Scenario 2 - Cluster(s) in New Zealand
It is Mid-February. H5N1 influenza is now spreading person-to-person in Western Sealand. The virus is not yet an efficient spreader so there is no widespread outbreak, although several thousand people have been infected. The case fatality rate is very high, at about 20%. Many of the fatalities collapse and die within a short time of becoming symptomatic, mostly with cyanotic mottling and/or subcutaneous haemorrhage. WHO and the Sealand government are making strenuous efforts to contain the situation, with internal travel restrictions in place and draconian penalties for non-compliance with government directives.
H5N1 is known to exist in birds in many other parts of Asia, but intensive surveillance of these regions has not provided evidence of person-to-person spread. It appears the pandemic strain is contained in Sealand. WHO has not yet issued a world pandemic alert, although it has issued a regional alert for South East Asia and Sealand.
New Zealand borders are closed to Sealand nationals except for those who demonstrate that they are from unaffected regions, pass an exit screening examination in Sealand, and undergo health assessments on arrival in New Zealand. These people are mostly students, business people, and those with family in New Zealand. The flow of people from Sealand is low, because of Sealand government restrictions.
General tourist traffic from Asia is substantially reduced from normal because of uncertainties associated with the pandemic situation. Tourists from Asian countries other than Sealand are not undergoing health assessments at the border, although all aircraft are now required to inform authorities of the health status of people on board before arrival in New Zealand.
In New Zealand there is intensive surveillance concentrated on regions surrounding airports and the normal tourist trails.
On a Saturday afternoon, a Medical Officer of Health (MOoH) of Crossville (in the North Island) contacts the MoH. Two people of Asian extraction turned up at a local GP medical centre on Friday with influenza-like illnesses. They were assessed and swabs taken. They were provided with advice and then discharged.
At about 1100 on Saturday morning, one of these people was found dead in their motel. The hotelier rang the police as part of normal process. The other person cannot be found, and the car in which they came is missing, not having been seen since the night before. The two people had been in the motel for two days since arriving in the country.
The MOoH has seen the body, and noted cyanotic mottling and the fact that the person had been dead for some hours. He is very concerned. He has directed that the unit be sealed for the time being until full infectious disease precautions can be provided for the removal of the body to the morgue.
MoH assembles a CIMS team and informs the Minister of developments. As a number of conditions could be involved, it is decided to wait until results from swabs and a post-mortem become available before making any decisions. MoH liaises with Police about the missing person and advises that if found, the person should be treated as infectious and appropriate precautions taken. MoH also alerts all DHBs and PHUs via a Code Yellow message.
During Sunday, several people present at a nearby Emergency Department (ED) had influenza-like illnesses. Most are itinerant market garden workers and backpacking tourists, living in various hostels and similar accommodation. None require admission. ED is taking full infection control precautions on MoH recommendation.
MoH also recommends that the after-hours surgery takes full infection control precautions, but can only recommend this, as primary care is essentially private business. MoH learns that about a dozen people have turned up at the after-hours surgery with flu-like symptoms, an unusual number for this time of year.
At 2300 on Sunday, the MOoH contacts the Ministry again. After complaining of being unwell in the early evening a receptionist from a local GP medical centre collapsed and died on arrival at the ED. During an attempted resuscitation, infection control precautions were inevitably less than perfect. Another person, whom relatives state went to the after-hours surgery earlier in the day because of the "flu", is now seriously ill in intensive care.
The Ministry re-convenes its CIMS team. In conversations with the local hospital the MoH learns that at around midnight, two more patients turned up at the ED with respiratory and circulatory collapse. At 0300 on Monday morning, the team advises the government that:
- An unknown disease causing respiratory collapse and death is present in the district;
- It may be H5N1 pandemic influenza, but this cannot yet be confirmed;
- The Ministry will put regional DHBs on full pandemic alert through Code Red messages;
- Local hospital staff and facilities, and other medical staff and facilities in the area have probably been exposed;
- The Ministry recommends that:
- The Minister unlocks the special powers available to Medical Officers of Health under the Health Act;
- That the Medical Officer of Health in charge establishes travel restrictions for the area;
- Until appropriate medical screening arrangements can be made, no people or goods should be allowed to move into or out of the area without the express permission of the Medical Officer of Health in charge;
- Public gatherings in the area should be prohibited until further notice;
- Schools, kindergartens, crèches, play-centres, educational campuses of all kinds, public libraries, video stores, game arcades and casinos in the area should not open on the Monday morning, and may be required to remain closed for an indefinite period;
- All possible efforts are made to find the missing Asian person, and to track anybody who is known to have left the area since Saturday.
The Government accepts all the Ministry's recommendations and expects them to be actioned immediately by the appropriate agencies.
Outline of Health Sector Actions
After a declaration of a national Health Emergency, Medical Officers of Health (MOoHs) have a wide range of powers available to detain, quarantine or isolate people who have or may have infectious diseases.
MoH will immediately issue a Code Red pandemic alert message, informing all health practitioners of the situation.
MoH, through their Regional Coordinators, will direct relevant DHBs to prepare for the release of PPE to identified hospitals, primary health care centres and first responders.
No hospital-to-hospital transfers will be made from the Hospital to places outside the infected area. Surveillance will be stepped up to the highest possible state, both in the area and in the rest of the country.
Intensive investigations of the cases in the Hospital will be made, with rapid PCR investigations to confirm or rule out H5N1 avian influenza. Initial results are likely to be available within 12 hours.
MoH will make ready-use supplies of anti-viral medication available to assist with the management of the situation.
MoH's CIMs team will advise the government on appropriate courses of action as the situation develops.
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