Global & Disaster Medicine

Archive for the ‘Pandemic’ Category

Stockpiling Ventilators for Influenza Pandemics


Commentary:  VentStockpilingCommentary-EID-June_2017


Emerging Infectious Diseases • • Vol. 23, No. 6, June 2017

“Diligent preparation and effective countermeasures are critical to mitigating future influenza pandemics. The 1918 influenza pandemic, the most severe in recent history, resulted in ≈50 million deaths globally, of which nearly 675,000 occurred in the United States (1). The 1957 and 2009 pandemics were less severe, causing ≈70,000 and 9,000–18,000 US deaths, respectively (1).

US Department of Health and Human Services (HHS) estimated that 865,000 US residents would be hospitalized during a moderate pandemic (as in 1957 and 1968) and 9.9 million during a severe pandemic (as in 1918).

When severe influenza outbreaks cause high rates of hospitalization, a surge of medical resources is required, including critical care supplies, antiviral medications, and personal protection equipment. Given uncertainty in the timing and severity of the next pandemic, as well as the time required to manufacture medical countermeasures, stockpiling is central to influenza preparedness (3). However, difficulty in forecasting and limited public health budgets often constrain decisions about sizes, locations, and deployment of such stockpiles. Mechanical ventilators are essential for treating influenza patients in severe acute respiratory failure. Substantial concern exists that intensive care units (ICUs) might have insufficient resources to treat all persons requiring ventilator support. Prior studies argue that current capacities are insufficient to handle even moderately severe pandemics and that sentinel reporting and model-based decision-making are critical for managing limited resources (4–6). For this reason, the United States has stockpiled mechanical ventilators in strategically located warehouses for use in public health emergencies, such as an influenza pandemic. The Centers for Disease Control and Prevention (CDC) manages this Strategic National Stockpile (SNS) and has plans for rapid deployment to states during critical events (7).

However, SNS ventilators might not suffice to meet demand during a severe public health emergency. In 2002, the SNS included ≈4,400 ventilators (8,9), and 4,500 SNS ventilators were added during 2009 and 2010. The American Association for Respiratory Care suggested the SNS inventory should increase to at least 11,000–16,000 ventilators in preparation for a severe influenza pandemic (10). The American Association for Respiratory Care and CDC (11) provide training on 3 types of SNS ventilators—LP10 (Covidien, Boulder, CO, USA); LTV1200 (CareFusion, Yorba Linda, CA, USA); and Uni-vent Eagle 754 (Impact Instrumentation, Inc., West Caldwell, NJ, USA)—to ensure proper use nationwide. In addition to the nationally held SNS, some US states maintain their own stockpiles. Successful deployment of central ventilator stockpiles, whether federal or state, requires rapid distribution to healthcare facilities with patients in need, along with adequate bed space, requisite supplies, and trained personnel Robust methods for sizing and locating ventilator stockpiles have not yet been developed (15). Wilgis (16) discussed the relative merits of central stockpiling of ventilators to be distributed during an emergency versus distributing ventilators to hospitals a priori. Centralized stockpiles benefit from better inventory tracking, more timely repairs, and superior allocation of a limited resource, but hospital-based supplies facilitate staff training, enable immediate use, and avoid the cost and logistical challenges of central storage and deployment. …..”


Movements during routine nursing procedures can increase the risk of face seal leakage of N95 respirators, according to a study that involved nursing students who wore backpack aerosol spectrometers that measured particles that entered the mask.

Am J Infection Control


  • N95 respirators, although adequately fitted, may not provide consistent protection for users.
  • Movements during nursing procedures can significantly increase the risk of face seal leakage.
  • Improvements in respirator design to minimize face seal leakage are essential.
  • Portable aerosol spectrometers offer a reliable method for real-time measurement of N95 mask fit.


The adequate fit of an N95 respirator is important for health care workers to reduce the transmission of airborne infectious diseases in the clinical setting. This study aimed to evaluate whether adequately sealed N95 respirators may provide consistent protection for the wearer while performing nursing procedures.


