Pandemic Influenza Planning

1. Pandemic Influenza Planning Frank J. Welch, MD, MSPH Medical Director Department of Health and Hospitals Office of Public Health

2. “We don’t know the timing of the next pandemic, how severe it will be. We don’t know what drugs will work. We don’t have a vaccine. Yet we are telling everyone to prepare for a pandemic. It’s tricky…This is scary and we don’t know… That’s themessage.”Dick Thompson World Health Organization December 2005

3. Discussion Topics • Influenza overview • 20th century pandemics • Current threat • Role of Public Health in preparedness and response • Unique preparedness issues for a pandemic

4. In Louisiana We Know How to Prepare for This:

5. How do we prepare for this? Animation Courtesy of Mathematica Visualizations – Jeff Bryant

6. http://worldvid.cit.nih.gov/flu/flu.wmvhttp://worldvid.cit.nih.gov/flu/flu.rmhttp://worldvid.cit.nih.gov/flu/flu.wmvhttp://worldvid.cit.nih.gov/flu/flu.rm Proceedings of the National Academy of Science, April 11, 2006 Vol. 103, No. 15: 5935 – 5940.

7. Flu terms • Seasonal (or common) flu • Respiratory illness that can be transmitted person to person. Most people have some immunity; vaccine available. What is left over from previous pandemics. • Avian (or bird) flu • Caused by influenza viruses that occur naturally among wild birds. The H5N1 variant is deadly to domestic fowl and can be transmitted from birds to humans. No human immunity and no vaccine. • Pandemic flu • A virulent human flu (often from mutation of an avian flu) that causes a global outbreak (pandemic) of serious illness. Since little natural immunity, the disease can spread easily from person to person. Currently no pandemic flu.

8. How does influenza spread? • Breathing in droplets • Produced when infected person talks/coughs/ sneezes • Touching an infected person or surface • Contaminated with the virus and then touching your own or someone else’s face • Incubation period = time from exposure to virus to development of symptoms • Varies, but usually 1-4 days

9. Flu Preventive Steps • Vaccination • Stay home when sick, 1 week from onset of symptoms • Cover your cough • Hand hygiene • Wash with soap and water regularly • Alcohol-based sanitizer if no water available • Avoid touching eyes, nose and mouth • Avoid close contact with people who are sick

10. Seasonal Flu Average U.S. deaths ~36,000/yr 200,000 hospitalizations Symptoms (sudden onset): fever, cough, runny nose, muscle pain; death often caused by complications like pneumonia Generally causes modest societal impact Manageable impact on domestic and world economy Pandemic Flu Number of deaths could be quite high (1918 death toll ~ 500,000) Symptoms may be more severe and complications more frequent May cause major impact on society Potential for severe impact on domestic and world economy Seasonal and Pandemic Flu

11. Seasonal Flu Outbreaks follow predictable patterns; annual; usually in winter Usually some immunity from previous exposure Complication risks- young, elderly and underlying health conditions Health systems usually meet needs Vaccine and antivirals usually available Pandemic Flu Unable to predict when; Occurs rarely (three times in 20th century – last 1968) No previous exposure; little or no pre-existing immunity Healthy people may be at increased risk Health systems may be overwhelmed Vaccine not available in early stages and antivirals may be in limited supply Seasonal and Pandemic Flu, cont

12. 20th Century Flu Pandemics • 1918 – Spanish Flu • Worldwide 20-50 million deaths • 500,000 deaths in US • 1957-1958 – Asian Flu • Worldwide 1-2 million deaths • 70,000 deaths in US • 1968-1969 – Hong Kong Flu • Worldwide 700,000 deaths • 34,000 deaths in US • Typical Influenza Season • 36,000 deaths in US

13. Avian (Bird) Influenza • Occurs naturally among birds • Wild birds worldwide carry the virus – usually no illness • Domesticated birds - can become ill and die • Humans • Can become infected -- severe illness and death • Most cases from close contact with infected poultry • May have rarely spread from one person to another • Cases/deaths since 2003 = 270/164 (60% mortality)

14. Will H5N1 cause the next pandemic? • Avian Flu not yet Pandemic Flu • Current outbreaks of H5N1 Avian Flu in poultry and birds are the largest ever documented • Impossible to predict next pandemic flu event • If not H5N1, then another

15. Occur unpredictably, not always in winter Variations in mortality, severity of illness and pattern of illness Rapid surge in number of cases over brief period of time, often measured in weeks Tend to occur in waves Each wave lasts about 2-3 months Subsequent waves may be more or less severe Generally occur 3-12 months after previous wave Lessons from Past Pandemics

