Not If, But When With two influenza pandemics in the 19th Century and three in the 20th Century, we’re due for next pandemic

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Not If, But WhenWith two influenza pandemics in
the 19th Century and three in the 20th Century,
were due for next pandemic

• Peter A. Reinhardt, Director
• Department of Environment, Health Safety

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More than any other time in history, mankind
faces a crossroads. One path leads to despair and
utter hopelessness. The other, to total
extinction. Let us pray we have the wisdom to
choose correctly.
Woody Allen
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Should We Worry About Avian Flu?
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I have been through some terrible things in my
life, some of which actually happened. Mark
Twain
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So Why Are We So Worried About Pandemic
Influenza?Because it follows the laws of risk
perception!
High Perceived Risk Not knowable/uncertain Control
led by others Coerced Immediate effect
Worried Likelihood judgment Exotic/new Severity
judgment Catastrophic
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Avian influenzasituation in IndonesiaWHO update
34 28 September 2006
The Ministry of Health in Indonesia has
confirmed the countrys 52nd death from H5N1
avian influenza. The 20-year-old man, whose
infection was announced on 27 September, died
early in the morning of 28 September. Of the 68
cases confirmed to date in Indonesia, 52 have
been fatal.
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H5N1 in Humans
First cases (18) reported in Hong Kong in 1997.
Six were fatal. Next outbreak occurred in
December 2003 Initially cases were limited to
Southeast Asia
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A Public Health Agency of Canada B American
Veterinary Medical Assn. C CDC
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H5N1 Avian Influenza in Humans
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Influenza Pandemics
HHS Pandemic Influenza Plan, October 2005, WHO
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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
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H5N1 Is Mutating Continuously
Evolution of H5N1 Avian Influenza Viruses in
Asia 2003-5. Phylogenetic relationships among N1
neuraminidase (NA) genes of H5N1 influenza
viruses.
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H5N1 Avian Influenza by Michael Specterpublic
health issues staff writer NEW YORKER2006
Most viruses stick to a single species. This one
(H5N1) has already affected a more diverse group
than any other type of flu, and it has killed
many animals previously thought to be resistant
blue pheasants, black swans, turtledoves, clouded
leopards, mice, pigs, domestic cats, and tigers.
Early in February (2006), nearly five hundred
open billed storks were found dead in Thailand's
largest freshwater swamp.
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Decades-old Variety of Equine (Horse) Influenza
has Emerged in DogsSummarized in HHMI
BulletinDecember 2005 CDC staff recognized the
pathogen as H3N8 equine influenza viruswhich
has occurred for at least 40 years in horses,
this virus suddenly made a complete jump into
greyhounds. Moreover, this newfound canine
influenzaquickly began to spread. Since the
winter of 2004 it has been confirmed
in outbreaks at racetracks in at least 11 states,
affecting thousands of greyhounds... "For
scientists worried about interspecies transfer of
influenza, this is a rare and striking example,"
says Ruben O. Donis, a CDC scientist If the
flu can jump from horses to dogs, why not from
dogs to people? Donis notes, "The reality is, we
just don't know."
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Global Pandemic Watch

• Good news
• No evidence of sustained human-to-human
  transmission
• No reported cases of H5N1 in the U.S. in
  migratory birds, poultry or humans
• Bad news
• H5N1 virus continues to circulate widely in Asia,
  Europe and Africa
• Eradication of H5N1 in birds is difficult
• Other avian influenza viruses detected in poultry
  in 2004 (H5N2 in Texas and H7N2 in Maryland)

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Is it Pandemic Yet?
Pandemic influenza occurs when a new, novel virus
appears, to which population has little or no
immunity And the novel virus is able to cause
severe illness in humans And the virus is capable
of sustained human-to-human transmission
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Defining 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.

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Defining a Pandemic WHO Phases

• 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.

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Impact of a Mild Influenza Pandemic in the
United States
75 100 million become ill 18 - 45 million
outpatient visits 300,000 - 800,000
hospitalizations 88,000 - 300,000 deaths
WHO and CDC, Pandemic Influenza Planning Guide
for State and Local Officials, 1999
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Characteristics Of An Influenza Pandemic

• Simultaneous outbreaks throughout the U.S. limits
  ability of a jurisdiction to assist others
• Many people may be asymptomatic while infectious
• Enormous demands on the healthcare system
• Potential disruption of national and community
  infrastructures including transportation,
  commerce, utilities and public safety due to
  illness and death among workers and their
  families
• Delays, shortages unavailability of vaccines
  antivirals

