Cenários de impacto de uma eventual pandemia de gripe na população portuguesa : morbilidade, mortalidade e necessidade de cuidados de saúde

RESUMO - Introdução — O presente estudo descreve os cenários de impacto que uma eventual pandemia de gripe poderá ter na população portuguesa e nos serviços de saúde. Trata-se de uma versão actualizada dos cenários preliminares que têm vindo a ser elaborados e discutidos desde 2005. Material e métodos — Os cenários assumem que a pandemia ocorrerá em duas ondas das quais a primeira (taxa de ataque: 10%) será menos intensa do que a segunda (taxas de ataque: 20%, 25% ou 30%). Neste trabalho são descritos apenas os cenários respeitantes à situação mais grave (taxa de ataque global = 10% + 30%). A elaboração dos cenários utilizou o método proposto por Meltzer, M. I., Cox, N. J. e Fukuda, K. (1999) mas com quase todos os parâmetros adaptados à população portuguesa. Esta adaptação incidiu sobre: 1. duração da pandemia; 2. taxa de letalidade; 3. percentagem da população com risco elevado de complicações; 4. percentagem de doentes com suspeita de gripe que procurará consulta; 5. tempo entre o início dos sintomas e a procura de cuidados; 6. percentagem de doentes que terá acesso efectivo a antiviral; 7. taxa de hospitalização por gripe e tempo médio de hospitalização; 8. percentagem de doentes hospitalizados que necessitarão de cuidados intensivos (CI) e tempo de internamento em CI; 9. efectividade de oseltamivir para evitar complicações e morte. Resultados — Os cenários correspondentes à situação mais grave (taxa de ataque global: 10% + 30%) são apresentados sem qualquer intervenção e, também, com utilização de oseltamivir para fins terapêuticos. Os resultados sem intervenção para o cenário «provável» indicam: • número total de casos — 4 142 447; • número total de indivíduos a necessitar de consulta — 5 799 426; • número total de hospitalizações — 113 712; • número total de internamentos em cuidados intensivos — 17 057; • número total de óbitos — 32 051; • número total de óbitos, nas semanas com valor máximo — 1.a onda: 2551, 2.a onda: 7651. Quando os cenários foram simulados entrando em linha de conta com a utilização de oseltamivir (considerando uma efectividade de 10% e 30%), verificou-se uma redução dos valores dos óbitos e hospitalizações calculados. O presente artigo também apresenta a distribuição semanal, no período de desenvolvimento da pandemia, dos vários resultados obtidos. Discussão — Os resultados apresentados devem ser interpretados como «cenários» e não como «previsões». De facto, as incertezas existentes em relação à doença e ao seu agente não permitem prever com rigor suficiente os seus impactos sobre a população e sobre os serviços de saúde. Por isso, os cenários agora apresentados servem, sobretudo, para fins de planeamento. Assim, a preparação da resposta à eventual pandemia pode ser apoiada em valores cujas ordens de grandeza correspondem às situações de mais elevada gravidade. Desta forma, a sua utilização para outros fins é inadequada e é vivamente desencorajada pelos autores.

Modelling scenarios of diffusion and control of pandemic influenza, italy

En aquest article es resumeixen els resultats publicats en un informe de l' ISS (Istituto Superiore di Sanità) del desembre de 2006, sobre un model matemàtic desenvolupat per un grup de treball que inclou a investigadors de les Universitats de Trento, Pisa i Roma, i els Instituts Nacionals de Salut (Istituto Superiore di Sanità, ISS), per avaluar i mesurar l'impacte de la transmissió i el control de la pandèmia de grip

