Ethical, Legal and Social Implications of First Response in Disasters Rome, 11-12 December 2008

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TM Ethical, Legal and Social Implications of First Response in Disasters Rome, 11-12 December 2008 Toby L Merlin, MD Deputy Director, Influenza Coordination Unit US Centers for Disease Control and Prevention Pandemic Influenza: Special Considerations for First Responders

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Ethical, Legal and Social Implications of First Response in Disasters Rome, 11-12 December 2008. Pandemic Influenza: Special Considerations for First Responders. Toby L Merlin, MD Deputy Director, Influenza Coordination Unit US Centers for Disease Control and Prevention. - PowerPoint PPT Presentation

Transcript of Ethical, Legal and Social Implications of First Response in Disasters Rome, 11-12 December 2008

Page 1: Ethical, Legal and Social Implications of First Response in Disasters Rome, 11-12 December 2008

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Ethical, Legal and Social Implications of First Response in Disasters

Rome, 11-12 December 2008

Ethical, Legal and Social Implications of First Response in Disasters

Rome, 11-12 December 2008

Toby L Merlin, MDDeputy Director, Influenza Coordination Unit

US Centers for Disease Control and Prevention

Toby L Merlin, MDDeputy Director, Influenza Coordination Unit

US Centers for Disease Control and Prevention

Pandemic Influenza: Special Considerations for First Responders

Pandemic Influenza: Special Considerations for First Responders

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1996-2001 1996-2004 1996-20081996-2005

Expansion of clade 2 into five 2nd order clades

Expansion of 2nd order clades into additional 3rd order clades

0

5

3

9

0.002 0.005

0

3

4

7

5

6

8

1

2

9

0.005 0.005

0

3

4

7

5

6

9

8

1

2.4

2.1

2.5

2.2

2.3

0

3

7

4

5

69

8

12.4

2.1.1

2.1.22.1.3

2.5

2.2

2.3.1

2.3.22.3.32.3.4

Evolution of the H5 hemagglutinin (Clade 2): 1996-2008

T. Davis-MVVB

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Emergence of Influenza A Viruses in HumansEmergence of Influenza A Viruses in Humans

H1H1

H1H1H3H3

H2H2

H7*H7*

H5*H5*

H9*H9*

19181918SpanishFlu H1N1SpanishFlu H1N1

19571957Asian

Flu H2N2Asian

Flu H2N2

1968 1968Hong KongFlu H3N2

Hong KongFlu H3N2

1980 1996 20021980 1996 2002

1997 2003-2008 1997 2003-2008

1915 1925 1935 1945 1955 1965 1975 1985 1995 20081915 1925 1935 1945 1955 1965 1975 1985 1995 2008

* Avian Flu* Avian Flu

2003 2004

2003 2004

1998 1999

2003

1998 1999

2003

19771977

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Impact of Next PandemicImpact of Next Pandemic

If an influenza pandemic like If an influenza pandemic like 1918-20 occurred today:1918-20 occurred today:

If an influenza pandemic like If an influenza pandemic like 1918-20 occurred today:1918-20 occurred today:

• 62 million people would 62 million people would die worldwide die worldwide

• 96% of deaths in 96% of deaths in developing worlddeveloping world

• Highest deaths among Highest deaths among 15-29 year olds15-29 year olds

• 62 million people would 62 million people would die worldwide die worldwide

• 96% of deaths in 96% of deaths in developing worlddeveloping world

• Highest deaths among Highest deaths among 15-29 year olds15-29 year olds

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Goals of Pandemic MitigationGoals of Pandemic Mitigation

Days since First Case

Dai

ly C

ases

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Pandemic InfluenzaSpecial Considerations for First Responders

in US Government Planning:

Pandemic InfluenzaSpecial Considerations for First Responders

in US Government Planning:

• Ethical principlesEthical principles• Occupational riskOccupational risk• Antiviral medicationAntiviral medication• Pandemic vaccinePandemic vaccine• Planning and coordination (Emergency Planning and coordination (Emergency

Medical Services checklist) Medical Services checklist)

• Ethical principlesEthical principles• Occupational riskOccupational risk• Antiviral medicationAntiviral medication• Pandemic vaccinePandemic vaccine• Planning and coordination (Emergency Planning and coordination (Emergency

Medical Services checklist) Medical Services checklist)

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Ethical Principles Ethical Principles

• Minimizing the harms of an influenza pandemic Minimizing the harms of an influenza pandemic may require targeting resources to specific may require targeting resources to specific groups that protect health and safety and groups that protect health and safety and provide essential community services. provide essential community services.

