Guthrie Birkhead, MD, MPH - New York State Department of Health


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  • Thank you. The purpose of this teleconference today is to discuss the draft document on ventilator triage which we are releasing for public comment. By way of background, I will go over some brief background on pandemic influenza and our ongoing pandemic response planning efforts.
  • Of all the public health crises that we plan for, an influenza pandemic is one of the most likely to actually occur. In fact, influenza pandemics occurred three times in the last century. This is a photograph from New York City in the 1918 pandemic.
  • This graph shows the crude death rate for infectious diseases in the United States over the course of the 20 th century. Superimposed over the general decline in deaths is the influenza pandemic of 1918-19 where death rates almost doubled, illustrating the dramatic effect that pandemics can have on the population. Much less severe pandemics occurred in 1957 and 1968, and show up only as blips on this graph. Today, the 1918 pandemic would be classified as a Category 5 pandemic in CDC’s new pandemic grading system, the worst case scenario that we use for our pandemic planning.
  • The 1918 pandemic was among the most deadly events in recorded human history, with an estimated 50-100 million deaths world wide and three quarters of a million deaths in the US. New York experienced about 10% of these deaths, or roughly 68,000. A proportional number of deaths today in New York would be about 150,000. By comparison, the 1957 and 1968 pandemics were much less severe. Many of the control measures which I will describe would probably not be needed in pandemics of this lesser magnitude. The 1918 pandemic was the “once in a century storm” that we have to plan for.
  • Pandemics are thought to arise when a new strain of influenza is introduced into humans from birds or other animals. In fact, we now know that the virus that caused the 1918 pandemic was probably an avian virus. That is why the current outbreak of avian influenza, which began in Southeast Asia in 2003 and has spread to Europe and Africa, is so concerning. To date, there have been 277 human cases of this avian flu and 168 deaths, a 61% death rate, in the 11 countries indicated by the red squares. Most of these cases were due to direct bird-to-human contact. To date there has not been any sustained human-to-human transmission, which would be a harbinger of a pandemic. If and when this might happen is unknown, but it could happen.
  • To estimate the impact of a pandemic on New York, we have used some standard modeling assumptions provided by the US Department of Health and Human Services (DHHS). They provide estimates for a moderate, 1957/1968 type pandemic, and a severe, 1918 type pandemic.
  • The estimates of pandemic flu cases, hospitalizations and deaths, are shown here. If a 1918-style, Category 5 pandemic occurred, without any control measures, we estimate that 35% of New Yorkers, or 6.75 million people, would become ill over a 6 week period. In this time period, there would be a big increase in outpatient visits and a 3-fold increase in hospitalizations. 153,000 New Yorkers would die from influenza and its complications, compared to 1400 flu deaths in an average year, and 17,000 total deaths in an average 6 week period.
  • In addition, modeling indicates that in the peak week of a 1918-type pandemic, baseline hospital ICU bed capacity would be exceeded by 896% and ventilator capacity by 293%. The projected shortfall in ventilators in the peak week would be about 1,256 for a moderate pandemic, and almost 17,000 for a severe pandemic. These figures are just for shortfall in the availability of ventilator equipment. It says nothing about the staffing required to operate the ventilators. It was data like these, presented at a New York City-wide meeting of hospitals in the fall of 2005, that lead to the recognition that we, public health and hospitals, needed to begin to plan for how we would cope with such a shortage of ventilators, and how in an extreme, almost unimaginable Category 5 pandemic situation decisions could be made fairly, equitably and rationally about which patients would get ventilators and which would not.
  • Let’s talk for a minute about what the goals would be of our pandemic influenza response. If a pandemic occurred, we would not be able to stop it from entering New York or from spreading. Rather, the goal of our pandemic flu response would be to delay the sharp, high peak of cases shown in pink in this schematic, and to reduce the height and area under the curve to spread out cases over a longer period of time, the white curve. This approach would spread out the impact of the pandemic on the health care system, including the need for ventilators, and on society. Lowering the peak of the curve means that we would not exceed surge capacity shown in the red-dotted line (this includes ventilator supply), by such a wide margin for such a long a period of time. This strategy also buys time for vaccine development, which may take up to 6 months.
