If you want to know how far we've come since the early days of discussing community preparations for a possible influenza pandemic, take a look at a story at CIDRAP News about a new guidance document prepared by the Association of State and Territorial Health Officials (ASTHO) and its partners. This is described as the first federal document of its kind prepared outside the federal government (although with a grant from CDC). It's about how to provide necessary resources and services to those who will need it most but who are also the hardest to reach. The 105 page document is aimed at state, local, territorial, and tribal health agencies meant to help them "prepare to help 'at-risk' groups--such as people who can't afford to stockpile food, don't speak English, or need assistance with daily activities--get through a pandemic":
"In the face of a pandemic we have to recognize that some of those services that serve them [vulnerable groups] today may be able to expand to meet the need, but some of them will break down," ASTHO Executive Director Paul E. Jarris, MD, MBA, told CIDRAP News. "How will we provide basic services to people who are homebound, for example, making sure they have food and water and care? This won't happen by accident."[snip]
The guidance consists of five chapters that discuss how to identify and collaborate with at-risk populations, communicate with and educate them about pandemic flu, provide clinical and non-clinical services to them, and how to test, exercise, measure, and improve their preparedness.
At-risk groups are defined as those that have the highest risk of suffering severe consequences from a pandemic or from measures used to fight the pandemic, such as community mitigation strategies. Examples include those who can't afford to stockpile food or stay home from work for even a short time; those who have no support network, such as homeless people and those who are socially or geographically isolated; and those who need help with daily activities because of physical disabilities, blindness, hearing impairment, medical conditions, or other factors.(CIDRAP News)
From the extended description at CIDRAP News this is ambitious and extremely important guidance on how to identify, communicate and work with vulnerable populations, such as the poor who have no food reserves, those who cannot afford to stay home or be out of work for even short periods, those with little or no social support and the disabled or physically or mentally challenged. The various chapters seem to be full of very practical suggestions, such as how to get the message out and through whom, community based vehicles for dissemination of information and supplies and the pros and cons of things like registries. This just scratches the surface of what seems to be in this document.
Much is made in the CIDRAP News story about the fact this federal guidance was developed by non-federal groups. But I think of even more significance is the effort and resources that have gone into thinking ahead about an obvious and foreseeable public health problem. This is an example of the community planning to help each other, not with antiviral or immunological magic bullets but with intent and priority. It's only a start. The suggestions and recommendations also have to be used and implemented by state and local agencies and communities. It will require allocating time, resources and money locally. In a real sense it is the acid test of the quality of a community as a community.
The task is still a daunting one, but at least local agencies won't be able to say it they don't even know how to approach it. They can just follow the advice on how to eat an elephant: one bite at a time. This report provides them with a knife, fork and ingredients list.
Full text (.pdf) of "At-Risk Populations and Pandemic Influenza: Planning Guidance for State, Territorial, Tribal and Local Health Departments"
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One in five ambulances in the US have to be diverted to the emergency section of another hospital now. That means precious time is lost, when the patient, for example has a heart attack. And we do not even have a pandemic. How can these hospitals possibly cope with an influx of pandemic patients?
50 million citizens do not have health insurance. How are these people going to be admitted to a hospital during a pandemic, if they cannot pay? If you were a hospital administrator during a pandemic, would you give priority to those with health insurance, regardless of the condition of the patient?
Hospitals do not have enough N-95 masks. If you are a nurse, will you decide not to report to work, because you do not have a mask to protect you, and you do not want to infect yourself and your family members, perhaps causing you and your family to die? Many who become infected will not die, but will be disabled the rest of their lives, due to organ damage, such as damage to the heart. Do you want to risk being disabled the rest of your life? Who will support your family?
Some doctors, paramedics, nurses, and other hospital staff in Australia have announced they will not report to work during a pandemic, because it is too dangerous, and they fear for their lives and the lives of their family.
If you are infected with bird flu in Australia, and you are taken to a hospital, will there be staff there to care for you? Australia is very close to Indonesia, and the Australians fear they will be hit first during a pandemic.
Do you remember the gas lines at stations during the period of gas rationing, when some motorists became angry and started shooting. Gas stations attendants had to carry guns to protect themselves. A pandemic will be much worse than waiting in line to buy gas. Will people who are full of fear and anger start shooting in supermarkets, to get food, or at pharmacies, to get medication? Police departments are being forced to terminate staff now, due to budget cuts. Who will protect you? Many police officers will be out sick.
