Tennessee Department of Health Pandemic Influenza Planning David Kirschke, MD Medical Epidemiologist Northeast Tennessee Regional Health Office

Nicholson KG. Lancet. 2003;326: Avian Influenza All 15 H and 9 N subtypes circulate in aquatic birds

Nicholson KG. Lancet. 2003;326: Avian Influenza All 15 H and 9 N subtypes circulate in aquatic birds Only certain types circulate in humans Virus that circulate in birds but not humans termed ‘avian’ influenza Low / highly pathogenic

Origin of Antigenic Shift and Pandemic Influenza

Phases of a Pandemic PERIODPHASEDESCRIPTION Interpandemic No human cases of novel influenza virus 1 No animal influenza viruses circulating with the potential to infect humans 2 Animal influenza virus is circulating with the potential to infect humans Pandemic Alert Human cases with increasingly efficient human-to- human spread 3 (Current situation) Human cases with rare or no human-to-human spread 4 Small clusters caused by human-to-human spread 5 Large regional clusters caused by human-to-human spread Pandemic Worldwide epidemic 6 Geographically widespread and efficiently spread from human-to-human

Nations With Confirmed Cases H5N1 Avian Influenza (16 Oct 2006) 256 cases with 151 (59%) deaths in 10 countries

Assumptions about Disease Transmission No one is immune to pandemic strain; 30% of population will become ill Most will become ill 2 days (range 1-10) after exposure to the virus People may be contagious up to 24 hours before they know they are sick People are most contagious the first 2 days of they are sick –Sick children are more contagious than adults On average, each ill person can infect 2 or 3 others (if no precautions are taken)

Assumptions about Disease Transmission Pandemics move through community in waves Each wave in a community will last 6-8 weeks There will be at least 2 “waves” of pandemic disease, likely separated by several months The entire pandemic period (all waves) will last about 18 months to 2 years Disease may break out in multiple locations simultaneously, or in isolated pockets

Key Activities to Minimize Impact of Pandemic Influenza* Surveillance for disease activity Accurate communication Use of social distancing measures Distribution and use of all available medical resources and personnel * Likely shortage of vaccine, antiviral medication, and advanced medical care

Objectives of Pandemic Planning Primary objective is to minimize morbidity and mortality from disease Secondary objectives are to preserve social function and minimize economic disruption

Planning Assumptions Based upon a pandemic of the severity of the influenza pandemic –Actual situation / response may vary Local planning is critical –Federal and state government capacity to meet the needs of individuals will be limited

Tennessee Pandemic Influenza Estimates CharacteristicModerateSevere* Illness (30%)1.8 million Outpatient Care900,000 Hospitalization17,300198,000 ICU Care2,57529,700 Mechanical Ventilation 1,30014,850 Deaths4,180 (0.2%)38,060 (2%) *HHS recommends that states plan for severe scenario

Regional Response Plan Continuity of Operations Disease Surveillance Laboratory Diagnostics Healthcare Planning Vaccine Distribution and Use Antiviral Drug Distribution and Use Public Health Communications Community Interventions Business Recommendations Legal Authority Pre-Pandemic Case Management Pre-Kindergarten through Twelfth Grade and Child Care Colleges and Universities Special Populations Workforce and Social Support

Health Care Planning: Surge Capacity Greatest challenge of pandemic response >25% more hospitalized patients than normal 40% absenteeism among employees Hospitals far short of this degree of surge capacity Non-traditional care locations and altered standards of care being discussed

Community Disease Control: Community Wide Measures Reduce Social Contact –School closures, snow days –Cancellation / discouragement of large public gatherings, possibly mass transit Educate about personal protection –Hand hygiene and respiratory etiquette –Avoid sick people if possible –Stay home when you are sick –Care for sick household members safely –Clinical advice hotline

Johnson City Daily Staff, October 1918 Community Interventions ― Johnson City, 1918 “Liberty Parade … called off” “Majestic, Edisonia, and Liberty Theaters closed until further notice.” “East Tennessee Fair closed as a precaution against spread of influenza in Knoxville.” “People are urged to stay home when they have symptoms of influenza.” “Collecting in crowds at the railway station will be prohibited.”

Colleges and Universities Subject to state policies concerning suspension of discretionary public gatherings but not by specific school closure requirements affecting preK-12 schools College students are older, have less continuous group contact than school-aged children, and are not considered a significant source of influenza spread in a community Closing dormitories or suspending classes may be recommended by regional or state health officers in collaboration with university officials in light of specific outbreak conditions Colleges and universities are encouraged to develop campus plans and to collaborate with local and regional pandemic planning officials for community pandemic plans.

Issues unique to colleges and universities include: Authorizing student trips to affected areas or to international programs How students’ health should be monitored Provision of hygiene supplies and education throughout campus Care of ill students on campus Classroom attendance policies when influenza is circulating Communication with students and families Housing of international students and others without other homes if the facility is closed Conditions under which the college or university would cancel classes

Planning Recommendations Each college and university should designate a person or group to be responsible for monitoring updated information and preparing for a pandemic; –One person be designated to liaise with regional and state health officials Pandemic response plans for colleges and universities should address the unique conditions of their institutions Planners should be familiar with policies outlined in federal and state plans Consider how to implement state policies to cancel non- essential public gatherings (Section 7) Representatives are encouraged to participate in local pandemic planning, as appropriate, along with public health and other community leaders to assure that the needs and resources of the college or university are considered into local plans

Resources Federal pandemic planning checklist for colleges and universities – State Pandemic Influenza Response Plan – Your local health department (see handout)