North Florida Region Domestic Security Task Force

1. North Florida Region Domestic Security Task Force Pandemic Influenza Workshop Setting the Pace for Florida's Leadership 11/292/05 Version 3.3

2. Pandemic Influenza Workshop Objectives • Raise awareness about impact of pandemic flu on the health care system and the community as a whole. • Increase understanding of the responsibilities of all community partners. • Determine the adequacy of current plans to address the range of anticipated events. • Identify gaps in coordination among community partners. • Promote planning continuity among all community partners. Prior Planning Prevents Pandemic Pandemonium

3. Pandemic Influenza Workshop Format • Education Format: • Influenza Virus Characteristics • History • Surveillance • Planning Prior Planning Prevents Pandemic Pandemonium

4. Pandemic Influenza Workshop Format • Exercise Format: • Interactive Tabletop • 3 Modules • Prepare, Respond, Recover, Mitigate • Hot Wash • Action Plan Prior Planning Prevents Pandemic Pandemonium

5. Pandemic Definition Pandemic: An infectious disease epidemic that affects people worldwide or over an extensive geographical area. Prior Planning Prevents Pandemic Pandemonium

6. Influenza Virus Characteristics Primitive “life” form Only one function: Replication Prior Planning Prevents Pandemic Pandemonium

7. Influenza Virus Infection Virus slips in RNA issues orders Viruses break out High efficiency High mutation rate Confuses body defenses Stellenbosch University, Tygerberg, South Africa Prior Planning Prevents Pandemic Pandemonium

8. Influenza Virus Characteristics Virus Exchange Program Wild Birds -- Chickens Chickens -- Humans Chickens -- Pigs Pigs -- Humans Humans -- Humans Prior Planning Prevents Pandemic Pandemonium

9. H5N1 Outbreak in Birds12/2003 – 03/2006 Countries Affected (confirmed in poultry) * - Only H5 confirmed, neuraminidase not determined December 2003-March 2006 Source: World Health Organization

11. Influenza Virus Transmission Direct – Viral particles are contained in droplets resulting from an uncovered sneeze or cough. Breathing them in can result in an infection. During a sneeze, millions of tiny droplets of water, mucus, and virus particles are expelled at 200 mph. Prior Planning Prevents Pandemic Pandemonium

12. Influenza Virus Transmission Indirect – Viral particles may survive for a short time on many surfaces (hands, door knobs, phones). Touching these surfaces may transmit infection through eyes, nose, or mouth. What precaution do these transmissions suggest? Prior Planning Prevents Pandemic Pandemonium

13. History “No disease the world has ever known even remotely resembles the great influenza epidemic of 1918. Presumed to have begun when sick farm animals infected soldiers in Kansas, spreading and mutating into a lethal strain as troops carried it to Europe, it exploded across the world with unequaled ferocity and speed. It killed more people in twenty weeks than AIDS has killed in twenty years; it killed more people in a year than the plagues of the Middle Ages killed in a century. Victims bled from the ears and nose, turned blue from lack of oxygen, suffered aches that felt like bones being broken, and died. In the United States, where bodies were stacked without coffins on trucks, nearly seven times as many people died of influenza as in the First World War.” Prior Planning Prevents Pandemic Pandemonium

14. History -- Images Prior Planning Prevents Pandemic Pandemonium

15. History – Some Statistics Death Toll Worldwide: 40 - 100 Million Death Toll US: 650,000 Normal Season Flu Death Toll: 36,000 Normal Sean Flu Hospitalizations: 200,000 Most Susceptible Population Age: 15-34 Number of Flu-Orphans in NYC: 21,000 I had a little bird His name was Enza I opened up the window And Influenza Prior Planning Prevents Pandemic Pandemonium

16. History -- Pandemic Spread • Exceptionally Virulent Strain • New and Rapid Population Mixing (Training Camps) • WWI Overseas Deployments • Initial Lack of Communications (Sedition Act) • Quarantine – None early on • Weak Public Health Infrastructure Liberty Bond Rally Prior Planning Prevents Pandemic Pandemonium

17. History – Other Pandemics 1957 Asian Flu -- US Deaths 69,800 1968 Hong Kong Flu – US Deaths 33,800 Pandemic Flu Scares: 1976 Swine Flu 1977 Russian Flu 1997 -1999 Avian Flu Non-Flu Scare: SARS Multi-Country Outbreak SARS Precautions Prior Planning Prevents Pandemic Pandemonium

