AHRQ released a condensed version of a 2007 mass medical care planning guide that contains updated resources and new information specific to H1N1.  Mass Medical Care With Scarce Resources: The Essentials is a resource for community planners to prepare for public health emergencies, such as pandemic flu, when demand for medical resources outweighs supply.  

The 70-page guide sets out a framework of basic steps that planners may take to prepare for a mass casualty event.  It addresses key questions that each community should ask to properly plan for a well coordinated operational response.  The guide addresses ethical and legal issues and provides tips on preparing for the provision of services to address pre-hospital, acute hospital care, alternative care sites, and palliative care during disaster conditions.  To illustrate how to apply these basic principles, the guide also includes a special section on influenza pandemic preparedness.  This new resource is an abbreviated version of AHRQ’s Mass Medical Care With Scarce Resources: a Community Planning Guide.  Mass Medical Care With Scarce Resources: The Essentials was prepared by Sally J. Phillips, R.N., Ph.D., and Kelly J. Johnson, M.P.H., of AHRQ and Ann Knebel, R.N., D.N.Sc., of the HHS Office of the Assistant Secretary for Preparedness and Response. A print copy is available by sending an e-mail to AHRQPubs@ahrq.hhs.gov.

http://www.google.com/hostednews/ap/article/ALeqM5iAkKSOkFd1cVedcZvlEJKdby_P7QD9B157F01

By MARILYNN MARCHIONE (AP) – 15 hours ago

Fast-food places have them. Banks and pharmacies do, too. Now hospitals are opening drive-thrus and drive-up tent clinics to screen and treat a swelling tide of swine flu patients.

Call it McTriage. And yes, you can get Tamiflu with that — if you’re sick enough to need it. Most people aren’t.

The idea behind these efforts is to keep coughing, feverish people out of regular emergency rooms, where they can infect heart attack victims and other very sick patients. The need has soared in recent weeks as flu has spread among schoolchildren before vaccine is available.

In Austin, Texas, Dell Children’s Medical Center had nearly 400 ER visits on Sunday alone, mostly kids with swine flu. Dozens were diverted to two tents outside, and there are plans to add a third.

In Memphis, Tenn., Le Bonheur (pronounced luh-BAHN-uhr) Children’s Hospital has had more than 5,500 kids with flu-like illness seek emergency care since Aug. 1. The hospital set up tents outside its ER on Sept. 11 and already has treated more than 900 cases in them.

Hope and Billy Howard took their 3-year-old daughter, Emma Smith, to one on Sunday. The little girl had a fever that would not break with over-the-counter medicine, complained of belly pain and refused to eat, and her parents could not reach her pediatrician.

"I didn’t know what to give her, and I didn’t want to take any chances," her mother said. At the tent ER, "we were in and out in 15 minutes."

Entire families who are sick have shown up at Bayne-Jones Army Community Hospital in Fort Polk, La., near the Texas state line.

"They just drive up in their pajamas," said Henry Johnson, a physician’s assistant who helped start a tent system there. People pull up, park and go through three tents, where they undergo an exam that includes having their temperature taken. They are usually sent home, with prescriptions if needed.

"It’s working out for us — nothing but rave reviews," he said.

Very few patients have needed to be admitted, doctors running these programs say.

Jim Bentley, policy chief at the American Hospital Association, said many hospitals are trying novel ways to care for more people than their emergency rooms can handle, especially children.

"You’re dealing often with anxious patients who want to know is it OK to care for them at home" versus the hospital, he said. "One thing a tent offers is a less intimidating atmosphere to the child," as opposed to an emergency room with its beeps and other noises and scary trauma cases, he said.

These programs can be part of disaster plans that each hospital must have, said Dr. Pat Crocker, chief of emergency medicine at Dell Children’s in Austin.

"It’s working great for flu, but it can be a model for hospitals all over the country to use for emergency surge capacity for other things," such as natural disasters or explosions, he said.

