Critical Infrastructure Groups Inter-meeting Work Group Summary

1. Critical Infrastructure Groups Inter-meeting Work Group Summary Joint ACIP/NVAC Meeting on Pandemic Influenza Vaccine Prioritization Atlanta, GA June 15-16, 2005

2. Ban Allos, ACIP Carolyn Bridges, NIP, CDC Dale Brown, DHS Louisa Chapman, NIP, CDC Elizabeth Falcone, NVPO Kathy Gensheimer, CSTE Penina Haber, OD, CDC Paul Hightower, DHS Arnold Kaufman, NCEH, CDC Max Kiefer, NIOSH, CDC Teri Palermo, NIOSH, CDC Ben Schwartz, NVPO Ray Strikas, NIP, CDC Marion Warwick, DHS David Weissman, NIOSH, CDC Pascale Wortley, NIP, CDC Participants

3. Goals of Group • Define groups essential to maintenance of critical infrastructure in the U.S.: • That would be part of influenza pandemic response and/or • Whose function may be substantially impacted by a pandemic • Healthcare workers considered by separate work group so not included • Identify proportions of persons within each group that would highest priority for vaccination (still in progress) • Prioritize among the groups, if possible

4. Overall Goals for Pandemic Planning • First, to minimize severe morbidity and mortality • Second, to preserve functioning of critical infrastructure and minimize economic loss

5. Process Taken by Group • Developed a list of assumptions on impact of a pandemic • Reviewed data on size and functions of critical infrastructure groups based on earlier work based on sources from: • White House, The National Strategy for the Physical Protection of Critical Infrastructures and Key Assets, February 2003 • Congressional Research Service, Critical Infrastructures: What Makes an Infrastructure Critical? January 2003 • New data from the Department of Homeland Security • Public Health Agency of Canada’s influenza pandemic plan • Considered • Experiences from recent table top exercises from non-influenza-related events • Relative paucity of information in essential services functions in prior pandemics • Major changes in business practices that may make systems more vulnerable

6. What is Critical Infrastructure? The framework of independent networks and systems comprising identifiable industries, institutions and distribution capabilities that provide a reliable flow of products and services essential to the defense and economic security of the U.S., smooth functioning of government at all levels, and society as a whole. President’s Commission on Critical Infrastructure Protection, 1997

7. Key Assumptions I • Influenza vaccine is primary means of influenza prevention • Overall goal of vaccine program will be to vaccinate all in U.S. who desire vaccination • HOWEVER, vaccine supply likely to be limited at least at the beginning of a pandemic

8. Key Assumptions II • Prioritized those functions that would most directly be involved in pandemic response, support maintenance of the healthcare system, and maintain public safety and functioning of critical infrastructure

9. Key Assumptions III • Vaccine production and use • Time from candidate vaccine strain to first doses likely 6 or more months • Current U.S. production capacity 5 M doses per week • 2 doses/person likely needed • Dept of Defense likely will be high priority for vaccination 0.5 M-1.5 M persons • Thus, need for rationale, explicit prioritization of vaccine

10. Key Assumptions IV • Health impact of a pandemic • 25% (range in working age 20-30% most likely) of persons may become ill in major wave • Additional persons will need to be home to care for ill family members • Outbreak period in a community 6-8 weeks per wave with possibly >1 wave in a community • Illness duration preventing work for uncomplicated case 5 days • Rates and age distribution of influenza-related hospitalizations and deaths may vary substantially from 1918 to 1968 scenario • 1-10% ill persons may be hospitalized • 0.1–1% ill persons may die

11. Principles for Prioritization of Vaccine Among Key Resource Workers in Critical Infrastructure Groups • The epidemiology of the next pandemic may dictate alteration of prioritization recommendations • Local needs and preferences may also alter prioritization at local level • Vaccination strategies must be feasible to implement and rationale used for decision clearly explainable • Because preventing severe illness and death is the first goal, critical infrastructure groups most directly tied to this goal were prioritized • Also, groups critical to maintenance of critical infrastructure prioritizes to meet secondary goal of pandemic planning