Abstracting and correlating heterogeneous events to detect complex scenarios

The research presented in this thesis addresses inherent problems in signaturebased intrusion detection systems (IDSs) operating in heterogeneous environments. The research proposes a solution to address the difficulties associated with multistep attack scenario specification and detection for such environments. The research has focused on two distinct problems: the representation of events derived from heterogeneous sources and multi-step attack specification and detection. The first part of the research investigates the application of an event abstraction model to event logs collected from a heterogeneous environment. The event abstraction model comprises a hierarchy of events derived from different log sources such as system audit data, application logs, captured network traffic, and intrusion detection system alerts. Unlike existing event abstraction models where low-level information may be discarded during the abstraction process, the event abstraction model presented in this work preserves all low-level information as well as providing high-level information in the form of abstract events. The event abstraction model presented in this work was designed independently of any particular IDS and thus may be used by any IDS, intrusion forensic tools, or monitoring tools. The second part of the research investigates the use of unification for multi-step attack scenario specification and detection. Multi-step attack scenarios are hard to specify and detect as they often involve the correlation of events from multiple sources which may be affected by time uncertainty. The unification algorithm provides a simple and straightforward scenario matching mechanism by using variable instantiation where variables represent events as defined in the event abstraction model. The third part of the research looks into the solution to address time uncertainty. Clock synchronisation is crucial for detecting multi-step attack scenarios which involve logs from multiple hosts. Issues involving time uncertainty have been largely neglected by intrusion detection research. The system presented in this research introduces two techniques for addressing time uncertainty issues: clock skew compensation and clock drift modelling using linear regression. An off-line IDS prototype for detecting multi-step attacks has been implemented. The prototype comprises two modules: implementation of the abstract event system architecture (AESA) and of the scenario detection module. The scenario detection module implements our signature language developed based on the Python programming language syntax and the unification-based scenario detection engine. The prototype has been evaluated using a publicly available dataset of real attack traffic and event logs and a synthetic dataset. The distinct features of the public dataset are the fact that it contains multi-step attacks which involve multiple hosts with clock skew and clock drift. These features allow us to demonstrate the application and the advantages of the contributions of this research. All instances of multi-step attacks in the dataset have been correctly identified even though there exists a significant clock skew and drift in the dataset. Future work identified by this research would be to develop a refined unification algorithm suitable for processing streams of events to enable an on-line detection. In terms of time uncertainty, identified future work would be to develop mechanisms which allows automatic clock skew and clock drift identification and correction. The immediate application of the research presented in this thesis is the framework of an off-line IDS which processes events from heterogeneous sources using abstraction and which can detect multi-step attack scenarios which may involve time uncertainty.

Dense Correspondence Extraction in Difficult Uncalibrated Scenarios

The relationship between multiple cameras viewing the same scene may be discovered automatically by finding corresponding points in the two views and then solving for the camera geometry. In camera networks with sparsely placed cameras, low resolution cameras or in scenes with few distinguishable features it may be difficult to find a sufficient number of reliable correspondences from which to compute geometry. This paper presents a method for extracting a larger number of correspondences from an initial set of putative correspondences without any knowledge of the scene or camera geometry. The method may be used to increase the number of correspondences and make geometry computations possible in cases where existing methods have produced insufficient correspondences.

Contrasting scenarios : embracing speech recognition

The purpose of this chapter is to describe the use of caricatured contrasting scenarios (Bødker, 2000) and how they can be used to consider potential designs for disruptive technologies. The disruptive technology in this case is Automatic Speech Recognition (ASR) software in workplace settings. The particular workplace is the Magistrates Court of the Australian Capital Territory.----- Caricatured contrasting scenarios are ideally suited to exploring how ASR might be implemented in a particular setting because they allow potential implementations to be “sketched” quickly and with little effort. This sketching of potential interactions and the emphasis of both positive and negative outcomes allows the benefits and pitfalls of design decisions to become apparent.----- A brief description of the Court is given, describing the reasons for choosing the Court for this case study. The work of the Court is framed as taking place in two modes: Front of house, where the courtroom itself is, and backstage, where documents are processed and the business of the court is recorded and encoded into various systems.----- Caricatured contrasting scenarios describing the introduction of ASR to the front of house are presented and then analysed. These scenarios show that the introduction of ASR to the court would be highly problematic.----- The final section describes how ASR could be re-imagined in order to make it useful for the court. A final scenario is presented that describes how this re-imagined ASR could be integrated into both the front of house and backstage of the court in a way that could strengthen both processes.

Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments.

