Preparing for Pandemic Influenza Cherise J Rohr-Allegrini, Ph.D., M.P.H. San Antonio Metro Health District

What is Avian Flu and what do we do about it? What is Pandemic Flu? How should hospitals prepare?

Avian Flu (H5N1) is NOT Pandemic Influenza To that end, it’s critical to remind you that while we are concerned about Avian Influenza and we are tracking its spread, Avian Influenza is NOT pandemic influenza. Pandemic Influenza

Currently there is no pandemic flu. Avian flu is caused by avian influenza viruses, which occur naturally among birds and ocassionally infect humans. Occassionally, a highly pathogenic strain emerges – H5N1. Seasonal flu is a contagious respiratory illness caused by influenza viruses infecting humans. Generally, most susceptible to severe illness and death are very young and very old. Pandemic flu a global outbreak, or pandemic, of a highly pathogenic strain that spreads easily from person to person. Otherwise healthy young adults severely affected. Currently there is no pandemic flu.

WHO Criteria for Pandemic Influenza The emergence of a disease (or strain/subtype) new to a population The agent infects humans, causing serious illness The agent spreads easily and sustainably among humans This distinction is extremely important. H5N1, or avian flu, fits the first two criteria, not the third. All cases of human infection have been associated with close contact with infected birds. If I get it, I can’t pass it on to you. The presence of H5N1 is an important public health concern, but it is not going to affect the population the way a pandemic would.

So why are we worried? This shows the distribution of Avian Influenza in the world as of today. Just a few months ago, this map included only Asia. In the last few weeks, infection in birds has spread rapidly across western Europe. It really is just a matter of time before H5N1 infection reaches North America. When that happens, it is important that we prevent panic in the community through proper education. We will step up our surveillance systems, which I’ll discuss later. The arrival of H5N1, even if only in birds, on the North American continent will be important for you as Health care providers. You’ll need to be more aware and investigate more thoroughly a flu-like illness. A critical question will be “Have you had any contact with poultry or other birds? Has anyone in your household had contact?”

Where are we now? Pandemic Alert Phase 3 So that’s where are with Avian flu. What about Pandemic flu? The WHO has established a “Pandemic Phase Chart”. According to the World Health Organization guidelines, the presence of human infection of H5N1 puts us in Pandemic alert phase 3 at this time.

Human infection(s) with a new subtype, but no human-to-human spread 12-26-03 to 4-19-06 HUMAN H5N1 CASES Cases Deaths Azerbaijan 8 5 Cambodia 6 China 16 11 Egypt 12 2 Indonesia 31 23 Iraq Thailand 22 14 Turkey 4 Viet Nam 93 42 TOTAL 202 109 WHO identifies 2 more stages in the pandemic alert period. That is once human to human transmission develops in either small or large clusters but is still localized. However, given the state of air travel today, we can expect that this period will be quite short.

Increased and sustained transmission in general population Pandemic Period Phase 6 Increased and sustained transmission in general population The stage we’re all preparing for now, is Phase 6, the Pandemic, where we have an increased and sustained transmission of the new subtype in the general population.

What does that mean for the 1 What does that mean for the 1.5 million people in the San Antonio/Bexar County area? What will that mean for us?

Wave 1: Wave 2: 25-50% Attack Rate 5% Attack Rate 4% hospitalization 325,000-750,000 infected 4% hospitalization 13,000-30,000 1.5-5% Fatality Rate 5000 deaths Wave 2: 5% Attack Rate 75,000 infected 4% hospitalization 3000 1.7% Fatality Rate 1275 deaths Pandemics typically occur in at least 2 waves. The likelihood a vaccine will be available for the entire population by the time the first wave hits is very small. These estimates are based upon previous pandemics. Public Health officials worldwide estimate that anywhere from 25-50% will become ill. It’s worth noting that in a pandemic situation it tends to be healthy young adults who are affected, whereas in seasonal flu, healthy young adults are the least likely to become seriously ill. In San Antonio that means anywhere from 325,000 to 750,000 people sick. If 4% of the ill require hospitalization, that could be up to 30,000 hospital beds. In San Antonio area hospitals, there are at present only 6000 beds available. SA hospitals also serve the greater region outside Bexar county. Metro Health is working with hospitals and the American Red Cross to address the possibility of establishing alternate care sites. We could also expect a fatality rate up to 5%. A second wave typically occurs a month or two after. If a vaccine is still not available, we can expect yet more illness in the community.