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a pandemic is a local crisis worldwide. It can
happen in every state and every city and every
town at almost the same time. A pandemic is not
like a hurricane or an earthquake, where
resources and help can be shifted from one area
to anotherevery community will need to rely on
its own planning and its own resources as it
fights the outbreak. HHS Secretary Michael O.
Leavitt, 13 March 2006
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Chancellors Advisory Committee on Pandemic
Influenza Preparedness
Subcommittees Closure/Suspension/Academic
Continuity Human Resources Fiscal
Issues/Business Continuity Communications Intern
ational Emergency Committee Information
Technology Research and Research Animals
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UNCs Avian Flu/Pandemic Flu Web Site
Provide facts dispel myths Tell people what they
can do to prepare and protect themselves Start to
discuss international travela pandemics first
impact to UNC Let people know what UNC is doing
to prepare and plan for pandemic influenza
reassure and calm
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Start The Mantra of Flu Prevention
Get a flu shot Wash your hands Avoid touching
your eyes, nose or mouth Cover your mouth with
tissue when sneezing Stay away from others if you
are sick don't go to class or work Avoid close
contact with people who are sick Get help if you
are sick
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Emergency Planning
Crisis Communi-cations Plan
Response Plan
Continuity Of Operations Plan
Individual and Family Plans
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Pandemic Emergency Planning
Crisis Communi-cations Plan
Response Plan
Continuity Of Operations Plans
Individual and Family Plans
Pandemic Influenza Response Plan
Pandemic Influenza COOPs
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Planning Objectives

• Minimize the risk of pandemic influenza to
  students, faculty and staff.
• Support students who remain in Chapel Hill.
• Continue functions essential to university and
  hospital operations during a pandemic.
• After the pandemic, resume normal teaching,
  research and service operations as soon as
  possible.

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Key Factors in Emergency Planning

• Risk
• Probability
• Consequence (severity of pandemic)
• Strengths
• Business resiliency
• External support
• Internal response capabilities

• Weaknesses
• Business vulnerability
• External vulnerabilities

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Do we close?Or do we stay open and weather the
storm?
It depends. The severity of an influenza pandemic
depends on the transmissibility, morbidity and
mortality of the influenza. Influenza caused by
the H5N1 strain appears to have a case fatality
rate, but we cannot predict the severity of the
next human pandemic. Will it look like 1918 or
1957?
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U.S. Influenza BurdenTypical 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.
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UNC-Chapel Hill Population
10,264 Full time employees (Fall 2005) 772 Part
time employees 27,267 Students (Fall
2005) 1,777 International students 3,000 U.S.
students from gt 600 mi. 7,400 Students in
residence halls (2005-6) 1,000 Students
family members in family housing
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Our Cloudy Crystal Ball
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CDC FluAid 2.0 Model Estimates
Assuming 35 gross attack rate student
population split 5050 among 0-18 and 19-64 yrs
age groups using 0.3 case fatality rate
(maximum) estimates. See http//www2.cdc.gov/od/fl
uaid/
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Our Greatest Risk
Our greatest risk is an easily transmissible
virus 7,400 students in residence halls living
in close proximity and sharing facilities.
Caring for a large number of ill students would
strain resources of Housing and Residential
Education, Campus Health Service and the UNC
Healthcare System, especially if the community is
similarly impacted and staff resources are
similarly depleted.
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Our Greatest Risk
Therefore, if a severe pandemic were to occur in
North Carolina, we should suspend on-campus
classes for 7-10 weeks.
We will want to make the class suspension
decision early in the period of contagion to
allow residential students to return to a
less-risky home environment. (We hope to be able
to resume the session after the wave has passed.)
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Pandemic Influenza Epidemic Curve
Epi curve
Assume that Epidemics will last 6 to 8 weeks in
affected communities. National Strategy for
Pandemic Influenza Implementation Plan, Homeland
Security Council, May 2006
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Multiple Community Outbreaks Wave
Community outbreaks (epi curves) are dynamic
Assume that each waveduring which community
outbreaks occur across the countrywill last 2 to
3 months. National Strategy for Pandemic
Influenza Implementation Plan, Homeland Security
Council, May 2006
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Draft UNC-Chapel Hill Criteria for Suspending
On-Campus Classes

• WHO Phase 6Pandemic period Increased and
  sustained transmission in the general U.S.
  population.
• Confirmation of a high rate of transmissibility,
  morbidity and/or mortality.
• Local public health recommendations to
  curtail/cancel public activities in North
  Carolina.
• Immediately preceded by falling class attendance,
  students leaving campus.
• Rising employee absenteeism.

