Pandemic Influenza Governors Taskforce for Pandemic Influenza Preparedness

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Pandemic InfluenzaGovernors Taskforce for
Pandemic Influenza Preparedness

• Robert T. Rolfs, MD, MPH
• Utah Department of Health
• September 7, 2006

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Topics

• About Influenza
• Seasonal Influenza
• Avian Influenza (AI)
• Pandemic Influenza
• Pandemic Preparedness
• Policy Issues for Taskforce

Credit L. Stammard, 1995
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Influenza Virus
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About Influenza

• Viral illness types A, B and C
• Influenza A typed by surface antigens
• Haemagglutinin (H1-H16)
• Neuraminidase (N1-N9)
• Clinical illness
• Incubation period 1-2 days
• Abrupt onset fever, chills, muscle aches
  (myalgia), headache, followed by cough, sore
  throat, nasal congestion
• 5-6 days restricted activity, 3 days lost from
  school or work

Incubation period time from infection to
onset of symptoms
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About InfluenzaTransmission

• Person to person
• Respiratory droplets (5-10 µm)
• Contaminated hands and surfaces
• Short distance airborne transmission ?
• Infectious period
• 1 day before to 5 days after onset
• Peak viral shedding in 24-48 hrs after illness
  onset
• Rapid spread of influenza epidemics
• Short incubation period (1-2 days)
• Peak infectiousness at onset of illness
• Shedding can be longer in children and those
  with impaired immune response

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About InfluenzaHow the Virus Changes

• Influenza viruses are prone to genetic change
• Antigenic drift
• Progressive, smaller changes that allow virus to
  continue to spread
• Reason vaccines need to change from year-to-year
• Antigenic shift
• Appearance of new, very different virus
• People have not been exposed and immune system
  doesnt recognize virus or provide protection

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What is Seasonal Influenza?

• Annual seasonal epidemics
• Attack rates average 5-20
• Estimated 20-40,000 deaths in U.S. annually
• Greatest effect on very young and older adults
• Result of antigenic drift
• Ongoing changes of influenza viruses that allow
  people to be infected more than once

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Percentage of Visits for Influenza-like illness
(ILI) Reported by Sentinel ProvidersUtah 2003-4,
2004-5 and 2005-06 seasons
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Influenza-associated Hospitalizations Utah
2005-2006

• Date as of March 1, 2006

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AVIAN INFLUENZA
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What is Avian Influenza? Bird Flu

• Many varieties of influenza occur in birds
• Primarily affect wild aquatic birds
• Serious illness is unusual in wild birds
• Illness more severe in domestic poultry,
  classified based on severity
• Low pathogenic (LPAI)
• High pathogenic (HPAI)
• Most avian influenza viruses dont infect humans

Only H5 and H7 cause HPAIV
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Avian Influenza in Utah

• Currently, highly pathogenic influenza is not
  found in the Utah bird population
• The dangerous highly pathogenic avian influenza A
  (H5N1) has not been detected in the US
• The consequences of an outbreak could be severe
  to the poultry industry which generates 100
  million a year and employs hundreds.

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What is Pandemic Influenza?

• Global outbreak of influenza
• Caused by 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.
• Past pandemics have caused high levels of
  illness, death, social disruption and economic
  loss.

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Pandemic Influenza in the 20th Century
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Influenza pandemics death rates by age
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1918 Influenza PandemicDeath rates - United
Kingdom, 1918-19
Tauberberger JK, Morens DM. 1918 Influenza the
Mother of All Pandemics. EID 20612(1).
http//www.cdc.gov/ncidod/eid/vol12no01/05-0979.ht
mFigure1
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Spread of H2N2 in 1957
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Aug 30-Oct 17, 1968
July 17 Hong Kong Sept 2 1st US
cases Late Sept/Oct - civilian
outbreaks AK, PR
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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Week 40-42, 1968
3rd wk Oct 1st civilian outbreak in continental
U.S. - Needles CA 35-40 affected
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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Week 45, 1968
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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Week 46, 1968
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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Week 47, 1968
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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Week 49, 1968
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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Week 50, 1968
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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Week 52, 1968
50 states affected in 2 months after 1st
civilian outbreak in CA
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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1968 Pandemic peak by state
Sharrar RG. National influenza experience in the
US, 1968-1969. Bull. WHO 196941361-66.
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CURRENT SITUATION
www.pandemicflu.gov (accessed September 5, 2006)
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Avian Influenza H5N12003 - present

• 1996 initial outbreak in Hong Kong, 18 hosp 6
  deaths
• 2003-2004
• poultry outbreaks in China, Viet Nam, Thailand,
  Korea
• Human cases in Hong Kong, Viet Nam, Thailand
• 2005
• Ongoing poultry outbreaks human infections in 5
  nations
• 1st human-to-human transmission
• Wild birds found to be infected
• Spread to Eurasia
• 2006 - Rapid spread into Africa and Europe

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Avian Influenza (H5N1) 2003-2006

• Epizootic (animal epidemic) of unprecedented
  scope
• Poultry or wild bird outbreaks in 53 nations in
  Asia, Africa, Europe
• Death or destruction of hundreds of million birds
• Spread by migratory birds and shipment of poultry
  and related products

Poultry outbreaks as of June 29, including
current and controlled outbreaks
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Avian Influenza (H5N1) Human disease 2003-2006

• Human cases 241 cases with 141 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 August
23, 2006
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Avian Influenza H5N1 Human Cases Deaths,
2003-2006
2006 Cases/Deaths through July 4, 2006
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Nations With Confirmed Cases H5N1 Avian
Influenza(July 7, 2006)
www.pandemicflu.gov (accessed July 12, 2006)
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Avian Influenza (H5N1)The Next Pandemic?

