“A SEVERE FLU PANDEMIC… could kill more than 33 million people worldwide in just 250 days.” – “Boy, do we not have our act together.” — Bill Gates”. (J)

“It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.”

“Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,”..”

 “No battle plan survives contact with the enemy” * 

Worth reading:

The Next Plague Is Coming. Is America Ready?, by Ed Yong


ASSIGNMENT: Does your community have a seasonal flu EMERGENCY RESPONSE PLAN? Do your community’s hospitals have SURGE CAPACITY  and RAPID RESPONSE TEAMS? If not, develop a plan!


In July of 2009 the Mayor of Hoboken asked me to organize a H1N1 “Swine Flu” Task Force. We started with a set of questions based on reports from communities that had already experienced a Swine Flu surge:

Health Officer: Where vaccination sites should be established? Is there a special plan to monitor restaurants and food shops where flu-related safety guidelines need to be strictly enforced? Who will start preparing a Community Education plan?

Hospital: What is the back-up plan if hospital becomes “contaminated” and is closed to admissions, or if nursing staff is depleted by flu-related absenteeism, etc.? ICU triage? Availability of respirators?

OEM:  off-site screening centers if hospital ER is on overload

Hoboken Volunteer Ambulance Corps:  “mutual assist” plan

Hoboken Police Department & Hoboken Fire Department: back-up plan if the ranks get depleted by the flu

BOE: criteria in deciding whether or not to close schools

Stevens Institute of Technology: surveillance and plan for (college) students

“Field Manual” for the Mayor outlining all variabilities and options

Why was there no swine flu surge in NJ/ NYC metro area? maybe “herd” immunity” from prior year’s flu?

“Australia had an unusually early and fairly severe flu season this year. Since that may foretell a serious outbreak on its way in the United States, public health experts now are urging Americans to get their flu shots as soon as possible.

“It’s too early to tell for sure, because sometimes Australia is predictive and sometimes it’s not,” said Dr. Daniel B. Jernigan, director of the influenza division of the Centers for Disease Control and Prevention. “But the best move is to get the vaccine right now.”..

In 2017, Australia suffered its worst outbreak in the 20 years since modern surveillance techniques were adopted. The 2017-2018 flu season in the United States, which followed six months later as winter came to the Northern Hemisphere, was one of the worst in modern American memory, with an estimated 79,000 dead.” (A)

“Maryland health officials on Tuesday confirmed the first 11 influenza cases of the flu season. Officials urge Marylanders to get vaccinated.

“We don’t know yet whether flu activity this early indicates a particularly bad season on the horizon,” Maryland Department of Health Secretary Robert R. Neall said in a statement. “Still, we can’t emphasize strongly enough – get your flu shot now. Don’t put it off. The vaccine is widely available at grocery stores, pharmacies and local health clinics, in addition to your doctor’s office.”

Most of the 11 cases recorded since Sept. 1 have been subtyped as influenza A, with a few classified as influenza B. Though most influenza cases are mild, the virus can pose a serious risk for young children, seniors, pregnant women and people with compromised immune systems.

During last year’s flu season, 3,274 people were hospitalized and 82 died as a result of the flu in Maryland, according to state health officials.” (B)

“The first pediatric influenza-associated death of the 2019-20 flu season has been reported in California. According to a statement issued by Riverside University Health System a 4-year-old child who tested positive for the flu and had underlying health issues passed away from his illness.

According to the US Centers for Disease Control and Prevention (CDC) a total of 130 influenza-associated pediatric deaths were reported during the 2018-19 flu season. This number was a decrease from the 187 pediatric deaths reported during the 2017-18 season.

CDC investigators hypothesize that the real-world impact of the flu is being underreported. “Using mathematical modeling to account for under-detection, CDC estimates that the actual number of flu-related deaths in children during [the 2017-18] season was closer to 600—nearly 3 times what was reported through existing mechanisms,” the authors of a recent report wrote in a flu spotlight.

Cameron Kaiser, MD, public health officer of Riverside County, says that this early season death could be predictive of a severe flu season.” (C)

“The overall effectiveness of last flu season’s vaccine was only 29% because it didn’t protect against a flu virus that appeared later in the season, according to the U.S. Centers for Disease Control and Prevention.

It said the vaccine was 47% effective into February, but that dropped to just 9% after the late strain showed up, the Associated Press reported.

Flu vaccines are created each year to protect against flu strains predicted to be circulating in the upcoming season.

The effectiveness of last season’s vaccine was the second lowest since 2011. The vaccine for the 2014-15 flu season was only 19% effective, the AP reported.” (D)

It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.

Twice a year influenza experts meet at the World Health Organization to pore over surveillance data provided by countries around the world to try to predict which strains are becoming the most dominant. The Northern Hemisphere strain selection meeting is held in late February; the Southern Hemisphere meeting occurs in late September.

