see Bath Salts: Stronger than dirt!.

According to the DAWN report, 11,406 emergency department visits involved a synthetic cannabiod product. Ages 12 to 29 years made up three quarters of those visits with an overwhelming majority of users being male.

The DAWN report also notes that:
"They [synthetic marijuana] have been reported to cause agitation, anxiety, nausea, vomiting, tachycardia, elevated blood pressure, tremor, seizures, hallucinations, paranoid behavior, and nonresponsiveness."
Polypharmacy use is often seen with synthetic bath salts, it may not be a large issue among synthetic marijuana usesers. Fifty-nine percent of those reporting to ED after synthetic marijuana use (12 to 29 age group) had no other substances involved. When polypharmacy was present, alcohol was found in 13% of cases and other pharmaceuticals used in 17%.

Synthetic drugs including bath salts and synthetic marijuana have captured the attention of public health officials, hospital staff and the media. The use of these materials continues to climb as does the awareness to the consequences. The CDC published its first article on the subject of bath salts in the May, 2011 edition of Morbidity and Mortality Weekly Report (MMWR) [Emergency Department Visits After Use of a Drug Sold as "Bath Salts"]. Since that report nearly two years ago, the use of synthetic drugs continues to rise.

A recent high profile case involving a young woman from Texas and a new CDC finding have added to the list of dangers from synthetic drugs use. A CNN news story indicates that a teenage girl from Cypress, Texas had been diagnosed with vasculitis after smoking synthetic marijuana that may have contributed to a stroke and resulting in two weeks ICU care. The CDC is reporting in its February 15, 2013 MMWR cases of unexplained acute kidney injury associatied with synthetic cannabinoid use. MMWR report indicates:
"AKI has not been reported previously in users of SCs and might be associated with 1) a previously unrecognized toxicity, 2) a contaminant or a known nephrotoxin present in a single batch of drug, or 3) a new SC compound entering the market."
Also, according to the CDC; "Synthetic cannabinoids (SCs) are psychoactive chemicals dissolved in solvent, applied to plant material, and smoked as a drug of abuse. They are sold in "head shops" and tobacco and convenience stores under labels such as "synthetic marijuana," "herbal incense," "potpourri," and "spice." Most reports of adverse events related to SCs have been neurologic, cardiovascular, or sympathomimetic."

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 4, 2012). The DAWN Report: Drug-Related Emergency Department Visits Involving Synthetic Cannabinoids. Rockville, MD.

Acute Kidney Injury Associated with Synthetic Cannabinoid Use - Multiple States, 2012. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report. February 15, 2013 / 62 (06); 93-98

Teen narrowly escapes death after smoking synthetic marijuana CNN and affiliate news reporting.

Synthetic cannabis, Wikipedia

February 26, 2013

CDC Defines the Biological Threat

CDC Categorizes Bioterrorism Agents and Diseases

Events involving naturally occurring  pathogens and weaponized biological agents share many features.  The intentional release of smallpox would make world-wide front page news and would be a devastating global public health crisis. Naturally occurring biological events are no different, albeit much less glamorous. Naturally occurring biological events can be as devastating as any intentional biological event, but we rarely consider seasonal flu as a "major event". The fact is that any biologic event can have a profound physical and psychological impact on society and culture. The 2012/2013 Influenza season is a good example of how a naturally occurring event can impact public health. Solid biologic event planning is the key to successful operation during a natural or intentional event. You need know how to write your biologic plan and should avoid common pitfalls in bio-event planning.

The Centers for Disease Control and Prevention list biological agents into categories according to potential harm and ability to be manipulated. Category A biologic agents are those pathogen (bacteria, toxins, and virus) that are rarely seen in the United States and have potential to be enhanced or engineered in order to increase the likelihood of harm. Pathogens in Category A include:
  • Anthrax
  • Botulism
  • Plague
  • Smallpox
  • Tularemia
  • Viral  hemorrhagic fevers

According to the CDC Bioterrorism Agents/Diseases page, Category A biologic agents  pose a risk to national security because they can be easily transmitted person to person, have high mortality rates/major public health impact, could cause panic and social disruption, and require special public health preparedness.

Category B pathogens are defined as those that are moderately easy to disseminate, result in moderate mobility rates and low mortality rates, and need specific enhancements of CDC diagnostic capacity and surveillance. 

Visit the CDC Bioterrorism agents/diseases page for further details on category B pathogens.

Category C pathogens are defined by the Centers for Disease Control and Prevention as those emerging pathogens that could be engineered for mass dissemination in the future. Factors in this making this determination include availability, ease of production and dissemination, and potential for high morbidity/mortality rates with major public health impact.

 Visit the CDC Bioterrorism agents/diseases page for further details on category C pathogens.

What could we do to a virus, toxin, or bacteria to enhance its effects? The first step in answering that question is to understand the target potential (hard or soft) and dissemination. Understand also that intentional biological events may utilize indirect means of dissemination. Person to person spread of disease is possible in both natural and intentional events.

Additional Media
How to write your biologic plan

Four pitfalls to avoid in biologic planning

What good plans have that bad ones don't

The Bioterrorist Next Door

Clinton Warns of Bioweapon threat

Black Death DNA

Alarm Dutch lab creates killer flu