Transcript Information about Pandemic Influenza

Information about Pandemic
Influenza
Harvey Kayman, MD, MPH, PHMO III
California Department of Public Health
Division of Communicable Disease Control
Immunization Branch
Objectives
• Learn about Pandemic
Influenza
• Learn how to prevent,
protect, and mitigate
• Learn what challenges we
face
The three criteria of a Pandemic
• Ability to isolate a new
influenza virus from a human.
• Can be spread from human to
human.
• Spreads worldwide.
An influenza A pandemic:
• is a global disease outbreak.
• occurs when there is little or no
immunity to that strain of
influenza in the human
population.
• causes serious illness, and can
sweep through populations.
Seasonal versus Pandemic
Influenza
• Drift: Slight changesH3N2 to new H3N2
Seasonal Influenza
• Shift: Big changes• H5N1 appears in Humans=
Pandemic Influenza
The AVIAN H5N1 virus has raised
concerns about a potential human
pandemic because:
• It is especially virulent.
• It is being spread by migratory birds
and transported domestic poultry.
• It can be transmitted from birds to
mammals and in some limited
circumstances to humans.
The origins of influenza A virus
Human influenza A viruses start as avian (bird) influenza viruses
Migratory
water birds
Domestic birds
Humans
and other
animals
Rapid Worldwide Spread
• The entire world population is
susceptible to a pandemic with
a new strain of virus.
• Countries can delay arrival of
the virus.
Community-Based Interventions
1. Delay disease transmission and outbreak peak
2. Decompress peak burden on healthcare infrastructure
3. Diminish overall cases and health impacts
#1
Pandemic outbreak:
No intervention
#2
Daily
Cases
Pandemic outbreak:
With intervention
#3
Days since First Case
11
Pandemics are not new:
• Pandemics since, at least, the
sixteenth century.
• The 1918 “Spanish flu,” is
generally regarded as the
most deadly disease event in
human history.
History of PI Deaths in the 20th
century
• 1918 PI-500,000 U.S. deaths and
up to 40 million deaths worldwide.
• 1957 PI-70,000 U.S. deaths and
1-2 million deaths worldwide.
• 1968 PI-34,000 U.S. deaths and
700,000 deaths worldwide
History of PI in the 20th century
40000000
35000000
30000000
25000000
USA
World
20000000
15000000
10000000
5000000
0
1918
1957
1968
Flu after WW I
• While most deaths from seasonal
influenza occur in the very young
or very old, the deaths from this
pandemic were primarily in those
aged 15-35, with 99% of deaths in
those under 65.
Case-fatality rates (panel C, solid line
1918-19; dotted line-usual seasonal flu
Waves of severe illness
• Pandemics occur in waves of sickness,
and the virus may increase in potency
between outbreaks.
• The mortality rate of the pandemic of
1918-1919 increased tenfold with the
arrival of the second wave.
• Waves generally last two to three months.
Three pandemic waves: weekly
combined flu and pneumonia
mortality, U K, 1918–1919 (21).
Characteristics
• The influenza virus mutates and
evolves often during Pandemics and
between seasons.
• Illness is more severe if the virus
attaches to lung tissue and causes an
extreme immune response.
Contagiousness
• The typical period between infection and
the onset of symptoms is two days
• Persons who have become ill may
transmit the infection as early as one day
before the onset of symptoms
• The risk of infection is greatest the first two
days of illness
• Children play a substantial role in the
transmission of influenza
Potential Risk Factors for Humans
•
•
•
•
Slaughtering,
De-feathering, or
Preparing sick poultry for cooking;
Playing with or holding diseased or dead
poultry;
• Handling fighting cocks or ducks that
appear to be well; and
• Consuming raw or undercooked poultry or
poultry products NEJM 2008;358:261-73.(1/17/08)
High death rates may be largely
determined by four factors:
• (1) the number of people who
become infected;
• (2) the virulence of the virus;
• (3) the underlying characteristics and
vulnerability of affected populations;
and
• (4) the degree of effectiveness of
preventive measures.
H5N1 Cases and Deaths as of
May, 2008 WHO
400
350
300
250
200
Cases
Deaths
150
100
50
0
2003 2004
2005 2006
2007 as of 5 Total
08
Potential need for care in USA
Characteristic
Moderate
Severe
# Ill
90 million
90 million
# in OPD
45 million
45 million
# need Hospital 1 million
10 million
# need ICU
125,000
745,000
# Ventilators
65,000
745,000
# of Deaths
200,000
2 million
Citizens develop strategies for
action In Kansas City 2008
• Most people know very little about
pandemic flu.
• Workshop participants grappled with
the question of how to inform people
of the need to prepare for pandemic
flu in a way that would encourage
action.
•
One KC Voice Pandemic Flu Citizen Engagement Project 2008
Barriers to preparation
• The need to earn a paycheck.
• No sense of urgency, and no perceived
incentives for action.
• Few neighborhood, church and school
leaders are involved in preparing for
pandemic flu.
• People will disregard health department
advisories if they feel they need to care for
children or parents.
•
One KC Voice Pandemic Flu Citizen Engagement Project 2008
Protective and Mitigating
responses
• Cross sector planning and collaboration
including governmental preparedness
• Cross boundary planning and
collaboration
• Adopt unified command structure, and
vocabulary using Incident Command
System
• Improve and expand training systems
• Legal issues and legal system
Obtain and Track Impact of the
Pandemic (Surveillance):
• Detect initial cases of PI
• Identify virus and treatment susceptibility
in Laboratory
• Improve electronic data reporting system
to track:




Attack rates
Rates of influenza hospitalization
Case fatality rates
Isolated and quarantined persons, treatment and
support.
