Pandemic Influenza Planning Frank J. Welch, MD, MSPH Medical Director Department of Health and Hospitals Office of Public Health Hello and welcome to this presentation dealing with a potential pandemic flu event and how this would affect you. My name is Tina Stefanski and I am the Administrator and Medical Director for the Louisiana Department of Health and Hospital’s Region IV Office of Public Health. The Office of Public Health is your state health department. Many of you know the Office of Public Health as the agency that delivers invaluable public health services through the parish health units. However, we are involved in many other important activities outside the four walls of the parish health units. One of these is pandemic flu planning.

“We don’t know the timing of the next pandemic, how severe it will be “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 the message.” Dick Thompson World Health Organization December 2005

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

In Louisiana We Know How to Prepare for This:

How do we prepare for this? Explain Spread Scenario Animation Courtesy of Mathematica Visualizations – Jeff Bryant

http://worldvid. cit. nih. gov/flu/flu. wmv http://worldvid. cit. nih http://worldvid.cit.nih.gov/flu/flu.wmv http://worldvid.cit.nih.gov/flu/flu.rm This is an 80-second animation you may wish to review. Each dot represents a census tract (more of nation’s population in the eastern part of the country). The dots start as green and change to red as more people in that tract become infected. The dots change back to green as people recover. Proceedings of the National Academy of Science, April 11, 2006 Vol. 103, No. 15: 5935 – 5940.

Flu terms Seasonal (or common) flu Avian (or bird) flu Pandemic 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.

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 Influenza is easily passed from person to person through breathing in droplets containing the virus, produced when infected person talks, coughs or sneezes. It is also transmitted by touching an infected person or surface contaminated with the virus and then touching your own or someone else’s face. This picture on the right gives you an idea of the large droplets produced by someone who has influenza when they sneeze and how these droplets can fall on other people or surfaces allowing transmission. These large droplets generally do not remain suspended in the air and only travel about 3 feet through the air.

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 What should we do to prevent the transmission of influenza? Our best protection against seasonal flu is vaccination. However, it is important to stay home when you are sick with the flu, even though your role at work or your attendance in school may be vital. Always remember to cover your cough, wash your hands regularly, and avoid touching your eyes, nose and mouth. Also avoid close contact with people who are sick with the flu as much as possible. As you will learn, these basic measures may be our most powerful weapons when combating pandemic flu.

Seasonal and Pandemic Flu 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, cont 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

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 Looking at some of the flu pandemics in the 20th century, There was one that ran from 1968 to 1969. At least 700,000 people died worldwide. There were 34,000 deaths in US. There was a flu pandemic that occurred from 1957 to 1958. At least 1.5 million people died worldwide. There were 70,000 deaths in US. And the worst pandemic occurred from 1918 to 1919 spreading around the globe in 4-6 months. At least 40-50 million people died worldwide. And there were 500,000 – 650,000 deaths in the US. During the course of the epidemic, 47% of all deaths were from influenza & its complications. Two major issues: overcrowding & public information withheld All of this is in comparison to a typical influenza season where we see 36,000 deaths in US. Typical Influenza Season 36,000 deaths in US

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) Avian influenza is an infection occurring naturally among birds caused by avian influenza viruses (e.g. H5N1 virus). Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them. It can make some domesticated birds, including chickens, ducks, and turkeys, very sick and die. The avian influenza virus has infected some people, causing severe illness and death.. Most cases of avian influenza infection in humans have resulted from direct or close contact with infected poultry . In very rare cases, the virus may have spread from one person to another. The very few people who may have gotten bird flu from another person did not pass it on. There have been sporadic human cases: starting in 2003 running through January 29, 2007, there have been 270 cases with 164 deaths most in young and healthy with case-fatality rate of around 60%

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

Lessons from Past Pandemics 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 that have been learned from past pandemic flu events include the following: These events occur unpredictably and not always in winter. There have been great variations in mortality, or death, severity of illness and pattern of illness, or ages most severely affected. There is a rapid surge in number of cases over brief period of time, often measured in weeks. Again these pandemics tend to occur in waves; and subsequent waves may be more or less severe – Experts agree that there will be 1-6 months between identification of a novel virus and widespread outbreaks in the US.

Earlier, you saw computer modeling of a future pandemic, this shows what happened in 1918. http://www.pbs.org/wgbh/amex/influenza/maps/index.html

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

Estimated Pandemic Influenza Impact 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 Large US impact will make it difficult to rely on help from other parts of the country.

Pandemic Flu: Current Status Interpandemic Pandemic alert Pandemic Phase 1 Phase 2 Phase 3 Phase 4 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 The current status of the H5N1 bird flu situation places us in what’s called Phase 3 of the World Health Organization pandemic flu classification. As you can see, this means we are in the lowest stage of a pandemic alert. Current H5N1 status WHO Global Influenza Preparedness Plan, 2005. Available at: http://www.who.int/csr/resources/publications/influenza/GIP_2005_5Eweb.pdf

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 There is currently no pandemic influenza in the world. For pandemic influenza to occur, three conditions must be met: a new influenza A virus appears or “emerges” in the human population it causes serious illness in people it spreads easily from person to person worldwide

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.

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.

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

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

Pandemic Flu homepage

Example of Federal Checklists

Federal Checklists 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

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

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

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 Recovery Guide for Critical Infrastructure and Key Resources Publication Date: 9-19-2006

References State Pandemic Resources Family Readiness Guide 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