Commonn Sense Influenza

Prevention of transmission of flu sometimes takes on a life of its own. The media hype and hysteria can easily overwhelm the facts. We need to remember that the flu virus is one of the most infectious pathogens we know of and that Type A influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza. Knowledge and common sense can keep us safe.

The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

There are several types of influenza viruses and  influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.

DHS Fires Back with Active Shooter Preparedness

The Department of Homeland Security is hosting an Active Shooter Preparedness site loaded with a variety of interactive, web-based tools and instructional aids.

Poster from DHS Active Shooter Preparedness

The Active Shooter Preparedness site offers the following resources 

• Active Shooter: What Can You Do Course
• Active Shooter Webinar
• Active Shooter Workshop Series
• Active Shooter: How to Respond Resource Materials
• Options for Consideration Active Shooter Training Video
• U.S. Secret Service (USSS) Active Shooter Related Research
• Active Shooter Resources for Law Enforcement and Trainers: Request for Access to Joint Countering Violent Extremism (CVE) Portal
 

Most of the material hosted by DHS is ready-to-use or self-study format. This site is ideal for in-service training. According to the DHS Active Shooter Preparedness site:

The Department of Homeland Security (DHS) aims to enhance preparedness through a ”whole community” approach by providing training, products, and resources to a broad range of stakeholders on issues such as active shooter awareness, incident response, and workplace violence. In many cases, there is no pattern or method to the selection of victims by an active shooter, and these situations are by their very nature are unpredictable and evolve quickly. DHS offers free courses, materials, and workshops to better prepare you to deal with an active shooter situation and to raise awareness of behaviors that represent pre-incident indicators and characteristics of active shooters.

For more, see prior MJ postings Soft Targets Attractive to Active Shooter Events and MJ Podcast #187: Inside Look at Net Talon. Also recommended: Net Talon

 

Highlights

Active Shooter: How to Respond Resource Materials provides quick and easy reading materials for businesses, offices and schools in preparing for an active shooter event. Print materials available include: active shooter booklet, active shooter poster and active shooter pocket card.

The Active Shooter Training Video gives simple and easy to follow recommendations for personal safety during a shooter event. This video is crisp and to the point and would be ideal for introducing the topic to a workforce and supporting training already in progress.

For those interested in case study, the United States Secret Service has provided several research papers related to active shooter events.

• Campus Attacks: Targeted Violence Affecting Institutions of Higher Education
• Prior Knowledge of Potential School-Based Violence: Information Students Learn May Prevent a Targeted Attack
• Assassination in the United States: An Operational Study of Recent Assassins, Attackers, and Near Lethal Approaches
• Protective Intelligence & Threat Assessment Investigations: A Guide for State and Local Law Enforcement Officials
• Threat Assessment: An Approach to Prevent Targeted Violence
• Threat Assessment: Defining an Approach for Evaluating Risk of Targeted Violence

The Best Disease Prevention is Action

More than vaccine, personal protection requires personal action

Personal protection equipment (PPE) can protect us from everything from anthrax to influenza but use of such equipment is unrealized as is the value of a good infection control program until someone gets sick.  Our personal protection is more than  a “thing” we put on, our best personal protection is our action.

No matter which side of the mandated vaccine debate you happen to be on, vaccine is a top preventive measure. Vaccines are proven to be safe and effective. Not only do they provide the individual with protection from specific diseases, vaccination also provides herd immunity to a given population. A community that is vaccinated and protected against disease also protects those who have not developed immunity. Herd immunity is vital to those with compromised immune systems and even to some healthy groups such as schoolchildren.

CDC photo

Pharmacological measures such as vaccine are fantastic at preventing disease. However, the downfall is that they are not always readily available and pharmaceutical shortages have become frequent. Deployment of vaccine and oral medications can be challenging. It's important to understand the role of non-pharmaceutical interventions in disease spread control. The non- pharmaceutical interventions include; hand washing, respiratory etiquette, appropriate social isolation.

Hand hygiene, the simple act of washing your hands, is rated as the number one means for preventing the spread of disease. The use of warm water and soap for washing hands for between 15 and 30 seconds is a major component in effectively stopping disease spread in any population.

Respiratory etiquette means covering your cough and your sneeze and limiting other secretions you discharge from your mouth or nose. Covering your cough and sneeze is a mainstay of respiratory etiquette and helps prevent droplet transmission of disease. Droplet transmission is a major mode of transmission for Type A influenza. Don't be afraid to put a mask on yourself or patients exhibiting signs of influenza-like illness. Placing a mask on the patient goes a long way to containing the source of the droplets and respiratory secretions at the source and placing a mask on you significantly decreases your intake potential of those droplets and respiratory secretions. The Centers for Disease Control and Prevention noted that standard surgical masks were sufficient to prevent droplet transmission in the setting of many respiratory illnesses including Type A influenza.

Social distancing means staying home when you're sick and includes staying out of public areas when you're ill. It does us no good to have someone stay home from work and/or school only to go to the local shopping mall or otherwise be out in public. I realize this is not a popular topic with many employers but the fact remains that people who are ill with gastrointestinal problems or respiratory illness should not be in a position to spread that disease whenever possible.

Simply wiping down flat surfaces in your work environment will go a long way to preventing your exposure to disease and the spread of many illnesses. Many commercial products are available for this purpose and a quick wipe on telephones and computer keyboards will help prevent disease spread.

Flu Emergency. How prepared are we?

