Pandemic Influenza, Government, and Business: Balancing Public Health and Economic Risks

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Pandemic Influenza, Government, and Business
Balancing Public Health and Economic Risks

• Douglas Ball, MD, MA
• Department of Community and Preventive Medicine
• University of Rochester School of Medicine
• douglas_ball_at_urmc.rochester.edu

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Overview

• Some things about Influenza A
• Some things about Pandemics
• Some things about Disease Control
• Planning for Pandemics
• What to expect from a pandemic.
• What to expect from the Government.
• What to expect from the workforce.
• How to plan.
• Resources

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Influenza A virus subtypes

• 16 HA antigens (H1 to H16)
• 9 NA antigens (N1 to N9)
• Human disease historically
• HA (H1, H2, and H3)
• NA (N1 and N2)
• More recently, human disease from avian origin
• HA (H5, H7, and H9)

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Two Very Important Properties

• "Antigenic drift" refers to the process of small
  genetic changes that influenza viruses
  continuously undergo from year to year, which
  necessitates the development of new vaccines
  annually.
• "Antigenic shift" refers to substantial genetic
  changes caused by the process of genetic
  reassortment.

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Avian influenza

• Influenza A subtypes that primarily affect birds.
  
• H5N1
• 191 human cases, 50 case mortality rate
• New York State Department of Agriculture and
  Markets
• The New York State Department of Environmental
  Conservations Wildlife Pathology Unit

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What is Pandemic Influenza?

• Highly pathogenic for humans.
• Efficiently transmitted between humans.
• Genetically unique.

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Routes of transmission

• Direct and indirect contact
• Droplet
• Airborne
• How much transmission occurs before symptoms are
  present???

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WHO Pandemic Phases
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WHO Pandemic Phases
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Historical pandemics

• Three pandemics occurred during the 20th century
• 1918-19 Spanish Flu.
• 1957-58 Asian Flu.
• 1968-69 Hong Kong Flu.

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Historical pandemics 1918-1919

• 1918-1919 (Spanish Flu)
• Strain was H1N1, with probable avian origin
• 500 million ill worldwide
• 40-50 million dead worldwide
• Attack rate 40 of people in exposed populations
  fell ill
• Case fatality rate 2.5-5 of ill died as a
  result of the illness

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1918 Pandemic waves
Taubenberger JK, Morens DM. 1918 Influenza the
Mother of All Pandemics. Emerging Infectious
Diseases 20061217.
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1918 Pandemic distorted case mortality
Taubenberger JK, Morens DM. 1918 Influenza the
Mother of All Pandemics. Emerging Infectious
Diseases 20061220.
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Historical pandemics 1957-58

• 1957-58 (Asian Flu)
• Cause was H2N2, via a re-assortment event
• 2 million dead worldwide
• Attack rate 20-70 of people in exposed
  populations fell ill
• Case fatality rate 0.1-0.2 of ill died as a
  result of the illness

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Historical pandemics 1968-69

• 1968-69 (Hong Kong Flu)
• Strain was H3N2, via a re-assortment event
• 1 million dead worldwide
• Attack rate 15 of people in exposed populations
  fell ill
• Case fatality rate 0.1-0.2 of ill died as a
  result of the illness

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Pandemic features

• Great variation in mortality, severity of
  illness, and patterns of spread.
• Rapid surge in cases and exponential increase
  over a very brief time, often measured in weeks.
• Severe disease in non-traditional age groups,
  namely young adults, is a major determinant of a
  pandemic's overall impact.
• Subsequent waves more severe then primary wave.

