Pandemic Influenza Preparedness and Response: California perspective

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Pandemic Influenza Preparedness and Response
California perspective

• Howard Backer, MD, MPH
• California Department of Health Services

Sandra Shewry, Director Mark Horton, State Public
Health Officer Betsey Lyman, Deputy Director,
Emergency Preparedness
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State Responsibilities

• Office Emergency Services (OES)
• Coordinates responding agencies and mutual aid
• CDHS and EMSA
• Liaison with CDC for policies, science,
  information
• Develop state policy
• Emergency regulations
• Technical assistance, direct assistance to LHDs
• Collate, analyze, interpret state level data,
  surveillance
• Coordinate health care response and surge
  capacity
• Distribution of vaccine and antivirals to local
  jurisdictions
• Communication message coordination

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California Dept Health Services Pandemic
Planwww.dhs.ca.gov

• Organization of response and authorities
• Surveillance and laboratory confirmation
• Health care planning
• Infection control and case management
• Vaccine and antiviral use
• Community Outbreak Control
• Communications

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Planning Assumptions

• Limited mutual aid
• Sustained response
• No business as usual
• All sectors of society and govt involved
• Workforce disruption
• Other disasters may still occur

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Outbreak Containment Measures vary as pandemic
develops

• Pharmaceuticals vaccine and antivirals
• Reduce individual exposure to virus
• Isolation (confinement) of ill persons
• Community-based containment
• Limiting public contact
• Cancellation of events and schools

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Vaccine for Pandemic Influenza

• State responsibilities
• Refine national priorities for vaccination
• Decision Analysis Scoring Tool
• www.idready.org/
• Distribution strategies to local jurisdictions
  and to priority groups
• Integrate with SNS plan

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Vaccine Production and Stockpile

• Currently 6-18 million courses H5N1 prepandemic
  vaccine
• (2-6 of population)
• Current capacity 14-42 million courses/yr
• (5-14 of population)
• Front line health care and safety 5 pop
• Initial prepandemic vaccines require 6 times the
  amount and twice the doses of annual influenza
  vaccine

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Global Influenza Vaccine Production
18 producers worldwide Only 1 producer in U.S.
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Anti-viral Medication

• Size and composition of stockpiles at state and
  local level
• Cost
• Efficacy
• Availability
• Policy for use
• Containment
• Treatment
• Prophylaxis
• Distribution strategy to allow early use

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Antiviral Chemoprophylaxis of Influenza
1 Monto JAMA 1999 28231 2 Hayden NEJM 1999
3411336 3 Hayden NEJM 2000 34312882 4
Gravenstein J Am Med Dir Assoc 6359 2005 5
Peters J Am Gerontol Soc 2001 4041025
Slide courtesy of A Pavia, U. Utah
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Effects of Oseltamivir on Time to Resolution of
all Flu Symptoms
21 hours
32 hours
plt0.001 p0.004 Treanor et al. JAMA 283 2000
Slide courtesy of A Pavia, U. Utah
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Oseltamivir Treatment Combined RCT Database
Effect on Hospitalizations
Kaiser et al. Arch Intern Med 1631667, 2003
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Impact of Antiviral Therapy on Influenza
Complications, Retrospective Analysis, Nursing
Home Residents, Canada
Percent
Bowles et al. J Am Geriat Soc 2002
Slide courtesy of A Pavia, U. Utah
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Los Angeles--Flu Season 1997-1998
Health Care Capacity

• Public asked to avoid unnecessary ER visits
• Hospitals full bursting at the seams!
• People just kept coming in, but not enough beds,
  gurneys, or ventilators.
• Emergency staff working double shifts and sick

Glaser et al. 2002 Emerging Infectious Diseases
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Licensed beds per 100,000 persons, Los Angeles
County, 19911997
Glaser et al. 2002 Emerging Infectious Diseases
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Surge Capacity

• Flexibility of health care delivery system to
  accommodate large number of patients
• Beds
• Personnel
• Equipment

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Calculated using FluSurge (Assumptions altered)
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Initial Steps for Healthcare Facility Surge
Capacity Response

• 10 of staffed beds from expedited discharge
• 10 of staffed beds from cancellation of elective
  surgeries and other elective admissions
• 10 licensed beds not currently staffed or other
  unlicensed treatment areas within the hospital

Hick JL, Hanfling D, Burstein JL, et al.,
Healthcare Facility and Community Strategies for
Patient Care Surge Capacity, Annals of Emergency
Medicine. September 2004.
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Emergency Regulatory Support for Surge

• Facility licensing and staffing regulations
• Scope of practice for health professionals
• Professional licensing
• Volunteer registration

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Surge Planning Strategies

• Alternate care sites
• Altered standards of care
• http//www.ahrq.gov/research/altstand/
• Triage of mechanical ventilation in an epidemic
  Acad Emerg Med. 2006 Feb13(2)195-8
• Staff recruitment and retention plans
• Volunteer registration
• Regulatory changes
• Medico-legal issues

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Basic respiratory hygiene measures
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Risk Communications

• Prepare the public with realistic scenarios and
  likely containment measures
• Inform public of actions they can take
• Train spokespersons at state and local levels
• Prepare health care and public health for their
  involvement
• Develop rapid communication channels with medical
  care
• Involve non-health sectors in preparedness
  activities

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• Any local government that fails to prepare
  expecting the federal or state government to step
  in will be tragically wrong.
• HHS Secretary Michael Leavitt
• CA Pandemic Influenza Summit Mar 30, 2006

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EXECUTIVE ORDER S-04-06April 18, 2006

• Emergency Partnership Advisory Workgroup
• OES shall promulgate model COGO plans and
  guidelines
• All Executive Branch agencies shall update their
  Continuity of Operations-Continuity of Government
  plans
• Working group of representatives from hospitals
  and health facilities to ensure local health
  facility surge capacity plans achieve HRSA
  benchmarks
• California Service Corps, in cooperation with
  HHS, OES, OHS, and non-profit volunteer
  organizations, shall ensure the coordination of
  volunteer activities

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Models of Government(adapted from Governing by
Network by Goldsmith Eggers, p. 20)
Low Public-private cooperation High
Low Network management capabilities
High
Gene W. Matthews Public Health Law, CDC Foundation
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Local Government, Business, Community
Organizations

• Continuity of Operations
• Staffing and leadership succession
• Telecommuting options
• Evaluate need for personal public contact
• Hygiene measures in work place
• Critical supply chain
• Support community and public health response