NYS, Boston declare public health emergency as widespread flu remains "intense"

New York State joined Boston, MA by declaring a public health emergency as a result of seasonal influenza. Boston Mayor Thomas Menino made the emergency declaration on January 9, 2013, New York followed with its own emergency declaration at the direction Governor Cuomo on January 12.

The NYS declaration includes an Executive Order that allows pharmacists to administer flu vaccination to people six-months and older. Governor Cuomo strongly urged all New Yorkers to get a flu shot and directed the NYS Health Department to "to marshal all needed resources to address this public health emergency and remove all barriers to ensure that all New Yorkers - children and adults alike - have access to critically needed flu vaccines." Mayor Menino included statements urging people to remain home when sick in addition to getting a flu vaccine. Mayor Menino further stated that "This is not only a health concern, but also an economic concern for families..."

Could we see flu coming?
The public health emergencies in Boston and New York State were issued during week 2 (January) 2013 while influenza had been identified as "high" or "widespread" in some states since week 46 (November) 2012. According to the Centers for Disease Control and Prevention,  Mississippi was experiencing high or widespread flu activity in November (week 46) and by week 47, flu was identified as high or widespread in Tennessee, Alabama, Louisiana, and Texas. By week 52 there were 30 states, including New York and Boston, that made the list of states experiencing high or widespread flu.

By comparison, Google Flu Trends identified NY and Massachusetts as having "high" flu activity on December 12, 2012. Flu activity was identified as "intense" in  NY and in Boston on December 23, 2012.

Both the NY and Boston public health officials encourage vaccination and have opened flu vaccine clinics and since the declarations of emergencies, mainstream media attention has expanded. Looking back, we haven't seen the flu awareness campaign as we did in response to the 2009 Swine flu situation.

Are public health and local health care systems prepared to deal with unexpected biologic situations? The answer is not reassuring.  According to Trust for Americas Health 10th annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report, 35 states and Washington, D.C. scored a six or lower on 10 key indicators of public health preparedness. See also States Lagging in Emergency Preparedness by Healthday News.

While the 2012/2013 Flu Season continues, the question on the minds of many is: why is flu so bad this year?  While this question will be studied and debated, an easy answer may be that people simply did not get vaccinated and were unprepared for an early start to the flu season. The CDC states that its too early to define peak of flu season. However, the Washington Post is reporting that over 60% of Americans have not been vaccinated as of November 2012. Meanwhile, an interesting side story is developing...despite low vaccination rates, retail and healthcare systems are reporting dwindling vaccine supply. If vaccine supply is drying up when 60% of the population didn't get the shot, how ready were we in the first place?

No vaccine, no mask? No job

Healthcare providers fired over flu vaccine mandate

ABC is reporting the firing of eight hospital Indiana hospital employees, three of them nurses, for failure to comply with influenza vaccination program. USA Today is running a story about a registered nurse who has been fired for not wearing a mask after declining flu vaccine. These reports indicate a growing trend in healthcare: comply with flu vaccine mandates or risk loosing your job.

Mandate the shot or not? We may have an answer to that question.
There are indications that mandated participation in flu vaccine programs have become normal. Notice the term flu vaccination program, meaning that there is more than just vaccine involved. Flu programs typically give the healthcare employee a choice to be vaccinated or, decline the vaccine and wear a mask while at work. Having reviewed a number of policies, we've noticed a growing number of healthcare agencies (including non-hospital facilities) have begun to require "participation" in a flu program. The meaning of the word "participation" changes frequently between facilities and can indicate a vaccine requirement, receipt of vaccine or signed declination, or vaccine/decline and wear a mask.

As noted in the USA Today piece, some healthcare providers feel stigmatized by being requiered to wear a mask. Some may consider their privacy has been eroded as they feel compelled to explain why they have to wear a mask.

No shelter for you! In case of emergency, go some place else

Identifying where not to shelter is becoming popular. 

The reason should be no surprise.

People may evacuate or shelter in place during a disaster situation. Evacuees often find themselves seeking refuge in an established shelter of one type or another. Shelters are typically preplanned and established within the framework of a disaster plan that includes a system of public information. Those who don't evacuate to a shelter, didn't receive shelter information, or are unfamiliar with their current location, may find themselves seeking safe haven at locations of perceived safety. Public locations such as schools and libraries may be thought of as "places to go" during a crisis. Similarly, other installations may represent a location of service or place to go for help. Fire stations and healthcare facilities are often understood to be locations were the public can go for help in times of crisis. But are these locations suitable and prepared to become shelters during disaster or crisis situations?


What happens when public expectation is not met?

Photo credit: Michael Ehrman

We discussed this topic in the aftermath of hurricane Katrina and the Tenet health decision. Tenet Health, owners of  a New Orleans hospital, were sued by the people who sought shelter at the hospital during and after hurricane Katrina. The suit alleged that the hospital was not prepared to deal with the disaster situation and provide for the needs of those who sought shelter at the hospital. It'd be important to to note that those who came to the hospital during Katrina were not patients. Since the public had never been told not to shelter there, it was a reasonable expectation that the hospital was a shelter and, therefore, liable. At the time of publication, we called the Tenet decision the biggest healthcare preparedness ruling that no one is talking about. While the monetary impact of the suit may not have been impressive, the implications of the outcome were president setting. More and more we're seeing signs posted telling the public that this place "is not a shelter". It seems a little creepy to find a sign on the door of your local school or hospital or Moose Lodge reminding you to go someplace else in the event of an emergency.

Michael Ehrman, retired emergency manager and long time MJ follower, sent in the above photo taken at a school in his area. What locations in your ares might be considered to be a safe haven or shelter by the public? Is your agency prepared to take in refugees during a disaster? Finally, are you aware of public perceptions concerning sheltering in your area? In the wake of natural disasters like Hurricane Katrina and more recently, Super Storm Sandy, this would be a good time to explore those questions and include the proper information in your public education and preparedness efforts.

