Title: PREPAREDNESS FOR AN INFLUENZA PANDEMIC: FOCUS ON VACCINE DEVELOPMENT AND UNC HOSPITALS PREPAREDNESS
1PREPAREDNESS FOR AN INFLUENZA PANDEMIC FOCUS ON
VACCINE DEVELOPMENT AND UNC HOSPITALS
PREPAREDNESS
- David Jay Weber, M.D., M.P.H.
- Professor of Medicine, Pediatrics Epidemiology
- Medical Director, Hospital Epidemiology and
Occupational Health - University of North Carolina at Chapel Hill
2SOURCE OF SLIDES
- Robert Belshe, Washington University
- Nancy Cox, CDC
- Jeffrey Engel, NC Health Department
- James Matthews, Sanofi Pasteur
- Andrew Pavia, University of Utah
- Bill Schaffner, Vanderbilt
- David Shay, CDC
- Jay Steinberg, Emory
3INFLUENZA PRIMER
4Influenza Disease Burden to U.S. Societyin an
Average Year
Deaths 25,000 - 72,000
Hospitalizations 114,000 - 257,500
Physician visits 25 million
Infections and illnesses 50 - 60 million
Thompson WW et al. JAMA. 2003289179-86. Couch
RB. Ann Intern Med. 2000133992-8. Patriarca PA.
JAMA. 199928275-7. ACIP. MMWR.
200453(RR06)1-40.
5INFLUENZA BIOLOGY IMPACT
- Single-stranded, enveloped, RNA virus
(orthomyxoviridae family) - Influenza A
- Potentially severe illness epidemic and
pandemics - Rapidly changing
- Influenza B
- Usually less severe illness may cause epidemics
- More uniform
- Influenza C
- Usually mild or asymptomatic illness
6INFLUENZA BIOLOGY IMPACT
- Impact
- 25-50 million people contract influenza annually
(attack rate of 10-20) - 226,000 hospitalizations per year
- 36,000 deaths per year
- Cost 1 to 3 billion dollars per year
- Causes respiratory tract disease
- Sudden onset
- More severe pneumonia during pregnancy
- No carrier state (but inapparent illness may
occur)
7Influenza Activity Can Peak From December
Through May
Month of peak influenza activity during influenza
seasons in the United States, 19762002
11
6
4
3
1
1
www.cdc.gov/nip/publications/pink/flu.pdf.
8Structure of the Influenza Virus
Hemagglutinin (HA)
Neuraminidase (NA)
M2
Nucleoprotein (NP)
M1
Polymerase (P) Proteins
Adapted from Hayden FG et al. Clin Virol.
1997911-42.
9Viral Nomenclature
Type of Nuclear Material
Hemagglutinin
Neuraminidase
A / Sydney / 184 / 93 (H3N2)
Virus subtype
Virus type
Geographic origin
Year of isolation
Strain number
CDC. Atkinson W, et al. Chapter 13 Influenza.
In Epidemiology and Prevention of
Vaccine-Preventable Diseases, 4th ed. Department
of Health and Human Services, Public Health
Service, 1998, 220
10 Timeline of Emergence of Influenza A Viruses
in Humans
Avian Influenza
H7
H9
H5
Russian Influenza
H5
H1
Asian Influenza
H3
Spanish Influenza
H2
Hong Kong Influenza
H1
1918
1957
1968
1977
1997
2003
1998/9
11Antigenic Drift
12Antigenic Shift
13Why the Concern? During the past 100 years,
there have been three major pandemics, and there
are strong signals in recent years of pandemic
potential (epizootics of avian flu)
H5N1
H7N7
H5N1
H9N2
H5N1
H1N1
H3N2
Different Viruses Migratory Birds Domestic Poultry
H2N2
DIFFERENT VIRUSES Migratory Birds Domestic Poultry
H1N1
2003
1968
1957
1918
2004/5
1977
1997
1999
1918
1918
50 - 100 millions
1 million
800 000
?