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Quarantine and Isolation
When the influenza pandemic first arrives in
Chapel Hill, Public Health authorities will ask
daycare facilities and K-12 (or K-6) schools to
close. UNC students, faculty and staff will
not be subject to quarantine. Instead, public
health officials will recommend voluntary social
distancing measures. Initial clusters in the
world (and U.S.) will be asked to isolate
voluntarily orders will be issued only if they
do not. VERY UNLIKELY An extremely contagious
outbreak could force us to quarantine students.
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While Classes Are Suspended
5,700 students and student families will likely
remain in Chapel Hill because of international
travel restrictions, other travel difficulties,
or because they do not have a suitable
alternative living option.

• 700 students (e.g., international students) will
  remain in residence halls scattered in various
  locations (no longer living in close proximity).
  They will need support.
• 1,000 people in family housing will be in close
  quarters and at relatively high risk.
• 4,000 students will remain in off-campus housing,
  including fraternities and sororities.

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While Classes Are Suspended
Assuming 35 gross attack rate student and
family population split 5050 among 0-18 and
19-64 yrs age groups using 0.2 case fatality
rate (most likely) estimates for employees. See
http//www2.cdc.gov/od/fluaid/
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Employee Absenteeism
Assume that up to 40 percent of staff may be
absent for periods of about 2 weeks at the height
of a pandemic wave, with lower levels of staff
absent for a few weeks on either side of the
peak. Absenteeism will increase not only because
of personal illnessbut also because employees
may be caring for ill family members, under
voluntary home isolation due to an ill
household member, minding children dismissed from
school, following public health guidance, or
simply staying at home out of safety
concerns. National Strategy for Pandemic
Influenza Implementation Plan, Homeland Security
Council, May 2006
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Issues While Classes Are Suspended

• Housing and Residential Education, and Campus
  Health Service need to care for remaining ill
  students and their families.
• What activities can continue?
• What activities should we postpone?
• What essential functions will need to continue
  even when classes are suspended?

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Examples of Essential Personnelthese staff must
come to work while classes are suspended

• Police and 911 Center staff
• Housing and dining services staff
• Utility workers (power, water and sewage)
• IT and telecommunications staff
• Payroll, accounting and purchasing staff
• Campus Health Services
• Employee Health Clinic
• Facility repair workers

Departments are to identify their key personnel,
leaders and those responsible for essential
functions as public health emergency employees.
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NC OSP Leave for Communicable Disease Policy

• Governor may order or Agency may invoke in
  consultation with local public health officials
• May close the Agency
• If advisable, may exclude employees from the
  workplace
• Agency must pre-determine mandatory/essential
  operations

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NC OSP Leave for Communicable Disease Policy

• Emergency employees who are required to work are
  granted full compensatory time or pay
• Employees in isolation, quarantine or advised not
  to come to work are granted administrative leave
• Agency may require employees to work at home

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Any community that fails to prepare, with the
expectation that the federal government orthe
state government will come to their rescuewill
be tragically wrong. Instead the federal
government will work on developing vaccines,
stockpiling medications, working out how to
communicate in case of a disaster, and
monitoring Local communities should think
about their priorities. "If you don't have
enough ventilatorsmaybe you ought to be thinking
about more ventilators rather than remodeling the
swimming pool. HHS Secretary Michael O.
Leavitt, April 2006
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Protection for Essential Personnel

• Practices
• Handwashing
• Equipment (PPE)
• Gloves if around ill students
• N-95s if exposed to aerosol-generating
  procedures (e.g., intubations)
• Surgical masks when they are in close contact
  with others (influenza is droplet spread)
• High priority for antivirals and/or vaccine if
  available
• Their families
• Ensure they are prepared and protected
• Priority of for antivirals and/or vaccine if
  available

• Disperse workers

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PPE for Employees Who May Have Contact with Sick
Students
25,000 N-95 respirators 105 employees x 60 day
x 4 changes/day 31,500 pairs of gloves 105
employees x 60 day x 5 changes/day
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PPE for Other High Risk Public Health Emergency
Employees(Non health care workers)
120,000 Surgical Masks 1,000 x 60 day duration
x 2 changes/day
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Personal Protective Equipment
CDC has issued PPE guidance only for patient
care. UNC will follow CDC PPE guidance for those
in CDC-identified high risk jobs, and those who
perform high risk duties. We have purchased
limited quantities of masks and gloves for
employees who work for the Campus Health Service
and Housing. CDCs PPE recommendations rely on
risk (e.g., direct contact with sick patients),
so it is not likely that our limited PPE stocks
will be available to all public health emergency
employees. Departments that wish to assess their
PPE needs should contact the EHS.
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Planning Assumptions

• Public health officials may request that UNC take
  social distancing measures such as canceling
  public events. If a severe outbreak were to
  occur, we should expect to suspend on-campus
  classes for 7 10 weeks.
• Absent employees include leaders, heads and
  essential personnel.
• Fifty percent of your supplies will not be
  available during the 7-10 week period of
  contagion.
• The wave will occur during the fall or spring
  semester.