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Disease control strategies

• Vaccination
• Pharmacologic
• Prophylaxis
• Treatment
• Non-pharmacologic
• Isolation and Quarantine
• Social Distancing
• Hygiene
• Decontamination
• Personal Protective Equipment

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Pandemic vaccine

• Annual vaccine is trivalent (3 strains), pandemic
  vaccine will be monovalent.
• Production using current technologies would
  likely take 4-5 months ? may not be available
  before 1st pandemic wave
• There will be vaccine shortages initially
• 2 doses may be necessary to ensure immunity
• H5N1 Vaccines are in clinical trials

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Pharmacologic prophylaxis and treatment of
influenza

• Two groups of antiviral agents are available for
  treatment and prophylaxis of influenza
• adamantanes
• amantadine
• rimantadine
• neuraminidase inhibitors
• oseltamivir
• zanamivir

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Isolation and quarantine

• Only shown to be effective in preventing
  transmission in closed settings.
• Recommended if pandemic influenza strain is
  highly localized and limited.

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Limitations for Influenza

• Short incubation period.
• Possible pre-symptomatic spread.
• Possible asymptomatic illness.

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Social distancing and hygiene

• Limited success during past pandemics.
• Wearing masks in public apparently helpful.
• Hand washing and respiratory hygiene/cough
  etiquette may help, but benefit is undemonstrated.

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Decontamination

• The influenza virus is extremely sensitive to
  almost any disinfectant. However, it is very
  difficult to inactivate the virus if it is in
  organic material, such as feces.
• Disinfectants that will kill avian influenza
  virus
• Any detergent
• Formaldehyde
• Bleach
• Ammonia
• Acids
• Heating to 90ºF for 3 hours, 100ºF for 30 min.
• Drying
• Iodine containing solutions
• Cardona C. UC Davis Veterinary Medicine
  Extension. AI Recommendations. Available at
  http//www.vetmed.ucdavis.edu/vetext/INF-PO_AI.htm
  l Accessed February 06, 2006.

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Surgical masks

• FDA Surgical Mask Approval Criteria
• A surgical mask covers the users nose and mouth
  and provides a physical barrier to fluids and
  particulate materials.
• A surgical respirator is fitted to the users
  face, forming a seal that provides a physical
  barrier to fluids, particulate materials, and
  aerosols.
• NYS DOH
• Wear a surgical or procedure mask for close
  contact with infectious patients (i.e., within 3
  feet).

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Ways that pandemic planning is different

• Influenza pandemics are expected but arrive with
  very little warning.
• Outbreaks can be expected to occur simultaneously
  throughout much of the U.S.
• The effect of pandemic influenza on individual
  communities will be relatively prolonged (weeks
  to months) in comparison to disasters of shorter
  duration.

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Ways that pandemic planning is different

• The number of persons affected will be high.
• Effective preventive and therapeutic measures,
  including vaccine and antiviral agents, are
  likely to be delayed and in short supply.
• There may be significant shortages of personnel
  in other sectors that provide critical public
  safety services.

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A question of risk

• Risk Hazard X Probability

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Which model?

• Department of Health and Human Services Pandemic
  Plan (and NYS DOH plan)
• Very detailed, mild and severe scenario.
• Duration of absenteeism not quantified.
• 10 worker absence for child care and care of ill
  relatives suggested.

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Which model?

• Congressional Budget Office
• Comprehensive mild and severe scenarios.
• Includes numbers of days workers expected to miss.

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Which model?

• FluSurge 2.0
• A CDC modeling tool.
• Does not model the DHHS-stated planning
  assumptions.

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Comparison For Monroe County

• DHHS Assumptions
• 30 overall attack rate.
• 2.5 case mortality rate.
• For population of 738422, there will be 5, 538
  deaths.
• FluSurge 2.0
• 35 overall attack rate.
• For population of 738422, there will be 1,158
  deaths in the worst case scenario.

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Congressional Budget Office

• Severe Pandemic Projection for Monroe County
• 220 thousand will fall ill (30 of total
  population)
• 5,500 will die (2.5 of those who fall ill)
• Workforce Effects
• 30 of the workforce will be affected.
• For surviving ill, average time away from work
  will be 3 weeks.
• 2,750 workers will die (0.75 permanent reduction
  of the workforce).