The selections that officials made…for the next Southern Hemisphere vaccine suggest that two of four viruses in the Northern Hemisphere vaccine that doctors and pharmacies are now pressing people to get may not be optimally protective this winter. Those two are influenza A/H3N2 and the influenza B/Victoria virus…

Flu vaccine is a four-in-one or a three-in-one shot that protects against both influenza A viruses — H3N2 and H1N1 — and either both or one of the influenza B viruses, B/Victoria and B/Yamagata. Most flu vaccine is made with killed viruses, and most vaccine used in the United States is quadrivalent — four-in-one…

Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,” Hensley said, adding that flu vaccines “often protect against severe disease even when … mismatched.” (E)

“A shortage of high dose flu shots is concerning some older adults.

The Vanderburgh County Health Department says people older than 65 are recommended to take a high dose flu shot.

Director of Clinical Outreach, Lynn Herr, says there is an option rather than not getting the shot at all.

“Then we need to have a conversation with our primary caregiver saying go ahead and get the regular or go ahead and wait for the higher dose flu shot.”

According to the CDC, the high dose vaccine helps people 65 years or older have a better fight against the flu.

This shot contains four times the antigen than a regular flu shot.” (F)


 What Are “Emergencies”? Emergencies are incidents that threaten public safety, health and welfare.  If severe or prolonged, they can exceed the capacity of first responders, local fire fighters or law enforcement officials.  Such incidents range widely in size, location, cause, and effect, but nearly all have an environmental component.” (G) 

Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients—one that challenges or exceeds normal operating capacity. The surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations.

Because of its relation to patient volume, most current initiatives to address surge capacity focus on identifying adequate numbers of hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem with this approach is that the necessary standby quantity of each critical asset depends on the systems and processes that:

Identify the medical need

Identify the resources to address the need in a timely manner

Move the resources expeditiously to locations of patient need (as applicable)

Manage and support the resources to their absolute maximum capacity.

In other words, fewer standby resources are necessary if systems are in place to maximize the abilities of existing operational resources. Moreover, the integration of additional resources (whether standby, mutual aid, State or Federal aid) is difficult without adequate management systems. Thus, medical surge capacity is primarily about the systems and processes that influence specific asset quantity.

Basic example: If a hospital wishes to have the capacity to medically manage 10 additional patients on respirators, it could buy, store, and maintain 10 respirators. This would provide an important component of that capacity (other critical care equipment and staff would also be needed), but it would also be very expensive for the facility. If the hospital establishes a mutual aid and/or cooperative agreement with regional hospitals, it might be able to rely on neighboring hospitals to loan respirators and credentialed staff and, therefore, might need to invest in only a few standby items (e.g., extra critical care beds), minimizing purchase and maintenance of expensive equipment that generate no income except during rare emergency situations.”  (H)

Today, Rapid Response Teams (RRTs) are a crucial component of many hospitals.  Implementing a RRT was one of the six strategies that defined the Institute for Healthcare Improvement (IHI) 100,000 Lives campaign.  Most RRTs consist of critical care nurses, but they can also include respiratory therapists, pharmacists, and physicians.

Research consistently shows that patients exhibit signs and symptoms of deterioration for several hours prior to a code.  These symptoms include changes in vital signs, mental status, and lab markers. The goal of a RRT is to intervene upstream from a potential code.  They reach the patient before deterioration turns into crisis.  This is different than a code blue team that typically responds to a patient that has already decompensated to cardiac arrest.

Historically, most hospitals relied on busy bedside nurses to identify crashing patients and call for rapid response.  With 49 states having no limits on the number of patients assigned per nurse, many medical-surgical ward nurses are caring for 6 or more patients per shift.  Placing this additional responsibility on their already over-flowing plate is challenging at best.  Providing a RRT empowers bedside nurses to trigger an escalation of care earlier and faster. (I)

“… even the U.S. is disturbingly vulnerable—and in some respects is becoming quickly more so. It depends on a just-in-time medical economy, in which stockpiles are limited and even key items are made to order. Most of the intravenous bags used in the country are manufactured in Puerto Rico, so when Hurricane Maria devastated the island last September, the bags fell in short supply. Some hospitals were forced to inject saline with syringes—and so syringe supplies started running low too. The most common lifesaving drugs all depend on long supply chains that include India and China—chains that would likely break in a severe pandemic. “Each year, the system gets leaner and leaner,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It doesn’t take much of a hiccup anymore to challenge it.”” (J)

“One hundred years ago, in 1918, a strain of H1N1 flu swept the world. It might have originated in Haskell County, Kansas, or in France or China—but soon it was everywhere. In two years, it killed as many as 100 million people—5 percent of the world’s population, and far more than the number who died in World War I. It killed not just the very young, old, and sick, but also the strong and fit, bringing them down through their own violent immune responses. It killed so quickly that hospitals ran out of beds, cities ran out of coffins, and coroners could not meet the demand for death certificates. It lowered Americans’ life expectancy by more than a decade. “The flu resculpted human populations more radically than anything since the Black Death,” Laura Spinney wrote in Pale Rider, her 2017 book about the pandemic. It was one of the deadliest natural disasters in history—a potent reminder of the threat posed by disease.” (K)

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PANDEMIC PREPAREDNESS. “It’s like a chain—one weak link and the whole thing falls apart. You need no weak links.”

Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)

“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza


* Helmuth von Moltke the Elder.