Related posts:
Forward thinking: Bringing the Katrina Healthcare Decision Home
Message from Katrina: Hospitals, be ready

Thirteen years after Columbine, what have we learned about school shootings?

 Are we any further ahead at preventing school shootings today than we were in 1999?

Our prayers are with the victims, survivors, and rescuers...

Newtown CT joined the ranks of the those communities devistated by a school shooting event  on December 14, 2012 when a 20-year-old carries out shooting event at an elementary school. The lone attacker is reportedly to have fatally shot his mother as she slept, stealing two pistols and one rifle, prior to going to the Sandy Hook Elementary School.


According to media reports, he forced entry, easily defeating school security systems, by shooting out a window and proceeded to shoot two school administrative staff and children in a first grade class. All the children were between six and seven-years-old. Authorities are reporting a total of 20 children and 7 adults murdered.

It’s sad to say it and hard to hear it. It's even harder to understand. Sadly, it is a topic we've visited many times in this blog and podcast. We've discussed active shooter events and civilian soft targets as much as we've talked about chemical and biological weapons.

We most recently spoke on this topic after the Aurora Colorado movie theater shootings. Our opinions are the same today as they were after that tragedy. The liberal left and conservative right have it all wrong when it comes to finding causes and preventing similar active shooter events. (listen to MJ 238 Aurora CO Movie Shootings - Why we’ve got it all wrong) Stricter gun control will not solve this issue. More people with guns will not prevent future attacks.

Commonalities in active shooter events

• Civilian soft target remain the location of choice. Hospitals also remain at risk with once such active shooter event taking place almost simultaneously at a hospital in Birmingham, Alabama. The Sandy Hook School did have some level of security but it was circumvented. Why was it so easy to breach?

• Gunshot wounds inflicted at close range. The rate of fire and physical confines produce a rapid attack with high fatality rate. There is little opportunity for protective action because of the speed of the event (possibly also because of the age of majority of the victims and the situation they are in).

• Ancillary event - some other related occurrence, prior to main event, that would herald the main attack - shooting his mother, in this case. Use of explosives in other situations to draw attention away form the intended target or as a secondary event to create further casualties.

• History - in many of the cases the alleged perpetrator has had a mental illness diagnosis

Shooting events at high profile soft targets are difficult to prevent and have significant, long-lasting effects. They also have numerous commonalities that can be used to aid planning efforts.

"Locations of critical infrastructure such as hospitals, will need to be protected from attack as will other civilian locations. Hotels, coffee shops, and shopping centers lack the deterrents necessary to prevent attacks. The psychological impact of an attack on any of these soft targets will nearly as devastating as the loss of life."

How ready are we for active shooter events? A question asked too many times over the last seven years.

Active shooter situation may be the most difficult to domestic terrorism situation to deal with. Many of the active shooter situations take place in a work environment or in a public venue with little or no warning. Firearms of all varieties have been noted in active shooter case studies from the United States. According to the Department of Homeland Security:

"An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims..."

These events are unpredictable in nature and timing, but the outcomes and be generically predicted.  If we follow the basic principles of Life Safety, Incident Stabilization, and Property Conservation, we'll be able to keep personnel safety and response priorities in balance.

Key to remember that soft targets continue to be chosen by active shooters and present significant threats. Preplanning and inter-agency cooperation is paramount to reducing the loss of life.

Active shooter situations in a soft target location - a mall, school, hospital/health care environment, or sporting events are disastrous. The answer may be someplace between the left and right...

Screen savers and call bells offer hand hygiene reminders

Two studies look at infection control prompts

Non-pharmaceutical interventions for preventing and controlling infection often take a back seat to vaccination programs. This is especially true during flu season. While vaccination is a vital cornerstone of preventing disease spread, limited access to vaccine and reluctance of staff to get vaccinated can cripple your vaccination program. Non-pharmaceutical interventions are easily taught and integrated within your daily routine. The typical non-pharmaceutical interventions include hand hygiene, respiratory etiquette, and appropriate social distancing, and should be readily available at all times. Hand hygiene is historically considered the most important of these interventions for controlling the spread of disease.

How do we increase voluntary compliance with such an important intervention?

Two studies published in the American Journal of Infection Control looked specifically at ways to improve hand hygiene compliance.

Sample screen saver message

Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior.
Can your screen saver change hand hygiene habits? Apparently so, according to the authors of this study. They concluded that by placing gain-framed messages highlighting the benefits of hand hygiene on computer screen savers that compliance was increased.

Evidenced based or not, this seems like a good idea. Screen savers are a venue for delivering a message to your target audience. Rather than displaying some random graphic or blank screen, use the screen saver to reinforce important information on relevant topics.

Positive deviance: Using a nurse call system to evaluate hand hygiene practices evaluated the use of staff alerting system (referred to in the study as a nurse call system) to improve compliance with hand hygiene when entering and leaving a patient care area.
This study monitored the use of alcohol based hand sanitizers using electronic counters. They found that the use of hand sanitizer increased after linking the call system and sanitizer use data - using the call system as a reminder to use hand sanitizer - with higher utilization rates remaining for 2 years. They also noted a trend toward lower device-related infections, including urinary catheter-associated infections.

The study concluded: “The PD [positive deviance] approach to hand hygiene produced increased compliance, as measured by increased consumption of alcohol hand sanitizer, an improved ratio of alcohol hand rub uses to nurse visits, and a reduced rate of device-related infections, with results sustained over 2 years.”