Executive summary Objective: The aims of this study were to identify the impact of Pandemic (H1N1) 2009 Influenza on Australian Emergency Departments (EDs) and their staff, and to inform planning, preparedness, and response management arrangements for future pandemics, as well as managing infectious patients presenting to EDs in everyday practice. Methods This study involved three elements: 1. The first element of the study was an examination of published material including published statistics. Standard literature research methods were used to identify relevant published articles. In addition, data about ED demand was obtained from Australian Government Department of Health and Ageing (DoHA) publications, with several state health departments providing more detailed data. 2. The second element of the study was a survey of Directors of Emergency Medicine identified with the assistance of the Australasian College for Emergency Medicine (ACEM). This survey retrieved data about demand for ED services and elicited qualitative comments on the impact of the pandemic on ED management. 3. The third element of the study was a survey of ED staff. A questionnaire was emailed to members of three professional colleges—the ACEM; the Australian College of Emergency Nursing (ACEN); and the College of Emergency Nursing Australasia (CENA). The overall response rate for the survey was 18.4%, with 618 usable responses from 3355 distributed questionnaires. Topics covered by the survey included ED conditions during the (H1N1) 2009 influenza pandemic; information received about Pandemic (H1N1) 2009 Influenza; pandemic plans; the impact of the pandemic on ED staff with respect to stress; illness prevention measures; support received from others in work role; staff and others’ illness during the pandemic; other factors causing ED staff to miss work during the pandemic; and vaccination against Pandemic (H1N1) 2009 Influenza. Both qualitative and quantitative data were collected and analysed. Results: The results obtained from Directors of Emergency Medicine quantifying the impact of the pandemic were too limited for interpretation. Data sourced from health departments and published sources demonstrated an increase in influenza-like illness (ILI) presentations of between one and a half and three times the normal level of presentations of ILIs. Directors of Emergency Medicine reported a reasonable level of preparation for the pandemic, with most reporting the use of pandemic plans that translated into relatively effective operational infection control responses. Directors reported a highly significant impact on EDs and their staff from the pandemic. Growth in demand and related ED congestion were highly significant factors causing distress within the departments. Most (64%) respondents established a ‘flu clinic’ either as part of Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments. the ED operations or external to it. They did not note a significantly higher rate of sick leave than usual. Responses relating to the impact on staff were proportional to the size of the colleges. Most respondents felt strongly that Pandemic (H1N1) 2009 Influenza had a significant impact on demand in their ED, with most patients having low levels of clinical urgency. Most respondents felt that the pandemic had a negative impact on the care of other patients, and 94% revealed some increase in stress due to lack of space for patients, increased demand, and filling staff deficits. Levels of concern about themselves or their family members contracting the illness were less significant than expected. Nurses displayed significantly higher levels of stress overall, particularly in relation to skill-mix requirements, lack of supplies and equipment, and patient and patients’ family aggression. More than one-third of respondents became ill with an ILI. Whilst respondents themselves reported taking low levels of sick leave, respondents cited difficulties with replacing absent staff. Ranked from highest to lowest, respondents gained useful support from ED colleagues, ED administration, their hospital occupational health department, hospital administration, professional colleges, state health department, and their unions. Respondents were generally positive about the information they received overall; however, the volume of information was considered excessive and sometimes inconsistent. The media was criticised as scaremongering and sensationalist and as being the cause of many unnecessary presentations to EDs. Of concern to the investigators was that a large proportion (43%) of respondents did not know whether a pandemic plan existed for their department or hospital. A small number of staff reported being redeployed from their usual workplace for personal risk factors or operational reasons. As at the time of survey (29 October –18 December 2009), 26% of ED staff reported being vaccinated against Pandemic (H1N1) 2009 Influenza. Of those not vaccinated, half indicated they would ‘definitely’ or ‘probably’ not get vaccinated, with the main reasons being the vaccine was ‘rushed into production’, ‘not properly tested’, ‘came out too late’, or not needed due to prior infection or exposure, or due to the mildness of the disease. Conclusion: Pandemic (H1N1) 2009 Influenza had a significant impact on Australian Emergency Departments. The pandemic exposed problems in existing plans, particularly a lack of guidelines, general information overload, and confusion due to the lack of a single authoritative information source. Of concern was the high proportion of respondents who did not know if their hospital or department had a pandemic plan. Nationally, the pandemic communication strategy needs a detailed review, with more engagement with media networks to encourage responsible and consistent reporting. Also of concern was the low level of immunisation, and the low level of intention to accept vaccination. This is a problem seen in many previous studies relating to seasonal influenza and health care workers. The design of EDs needs to be addressed to better manage infectious patients. Significant workforce issues were confronted in this pandemic, including maintaining appropriate staffing levels; staff exposure to illness; access to, and appropriate use of, personal protective equipment (PPE); and the difficulties associated with working in PPE for prolonged periods. An administrative issue of note was the reporting requirement, which created considerable additional stress for staff within EDs. Peer and local support strategies helped ensure staff felt their needs were provided for, creating resilience, dependability, and stability in the ED workforce. Policies regarding the establishment of flu clinics need to be reviewed. The ability to create surge capacity within EDs by considering staffing, equipment, physical space, and stores is of primary importance for future pandemics.

