Dr. Theresa Tam Manager, Respiratory Infections Section

1. Pandemic Influenza Planning An Evolution to the Approach for National Communicable Disease Emergencies Dr. Theresa Tam Manager, Respiratory Infections Section Immunization and Respiratory Infections Division Health SantéCanada Canada Teleclass, Association of Local Public Health Agencies, October 21, 2003

2. Outline • Background on influenza virus and pandemics • Evolution of the Canadian Pandemic Influenza Plan • How the Canadian plan and processes were used during the H5N1 and SARS response • How the Plan will be modified: • successes, challenges and lessons learnt from SARS • model for communicable disease emergency response plans

3. Influenza Virus The Pandemic Agent

4. Influenza Virus: orthomyxoviridae • RNA virus, 8 segments mutate or recombine resulting in new viral strains • Lipid membrane contains two spike glycoproteins: • haemagglutinin • neuraminidase

5. ABC of Influenza Virus • Influenza A (avian, humans, swine, equine, marine mammals) • 15 hemagglutinin subtypes • current human strains • H1N1 (H1N2) • H3N2 • Influenza B (humans) • Influenza C (humans, swine) The natural hosts of influenza A

6. Antigenic Shift and Drift Antigenic drift: a gradual change in the hemagglutinin and/or the neuraminidase proteins when the virus goes through a series of minor mutations and evolves over time (Influenza A & B) Antigenic shift: an abrupt and major change in the hemagglutinin and/or the neuraminidase proteins resulting in the sudden appearance of a new influenza virus subtype (Influenza A)

7. Influenza Pandemics:How Do They Occur? Type A Type B Annual Flu ANTIGENIC SHIFT Novel virus No resistance Human to human transmission Illnesses and deaths PANDEMIC

8. Pandemic Influenza • What is it? • Why plan for it? • What can be done to prepare for it?

9. Pandemic Influenza History • Spanish Flu 1918 • Asian Flu 1957 • Hong Kong Flu 1968 Pandemic scares: • Swine Flu 1976 • Hong Kong Avian Flu 1997 and 2003

10. Each Pandemic is Different Year Interval(yrs) Subtype Severity 1889 -- H3N2 moderate 1918 29 H1N1 severe 1957 39 H2N2 severe 1968 11 H3N2 moderate 1977 9 H1N1 mild

11. Pandemic InfluenzaWhat We Know and the Uncertainties • Another influenza pandemic is INEVITABLE • Timing and epidemiology UNPREDICTABLE • SHORT LEAD TIME • presence in Canada < 3 months (much shorter?) • 1st peak in illness within 5-7 months • Outbreaks will occur SIMULTANEOUSLY in multiple locations, in multiple waves

12. Influenza Pandemics: Then and Now • Increase in world population and changing demographics (e.g. immunocompromised hosts) • Jets may spread the disease very rapidly in hours or days • In developed countries • Improved medical care, antibiotics for secondary infections • Vaccines and antivirals for prophylaxis • Antiviral drugs for treatment

13. Pandemic InfluenzaEstimating the Impact Health Resource Scarcity In Canada, if vaccine is unavailable, EXPECT: • 11,000 to 58,000 deaths • 34,000 to 138,000 hospitalizations • 2 to 5 million outpatients • economic costs • health care: $330M to $1.4B • societal: $5B to $38B Societal Disruption

14. Recent Experience with Avian Influenza • 1997 H5N1 in Hong Kong • 18 cases and 6 deaths • Mass culling of poultry • International demand for antiviral drugs • 2003 • H5N1 in China/Hong Kong • Two persons with confirmed infection; two fatalities • H7N7 in the Netherlands • One death and > 80 cases of mild disease in humans associated with affected poultry farms • Human to human spread

15. Pandemic Influenza • Planning & preparing • to better manage • tomorrow’s pandemic • consequences ... • today

16. Preparedness Activities: International

17. Global Agenda for Influenza Surveillance and Control (WHO) Major Themes 1. Improvement in the quality and coverage of virological and epidemiological influenza surveillance 2. Improvement in the understanding of health and economic burden of influenza, including benefits from epidemic control and pandemic preparedness

18. Global Agenda for Influenza Surveillance and Control (WHO) Major Themes 3. Expansion in the use of existing vaccines, particularly in developing countries and in high-risk groups and acceleration in the introduction of new vaccines 4. Increase in national and global epidemic and pandemic preparedness, including vaccine and pharmaceutical supplies

19. Global Influenza Surveillance Network • Virological surveillance 110 national influenza laboratories 1 lab/country >1 lab/country 4 regional reference centres WHO Global Agenda, May 2002 To expand the existing laboratory surveillance network and increase disease surveillance for influenza control and pandemic preparedness.

