1. Challenges in Delivering Pandemic Vaccine from a City Health Department Perspective 43nd National Immunization Conference
Fernando A. Guerra, M.D., M.P.H.
Director of Health
San Antonio Metropolitan Health District

2. Objectives What can we expect in a Pandemic?
Discuss the major challenges faced by a city health department 2

3. What does that mean for the 1
What does that mean for the 1.5 million people in my community, or other local health departments? 3

4. HISTORY is the best predictor of the FUTURE
1918 Spanish Flu
1957 Asian Flu
1968 Hong Kong Flu
Present or Future??? 4

5. Historical Precedence 1917 - 1918 Pandemic
San Antonio had the highest morbidity rate of any city in the country
98% of households had at least one person infected
> 50 % of the population fell ill 5

6. Avian Flu (H5N1) Pandemic Influenza is NOT 6
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 6

7. Currently there is no pandemic flu.
Avian flu is caused by avian influenza viruses occurring naturally among birds
Occasionally infect humans
Occasionally, a highly pathogenic strain emerges, such as 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 is a global outbreak of a highly pathogenic strain
Spreads easily from person to person
Otherwise healthy young adults severely affected.
Currently there is no pandemic flu. 7

8. 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. 8

9. Challenges for a City Health Department
Minimize serious illness, hospitalizations, and mortality
Implement control measures
Developing and preserving critical infrastructure/workforce
Variety of health department capacities
Minimizing social disruption
Latency in viral identification/vaccine development
Surveillance 9

10. Surveillance Systems to Monitor and Detect Influenza
Syndromic Surveillance
Monitor School Absenteeism
Over the counter drug sales
Sentinel Clinics
One of the key components of any plan is surveillance. SAMHD conducts a number of different surveillance systems to monitor and detect influenza activity in San Antonio/Bexar County.
At present we obtain numbers of absentees from one school district. Kids are the first to get sick, and before they see their doctor they stay home from school. Kids are also infectious for longer and shed more virus. We are expanding this to include school districts throughout the city.
HEB drugstores reports sales weekly of over the counter drugs. This is another clue to illness in the community before people are sick enough to see their doctor or go to hospital.
Flu is currently not a reportable disease required by state law. Instead, we have 13 clinics throughout the city which report flu like illness. We obtain a sample from the patient which is then sent to the state labs for testing. 10

11. Surveillance Systems Flu-like illness reports from Texas Med Clinics
Redbat ER Syndromic Surveillance
Texas Med Clinics and soon, University Health Services, provide us data weekly on the number of patients presenting with flu-like illness.
In each hospital ER there’s a system in place where the symptoms are entered into a program which is then submitted to our Epidemiology division on a daily basis.
Taken together, these systems allow us to detect flu-like illness throughout the community before it becomes a large scale epidemic. 11

12. Challenges for a City Health Department (cont’d.)
Identifying and responding to the needs of vulnerable populations
Comorbidities
Disabled
Intellectually compromised
Elderly and dependent
Maintaining an adequate Stockpile
Supplies
Vaccine/ Anti-virals
Shelf Life
Storage
Maintaining adequate funding and resources
Prioritizing and Rationing???
Establishing MOUs with municipalities and school districts
Oath of Office
Selecting POD/Vaccine Facilities
Other models, i.e. drive-thru/mobile sites 12

14. Challenges for a City Health Department (cont’d.)
2-wave “Epi Curve”
Maintaining a supply of well-trained staff and volunteers to deliver and administer vaccine
Public Health vs. Hospital
Credentialing
Multi-agency coordination and collaboration (ICS)
Engaging the public
General information; Informed consent; user-friendly documents
Discrepancy of Categorization of Pandemic Influenza phases, i.e. WHO vs. U.S. Federal agencies 14

15. Federal Government Response Stages
Pandemic Phases
WHO Phases
Federal Government Response Stages
INTER-PANDEMIC PERIOD 1
Low risk of human cases
New domestic animal
outbreak in at-risk country 2
Higher risk of human cases
PANDEMIC ALERT PERIOD 3
Human infection with a new
subtype, but no human-to
human spread
Suspected human outbreak
overseas 4
Evidence of increase of
human-to-human spread
(small clusters)
Confirmed human outbreak 5
Evidence of increased human-
to-human spread
(large clusters)
PANDEMIC PERIOD 6
Efficient and sustained
transmission in human
population
Widespread human
outbreaks in multiple
locations overseas
First human case in North
America
Spread throughout United
States
Recovery and preparation
for subsequent waves

16. “The greatest challenge for us is the unknown……”
F.A. Guerra, M.D., M.P.H. 16