1. Pandemic Response Briefing to Business & Community Leader Scenario time: Oct 24 Group 2 Tammy Hunt David Broudy

2. Outline 1.The challenge Without intervention: 800K - 9.6M Hospitalizations 18-42M outpatient visits 80K - 285K deaths 2.Epidemiology: Breaking the cycle of transmission 3.What is to be done? A strategy for communities

3. Why Multnomah Co should support community interventions Medical measures may be delayed Efficacy of vaccine and antivirals unknown Infection Control Measures are effective History of 1918 Pandemic supports aggressively limiting assemblage –The longer you wait to intervene, the worse the effects of the epidemic Working together and building our community is good for business and good public health

4. Social Distancing and Infection Control Social Distancing (Contact Interventions) –School closure –Work closure (telecommuting) –Cancellation of public gatherings Infection Control (Transmission Interventions) –Facemasks –Cough etiquette –Hand hygiene

5. Non-pharmaceutical Interventions Ill persons should be isolated (home vs hospital) Voluntary home quarantine for household contacts Social distancing measures –School closures may have profound impact –Keep your business going by allowing employees to work from home –Cancellation of public events Individual infection control measures work –Hand washing and cough etiquette for all –Mask use for ill persons, PPE stratified by risk –Disinfection of environmental surfaces as needed

6. Community-Based Interventions 1. Delay disease transmission and outbreak peak 2. Decompress peak burden on healthcare infrastructure 3. Diminish overall cases and health impacts Daily Cases #1 #2 #3 Days since First Case Pandemic outbreak: No intervention Pandemic outbreak: With intervention

8. Susceptible to Targeted Attack

10. Effect of R 0 on Epidemic Curve Eubank S, personal communication

11. A Tale of Many Cities: What Does History Teach Us?

12. "...Spanish influenza is now present and probably will become epidemic in the City of St. Louis. In view of this proclamation, and under the authority vested in me by the City Charter of the City of St. Louis, after such proclamation in order to prevent all unnecessary public gatherings through the medium by which this disease is disseminated, I hereby order that all theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions to be at once closed and discontinued until further notice." --Mayor Henry Keil (October 7, 1918)

13. Liberty Loan Parade September 28, 1918

14. The drastic actions of Mayor Keil were sensible considering by October 7th, 167,000 cases had broken out, with 4,910 deaths, across the eastern United States. Mayor Keil's actions perhaps spared St. Louis of the worst outbreaks. For instance for the October 10-November 2 time frame the following deaths were reported: New York, 16,705Boston, 3,694 Philadelphia, 12,162 Chicago, 7,405; Baltimore, 3,507St. Louis 784.

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

17. 1918 Age-specific Attack Rates McLaughlin AJ. Epidemiology and Etiology of Influenza. Boston Medical and Surgical Journal, July 1920.

18. Why close schools? In 1918 the “spanish flu” had an unusually high attack rate among younger people Small children are efficient incubators and spreaders of infectious diseases Preventing the spread of the flu among children will reduce spread to families Reducing serious illness and death among working age adults will reduce impact on economy Flattening the epidemiology curve will allow distribution of scarce resources over longer periods.

19. To ChildrenTo TeenagersTo AdultsTo SeniorsTotal From From Children21.4 3.017.41.643.4 From Teenagers 2.410.4 8.50.721.9 From Adults 4.6 3.122.41.831.8 From Seniors 0.2 0.1 0.81.7 2.8 Total To28.616.649.05.7 Children/Teenagers 29% Adults 59% Seniors 12% Demographics Glass, RJ, et al. Local mitigation strategies for pandemic influenza. NISAC, SAND Number: 2005-7955J School Household Workplace Likely sites of transmission Who Infects Whom?

20. MONTREAL 11.5% SAN FRANCISCO 8.8% ST. LOUIS 2.2% Model Predictions – 1918 Interventions Ro = 2.1, 2% case fatality rate

21. Model Predictions – 1918 Interventions Ro = 2.1, 2% case fatality rate

22. Intervention Delay Sensitivity *ScenariosAttack Rate (%)Deaths No intervention 46.880,405 Intervention at 12% 27.747,511 Intervention at 8% 23.941,045 Intervention at 2% 9.715,782 Intervention at 1% 5.39,107 Intervention at 1% w/ TARP Case Rx, HH Px 2.94,889 *Longini model for Chicago pop 8.8M, NPI intervention TLC w 30% compliance HH-Q

23. Acknowledgements Many of these slides are from a presentation by Martin Cetron, MD, Div Global Migration and Immigration, CDC Thanks to Subject Matter Expert for Group 2: –Chris Felstadt –Norm Nedell –Peter Rigby –Karen Pendelton –Matt Bernard –Diane Bonne, Facilitator Martin, MD Director, Division of Global Migration and Quarantine Centers for Disease Control and \, MD Director, Division of Global Migration and Quarantine Centers for Disease Control and, MD Director, Division of Global Migration and Quarantine Centers for Disease Control and Prevention