If someone breaks into your house, will you be sure the police will respond? How long will it take them to respond?
Will criminals be free to commit crimes of all kinds, as they did during Katrina in New Orleans?
The University of Albany School of Public Health (SUNY) provides short online preparedness courses. Of those that I've taken over the last couple of years, the most recent, Alternative Marketing & Messaging to Prepare Vulnerable Populations, was one of the best. Most of these UA courses are given through the webcast facilities of the Upper Midwest Center for Public Health Preparedness:
www.prepareiowa.com
Other courses, such as U Iowa courses, are also available there. These are all free of charge and usually take 75 minutes; at the end of the course, after taking a brief test (usually about 5 questions), a certificate is provided with CE credits of various types. Most courses have downloadable handouts available.
Courses are first given by live webcast but are available a week or so later by videostreaming.
Examples: Public Health Preparedness and Leadership in Crisis Situations; Ethical Hazards in Pandemic Flu Planning and Response; Mass evacuation to Rural Communities; Managing Contemporary Mass Fatalities Incident; Natural Toxins and Bioterrorism; Avian Influenza: Zoonosis of the Decade; World Trade Center Study (High Rise Building Evacuation); Addressing Chronic Health Care Needs in Disasters: The Houston (Katrina) experience; Avian Pathogens as Zoonotic Public Health Threats
Stillwaggon,
Talk about a vulnerable population, how about our prisons. If there are not enough prison guards, because they are out sick, do you know how bad it could get inside our prisons? Many prisoners are there for non-violent crimes, like cocaine possession. When the hell are they going to legalize drugs. It costs $30,000 per year to keep a drug addict in prison. They could send the addict to Havard for that amount. These people will die like flies during a pandemic, and there will be violence in the prisons. And the minority population is very high. Where is the social justice in letting these people die during a pandemic?
I live in Medellin Colombia. If you want to see a vulnerable population, just look at all the shacks piled up on the hillsides. There are 4 million displaced citizens, due to the civil war. Who will protect my butt when this place explodes? The cities have paramilitary forces, guerrilla militias, and common criminals all over the place. Do you have a course on how to control these people? Do you have a course on how to keep Colombia from blowing up during a pandemic?
The border with Mexico will have to be sealed off, or you will have an invasion of desperate people coming across the border. Do you have a course on how to keep Mexico from exploding?
Thank you Revere for this Post, it will reach more people via the journalist reading you.
My fellow First Nations (American Hemisphere Indians) need as much informations as possible.
With our experience of devastating epidemics and pandemics we do have an expertise to share, for now, most of the Leaders of Collectivities are gathering informations.
Sincere thanks,
Snowy
Herman wrote: Who will protect my butt when this place explodes?
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Herman,
You are SO ahead of the curve by even knowing about the pandemic. 95%+ of the US population is clueless. You MUST be prepared to protect your own butt. If you can protect a couple of other folks too you will be a hero.
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Stillwagon-You went that far. Do the FEMA courses here.
http://training.fema.gov/IS/
Start with 100 and go to 800 level. They do provide some college credits. Once you go thru that you'll see more and more why Katrina happened and how a single person, a governor was responsible for the effects of Katrina. It will surely invoke the thoughts of Andrew as well. To me it was a set up to try to lure GWB into an impeachment trap. He didnt bite. Haley Barbour of Miss. signed his federalization request as the storm was hitting the beach as did Alabama's governor. They added to it as it moved north. Gov. Blanco has water rising a foot every fifteen minutes in the 9th and she waited 3 days as did Lawton Chiles (both democrats) before signing the order. How very convenient.
As for the post Revere I have read it but this still has no real resources attached to it. The Mormons by the equivalent of a fatwah are required to keep food on the shelves and be prepared for what is the equivalent of the end of days. When the snowmelt in the mountains of Utah several years ago happened, they were drowning, but they were eating good. They were as prepared as anyone could be.
The people you and they describe though, unless family, friends or the churches can come up with care and food then they simply wont make it if its more than an 8% event. Cold hard facts so if you have family or friends that need care, you either prepare or you will be euthanizing them in a slow way. I cant even think by looking at what the numbers are for an 8% world event that there will even be a health care system for the people described. They are going to try to protect the seed corn first and everyone else is going to come second. That likely means my butt too.