  • How would this goal of flattening out the pandemic curve be accomplished? First, early in the worldwide flu pandemic, prior to disease transmission in the State, we would conduct surveillance for illness in recent travelers, as we did in the SARS epidemic in 2003, coupled with rapid diagnostic testing and isolation of ill persons and contacts. These steps will hopefully delay, but ultimately would not prevent, the full scale introduction of pandemic flu into the state. In this early period, we also would initiate steps in the health care system and in the community to prepare for the arrival of the pandemic. Once the pandemic has arrived, with in-State person-to-person transmission detected, we would implement a series of community containment measures, so-called “social distancing” such as school closures and banning mass gatherings, and we would ask employers to institute workplace changes, such as having workers work from home or use alternating work schedules. We would also implement our health care system surge plan, begin to manage health care system assets, and work with other state agencies to mitigate the societal and economic impacts of the pandemic.
  • What have we accomplished to date in developing and testing this response plan? DOH has helped develop and continually updates the Pandemic Influenza Annex to the state “All Hazards” plan. The State Pandemic Annex is consistent with the Federal pandemic plan. In a pandemic, DOH and SEMO would lead the state response. Since 2002, 16 statewide multi agency table tops and 18 full scale exercises have been conducted on various aspects of overall public health preparedness. Based on protocols used every year during flu season, DOH will conduct human disease surveillance and the Wadsworth lab will conduct lab testing including sophisticated viral typing. And in a pandemic, DOH would coordinate the health care system response including emergency medical services. The Department maintains a statewide electronic health alert system to keep the medical community, state agencies and others apprised of the situation, and tracks health system resources through the HERDS system. DOH has built and maintains the state Medical Emergency Response Cache, or MERC which currently includes: 1 million antiviral treatment courses, 4 million surgical masks, half a million N95 masks, 850 ventilators, other medical supplies. A $29 million line in this year’s Executive Budget will allow us to continue to purchase antiviral medications, with to goal in the next 3 years of stockpiling enough medication to treat all New Yorker’s who become ill in a pandemic. Finally, DOH administers the states’ two large federal public health and hospital preparedness grants, and is the liaison to the federal medical stockpile.
  • The health care system is developing medical surge plans. These include steps to open up hospital beds, such as stopping elective admissions, discharging all stable patients from hospitals and nursing homes, and expanding the number of staffed beds. Outside of New York City, the state has funded 8 regional resource center hospitals to conduct regional planning to create 500 hospital surge beds per million population. These steps would add up to 10,000 hospital beds to our current total of 40,000, a 25% increase. Much of the care would be provided by volunteer physicians and nurses, recruitment of whom is underway. Because no conceivable surge scenario would produce enough hospital beds for a Category 5 pandemic, planning is also underway for alternate care sites, such as armories, gyms, and similar settings where basic supportive care would be provided, as well as educational information and support for people to care for family members at home. Finally, we have developed the ventilator allocation protocol that we are rolling out for public comment today.
  • Before we get into a discussion of allocating ventilators among patients, I want to be clear that this would only be a last resort in an extreme, almost unimaginable situation. In a pandemic, all efforts should be made to fully utilize all available ventilators on a statewide basis before going to a triage system. First, Hospitals must exhaust all its normal sources of that asset including hospital network relationships, Mutual Aid or other agreements between hospitals, and all vendor sources. If a shortage still exists, all request for assets by hospital must be directed to local Emergency Operations Center (EOC) and HERDS. HERDS data are utilized by the Unified Health Command to understand the county and state-wide situation before making asset allocation decisions or requesting state assets. HERDS data from all affected areas will be reviewed by the Unified Health Command at State level to inform its decision-making. Requested ventilators will be drawn from the national stockpile, the state stockpile and possibly be a redistribution of unneeded or less needed assets.
  • One final point to make is that we essentially conduct “live fire exercises” of our pandemic response plan each year during the flu season. For example, in 2004, we had experience in managing the flu vaccine shortage that occurred that year. Every year we use the same HERDS system we would use in a pandemic to do disease surveillance, lab reporting, hospital bed reporting, and drug utilization. We have distributed antivirals from the MERC for use in nursing home flu outbreaks, and the electronic Health Alert Network (HAN) and Health Provider Network (HPN) systems are used regularly. Ambulance diversion during flu season is a fairly regular event, and flu season is often a challenge to hospital bed management, and systems like cohorting of flu patients should be tested.