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Likelihood of a pandemic

• Pandemics have occurred an average of every 24
  years over the last 300 years.
• Large HPAI pandemic may be a harbinger of a human
  pandemic
• now endemic in eastern Asia.
• expanding mammalian host range and geographic
  extent.
• high case-fatality rate.
• two recent mutations -gtbetter adapted to humans.

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Travel restrictions

• Point-of-entry screening.
• Isolating persons and identifying and
  quarantining contacts.
• Limiting or canceling nonessential travel.
• Isolating ill arriving passengers on flights and
  quarantining passengers and crew.
• Closing mass transit systems and interstate bus
  and train routes.

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Containment strategies for different groups

• Individuals or groups of exposed persons
  isolation and quarantine.
• Entire communities
• Promotion of community-wide infection control
  measures including respiratory hygiene/cough
  etiquette, hand hygiene, and avoiding public
  gatherings.
• Snow days and self-shielding
• Closure of office buildings, shopping malls,
  schools, and public transportation are potential
  community containment measures during a pandemic.

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Workforce

• Marked reduction in workforce due to
• Fear of contracting illness and fear related
  behaviors.
• Child and elder care obligations and absences.
• Personal illness and absence.
• Deaths.

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Common sense planning

• Identify essential employees and other critical
  inputs.
• Provide sufficient and accessible infection
  control supplies in all business locations.
• Establish policies for employees who have been
  exposed to pandemic influenza, are suspected to
  be ill, or become ill at the worksite.
• Anticipate employee fear and anxiety, rumors and
  misinformation, and plan communications
  accordingly.

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Other less obvious issues

• Establish policies for flexible worksite and
  flexible work hours.
• Establish policies for preventing influenza
  spread at the worksite.
• Evacuate employees working in or near an affected
  area.

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Other less obvious issues

• Establish policies for employee compensation and
  sick-leave absences unique to a pandemic
• non-punitive.
• liberal leave.
• Self-shielding.
• Caring for well children home from closed
  schools.
• Quarantine.

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Players on your team

• Your Company
• Line Management
• Human Resources
• Occupational Health
• Logistics
• Information Technology
• Public Health Department

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Local Health Departments

• Monroe County Health DepartmentCOMMISSIONERAndr
  ew Doniger, MD, MPHPHONE  585-753-2991E-mail 
  adoniger_at_monroecounty.gov
• Orleans County Health DepartmentPUBLIC HEALTH
  DIRECTOR/DIR. OF ENVIRON. HEALTHAndrew
  LucyszynE-mail  alucyszyn_at_orleansny.com
• Genesee County Public Health DepartmentPUBLIC
  HEALTH DIRECTORChristopher M. Szwagiel, MS,
  MPH, DrPHPHONE  [phone] x 5496E-mail 
  cszwagiel_at_co.genesee.ny.us
• Wyoming County Health DepartmentInterim PUBLIC
  HEALTH DIRECTORGregory Collins, DOPHONE 
  [phone]E-mail Gcollins_at_wyomingco.net

• Livingston County Health DepartmentPUBLIC HEALTH
  DIRECTORJoan H. EllisonPHONE 
  585-243-7270E-mail  jellison_at_co.livingston.ny.us
  
• Ontario County Comm. Health ServicesPUBLIC
  HEALTH DIRECTORJody Gray, RN, MSNPHONE
  585-396-4343E-mail  jody.gray_at_co.ontario.ny.us
• Wayne County Public Health ServicePUBLIC HEALTH
  DIRECTORLinda Michielson, RN, MS, ANPPHONE 
  315-946-5749E-Mail lmichielson_at_co.wayne.ny.us
• The New York State Association of County Health
  Officialswww.nysacho.org/Directory/directory.html
  

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Resources

• Department of Health and Human Services Pandemic
  Plan
• www.cdc.gov/flu/pandemic/
• New York State Department of Health
• www.health.state.ny.us/diseases/communicable/influ
  enza/pandemic/index.htm
• Federal Pandemic Planning Resources Including
  Checklist
• www.pandemicflu.gov
• The Occupational Health Disaster Expert Network
• ohden.sph.unc.edu