Gilmoreaz,
Thanks for the comments. Please read this:
HONG KONG (Reuters) - One of China's top doctors has said that the H5N1 bird flu virus has shown signs of mutation and can kill human victims more easily if treatment is not given early enough, newspapers reported on Tuesday.
Zhong Nanshan, an expert on respiratory diseases, told reporters in Beijing that vigilance should be kept up, especially when H5N1 human cases are surfacing at a time when seasonal human influenza is at a peak.
What I want to stress is this:
"H5N1 bird flu virus has shown signs of mutation and can kill human victims more easily"
H5N1 already has a mortality rate of about 60%, and now the doctor says there are mutations that allow it to kill more easily. Is he talking about a mortality rate of 100%, or what?
And Niman is talking about receptor binding domain changes that may allow the virus to infect humans more easily, and if one more small change occurs, a pandemic may be happen.
Dr. Nashan says:
H5N1 bird flu virus has shown signs of mutation
Is he talking about the same mutations Niman refers to?
Has this monster finally almost reached the final mutation necessary to produce a pandemic?
It would be a great service to us all for anyone aware of exactly what these mutations are, to inform us promptly.
We could now be very close to the point where the Titanic hits the iceberg.
Gilmoreaz,
Just so you will be relaxed and happy over the weekend, I wanted to provide you with this wonderful quote from Niman:
"Recent data on receptor binding domain changes suggest one or two changes could produce an efficiently transmitted H5N1, which when linked to the current high case fatality, would have catastrophic consequences."
Herman,
The organization that does the vulnerable populations course does take into consideration 'clients of the criminal justice system', ex-convicts, registered sex offenders and other socially isolated people.
Randolph,
I am aware of the FEMA courses. Our town has arranged for the Incident Command training to be given live at our site for those of us who are members of the local Medical Reserve Corps. Thanks for the suggestion.
Despite the available resources (and the box of N-95 masks in my closet), I have not been converted from my status as a pessimist.
Stillwaggon,
Thank you for your comments. It appears your organization does excellent work.
Please keep your N-95 masks safe, since recent H5N1 mutations may mean you will need them soon. I will do the same with my N-95 masks. Please read:
"One of the reasons that we are not constantly overrun with avian flu viruses popping straight out of birds and into people, and why we havent yet had a human H5N1 pandemic, is that bird-infecting flu virus H proteins bind to a sialic acid (SA) α2,3Gal(actose) receptor - which in birds is predominantly found in the enteric tract, which is why the virus is shed prolifically via faeces in birds, but is not much found in humans except for deep in the respiratory tract, which is difficult to reach. Thus, while humans can be infected by H5N1 viruses, this is rare, and so far onward transmission to other humans has not been reliably documented. Human-adapted flu viruses, on the other hand, bind preferentially to an SAα2,6Gal receptor - which is found predominantly in the upper respiratory tract, meaning the virus can much more easily infect and be transmitted. The frightening thing is that it takes only a few mutations in the H gene - 3 in the case of the legendary H1N1 Spanish Flu pandemic virus - to change from one type to the other, and only 2 to bind both types relatively weakly.
So Prasert Auewarakul and colleagues have isolated, from a fatal infection of a 5-year-old boy, a population of H5 HA sequences which are distributed evenly between the bird type (SAα2,3Gal-binding) and a mutant type (SAα2,3Gal- and SAα2,6Gal-binding). The mutant HA protein had two substitutions, at positions 129 and 134 (lL129V and A134V). These two residues are located close to part of the receptor binding domain, and apparently alter the binding specificity by changing the configuration of the binding pocket.
The implications of this are very worrying indeed: a lethal virus which can bind both bird and human receptors was selected for in a single bird-human transmission event - just like the Spanish Flu H1N1 HA reconstructed from archival tissue samples, which we should need no reminding, went on to kill in excess of 60 million people. In the age of the steam train and ship. This means that we could be just one infection away from The Big One - with death tolls predicted to be in the range of tens of millions."
This summary is from a recent H5N1 death in Egypt. This virus may be very close now to efficient human transmission.
That would imply the possible death of millons and millions of people, with a mortality rate of perhaps 60%.
FWIW, When I did them, you had to do the NIMS (ICS) 700-800 courses first, as they were the intro to the "concept". Then, you could do the ICS 100-200 online. The ICS 300-400 courses had to be donoe "live". I dunno if that has changed or not.
MoM