• Have conditions been met for a pandemic?
• Novel antigens no human immunity - Yes
• Human infection Yes
• Causes serious illness - Yes
• Effective person-to-person spread No

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A PANDEMIC TODAY WHAT IT MIGHT LOOK LIKE
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Pandemic Influenza ImpactUtah Projections
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 dont account for
age differences in populations
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Pandemic Influenza ProjectionsUtah Moderate
(1957/68-like)
At peak 150 admissions per day
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Pandemic Influenza ProjectionsUtah Severe
(1918-like)
At peak 1700 admissions per day
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Pandemic InfluenzaExamples of Community Impact

• High absenteeism rates at work/school
• Illness, caring for dependents, limiting
  transmission
• Possible school closures
• Event cancellations concerts, meetings,
  conventions, etc.
• Travel restrictions and decreased tourism
• Economic impact on business
• Shortages of supplies
• Difficulty keeping police, fireman, doctors,
  nurses, and other critical service providers
  working
• Hospitals full delayed care for routine or even
  urgent illnesses

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Pandemic InfluenzaPublic Health Capacity

• Public health has changed since Sept 11, 2001 and
  subsequent anthrax attacks
• All Hazards Disaster Planning
• Epidemiology Disease Surveillance
• Laboratory Testing
• Information Communication Systems
• Stockpiles and Mass Vaccination Capability
• Effective Risk Communication
• Training Exercises
• Hospital Preparedness

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Pandemic InfluenzaPlanning Assumptions

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

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Pandemic Influenza PlanA Roadmap

• Identified what public health needs to do
• Surveillance, containment, communications, state
  and local coordination, infection control
• Pandemic Influenza Workgroup
• Planning and activities in 12 Local Health
  Departments
• Identified where we need help
• Governors Taskforce to address key policy
  questions
• Too big for (any) government alone
• Will require efforts of entire community

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Utah Pandemic PlanIssues for Governors Taskforce

• Credible and effective decision-making
• Capacity of health care system
• Maintaining essential business and community
  services
• Support for people confined by illness or to
  limit spread
• Antiviral stockpile and use
• Vaccine priorities

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Governors Taskforce Issue 1 Effective
Credible Decision-making

• A pandemic will severely stress society and pose
  challenges for governments and other entities.
• Difficult decisions that will greatly affect
  peoples lives
• Allocating scarce resources (e.g., medical care,
  vaccine)
• Closing schools and cancelling events
• Restricting travel and other usual activities
• Trust in decision-making processes can affect
  community cooperation, cohesion, and resilience
• Existing legal authority may not be adequate to
  support effective response during a pandemic

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Governors Taskforce Issue 2 Adequacy of Health
Care Surge Capacity

• A pandemic could severely stress or overwhelm the
  capacity of health care system.
• Health care system has limited excess capacity
  and limited ability to expand that capacity
• It may be impossible to meet usual standards of
  care
• Need to protect integrity of health care system
  and of providers during and after pandemic

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Governors Taskforce Issue 3 Maintaining
Essential Business and Community Services

• A pandemic can disrupt business operations and
  provision of essential services in several ways.
• Businesses will need to operate with diminished
  workforce, and with travel and gathering
  restrictions
• Just-in-time supply lines are vulnerable to
  disruption during a pandemic with global impact
• Fear and uncertainty
• Police, fire, EMS, and other providers of
  essential community services will be challenged
  to maintain essential services

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Governors Taskforce Issue 4 Support for those
Confined by Illness or to Limit Spread

• Both the ill and their caregivers may need
  support, including
• Information, supplies, childcare, basic needs
  (e.g., food), financial assistance, mental health
  care, medical care.
• The impact and need for support will be greatest
  for those who are most vulnerable due to
  preexisting illness, poverty, or social or
  physical isolation.
• Social service agencies and voluntary
  organizations may be overwhelmed by need for
  services and will themselves face the challenges
  of the pandemic

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Governors Taskforce Issue 5 Antiviral
medications Stockpile, Management and Use

• Antiviral medications can prevent and treat
  influenza.
• Efficacy for a pandemic strain is uncertain, but
  it is generally believed they would help.
• Availability during a pandemic will require
  stockpile
• Funding needs to be identified to purchase
  stockpile
• If a pandemic doesnt occur during usable life of
  the medications, the medications could go unused.
• Priorities must be set for appropriate use of
  stockpiled antiviral medications and mechanisms
  established to adjust those priorities if needed.

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Governors Taskforce Issue 6 Vaccine Management
and Use

• Vaccine would be the most effective tool against
  a pandemic virus
• Unlikely to be available initially
• When available, supply will be insufficient
• Priorities must be set for appropriate use and a
  mechanism established to adjust priorities if
  necessary.

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Pandemic and Avian InfluenzaAdditional
information

• Utah http//www.pandemicflu.utah.gov
• U.S. 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