Under a program at Stanford University in Palo Alto, Calif., many flu patients will not even have to leave their cars.

Stanford Hospitals and Clinics and Lucille Packard Children’s Hospital share an ER, and recently tested a drive-thru system for flu patients in a parking ramp. Forty Red Cross volunteers played the parts of actual patients who sought emergency care in April and May, when swine flu first emerged.

Doctors in the drive-thru drill correctly "admitted" the six volunteers who needed to be hospitalized, and correctly sent the 34 others home, said Dr. Eric Weiss, medical director of disaster planning for the hospitals.

The drive-thru shaved 80 minutes off the typical two-hour wait in the regular emergency room. The plan is to put it into action whenever swine flu patients swamp the ER.

It works like this:

A nurse near the ER stops cars and sends appropriate cases to the drive-thru. Signs tell families to tune the radio to a public broadcasting station that describes what happens next.

"The patient’s automobile acts as a self-contained isolation compartment, a moving exam room," Weiss said. "The hoods of the cars make excellent places to write notes," and medical records are slid under the windshield wipers.

Through the car window, a doctor uses a device that clips on a finger to measure blood pressure, pulse and breathing rates. Fingerstick blood tests can be done.

In nearby tents, diabetics can get a urine test for blood sugar, and heart patients can get an EKG. Portable X-rays are available, too. The last stop has a pharmacy to get vaccine, medicines or a prescription to fill.

http://www.google.com/hostednews/ap/article/ALeqM5h30hTsG16IE9GlKLcHW9BZwlRzQAD9B1HJG80

By JIM GOMEZ (AP)

MANILA, Philippines — Two bomb attacks in one day in the southern Philippines — the first of which killed two U.S. soldiers — could signal that al-Qaida-linked militants are launching a new offensive in the region, officials said Wednesday.

Military officials blamed the Abu Sayyaf group for planting explosives that damaged a bridge used by army tanks Tuesday night, just hours after an improvised land mine exploded under a military convoy carrying American troops.

Both attacks were in Indanan township on Jolo island, where the Abu Sayyaf has jungle strongholds and has evaded joint Philippine and U.S. military operations for years.

The attack on the convoy killed U.S. troops in the southern Philippines for the first time in seven years, and the bridge attack appeared to be directed at hampering the military’s ability to respond to further attacks, said regional military commander Maj. Gen. Benjamin Dolorfino.

"One indication is they might be planning to attack military camps or detachments and they want to limit our mobility," Dolorfino told The Associated Press.

U.S. Maj. Bradley Gordon said the two Americans killed Tuesday were U.S. Army soldiers who were members of the task force deployed to help quell militants in the southern Philippines.

Dolorfino said the two Americans were in the front of a Humvee — one was driving — when it ran over a powerful improvised explosive device buried in the road. The blast was powerful enough to flip the vehicle over. One Philippines marine was also killed and two wounded.

Security analyst Zachary Abuza, who has made extensive studies on the Abu Sayyaf, said U.S. deaths were not likely to alter Washington’s commitment of troops to the southern Philippines because the effort has been held up as a successful civic-oriented campaign that could be replicated elsewhere.

Filipino Sen. Miriam Defensor Santiago, however, questioned why the American troops were in a combat zone when they were supposed to be banned by the Philippine constitution from engaging in local combat.

Santiago has spearheaded efforts to get the government to scrap an agreement that allows American troops to stay in the south to provide training and other noncombat support to Filipino soldiers battling the Abu Sayyaf.

Abu Sayyaf is believed to have about 400 fighters, to have received funds from al-Qaida and is suspected of sheltering militants from the larger Southeast Asian terror group Jemaah Islamiyah.

http://www.google.com/hostednews/ap/article/ALeqM5i6eatUwlDQQIHZiKqXjLHTmQSrogD9B1HABO2

By ROHAN SULLIVAN (AP

MANILA, Philippines — One of the most destructive storms in years extended its deadly path across Southeast Asia, blowing down wooden villages in Cambodia and crushing Vietnamese houses under mudslides after submerging much of the Philippine capital.

