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PED-EM-L  August 2009

PED-EM-L August 2009

Subject:

H1N1 Situation Update- Social Outcry and Civil Unrest Indicators

From:

James Wilson <[log in to unmask]>

Reply-To:

James Wilson <[log in to unmask]>

Date:

Tue, 25 Aug 2009 12:15:18 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (157 lines)

United States H1N1 Situation Update- August 23, 2009
 
Background
 
Veratect issued advisories on July 27th and August 6th documenting
indications of an apparent resurgence of H1N1 from latitudes in the southern
hemisphere, then across the equator to Mexico, followed by reporting inside
the southern US.  Veratectıs advisory posted on July 27th stated an
expectation that reports of resurgence would be documented at the southern
US border within one to two weeks. This occurred 10 days later.
 
It was noted a similar pattern was observed in Australasia, a finding
subsequently supported by Australian officials.
 
Current Situation
 
Within the last week, there has been a substantial change in reporting of
H1N1 cases in elementary schools in California, Kentucky, Tennessee, and
Georgia, and universities in North Carolina (Duke University), Alabama
(University of Alabama), Kansas (University of Kansas), Oklahoma (Oklahoma
State University), Mississippi (Mississippi State University), and Louisiana
(Louisiana State University).  In the case of elementary schools, classes
were in session 1 to 2 weeks before H1N1 cases were reported.  In the case
of some of the universities, classes were in session 2 days before reporting
of H1N1 cases.  We surmise schools around the country are highly sensitized
to report influenza like illness and suspected H1N1, however in the case of
Alabama, pediatric intensive care units have reported an increase in
admissions. This follows reports nationwide of H1N1 outbreaks at summer
camps.
 
This information does not reflect the results of an official forensic
epidemiological investigation. It is unclear yet if reports of outbreaks in
schools is indicative of a statistically significant change from an already
high level of H1N1 transmission in the United States.  That said, it was
readily anticipated H1N1 transmission would be seen once schools began
session.

Point of Focus: Social Outcry and Civil Unrest Associated with the Pandemic
 
The below observations pertain to a comprehensive review of Veratectıs
records for select southern hemisphere countries that have experienced
intense H1N1 transmission during a temperate zone winter (Chile, Argentina,
Australia, and New Zealand), two additional countries who are culturally
analogous to the United States (Canada and the UK), and the United States.
This is representative of 3,859 reports derived from multiple source types
filed in near-real time for nearly 250,000 event indicators.  Veratect
monitors not only direct indicators of infectious disease transmission but
also social reaction indicators. Specifically, Veratect closely monitors the
dynamic between social harmony and civil unrest, which may be disrupted if
certain social conditions are present.  Below we present summary
observations and implications for northern hemisphere countries about to
experience H1N1 transmission in a temperate zone winter.
 
Triggers for public outcry and dissent include the following:
 
1.     Primary Triggers: continuous and geographically focused reporting of
fatalities, particularly those involving previously healthy children and
pregnant mothers (and their unborn fetuses)
2.     Secondary Trigger: within the context of multi-sector infrastructure
strain.  In regards to the medical infrastructure, this refers to combined
strain at the levels of outpatient, EMS, emergency department, ward and
intensive care unit (ICU) medical care.
 
The dynamic observed is a discrepancy between local community-specific
social expectation for official risk communication to the public, access to
medical care, and public health intervention.  The below highlight specific
examples documented; note, these examples represent the involved local
communityıs expressed reasons for public outcry:
 
·       Failure to communicate early warning and situational awareness
o   Early warning notification not occurring in a timely fashion
o   Ongoing, updated situational awareness is not consistent and timely
o   Information regarding situational awareness is not transparent to the
public
 
·       Failure to meet expected standards of medical care
o   Failure to diagnose patients properly due to false negative screening
test results
o   Failure to screen properly (i.e., triage) at emergency departments when
patient(s) eventually required admission to the ICU
o   Lack of access to ICU bed due to ICU personnel absenteeism, staff
shortages otherwise, lack of ventilators or Extra-Corporeal Membrane
Oxygenation (ECMO) machines, or ICU beds themselves.
o   Inappropriate dispensation of antivirals when life-threatening clinical
presentation was not due to H1N1 (fatalities were documented)
o   Inadequate access to medications due to lack of supply or otherwise
(e.g., Tamiflu)
o   Non-H1N1 related fatalities due to EMS / emergency department / ICU
urban grid overwhelmed
 
·       Failure to meet expected standards of public health intervention
o   Failure to activate emergency plans in a timely fashion
o   Lack of response coordination
o   Inconsistent implementation of countermeasures
o   Failure to engage subject matter expert opinion
o   Failure to discourage mass gatherings
o   Failure to close schools and prisons
 
Sources of outcry included the general public and specific interest groups
such as families of patients, labor unions, indigenous peoples, and parents
of school aged children.
 
In regards to the provision of early warning and situational awareness
information, public outcry was focused at officials (national, regional,
local), hospitals, and schools.  The most extreme social reactions were
observed with the school scenario, which relates to the above observation
regarding potential fatalities involving children and pregnant mothers who
were teachers in the involved schools.  Extreme reactions ranged from
peaceful demonstrations comprised of parents and teachers to a gunman
entering a school to confront the superintendant.  As the United States
enters the coming influenza season, there is already sentiment building as
to whether schools should be closed until a safe H1N1 vaccine is available
to the public.  
 
Regarding expectations for standard of medical care, the majority of public
outcry was directed at hospitals.  Veratect has documented public sentiment
questioning whether hospitals, schools, EMS, and other delivery groups for
the H1N1 vaccine are legally responsible for adverse clinical reactions to
the vaccine.  Additionally, there has been questions registered about legal
liability of healthcare providers who do not provide adequate care to
victims of H1N1 infection.
 
Public outcry due to perceived failure to meet standards of public health
intervention was directed at officials, school administration, and prison
administration.  Similar to the question of legal liability for medical
malpractice, questions have been raised in regards to public health
organization liability for effective implementation of public health
intervention and risk communication.


Should you have any questions about this report, please do not hesitate to
contact Dr. James Wilson (contact information in the signature block below).



James M. Wilson V, MD
Chief Technical Officer and Chief Scientist
Veratect Corporation
Kirkland, Washington
571.225.3671
[log in to unmask]

The information contained in this email is Veratect Corporation confidential
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