Mortality
Asian Flu
Hong Kong Flu
Spanish flu
1950
1925
1975
2000
14Antigenic Change - Shift
15INFLUENA PANDEMICS IN THE 20th CENTURY
HHS Pandemic Influenza Plan, October 2005
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17Americas deaths from influenza were greater than
the number of U.S. servicemen killed in any war
Thousands
Civil WWI 1918-19 WWII
Korean Vietnam War
Influenza War War
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19Worldwide Spread in 6 Months Spread of H2N2
Influenza in 1957 Asian Flu
Feb-Mar 1957Apr-May 1957Jun-Jul-Aug 1957
68,000 deaths, US
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21INFLUENZA ANTIVIRAL THERAPIES
- Amantadine Influenza A
- Treatment and prophylaxis dose adjust in renal
failure - Rimantadine Influenza A
- Treatment and prophylaxis dose adjust in renal
and hepatic failure - Oseltamivir Tamiflu Influenza A B
- Treatment (5 days) and prophylaxis (PEP 7 days
Seasonal 42 days) dose adjust in renal failure - Zanamivir Relenza Influenza A B
- Treatment only
- Must begin therapy within 2 days of onset of
illness
22Antiviral Agents for Treatment
Modified from Couch RB, Ann Intern Med.
2000133992-998
23Antiviral Agents for Prophylaxis
Not FDA approved
Modified from Couch RB, Ann Intern Med.
2000133992-998
24Moscona, A. N Engl J Med 20053531363-1373
25INFLUENZA - ANTIVIRAL THERAPIESTOXICITIES
- Amantadine and rimantadine
- CNS (anxiety, insomnia, seizures,
hallucinations), GI - CNS toxicity greater in patients on amantadine
- Resistance develops in 10-30 during treatment
course - Teratogenic and embryogenic in animals
- Zanamivir
- Brochospasm (avoid in asthmatics)
- Oseltamivir
- GI (nausea and/or vomiting 5-10)
26ANTIVIRAL THERAPY OF INFLUENZA
? No placebo-controlled study or not reported
Source Andrew Pavia, Pandemic Influenza
Planning, Emory, Nov. 2005
27ANTIVIRAL RESISTANT INFLUENZA DURING TREATMENT
Roberts N. Trans R Roc Lond 20013561895 Kiao,
et al. Lancet 2004364750
28OSELTAMIVIR EFFICACY
29Tamiflu (oseltamivir phosphate) Seasonal
Prophylaxis in a Vaccinated Frail Elderly
Population Results
of patients with laboratory-confirmed clinical
influenza
Data on file (Ref. 155-027). Hoffmann-La Roche
Inc.
30OSELTAMIVIR IMPACT ON LOWER RESIRATORY TRACT
COMPLICATIONS (LRTC)
- Analysis of prospective data from patients
enrolled in 10 placebo controlled trials (N3564) - Results confirmed influenza (oseltamivir vs
placebo) - Reduced overall antibiotic use 14.0 vs 19.1
(p - Reduced LRTCs-associated antibiotic use 4.6 vs
10.3 (p - Reduced LRTCs leading to antibiotics in high risk
patients 12.2 vs 18.5 (p0.02) - Reduce overall hospitalizations 1.0 vs 1.7
(p0.02) - Unconfirmed influenza No difference in
incidence of LRTC, overall antibiotic use or
hospitalizations
31Day of onset of antibiotic therapy for lower
respiratory tract complications in oseltamivir
(75 mg twice daily) and placebo recipients with
influenza infection
Kaiser, L. et al. Arch Intern Med
20031631667-1672.
32Day of hospitalization among placebo- or
oseltamivir (75 mg twice daily) - treated adults
with influenza infection
Kaiser, L. et al. Arch Intern Med
20031631667-1672.
33ANTIVIRALS FOR CHEMOPROPHYLAXIS CDC
RECOMMENDATIONS
- Community outbreak (usual duration 6-8 weeks)
- Persons at high risk of serious complications
- Persons at high risk of serious complications
following vaccination until immunity develops (2
weeks for adults, 6 weeks for first time
pediatric vaccinees) - Persons who are not expected to mount a
sufficient immune response due to
immunosuppression - Healthcare workers with direct patient care
responsibilities unable to obtain vaccine
34AVIAN INFLUENZA
35PANDEMIC INFLUENZA PLANNING CHALLENGES
- Worldwide distribution
- Simultaneous appearance in multiple
states/locales - Long duration (2 years)
- Surge capacity Medications, ventilators,
hospital beds, personnel - Personnel Exhaustion, concerns about infection
- Inadequate antivirals and distribution/allocation
- Vaccine development and distribution/allocation
- Maintaining infrastructure
- Maintaining quarantine
36CHARACTERISTICS OF AN INFLUENZA PANDEMIC
- The ability of the virus to spread worldwide
- Simultaneous outbreaks throughout the US,
limiting the ability of an jurisdiction to
provide assistance to other areas - The fact that many people may be asymptomatic
while infectious - Enormous demands on the healthcare system
- Delays and shortages in the availability of
vaccines and antivirals - Potential disruption of national and community
infrastructures including transportation,
commerce, utilities and public safety due to
illness and death among workers and their
families - Duration 2 years
37AVIAN INFLUENZA EPIDEMIOLOGY
38Current Influenza A/H3N2 is Partly Derived from
the 1918 Virus
Taubenberger et al, Nature, Oct 2005
39Defining a Pandemic WHO Phases
- Phase 1. No new influenza virus subtypes detected
in humans. If animals are infected, risk to
humans is low. - Phase 2. No new influenza virus subtypes detected
in humans. However, a circulating animal
influenza virus subtype poses a substantial risk
of human disease. - Phase 3. Isolated human infections, no
human-to-human spread except rare close contacts.