18. Inter-Pandemic Period – Phases 1 and 2 • Inter-Pandemic Period – Phases 1 and 2 • No new influenza virus • Develop plans and exercise them • Educate the public (throughout all phases) • Vaccinate public • Surveillance Prior Planning Prevents Pandemic Pandemonium

19. Pandemic Alert Period – Phase 3 The phase we are currently in • Pandemic Alert Period—Phase 3 • Human infection with a new subtype • No human to human spread • Monitor the situation via surveillance systems and communication with Florida DOH • Communicate with community partners Prior Planning Prevents Pandemic Pandemonium

20. Pandemic Alert Period – Phase 3 The phase we are currently in • Pandemic Alert Period—Phase 3 Actions • Stockpile masks, hand-sanitizer, anti-virals • Nationally—encouraging the development of vaccine • Nationally—develop more rapid testing methods • State-Increase surge capacity of laboratories Prior Planning Prevents Pandemic Pandemonium

21. Human Cases of H5N1 Avian Flu 2003-2006 55% As of 04/04/06 Source: World Health Organization (laboratory confirmed cases)

22. Pandemic Alert Period – Phase 4 • Pandemic Alert Period—Phase 4 • Limited human to human transmission • Isolate / treat the sick • Vaccinate / treat close contacts • Encourage self-quarantine Prior Planning Prevents Pandemic Pandemonium

23. Pandemic Alert Period – Phase 5 • Pandemic Alert Period—Phase 5 • Larger clusters but still localized • Adjust and maximize resources—questionable use of points of distribution (drugs are trickling in) • If available deploy prototype vaccine • Questionable use of points of distribution • Decision on who to vaccinate (ethics?) • Assess staffing issues • Travel restrictions • Social distancing Prior Planning Prevents Pandemic Pandemonium

24. Pandemic Alert Period – Phase 6 • Pandemic Period-Phase 6 • Increased and sustained transmission • Alternative treatment sites • Ventilator decisions • State resources for aid • Continue risk management • Maintain surveillance, including deaths • Morgue surge capacity • Funeral supplies may be limited Prior Planning Prevents Pandemic Pandemonium

25. Human Surveillance • Sentinel physicians – how many are in your county? • ESSENCE – influenza symptoms, patient load, etc. • BIOSENSE – military hospitals • EpiCom • Vital Statistics – death rates • School absenteeism Prior Planning Prevents Pandemic Pandemonium

26. Surveillance Partners • Sentinel Physicians • Hospitals • County Health Departments • Department of Health and Private Labs • Department of Agriculture and Consumer Services • Centers for Disease Control and Prevention (CDC) • World Health Organization (WHO) • Communication! – Communication! – Communication! Prior Planning Prevents Pandemic Pandemonium

27. Between Waves • Between waves • Ensure staff recovery • Re-stock supplies/medications • Lessons learned to improve Prior Planning Prevents Pandemic Pandemonium

28. Influenza H5N1 – Avian Flu • Current Situation -- Avian Flu – Phase 3: • Bird to Human transmission still very rare • Vaccine in development for birds for H5N1 • Vaccine in development for H5N1 for humans – this is not the same as a human to human virus we are planning for • Human to Human transmission even more rare • We can’t develop a vaccine until we know the human to human strain • Will this be the “Big One”? Prior Planning Prevents Pandemic Pandemonium

29. Request to Fund – National Strategy • Global surveillance $ 251 million • Vaccine technology $ 2.8 billion • Purchase medication • and vaccines $ 800 million • Vaccine for HHS $ 1.5 billion • Stockpile anti-virals $ 1.0 billion • Emergency preparedness $ 644 million • Total $ 7.1 billion Prior Planning Prevents Pandemic Pandemonium DOH – 12/5/05

30. Influenza H5N1 – Avian Flu The thing to Keep in Mind for Now: NOT Recommended. Prior Planning Prevents Pandemic Pandemonium

