Pandemic Planning Update

1
Pandemic Planning Update
Dr. Peter WaldApril, 2008
Pandemic adj 1 epidemic over a wide geographical
area "a pandemic outbreak of malaria"2 existing
everywhere "pandemic fear of nuclear war" n an
epidemic that is geographically widespread
occurring throughout a region or even throughout
the world.
2
Overview

• Regular influenza.
• Avian influenza.
• Pandemic influenza.
• Potential business impacts.
• Mitigation strategies.
• Resources.

3
Emergency hospital-1918 flu , Camp Funston,
Kansas

• US Army files

4
Regular influenza

• Typical flu symptoms-sudden onset, 1-4d (average
  2d) incubation.
• Fever gt101, HA, tired, aches, cough, sore throat,
  runny nose.
• Adults can infect others 1 day before symptoms
  up to 7 days after (average 5d).
• Children shed virus 6 d before symptoms are
  infectious gt10 days.
• Spread by coughing and sneezing (droplets, some
  airborne) and contact.
• Survives 12-24 hr hard surface 8-12 hr porous,
  longer if cold dry.
• During typical year 10-20 of world infected,
  lt0.1 case fatality rate.
• Kills about 36,000 US/yr usually secondary
  infection or heart failure.
• U shaped mortality curve.

Vaccine is the best defense
5
Avian influenza

• 373 confirmed reported cases-236 fatal as of
  March 18, 2008.
• Zoonosis- human disease acquired from animals
  where we are an accidental host.
• Backyard agriculture in SE and Central Asia.
• H5N1 strain first appeared in China in 1993 and
  first caused human disease in 1997.
• Primarily children, teens, young adults-20s-40s.
• Longer incubation than regular flu (2-8 days).
• Aggressive clinical course with an average of 6
  days to respiratory failure.
• Concern is mixing of human or pig virus with this
  H5N1 may result in gene (RNA) trading called
  reassortment -gt lethal and easily transmittable
  virus or mutation easing transmission between
  people. Such an event would mark the start of an
  influenza pandemic.
• Good news so far-no sustained person-to-person
  transmission.

6
Avian Flu Update-03/18/08
7
H5N1 Confirmed Human Cases
8
H5N1 Confirmed Poultry and Wild Birds Cases
9
Pandemic influenza

• Pandemic influenza-global outbreak is caused by
  new subtype A virus (antigenic shift) that is
  transmitted to humans
• to which humans have no immunity.
• High lethality.
• Easy person-to person transmission.
• Pandemic age shift (W shaped mortality curve).
• Expect 3-4 pandemics per century one every 10-50
  yrs.
• 1918-19, Spanish flu (H1N1)-40-50 million deaths
  30-35 infected, 1-2 mortality, ages 20-40 yrs
  highest deaths (10-20 ), recent sequencing of
  preserved samples shows this was a mutated avian
  flu virus which jumped directly to people.
• 1957- 58, Asian flu (H2N2) - 70,000 excess deaths
  US, 40 deaths under age 65, avian human flu
  virus combo.
• 1968- 69, Hong Kong flu (H3N2)- 34,000 excess
  deaths US, 1/6th case fatality rate of 1918-19,
  avian flu virus combo, still circulating and in
  current vaccines.

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Pandemic influenza

• Early wave of milder disease (herald wave),
  then second wave 6-12 months later of severe
  disease.
• Pandemics last 24-36 months before population
  resistance emerges (less if vaccine available).
• 15-35 young adults ill.
• Majority of deaths from virus directly- acute
  respiratory distress or cytokine storm, not
  secondary pneumonia like regular flu.
• Vaccines-1st line of defense would not be widely
  available at start of pandemic.
• Potential vaccine candidate now in Phase 1
  testing.
• Limited, slow production capacity.
• National planning focus will be
• Minimize spread of disease.
• Reduce illness and death.
• Maintain essential services.
• Limit economic and social consequences.

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Pandemic influenza-WHO Phases

• Inter-pandemic period.
• Phase 1 No new influenza virus subtypes have
  been detected in humans. An influenza virus
  subtype that has caused human infection may be
  present in animals. If present in animals, the
  risk of human infection or disease is considered
  to be low.
• Phase 2 No new influenza virus subtypes have
  been detected in humans. However, a circulating
  animal influenza virus subtype poses a
  substantial risk of human disease.
• Pandemic alert period.
• Phase 3 Human infection(s) with a new subtype,
  but no human-to-human spread, or at most rare
  instances of spread to a close contact. WE ARE
  STILL HERE
• Phase 4 Small cluster(s) with limited
  human-to-human transmission but spread is highly
  localized, suggesting that the virus is not well
  adapted to humans.
• Phase 5 Larger cluster(s) but human-to-human
  spread still localized, suggesting that the virus
  is becoming increasingly better adapted to
  humans, but may not yet be fully transmissible
  (substantial pandemic risk).
• Pandemic period.
• Phase 6 Pandemic increased and sustained
  transmission in general population.