Federal Medical Stations

Providing special needs care in less than 48 hours

What do you get when you add 24 hours and 40,000 square feet of
 medical equipment? You get a Federal Medical Station or FMS.

The FMS is part of the Centers for Disease Control and Preventions Strategic National Stockpile program and is designed to fill a gap that exists between disaster shelters and temporary hospitals. According to the CDC Works For You 24/7 Blog, Federal Medical Stations are non-emergency medical installations used during disaster situations to care for people with special medical needs and  chronic health conditions. They also include services for those with mental health issues. The CDC notes that FMS can be operational within 48 hours and their operational period is open-ended.

 It’s vitally important that basic medical needs are met during disaster situations and meeting those needs becomes an extraordinary challenge when hospitals are compromised or destroyed. While the FMS’s are not hospitals, they provide an invaluable resource and example for the disaster and emergency management community. Federal Medical Stations become a force multiplier by providing routine medical care for those with routine medical conditions, including the provision of routine medications, by sheltering those people, and keeping them out of an already stressed healthcare system during disaster. The FMS has the extra dimension of meeting mental health needs.

The FMS system relies on the asset management and logistics of the Strategic National Stockpile (SNS) for deployment. The SNS is a combination of warehoused supplies and vendor managed inventories of critical medications and equipment that can be shipped in bulk to areas in need. Each city or jurisdiction should have a plan in place (and tested) to receive assets from the SNS.

Photo Credit: CDC - Federal Medical Station

Creation of civilian, locally-based medical stations (in addition to disaster shelters) would be a major improvement to local and regional preparedness. Systems like the FMS should be reproduced by local jurisdictions to meet the expected needs of a community during crisis. We’re not suggesting reinvention of the entire system or duplication of existing programs. A smaller scale version of the FMS that is readily available to local governments with minimal lag-time would improve local response to crisis and disaster situations.

Influenza Vaccine Overrated?

Study reignites vaccine, antiviral controversy

Debate to mandate the (flu) shot or not for healthcare workers in the United States continues as additional data suggests seasonal influenza vaccine may not be all its cracked up to be.

Canadian healthcare workers are getting two differing opinions on mandated flu vaccine according to a report published by Public Health Ontario/Canadian Medical Association. Some Canadian researches continue to endorse the mandated flu vaccine policy for healthcare workers citing an 86% effectiveness when the vaccine is well matched to circulating virus. Researchers also claim that flu vaccination of healthcare workers in long-term care facilities (LTCF) may decrease resident flu mortality by 5-20%. The Canadian report, published in CIDRAP, the Public Health Ontario editorial indicates that flu strains that may produce Guillian-Barre Syndrome (GBS) are avoided in vaccine production. Its not clear how, exactly, GBS causing strains of influenza are kept out of vaccine production.

In the United States many healthcare systems and some sates are mandating participation in a flu vaccination program, according to the Centers for Disease Control and Prevention (CDC). “Participation” may include mandated vaccine, vaccine or singing a declination form, or mandated to don a mask.

Adding to the vaccine mandate controversy is a report from the Center for Infectious Disease Research and Policy at the University of Minnesota. This report proposes that seasonal influenza vaccine offers little protection to otherwise healthy young and middle-age individuals. They also believe that the benefit may be even less for those greater than 65 years of age. The New York Times recently printed an editorial on this topic.

While the vaccine debate continues, use of the antiviral drug Tamiflu is drawing concern. You may recall that Tamiflu (oseltamivir), and a class of medications known as Neuraminidase (NA) inhibitors, has been used to treat influenza. These medications are also on the CDC list for the treatment of seasonal influenza. However, reports have suggested that influenza has become (or is becoming) resistant to Tamiflu. One report from the CDC (9 Jan 09) states early data from a limited number of states indicating that a high proportion of influenza A (H1N1) viruses are resistant to the influenza antiviral medication oseltamivir (Tamiflu®). An article in Medscape highlights Tamiflu concerns brought on by researchers in the British Medical Journal. If you'd like to read in scientific detail about Tamiflu resistance, check out this post from the Virology Blog.

What’s the answer?
We have to remember that season influenza A continues to change every year. Some years the vaccine is well matched to the circulating strain, while other years it may not be. Its important to have an understanding of the terminology, types and impact of influenza (see 3 things to know about seasonal flu MJ 11/10). You should also brush up on the non-pharmaceutical interventions of hand hygiene, respiratory etiquette, and (appropriate) social distancing.

Selling the Preparedness Mindset

A recent comment got my attention; it should get yours, too. 

 

Aaron Marks posted a comment in response to No surprises in Sandy's wake that will hit home for many in emergency management as we struggle to make a successful pitch for preparedness. Although his comment specific to business and commercial preparedness, I think the spirit of the post can be applied to the public/civilian.

Aaron Marks writes:


For most of the people who follow MJ you're preaching to the choir here. The million dollar question is how do we fix it? 

I spend most of my time these days trying to convince business owners to invest in preparedness - with extremely limited success. Most of the decision-makers and so-called leaders out there just don't want to acknowledge that there is an issue because once they acknowledge it there may be liability associated with failing to do something about it. How do we convince 'the massess' that preparedness is an INVESTMENT and not a cost?

Why is preparedness such a hard topic to sell?

We should put the word sell in parenthesis. We can be selling the idea of preparedness or selling a product or service related to preparedness, or both. In there may be the problem. We’re trying to convince people in the community, business owners, public officials, or civilians that a certain action needs to be taken when most of those we’re selling to haven’t ever experienced any kind of serious event. And they don’t think they ever will. Many individuals and business owners have used phrases like “that’s what I have insurance for” when rationalizing their lack of preparedness.

