Realistic Community Pan Flu Strategies: Pre-Pandemic Plan P

1. Realistic Community Pan Flu Strategies: Pre-Pandemic Plan (P�) Tom Betz MD, MPH Regional Medical Director Health Service Region 7 Texas Department of State Health Services

2. Questions? What respiratory virus causes over 36,000 deaths in the US every year? What vaccine preventable infection causes more death and disability in Texas and the nation than all other vaccine preventable infections combined?

3. Definitions Epidemic � a located cluster of cases Pandemic � worldwide epidemic

4. Each year is a worldwide epidemic. Meets criteria for pandemic. Influenza

6. Pandemic Influenza It�s all about the virus

7. Each year in the United States, seasonal flu epidemics may cause as many as 50�60 million infections and illnesses. On average 25 million ill people will seek some form of health care and as many as 200,000 people will require hospitalization. Approximately 36,000 deaths are attributed each year to influenza.Each year in the United States, seasonal flu epidemics may cause as many as 50�60 million infections and illnesses. On average 25 million ill people will seek some form of health care and as many as 200,000 people will require hospitalization. Approximately 36,000 deaths are attributed each year to influenza.

8. Pandemic Flu Virus The size of the iceberg will be about the same. The tip of the iceberg may be much greater. The difference is in the virulence/pathogenicity of the virus to cause serious illness and death, not necessarily greater infectivity.

9. Key Medical Idea Anything that we can do to make the pandemic flu strain behave more like a seasonal flu virus will save lives and disability. Identify what makes the pandemic strain unique: Cytokine storm? Level of attachment in the respiratory system?

10. Medical Options Protection or partial protection with vaccines: both seasonal and panflu Use of antivirals Cytokine inhibitors? Antibodies from those previously infected? Some new idea?

11. Influenza Virus Three types A, B, C Surface antigens H (hemagglutinin) N (neuraminidase) Influenza A has subtypes H3N2, H1N1 (common human) H7N7 (avian 2003, The Netherlands) H5N2 (avian vaccine) H9N2 (human case in Hong Kong, SAR China, 2003) H5N1 (current avian strain of concern)

13. The Influenza Virus

14. Key Influenza Components Hemagglutinin (HA) Major antigen of influenza Rod-shaped spikes of glycoproteins Key component of viral attachment to cell Protein most frequently associated with antigenic variation in influenza 16 hemagglutinin subtypes identified Antibody to HA antigens provides immunity

15. Key Influenza Components Neuraminidase (NA) Mushroom-like spikes of glycoproteins Assist in the release of viruses from infected cells Key target of antiviral drugs Tamiflu and Relenza Some antigenic variation 9 subtypes identified Antibodies to NA Decrease viral shedding Decrease illness severity

16. Key Influenza Components M2 protein Transmembrane protein that forms an ion channel for protons Target for amantadine and rimantadine Binding to M2 protein inhibits it from acting as ion channel ? no acidification ?no viral uncoating Influenza A and influenza B have different M2 proteins Amantadine and rimantadine are ineffective against influenza B

17. Nomenclature A/Fujian/411/2002(H3N2) A Influenza type Fujian geographic source 411 isolate number 2002 year of isolation (H3N2) hemaglutinin and neuraminidase subtype others (H1N1), (H5N1) etc.

19. Antiviral Therapy of Influenza M2 inhibitors Amantadine (Symmetrel) Rimantadine (Flumadine) Effective against influenza A only Extensive resistance already exists Not currently recommended Neuraminidase inhibitors Oseltamivir (Tamiflu) oral Zanamivir (Relenza) inhaled Effective against influenza A and influenza B Antiviral therapy must be started within first 48 hours to be of use Decreases duration of symptoms ~24 hours Decreases duration of symptoms up to 3 days in patients with severe disease Real value may be in reducing complications and death