The death toll Wednesday climbed past 300 and was rising.

"We’re used to storms that sweep away one or two houses. But I’ve never seen a storm this strong," said Nam Tum, governor of Cambodia’s Kampong Thom province.

The immediate threat was easing as Typhoon Ketsana was downgraded to a tropical depression as it crossed Wednesday into a fourth nation, Laos. But its powerful winds and pummeling rain left a snaking trail of destruction.

Landslides triggered by the storm slammed into houses in central Vietnam on Tuesday, burying at least seven people including five members of the same family, the government said. They were among 52 people killed in the country, some by falling trees, officials said.

The storm destroyed or damaged nearly 170,000 homes and flattened crops across six central Vietnamese provinces, officials said. More than 350,000 people were evacuated from the typhoon’s path, posing a logistical headache to shelter and feed them.

"The scale of the devastation is stretching all of us," said Minnie Portales, a World Vision aid agency official in the Philippines. The agency said it was scrambling to assess the needs of victims in four countries, including the possibility that Laos would have damage.

Parts of hard-hit Quang Nam province were cut off by floodwaters and fallen trees on roads, said local official Nguyen Hoai Phuong. World Vision said Quang Tri province was also unreachable.

In neighboring Cambodia, at least 11 people were killed and 29 injured Tuesday as the storm toppled dozens of rickety houses in Kampong Thom province, about 80 miles (130 kilometers) north of the capital, Phnom Penh.

Five members of the same family died when the storm toppled their home as they ate dinner, said Neth Sophana of the Red Cross. Others were swept away by floodwaters.

Neth Sophana said about 90 homes were destroyed.

Authorities were searching for more victims and rushing food, medical supplies and plastic sheeting for temporary tents to storm-hit areas.

Light rain was falling over some parts of the disaster zone Wednesday, and most rivers had peaked in the morning and were starting to slowly recede, Vietnam’s National Weather Forecast Center said.

But the cleanup task was enormous.

In the Philippines, Ketsana on Saturday triggered the worst flooding in 40 years across a swath of the island nation’s north and submerged riverside districts of the sprawling capital of 12 million people.

Officials said 2.3 million people had their homes swamped, and 400,000 were seeking help in relief centers hastily set up in schools and other public buildings — even the presidential palace. The Philippines death toll stood at 246, with 42 people missing.

Frustration boiled over at some sites.

Flood victims rushed at an army helicopter delivering boxes of clothes to a relief center in Rodriguez town in hard-hit Rizal province just east of the capital, an Associated Press photographer at the scene said. No one was apparently injured.

Elsewhere in Rizal, police said they were investigating reports that flood victims mobbed two convoys carrying relief supplies and pelted the trucks with stones.

At relief centers, women and children clutching bags of belongings lined up for bottled water, boiled eggs and packets of instant noodles for a fourth day. Men waded through thick, gooey sludge back to their homes to clean up the mud — sometimes two feet (half a meter) deep — using shovels and brooms.

Another tropical storm was headed toward the southern Philippines on Wednesday but was still 600 miles (1,000 kilometers) off the coast. If it stays on its current path, it could bring winds more powerful than Ketsana’s and driving rain back to the Manila area Saturday, said Nathaniel Cruz of the government’s weather agency.

The government has declared a "state of calamity" in Manila and 25 storm-hit provinces and estimated the damage at $100 million. It concedes its ability to cope with the disaster is stretched to the limit and has appealed for foreign aid, and accepted pledges from the United States, Australia, Japan and other nations.