• Targeting limited resources to protect societal Targeting limited resources to protect societal interests is ethically appropriate.interests is ethically appropriate.

• Minimizing the harms of an influenza pandemic Minimizing the harms of an influenza pandemic may require targeting resources to specific may require targeting resources to specific groups that protect health and safety and groups that protect health and safety and provide essential community services. provide essential community services.

• Targeting limited resources to protect societal Targeting limited resources to protect societal interests is ethically appropriate.interests is ethically appropriate.

Principal of Preserving Function of SocietyPrincipal of Preserving Function of SocietyPrincipal of Preserving Function of SocietyPrincipal of Preserving Function of Society

Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007

Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007

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Ethical Principles Ethical Principles

• Workers who assume increased risks due to their Workers who assume increased risks due to their occupation and who provide benefits broadly to occupation and who provide benefits broadly to society – such as healthcare workers, firefighters, society – such as healthcare workers, firefighters, emergency medical services personnel, etc. – emergency medical services personnel, etc. – should be protected, if possible.should be protected, if possible. • Society has an obligation to provide health Society has an obligation to provide health workers with the protection and tools they need. workers with the protection and tools they need.

• Workers who assume increased risks due to their Workers who assume increased risks due to their occupation and who provide benefits broadly to occupation and who provide benefits broadly to society – such as healthcare workers, firefighters, society – such as healthcare workers, firefighters, emergency medical services personnel, etc. – emergency medical services personnel, etc. – should be protected, if possible.should be protected, if possible. • Society has an obligation to provide health Society has an obligation to provide health workers with the protection and tools they need. workers with the protection and tools they need.

Principle of ReciprocityPrinciple of ReciprocityPrinciple of ReciprocityPrinciple of Reciprocity

Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007

Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007

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Ethical Principles Ethical Principles

• Confronting some degree of personal risk Confronting some degree of personal risk comes with the job of being a health comes with the job of being a health professional or first responder. They have an professional or first responder. They have an ethical contract with society at large. ethical contract with society at large.

• Confronting some degree of personal risk Confronting some degree of personal risk comes with the job of being a health comes with the job of being a health professional or first responder. They have an professional or first responder. They have an ethical contract with society at large. ethical contract with society at large.

Professional ResponsibilityProfessional ResponsibilityProfessional ResponsibilityProfessional Responsibility

Reference: White paper prepared for the Centers for Disease Control and Reference: White paper prepared for the Centers for Disease Control and Prevention. Ethics Subcommittee of the Advisory Committee to the Director. Prevention. Ethics Subcommittee of the Advisory Committee to the Director.

Reference: White paper prepared for the Centers for Disease Control and Reference: White paper prepared for the Centers for Disease Control and Prevention. Ethics Subcommittee of the Advisory Committee to the Director. Prevention. Ethics Subcommittee of the Advisory Committee to the Director.

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Occupational Risk Pyramid for Pandemic Influenza

Occupational Risk Pyramid for Pandemic Influenza

VeryHigh

High

Medium

Lower Risk (Caution)

Reference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health Administration

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Occupational Risk Pyramid for Pandemic Influenza

Occupational Risk Pyramid for Pandemic Influenza

• Performing aerosol-generating Performing aerosol-generating proceduresprocedures

• Performing aerosol-generating Performing aerosol-generating proceduresproceduresVery

High

High

• Entering rooms of suspect patientsEntering rooms of suspect patients

• Transporting suspect patients in Transporting suspect patients in closed vehicleclosed vehicle

• Performing autopsies on suspect Performing autopsies on suspect patientspatients

• Entering rooms of suspect patientsEntering rooms of suspect patients

• Transporting suspect patients in Transporting suspect patients in closed vehicleclosed vehicle

• Performing autopsies on suspect Performing autopsies on suspect patientspatients

Reference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health Administration

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Personal Protective EquipmentPersonal Protective Equipment

• N95 (or higher) respirators during N95 (or higher) respirators during direct contact with pandemic direct contact with pandemic influenza patientsinfluenza patients

• Surgical masks if N95 respirators Surgical masks if N95 respirators not availablenot available

• Use of surgical masks for “source Use of surgical masks for “source control” of symptomatic personscontrol” of symptomatic persons