Health Systems Response: Demand for services may require non-standard approaches Discharge of all but critically ill hospital patients Expansion of hospital capacity by using all available space and less than code compliance beds Increase of patient ratio to hospital staff Stop elective procedures Set up alternate treatment facilities

What do Hospitals Need to Do to Prepare NOW? Develop Emergency Plan specific for Pandemic Influenza Educate staff Avian vs. Pandemic flu Infection control procedures Respiratory Hygiene Etiquette Policies and Procedures for care of pandemic patients Training for non-clinical staff to assist clinicians Personal protective measures

What do Hospitals Need to Do to Prepare NOW? Staffing Concerns Determine # of staff, report to local SNS Coordinator Maintain accurate call down lists Identify # of Reservists on staff Medical staff who work at multiple facilities should choose a primary Identify possible volunteers whose primary commitment is to your facility Make contingency plans for 20-50% reduction of current workforce

Health Systems Response Determine your surge capacity Facility Access When to limit? How to limit? Occupational Health How to manage ill workers? Time-off policies Vaccination and antivirals

Health Systems Response in a Pandemic Activate Pandemic Response Plan Report to the RMOC Number of patients on ventilators Number of available ventilators Number of beds occupied Number of beds available Estimates of staffing levels (MDs, nurses) Report to SAMHD Emergency room visit trends: syndromic surveillance SNS If available

Strategic National Stockpile (SNS) A repository of antibiotics, antidotes, antitoxins, and life support medications Delivered within 12 hrs of request If a vaccine is available, administer immediately to staff and family members: Critical Government Officials First Responders (Including Hospital Staff) Critical Services (City and County, including Utilities) Volunteers Vaccines and medicines will be in short supply and will have to be allocated on a priority basis

Public Information and Communication Pre-Pandemic: Coordinate with SAMHD PIO, COSA PIO, Hospital PIOs to generate talking points and community education Pandemic: JIC established by COSA EOC to include COSA PIO, SAMHD PIO and collaborate with hospital PIOs One Message to public PI plays a key role in the preparation stage we are in now and will continue to do so throughout a pandemic. Through media releases the public will be informed of the current situation, what to expect and how to prepare. In addition to media releases, SAMHD and Emergency Management are conducting a series of talks to different groups throughout the community to educate and assist in preparation

Summary Avian flu (H5N1) is a health concern It is NOT pandemic Influenza Each Hospital should have a contingency plan specific for pandemic influenza to include: Emergency procedures Infection Control* Public Information Vaccine for pandemic flu may or may not be available If not, focus on personal protective measures Remember Avian Flu, while a public health concern we are addressing and all should be aware of, is NOT pandemic flu. We’re preparing for both at this time. A Vaccine specifically for a pandemic strain may not be available, so it’s important to focus upon what we can each do to protect ourselves and those around us. If it is available, SNS sites will be established throughout the community to vaccinate. Every city agency and every business should be prepared to deal with the loss of their workforce and other critical elements should a pandemic occur Each citizen should have a plan in place for themselves and their families

Pandemic Influenza Planning Group CDC Emergency Response (770) 488-7100 SAMHD Emergency Response (210) 207-5777 SAMHD – Fernando Guerra, MD, Director (210) 207-8731 SAMHD PHEP Epidemiology- Cherise Rohr-Allegrini, PhD, (210) 207-8911 SAMHD PHEP - Roger Pollock, Program Manager (210) 207-8752 SAMHD PHEP Epidemiology - Roger Sanchez (210) 207-8876 SAMHD PHEP – Frank Chance, SNS Coordinator (210) 207-2145 SAMHD PHEP – Phil Vaughan, BL-3 Lab Coordinator (210) 207-5883 http://www.sanantonio.gov/health http://www.pandemicflu.gov