Link:  http://www.who.int/dg/speeches/2009/paho_committee_20090928/en/index.html

Mr President, honourable ministers, distinguished delegates, Dr Roses, friends and colleagues in the UN system, ladies and gentlemen,

We are meeting at a time when the first influenza pandemic of the 21st century continues to sweep around the world. When the pandemic comes to an end, sometime in the future, we will see a flurry of assessments of the event, its impact, and how it was managed.

We will also see what the world’s collective action to tackle inequities really means. The performance of individual governments will be scrutinized, as will that of WHO, and that of the international community.

The impact will be judged as negligible, or it will be devastating. Officials over-reacted, or underplayed the threat. The whole thing was overblown, or preparedness was vastly inadequate. The international community did well to address fairness and equity, or it did poorly.

All of these diverse perceptions will find some resonance, depending on where people lived, or worked, or went to school when the first pandemic of the 21st century swept through the world.

I personally believe that this pandemic will be a watershed event. I say this not because we anticipate large numbers of deaths or major disruptions to economies and societies. We do not. WHO continues to assess the impact of the H1N1 pandemic, at the global level, as moderate.

I cannot address this region without talking about performance and the world’s collective action to tackle the influenza pandemic. Let me offer you my assessment of the situation so far. Overall, WHO Member States, especially in this region, development partners, industry, and UN agencies, including the WHO secretariat, have done well.

I can give specific examples to illustrate this. Globally, Member States are seeing a return on the investments made over the last few years in strengthening health systems in the face of the threat from H5N1 avian influenza. Increased surveillance and laboratory capacity has meant we are better prepared than before, though we still have a long way to go.

I thank Member States for their wisdom in revising and adopting the International Health Regulations (2005), which have provided a legal framework for countries and the WHO Secretariat to act responsibly and promptly in their responses.

The region has demonstrated leadership and commitment in its response to the pandemic. On 24 April, in this very building, I connected with Mexico to discuss the outbreak. Later that day, I met with staff from the US Department of Health and Human Services and connected with the Centers for Disease Control and Prevention.

I want to pay tribute to the President of Mexico, who responded with great leadership, transparency, and courage. Mexico provided an early warning to the world. Quite unfairly, the “reward” was a punishment of great economic losses.

Canada and the USA have shown admirable leadership and solidarity in managing their own outbreaks and in supporting the efforts of Mexico and other countries. Argentina, Brazil, Chile and other countries also provided valuable information that has helped us in the response to the pandemic.

Scientists in the US CDC, along with other WHO collaborating centres in Australia, Japan, the UK, and the US, worked tirelessly to study the virus, develop diagnostic reagents, and prepare virus seed strains for vaccine development, which they shared freely with manufacturers in developed and developing countries.

The pharmaceutical industry has also responded, with donations of antivirals by Roche Holding AG and GlaxoSmithKline. The first donation of oseltamivir by Roche has been sent to 121 developing countries. The vaccine industry has also responded with donations of 150 million doses of pandemic vaccine by sanofi-aventis and GlaxoSmithKline. Industry is demonstrating it is part of the solution.

Led by the USA, nine countries, including Brazil from this region, have responded to WHO’s call for solidarity and are donating pandemic vaccines to developing countries. I know that other countries from the region will be making similar announcements shortly.

Overall, the media has been responsible in acting as a bridge of information to the general public. Last but not least, staff within WHO have responded well. They make me proud.

Ladies and gentlemen,

What are our future challenges?

I believe the pandemic will be a watershed event because the consequences are likely to be so uneven and so unfairly felt. The hard-won gains towards the Millennium Development Goals may be reversed, and the prospect of reaching the MDGs by 2015 is ever more remote.

I say this because the pandemic is spreading in a world where differences, in health status, in access to care, in quality of care, and in resources for health, are greater than at any time in recent history.

The overwhelming majority of cases experience mild illness with spontaneous recovery. But as the number of infections mounts, this largely reassuring picture will be undercut by extremes – in the clinical spectrum of disease, in public opinion, in access to vaccines and other interventions, in response capacity, and in impact.

