Prepared: Come What May

Basic kit : NWS radio, First Aid Kit, Lanterns, Water & Food & cash

 

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I spent some time yesterday  `refreshing’ my freshwater stockpile (40+ gals: enough for me and the cat for a month), rotating my modest supply of soon-to-expire canned foods from my emergencies stores into my `use soon’ pantry, and swapping out my nearly year-old 30-day supply of essential Rx meds (blood pressure & gout) with newer refills, while I use up the old ones.

 

I also changed out the perishables in my `bug out bag’ (see NPM14: When You’ve Got To `Get Out Of Dodge’ In A Hurry), checked the batteries in my flashlights, and inspected my first aid kit(s) to make sure all was in order.  

My Bug-out-bag, Canteen, & Toiletry kit

All in all, I spent a couple of hours, and a few dollars.  Cheap insurance, by any measure.

Not because I’m expecting some sort of cataclysm, or imminent disaster, but because these are the things all of us should be doing on a regular basis in order to be prepared for . ..  whatever comes next.

We are, after all, just a little more than a month from the traditional start of spring tornado season, power outages can happen at any time, and for much of the country, it’s always earthquake season.  While not a worry where I live, we do get occasional hurricanes during the summer months so as not make us feel left out.

 

And while I’m not foolish enough to predict the timing - or the source - of the next pandemic, we do know that pandemics happen.  I’ve lived through three of them (1957, 1968, 2009), along with the pseudo-pandemic of 1977 (the return of H1N1 aka The Russian Flu), and could well see another in my lifetime. 

 

 

 

Having spent a decade in EMS, and fifteen years living aboard boats, I’ve learned how quickly things can turn dicey, often without warning.  I’ve seen how a lack of preparedness – or knowledge of what to do in an emergency - can compound a crisis, and make matters far worse.

And so I do the little things, like keeping some extra food and water on hand (72 hrs should be the minimum), a good first aid kit, a NWS weather radio, and I carry a concise medical history (see Those Who Forget Their History . . . .) in my wallet.

I also have a couple of Disaster buddies (see In An Emergency, Who Has Your Back?) to whom I can turn in a crisis, and who know they can call on me as well.

While the Internet glorifies preparing for doomsday – a Yellowstone eruption, an asteroid strike, or the Zombie Apocalypse – real preparedness means being ready to deal with far more likely (and survivable) threats like fires, floods, storms, power outages, and earthquakes.

 

Simple preparedness doesn’t have to be difficult, time consuming or expensive.  The big obstacle for most people seems to boil down to simply `getting around to it.” 

So today, while you wait for the big game to begin, why not put together your own family emergency kit? 

 

A few gallons of water per person, at least a 72 hours supply of ready-to-eat food supplies, some flashlights and batteries, a first aid kit, (extra points for having an NWS weather radio),  and a family emergency communications plan . . . .

This from Ready.gov.

 

MAKE A PLAN

Your family may not be together when a disaster strikes so it is important to plan in advance: how you will get to a safe place; how you will contact one another; how you will get back together; and what you will do in different situations. Read more about Family Communication during an emergency.

Ready.gov has made it simple for you to make a family emergency plan. Download the Family Communication Plan for Parents and Kids (PDF - 1.2 Mb) and fill out the sections before printing it or emailing it to your family and friends.

You should also inquire about emergency plans at places where your family spends time: work, daycare and school, faith organizations, sports events and commuting. If no plans exist, consider volunteering to help create one. Talk to community leaders, your colleagues, neighbors and members of faith or civic organizations about how you can work together in the event of an emergency. You will be better prepared to safely reunite your family and loved ones during an emergency if you think ahead and communicate with others in advance. Read more about school and workplace plans.

 

 

You don’t have to build a bunker, stockpile a year’s worth of beans and rice, and learn Ninja skills in order to be well prepared.  Small, simple, preps can see you through most emergencies.

 

You make them - not to survive the apocalypse – but in order to buy time until outside help can arrive.

 

Over time you can build out your kit, and hopefully move from having just the bare minimum of 72hrs of supplies, to enough to last a week or 10 days.  For more on how to prepare, visit these websites:

 

FEMA http://www.fema.gov/index.shtm

READY.GOV http://www.ready.gov/

AMERICAN RED CROSS http://www.redcross.org/

 

And you can use this link to find earlier emergency preparedness posts on this blog.

