Pandemic Influenza Perspectives from Federal and State Public Health

1. Pandemic InfluenzaPerspectives from Federal and State Public Health Date Presenter North Carolina Division of Public Health

2. Objectives • Review influenza basics • Assess current pandemic threat • Describe pandemic planning in the United States and in North Carolina

3. Flu Basics: Viral Infection • Fever • Headache • Muscle aches • Extreme fatigue • Dry cough • Sore throat • Runny or stuffy nose CDC Public Health Image Library

4. Flu Complications • Bronchitis • Pneumonia • Dehydration • Worsening of chronic illness • Sinus or ear problems in children • Death • ~65/100,000 infections • 80-90% >65 y/o

5. Seasonal Influenza: Key Facts • Transmission “Respiratory droplets” • An infected person infects ~1.5—3 others • Incubation Period1 to 5 days from exposure • Contagious Period • 1-2 days before illness begins* • 4-5 days after onset • Timing • Seasonal flu: Wintertime peak • Occasional importation from Southern hemisphere • Pandemic: anytime *low likelihood of transmission

6. Avian Influenza H5N1: Key Facts • Transmission to humans: Rare • Extensive contact with infected birds • Contagiousness • Very rarely spread between humans • Spread among birds: increasing • Birds and poultry in Southeast Asia, Asia, Indonesia, Europe, Africa, Middle East… • Severity • Of 281 people infected with H5N1 Avian Flu, 169 (60%) have died

9. Pandemic Influenza: Key Facts • Pandemic = worldwide epidemic • New influenza virus  No immunity • Spreads from person-to-person • Presumed to be like seasonal flu: respiratory droplets • Can cause severe disease • Incubation Period • Presumed like seasonal flu: 1 to 5 days • Contagious Period • Presumed to be similar to seasonal flu • Timing • Waves that last weeks and could begin anytime

10. Influenza Impacts

11. Influenza Countermeasures

12. Seasonal Flu in NC Week 1 = early January Week 52 = late December

13. Sentinel and Emergency Department Surveillance in NC Week 1 = early January Week 52 = late December

14. Prevention of Seasonal Influenza • Annual vaccination • Injection • Inactivated • Nasal mist • Live attenuated • Prophylactic medicines • Avoid ill persons • Respiratory hygiene & etiquette: “Cover your cough” southbirminghampct.nhs.uk

15. Pandemic Influenza Emergence • Novel virus • Human-to-human transmission • “R0” = number of people an infected person infects • Severity of illness • Case fatality ratio (CFR)

16. Pandemic Influenza Emergence • Novel virus • Human-to-human transmission • “R0” = number of people an infected person infects • Severity of illness • Case fatality ratio (CFR)

17. Pandemic Severity • CDC Pandemic Severity Index • Basis: Case Fatality Ratio • Category 1 “Mild” • Category 5 “Catastrophic”

18. Pandemics of the 20th Century *Novel virus that didn’t cause a pandemic

20. Pandemic Influenza Multiple waves possible • Six to eight weeks Weekly combined influenza and pneumonia mortality, United Kingdom, 1918–1919. -JKTaubenberger and DM Morens. 1918 Influenza: the Mother of All Pandemics. EID, Jan. 2006

21. Does Age Matter? Age at death, per 100,000 persons in each age group, United States, 1911–1918 -JK Taubenberger and DM Morens.1918 Influenza: the Mother of All Pandemics. EID, Jan. 2006

22. Pandemic Flu Vaccine and Drugs • Vaccine • Delayed production • May require two doses • Drugs • Supplies: limited • Distribution: unfamiliar • Prioritization rationing  fear…

23. Pandemic Influenza PlanningFederal and State Perspectives Overall Goals Reduce deaths Reduce illnesses Reduce social disruption

24. Current Pandemic Planning Assumptions • We’ll have some notice • Don’t expect federal or state “rescue” • Duration of event: weeks to months • Absenteeism • Plan for 30-40% for at least 2 weeks • Vaccine • Late, limited • Anti-virals • Insufficient stockpile for preventive treatment • Sufficient for some treatment

25. Federal and State Public Health Roles • Leadership—in collaboration with emergency management • Information—regular updates, interim guidance • Coordination—with multiple agencies and jurisdictions, e.g. counties, state agencies • Evaluation—measure interventions’ effects