20. Rationale forStrengthening International Influenza Surveillance • Surveillance of human, wild and domestic animal populations in high risk areas is key to: • vaccine development • development of an early warning system for viruses with pandemic potential Areas where birds, pigs and humans live in close proximity are high risk environments for antigenic drift and shift.

21. WHO Pandemic Phases • Phase 0, Level 0 - Inter-Pandemic period • Phase 0, Level 1 - Novel virus identification in a human • Phase 0, Level 2 - Human infection confirmed • Phase 0, Level 3 - Human-to-Human transmission confirmed • Phase 1 - Pandemic confirmed • Phase 2 - Outbreaks in multiple geographic areas • Phase 3 - End of first wave • Phase 4 - Second or later waves • Phase 5 - Post-Pandemic / Recovery

22. International Pandemic Preparedness • Development of pandemic plans • Approximately 30 countries worldwide have a plan • Use of the WHO Pandemic Phases improves communication and consistency • Requires national coordination and agreement on goals of pandemic preparedness and response • National surveillance for influenza-like illness and influenza viruses • Vaccine strategies • Development of Stockpiles / Antiviral strategy

23. Preparedness Activities Canada

24. Overall Goal of Pandemic Preparedness and Response First, to minimize serious illness and overall deaths, and second to minimize societal societal disruption among Canadians as a result of an influenza pandemic.

25. Pandemic Planning Milestones 1998-2002 • Post H5N1 outbreak in Hong Kong • First national meeting (Jan. 2000) • Federal/Provincial/Territorial Working Agreement (Mar. 2001) • Pandemic vaccine contract (Sep. 2001) • Pandemic Influenza Committee (PIC) (Mar. 2002) • Extensive stakeholder consultations on the Canadian Pandemic Influenza Plan (Summer 2002)

26. Pandemic Planning in Evolution - 2003 • “Exercised” pandemic plan structures & processes • H5N1 in Hong Kong and H7N7 in Netherlands • SARS outbreak • other emergency exercises • TOPOFF2 • Global Mercury – international communications • Incorporating SARS lessons learnt

27. Overview of the Plan • Executive Summary • Overview • List of Annexes • I. INTRODUCTION • Goal of Influenza Pandemic Preparedness and Response • Overview of the Plan • Roles and Responsibilities • The Pandemic Influenza Committee • The Pre-Pandemic Period • The Pandemic Period • The Post-Pandemic Period • II. BACKGROUND • Epidemiology of Pandemic Influenza • Estimated Impact of an Influenza Pandemic on Canadians • Terminology • Pandemic Phases • List of Abbreviations • Legal Issues • Ethical Issues • III. PREPAREDNESS SECTION • Introduction (to Preparedness Section) • Components of the Preparedness Section • Surveillance and Lab Testing • Vaccine Programs • Antivirals • Health Services Emergency Planning • Emergency Services • Public Health Measures • Communications • Planning Activities by Components • Pandemic Planning Checklists • IV. RESPONSE SECTION • Introduction (to Response Section) • Phased Approach • Experience to Date • Key Response Activities by Pandemic Phase WHO Phases • V. RECOVERY SECTION • In development VI. ANNEXES

28. NationalWorking Groups Pandemic Influenza SARS • Surveillance and epidemiology • Laboratorytesting • Vaccines • Antivirals (Special Access Program) • Public Health Measures • Communication • Health Services • Resource Management • Non-Traditional Sites and Workers • Mass fatalities • Clinical Care • Infection Control

29. SARS: Recognition and Response • 14 Feb: Official confirmation of outbreak of atypical pneumonia with 305 cases and 5 deaths, Guangdong • 19 Feb: Hong Kong SAR, 2 cases of influenza A/H5N1 • Canada’s Pandemic Influenza Committee activated • FluWatch surveillance system on alert • Pandemic surveillance protocol developed • Communications strategy and fact sheets • 12 March: 1st WHO global alert for atypical pneumonia • 13 March: Health Canada advised of cases of atypical pneumonia in Ontario and British Columbia

30. Issues, What Issues? Health SantéCanada Canada

31. Successes • Pandemic influenza structures and processes were successfully translated to respond to SARS • Early phases of the national pandemic influenza response tested and applied to another emerging infectious disease • Disease control measures, despite uncertainties, appear to have been largely effective • Rapid knowledge generation and translation through existing networks for influenza and new partnerships • international and national laboratory, epidemiology and clinical care experts worked together • National health crisis communications network worked well

32. Key Challenges • Insufficient public health infrastructure, policies, procedures and legislation to support public health action at all levels • Lack of infrastructure and processes for real time data sharing • Time lag in epidemiologic data generation and application of evidence to public health action • Making decisions on public health measures with insufficient evidence • e.g. travel-related interventions

33. Key Challenges • Laboratory testing • over-testing and inability to prioritise specimens • research versus public health needs • Use of surveillance case definitions for clinical purposes • Retrospective epidemiologic linkage of cases • Communicating the progress and impact of the epidemic to decision makers and the public • National and international inconsistency in case definitions