What we’re “selling” is the preparedness mindset.

Persuading anyone to buy or do something they don’t think they need is an extraordinary uphill trek. After terrorist attacks and natural disasters woke us from the slumber of complacency, we’re eager to hit the snooze alarm and get back to business as usual. Or at least back to business of the new normal...whatever that may be.

The sad and unrelenting fact is that in the face terrorism, pandemics, and devastating natural disasters, many continue to believe that “its not going to happen to me.” In June, 2008, we wrote about this in the posting In search of preparedness in America. That post generated considerable discussion. As I wrote then “governments seem to have lacked the stamina to keep up with preparedness...” and I continue to believe that today. The response to and recovery from Hurricane Sandy continue to make my point here in 2012. You’d think that with Sandy fresh in our minds that preparedness would sell itself.

The liability of acknowledgment.

We also described an interesting, yet disturbing trend in October, 2010 (see Cassandra Paradox)  - We’ll call it the Theory of Successful Blame.

“Emergency planners, managers, and responders are responsible for actions taken (or not) before, during, and after disaster situations. While emergency planners, managers and responder should be held accountable for their performance during crisis or the performance of their planning or training preparedness, it seems that the need to have a scapegoat overpowers the reality that many of the disaster situations are fluid and may not evolve as predicted. Unreasonable expectations need to hold someone accountable when an unpredictable situation goes astray.”

The point is that acknowledged or not, someone is going to be held accountable. The preparedness liability exists and will remain on someones shoulders. A review of of the Hurricane Katrina/Tenent Health decision is a good reminder of this.

How do we convince the masses?

What we should be doing is informing and keeping it simple. Informing that preparedness is a cost effective in financial and life safety terms. We can provide information and rationale that may be helpful in bringing awareness to the forefront.

E. L. Quarantelli (University of Delaware Disaster Research Center) is my most cherished resource on emergency management teaching. In his paper More and Worse Disasters in the Future (1991); Quarantelli provides us with decent talking points, if not ammunition, to get people thinking about their need to embrace preparedness (click here for PDF).

For example, Quarantelli suggests that:

• Natural disasters will increasingly generate technological disasters
• Old kinds of natural disaster agents will simply have more hit and along some lines more vulnerable populations to impact
• There are technological advances that add complexity to old threats
• Many of the future threats or risks have high catastrophic potentials by way of the casualties or kinds of injuries they may generate
• Some of the future disasters while occasioning relatively few casualties or physical damage will be very economically costly or socially disruptive

Perhaps the most poignant statement in his paper is this:

Better disaster planning can mitigate the impact of these future kinds of disaster but will not prevent their occurrence.

 On a more individual note, you might consider advocating a preparedness program that focuses on the home and the family. Doing as much as possible towards making individuals and family groups will go a long way in making communities as a whole more resilient in times of crisis.

Healthcare realities you can't ignore...anymore

Healthcare facilities: part domestic preparedness and part public safety.

Simply meeting building and fire codes do not equate to resiliency and checking off the Joint Commission preparedness requirements does not mean you're prepared.

Healthcare facilities will need to function before, during and after an event. The goal is to maintain operation as independently as possible for any foreseeable threat in your hazard vulnerability assessment. Those that can’t do that will need to evacuate or move their operations to another facility. Sheltering in place or evacuation are clearly realities each facility must face. They’re big decisions. Both options require substantial pre-planning and functionality between facilities.

Sheltering in place.

Deciding to remain in your facility during an event (sheltering in place) is not an easy choice. On the surface it may appear that staying put is a simple thing to do but, sheltering in place (making the decision not to evacuate ahead of a threat) comes with its own set of risks. Hopefully you have a robust 96-hour plan that you’ve trained on and tested. Hopefully it’ll see you through the situation. Even with solid planing, we have to has how long can you remain in your facility without outside support? Of course you have memorandums of understanding (MOU) with a variety of vendors as required by the Joint Commission. So, you're set. Right? The interesting thing about MOU's is that your vendor has an MOU with  all their clients, not just you. Will they be able to deliver their goods or services when demand is maxed out by all clients? Consider that infrastructure damage, such as damage to roads and bridges, will prevent shipments from making it to your supplier and further, prevent them from making delivery to you.

Part of sheltering in place is having a series of decision points or triggers that will tell you when its time to change tactics. Trigger events are situations that cause you reconsider your current position and may indicate the need for evacuation.

If you haven’t got a functional 96-hour plan or if your plans are questionable, you may want to consider evacuation ahead of a threat if possible.

Evacuation.

Evacuation of a healthcare facility is a major event. There are risks to go along with the benefits. Before you give the order to begin the evacuation process you need to consider the following:

• Will this be a full or partial evacuation?

• What is the available capacity of receiving facilities? Can they absorb the number of patients we wish to send?

• Have the receiving facilities damaged by the current event or are they in danger of being evacuated themselves?

• What resources are available to move people and equipment?

• What are the risks of going out into the environment?

Keep in mind that surge capacity may exist before an event, but not during or after. Evacuations must be done early or pre-event whenever possible. Ideally, your evacuation plans and triggers have been shared and tested with other facilities.

Vermont EMS Conference

Vermont EMS Conference, Burlington VT

I'd like to extend a special thanks to conference attendees and organizers, especially All Clear Emergency Management, for inviting me to present at the Vermont EMS Con!