Incorporating authentic assessment into different university learning scenarios

There is a current requirement for universities to prepare graduates who are skilled in practical as well as theoretical knowledge of the workplace. It is argued in this paper that assessment, as integral to the teaching/learning process, should also relate to the real world context of the workplace, in that students are able to transform, use and apply the knowledge that they learn into these contexts. While assessment authentic for students in a university setting is often a difficult task for lecturers. This paper discusses three different learning contexts that involved different assessment experiences linked in some way to real world learning and application of the theory. The results of the trial indicated that as contexts became close to a real world experience, the sustainability of the assessment became more problematic. While acknowledging the difficulty of these practices, it is suggested that there is a need for a continuous cycle of evaluation amid some creative and innovative approaches to assessment practice.

Prospective bus rapid transit scenarios for pilot corridor in Dhaka

Dhaka doesn’t have a mature transport system. Lacking in institutional arrangements, policy and planning, and law enforcement, the transport system operates has developed ad hoc and is situationally problematic. Absence of proper coordination between modes, poor public transport system, inadequate pedestrian facilities, and environmental degradation justify full consideration of Bus Rapid Transit (BRT) in Dhaka. BRT centres on sustainable transport principles. BRT is a system, which is capable to mitigate Dhaka’s transport problem if properly planned. In Strategic transport plan of Dhaka three BRT transport corridor has been proposed and BRT pre-feasibility study came up with one pilot corridor for early implementation of BRT. This paper first reviews international best practices then explores various BRT system packages and evaluates the suitability of these BRT packages by analyzing current bus service condition and physical and geometric configuration along the BRT pilot corridor. It concludes by proposing some BRT scenarios, which can be considered for further evaluation with respect to speed, delay, travel time and environmental pollution.

Anticipated behaviours of emergency prehospital medical care providers during an influenza pandemic

Introduction: Emergency prehospital medical care providers are frontline health workers during emergencies. However, little is known about their attitudes, perceptions, and likely behaviors during emergency conditions. Understanding these attitudes and behaviors is crucial to mitigating the psychological and operational effects of biohazard events such as pandemic influenza, and will support the business continuity of essential prehospital services. ----- ----- Problem: This study was designed to investigate the association between knowledge and attitudes regarding avian influenza on likely behavioral responses of Australian emergency prehospital medical care providers in pandemic conditions. ----- ----- Methods: Using a reply-paid postal questionnaire, the knowledge and attitudes of a national, stratified, random sample of the Australian emergency prehospital medical care workforce in relation to pandemic influenza were investigated. In addition to knowledge and attitudes, there were five measures of anticipated behavior during pandemic conditions: (1) preparedness to wear personal protective equipment (PPE); (2) preparedness to change role; (3) willingness to work; and likely refusal to work with colleagues who were exposed to (4) known and (5) suspected influenza. Multiple logistic regression models were constructed to determine the independent predictors of each of the anticipated behaviors, while controlling for other relevant variables. ----- ----- Results: Almost half (43%) of the 725 emergency prehospital medical care personnel who responded to the survey indicated that they would be unwilling to work during pandemic conditions; one-quarter indicated that they would not be prepared to work in PPE; and one-third would refuse to work with a colleague exposed to a known case of pandemic human influenza. Willingness to work during a pandemic (OR = 1.41; 95% CI = 1.0–1.9), and willingness to change roles (OR = 1.44; 95% CI = 1.04–2.0) significantly increased with adequate knowledge about infectious agents generally. Generally, refusal to work with exposed (OR = 0.48; 95% CI = 0.3–0.7) or potentially exposed (OR = 0.43; 95% CI = 0.3–0.6) colleagues significantly decreased with adequate knowledge about infectious agents. Confidence in the employer’s capacity to respond appropriately to a pandemic significantly increased employee willingness to work (OR = 2.83; 95% CI = 1.9–4.1); willingness to change roles during a pandemic (OR = 1.52; 95% CI = 1.1–2.1); preparedness to wear PPE (OR = 1.68; 95% CI = 1.1–2.5); and significantly decreased the likelihood of refusing to work with colleagues exposed to (suspected) influenza (OR = 0.59; 95% CI = 0.4–0.9). ----- ----- Conclusions:These findings indicate that education and training alone will not adequately prepare the emergency prehospital medical workforce for a pandemic. It is crucial to address the concerns of ambulance personnel and the perceived concerns of their relationship with partners in order to maintain an effective prehospital emergency medical care service during pandemic conditions.