The world will see proof of the validity of arguments public health has been making for decades. Weak health systems cost lives. Equity matters in health in a life-and-death way.

This is nothing new. This is true for a multitude of diseases and health conditions, like HIV/AIDS, tuberculosis, malaria, noncommunicable diseases, and maternal and child health.

But when exactly the same virus causes manageable disruption in wealthy countries, but devastation for health care elsewhere, we will see what inequity really means in a measurable way, in a compressed time frame. We will see this under the bright spotlights of public concern and media attention.

Clinically, this is a virus of extremes. It does not seem to have a middle ground. At one extreme are the mild cases. At the other extreme is a small subset of patients who rapidly fall seriously ill, sometimes going from normal respiratory function to multi-organ failure within 24 hours.

Even if the proportion of severe cases remains small, the numbers will grow and the burden will get bigger as more and more people become infected. Emergency rooms and intensive care units will feel the true heat of the pandemic. Saving these lives depends on rapid access to highly specialized care in highly specialized facilities that are simply not available in large parts of the developing world.

I do not need to say more.

Ladies and gentlemen,

This region is the centre of excellence for primary health care. This region understands the importance of making equity an explicit policy objective. This region has been at the forefront of efforts to address the social determinants of health.

As Dr Roses notes in her annual report, this region takes the principles of primary health care into account in all activities aimed at technical cooperation. In her report, Dr Roses has much to say about the region’s new vision of primary health care. She cites abundant experience showing that this is the most effective approach for promoting equitable and sustainable improvements in health.

Strong health systems organized and managed according to the principles of primary health care give countries the resilience needed to weather global crises – like the severe economic downturn, a climate that is changing for the worse, and an influenza pandemic that is now unstoppable.

I also agree with her observation that many of the challenges facing public health today are largely similar to those that gave rise to the Declaration of Alma-Ata three decades ago. These issues are well worth raising again at a time of economic upheaval and turbulent change.

The financial crisis hit the world where it hurts the most: money. The world has to pay attention. Leaders in sectors with far more clout than public health are experiencing a major shift in thinking about how this world operates at the international level. We are seeing a shift in thinking about what we, collectively, want to achieve.

We are hearing high-level talk about the need to give international systems and policies a moral dimension, and make them responsive to the genuine values and concerns of society. We saw this at the G20 summit last week, which is forging a new world economic order that is inherently more inclusive and more fair.

We hear calls for values like community, equity, and social justice that are new in the vocabulary of world leaders, but very familiar to public health. These are the values long embodied in the primary health care approach.

Perhaps some of our age-old arguments will now be heard as the influenza pandemic, in parallel, proves the point in a way that will be hard to ignore.

I wish you a most productive meeting. In doing so, I also urge you to persist in your agendas for primary health care, equity, and social justice in your unique spirit of pan-American solidarity.

Thank you.

http://edition.cnn.com/2009/WORLD/asiapcf/09/30/samoa.earthquake/ 

Dozens dead as tsunami slams into Samoan islands

CNN) — A huge emergency effort is under way in the Samoan islands after towering tsunami waves triggered by an 8.0 earthquake left dozens dead and entire villages flattened or submerged.

A damaged boat washed up inside a building in Pago Pago, American Samoa.

At least 77 people are so far confirmed dead in American Samoa and neighboring Samoa but officials fear the toll will rise as rescue workers work to reach outlying villages. Seven people were also confirmed killed in Tonga.

The quake hit the small cluster of Samoan islands in the South Pacific early Tuesday.

In Samoa, the death toll currently stands at 55, according to government minister Maulolo Tavita, but he said he feared the number of casualities would continue to rise.

In American Samoa 22 people were confirmed dead by late Tuesday. But Salamo Laumoli, director of health services at the LBJ Tropical Medical Center in the capital, Pago Pago, said he feared more fatalities would turn up as rescue workers were still trying to access parts of the island severed by damaged infrastructure.