  • Clearly as we’ve seen, we face very significant ongoing challenges. Addressing these challenges will require the concerted efforts of all of us. As we’ve seen, a 1918-style pandemic would overwhelm current healthcare system surge planning. We need to further develop plans to care for sick people in the community. The current assumption is that vaccine would not be available for 6 months after a pandemic begins, and even then supplies would be limited. Despite our ongoing stockpiling of antiviral medications, we currently do not have enough for prophylaxis of health care workers and first responders. We need to further build our stockpile and develop the systems to manage the dispensing of these scarce resources. On the community side, we have only begun the think through the issues of the impacts of school closures and only recently held our first, day long table top exercise with State Ed and the school communities. This is the subject of ongoing planning. Overshadowing any planning effort is the 35% illness and absenteeism rates that mean government and business will have to run short handed for weeks or months. Continuity of operations planning is critical to manage this problem. And the high number of deaths would strain not only mortuary capacity, but more fundamentally would strain societal resolve as well.
  • Specifically in the medical surge arena, most of the plans we have are preliminary and untested, indeed they are difficult to really test fully. Will we have enough volunteer doctors and nurses to staff the beds we can free up, and also provide care in the community? More work needs to be done on organizing these efforts. Will the public accept care in the community? And will rationing of limited resources be accepted by health care workers or patients, even with ethical safeguards built in? This last question brings us directly to the ventilator triage protocol, which we are presenting for discussion today.
  • Here is our contact information for you to submit written comments and web links for more information. We look forward a full discussion of this issue with you. I’d like to turn it over to Dr. Tia Powell from the New York State Taskforce on Life and the Law, for a discussion of the triage document itself. Tia…
  • Guthrie Birkhead, MD, MPH - New York State Department of Health

    1. 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
    2. 3. Source: MMWR 1999;48:621-29
    3. 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” 50-100 m deaths 675,000 US deaths 1-4 m deaths 70,000 US deaths 1-4 m deaths 34,000 US deaths
    4. 5. Source: Nations With Confirmed Cases of H5N1 Avian Influenza (March 2007)
    5. 6. Influenza Pandemic Scenarios <ul><li>DHHS Plan – Moderate Scenario </li></ul><ul><ul><li>1957/1968 Influenza Outbreak </li></ul></ul><ul><ul><li>35% Attack Rate </li></ul></ul><ul><li>DHHS Plan – Severe Scenario </li></ul><ul><ul><li>1918 Influenza Outbreak </li></ul></ul><ul><ul><li>35% Attack Rate </li></ul></ul>
    6. 7. Estimated Impact of Pandemic Influenza (6-Week Period), NYS <ul><ul><ul><li>*vs. 1400 flu deaths in an average season, vs. 17,500 total deaths in an average 6 week period </li></ul></ul></ul>153,301 (2.3% of those ill) 18,650 (0.28% of those ill) Flu Deaths* (6 weeks) 161,834 (21% of total hospital admissions) 19,688 (21% of total hospital admissions) Flu Hospitals Admissions in peak week 770,640 (4.0% of total pop, 11.4% of those ill) 93,753 (0.5% of total pop, 1.4% of those ill) Flu Hospital Admissions (6 weeks) 3.22 M (47.7% of those ill) 3.60 M (53.3% of those ill) Flu Outpatient Visits (6 weeks) 6.75 M (35% of population) 6.75 M (35% of population) Flu Illness (6 weeks) Severe (1918-like) Moderate (1957/68-like) NYS pop = 19.28 million (2005 census estimates)
    7. 8. 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. 115,596 (15% of those hospitalized) 14,062 (15% of those hospitalized) ICU care 35,688 (896% of available beds) * 4,342 (109% of available beds) * ICU beds in peak week - 16,929 ** -1,256 ** Vents: Projected Shortfall 57,798 (7.5% of those hospitalized) 7,031 (7.5% of those hospitalized) Mechanical ventilation 17,844 (293% of all vents) ** 2,171 (36% of all vents) ** Vents in peak week Severe (1918-like) Moderate (1957/68-like) NYS pop = 19.28 million (2005 census estimates)
    8. 9. Goal of Pandemic Flu Response