Bulgaria: Additional H5N1 Outbreak Reported

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Earlier this week we saw media reports, and then an OIE Notification Of H5N1 In Bulgaria, when a dead pelican near the Poda Protected Area located south of the port city of Bourgas on the Black Sea tested positive for avian flu. This was the first detection of the virus in Bulgaria since 2010.

Today there are media reports of a small outbreak in the nearby village of Konstantinovo.

 

 

Secondary outbreak of bird flu discovered in Bulgaria’s Konstantinovo

31 January 2015 | 16:36 | FOCUS News Agency

 

Burgas. A secondary outbreak of bird flu was discovered in the village of Konstantinovo, coastal Kameno Municipality, Dr Georgi Mitev, head of the district directorate of the Bulgarian Food Safety Agency, told Radio FOCUS – Burgas.

The case concerns hens in the yard of the village and tests have been run to confirm it but will be officially announced on Monday.

The village borders Lake Mandra, where there are many wild and migratory birds.

(Continue . . .)

 

CDC Interim Guidance On Antiviral Chemoprophylaxis For Persons With Exposure To Avian Flu

Photo Credit – FAO

 

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Last night the CDC released a pair of interim guidance documents for clinicians and public health officials on how to deal with patients suspected of being exposed to novel (primarily avian) influenza. I blogged about the first guidance document earlier today in CDC Interim Guidance For Testing For Novel Flu.

Although we haven’t had to deal with HPAI much in North America, the standard procedure it to treat – prophylactically with antivirals – anyone with known exposure to infected birds. 

 

Often in Asia or the Middle East, this has included cullers who have been charged with destroying an infected flock of poultry, or family members of someone diagnosed with H5N1 or H7N9.  With the recent arrival of HPAI H5 viruses in migratory and wild birds to North America, it is possible that some North American poultry workers (or hunters) may be exposed to infected birds. 

 

While the HPAI H5 viruses currently circulating in North America have not been directly associated with human infection, viruses evolve over time, and the CDC is wisely considering them a potential human health hazard.  The CDC has therefore released the following interim guidance.

 

Interim Guidance on Influenza Antiviral Chemoprophylaxis of Persons Exposed to Birds with Avian Influenza A Viruses Associated with Severe Human Disease or with the Potential to Cause Severe Human Disease

• Español
• Background
• Exposure to Birds Infected with Avian Influenza
• Monitoring of Exposed Persons
• Post-exposure Chemoprophylaxis of Exposed Persons
• Footnotes

Background

This document provides interim guidance for clinicians and public health professionals in the United States on follow-up and influenza antiviral chemoprophylaxis of persons exposed to birds infected with avian influenza A viruses associated either with severe human disease or thought to have the potential to cause severe human disease. Examples of viruses associated with severe human disease include Asian avian influenza A (H5N1) and A (H7N9) viruses. Examples of viruses with the potential to cause severe human disease include avian influenza A (H5N2) and (H5N8) viruses, and a new reassortant avian influenza A (H5N1) virus¹, all of which were detected in wild and domestic birds in North America in December 2014 and January 2015. There is limited experience with these newly detected viruses to inform public health guidance. However, these viruses are thought to have the potential to infect people and cause severe illness. To date no human avian influenza infections have been documented in the U.S. CDC will update this guidance as additional information becomes available.

Exposure to Birds Infected with Avian Influenza

An exposed person is defined as a person with contact² in the past 10 days³ to infected sick or dead birds, or infected flocks. Infected refers to infection with avian influenza A viruses associated with severe human disease or which have the potential to cause severe human disease.

Top of Page

Monitoring of Exposed Persons

Exposed persons should monitor themselves for new illness for 10 days after the last known exposure. The presence of fever and respiratory symptoms (e.g., cough, sore throat, shortness of breath, difficulty breathing) should be assessed daily during this period.

Any exposed person who has a new fever or respiratory symptoms should be referred for prompt medical evaluation, antiviral treatment, and testing for avian influenza (A) virus infection.

Post-exposure Chemoprophylaxis of Exposed Persons

Chemoprophylaxis with influenza antiviral medications can be considered for all exposed persons. Decisions to initiate antiviral chemoprophylaxis should be based on clinical judgment, with consideration given to the type of exposure and to whether the exposed person is at high risk for complications from influenza.