"I thought it was the end of the world," said Laumoli. "I have never felt an earthquake like that before."

In Tonga, Lord Tuita, the acting prime minister, said at least seven people have been confirmed dead on the northern island of Niuatoputapu. Three others were missing and four people were being treated for serious injuries, he said.

"The hospital on the island is reported to have suffered major damage; telephone communications has been cut as a result of damage to equipment and facilities on the island; homes and government buildings have been destroyed; the airport runway has been severely damaged making it impossible for any fixed wing aircraft to land," a statement from the Tongan prime minister’s office said.

A series of aftershocks reverberated through the region Tuesday as reports emerged of entire villages flattened or submerged by the tsunami. The walls of water were so strong that they twisted concrete beams and mangled cars. Roads, buildings and private homes were heavily damaged.

Laumoli said people in outlying villages on one end of the main American Samoa island have been cut off because the connecting bridge was washed away.

The Pacific Tsunami Warning Center in Ewa Beach, Hawaii, has canceled tsunami watches and warnings for American Samoa. However, a tsunami advisory is still in effect for for the coastal areas of California and Oregon. The Japan Meteorological Agency canceled a tsunami advisory along its eastern coast Wednesday. The precautionary alert meant forecasters feared a tsunami wave of less than a foot and a half was possible.

American Samoa Gov. Togiola Tulafono, speaking from Hawaii, said Tuesday’s quake ranked "right up there with some of the worst" disasters on the island. He said about 50 people had been treated for injuries so far but he expected that number to rise as well.

He said he had spoken to the military about mobilizing reserve forces for assistance.

President Barack Obama declared American Samoa a major disaster area, ordering federal aid to supplement local efforts.

The tsunami waves hit right in the middle of the Pago Pago harbor, just a few feet above sea level.

"The wave came onshore and washed out people’s homes," said Cinta Brown, an American Samoa homeland security official working at the island’s emergency operations center. 

The same happened on the hard-hit east and west sides of American Samoa, said Brown who was standing in a parking lot when her sports utility vehicle began rocking left and right. She could hear the rattling of metal of a large chain-link fence around the lot.

"It shakes you because you know something else is coming," she said.

The quake generated three separate tsunami waves, the largest measuring 5.1 feet from sea level height, said Vindell Hsu, a geophysicist with the Pacific Tsunami Warning Center. Preliminary data had originally reported a larger tsunami.

In Samoa, Tavita, the government minister, said he had spent hours speaking with village mayors and affected families left in shock by the disaster.

Tulafono, the American Samoa governor, was on his way back home from Hawaii on Tuesday night on one of two U.S. Coast Guard C-130 transport planes delivering aid.

The Coast Guard is also transporting more than 20 officials from the Federal Emergency Management Agency to American Samoa, said John Hamill, external affairs officer for FEMA in Oakland, California.

The FEMA team will include a variety of debris experts, housing experts, members of the Corps of Engineers, and other disaster relief specialists, Hamill said.

CNN, 9/30/09:   “At least 23 people died when part of a church collapsed in
eastern Nepal, police said Wednesday.”

Link: �
…. http://edition.cnn.com/2009/WORLD/asiapcf/09/30/nepal.church.collapse/index.html

 Source:  http://edition.cnn.com/2009/WORLD/asiapcf/09/30/samoa.earthquake/index.html

FIGURE. Histochemical and immunohistochemical diagnosis of Streptococcus pneumoniae infection in a patient with confirmed 2009 pandemic influenza A (H1N1). (A) Detection of Gram-positive cocci (arrows) with use of Lillie- Twort Gram stain of lung tissue (original magnification ×63). (B) Immunohistochemical staining of multiple S. pneumoniae (arrows) with use of immunoalkaline phosphatase with naphthol-fast red and hematoxylin counterstain (original magnification ×63).

Source:   CDC (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e0929a1.htm?s_cid=rr58e0929a1_e)