Pandemic Influenza Perspectives from Federal and State Public Health DatePresenter North Carolina Division of Public Health

Objectives Review influenza basics Review influenza basics Assess current pandemic threat Assess current pandemic threat Describe pandemic planning in the United States and in North Carolina Describe pandemic planning in the United States and in North Carolina

Flu Basics: Viral Infection Fever Fever Headache Headache Muscle aches Muscle aches Extreme fatigue Extreme fatigue Dry cough Dry cough Sore throat Sore throat Runny or stuffy nose Runny or stuffy nose CDC Public Health Image Library

Flu Complications Bronchitis Bronchitis Pneumonia Pneumonia Dehydration Dehydration Worsening of chronic illness Worsening of chronic illness Sinus or ear problems in children Sinus or ear problems in children Death Death ~65/100,000 infections~65/100,000 infections 80-90% >65 y/o80-90% >65 y/o

Seasonal Influenza: Key Facts Transmission Respiratory droplets Transmission Respiratory droplets An infected person infects ~1.53 othersAn infected person infects ~1.53 others Incubation Period 1 to 5 days from exposure Incubation Period 1 to 5 days from exposure Contagious Period Contagious Period 1-2 days before illness begins*1-2 days before illness begins* 4-5 days after onset4-5 days after onset Timing Timing Seasonal flu: Wintertime peakSeasonal flu: Wintertime peak Occasional importation from Southern hemisphereOccasional importation from Southern hemisphere Pandemic: anytimePandemic: anytime *low likelihood of transmission

Avian Influenza H5N1: Key Facts Transmission to humans: Rare Transmission to humans: Rare Extensive contact with infected birdsExtensive contact with infected birds Contagiousness Contagiousness Very rarely spread between humansVery rarely spread between humans Spread among birds: increasingSpread among birds: increasing Birds and poultry in Southeast Asia, Asia, Indonesia, Europe, Africa, Middle East… Birds and poultry in Southeast Asia, Asia, Indonesia, Europe, Africa, Middle East… Severity Severity Of 281 people infected with H5N1 Avian Flu, 169 (60%) have diedOf 281 people infected with H5N1 Avian Flu, 169 (60%) have died

Pandemic Influenza: Key Facts Pandemic = worldwide epidemic Pandemic = worldwide epidemic New influenza virus No immunityNew influenza virus No immunity Spreads from person-to-personSpreads from person-to-person Presumed to be like seasonal flu: respiratory droplets Presumed to be like seasonal flu: respiratory droplets Can cause severe diseaseCan cause severe disease Incubation Period Incubation Period Presumed like seasonal flu: 1 to 5 daysPresumed like seasonal flu: 1 to 5 days Contagious Period Contagious Period Presumed to be similar to seasonal fluPresumed to be similar to seasonal flu Timing Timing Waves that last weeks and could begin anytimeWaves that last weeks and could begin anytime

Influenza Impacts Type of Influenza ImpactSeasonalAvianPandemic FrequencyAnnualRare ~3 - 5 per century % Infected 30< % Fatal ~0.05>

Influenza Countermeasures Counter- measures SeasonalAvianPandemic Vaccine++-+/- Anti-virals++++/- Non- Pharmaceutical Interventions (NPIs) +++/-++

Week 1 = early January Week 52 = late December Seasonal Flu in NC

Week 1 = early January Week 52 = late December Sentinel and Emergency Department Surveillance in NC

Prevention of Seasonal Influenza Annual vaccination Annual vaccination InjectionInjection Inactivated Inactivated Nasal mistNasal mist Live attenuated Live attenuated Prophylactic medicines Prophylactic medicines Avoid ill persons Avoid ill persons Respiratory hygiene & etiquette: Cover your cough Respiratory hygiene & etiquette: Cover your cough southbirminghampct.nhs.uk

Pandemic Influenza Emergence Novel virus Novel virus Human-to-human transmission Human-to-human transmission R 0 = number of people an infected person infectsR 0 = number of people an infected person infects Severity of illness Severity of illness Case fatality ratio (CFR)Case fatality ratio (CFR)