If antiviral chemoprophylaxis is initiated, treatment dosing for the neuraminidase inhibitors oseltamivir or zanamivir (one dose twice daily) is recommended in these instances instead of the typical antiviral chemoprophylaxis regimen (once daily).⁴ For specific dosage recommendations for treatment by age group, please see Influenza Antiviral Medications: Summary for Clinicians. Physicians should consult the manufacturer’s package insert for dosing, limitations of populations studied, contraindications, and adverse effects.

Chemoprophylaxis is not routinely recommended for personnel involved in culling non-infected or likely non-infected bird populations as a control measure or personnel involved in handling sick birds or decontaminating affected environments (including animal disposal) who used proper personal protective equipment.

See CDC guidance for follow-up and antiviral chemoprophylaxis of contacts of cases of human infection with avian influenza A viruses associated with severe human disease.

Footnotes

¹ The H5N1 virus isolated from a US wild bird is a new mixed-origin virus (a “reassortant”) that is genetically different from the avian H5N1 viruses that have caused human infections with high mortality in several other countries (notably in Asia and Africa). No human infections with this new reassortant H5N1 virus have been reported.

² This direct exposure may include: contact with birds (e.g., handling, slaughtering, defeathering, butchering, preparation for consumption); direct contact with surfaces contaminated with feces or bird parts (carcasses, internal organs, etc.); or prolonged exposure to birds in a confined space.

³ The potential incubation period is unknown for avian influenza A viruses which are not yet known to cause human disease. Available data suggest that the estimated incubation period for human infection with H5N1 and H7N9 viruses is generally 3 to 7 days, but has been reported to be as long as 10 days.

⁴ This recommendation for twice daily antiviral chemoprophylaxis dosing frequency is based on limited data that support higher chemoprophylaxis dosing in animals for avian A(H5N1) virus (Boltz DA, et al JID 2008;197:1315) and the desire to reduce the potential for development of resistance while receiving once daily dosing ( BazM, et al NEJM 2009;361:2296; Cane A et al PIDJ 2010;29:384; MMWR 2009;58:969).

CDC Interim Guidance For Testing For Novel Flu

 

Credit NIAID 

 

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While the risk to the public remains low, the importation this month of two cases of H7N9 into Canada from China, the ongoing outbreak of H5N1 in Egypt, and the recent introduction of HPAI H5 viruses via wild and migratory birds into North America are all reasons why doctors around the country need to be aware of the potential for seeing novel flu cases.

The HPAI H5 viruses currently circulating in North America have not been associated with human infection - but they are related to H5 viruses that have - and so they are deserving of extra scrutiny and vigilance.  

Last night the CDC published extensive interim guidelines on the handling of suspected novel flu patients for clinicians and public health entities, excerpts of which I’ve posted below:  They also published Interim Guidance on Influenza Antiviral Chemoprophylaxis of Persons Exposed to Birds with Avian Flu, which I will cover in my next blog.

 

 

Interim Guidance on Testing, Specimen Collection, and Processing for Patients with Suspected Infection with Novel Influenza A Viruses with the Potential to Cause Severe Disease in Humans

On this Page

• Background and Purpose
• Recommendations for Surveillance, Testing, and Investigation
• When Specimens Should Be Collected
• Infection Control when Collecting Specimens
• Preferred Respiratory Specimens
• Swabs
• Storing Clinical Specimens
• Shipping Clinical Specimens to State Public Health Laboratories
• Diagnostic Testing
• Testing at State Health Departments
• Antiviral Treatment
• Shipping Clinical Specimens to CDC

Background and Purpose

This document provides interim guidance for clinicians and public health professionals in the United States on appropriate testing, specimen collection and processing for patients who may be infected with novel influenza A viruses with the potential to cause severe illness in people. Examples of such viruses include Asian-lineage avian influenza A (H5N2), (H5N8), and (H5N1)¹ viruses, which were detected in wild and domestic birds in North America in December 2014 and January 2015; these viruses may have some or all of their genes from Asian avian influenza viruses, but for simplicity will all be referred to as “newly detected avian influenza A H5” viruses in this guidance document. Other newly detected avian influenza A H5 viruses also may have the potential to cause severe disease in humans. For a list of avian influenza A H5 virus infections identified in birds in the United States, and their locations, please see an update on avian influenza findings maintained by the US Department of Agriculture. CDC will update this guidance as additional information becomes available.