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Stepwise Preparations
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Process of Continuity of Operations Planning

• Assess strengths and vulnerabilities
• Consider reasonable worst case assumptions
• Plan strategicallythink like a chess player,
  several steps ahead
• Consider interrelationships and
  dependencieslearn what others plan to do.

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Continuity of Operations Plans
Your Departments Objectives Emergency
Communication Systems Emergency Access to
Information and Systems Your Departments
Essential Functions Your Departments Leadership
Succession Key Internal (Within UNC)
Dependencies Key External Dependencies Mitigation
Strategies Exercising Your Plan Informing Your
Staff Recovery After the Pandemic
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Selection of Public Health Emergency Employees
Responsible for functions that are absolutely
essential to the continuation of core operations
(e.g., protection of health or property, support
of campus health service or UNC Hospitals,
payroll) during a multi-week emergency when
classes and other activities are suspended. They
must satisfactorily perform their
responsibilities.
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Will Distance Learning Help?Not much total
distance learning credit hours at UNC
Some instruction might continue using a less
formal form of distance learning.
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Planning Issues for PI Financial Risks and
Possible Impacts
Assume classes suspended for 8 weeks for two
periods within the fiscal/academic year.

• Research units and grants
• Payroll
• Meal plan purchases
• Student debt fee
• Tuitionwill we give refunds?

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Home Emergency Planning for Individuals and
Families
Employees, students and their families should
plan for emergencies that could impact them in
their home, apartment or residence hall.
Hurricane Katrina taught us that employees may
not show up for work if they are concerned for
the safety and security of their families.
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After the Wave Has Passed
After the wave has passed, recovery will be slow
and difficult. Grieving and adjustment for those
who have lost loved ones, friends and
coworkers. Those who became ill and survived may
take months to fully recover. Exhausted
caregivers will need rest, time off to get their
affairs in order, and mental health support.
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After the Wave Has Passed
Business will be slow to recover, slow to
replenish inventories, and slow to replace
labor. Economic loss will cause business to
contract, cut costs, and layoff workers. Worry
and fear of the next wave.
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Coordination With Outside Entities
UNC General Administration (UNC System) UNC
Healthcare and Hospitals Orange Water and Sewer
Authority Town of Chapel Hill (bus service) Duke
Power Orange County Health Department
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Role of CDC and State and Local Health
Departments

• Umbrella response plan
• Surveillance
• Outbreak investigation
• Social distancing recommendations
• Isolation and quarantine
• Strategic National Stockpile distribution
  (antivirals vaccine)
• Information authority (severity, transmission,
  etc.)

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Quenching PlanPublic health officials are
actively planning to slow (or quench) the spread
of pandemic influenza

• Public health officials are closely surveilling
  suspected cases via doctors offices, clinics,
  hospitals and local public health departments.
• Public health officials will attempt to isolate
  the first clusters to prevent the first cases
  from exposing others.

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Quenching Plan

• As soon as the first cases appear locally, health
  officials will close daycare facilities and K-12
  schools for those locales. Public health
  officials will recommend that the local
  population take other social distancing and
  self-shielding measures.
• Antiviral drugsalthough in short supplywill
  quickly be distributed to those exposed to the
  first cases, as well as local susceptible
  populations

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Quenching Plan

• A vaccine based on H5N1although of limited
  effectiveness and in very short supplywill be
  rushed into use for people near the first
  clusters, and for local susceptible populations

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Quenching and Its Affects
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Epidemic Curves With Quenching
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Recommendations

• The next flu pandemic may not happen in our
  lifetimes, but some other type of disaster most
  assuredly will.
• Take this as an opportunity to improve
• All-hazard emergency plans and preparedness
• The structure and processes for emergency
  command, management decisionmaking
• Continuity of Operation (COOP)/Business
  Continuity Plans
• On-campus mass dispensing/vaccination procedures

Tornado in Miami, 12 May 1997
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References and Acknowledgements

• www.who.org
• www.cdc.gov
• www.pandemicflu.gov
• http//www.cshema.org/resource/pandemic0306.htm
• David J. Weber MD, MPH, MPA, University of North
  Carolina - Chapel Hill
• Scott F. Dowell MD, MPH, Centers for Disease
  Control Prevention
• John Covely, Communications/Emergency Planning
  consultant

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Questions?
Peter A. Reinhardt, Director Department of
Environment, Health Safety University of North
Carolina 1120 Estes Drive Extension, CB
1650 Chapel Hill, NC 27599-1650 http//ehs.unc.e
du pareinhardt_at_ehs.unc.edu 919-843-5913