- Phase 4. Small, highly localized cluster(s),
limited human-to-human transmission. - Phase 5. Larger localized cluster(s) limited
human-to-human spread. Substantial pandemic
risk. - Phase 6. Pandemic phase Sustained transmission
among humans occurs.
40AVIAN INFLUENZA EPIDEMIOLOGY
- Multiple outbreaks of H5N1 in Asia since 1997
- Recently animal evidence of H5N1 infection (duck
strain) - Pigs serologic/culture in china (ProMed)
- Cats experimental infection (Kuiken. Science,
2004 9/02)
41AVIAN INFLUENZA EPIDEMIOLOGY
- Human-to-human cases reported
- Retrospective serologic evidence 1997
- Outbreak (Chan CID)
- 3.7 healthcare workers
- 6/51 household contacts
- Possible one family cluster (N2) in current
Thailand outbreak - Requires close contact, inefficient transmission
42AVIAN INFLUENZA
- Treatment
- Neuraminidase inhibitors
- Oseltamivir (Tamiflu)
- Zanamivir (Inhaled)
- Current H5N1 Amantadine and Rimantadine Resistant
- For influenza clinical activity only if given in
1st 48 hours - Likely would also work for chemoprophylaxis
- Eradication
- Large scale culling of birds
43Some Avian-to-Human Influenza Transmissions
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45H5N1 SNAPSHOT NOVEMBER 2005
- 124 human cases, 63 deaths (50)
- N5H1 strains now present in 17 countries
- Virus spreading beyond the original geographic
region to mainland China, Philippines, Siberia,
Indonesia, Malayasia, Turkey (5 new countries
since July) - 150 million birds culled (cost 10 billion)
46FACTORS LEADING TO CONCERN OF AN H5N1 INFLUENZA
PANDEMIC
- Avian H5N1 is widespread and endemic in Asia with
spread to Russia and Europe - Avian H5N1 is becoming more deadly in a growing
number of bird and mammals species - Wild birds and domestic ducks may be
asymptomatically infected - The virus is able to transmit directly from birds
to some mammals and in some circumstances to
people - Sporadic spread directly from animals to humans
suspected human-to-human transmission in rare
instances - Genetic studies demonstrated ongoing evolution of
H5N1
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48AVIAN INFLUENA PREPAREDNESS
49PANDEMIC INFLUENZA IMPACT, US
HHS Pandemic Influenza Plan, October 2005
50PANDEMIC INFLUENZA IMPACT, NC
Assumes a 25 attack rate NC Pandemic Influenza
Plan, October 2005
51AVIAN INFLUENZA IMPACT, NC
- Number of cases 1,856,296
- Hospitalizations 65,637
- Deaths 14,987
- Assumptions strain 3x more lethal than 1968-69
Hong Kong influenza - Source USA Today, 11 October 2005
52NATIONAL PROBLEMS(Not Under Control of Hospital)
- General issues
- Lack of surge capacity (ICU beds, ventilators,
floor beds) - Nursing shortage
- Just in time delivery of goods
- Response to avian influenza
- Inadequate supply of PPE
- Inadequate supply of antivirals
- Lack of effective vaccine for avian influenza
- Public hysteria
53NATIONAL PROBLEMS(Not Under Control of Hospital)
- Other issues
- No defined CDC isolation category for isolation
of highly communicable diseases (i.e., diseases
for whom airborne with eye protection
recommended) Avian influenza, SARS, certain
viral hemorrhagic fevers
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55AVIAN INFLUENZA ANTIVIRALS
56Recommendations - Priority groups
- 1. Hospitalized patients with influenza
- 2. HCWs and EMS workers with direct patient
contact - 3. Highest risk outpatients
- 4. Pandemic health responders, public safety
key government decision makers - 5. Other high risk outpatients
- 6. Outbreak response (eg PEP in nursing homes)
- 7. Prophylaxis HCWs in ER, ICU, EMS, dialysis
- 8. Pandemic societal responders other HCWs
- 9. Other outpatients
- 1O. Prophylaxis for highest risk outpatients
- 11. Prophylaxis for other HCWs w/ patient contact
57Proposed Priority Target Groups
58Estimated Pandemic Mortality, UK, 1918-19
Gani et al. Emerging Infect Dis 111355, 2005