The appearance of newly detected avian influenza A H5 viruses in North America may increase the likelihood of human infection with these viruses in the United States. Because these newly identified avian influenza A H5 viruses are related to avian influenza A viruses associated with severe disease in humans (e.g., highly pathogenic Asian-lineage avian influenza A (H5N1) virus), they should be regarded as having the potential to cause severe disease in humans until shown otherwise. Other CDC guidance provides recommendations for influenza viruses known to be associated with severe disease in humans.

¹ The H5N1 virus isolated in the United States in January 2015 is a new mixed-origin virus (a “reassortant”) that is genetically different from the H5N1 virus found in several other countries (notably in Asia and Africa), which has caused human infections with high mortality. Although it is related to the H5N1 virus that has caused human infections with high mortality, the ability of this new reassortant H5N1 virus to cause severe disease is currently unknown.

Recommendations for Surveillance, Testing, and Investigation

Clinicians and public health personnel should consider the following recommendations for surveillance and testing:

1. Consider the possibility of infection with novel influenza A viruses with the potential to cause severe disease in humans in patients with medically-attended influenza-like illness (ILI) and acute respiratory infection (ARI) who have had recent contact¹ (<10 days prior to illness onset) with sick or dead birds in any of the following categories²:
   1. Domestic poultry (e.g., chickens, turkeys, ducks)
   2. Wild aquatic birds (e.g., ducks, geese, swans)
   3. Captive birds of prey (e.g., falcons) that have had contact with wild aquatic birds
2. If infection with a novel influenza A virus with the potential to cause severe disease in humans is possible, respiratory specimens should be collected with appropriate infection control precautions and sent to the state or local health department for immediate testing (see guidance below).
3. If infection with a novel influenza A virus with the potential to cause severe disease in humans is suspected, state health departments are encouraged to initiate a public health investigation with animal health partners and should notify CDC promptly.

¹ Contact may include: direct contact with birds (e.g., handling, slaughtering, defeathering, butchering, preparation for consumption); or direct contact with surfaces contaminated with feces or bird parts (carcasses, internal organs, etc.); or prolonged exposure to birds in a confined space.

² For questions or concerns about possible human infection in patients with exposures to birds not listed here, please contact CDC. Exposures that occur in geographic regions in the United States where newly detected avian influenza A H5 viruses have been identified are of most concern.

When Specimens Should Be Collected

The duration of shedding of novel influenza A viruses in humans is largely unknown, and there are currently limited data describing prolonged shedding of people infected with these viruses. Therefore, the estimated duration of viral shedding is based upon seasonal influenza virus infection. Specimens should be obtained for novel influenza A virus testing as soon as possible after illness onset, ideally within 7 days of illness onset. However, as some persons who are infected with seasonal influenza viruses are known to shed virus for longer periods (e.g., children and immunocompromised persons), specimens should be tested for novel influenza A virus even if obtained after 7 days from illness onset. Note that prolonged shedding of influenza virus in the lower respiratory tract has been documented for critically ill patients with highly-pathogenic avian influenza A H5N1 virus and avian influenza A H7N9 virus infections.

(Continue . . . )

HK CHP Notified Of 2 H7N9 Cases In Guangdong Province

Credit Wikipedia

 

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Guangdong Province’s streak of H7N9 reports continues with two more cases reported to Hong Kong’s CHP today.

 

 

CHP notified of two human cases of avian influenza A(H7N9) in Guangdong

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (January 31) closely monitoring two additional human cases of avian influenza A(H7N9) notified by the Health and Family Planning Commission of Guangdong Province (GDHFPC), and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the GDHFPC, a male patient aged 48 (in Jieyang) died while a female patient aged nine (in Shanwei) is in stable condition and was hospitalised for management.

To date, 504 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities, respectively in Zhejiang (146 cases), Guangdong (142 cases), Jiangsu (63 cases), Shanghai (44 cases), Fujian (28 cases), Hunan (24 cases), Anhui (17 cases), Jiangxi (nine cases), Xinjiang (nine cases), Shandong (six cases), Beijing (five cases), Henan (four cases), Guangxi (three cases), Jilin (two cases), Guizhou (one case) and Hebei (one case).

(Continue . . . )

 

The number of case reports in Guangdong are about on par with what we saw this time last year, unfortunately we’ve heard relatively little news from the other provinces.  Hopefully we’ll get a better idea of China’s overall situation from their respective monthly provincial epidemiological reports and from China’s notifications to the World Health Organization.

