1. Preparing for a Influenza Pandemic in Utah Robert T. Rolfs, MD, MPH Utah Department of Health December 4, 2006

2. About Influenza Viral illness - Influenza A, B, C Abrupt onset fever, chills, muscle aches, headache, followed by cough, sore throat, nasal congestion 5-6 days restricted activity, 3 days lost from school or work Transmission – person to person Respiratory droplets, contaminated hands/surfaces, aerosol Infectious – 1 day before to 5 days after illness onset Short time from infection to transmission leads to rapid spread in community

3. Spread of an Infectious Disease Generation Time Days12345678 SARS - Generation time = 8-10 days Influenza - Generation time = 2-4 days

4. What is Seasonal Influenza? “Annual” seasonal epidemics “Annual” seasonal epidemics Attack rates average 5-20% Attack rates average 5-20% 20-40,000 deaths in U.S. annually 20-40,000 deaths in U.S. annually Greatest effect on very young and older adults Greatest effect on very young and older adults Result of antigenic “drift” Result of antigenic “drift” Ongoing changes of influenza viruses that allow people to be infected more than once Ongoing changes of influenza viruses that allow people to be infected more than once

5. Percentage of Visits for Influenza-like illness (ILI) Reported by Sentinel Providers Utah 2003-4, 2004-5 and 2005-06 seasons

6. Influenza-associated Hospitalizations Utah 2005-2006* Date as of March 1, 2006

7. Student Absenteeism Rates 2005-2006 Influenza Season

8. Many varieties of influenza occur in birds Many varieties of influenza occur in birds Primarily affects wild aquatic birds Primarily affects wild aquatic birds Serious illness is unusual in wild birds Serious illness is unusual in wild birds Illness more severe in domestic poultry, classified based on severity Illness more severe in domestic poultry, classified based on severity Most avian influenza viruses don’t infect humans Most avian influenza viruses don’t infect humans Highly pathogenic avian influenza is not found in Utah at this time Highly pathogenic avian influenza is not found in Utah at this time Avian Influenza

9. What is an Influenza Pandemic? Global outbreak of influenza Global outbreak of influenza Appearance of new type of influenza A virus to which people have no immunity Appearance of new type of influenza A virus to which people have no immunity Can cause serious illness and spread rapidly from person to person worldwide. Can cause serious illness and spread rapidly from person to person worldwide. Past pandemics have caused high levels of illness, death, social disruption and economic loss. Past pandemics have caused high levels of illness, death, social disruption and economic loss.

10. PandemicStrain Est. Deaths U.S. Worldwide Spanish(1918-19)H1N1~650,000 ~50 million Asian(1957-58)H2N2~70,000 > 1 million Hong Kong (1968-69)H3N2~34,000 > 1 million Influenza Pandemics in the 20 th Century

11. Influenza pandemics – death rates by age

12. 1918 Influenza Pandemic Death rates - United Kingdom, 1918-19 Tauberberger JK, Morens DM. 1918 Influenza: the Mother of All Pandemics. EID 206;12(1). http://www.cdc.gov/ncidod/eid/vol12no01/05-0979.htm#Figure1 http://www.cdc.gov/ncidod/eid/vol12no01/05-0979.htm#Figure1

13. Iowa State gymnasium, converted into hospital, 1918 flu epidemic

15. Spread of H2N2 in 1957

16. 1968 Pandemic – peak by state Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

17. Avian Influenza H5N1 1997 – Hong Kong outbreak 1997 – Hong Kong outbreak 18 persons hospitalized & 6 deaths 18 persons hospitalized & 6 deaths Live bird markets, controlled by destruction of poultry (>1.5 million) Live bird markets, controlled by destruction of poultry (>1.5 million) 2003 Re-emerged in China, Vietnam, Thailand, Korea 2003 Re-emerged in China, Vietnam, Thailand, Korea Poultry outbreaks and human cases Poultry outbreaks and human cases 2005 – 2006 2005 – 2006 Ongoing poultry outbreaks & human infections Ongoing poultry outbreaks & human infections 1 st human-to-human transmission 1 st human-to-human transmission Wild birds, other mammals found infected Wild birds, other mammals found infected Spread to Eurasia, Africa, and Europe Spread to Eurasia, Africa, and Europe

18. Avian Influenza (H5N1) Human disease 2003-2006 Human cases – 258 cases with 154 deaths > 50% case fatality rate How people get it Direct contact with poultry Very limited person-to-person spread Effective person-to-person spread is not occurring at this time Human cases are from Dec. 26, 2003 through November 29, 2006

19. Avian Influenza H5N1 Human Cases – 2003-2006 * Country2003200420052006 Total Cases (Deaths) Azerbaijan8 8 (5) Djibouti1 1 (0) Egypt15 15 (6) Iraq3 3 (2) Turkey12 12 (4) Cambodia42 6 (6) China812 21 (14) Indonesia1753 72 (55) Thailand1753 25 (17) Vietnam32961 93 (42) * Human cases through October 16, 2006

20. Nations With Confirmed Cases H5N1 Avian Influenza (July 7, 2006) www.pandemicflu.govwww.pandemicflu.gov (accessed October 22, 2006)