22. Composition of 2007-2008 Influenza vaccine TIV and LAIV A/Wisconsin/67/2005 (H3N2)-like virus * A/Solomon Islands/3/2006 (H1N1)-like virus B/Malaysia/2506/2004-like virus* *- unchanged from last year

23. Vaccine Strains vs Circulating Virus in US: 2003-2008

27. Recorded Influenza Pandemics

28. Pre-1918 Flu Pandemics 1510 1557 1580 1593 1729 1732 1762 1778 1830 1833 1836 1847 1887

29. 20th Century Pandemics

30. 1918 - THE SPANISH LADY The most lethal medical event in the history of mankind Not even Bubonic Plague (The Black Death) killed as many people so rapidly 20 to 30 million deaths worldwide in 4 months ~549,000 to 675,000 deaths in the U.S.A. (~2.5% of the U.S. population at the time) 85% of the deaths in U.S. servicemen in World War I was due to the Spanish Flu Life expectancy decreased by 12 years in the U.S.

31. 1918 In the spring of 1918, as the nation mobilized for war, a Private reported to an Army hospital in Kansas. He was diagnosed with the flu, a disease doctors knew little about. Before the year was out, America would be ravaged by a flu epidemic that killed 675,000--more than in all the wars of this century combined--before disappearing as mysteriously as it began.

32. Practical Epi Principle Every pandemic starts with one person. If you prevent infection in that person, you prevent the pandemic.

33. THE SPANISH FLU In March of 1918, the fourth year of World War I, a cook named Albert Gitchell at Camp Funston in Fort Riley, Kansas became ill with headache, fever, and chills. The next day 40 more soldiers became ill. The next week 522 soldiers were hospitalized Soldiers from Camp Funston were sent aboard cramped military transport boats to multiple bases in Europe. In April of 1918, a severe respiratory illness began raging in England, France, and Spain.

35. THE SPANISH FLU News reports of the illness and death rates were censored during wartime except in Spain where the disease and fatalities were widely reported, hence the name �The Spanish Flu� or �The Spanish Lady� In late August 1918, troops began returning home from Europe and widespread disease began to appear all over the United States. In October 1918, 10% of the U.S. workforce was bedridden. Over 200,000 people in the U.S. died that month. Massive hysteria and panic developed. There was a nationwide shortage of coffins, with mass graves dug in large cities.

37. Avian Flu H5/N1 16 other H serotypes Potential for pandemic real? Bird to human transmission High pathogenicity in humans ? Not yet adapted for human to human transmission

38. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) since 26 December 2003 to 28 May 2008

40. Reassortment (in humans)

41. Reassortment (in pigs)

43. SARS vs Influenza2003 � 2004

45. Pandemic Flu Concerns Pathogenicity: Is it related to inherent characteristics of the virus? Is it related to a pathologic host response that creates extensive tissue damage through immune system release of cytokines and other endogenous agents Is it a combination of both?

46. Questions Do we focus on early identification and containment? Do we focus on damage control? The distribution of resources-vaccines, antivirals-will depend on the approach selected. Medical vs. epidemiologic vs. political/ethical approaches

47. Clinical vs Epidemiological High risk for complications does not equate with high risk for infection. If goal is to limit spread, we need to look past clinical to epidemiologic data.

48. If the objective is to decrease morbidity and mortality How best to do this? Direct reduction of complications in high risk groups once they become infected. VS Reducing spread of infection at the community level and thereby limiting the number of high risk persons who become infected.

49. �In the end, the choice is between illusion or reality�you can�t have both.� Ron Streicher

54. Who is W. Paul Glezen MD and Why Should We Listen to Him? Starting out as a CDC Epidemic Intelligence Service (EIS) Officer assigned to the North Carolina State Health Department in 1957, has 51 years of experience with influenza. Has consistently predicted influenza vaccination and antiviral trends and practices, often besting CDC and DSHS recommendations. Key developer of FluMist and early advocate of the importance of children in the spread of influenza at the community level.