Pandemic Influenza Emergence Novel virus Novel virus Human-to-human transmission Human-to-human transmission R 0 = number of people an infected person infectsR 0 = number of people an infected person infects Severity of illness Severity of illness Case fatality ratio (CFR)Case fatality ratio (CFR)

Pandemic Severity CDC Pandemic Severity Index Basis: Case Fatality Ratio Category 1 Mild Category 5 Catastrophic

Pandemics of the 20 th Century Year US Mortality Spanish flu 550, Asian 69, Hong Kong 33, Russian* 8,300 *Novel virus that didnt cause a pandemic

Pandemic Influenza Multiple waves possible Six to eight weeksSix to eight weeks Weekly combined influenza and pneumonia mortality, United Kingdom, 1918– JK Taubenberger and DM Morens Influenza: the Mother of All Pandemics. EID, Jan. 2006

Does Age Matter? Age at death, per 100,000 persons in each age group, United States, 1911–1918 -JK Taubenberger and DM Morens.1918 Influenza: the Mother of All Pandemics. EID, Jan. 2006

Pandemic Flu Vaccine and Drugs Vaccine Vaccine Delayed productionDelayed production May require two dosesMay require two doses Drugs Drugs Supplies: limitedSupplies: limited Distribution: unfamiliarDistribution: unfamiliar Prioritization rationing fear… Prioritization rationing fear…

Pandemic Influenza Planning Federal and State Perspectives Overall Goals Reduce deaths Reduce illnesses Reduce social disruption

Current Pandemic Planning Assumptions Well have some notice Well have some notice Dont expect federal or state rescue Dont expect federal or state rescue Duration of event: weeks to months Duration of event: weeks to months Absenteeism Absenteeism Plan for 30-40% for at least 2 weeksPlan for 30-40% for at least 2 weeks Vaccine Vaccine Late, limitedLate, limited Anti-virals Anti-virals Insufficient stockpile for preventive treatmentInsufficient stockpile for preventive treatment Sufficient for some treatmentSufficient for some treatment

Federal and State Public Health Roles Leadershipin collaboration with emergency management Leadershipin collaboration with emergency management Informationregular updates, interim guidance Informationregular updates, interim guidance Coordinationwith multiple agencies and jurisdictions, e.g. counties, state agencies Coordinationwith multiple agencies and jurisdictions, e.g. counties, state agencies Evaluationmeasure interventions effects Evaluationmeasure interventions effects

Public Healths Legal Authorities CDC State Public Health County or City Health Departments CDC State Public Health County or City Health Departments Federalguidance only Federalguidance only Stateguidance and legal authority Stateguidance and legal authority County/Local Health Departmentswhere guidance and legal authority meet real people County/Local Health Departmentswhere guidance and legal authority meet real people

Federal Guidance DHS/HHS/CDC leadership All Federal Cabinet Level Agencies Justice Defense Commerce Treasury

State Guidance Division of Public Health leadership Governor Executive Order: All executive level agencies to create pan-flu continuity of operations plans (COOPS)

How To Slow a Pandemic: Latest CDC Guidance 1. Ill persons should be treated* and stay away from others 2. Exposed persons should stay away from others and receive prophylaxis* 3. More social distance between children in schools and childcare 4. More social distance between adults at work and play *If sufficient medicine is available *If sufficient medicine is available

Delay and Limit New Cases Time Impact No interventions With interventions

Weekly mortality data provided by Marc Lipsitch (personal communication)

St. Louis First death recorded Mayor closes theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions until further notice Closing order withdrawn Estimated attack rate before interventions: 2.2% Source: Lipsitch M, Hatchett R, Mecher C

Pittsburgh 3.7%* Estimated attack rate before interventions: Theaters, saloons closed* Sports suspended Churches closed Schools, libraries closed Source: Lipsitch M, Hatchett R, Mecher C

Non-Pharmaceutical Interventions Social Distancing More distance between persons spread of germs less likely More distance between persons spread of germs less likely More distance, fewer persons reduced social density fewer opportunities More distance, fewer persons reduced social density fewer opportunities Examples: Examples: Cancel indoor arena eventsCancel indoor arena events Dismiss students from schoolsDismiss students from schools Increase distance between workers/Limit workplace interactionsIncrease distance between workers/Limit workplace interactions Tele-work, stagger schedules, Net-meetings Tele-work, stagger schedules, Net-meetings

Pandemic Severity CDCs Pandemic Severity Index Category 1 –mild Category 3 –moderate Category 5 –catastrophic Interventions α Severity Index Category 1 Ill persons stay home Schools generally not closed Category 5 Almost everyone stays home!