    9. 10. Principles of New York’s Pandemic Influenza Response <ul><li>Early (prior to transmission in State) </li></ul><ul><ul><li>Surveillance for illness in recent travelers </li></ul></ul><ul><ul><li>Rapid diagnostic laboratory testing </li></ul></ul><ul><ul><li>Isolation of ill persons and contacts </li></ul></ul><ul><ul><li>Health system and communities placed on alert </li></ul></ul><ul><li>Pandemic declared in State (person-to-person transmission) </li></ul><ul><ul><li>Community containment or “social distancing” including school closures, cancel mass gatherings, “work from home” and alternate work schedules </li></ul></ul><ul><ul><li>Implement health care system surge capacity plan </li></ul></ul><ul><ul><li>Manage health care system assets </li></ul></ul><ul><ul><li>Mitigate societal and economic impacts </li></ul></ul>
    10. 11. Pan Flu Planning: Accomplishments State Health Department <ul><li>Helps develop and update the Pandemic Influenza Annex to the State’s “All Hazards” plan. Lead response with SEMO. </li></ul><ul><ul><li> </li></ul></ul><ul><li>Since 2003: 16 statewide, multi agency table tops and 18 full scale preparedness exercises </li></ul><ul><li>Conducts human disease surveillance and lab testing. </li></ul><ul><li>Coordinates health care system response & EMS services </li></ul><ul><li>Maintains statewide electronic systems to issue health alerts (HAN) and track health system resources (HERDS) </li></ul><ul><li>Maintains Medical Emergency Response Cache (MERC) </li></ul><ul><ul><li>1 million antiviral treatment courses, 4 million surgical masks, 500,000 N95 masks, 850 ventilators, other medical supplies. </li></ul></ul><ul><li>Administers federal public health/hospital preparedness grants; liaison with federal emergency medical stockpile </li></ul>
    11. 12. Pan Flu Planning: Accomplishments Health Care System <ul><li>Surge plan: stop elective admissions, discharge all stable patients from hospitals and nursing homes, expand number of staffed beds </li></ul><ul><li>8 Regional Resource Centers (RRCs) hospitals funded for regional planning. NYC hospitals funded separately </li></ul><ul><li>Regional surge plan (500 beds per 1 million pop) </li></ul><ul><li>Develop lists of volunteer physicians and nurses </li></ul><ul><li>Alternate site care planning, including home care </li></ul><ul><li>Ventilator allocation protocol roll out </li></ul><ul><li>Drills & Exercises </li></ul>
    12. 13. Ventilator Requests in a Pandemic 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 Networks, MOU’s, and vendor sources have been exhausted Ventilator resources: national stockpile, state stockpile, redistribution of assets
    13. 14. Pan Flu Planning: Accomplishments “ Live Fire Exercises” – i.e. Seasonal flu <ul><li>2004 – managed flu vaccine shortage </li></ul><ul><li>Disease surveillance and outbreak control </li></ul><ul><ul><li>Lab reporting, HERDS reporting of hospital bed reporting, drug utilization </li></ul></ul><ul><li>Supply antivirals from MERC </li></ul><ul><li>Vaccination “point of dispensing” (POD) drills </li></ul><ul><li>Electronic health alert system utilized (HAN, HPN) </li></ul><ul><li>Ambulance diversion </li></ul><ul><li>Hospital bed management, cohorting </li></ul>
    14. 15. Pan Flu Planning: Ongoing Challenges <ul><li>1918-style pandemic would overwhelm current healthcare planning (500 surge beds per million) </li></ul><ul><li>Pharmaceutical interventions: </li></ul><ul><ul><li>Vaccine would not be available for 6 months: and then only limited supply (e.g. 100K doses per week) </li></ul></ul><ul><ul><li>Antivirals would only be available for treatment, not prophylaxis </li></ul></ul><ul><li>Non-pharmaceutical interventions (community containment): </li></ul><ul><ul><li>Social distancing/school closures/ban mass gatherings </li></ul></ul><ul><li>35% illness rate and higher rates of absenteeism would strain infrastructure functioning at all levels </li></ul><ul><li>High number of deaths would strain mortuary capacity as well as societal resolve. </li></ul>
    15. 16. Pan Flu Planning: Ongoing Challenges Medical Surge <ul><li>Locate, equip and staff surge beds </li></ul><ul><li>Volunteer/retired health care workers </li></ul><ul><li>Provide care in home/community settings </li></ul><ul><li>Protocols for ethical rationing of limited resources </li></ul><ul><ul><li>Ventilator Triage protocol </li></ul></ul>
    16. 17. Contact Information <ul><li>NYSDOH email for comments: </li></ul><ul><li> [email_address] </li></ul><ul><li>Websites for more information: </li></ul><ul><li>State: Federal </li></ul>