1 Allocation of Ventilators in an Influenza Pandemic Statewide Videoconference March 16, 2007 Pandemic Influenza Preparedness Planning Guthrie Birkhead, MD, MPH New York State Department of Health

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3 Source: MMWR 1999;48:621-29

4 Influenza Pandemics: 20 th Century Credit: US National Museum of Health and Medicine A(H1N1) A(H2N2) A(H3N2) 1918: “Spanish Flu”1957: “Asian Flu”1968: “Hong Kong Flu” m deaths 675,000 US deaths 1-4 m deaths 70,000 US deaths 1-4 m deaths 34,000 US deaths

5 Source: Nations With Confirmed Cases of H5N1 Avian Influenza (March 2007)

6 Influenza Pandemic Scenarios DHHS Plan – Moderate Scenario –1957/1968 Influenza Outbreak –35% Attack Rate DHHS Plan – Severe Scenario –1918 Influenza Outbreak –35% Attack Rate

NYS pop = million (2005 census estimates) Moderate (1957/68-like) Severe (1918-like) Flu Illness (6 weeks) 6.75 M (35% of population) 6.75 M (35% of population) Flu Outpatient Visits (6 weeks) 3.60 M (53.3% of those ill) 3.22 M (47.7% of those ill) Flu Hospital Admissions (6 weeks) 93,753 (0.5% of total pop, 1.4% of those ill) 770,640 (4.0% of total pop, 11.4% of those ill) Flu Hospitals Admissions in peak week 19,688 (21% of total hospital admissions) 161,834 (21% of total hospital admissions) Flu Deaths* (6 weeks)18,650 (0.28% of those ill)153,301 (2.3% of those ill) Estimated Impact of Pandemic Influenza (6-Week Period), NYS *vs flu deaths in an average season, vs. 17,500 total deaths in an average 6 week period

NYS pop = million (2005 census estimates) Moderate (1957/68-like) Severe (1918-like) ICU care 14,062 (15% of those hospitalized) 115,596 (15% of those hospitalized) ICU beds in peak week 4,342 (109% of available beds) * 35,688 (896% of available beds) * Mechanical ventilation 7,031 (7.5% of those hospitalized) 57,798 (7.5% of those hospitalized) Vents in peak week2,171 (36% of all vents) **17,844 (293% of all vents) ** Vents: Projected Shortfall-1,256 ** - 16,929 ** Estimated Hospital Impact of Pandemic Influenza, NYS *HERDS Critical Asset Survey = 3,981 staffed ICU beds. **An estimated 85% of the 6,100 vents are routinely in use.

9 Goal of Pandemic Flu Response

10 Principles of New York’s Pandemic Influenza Response Early (prior to transmission in State) –Surveillance for illness in recent travelers –Rapid diagnostic laboratory testing –Isolation of ill persons and contacts –Health system and communities placed on alert Pandemic declared in State (person-to-person transmission) –Community containment or “social distancing” including school closures, cancel mass gatherings, “work from home” and alternate work schedules –Implement health care system surge capacity plan –Manage health care system assets –Mitigate societal and economic impacts

11 Pan Flu Planning: Accomplishments State Health Department Helps develop and update the Pandemic Influenza Annex to the State’s “All Hazards” plan. Lead response with SEMO. – Since 2003: 16 statewide, multi agency table tops and 18 full scale preparedness exercises Conducts human disease surveillance and lab testing. Coordinates health care system response & EMS services Maintains statewide electronic systems to issue health alerts (HAN) and track health system resources (HERDS) Maintains Medical Emergency Response Cache (MERC) –1 million antiviral treatment courses, 4 million surgical masks, 500,000 N95 masks, 850 ventilators, other medical supplies. Administers federal public health/hospital preparedness grants; liaison with federal emergency medical stockpile

12 Pan Flu Planning: Accomplishments Health Care System Surge plan: stop elective admissions, discharge all stable patients from hospitals and nursing homes, expand number of staffed beds 8 Regional Resource Centers (RRCs) hospitals funded for regional planning. NYC hospitals funded separately Regional surge plan (500 beds per 1 million pop) Develop lists of volunteer physicians and nurses Alternate site care planning, including home care Ventilator allocation protocol roll out Drills & Exercises

13 Hospital Incident Commander Local EOC (Emergency Manager) State EOC DOH (Unified Health Command) HERDS Hospitals report ventilator data DOH uses data for resource allocation decision making Ventilator Requests in a Pandemic Networks, MOU’s, and vendor sources have been exhausted Ventilator resources: national stockpile, state stockpile, redistribution of assets

14 Pan Flu Planning: Accomplishments “ Live Fire Exercises” – i.e. Seasonal flu 2004 – managed flu vaccine shortage Disease surveillance and outbreak control –Lab reporting, HERDS reporting of hospital bed reporting, drug utilization Supply antivirals from MERC Vaccination “point of dispensing” (POD) drills Electronic health alert system utilized (HAN, HPN) Ambulance diversion Hospital bed management, cohorting

15 Pan Flu Planning: Ongoing Challenges 1918-style pandemic would overwhelm current healthcare planning (500 surge beds per million) Pharmaceutical interventions: –Vaccine would not be available for 6 months: and then only limited supply (e.g. 100K doses per week) –Antivirals would only be available for treatment, not prophylaxis Non-pharmaceutical interventions (community containment): –Social distancing/school closures/ban mass gatherings 35% illness rate and higher rates of absenteeism would strain infrastructure functioning at all levels High number of deaths would strain mortuary capacity as well as societal resolve.

16 Pan Flu Planning: Ongoing Challenges Medical Surge Locate, equip and staff surge beds Volunteer/retired health care workers Provide care in home/community settings Protocols for ethical rationing of limited resources –Ventilator Triage protocol

17 Contact Information NYSDOH for comments: Websites for more information: State: Federalwww.pandemicflu.gov