Attitudes to living and working in pandemic conditions among emergency prehospital medical care personnel

Introduction: Little is known about the risk perceptions and attitudes of healthcare personnel, especially of emergency prehospital medical care personnel, regarding the possibility of an outbreak or epidemic event. Problem: This study was designed to investigate pre-event knowledge and attitudes of a national sample of the emergency prehospital medical care providers in relation to a potential human influenza pandemic, and to determine predictors of these attitudes. Methods: Surveys were distributed to a random, cross-sectional sample of 20% of the Australian emergency prehospital medical care workforce (n = 2,929), stratified by the nine services operating in Australia, as well as by gender and location. The surveys included: (1) demographic information; (2) knowledge of influenza; and (3) attitudes and perceptions related to working during influenza pandemic conditions. Multiple logistic regression models were constructed to identify predictors of pandemic-related risk perceptions. Results: Among the 725 Australian emergency prehospital medical care personnel who responded, 89% were very anxious about working during pandemic conditions, and 85% perceived a high personal risk associated with working in such conditions. In general, respondents demonstrated poor knowledge in relation to avian influenza, influenza generally, and infection transmission methods. Less than 5% of respondents perceived that they had adequate education/training about avian influenza. Logistic regression analyses indicate that, in managing the attitudes and risk perceptions of emergency prehospital medical care staff, particular attention should be directed toward the paid, male workforce (as opposed to volunteers), and on personnel whose relationship partners do not work in the health industry. Conclusions: These results highlight the potentially crucial role of education and training in pandemic preparedness. Organizations that provide emergency prehospital medical care must address this apparent lack of knowledge regarding infection transmission, and procedures for protection and decontamination. Careful management of the perceptions of emergency prehospital medical care personnel during a pandemic is likely to be critical in achieving an effective response to a widespread outbreak of infectious disease.

Projecting future heat-related mortality under climate change scenarios : A systematic review

Background: Heat-related mortality is a matter of great public health concern, especially in the light of climate change. Although many studies have found associations between high temperatures and mortality, more research is needed to project the future impacts of climate change on heat-related mortality. Objectives: We conducted a systematic review of research and methods for projecting future heat-related mortality under climate change scenarios. Data sources and extraction: A literature search was conducted in August 2010, using the electronic databases PubMed, Scopus, ScienceDirect, ProQuest, and Web of Science. The search was limited to peer-reviewed journal articles published in English up to 2010. Data synthesis: The review included 14 studies that fulfilled the inclusion criteria. Most projections showed that climate change would result in a substantial increase in heat-related mortality. Projecting heat-related mortality requires understanding of the historical temperature-mortality relationships, and consideration of the future changes in climate, population and acclimatization. Further research is needed to provide a stronger theoretical framework for projections, including a better understanding of socio-economic development, adaptation strategies, land-use patterns, air pollution and mortality displacement. Conclusions: Scenario-based projection research will meaningfully contribute to assessing and managing the potential impacts of climate change on heat-related mortality.