34. Lessons Learned: Coordination and Operations • Clear command structure required • Provinces without well developed pandemic plans had to create structures immediately to deal with health emergency • Dedicated team leadership is essential • Need to strengthen human resource planning and surge capacity in emergency plans • Psycho-social support: post traumatic stress

35. Lessons Learned: Advance Planning • Incident management structure used at Health Canada • Coordination and Operations • Technical (surveillance, epidemiology, public health guidelines etc.) • Logistics • Crisis communications • Advance Planning Group needed

36. Lessons Learned: Disease Control • Quarantine and isolation measures were generally acceptable to the public • Cancellation of public gatherings will happen regardless of public health recommendations • Multiple partners need to be involved in the implementation of public health measures • Education and information dissemination • media, NGOs, professional societies, businesses, schools… • Blood and border issues will arise quickly

37. Lessons Learned: Surveillance • Lack of integrated mechanisms and processes for surveillance • Strengthen interface between hospital and public health • Epidemiological, clinical and laboratory data linkage • Establish case definitions with rationale • Consistent use of definitions nationally AND strive for international consistency • Pre-establish minimum dataset and data sharing agreements for emerging infectious diseases • Establish mechanism and processes for alerting public health and health care providers in real time

38. Lessons Learned: Outbreak Investigation • Enhance epidemiological capacity at all levels • multi-disciplinary outbreak investigation teams • Improve ability to mobilize resources across jurisdictions • Clarify or establish roles and responsibilities and collaboration mechanisms for a multi-jurisdictional response • Increase training programs, including short courses that can be rapidly implemented

39. Lessons Learned: Communication • Pre-established national networks worked; need to strengthen international networks • Establish communication processes that permit optimal use of all participants time • Human resources needed to translate science (particularly epidemiology) into public information • Potential for case counts to become politicized • Perception IS reality

40. Lessons Learned: Infection Control in Acute Care Settings • Lack of trained infection control personnel • Varying capacity for surveillance and need to coordinate with public health • Negative impact of intensive SARS infection control measures • Health care worker well-being • Increase in other nosocomial infections e.g. MRSA, VRE • Missed or not reported tuberculosis cases • Ongoing training needed e.g. how to put on / remove personal protective equipment

41. Lessons Learned: Health Services Pandemic influenza guidelines useful • Resource management • Managing hospital triaging and transfers • Dedicated SARS units • Lack of supplies • Staff exhaustion • Security requirements • Non-traditional sites / workers • Sites administered through acute care setting • City buses as screening units outside hospitals • Lack of volunteers, no medical/nursing students

42. Response to SARS vs Influenza Pandemics SARS • Goal = Containment Flu Pandemic • Goal = Reducing Morbidity and Mortality • Major challenge to national capacity

43. Looking into the Future • Canadian Pandemic Influenza Plan 2003 • “Exercising” of the Plan • Generic approach to communicable disease emergency plans • Phase approach for advance planning • Antiviral stockpile • Strengthening pandemic preparedness in special populations: First Nations and Inuit, isolated communities

44. Preparedness Activities: Regional and Local Levels

45. Within Canada… • Most Provinces and Territories have developed plans for pandemic influenza • Some provinces and territories are at the stage where they are testing their plans • Local level planning is occurring • Post-SARS high level of recognition for need for plans to mitigate the impact of pandemic influenza

46. Strategies for Local Planning • Get all stakeholders involved • Agree upon goals and objectives • Divide and conquer suing existing expertise • Consolidate and re-assess • Incorporate lessons learned from other experiences that have “challenged” the system or facility – e.g. SARS • Test and evaluate plan and revise as necessary • Ongoing education of stakeholders, potential partners and public

47. References • The BC Pandemic Influenza Preparedness Plan • http://www.bccdc.org/content.php?item=150 • Minnesota Pandemic Influenza Prevention and Control Guidelines • http://www.health.state.mn.us/divs/idepc/diseases/flu/pandemic.html (includes Guide to Local Planning) • WHO website on Global Agenda for Influenza Surveillance and Control <http://www.who.int/csr/disease/influenza/globalagenda/en/>

48. References • Health Canada: FluWatch and SARS <http://www.hc-sc.gc.ca/> • Special Issue: Influenza Vaccine.Vaccine Volume 21 (16) 1 May 2003. • “The State of Infection Surveillance and Control in Canadian Acute Care Hospitals” • Zoutman et al., AJIC, August 2003

49. Acknowledgements The many Canadian experts in public health, epidemiology, infection control, infectious disease, laboratory sciences and communications who continue to contribute their time and expertise to - developing, implementing and evaluating our national SARS response - developing, reviewing and evaluating the Canadian Pandemic Influenza Plan Thank you