Participants were a group of nursing students (N = 120). The best fitting respirator for these participants was identified from the 3 common models, 1860, 1860S, and 1870+ (3M), using the quantitative fit test (QNFT) method. Participants performed nursing procedures for 10-minute periods while wearing a backpack containing the portable aerosol spectrometers throughout the assessment to detect air particles inside the respirator.


The average fit factor of the best fitting respirator worn by the participants dropped significantly after nursing procedures (184.85 vs 134.71) as detected by the QNFT. In addition, significant differences in particle concentration of different sizes (>0.3, >0.4, >1.0, and >4.0 µm) inside the respirator were detected by the portable aerosol spectrometers before, during, and after nursing procedures.


Body movements during nursing procedures may increase the risk of face seal leakage. Further research, including the development of prototype devices for better respirator fit, is necessary to improve respiratory protection of users.

Trump & Deadly Disease

NY Times

  • “…..President Trump’s budget would cut funding for the National Institutes of Health by 18 percent.
  • It would cut the State Department and the United States Agency for International Development, a key vehicle for preventing and responding to outbreaks before they reach our shores, by 28 percent.
  • And the repeal of the Affordable Care Act would kill the billion-dollar Prevention and Public Health Fund, which provides funding for the Centers for Disease Control and Prevention to fight outbreaks of infectious disease.
  • (While the budget also calls for the creation of an emergency fund to respond to outbreaks, there is no indication that it would offset the other cuts, or where the money would come from.)
  • We are already witnessing an outbreak of influenza in birds — the H7N9 strain, in China — that could be the source for the next human pandemic. Since October, over 500 people have been infected; more than 34 percent have died. Most victims had contact with infected poultry, yet three recent clusters appear to be from person-to-person transmission. Will H7N9 mutate to become easily transmitted between humans? We don’t know. But without sufficient supplies of a vaccine, we are not prepared to stop it…….”

Two US senators and three members of Congress penned a letter this week to Tom Price, the secretary of Health and Human Services (HHS), voicing their concern over President Trump’s proposed cuts to government agencies whose work enables pandemic preparedness.

Letter to Tom Price

Inauguration Day Crowds in Washington, D.C.




US officials charged with preparing the country for influenza pandemics conclude that the stored H7N9 vaccine doesn’t adequately protect against a new branch of this virus family, and a new vaccine is needed.


“…the Biomedical Advanced Research and Development Authority, or BARDA, said the H7N9 vaccine in the [US Strategic National Stockpile (SNS)] would not fend off a new family of these viruses that has emerged in China, known as the eastern or Yangtze River Delta lineage of the viruses….”

  • The H7N9 virus is evolving and has essentially split into two groups that are now different enough that vaccine for one might not protect very well against viruses from the other.
  • The US stockpile currently contains enough vaccines to inoculate about 12 million people against the older lineage of H7N9, the southern or Pearl River Delta viruses.
  • The vaccines in the pandemic flu stockpile are intended to protect first responders in the case one of the highest-risk bird flu viruses triggers a pandemic. BARDA’s policy is to maintain enough vaccine for each of these top threats to be able to vaccinate 20 million people. As each person would need both a primer and a booster dose, that means 40 million doses of vaccine for each viral threat.


Markers of Disease Severity in Patients with Spanish Influenza in the Japanese Armed Forces, 1919–1920

EID Journal

Kudo K, Manabe T, Izumi S, Takasaki J, Fujikura Y, Kawana A, et al. Markers of disease severity in patients with Spanish influenza in the Japanese Armed Forces, 1919–1920. Emerg Infect Dis. 2017 Apr [date cited].

“…..The first and second waves of the Spanish influenza pandemic in Japan affected ≈21 million persons (257,000 deaths) and 2 million persons (127,000 deaths), respectively. ……….

The Study

We analyzed medical charts preserved at the former First Army Hospital in Tokyo, Japan, and other affiliated hospitals. We previously described the clinical features of Spanish influenza among patients who were hospitalized at several study sites (2). Recently, additional records of patients affected by the second wave of disease during 1919–1920 were discovered, and these patients were the subjects of this study.