I truly enjoy public speaking and presenting at emergency service conferences and in 2012 I've been invited to conferences from Alaska to Vermont and many places in between. Speaking at conferences and meeting other emergency management and EMS professionals always excites me. I often return home energized from meeting proactive people and with a head full of new ideas.  The sessions on Special Needs in Crisis and School Bus Rescue were very well attended with a considerable amount of audience participation. Just the way I like it.

Travel to the Vermont conference had an added, albeit challenging, twist...hurricane Sandy. When I left home in the afternoon of October 28 predictions for Sandy's landfall were being confirmed. I figured I'd bump into this category 1 storm at some point.

On the NYS Thruway Eastbound

It wasn't long before I was driving along side convoys of utility trucks with license plates from the Great Lakes area to the Gulf Coast.

The road conditions pictured at left are actually from a local weather system and not from Sandy...I'd meet up with her later.

Welcome to VT

The approach to Vermont. Leaving New York and entering Vermont is punctuated by crossing Lake Champlain via this massive bridge.

Note that, while overcast, the weather is nothing less than cooperative at this point. From here its another hour into Burlington. A six-hour drive from Rochester, NY.

Sums up my feeling toward air travel in general

After getting checked in and settled I took a recon walk to check out the conference area and rooms.

Along the way I found a pumpkin carving display in the hotel lobby. The carvings had a obvious EMS theme.

The Scare Care pumpkin...precisely summarizes my feelings on air travel.

A bit less inventive but obligatory Star of Life pumpkin.

As I said, an EMS theme. When I checked back the next morning there was something missing.

Take note of the topic listed just below mine. I was impressed with the number of emergency management/preparedness topics at this conference. Rory Putnam is the EMS Clinical coordinator at Northern Essex Community College. He hit a home run with his talk on EMS preparedness. Rory and I had a few minutes to talk during lunch. I appreciated his insights on EMS and disaster situations and hope to have him on Mitigation Journal podcast soon.

No laptop for me.  This was the second conference I worked entirely from my iPad and controlled with the iPhone. I use Keynote (Mac version of PPT) on my iPad and Keynote Remote for iPhone. Connected via Bluetooth I can see current slide, preview next slide and view speaker notes on the phone.

The iPad/iPhone-Keynote setup is simple to use and user-friendly at the podium or walking around the room. 

The Special Needs topics have been growing in popularity. This session focused on preparedness, including a how-to on conducting a hazard vulnerability assessment.

As with all my presentations, I customized the content with Vermont-specific statistics to add relevance to the message. 

A not-so-ominous to the South approaching the Vermont/NY state line at 5pm October 29, 2012. 

Welcome to NY...just ahead of Sandy. I did feel a sense of accomplishment knowing I'd filled my gas tank in Vermont and paid a buck-fifty less per gallon than I would in NY.

This is also the point in the trip when the weather started to change. My drive through the Southeastern Adirondacks was a zig-zag of downed trees and wind-driven rain. It was also darker than I've ever known it to be. No pictures...but made it home safe.

Thanks, again to the organizers of the VT EMS Con. I had a wonderful, albeit short, visit. See you next year.

Evacuation: Should I Stay or Should I Go?

Not an easy decision but its not a trick question

When to order an evacuation is no easy decision. It never has been. Its also not a trick question and you have plenty of time to study for the test.

Controversy surrounding evacuation of civilian populations and healthcare facilities has bubbled for many years without clear resolution. And for good reason - there is no "one size fits all" approach to the problem.

The hard taught lessons from Katrina, Joplin, and Tokyo showed up on another disaster test. The final grade isn't in, but its not looking good. In the aftermath of hurricane Sandy, as the public and public health struggle to regain a foot hold on normalcy, we're wondering why problems of power, evacuation, sheltering, and fuel are persisting.

Here's a review of evacuation considerations from Mitigation Journal edition #41 - Should I Stay or Should I Go? Points to consider when deciding to shelter in place or Evacuate - overviews issues for individuals, families, and healthcare facilities to consider when making this critical decision.

MJ Podcast #41published October, 2007*
 

*Note: original audio from 2007 and has not been edited. It may contain outdated material.

Decontamination at health care facilities

Hurricane Sandy a setup for success

Pre landfall actions minimize loss of life

A major storm known as hurricane Sandy barrels up East Coast and is predicted to collide with two other storm systems to form “a perfect storm”. As Sandy reaches the conversion point with these two other storms, it becomes clear that it will make landfall in the most populated areas of the nation. Coastal areas of the Northeast including Philadelphia, New York City and New Jersey are in the direct path of the predicted landfall.

The aftermath of the storm is nothing short of devastation. The damage done in New York City alone rivals that of September 11, 2001. Yet the loss of life remains minimal because of actions taken by local government officials prior to the storm making landfall.

Good decisions and actions were made possible in the pre-storm phase because of solid predictive evidence and what I’ll call “techno-intel” - the ability to rely on multiple pieces of technology to provide situational awareness. Local government officials including Mayor Bloomberg from New York City and Mayor Christie from New Jersey were on the same page and delivered a consistent message to the public. Unlike other natural disaster situations, these officials listened to the predictions and took appropriate, measured action in the pre-landfall phase that included emergency declarations and realistic public information. These pre-landfall declarations allowed access to resources to be pre-positioned ahead of the storm, activation of response teams, and access to funding streams. These actions will be proven to have saved lives.

Perhaps one of the most important pre-landfall actions of the hurricane Sandy event was a consistent nature of the warnings given by the local government officials. I believe that because these messages were consistent, clear (blunt), and described the actions to be taken by the population, the loss of life has been kept to minimum.