57. Primary Objective: Decide if Texas General Revenue (GR) funds should be used to purchase stockpiles of Tamiflu� as part of CDC coordinated purchase.

58. Group Response:Texas GR funds would be better spent in support of a Pre-Pandemic Plan (P3) that provides a coordinated response platform based on seasonal influenza activities.

59. Overarching strategy:The best way to prepare for pandemic flu is to practice annually on seasonal flu.Code name: P� (P cubed): Pre-Pandemic Plan

60. Components of the P� Strategy: Increase surveillance and rapid virus identification capabilities for seasonal influenza. Universal seasonal influenza vaccination for all Texans Targeted use of antivirals for seasonal influenza in symptomatic individuals (within 48 hours of onset of symptoms) and close contacts to attenuate illness in those infected and prevent spread of infection in those exposed.

61. Components of the P� Strategy (cont.) Establish recommended standards of practice for health care providers regarding the use of antiviral agents for treating and preventing seasonal influenza. Utilize the private practitioner-retail pharmacy network to care for and treat those persons with seasonal influenza who have their own health care providers and insurance coverage. Work with insurance carriers and third party payers to cover antiviral treatment of symptomatic individuals with seasonal influenza and antiviral prophylaxis for family members and close contacts.

62. Components of the P� Strategy (cont.) Develop community response plans to support continuation of essential services; including health care, utilities, maintenance of food and water supplies through retail outlets, and law enforcement/fire department/emergency medical services. Craft and augment educational efforts to establish buy-in and cooperation at the individual and organizational levels within the community. Provide clear and consistent educational messages.

63. Rationale For P3: Seasonal flu is a significant public health problem that is a major cause of morbidity and mortality annually in Texas: 36,000 US deaths attributed to seasonal influenza each year/estimated 3,000 � 4,000 Texas deaths annually.

64. P3 Rationale: (cont.) Seasonal flu and pandemic flu have several characteristics in common: Vaccination against seasonal flu may be expected to offer some degree of cross protection against a pandemic flu strain and avoid a co-infection of seasonal flu on top of a pandemic flu infection.

65. P3 Rationale: (cont.) reducing the impact of seasonal influenza on the citizenry, recruiting the private provider community into the overall response effort, incorporating retail pharmacies into the antiviral distribution pipelines, and providing incentives to pharmaceutical manufacturers to both increase production and availability of antivirals as well as encouraging the research and development of more effective antiviral agents.

66. P3 Rationale: (cont.) Universal seasonal influenza vaccination of the citizenry should be a part of any seasonal influenza / pandemic flu response plan. Current planned national seasonal flu vaccine production (115 million doses) for the coming year falls far short of the 200 million+ doses needed to achieve the goal of universal annual immunization against seasonal influenza. In spite of this, not all vaccine will be used based on past years� experience.

67. P3 Rationale: (cont.) Seasonal flu vaccine is expected to provide at least some partial protection against pandemic flu, in addition to reducing the impact of pandemic flu infection by minimizing risk for seasonal/pandemic flu co-infections.

68. P3 Rationale: (cont.) Public Health should not be expected to carry the full responsibility for addressing the pandemic flu response effort. Nearly 2/3 of Texans currently have health care providers and insurance. This existing framework of care will serve as the primary care and prevention platform for dealing with pandemic flu. The treatment and prevention of seasonal flu should be incorporated into the standards of practice so that this becomes ingrained into the physician/patient/insurance carrier-third party payer relationship/retail pharmacy relationship.

69. P3 Rationale: (cont.) The limited routine use of antivirals in the treatment and prevention of seasonal influenza contributes to the antiviral shortage and limited development of new antiviral agents. Incorporating the use of antivirals into the standards of practice for seasonal influenza would not only integrate the use and distribution of antivirals into mainstream medicine and retail pharmacies but also provide incentives for manufacturers to produce more antivirals, carry out research and development on better antivirals, and allow the systematic rotation of antiviral stocks within this existing network.

