Pandemic Flu

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Pandemic Flu

• Emergency Planning When the Hazard Is Posed by
  People, Not Processes

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What Kind of Flu??
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What is Pandemic Flu ? WHO Definition

• New Influenza A virus emerges
• 2. New virus causes serious human disease
• 3. Human to Human transmission

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WHO Pandemic Phases
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Pandemic Factoid

• Pandemics are inevitable
• Not IF but WHEN
• There will be little warning
• Outbreaks will occur simultaneously in many areas
• The world is overdue
• The pandemic clock is ticking loudly.
  Unfortunately, we dont know what time it is.

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Pandemics Happen
H9
1998 1999 2003

H5
1997 2003-2005
H7
1980 1996 2002
2003 2004
H1
H3
H2
H1
1977
1915 1925 1935
1945 1955 1965
1975 1985
1995 2005
Avian Flu
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MODES OF TRANSMISSIONRespiratory Illnesses

• Contact Transmission direct indirect with
  self- inoculation
• Droplet Transmission projectile drops
• Airborne Transmission inhalation of small
  particle aerosol, lt 10 microns aka droplet
  nuclei

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TRANSMISSION Role of Airborne Droplet Nuclei
The relative contribution of each transmission
source is unknown Expert opinions differ on the
relative importance of airborne transmission HHS
pandemic plan reports minimal airborne
transmission NIOSH and others differ.
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TRANSMISSION Human (Seasonal) Influenza

• Aerosol infectious for at least 24 hours
• Indoors, low humidity
• 5 minutes on hands
• 24 48 hrs on non-porous surfaces
• People are reservoirs
• Incubation period 2-4 days (WHO)
• Contagious at least 24 hrs before symptoms
• Children transmit virus gt 7 days
• Immuno-compromised may transmit for weeks

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Pandemics Learning From History

• 1918-1919
• - 50 - 100 million deaths worldwide
• - 3-5 percent of the worlds population died
• - Life expectancy dropped 10 years.
• - Highest mortality rate was 16 -24 year olds

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SOCIETAL IMPACT

• Letter from U.S. Army physician, 1918
• These men start with what appears to be an
  ordinary attack of LaGrippe or Influenza, and
  when brought to the Hosp. they very rapidly
  develop the most vicious type of Pneumonia that
  has ever been seen...and a few hours later you
  can begin to see the Cyanosis extending from
  their ears and spreading all over the face, until
  it is hard to distinguish the colored men from
  the white. It is only a matter of a few hours
  then until death comesIt is horrible. One can
  stand it to see one, two or twenty men die, but
  to see these poor devils dropping like flies.
  We have been averaging about 100 deaths per day.
  We have lost an outrageous number of Nurses and
  Drs. For several days there were no coffins and
  bodies piled up something fierce (Grist, 1979)

IOM Threat of Pandemic Influenza, 2005
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The Pandemic Map
Urban Areas Affected First National Spread
Within 1-2 Months
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Pandemic The US Impact

• 50 or more ill people will seek medical care
• of hospitalizations / deaths depends on
  virulence
• (capacity to cause severe illness) of the
  pandemic virus

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Impact to Health Care System

• Extreme Staffing Shortage
• Shortage of beds, facility space, supplies
• Hospital morgues, Medical Examiners and mortuary
  services overwhelmed

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Influenza Signs and Symptoms

• High Fever
• Headache
• Fatigue
• Cough
• Sore throat

• Runny Nose
• Body Aches
• Diarrhea
• Vomiting

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Antiviral Drugs

• Effective for treatment (Early diagnosis)
• Effective for prophylaxis
• Worldwide Shortage
• National Stockpile Increasing

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Vaccine Development

• H5N1 Vaccine Stockpiled
• 4 Million Doses
• Questionable Efficacy
• Pandemic Vaccine 6 month wait