12. Major Limitation • Very little information on impact of prior pandemics on critical infrastructure outside of healthcare sector • Because of changes in business management practices, particularly in past decade, experience from prior pandemics may have less relevance

13. Two Main Tiers Defined I • Tier one • Persons working in influenza vaccine and antiviral medication production • 10,000-20,000 persons • Key government health decision makers • principally those in executive branch of local/state/fed government who develop and implement health-related policy • total number persons not yet determined • Non-healthcare workers in public health needed to • assess pandemic impact • allocate resources • develop and implement pandemic-related policy and guidance • assist with distribution vaccine and antivirals • total number of persons not yet determined

14. Two Main Tiers Defined II • Tier one, con’t • Public safety workers (fire, police, correctional facility, dispatchers) • Critical for responding to emergencies with health implications and likely to be called on to ensure order at vaccination/antiviral clinics and maintain public order • Total number: 2,987,000 • Critical number: yet to be determined • Utility service workers (water, power, sewage management) • Provide essential services for healthcare system and all other sectors where loss of service would likely to contribute to additional illness and protect overall public safety and critical infrastructure • Total number: 364,000 • Critical number: yet to be determined

15. Two Main Tiers Defined III • Tier two • Transportation workers to maintain critical supplies of food, water, fuel and medical materials or who are likely to transport healthcare workers and patients to medical facilities • Total number: 3.8 million (DHS industry estimate including trucking, passenger ground transportation, rail and water transportation) • Critical number: yet to be determined • Telecommunications • Essential for accessing and delivering healthcare and response to emergencies and maintenance of critical infrastructure • Total number: 1.08 million • Critical number: yet to be determined

16. Two Main Tiers Defined IV • Tier two, con’t • Mortuary services • Deaths expected to rise. Although probably little direct health impact, large delays in these services could have substantial social/psychological impact • Total number: 61,780 persons • Critical number: yet to be determined • Waste management • With large reductions in this service, could possibly create health hazards • Total number: 321,190 persons • Critical number: yet to be determined

17. Two Main Tiers Defined V • Tier two, con’t • Judicial branches of government • Some functioning needed for maintenance of community function • Total number of persons: 72,980 • Critical number: yet to be determined • Financial Services • Some basic functioning necessary for maintenance critial societal service • This sector has developed estimate of critical personnel to prevent financial system collapse • Critical number: 1,000 persons

18. Critical Infrastructure Groups Considered Personnel Cumulative Element(1,000’s)total (1,000’s) Health care 11,830 11,830 Ambulatory services 885 12,715 Vaccine and antivirals manu. 20 12,735 Key Executive Branch personnel ?100 12,835 for health care decisions Non-healthcare PH workers ?200 13,035 Public safety 2,987 16,022 Utilities 364 16,386 Transportation 3,800 20,186 Telecommunications 1,052 21,986 Funeral directors/embalmers 62 21,238 Waste management 321 21,559 Judiciary 73 21,632 Financial industry 1 21,633 High risk persons (all) 88,300

19. More Work to Be Done • Critical infrastructure groups described in prioritization are grossly defined • Additional evaluation needed to • Further define specific sections of each group critical for maintenance of function • Evaluate surge capacity • Establish mechanisms for identifying these personnel and feasible means for vaccine and/or antiviral medication delivery • Identify additional groups along supply chains that may also need to be prioritized (e.g. critical food groups needed to supply food for transportation)

20. Other Recommendations • Recommend federal support for expansion of U.S. influenza vaccine manufacturing capacity • Evaluation of technologies to speed vaccine production and assess dose sparing strategies (e.g. use of adjuvants, intradermal delivery) also high priority to improve vaccine availability • Set aside some vaccine and antivirals to vaccinate groups of workers who may need to respond to unforeseen emergencies

21. Pandemic vaccination program progress toward meeting 80% goal for target groups, assuming 5 million doses available per week** Pandemic begins ???? No. doses for immunity Vaccinated Population(cumulative millions) High Risk + HCW High Risk Only HCW Only Critical Infrastructure Only * Also, roughly equal to immunizing 80% of all children under the age of 18 ** Assume no waste and all vaccine goes to target group