Another key factor in the storm response is the protection of infrastructure. Mayor Bloomberg ordered mass transit shutdown well ahead of the landfall hurricane Sandy. This action reinforced to the public evacuation orders must be followed within a given period of time and allowed for vehicles such as buses and subway trains to be sheltered and serviced. Getting mass transportation vehicles to shelters where they could be prepared for a return to service after the storm would allow them to be used in the recovery phase.

As I write this the recovery from hurricane Sandy is just beginning. There has been loss of life and the physical damage has yet to be fully assessed.

Local government officials have listened to the experts and taken an all hazards approach to preparedness with good planning and execution. As of today it seems the residual impact from this “super storm” will be contained to an absolute minimum.

MJ 240: Why do we have to pay for CPR training? Should flu vaccine be mandated for health care providers?

Edition 240 October 21, 2012

This week on Mitigation Journal:

Why do we have to pay for citizen CPR training?

Mandate the shot or not?

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at www.mitigationjournal.org

Check out this episode!

Mandate the shot or not?

Debate over mandated vaccination continues

Voice your opinion, take our informal poll located in the right sidebar. 

What rights do I forfeit to work in health care?

Do health care workers have a "duty" to be vaccinated against seasonal flu? 
The answer to that question is "yes" ccording to the New York Times  who published an article suggesting that health care workers "should know better and anyone". The article cites a recent survey conducted by the CDC and claims that while doctors and nurses are "getting the message" about flu vaccination, mid-level providers and other health staff are not. They goe on to state that "Vaccinations of health care personnel should be required, either by state laws or by employers" and further notes that compliance is 95% when flu vaccination is mandated by an employer.

Should health care employers "mandate" workers to be vaccinated?
According to an opinion published in Medscape, Why Hospital Workers Should Be Forced To Get Flu Shots, by Arthur L. Caplan, PhD, the answer to the question of mandated flu vaccine is clearly affirmative. Correctly noting that seasonal influenza impacts high risk groups such as extremes of age, immune-compromised, and those living in long term care facilities, he states -

"Ethically, your first obligation is to do no harm. If you are there to do no harm and that is your primary obligation, then you cannot put your personal choice or your personal reluctance to get that shot above doing harm. And you are likely to do harm to others if you do not get that shot."

He goes on to say -

"...every code of ethics that I have seen -- medical, nursing, and others -- says that we put patient interests first. It is not in the patient's interest for you to not get a flu shot. If we are putting patient interests first, if that rhetoric is what we believe in our codes of ethics, what we teach in our medical and nursing schools, there is no excuse for not getting a flu shot."

Can a seasonal influenza vaccine be mandated as a "condition of employment" be enforced?
New York State attempted to mandate vaccine during the 2009 H1N1pandemic for all health care workers. The vaccine mandate was made by then Governor David Patterson despite a lack of vaccine, a sustainable mass vaccination program or a declaration of public health emergency. There was also considerable debate as to who, exactly, was considered health care workers. Most studies overlook non staff health care professionals such as EMS providers, firefigters and other public safety responders who contact the public in and out of the hospital setting.

Should we include environmental/support service staff or provide for blanket inclusion of anyone who would walk into a hospital?

Not everyone agrees with vaccine mandates.
New York State Nurses Association vigorously opposed the vaccine mandate in 2009. (See NYS Nurses Opposes Mandates for Vaccine) In June, 2010, the Centers for Disease Control and Prevention issued a statement saying they would not endorse mandated flu vaccines for health care workers for that year. The announcement by the CDC was a reversal from their controversial stance in 2009 that anyone working in a hospital must be vaccinated against the H1N1 Swine Flu. The full text of the CDC's statement can be found here.

Can vaccination be mandated without a formal declaration of a public health emergency?
You may recall that the United States Army (2003) had to resort to disciplinary action against soldiers who refused mandated Anthrax vaccine in preparation for deployment to a area with a credible Anthrax threat. The Army Anthrax vaccination program was eventually halted by federal court in 2006.  

If the Army cannot mandate vaccine soldiers in the presence of a credible threat, can anyone mandate civilian health care workers to be vaccinated in the absence of public health emergency?

If health care providers are mandated to be vaccinated today, what will be mandated tomorrow? 
What do the experts say? The opinion of the CDC is echoed by other infectious disease. The Society for Health care Epidemiology of America (SHEA) has released a position paper endorsing mandated vaccination with endorsement from the Infectious Disease Society of America. According to the SHEA media release:

"...influenza vaccination of health care personnel [is] a core patient safety practice that should be a condition of both initial and continued employment in health care facilities."

More than one controversy in this situation.
There is no doubt that flu vaccination will prevent the spread of flu, seasonal or otherwise. Public health history reminds us that viruses like Smallpox can be eradicated by a staunch vaccination effort. But can we expect to vanquish Type A influenza by mandating seasonal flu vaccination?

Don't listen to me! Recording without consent in healthcare

Is recording without consent a real concern?

 Are you being recorded without consent? Imagine your reaction when you discover a patient or family member has been secretly recording your interactions with them. A MJ follower recently had such a discovery and was (not surprisingly) concerned...

T.U. is an RN from Central New York and writes:
"...I was appalled to find that a patient had coordinated with family to record interactions with their health providers. A family member recorded (our voices) on a smartphone by simply leaving it on the table while another filmed encounters on another phone. All this without the nurses knowing about it. We found out about it only when a recording was accidentally played while a housekeeper was cleaning the room."