A total of 470 patients hospitalized during January 1919–January 1920 and diagnosed with Spanish influenza (as “epidemic cold” or “pneumonia due to epidemic cold”) fit the criteria for inclusion in the study. All patients were male soldiers or officers in the military of Japan. We collected data concerning patients’ general background and physical assessments, including lung sounds and fever charts. Among all patients, 8 (2%) died. We divided the patients who survived (n = 462, 98%) into 3 groups on the basis of hospitalization length: <10 days (28%), 11–20 days (34%), and >21 days (36%); we compared variables among the 3 groups. High fever was defined as a body temperature >38°C, and diphasic fever was defined as a body temperature >38°C after the initial fever had decreased to <37.5°C. Data on adventitious lung sounds collected during the hospitalization period were classified (on the basis of international classifications) as continuous, discontinuous, bronchial on the chest wall, and friction rub sounds (3). The study was approved by the Institutional Review Board of the National Center for Global Health and Medicine, Tokyo, Japan.

Of the 8 patients who died, 6 died within 10 days of hospital admission. Median length of hospitalization was 7 days for nonsurvivors and 16 days for survivors. The proportion of patients with audible adventitious lung sounds was significantly higher among those hospitalized for >21 days and among those who did not survive (Table 1( Factors associated with the length of hospitalization in survivors (identified by using a Cox hazard proportional model) included diphasic fever, >6 days of continuing high fever from admission, a maximum respiration rate >26 breaths/min, and adventitious discontinuous lung sounds (Table 2(……”

A new study indicates that the antiviral drug oseltamivir can reduce influenza infections and prevent deaths in a cost-saving manner under most pandemic scenarios.

British Journal of Clinical Pharmacology


Oseltamivir 75 mg relative to no treatment reduced the median number of infected patients, increased ΔQALY by deaths averted, and was cost-saving under all scenarios; 150 mg relative to 75 mg was not cost effective in low transmissibility scenarios but was cost saving in high transmissibility scenarios……”



Coalition for Epidemic Preparedness Innovations raises $500 million

NY Times

“Stung by the lack of vaccines to fight the West African Ebola epidemic, a group of prominent donors announced Wednesday that they had raised almost $500 million for a new partnership to stop epidemics before they spiral out of control.

The partnership, the Coalition for Epidemic Preparedness Innovations, will initially develop and stockpile vaccines against three known viral threats, and also push the development of technology to brew large amounts of vaccine quickly when new threats…arise……Bill Gates, founder of the Bill and Melinda Gates Foundation, one of the largest initial donors…has often predicted that the catastrophe most likely to kill 10 million people in the near future is a pandemic rather than nuclear war, terrorism, famine or natural disaster.

The other donors….include the governments of Japan and Norway, and Britain’s Wellcome Trust. Each is putting up $100 million to $125 million over five years; Germany, India and the European Commission are expected to announce donations soon.

Six major vaccine makers — GlaxoSmithKline, Johnson & Johnson, Merck, Pfizer, Sanofi and Takeda — joined in the coalition as “partners” rather than donors, as did the World Health Organization and Doctors Without Borders……”


GlaxoSmithKline Plc, Johnson & Johnson and Sanofi are among drugmakers backing an effort to develop new vaccines that could be deployed swiftly to contain outbreaks before they spark global emergencies.


Question to out-going CDC chief: “What scares you the most? What keeps you awake at night?”

Washington Post

His answer:

Frieden: The biggest concern is always for an influenza pandemic. Even in a moderate flu year, [influenza] kills tens of thousands of Americans and sends hundreds of thousands to the hospital. That increase in mortality last year may have been driven in significant part by a worse flu season compared to a mild flu season the prior year. So flu, even in an average year, really causes a huge problem. And a pandemic really is the worst-case scenario. If you have something that spreads to a third of the population and can kill a significant proportion of those it affects, you have the makings of a major disaster.



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