59EFFICACY OF OSELTAMIVIR IN A MOUSE MODEL
(A/Vietnam/1203/04 H5N1)
Yen H-L, et al. JID 2005192665
60ANTIVIRALS
- Demand
- 40 million courses minimum needed to support
critical pandemic responses - 133 million courses minimum to treat all
infected and provide prophylaxis for critical
personnel - Supply
- 4 million courses in US National Stockpile
- Current stockpile based on used drugs for
treatment (more needed to provide prophylaxis) - Mouse model suggests need to treat for 8 days
rather than 5 days
61AVIAN INFLUENZA VACCINES
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63VACCINE BY THE NUMBERS
- 40 million estimated number of deaths worldwide
for 1918 pandemic - 6.2 billion worlds population
- 300 million doses worldwide capacity for
trivalent influenza vaccine - 900 million doses worldwide capacity for
monovalent vaccine (issues include yield,
adjuvant, process used, antigen content - 1 or 2 doses?
- /- 2 years expected duration of pandemic
- /- 6 months time from recognition of pandemic
till vaccine available - 9 countries number of countries with vaccine
capacity (70 in EU) - 3-5 million doses/week (15 ?g) current capacity
of US manufacturers
64Selected US Regulatory Issues Regarding a
Pandemic Antigenic Strain in Approved Vaccines
- Pandemic vaccine likely would be approved under
existing regulations for updating strains in
currently approved vaccines - WHO recommended pandemic strain could be
substituted into a monovalent preparation - Updating strains to monovalent, pandemic type
would be less burdened than approval of novel
vaccines - Issues of antigen quantity and number of doses
might require clinical trials
Wood Levandowski, Vaccine 211786-88, 2003
65Generalized Influenza Vaccine Global Production
Timetable (NH - Representative Year)
Egg supply organization
Egg supply for production
Seed lots
Monovalent batches
Formulation
Filling / Packaging
Packaging documentation
Ref Member State Release
Pharmaceutical file
MA
Clinical trial
Vaccine Delivery
WHO meeting D0 mid Feb
D0
Reagent availabilityEnd of May
Mid May
July/August
D0 - 6 months
66Vaccine Development
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
WHO/CDC)
WHO/CDC/FDA
CDC/FDA
FDA
FDA
FDA
manufacturers
clinic
67Sources of Information on Pandemic Influenza A
Vaccines
- Studies of contemporary, novel egg grown HA in
adults, (e.g., H9 and H5) - Studies of H2 in naïve subjects after 1968
- Studies of Swine Flu vaccine in 1976 or H1N1 in
younger adults in 1977 - Studies of TIV or LAIV in seronegative children
68Characteristics of Influenza Vaccines in Naïve
Subjects
- Different HAs exhibit different immunogenicity
- Two or three doses of HA required
- Adjuvants may reduce the number of doses of HA
needed - High doses of HA or adjuvant may broaden the
immune responses - LAIV single dose immunogenic, induces broad
immune responses - Unexpected interactions may occur (e.g. H2 and
H9)
69Experiences with Pandemic Vaccines
- A/USSR/92/77 (H1N1) - Immunogenicity studies
compared results in younger persons (born after
1957, naïve to H1) to older persons (born before
1957, likely previously infected with H1) - Large doses of vaccine, 60?g HA required for one
dose to be immunogenic - Two doses of 5?g was immunogenic
- Whole virus vaccines more immunogenic than split
virus, but whole virus vaccine was more
reactogenic - Adjuvants can enhance the immune responses and be
dose sparing in unprimed persons
70Breadth of Antibody Responses to H5N3 Vaccine
(A/Duck/Singapore/97)
Vaccine 30?g egg grown HA with ( ) or
without ( ) MF59 adjuvant, 3 doses,
neutralizing Ab
Stephenson et al, JID 1911210-1215, 2005
NEUT Ab
Three doses of adjuvanted influenza vaccine
produced with a 1997 avian strain can prime and
induce antibodies against H5N1 strains isolated
in 2003 and 2004
71Clinical Trials with Egg Grown HA-H5 Vaccine