CIDRAP News On The Lancet Oseltamivir (Tamiflu ®) Meta-Analysis

Photo Credit – Wikipedia

 

 

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I had plans this morning to write an overview of meta-analysis of Tamiflu effectiveness published January 29th in The Lancet, but I’m happy to note that last night Robert Roos of CIDRAP News has beaten me to it. Since I’m unlikely to improve upon his reportage, I’ll direct you to his excellent review – which you’ll want to read in its entirety - after which I’ll return with a little bit more.

 

Meta-analysis supports oseltamivir use in adults, notes side effects

Robert Roos | News Editor | CIDRAP News

Jan 30, 2015

A comprehensive new meta-analysis on the controversial topic of oseltamivir's effectiveness found that the drug reduces the duration of influenza symptoms and the risk of hospitalization in adults and adolescents, while increasing the risk of nausea and vomiting.

A US-British team, with Arnold S. Monto, MD, of the University of Michigan as senior author, included in the analysis all randomized controlled trials sponsored by Roche, the drug's manufacturer, as well as other relevant trials. The study, reported yesterday in The Lancet, was funded by Roche, but the researchers worked independently.

(Continue.  . . )

 

Over the past few years we’ve seen the demonization of influenza antivirals in the media (see Daily Mail: Ministers blew £650MILLION on useless anti-flu drugs), warnings of potential aberrant psychiatric behavior (see 2007 New Worries On Tamiflu), and repeated Cochrane group analyses that have found insufficient evidence that the drug reduces influenza complications.

Add in some serious foot-dragging by manufacturer Roche in releasing all of their testing data, and Tamiflu has become an easy drug for the public, and some doctors, to distrust.

Despite all of this `baggage’  the CDC, ECDC, UK’s PHE, and other public health agencies have steadfastly supported the early use of oseltamivir in the treatment of severe flu (see this week’s CDC Antiviral Letter to Providers and ECDC Influenza Season Risk Assessment).

The reason?

Even without the `gold standard’ Randomized controlled trials (RCTs) that the Cochrane group relies on for their analyses, we’ve seen numerous observational studies that lend support to the use of antivirals in severe influenza.

 

A few I’ve written about in the past include:

 

• In 2010 we saw an observational study that appeared in JAMA (see Study: Antivirals Saved Lives Of Pregnant Women) that strongly suggested that Tamiflu was life saving for some patients with pandemic flu.
• And again in 2010, in BMJ: Efficacy of Oseltamivir In Mild H1N1, we saw a study which suggested that the administration of oseltamivir may have significantly reduced the incidence of pneumonia among otherwise healthy pandemic H1N1 patients.
• In December of 2012, in Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic we looked at a meta-analysis of 90 observational studies that appeared in the  Journal of Infectious Diseases that spanned nearly 35,000 patients, 85% of whom has laboratory confirmed H1N1.

Their main finding was antiviral therapy - principally oseltamivir - initiated within 48 hours of onset, reduced the likelihood of severe outcomes, namely admission to a critical care unit or death, by 49 to 65%.

• Last March in The Lancet: Effectiveness Of NAI Antivirals In Reducing Mortality In Hospitalized H1N1pdm09 Cases we looked at yet another observational study conducted by researchers at The University of Nottingham – that reviewed more than 29,000 hospitalized H1N1pdm cases across 38 countries between 2009 and 2011, and found that the administration of NAI antivirals was associated with a 19% reduction in mortality compared to receiving no NAI treatment at all.
• And last summer, in  CID Journal: Under Utilization Of Antivirals For At Risk Flu Patients, we saw a study showing that antiviral drugs are underused for at-risk patients, while antibiotics (which don’t work against viral infections) are overused.

 

Added to this, we now have this new meta-analysis of the data from all published and unpublished clinical trials from 1997-2001, involving more than 4,300 patients. Patients with influenza (not just an ILI), who received the drug within 36 hours of onset of symptoms saw a reduction in the duration of their illness of 21% and a significant reduction in the risk of developing pneumonia or requiring hospitalization.

 

While nausea (9.9% vs 6.2% in controls) and vomiting (8.0% vs 3.3%)  were common side effects, no serious adverse reactions were reported, with no increase in psychiatric or neurological symptoms.

 

For uncomplicated influenza in a healthy individual (essentially what the Cochrane studies looked at), antivirals probably offer limited benefits.

 

But for severe influenza, or for people at risk of complications . . .

 

The preponderance of evidence shows that taking antivirals early can limit the severity and duration of symptoms – and for patients at risk of complications – that  could help keep them out of the hospital . . .  or worse.