Impact of an Influenza Pandemic United States Seasonal1957-like1918-like Illnesses million 90 million Outpatient visits 25 million 45 million Hospital visits 200,000865,000~5x 9.9 million ~50x Deaths36,000209,000~5x 1.9 million ~50x

Pandemic Impact in North Carolina Seasonal Moderate Pandemic* Severe Pandemic* Doctor visits 750, million Hospital visits 6,00035,000290,000 Deaths1,1007,95065,300 * Based on CDC software FluAid 2.0: Assumes a 35% attack rate, NC population of 8.5 million people.

Pandemic Influenza Planning Challenges Widespread event Widespread event Long duration Long duration Uncertainties Uncertainties SeveritySeverity Age-related impactsAge-related impacts BlindersBlinders Health services overwhelmed Health services overwhelmed Shortages likely ethical approaches neededShortages likely ethical approaches needed Medications, vaccines Medications, vaccines Equipment Equipment Hospital beds Hospital beds Personnel: ~30% absenteeism for 2 weeks Personnel: ~30% absenteeism for 2 weeks Health care settings as sources of infection?Health care settings as sources of infection?

Planning Partners: No One Untouched Hospitals Hospitals Emergency management agencies Emergency management agencies Local and regional public health Local and regional public health Business Sector Business Sector Schools and universities Schools and universities Faith-based Faith-based Other government Other government In other words… In other words… …everyone! Goal: Continuity of Operations

Critical Infrastructure/Key Resources Private Sector Focus Identify priorities Identify priorities Motivate action earlier Motivate action earlier Recognize differences between traditional COOPS and Pan Flu impacts Recognize differences between traditional COOPS and Pan Flu impacts Longer durationLonger duration AbsenteeismAbsenteeism

Prevention and Planning It Begins At Home The more you prepare yourself and your family, the more likely you can fulfill roles in an emergency The more you prepare yourself and your family, the more likely you can fulfill roles in an emergency

Possible Scenario Federal Response WHO Phase 6, Category 5 Severity WHO Phase 6, Category 5 Severity Sustained human-to-human transmission, high case fatality ratioSustained human-to-human transmission, high case fatality ratio Cases recognized in US Cases recognized in US President may proclaim State of Emergency President may proclaim State of Emergency DHS/CDC and all other Federal Agencies implement COOPs DHS/CDC and all other Federal Agencies implement COOPs Private sector partners encouraged to implement COOPs Private sector partners encouraged to implement COOPs Media Media

Possible Scenario State Response Cases recognized in US including NC Cases recognized in US including NC Governor proclaims State of Emergency, orders Governor proclaims State of Emergency, orders Students: dismissed from schoolsStudents: dismissed from schools Mass gatherings: cancelledMass gatherings: cancelled Church services: discouragedChurch services: discouraged Businesses: continuity of operations plansBusinesses: continuity of operations plans Hospitals: surge capacity + COOPsHospitals: surge capacity + COOPs Division of Public Health and NC Emergency Management Division of Public Health and NC Emergency Management Activate COOPs, EOCs, JICActivate COOPs, EOCs, JIC Work with CountiesWork with Counties Counties: COOPs within their jurisdictions Counties: COOPs within their jurisdictions

The Snow Day Approach - For 6-8 Weeks?

Emergency Ends The pandemic wave passes through The pandemic wave passes through Public Health measures impacts Public Health measures impacts Illnesses, deathsIllnesses, deaths Other impacts, losses to business sectorOther impacts, losses to business sector Plans refined Plans refined Vaccine or anti-flu drugs become available??? Vaccine or anti-flu drugs become available???

Questions Feedback Thanks

Contact Info Brant Goode, RN/BSN, MPH LCDR, USPHS CDC Career Epidemiology Field Officer assigned to North Carolina Division of Public Health Public Health Preparedness and Response (office) (fax) (mobile) or