- Healthy adults age 18-40 (J.Treanor, PI)
- Dose response study
- Compare placebo, 7.5µg, 15µg, 45µg or 90µg
- Vaccine given at times 0, 1 month
- Study completed, data pending, but HHS reports 2
doses of 90 mcg was immunogenic - Booster planned
- Healthy Children, Age 2-9, to begin soon
- Elderly, Age ?65, to begin soon
72Neutralizing Antibody Response to Two Doses of
rHA0 (H5) to A/HK/156/97 H5N1
with neut. response
45 ?g x2
Placebo
90 ?g x2
25 ?g x2
Treanor et al, Vaccine 191732-37, 2001
73Clinical Trials of Vaccines Designed for Pandemic
Influenza, Other Ongoing and Future Trials
74LAIV Induces Broad Immune Responses
Belshe et al, Peds ID, 2000
75H9/AA ca Live Virus Vaccine Provides Complete
Protection from Replication of Homologous and
Heterologous H9N2 Challenge Viruses in the A
(upper) and B (lower) Respiratory Tract in Mice
(A)
Virus titer (log10 TCID50/ml)
H9 Challenge Virus
1073 Immunizing Virus
(B)
Virus titer (log10 TCID50/ml)
Chen et al, Vaccine, 2003
H9 Challenge Virus
1073 Immunizing Virus
76Conclusions
- Hemagglutinins have different properties, several
need to be studied - 2 or 3 doses and high doses of purified HA will
be needed to induce antibodies to novel HAs - Strain variation will remain a significant
problem i.e. difficult to predict which vaccine
to stockpile - Developing vaccines to mimic priming by natural
infection is important - LAIV
- Adjuvanted HA subunit or rHA0
- Novel vaccines need to be developed
- Novel methods of production (I.e., cell culture
need to be commercialized)
77VACCINE RESPONSE
- Presidents proposed plan 7.1 billion
- Produce and stockpile H5N1 vaccine
- Develop cell culture systems for vaccine
development - HHS pandemic influenza plan
- Ensure domestic production capable of producing
vaccine within 6 mo - Stockpile oseltamivir
- NC State plan
- Responsible for distribution/allocation of
antivirals and vaccines
78NVAC/ACIP ALLOCATION PRIORITIES 1A
- Priority Groups
- Vaccine and antiviral manufacturers and others
essential to manufacturing and critical support
(40,000) - Medical workers and public health workers who are
involved in direct patient contact, other support
services essential for direct patient care, and
vaccinators (8-9 million)
- Rationale
- Need to assure maximum production of vaccine and
antiviral drugs - Healthcare workers are required for quality
medical care (studies show outcome is associated
with staff-to-patient ratios). There is little
surge capacity among healthcare sector personnel
to meet increased demand
79NVAC/ACIP ALLOCATION PRIORITIES 1B
- Priority Groups
- Persons 65 years with 1 or more influenza
high-risk conditions, not including essential
hypertension (18.2 million) - Persons 6 mo - 64 years with 2 or more influenza
high-risk conditions, not including essential
hypertension (6.9 million) - Persons 6 months or older with history of
hospitalization for pneumonia or influenza or
other influenza high-risk condition in the past
year (740,000)
- Rationale
- These groups are at high risk of hospitalization
and death. Excludes elderly in nursing homes and
those who are immunocompromised and would not
likely be protected by vaccination
80NVAC/ACIP ALLOCATION PRIORITIES 1C
- Priority Groups
- Pregnant women (3.0 million)
- Household contacts of severely immunocompromised
persons who would not be vaccinated due to likely
poor response to vaccine (1.95 million with
transplants, AIDS, and incident cancer x 1.4
household contacts per person 2.7 million
persons) - Household contacts of children million)
- Rationale
- In past pandemics and for annual influenza,
pregnant women have been at high risk
vaccination will also protect the infant who
cannot receive vaccine. - Vaccination of household contacts of
immunocompromised and young infants will decrease
risk of exposure and infection among those who
cannot be directly protected by vaccination.