 Discovering you've been recorded without your knowledge or permission stirs emotion and puts us on the defensive. Why would a patient or family want to record our actions? Are they upset about our care or waiting to catch proof of a mistake? Perhaps the family just wants to have a record of the conversation to remind themselves of our instructions. Those who provide care outside the hospital environment may be more aware of the potential for being recorded. EMS providers and firefighters frequently provide care in public locations and are always in a position to be recorded by bystanders. Radio transmissions are also recorded and often are played on various websites.

Recording devices have come along way

While there are many reasons why someone would record (audio/video) we often jump to the negative conclusion...a reasonable defense mechanism when were recorded without our permission or knowledge. If nothing else, finding out you've been recorded without your knowledge or permission, taints the environment of care.

The ever increasing popularity of smartphones and other portable devices makes covert recording an almost certain eventuality.  And here in New York, its perfectly legal to do. Okay, disclaimer time - I'm not a lawyer, I have no background in legal matters and Mitigation Journal is not (emphasis not) a blog for legal opinion or recommendation.With that in mind, lets move on...

Recording your healthcare providers conversation without consent is perfectly legal in New York and many other states. There are only 12 states with "all-party" legislation that requires consent for recording. That being said, I think its important to take a calm approach to the situation.
 
Upsetting as the situation may be, recordings made covertly (or overtly, for that matter) may not be of benefit during legal proceedings. While medical records are seldom questioned for authenticity, recordings made by patients and families may be. They can be edited, tampered with and it may be difficult to prove exactly who is talking on the recording.

Here are a few articles that I found helpful:

Be Careful Who and What You Are Recording

When Patients Audio Record Without Your Consent

Family may use secret recording in medical negligence suit

Secretly recording conversations with doctors... Is it legal?

 

MJ Podcast 239 West Nile Virus

Special joint podcast episode with the MedicCast and This Week in Virology

What is it about West Nile virus that has everybody talking? Do the number of infections and deaths from WNV this year make sense? Is this hype or example of emerging infectious disease threats to come?


Join me, Jamie Davis (MedicCast/Nursing Show/Insights in Nursing), Dr. Vincent Racaniello and Dr. Dickson Despommier (This Week in Virology) for everything you wanted to know about West Nile virus and more!


In this episode:

• Where did WNV come from? 
• How did WNV get to the United States? 
• What's driving the 2012 epidemic and is this really the worst ever? 
• How can we apply current knowlege to other emerging infectious diseases?

See also WNV Hype or Threat (Mitigation Journal 8/2012)

Subscription links (iTunes)
Mitigation Journal
This Week in Virology
MedicCast

Click player below to listen now or direct download here

http://traffic.libsyn.com/mitigationjournal/MJ_WNV_with_MC_TWiV.mp3

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Schools fail bio preparednes 101

U.S. Schools receive a failing grade in pandemics

If a biological agent targeted schools and children would try to prevent it?

Despite the global awareness of biological terrorism, emerging infectious diseases and the impact of diseases such as influenza, a majority of schools in the United States remain unprepared for a biological event. Only 40 percent of schools have updated their infection control/pandemic preparedness according to a study published in the American Journal of Infection Control. The study, conducted by Saint Louis University suggests that many schools in the United States are not prepared for a biological event despite experiences from the 2009 H1N1 pandemic event. As the threat from naturally occurring infectious disease and intentional acts of bioterrorism grow, the importance of community preparedness will increased. We know that one of the keys to a successful outcome in disaster situations is the preparation of local response agencies. Traditional responders and non-traditional responders (public health, hospitals) are the primary responders in any community during times of crisis. Unfortunately, hospital and public health preparedness may still be lacking. Schools should be included in the non-traditional responder group, considered part of critical infrastructure and as such, should be given direction for biologic preparedness according to their role in a biologic event. Best media coverage from Science Daily (http://www.sciencedaily.com/releases/2012/08/120830105323.htm)

• For biologic agent details, see Understanding Flu and Biologic events
• Need help writing your biologic response plan?
• Planning tips: What good plans have that bad ones don't
• Avoid these four pitfalls in biologic planning

Could school preparedness be any worse? Yes.
These findings question the general preparedness of critical infrastructure. The Saint Louis study looked at responses from about 2000 school nurses encompassing only in 26 states. If the results truly represent the biological preparedness efforts (or lack thereof) the school preparedness situation could be much, much worse and equate to greater risks. Closing schools during a biologic or pandemic event will not replace preparedness as studies have shown that kids don't often stay home.

Traditional elementary and high schools draw students together from a variety of social, economic, and cultural background. Bringing a student population together to share ventilation systems, food, water and sanitation, in close quarters, provides opportunity for disease spread. With this in mind, school systems must be a leader in educating students on proper hygiene and infection control measures. Non-pharmacological  interventions are vital to prevent the spread of disease and include hand hygiene, respiratory etiquette and appropriate social distancing. These simple measures are important for everyday health promotion but could be even more important in preventing or limiting the spread of influenza.

• Three things everyone should be doing to get bio-event ready

By the numbers, per the Saint Louis study.
According to the Saint Louis study, less than one-third of the sample schools maintained a supply of personal protective equipment (PPE). Even more concerning is the over 20% of the staff in these schools have no members trained in the schools disaster plan. Infection control training for students was reported by only one third of schools and conducted usually once a year or less.

The study also asserts a positive note, finding that nearly 75% of school nurses have recieved seasonal flu vaccination.While this is good news, its only a drop in the bucket. One person (school nurse) vaccinated for seasonal influenza will do little to stop the spread of the disease. When it comes to emerging diseases and intentional biologic releases there may be no vaccine and we'll need to rely on those non-pharmacological interventions.