• Gloves, eye protection, gowns Gloves, eye protection, gowns

• N95 (or higher) respirators during N95 (or higher) respirators during direct contact with pandemic direct contact with pandemic influenza patientsinfluenza patients

• Surgical masks if N95 respirators Surgical masks if N95 respirators not availablenot available

• Use of surgical masks for “source Use of surgical masks for “source control” of symptomatic personscontrol” of symptomatic persons

• Gloves, eye protection, gowns Gloves, eye protection, gowns

Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Setting during and Influenza Pandemic. October 2006. www.pandemicflu.gov Guidance on Preparing Workplaces for an Influenza Pandemic. OSHA 2007. www.pandemicflu.gov

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Antiviral MedicationAntiviral Medication

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Antiviral MedicationAntiviral Medication

Pre-exposure Prophylaxis

Post-exposure Prophylaxis

Rx

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Antiviral Medication:Proposed US Government Guidance

Antiviral Medication:Proposed US Government Guidance

Employers that provide frontline healthcare and Employers that provide frontline healthcare and emergency services should protect employees emergency services should protect employees who will be exposed to ill persons during a who will be exposed to ill persons during a pandemic. This guidance recommends pandemic. This guidance recommends providing providing antiviral prophylaxis to those very antiviral prophylaxis to those very high exposure risk and high exposure risk high exposure risk and high exposure risk employees for the duration of community employees for the duration of community pandemic outbreakspandemic outbreaks..

Employers that provide frontline healthcare and Employers that provide frontline healthcare and emergency services should protect employees emergency services should protect employees who will be exposed to ill persons during a who will be exposed to ill persons during a pandemic. This guidance recommends pandemic. This guidance recommends providing providing antiviral prophylaxis to those very antiviral prophylaxis to those very high exposure risk and high exposure risk high exposure risk and high exposure risk employees for the duration of community employees for the duration of community pandemic outbreakspandemic outbreaks..

Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 www.pandemicflu.govwww.pandemicflu.gov

Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 www.pandemicflu.govwww.pandemicflu.gov

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TMGuidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. www.pandemicflu.gov

Pandemic Influenza VaccinePandemic Influenza VaccineAllocation for US PopulationAllocation for US Population

Pandemic Influenza VaccinePandemic Influenza VaccineAllocation for US PopulationAllocation for US Population

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Pandemic Influenza Vaccination TiersPandemic Influenza Vaccination Tiers

Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. www.pandemicflu.gov www.pandemicflu.gov

Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. www.pandemicflu.gov www.pandemicflu.gov

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Emergency Medical Service ChecklistEmergency Medical Service Checklist

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Toby L Merlin, MDDeputy Director, Influenza Coordination Unit

US Centers for Disease Control and Prevention

Toby L Merlin, MDDeputy Director, Influenza Coordination Unit

US Centers for Disease Control and Prevention

001 404 639 [email protected] 404 639 [email protected]

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References www.pandemicflu.gov

References www.pandemicflu.gov

• Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention, February 2007 (www.cdc.gov)

• Guidance on Antiviral Drug Use during an Influenza Pandemic, December 2008

• Considerations for Antiviral Drug Stockpiling by Employers, December 2008 

• Guidance on Allocating and Targeting Pandemic Influenza Vaccine• Interim Guidance on Planning for the Use of Surgical Masks and

Respirators in Health Care Settings during an Influenza Pandemic, October 2006  

• Emergency Medical Service and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist

• Citizen Voices on Pandemic Flu Choices:  A Report of the Public Engagement Pilot Project on Pandemic Influenza

• Guidance for Preparing Workplaces for a Pandemic (http://www.osha.gov/Publications/OSHA3327pandemic.pdf)

• Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention, February 2007 (www.cdc.gov)

• Guidance on Antiviral Drug Use during an Influenza Pandemic, December 2008

• Considerations for Antiviral Drug Stockpiling by Employers, December 2008 

• Guidance on Allocating and Targeting Pandemic Influenza Vaccine• Interim Guidance on Planning for the Use of Surgical Masks and

Respirators in Health Care Settings during an Influenza Pandemic, October 2006  

• Emergency Medical Service and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist

• Citizen Voices on Pandemic Flu Choices:  A Report of the Public Engagement Pilot Project on Pandemic Influenza

• Guidance for Preparing Workplaces for a Pandemic (http://www.osha.gov/Publications/OSHA3327pandemic.pdf)