26. Public Health’s Legal Authorities • CDC  State Public Health  County or City Health Departments • Federal—guidance only • www.pandemicflu.gov • www.cdc.gov • State—guidance and legal authority • www.epi.state.nc.us/epi/gcdc/pandemic.html • County/Local Health Departments—where guidance and legal authority meet real people

27. Federal Guidance • DHS/HHS/CDC—leadership • All Federal Cabinet Level Agencies • Justice • Defense • Commerce • Treasury

28. State Guidance • Division of Public Health leadership • Governor Executive Order: All executive level agencies to create pan-flu continuity of operations plans (COOPS)

29. How To Slow a Pandemic: Latest CDC Guidance • Ill persons should be treated* and stay away from others • Exposed persons should stay away from others and receive prophylaxis* • More ‘social distance’ between children in schools and childcare • More social distance between adults at work and play *If sufficient medicine is available

30. Delay and Limit New Cases No interventions With interventions Impact Time

31. Weekly mortality data provided by Marc Lipsitch (personal communication)

32. St. Louis Estimated attack rate before interventions: 2.2% First death recorded Mayor closes “theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions until further notice” Closing order withdrawn Source: Lipsitch M, Hatchett R, Mecher C

33. Pittsburgh Estimated attack rate before interventions: 3.7%* Theaters, saloons closed* Sports suspended Churches closed Schools, libraries closed Source: Lipsitch M, Hatchett R, Mecher C

34. Non-Pharmaceutical Interventions“Social Distancing” • More distance between persons  spread of germs less likely • More distance, fewer persons  reduced “social density”  fewer opportunities • Examples: • Cancel indoor arena events • Dismiss students from schools • Increase distance between workers/Limit workplace interactions • Tele-work, stagger schedules, Net-meetings

35. Pandemic Severity • CDC’s Pandemic Severity Index • Category 1 –mild • Category 3 –moderate • Category 5 –catastrophic • Interventions α Severity Index • Category 1 • Ill persons stay home • Schools generally not closed • Category 5 • Almost everyone stays home!

36. Impact of an Influenza PandemicUnited States

37. Pandemic Impact in North Carolina * Based on CDC software FluAid 2.0: Assumes a 35% attack rate, NC population of 8.5 million people.

38. Pandemic Influenza PlanningChallenges • Widespread event • Long duration • Uncertainties • Severity • Age-related impacts • Blinders • Health services overwhelmed • Shortages likely  ethical approaches needed • Medications, vaccines • Equipment • Hospital beds • Personnel: ~30% absenteeism for 2 weeks • Health care settings as sources of infection?

40. Hospitals Emergency management agencies Local and regional public health Business Sector Schools and universities Faith-based Other government In other words… …everyone! Planning Partners: No One Untouched Goal: Continuity of Operations

41. Critical Infrastructure/Key Resources Private Sector Focus • Identify priorities • Motivate action earlier • Recognize differences between traditional COOPS and Pan Flu impacts • Longer duration • Absenteeism

42. Prevention and PlanningIt Begins At Home • The more you prepare yourself and your family, the more likely you can fulfill roles in an emergency

43. Possible ScenarioFederal Response • WHO “Phase 6”, Category 5 Severity • Sustained human-to-human transmission, high case fatality ratio • Cases recognized in US • President may proclaim State of Emergency • DHS/CDC and all other Federal Agencies implement COOPs • Private sector partners encouraged to implement COOPs • Media

44. Possible ScenarioState Response • Cases recognized in US including NC • Governor proclaims State of Emergency, orders • Students: dismissed from schools • Mass gatherings: cancelled • Church services: discouraged • Businesses: continuity of operations plans • Hospitals: surge capacity + COOPs • Division of Public Health and NC Emergency Management • Activate COOPs, EOCs, JIC • Work with Counties • Counties: COOPs within their jurisdictions

45. The “Snow Day” Approach-For 6-8 Weeks?

46. Emergency Ends • The pandemic wave passes through • Public Health measures impacts • Illnesses, deaths • Other impacts, losses to business sector • Plans refined • Vaccine or anti-flu drugs become available???

47. Questions Feedback Thanks

48. Contact Info Brant Goode, RN/BSN, MPH LCDR, USPHS CDC Career Epidemiology Field Officer assigned to North Carolina Division of Public Health Public Health Preparedness and Response 919.715.6738 (office) 919.715.4699 (fax) 406.360.5247 (mobile) brant.goode@ncmail.net or bgoode@cdc.gov