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Pandemic Influenza Planning

Centers for Disease Control and
Prevention National Institute for Occupational
Safety and Health .
The findings and conclusions in this presentation
have not been formally disseminated by the
National Institute for Occupational Safety and
Health and should not be construed to represent
any agency determination or policy.
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Planning is Essential

• Plan for the impact of a potential pandemic
• Establish policies to be implemented in a
  pandemic
• Develop a written exposure control plan
• Plan for the impact on employees
• Communicate and train employees
• Anticipate fear and anxiety
• Coordinate with external organizations (insurers,
  health plans)

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Prevention in All Workplaces

• Exclude sources of infection.
• Screen and exclude workers with fever or
  respiratory symptoms
• Exclude individuals with ill household members
• Prevent transmission within the workplace
• Optimize hand hygiene
• Facilitate respiratory etiquette
• Maintain environmental hygiene

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Healthcare Settings

• Use appropriate infection control measures for
  workers
• Reinforce good hand hygiene
• Use appropriate barrier precautions (glove,
  gowns, eye protection), as recommended for
  standard and droplet precautions
• Use appropriate respiratory protection for
  workers providing direct care/in close proximity
  to infected patients
• Other measures
• Cohort healthcare workers assigned to outbreak
  unit
• Combine tasks to limit number of workers coming
  in contact with infected patients

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Personal Protective Equipment
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Respiratory Protection and Pandemic Influenza
An Evolving Story

• CDC received many comments on the infection
  control recommendations in Nov 05 HHS Pandemic
  Influenza Plan that related to mask and
  respirator use
• Concerns reflect lack of definitive data about
  short-range airborne transmission and reliance on
  seasonal influenza precautions as the default
• CDC workgroup formed to revisit healthcare worker
  and community guidelines

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Proposed Changes Respiratory Protection for
Healthcare Personnel

• N95 filtering facepiece (or higher) respirator
  Highest priority for the following activities
• Procedures that generate aerosols (endotracheal
  intubation, open suctioning, nebulizer treatment,
  bronchoscopy)
• Resuscitation of a patient with influenza
  (emergency intubation, cardiac pulmonary
  resuscitation)
• Direct patient care to pandemic influenza
  pneumonia patients (may produce larger proportion
  of respirable infectious particles)

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Proposed Changes (continued)

• N95 respirators prudent for other direct
  pandemic-influenza patient care activities.
• The use of respirators is de-linked from the
  requirement for an isolation room.
• For actual or anticipated shortages
• Prioritize respirators to high risk procedures
• Consider elastomeric respirators (must be
  decontaminated)
• Consider PAPRs particularly for high risk
  procedures

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Other PPE Considerations

• Large droplets (50-100 µm 3 feet) If
  respirators are in short supply, surgical masks
  should provide protection against these large
  droplets
• Small particle aerosols (2-10 µm, but up to 20 µm
  can evaporate to droplet nuclei) Surgical masks
  will not provide adequate protection
• Long range transmission not observed

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Strategic National Stockpile - Purchased Assets

• Pending delivery
• Surgical Masks (FDA)
• Total 51,560,100
• Respirators
• Surgical N95 (FDA/NIOSH)
• N95 (NIOSH)
• Total 103,997,380

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Pending Procurements

• Other PPE (besides masks/respirators)
• Gloves
• Gowns
• Face shields
• Antibacterial hand gel

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Non-Healthcare Workplaces

• Administrative Controls
• Reduce the number of people exposed to the hazard
  (work at home where possible, conduct meetings by
  teleconference)
• Decrease the time that people are exposed to the
  hazard (introduce better working practices and
  systems)
• Reduce exposures in the workplace (screen ill or
  potentially infectious persons from the
  workplace)

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Non-Healthcare Workplaces

• Administrative Controls (continued)
• Isolate the hazard (place masks on sick people
  until they can be removed from the workplace,
  implement incentives to ensure sick people stay
  home)
• Facilitate handwashing and respiratory etiquette
• Environmental cleaning (increase housekeeping,
  clean potential fomites)