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Business Impact

• Mortality review
• Regular flu lt0.1 1 death/1,000 cases.
• Pandemic flu 1918 est. 2 2/100 1 death/50
  cases.
• SARS 10 1 death/10 cases (remember low RR and
  774 deaths/8096 cases).
• Avian flu 60 154 death/258 cases (as of
  11/29/06).
• absent review
• 15-35 illness rate for pandemic flu.
• Add 10-20 for those not yet ill who will stay
  home, or who will be caring for or covering for
  ill family members.
• Easy to imagine 50 of work force out.

13
Mitigation Strategies

• We will be using basic public health tools
  initially
• Communication to employees on infection
  avoidance.
• Business continuation plans keyed to WHO alert
  levels.
• Identify and divide essential employee groups.
• Stay home/go home if youre sick (isolation of
  ill and quarantine of exposed often at
  home-driven by Public Health Departments).
• Social distancing (avoid mass gatherings-café,
  fitness, face-to-face meetings, travel).
• Decreasing environmental viral load.
• Prepare for vaccine availability.
• Employees first.
• Consider dependent vaccination also.
• Anti-virals not useful.

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Infection Avoidance and Decreasing Environmental
Virus Load

• Cover cough or sneeze respiratory hygiene
  education.
• Avoid close contact with coughing and sneezing
  people.
• Refrain from touching mouth, nose, eyes.
• Surgical masks for employees, N-95 respirators
  for Health Services.
• Clean hands frequently and encourage others to do
  same-soap and water or alcohol hand cleaner
  everywhere.
• Frequent decontamination of shared surfaces and
  increased air exchanges.
• Avoid crowds- provide food on floors and use
  designated bathroom.

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Business Continuation Priorities

• Monitor official recommendations (CDC and WHO).
• Non-essential employees work from home.
• Employee education on infection avoidance.
• Disinfection, infection control and social
  distancing.
• Management and referral of cases and suspected
  cases.
• Reduced workforce contingency plans.
• Consider travel restriction to other sites or to
  hot spots.

Be prepared for mass vaccination of employees
when vaccine is available.
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Operational Pandemic Preparedness Plan

• Plan Baseline
• Business Continuation Plans (30 day period)
• Critical Processes Essential Personnel /
  Critical Systems / Resources
• Plan Strategies
• Critical Personnel and Processes for 18 months
• Social Distancing
• Work from Home
• Stockpiling Supplies
• Decreasing Environmental Hazards

17
Business Continuation Priorities
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Resources

• US Government Main Pandemic Site
  www.pandemicflu.gov
• CDC Avian flu -http//www.cdc.gov/flu/avian/index.
  htm
• WHO avian flu home page -http//www.who.int/csr/di
  sease/avian_influenza/en/index.html
• DHHS Pandemic flu preparedness plan
  -http//www.dhhs.gov/nvpo/pandemicplan/
• WHO Pandemic flu preparedness plan
  -http//www.who.int/csr/resources/publications/inf
  luenza/WHO_CDS_CSR_GIP_2005_5/en/
• California Dept. of Health Services Pandemic
  Influenza Response Plan 2001 http//www.dhs.ca.gov
  /ps/dcdc/izgroup/pdf/pandemic.pdf
• International SOS -http//www.internationalsos.com
  /
• Promed-http//www.promedmail.org
• FBIIC/FSSCC Pandemic Flu Exercise of 2007
  www.fspanfluexercise.com/Pandemic20Flu20AAR.pdf
  
• CDC Pandemic Exercise II http//www.cidrap.umn.ed
  u/cidrap/content/influenza/panflu/news/mar1708exer
  cise.html
• Microbe Are We Ready For The Next Plague?Alan P
  Zelicoff, MD, Michael Bellomo. 2005
• The Threat of Pandemic Influenza Are We Ready?
  Workshop Summary.Institute of Medicine, Stacey L
  Knobler ( Editor), Alison Mack (Editor), Adel
  Mahmoud (Editor) 2005
• The Great Influenza The Epic Story of the
  Deadliest Plague in History. John M. Barry 2004
• Preparing for the Next Pandemic Michael
  Osterholm, Foreign Affairs, July/August 2005
  http//www.foreignaffairs.org/20050701faessay84402
  /michael-t-osterholm/preparing-for-the-next-pandem
  ic.html
• CDC workplace and flu site added 6/10/05
  http//www.cdc.gov/flu/workplace/
• The Oshkosh Flu Project (of 1918)
  http//www.uwosh.edu/archives/flu/project.htm

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Resources

• HPAI in birds fact sheets from OIE
• http//www.oie.int/eng/AVIAN_INFLUENZA/Diseas
  e20card.pdf
• OIE avian influenza home
• http//www.oie.int/eng/AVIAN_INFLUENZA/home.h
  tm
• FAO avian influenza home
• http//www.fao.org/ag/againfo/subjects/en/hea
  lth/diseases-cards/special_avian.html
• WHO-Responding to the avian influenza pandemic
  threat. Recommended strategic actions 9/1/05
• http//www.who.int/csr/resources/publications/inf
  luenza/WHO_CDS_CSR_GIP_05_8-EN.pdf
• NEJM articles on neuraminidase inhibitors and
  H5N1 in humans
• NEJM September 29, 2005 vol 35313
  pp363-1385
• Risk communication on pandemic flu discussion
  site-Peter Sandman
• http//www.psandman.com/col/panflu3.htm