16. http://www.pbs.org/wgbh/amex/influenza/maps/index.html

17. Estimated Louisiana Pandemic Influenza Impact • 3 million infected • 600,000 – 1.4 million clinically ill • 300,000 – 700,000 requiring outpatient care • 10,000 – 22,500 hospitalized • 3,000 – 6,000 deaths

18. Estimated Pandemic InfluenzaImpact in the US • 200 million persons infected • 38-89 million clinically ill • 18-42 million requiring outpatient care • 314,000 – 733,000 hospitalized • 89,000 – 207,000 deaths

19. Pandemic Flu: Current Status Interpandemic Pandemic alert Pandemic Phase 4 Phase 1 Phase 2 Phase 3 Larger clusters, localized Limited spread among humans Phase 5 Phase 6 No new virus in humans Animal viruses low risk to humans No new virus in humans Animal viruses low risk to humans New virus in humans Little/no spread among humans Small clusters, localized Limited spread among humans Increased and sustained spread in general human population Current H5N1 status WHO Global Influenza Preparedness Plan, 2005. Available at: http://www.who.int/csr/resources/publications/influenza/GIP_2005_5Eweb.pdf

20. Requirements for Pandemic Flu • For pandemic flu to occur, three conditions must be met: • A new influenza A virus appears or “emerges” in the human population  • The new virus causes serious illness in people  • The new virus spreads easily from person to person worldwide

21. Antiviral Medicines • Used for treatment of ill individuals, and rarely prophylaxis of contacts of an ill person. • Expensive, scarce, have side effects, and inappropriate use can cause viral resistance. • Antivirals from the SNS will be distributed to hospitals for patients ill with the PanFlu virus. • The SHO and the Office of Public Health will also provide guidelines on appropriate use of antivirals that are distributed. Public education will be very important given the scarcity of this resource. • Prioritizing within priority groups will be necessary given the limited supply. As with vaccine, it will be critical to clearly communicate with the public about the rational for priority groups.

22. Vaccines • Vaccine will likely not be available when the novel virus first affects communities. • Current manufacturing procedures require six to eight months before large amounts of vaccine are available for distribution. • Once a vaccine becomes available, it will be distributed through the Strategic National Stockpile system: • The target population will be the entire Louisiana population. • Demand for vaccine will be greater than the supply early in the course of the pandemic. • Once vaccine is available, it will need to be distributed as quickly as possible through Point of Dispensing (POD) sites. • Immunologic responses is poor to unknown. It is likely that a second (booster) dose of vaccine two to four weeks after the first dose is given will be required. • Like antivirals, early in distribution, vaccines will need to be prioritized.

25. Pandemic Flu Preparedness and Response Planning …must move beyond traditional notions of continuity of operations, as a pandemic promises to test the limits of current contingency plans. Pandemic Influenza – Preparedness,Response, and Recovery Guide for Critical Infrastructure and Key Resources Publication Date: 9-19-2006

26. How do we plan? • Understand roles • Federal, State, Local • Hospitals and Clinics • Business and Industry • Schools and Universities • Faith-Based and Community organizations • Individuals/families • Education • Collaboration

29. Federal planning State and local planning Individual planning Business planning Community and faith-based organizations planning School planning Child Care and Preschool School District (K – 12) Colleges and Universities Health Care planning Emergency Medical Services and non-emergent medical transport Medical offices and clinics Home Health Care Long-Term care Hospitals Federal Checklists

30. Selective recommendations from the Business, Community and School Planning Checklists Plan for up to 40% employee absenteeism for up to 2 months

31. Summary • Influenza pandemics are naturally recurring events – come in waves • Experts think the world may be on the brink of another pandemic • All countries will be affected; illness will be widespread; mortality rate will be high • Healthcare systems will be overwhelmed • Economic and social disruption will be great • Risk minimized through preventive steps • No vaccine initially • Plan beyond “traditional notions of continuity of operations” • Everyone needs to be prepared

32. When you do not know all the variables, but the risk is extreme, the lesson becomes: Plan for it all.Pandemic Influenza –Preparedness,Response, and RecoveryGuide for Critical Infrastructure and Key Resources Publication Date: 9-19-2006

33. References • State Pandemic Resources • http://www.dhh.louisiana.gov/offices/?ID=295 • Family Readiness Guide • http://www.dhh.state.la.us/offices/publications/ • Official Pandemic Flu Web Site • http://www.pandemicflu.gov/ • Pandemic Influenza Preparedness, Response, and Recovery Guide for Critical Infrastructure and Key Resources • http://www.pandemicflu.gov/plan/pdf.CIKRpandemicInfluenzaGuide.pdf