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Non-healthcare Workplaces

• Engineering Controls
• Introducing equipment to control the hazard
  (plexiglas shields, drive-up windows)
• Personal Protective Equipment
• No clear guidance on role of respiratory
  protection and other PPE for non-healthcare
  environments
• Will likely be used, however

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Key Knowledge Gaps

• What is the role of localized airborne
  transmission of small particles and droplet
  nuclei in the spread of human influenza virus?
• What are the relative contributions of large
  droplets verses small particles and droplet
  nuclei to disease transmission?
• What is the additional protective effect of N-95
  respirators over surgical masks in preventing
  influenza transmission in healthcare settings?
• What are the quantitative benefits of respirator
  use in non-healthcare work environments?

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National Strategy

• Announced 11/05, implementation plan 5/06
• Available at www.pandemicflu.gov
• Goals
• Stopping, slowing, otherwise limiting spread of a
  pandemic to the U.S.
• Limiting domestic spread and mitigating disease
• Sustaining infrastructure and mitigating impact
  to economy and functioning of society

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HHS Pandemic Plan

• Surveillance
• Laboratory Diagnostics
• Healthcare Planning
• Infection Control
• Clinical Guidelines
• Vaccine Distribution and Use
• Antiviral Drug Distribution and Use
• Community Disease Control and Prevention
• Managing Travel-related Risks of Disease
• Public Health Communications
• Workforce Support Psychosocial Considerations
  and Information Needs

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HHS Pandemic Influenza DoctrineSaving Lives

• A threat anywhere is a threateverywhere
• Quench first outbreaks detect andcontain where
  it emerges, if feasible
• International collaborations
• Frontline detection and response rapid
  laboratory diagnosis
• Isolation / quarantine / antiviral prophylaxis /
  social distancing / animal culling

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HHS Pandemic Influenza Doctrine

• Prevent or at least delay introduction into the
  United States
• May involve travel advisories, exit or entry
  screening
• For first cases, may involve isolation /
  short-term quarantine of arriving passengers

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HHS Pandemic Influenza Doctrine

• Slow spread, decrease illness and death, buy time
• Vaccine when available
• Antiviral treatment and isolation for people with
  illness
• Hand hygiene and infection control measures
• Quarantine for those exposed
• Social distancing
• Local decisions
• Effectively Communicate with Public

Unprepared
Impact
Prepared
Weeks
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Pandemic Influenza Checklists

• Provide framework for action
• Identify roles and responsibilities of multiple
  sectors

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Pandemic Influenza Checklists

• Released
• State and Local
• Business
• Preschool
• Schools (K-12)
• Colleges Universities
• Faith-based Community Organizations
• Medical Offices and Clinics
• Home Health Services
• Emergency Medical Services
• Individuals Families
• Hospital Preparedness

• Not Released
• Long term care
• Travel Industry
• Prison systems and facilities
• Law enforcement
• Childrens hospitals
• Health insurance
• Mortuary services

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Roles for Occupational Health and Safety
Personnel

• Be a source of reliable information
• Separating myth from fact
• Be well versed on modes of transmission and
  proper infection control approaches for the
  workplace
• Provide advise, recommendations help ensure
  priority occupations receive vaccine antivirals
• Provide advice on respiratory protection programs

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Roles (continued)

• Initiate joint discussions with management and
  labor to develop company influenza plans
• Prepare to make decisions, or provide input on,
  potential business closures.
• Work with Occupational Physicians
• Be prepared to make recommendations regarding
  international travel, precautions for overseas
  subsidiaries

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Roles (continued)

• Provide assessments of the relative risks of
  transmission in the workplace vs. elsewhere in
  the community and whether infection control
  recommendations can be made to reduce workplace
  transmission
• Determine when work at home is appropriate
• Determine the need for PPE
• Work with the local health department