70. P3 Rationale: (cont.) Strategic surveillance with rapid testing for seasonal/pandemic flu needs to be in place so that the identification of the introduction of seasonal/pandemic flu into Texas occurs at the earliest possible moment. The ability to rapidly distinguish between seasonal and pandemic flu strains is of vital importance in this early detection effort.

71. P3 Rationale: (cont.) Educational messages to the community, business partners, agencies, and individuals need to be consistent, accurate, and transparent. In the past, this has not always been the case.

74. �Plan? I have a plan. The only problem is it won�t work� Ned Land (Kirk Douglas) Disney�s 20,000 Leagues Under the Sea

75. WWTCD? What would the Commissioner Do? Dr. Eduardo Sanchez addressing the TMA: Fall 2006

76. The Public Health Approach to Pandemic Flu Surveillance and rapid identification Containment if possible Personal hygiene measures Antiviral agents Vaccines Improve response to seasonal flu

77. The best way to prepare for pandemic flu is to practice annually on seasonal flu.Nearly 2/3 of Texans have health care providers & insurance. This existing framework might be better utilized to manage seasonal & pandemic flu. 

78. Components of the Strategy Increase surveillance & rapid virus identification capabilities for seasonal flu. Universal seasonal flu vaccination for all Texans Targeted use of antivirals for seasonal flu in symptomatic individuals & close contacts to attenuate illness in those infected & prevent spread of infection in those exposed.

79. Bottom Line for Medical Professionals Practice good infection control measures Hand washing works Practice standards of care for managing persons with respiratory infections Rapid diagnosis important in establishing etiology

80. Bottom Line for Health Care Facilities Integrate action plans for hospitals, clinics, offices & public health Hospitals will not have adequate beds for expected surge Alternate care sites may be needed Individuals may need to be managed at home, perhaps under semi-hospital room conditions

81. Bottom Line for Home Care Home care will be vital in reducing impact of pandemic flu: Keeping infected isolated at home to minimize risk to others Families will need care guidelines and remote access to free medical resources to concentrate on acute care Cell phone & internet technology may be critical

82. Ethical Issues Ethical issues concerning service delivery during a flu pandemic must be resolved & the roles and responsibilities of staff & specific plans of action agreed to before the crisis. Failure to do so may place staff, patients, and their families at undue risk.

83. �The statement, �It�s worth it if it saves just one life is dangerously false if the same resources, used in a different manner, can save more than one life.�� Wm. Haddon Jr.

84. PanFlu FY 2009 � There is no money. We�ll have to think.� Lord Rutherford

86. How would Gene Roddenberry manage Pandemic Influenza decisions?

87. The Star Trek Corollaries

88. Star Trek Directive Seek out new life and new civilizations Pandemic Influenza Preparedness corollary Watch out for Avian Influenza strains (H5N1) and others. Learn about �exotic� food preparation lifestyles: eg: how to prepare civet cat Community Preparedness for Pandemic Influenza

89. Star Trek Directive Non-interference is the prime directive Pandemic Influenza Preparedness corollary Ignore the prime directive. Non-interference only applies to new worlds and civilizations. Community Preparedness for Pandemic Influenza

90. Star Trek Directive Keep your phaser set on stun Pandemic Influenza Preparedness corollary Wash your hands. Cover your mouth. Make sure you have adequate supplies of influenza vaccine and antivirals. Community Preparedness for Pandemic Influenza

91. Star Trek Directive Humans are highly illogical Pandemic Influenza Preparedness corollary Humans are highly illogical. Common sense is often in short supply in a crisis. The Bob Badger Corollary: �You can�t make things idiot-proof because they keep making better idiots.� Community Preparedness for Pandemic Influenza

92. Star Trek Directive Live long and prosper Pandemic Influenza Preparedness corollary Get your flu and pneumococcal vaccinations. If flu vaccine is not available, fall back on antivirals. Community Preparedness for Pandemic Influenza