81NVAC/ACIP ALLOCATION PRIORITIES 1D
- Priority Groups
- Public health emergency response workers critical
to pandemic response (assumed one-third of
estimated public health workforce 150,000) - Key government leaders
- Rationale
- Critical to implement pandemic response, such as
providing vaccinations and managing/monitoring
response activities - Preserving decision-making capacity also critical
for managing and implementing a response
82NVAC/ACIP ALLOCATION PRIORITIES 2A
- Priority Group
- Healthy 65 years and older (17.7 million)
- 6 months to 64 years with 1 high-risk condition
(35.8 million) - 6-23 months old, healthy (5.6 million)
- Rationale
- Groups that are also at increased risk but not as
high risk as population in Tier 1B
83NVAC/ACIP ALLOCATION PRIORITIES 2B
- Priority Groups
- Other public health emergency responders
(300,000) - Public safety workers including police, fire, and
correctional facility staff (2.99 million) - Utility workers essential for maintenance of
power, water, and sewage systems (364,000) - Transportation workers transporting fuel, water,
food, and medical supplies as well as public
ground public transportation (3.8 mil) - Telecommunications/IT for essential network
operations and maintenance (1.08 million)
- Rationale
- Includes critical infrastructure groups that have
impact on maintaining health (e.g., public safety
or transportation of medical supplies and food)
implementing a pandemic response and on
maintaining societal functions
84NVAC/ACIP ALLOCATION PRIORITIES 3
- Priority Groups
- Other key government health decision-makers
(estimated number not yet determined) - Funeral Directors and embalmers (62,000)
- Rationale
- Other important societal groups for a pandemic
response but of lower priority
85NVAC/ACIP ALLOCATION PRIORITIES 4
- Priority Groups
- Healthy persons 2-64 years not included in above
categories (179.3 million)
- Rationale
- All persons not included in other groups based on
objective to vaccinate all those who want
protection
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89LOCAL PREPAREDNESS
90LESSONS FROM SARS
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92SARS CASES AND OUTCOME
WHO 21 April 2004
93Total SARS Cases and Healthcare Workers by
Country
HCW
Total No. SARS cases
HCW
94Time-line NC Confirmed SARS Case, 2003
- 5/15-18 Visited Toronto
- 5/19-23 Worked at UNC
- 5/24 Developed fever (did not work)
- 5/27, 5/28, 6/1, 6/3 Visited LMD (free standing
clinic) - 5/30 Doxycycline begun for suspected RMSF
- 6/2 Respiratory symptoms
- 6/3 CXR with infiltrate SARS suspected, health
department notified
- 6/3, 6/9 Serum collected sent to CDC
- 6/9 Seroconversion to SARS-CoV
- 2 workplace contacts investigated for atypical
pneumonia - 6/13 Contact 1 diagnosed with mycoplasma 6/13
- 6/13 Contact 2 dies with pneumonia/ARDS
95SARS in Toronto, 2003
Orange County mans travel dates
96Index Case, June 8
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101AIR CONDITIONING
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104SARS CONTROL MEASURES
- Hospital Infection Control
- Early detection
- Containment Proper infection control,
environmental cleaning - Protection of personnel PPE, hand hygiene
- Community
- Active Surveillance
- Disease Investigation
- Isolation and Quarantine
105Hospital-based SARS surveillance Options for
Enhanced Surveillance
Facility with no SARS cases
Be alert for clusters of pneumonia among HCWs
Monitor HCWs taking care of SARS patients daily
for fever, cough or SOB
Screen all visitors
Fever, cough, or shortness of breath? SARS Risk
Factors?