31. Surveillance Urgency The Clock is Ticking…. We just don’t know what time it is. Pandemic Pandemonium

32. Pandemic Planning Prior Planning Prevents Pandemic Pandemonium

33. Planning Assumptions • We will have an epidemic soon of a strain of influenza to which none of us is immune. • We will likely have only a short window between when the strain is clearly causing disease and when it starts causing widespread disease where we live. • Vaccine likely won’t be available for 6 to 9 months after the epidemic starts. • Supplies of anti-virals will be far less than needed for total-population coverage or even coverage of high-priority groups. Prior Planning Prevents Pandemic Pandemonium

34. Planning Assumptions • Predicted Morbidity Range for Palm Beach County • 35% Attack Rate • Predicted Mortality Rate for Palm Beach County • 5% of those infected Prior Planning Prevents Pandemic Pandemonium

35. Planning Assumptions Prior Planning Prevents Pandemic Pandemonium

36. Planning Assumptions • Once the pandemic takes hold, we have to assume that there will be little to No Help from the national or state level – not just for days, but for weeks, and perhaps months. • We have to assume that every county and every community will be pretty much on its own in an influenza pandemic. • County Health Department will have ICS Lead. Prior Planning Prevents Pandemic Pandemonium

37. Planning Questions • When a vaccine first becomes available, who should get it? • How should we use the limited supplies of antiviral medications? (Tamiflu – 10 doses in five days. Must be taken within 48 hours.) • Given lack of vaccines and anti-virals, how do we approach reducing illness and death? • What is the right balance among minimizing health burden, economic damage, and societal damage? Prior Planning Prevents Pandemic Pandemonium

38. Planning – More Questions • Can we hold the fort till we can get vaccine? • The longer we can delay the onset of the epidemic in our community, the more illness we can prevent. • This will require vigorously applying measures that have limited effectiveness and a strong and continuous, risk communication campaign directed to all of our citizens. Prior Planning Prevents Pandemic Pandemonium

39. Planning – Isolation The placement of sick persons with specific infectious illness in separate rooms from those who are healthy. This is usually voluntary and may be at their own home or at a hospital Prior Planning Prevents Pandemic Pandemonium

40. Planning – Quarantine Usually voluntary, but the FDOH Secretary may declare a public health emergency and issue a quarantine order to separate and restrict movement of people who have been exposed to an infectious agent, and may therefore become infectious Prior Planning Prevents Pandemic Pandemonium

41. Planning – Options for Disease Prevention • Isolate the sick • Voluntary or legally mandated? • Quarantine well, exposed persons • Voluntary or legally mandated? • Limit personal interactions • e.g., close schools and day-care, stop large public gatherings Prior Planning Prevents Pandemic Pandemonium

42. Planning – Behavioral Modification Social Marketing • Change social norms about self-quarantine, personal hygiene, shaking hands, and masks. • Advise travel restrictions. • Home management of uncomplicated influenza • -- Recognition of complications • -- Management of complicated patients Prior Planning Prevents Pandemic Pandemonium

43. Planning – Social Issues • Stigmatization of vulnerable groups • Equity in access to care and in application of isolation and quarantine • Civil liberties balanced with effective disease control • Potential for civil disorder and vigilante actions • Trust in government and health care system institutions, especially if initial measures seem to fail • Long-term stress and behavioral health Prior Planning Prevents Pandemic Pandemonium

44. Planning – Economic Issues • Cost of care and cost of providing preventive measures. • Impact on essential services and general productivity of widespread illness – e.g., 10% of workforce out sick continuously for many weeks. • Curtailment of business travel, shopping, and entertainment venues. • Shipment of goods, including food, fuel, and essential supplies Prior Planning Prevents Pandemic Pandemonium

45. Planning – Communications Issues • Lots and lots of issues and opportunities with risk communication • Prompt, accurate, clear • Acknowledge uncertainties • Provide frequent updates as new info becomes available • Manage the level of expectations Prior Planning Prevents Pandemic Pandemonium

46. Communications • For Unusual death in domestic birds call: • USDA – Veterinary Services for Florida at • 1-866-536-7593 • The Florida Department of Agriculture recommends that you contact your local agriculture extension at Broward County Fish and Game – Non-Game Division 561-625-5122 – Sharon Hood • The Florida Dept of Agriculture / Division of Animal Industry can be reached at 850-410-0900

47. QUESTIONS? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Prior Planning Prevents Pandemic Pandemonium