1. 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.

2. “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

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

4. In Louisiana We Know How to Prepare for This:

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

6. http://worldvid. cit. nih. gov/flu/flu. wmv http://worldvid. cit. nih
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.

7. 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.

8. 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.

9. 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.

10. 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

11. 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

12. 20th Century Flu Pandemics
1918 – Spanish Flu
Worldwide million deaths
500,000 deaths in US
– Asian Flu
Worldwide 1-2 million deaths
70,000 deaths in US
– 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 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

13. 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%

14. 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

15. 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.

16. Earlier, you saw computer modeling of a future pandemic, this shows what happened in 1918.

17. 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

18. 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.

19. 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, Available at:

20. 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

21. 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.

22. 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.

25. 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:

26. 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

27. Pandemic Flu homepage

28. Example of Federal Checklists

29. 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

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

31. 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

32. 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:

33. References State Pandemic Resources Family Readiness Guide
Family Readiness Guide
Official Pandemic Flu Web Site
Pandemic Influenza Preparedness, Response, and Recovery Guide for Critical Infrastructure and Key Resources