Monitor daily healthcare workers
inpatients
Facility with unlinked nosocomial transmission
106LESSONS FROM SARS
- Need to nestle response to a highly communicable
disease in hospital disaster plan - Solution Revised disaster plan
- Concern about being labeled SARS hospital
- Work with NC State Health Department
- Must manage worker and public concern (i.e.,
provide public relations use local/state health
departments) - Improved communication within hospital and with
health departments - Inadequate supplies of PPE
- 3 months PPE stockpiled by hospital (being
increased to 6 months)
107LESSONS FROM SARS
- Inadequate outpatient facilities to handle highly
communicable diseases - Solution New ID clinic (all rooms meet CDC
airborne isolation requirements) - Need to screen for travel to endemic area at
entry to hospital or clinic - Message on phone while awaiting operator, signs
at hospital entry - Need for UNC Health Care System to have its own
diagnostic laboratory capacity (i.e., not rely on
CDC) - PCR developed for SARS-coV
108LESSONS FROM SARS
- Need for State policy on transport of patients
with highly communicable diseases - Solution Ongoing discussions with State Health
Department - Must manage worker exhaustion
- Solution enforced rest periods
- Inability of workers to adhere exactly to
guidelines for placing and removing PPE - Solution PPE monitor
109LOCAL PREPAREDNESS
110FEDERAL AND STATE LOCAL PREPAREDNESS
- HHS pandemic influenza plan
- Stockpile ventilators and other equipment in
Strategic National Stockpile - Widely available accurate rapid diagnostic tests
- Assist communities with surge mortuary services
- Provide psychosocial support to responders
111AVIAN INFLUENZA IMPACT, NC
- Number of cases 1,856,296
- Hospitalizations 65,637
- Deaths 14,987
- Assumptions strain 3x more lethal than 1968-69
Hong Kong influenza - Source USA Today, 11 October 2005
112UNC HOSPITAL PREPAREDNESS
- Surveillance
- Influenza like activity (ILI) in NC sentinel
sites, UNC ED - Laboratory tests for influenza (number and
frequency positive) - Diagnosis (detection)
- Rapid testing available for influenza A B, and
RSV (24/7) - PCR available to diagnosis all influenza A
strains (unable to differentiate H5N1 strains
from other influenza A strains) - Graded response (i.e., hierarchy of response
depending on threat) - Hospital response plan
- Modeled on SARS response plan
113INFLUENZA LIKE ILLNESS ACTIVITY, NC AND UNC ED,
2004-05
114INFLUENZA TESTS AND RESULTS, UNC, 2004-05
115UNC HOSPITAL PREPAREDNESS
- Cooperation with county and state public health
authorities - State response plan
- Communication pathways established (PHE network,
SPICE, others) - Nestle influenza response in disaster planning
- Hospital disaster plan
- Frequent drills
- Incident command system
- Access to senior administrators
- Ad Hoc Committee for vaccine distribution
(reports to MSEC)
116UNC HOSPITAL PREPAREDNESS
- Minimizing exposure
- Universal respiratory hygiene (signs in
clinics/ED, method to provide persons with
symptoms of URI tissues, mask, education) - Droplet precautions for persons with URI until
diagnosis rules out need for isolation - Adequate PPE supplies
- 3 month stockpile of PPE (especially N95
respirators) - Training and institution of special airborne
isolation - Components N95 respiratory, airborne isolation
room (negative pressure, direct out exhausted
air), eye protection
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118UNC HOSPITAL PREPAREDNESS
- Ability to rapidly train large numbers of
healthcare workers in use of N95 - Use train the trainers approach
- Multiple screeners available (NX)
- Plan for evaluating ill employees with URI
symptoms - Fever plus symptoms Relieve from duty, care per
LMD - Symptoms (work in PICU, NICU, BMTU) Rapid RSV
and influenza testing (positive test exclusion
from these units) - Symptoms without fever allowed to work while
wearing mask
119UNC HOSPITAL PREPAREDNESS
- Availability of facilities to safely screen
outpatients for highly communicable diseases - Infectious disease clinic 8 clinic rooms, all
meet airborne isolation requirements (direct out
exhausted air, negative pressure), separate
entrance that does not require movement through
hospital - Family Practice center Free standing facility
with multiple exam rooms, laboratory capacity,
near main hospital - Adequate number of isolation beds
- Airborne isolation beds available at UNC 75
(Adult ICU 13, Ped/Neonatal ICU 8, Adult floor
48, Peds floor 9)
120UNC HOSPITAL PREPAREDNESSUNDECIDED ISSUES
- Management of patients if beds unavailable and
transfer impossible - Use of unlicensed beds? (e.g., PACU, 24 hours
holding unit, clinics)? - Use of temporary facilities
- Triage/management of patients if ventilators
unavailable - Who lives and who dies
- Stockpiling of oseltamavir
- Pros Reduce anxiety among HCWs, availability
even if national shortage - Cons Expense, out dating of drug, reduce
availability to public - Currently unavailable
- Use for prophylaxis at discretion of Medical
Director, OHS
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