93. Star Trek Directive Infinite diversity in infinite combinations Pandemic Influenza Preparedness corollary Viruses do not read medical textbooks. They may not recognize sanctity of species and cross these boundaries. Community Preparedness for Pandemic Influenza

94. Star Trek Directive Tribbles hate Klingons (and Klingons hate Tribbles) Pandemic Influenza Preparedness corollary Make sure that your BERTs (biological emergency response team) and ERNIEs (everyday epi response network for investigative epidemiology) get along. Community Preparedness for Pandemic Influenza

95. Star Trek Directive Enemies are often invisible- like Klingons, they can be cloaked Pandemic Influenza Preparedness corollary Viruses are small. Aerosolized 1- 5 micron droplets can remain suspended for hours. Community Preparedness for Pandemic Influenza

96. Star Trek Directive Don�t put all of your ranking officers in one shuttlecraft Pandemic Influenza Preparedness corollary Don�t order all of your influenza vaccine from one provider. Community Preparedness for Pandemic Influenza

97. Star Trek Directive When your logic fails, trust a hunch Pandemic Influenza Preparedness corollary No change in directive. Community Preparedness for Pandemic Influenza

98. Star Trek Directive Insufficient data does not compute Pandemic Influenza Preparedness corollary Syntax change: Insufficient data do not compute; Substance change: but that doesn�t keep them from being incorporated into documents, guidelines, and position papers. Community Preparedness for Pandemic Influenza

99. Star Trek Directive If it can�t be fixed, just ask Scotty Pandemic Influenza Preparedness corollary If you�re down to impulse power and in danger of being sucked into a worm hole, call John Burlinson. Community Preparedness for Pandemic Influenza

100. Community Preparedness for Pandemic Influenza Star Trek Directive Even in our own world, sometimes we are aliens Pandemic Influenza Preparedness corollary The world of science and the world of politics have their own separate realities. Both occupy the same time/space continuum if at times appearing incompatible. The Ron Streicher corollary: �In the end, the choice is between illusion and reality�you can�t have both.�

101. Star Trek Directive When going out into the universe, remember, �Boldly go where no man has gone before!� Pandemic Influenza Preparedness corollary Sometimes it�s better to stay home�If you do go out, be sure to take your cell phone and alcohol-based hand sanitizer. Community Preparedness for Pandemic Influenza

103. Dr. McCoy�s 12-Step Pandemic Flu Plan for Earth Every earthling should be immunized against seasonal flu. If seasonal flu vaccine supplies are limited, top priority for flu vaccine should be given to those persons who work or associate with birds or pigs (not your kids, the 4 legged kind). If you have vaccine available after 2 and want to prevent the spread of flu in your communities, vaccinate kids.

104. Dr. McCoy�s 12-Step Pandemic Flu Plan for Earth (cont.) If you can�t figure out how to prioritize everyone and want to avoid all the confusion, make enough vaccine for the planet and see 1. Use your antivirals now. Unlike fine wines or Romulan ale, they don�t improve with age. Support your local docs and pharmacies. They are taking care of most people now �and you�re really going to need them when the big event happens.

105. Dr. McCoy�s 12-Step Pandemic Flu Plan for Earth (cont.) Set up a good early warning detection system. Test quickly and accurately to confirm what is going on. No, you can�t have my Tricorder. Use your own PCR.

106. Dr. McCoy�s 12-Step Pandemic Flu Plan for Earth (cont.) On game day, play your A-team�go to the dance with the people that brung you�or the time to try out a new pair of running shoes is not the day of the marathon. If you�re thinking about closing schools because of seasonal or pandemic flu, it�s probably too late. When you close the barn door behind infected cows, you still have infected, barnless cows.

107. Dr. McCoy�s 12-Step Pandemic Flu Plan for Earth (cont.) If you think you have thought of everything, think some more. If your plan isn�t working, try something else. Please don�t screw this up, I�ll have to deal with the consequences 2 centuries from now.

108. Questions?