21. Avian Influenza (H5N1) 2006 Unprecedented animal epidemic Unprecedented animal epidemic Poultry or wild bird outbreaks in > 53 nations in Asia, Africa, Europe Poultry or wild bird outbreaks in > 53 nations in Asia, Africa, Europe Unlike most avian influenza, it has infected people causing severe illness Unlike most avian influenza, it has infected people causing severe illness Have conditions been met for a pandemic? Have conditions been met for a pandemic?  Novel antigens – no human immunity - Yes  Serious human infection – Yes  Effective person-to-person spread – Not yet  Will it cause a pandemic? We don’t know

22. Another pandemic will occur someday

23. Pandemic Influenza Impact Utah Projections Moderate Pandemic 1957/1968-like Severe Pandemic 1918-like Illness (30%)759,000 Outpatient Care (50%) 379,000 Hospitalizations7,28083,550 ICU Care1,09012,520 Ventilator5506360 Death1,75015,930 Projections are based on the U.S. estimates included in the HHS Pandemic Influenza Plan, and based on Utah 2005 population estimate (2,529,000); these estimates don’t account for age differences in populations

24. Pandemic Influenza Projections Utah – Moderate (1957/68-like) At peak – 150 admissions per day

25. Pandemic Influenza Projections Utah – Severe (1918-like) At peak – 1700 admissions per day

26. Pandemic Influenza Examples of Community Impact High absenteeism rates at work/school (20-40%) High absenteeism rates at work/school (20-40%) Possible school closures Possible school closures Event cancellations – concerts, meetings, conventions Event cancellations – concerts, meetings, conventions Travel restrictions and decreased tourism Travel restrictions and decreased tourism Economic and business impact Economic and business impact Shortages of supplies Shortages of supplies Difficulty keeping police & firemen, doctors, nurses, and other critical service providers working Difficulty keeping police & firemen, doctors, nurses, and other critical service providers working Hospitals full – delayed care for routine or even urgent illnesses Hospitals full – delayed care for routine or even urgent illnesses

27. Pandemic Influenza Strengthening Public Health Capacity All Hazards Disaster Planning All Hazards Disaster Planning Epidemiology & Disease Surveillance Epidemiology & Disease Surveillance Laboratory Testing & Response Laboratory Testing & Response Information & Communication Systems Information & Communication Systems Effective Risk Communication Effective Risk Communication Training & Exercises Training & Exercises Hospital Preparedness Hospital Preparedness

28. Pandemic Influenza Planning Some planning assumptions Simultaneous outbreaks across Utah and U.S. Simultaneous outbreaks across Utah and U.S. Limited ability to share resources across jurisdictions Limited ability to share resources across jurisdictions In a given community, the epidemic will last 6-8 weeks In a given community, the epidemic will last 6-8 weeks No vaccine for first 6-8 months and shortages after that No vaccine for first 6-8 months and shortages after that Shortages of antiviral medications and probably of antibiotics and other medical supplies Shortages of antiviral medications and probably of antibiotics and other medical supplies Illness rates and absenteeism of 25% or more Illness rates and absenteeism of 25% or more Need for care may exceed capacity of health care system Need for care may exceed capacity of health care system

29. Pandemic Influenza Plan Utah Pandemic Influenza Plan – a roadmap Utah Pandemic Influenza Plan – a roadmap Identified what public health needs to do Identified what public health needs to do Pandemic influenza workgroup Pandemic influenza workgroup Local health department planning Local health department planning Identified issues requiring broader input and help to address Identified issues requiring broader input and help to address Governor’s Taskforce Governor’s Taskforce Too big for (any) government alone Too big for (any) government alone Local governments, faith-based & community organizations, businesses, families, individuals Local governments, faith-based & community organizations, businesses, families, individuals

30. Pandemic Influenza Preparedness Communications and coordination Communications and coordination Public/risk communications Public/risk communications Agency/partner coordination and communication Agency/partner coordination and communication Health care surge capacity Health care surge capacity Antiviral medication stockpile Antiviral medication stockpile Vaccine planning Vaccine planning Maintaining essential services Maintaining essential services Supporting vulnerable populations & essential responders Supporting vulnerable populations & essential responders

31. Pandemic Influenza Preparedness Community Mitigation Home isolation Home isolation Family quarantine Family quarantine School closure School closure Cancellation of mass gatherings Cancellation of mass gatherings Social distancing and respiratory hygiene Social distancing and respiratory hygiene

32. Pandemic Preparedness in Schools Planning Planning Maintaining core operations during pandemic Maintaining core operations during pandemic Communication Communication public health and other agencies/partners public health and other agencies/partners students and parents students and parents Infection control policies, procedures, supplies Infection control policies, procedures, supplies Keeping school safe, reducing spread of influenza Keeping school safe, reducing spread of influenza Continuity of student learning & operations Continuity of student learning & operations School closure planning School closure planning

33. Pandemic and Avian Influenza Additional information Utah: http://www.pandemicflu.utah.gov http://www.pandemicflu.utah.gov HHS: http://www.pandemicflu.gov http://www.pandemicflu.gov John M. Barry The Great Influenza: The Epic Story of the Deadliest Plague In History Neustadt R, Fineberg H. The Epidemic that Never Was: Policy-making and the Swine Flu Affair