Protective and Mitigating
responses
• Vaccine
• Antiviral medications
• Other medications to reduce
inflammation ??
• Personal protective equipment;
Masks and respirators, etc.
Immunization
.
N Engl J Med 2008;358:261-73
• Safe and immunogenic inactivated H5 vaccines
have been developed.
• Decisions regarding the use of vaccine before a
pandemic and stockpiling require complex risk–
benefit and cost–benefit analyses:
• Effects on the seasonal capacity of vaccine
production, timing and cause of the next
influenza pandemic are unknown, and
• Unclear if immunization of large populations
could have adverse consequences.
Anti-Viral Drug treatment
• Early treatment with oseltamivir
(Tamiflu™) is recommended,
• Rx may improve survival,
• Optimal dose and duration of therapy
uncertain.
• Mortality remains high despite oseltamivir;
• Late initiation of therapy a major factor.
•
N Engl J Med 2008;358:261-73.
Initiate Social Distancing:
• Dismiss students
• Cancel large gatherings
• Restrict mall usage and business
activities.
• Restrict travel on public
transportation.
16000
Philadelphia
St. Louis
14000
12000
10000
8000
6000
4000
2000
/1
9/ 91
21 8
/1
9/ 91
28 8
/1
10 918
/5
10 / 19
/1 18
2
10 /191
/1
9/ 8
10 19
/2 18
6/
1
11 91
/2 8
/1
11 91
/9 8
11 /19
/1 18
6/
11 19
/2 18
3/
11 19
/3 1 8
0/
1
12 91
/7 8
12 /19
/1 18
4/
12 19
/2 18
1
12 /19
/2 18
8/
19
18
0
9/
14
Deaths Rates / 100,000 Population
(Annual Basis)
1918 Death Rates: Philadelphia v St. Louis
Date
Collins SD, Frost WH, Gover M, Sydenstricker E: Mortality from influenza and pneumonia in the 50
largest cities of the United States First Edition Washington: U.S. Government Printing Office 1930.
16
Communications:
• Improve risk communication, both
to and from constituents.
• Improve interoperable
communications networks
between State, public health,
health care community, EMS,
9-1-1, emergency management,
public safety etc.
Protective and Mitigating
responses
• Prepare for security and law
enforcement challenges.
• Prepare for ethical challenges
and the “least unfair” resource
allocation.
• Prepare for spiritual challenges
on population and personal
levels.
Protective and Mitigating
responses
• Anticipate concerns and needs of
at-risk individuals and
populations.
• Attend to Mental Health/Disaster
mental health system design.
Assessment and Concerns:
• Assess available work capacities,
commodities, equipment, and personnel
for all sectors.
• Improve Health Care system SURGE
capacity
• Create protocols to expand healthcare
services
Ports of Entry
• Develop a port of entry (POE) communicable
disease response plan for locations with a
Quarantine Station --which includes ill
passenger assessment and isolation procedures
• Ready legal orders for detention, isolation,
quarantine, and conditional release of
passengers or crew members
• Prepare for serious mental health challenges at
Ports of Entry.
Community disease containment
• WHO recommendations:
– advise ill people to remain at home
– use measures to increase social
distance
– mask use by the public should be
based on risk; routine mask use
should be permitted, but not required
– hand hygiene and respiratory
hygiene/cough etiquette should be
strongly encouraged
Community disease containment
• Although nonpharmaceutical
interventions may be the only
interventions available for
community disease containment
early in a pandemic, the
effectiveness of such interventions
has not been well studied
Health Care Systems
Overloaded
• Infection and illness rates may soar.
• A substantial percentage of the
world’s population will likely require
some form of medical care.
• Nations are unlikely to have the staff,
facilities, equipment and hospital
beds needed to cope with large
numbers of people who suddenly fall
ill.
Medical Supplies Inadequate
• The need for vaccine is likely to
outstrip supply.
• The need for antiviral drugs is also
likely to be inadequate early in a
pandemic, so will need to be
“allocated”.
• Difficult decisions will need to be
made regarding who gets antiviral
drugs and vaccines.
All Supplies Inadequate
• A pandemic can create a shortage of
hospital beds, ventilators and other
supplies.
• A pandemic can create a shortage of all
commodities; especially fuel, food, and
essentials.
• Surge capacity at non-traditional sites
such as schools may be created to cope
with demand.
Economic and Social Disruption
• Travel bans, student dismissal,
closure of businesses and
cancellations of events could have
major impact on communities and
citizens.
• Care for sick family members and
fear of exposure can result in
significant worker absenteeism.
Economic costs
• According to the Congressional
Budget Office, an outbreak on the
scale of the 1918 pandemic could
result in a loss of 5% of gross
domestic product, or a national
income loss of approximately 600
billion dollars.
A Framework for Planners Preparing to
Manage Deaths
• It is clear increased numbers of natural
deaths in a potentially short period of time
will place considerable pressure on all
local Public Services providers.
• Systems for receiving and disseminating
information will need to be robust and
capable of moving at a fast pace-tell it all,
tell it truthfully and tell it quickly.
•
The Home Office: Mass Fatalities Section (Pandemic Influenza Consultation) London
•
http://www.ukresilience.info/upload/assets/www.ukresilience.info/flu_managing_deaths.pdf
Trigger Points for Different Ways of
Working
• Scale of increased deaths.
• Limited storage space at local mortuaries
and funeral parlors
• Absenteeism.
• How to complete death certificates.
• Political policy formulation and
implementation; the activation of
emergency regulations.
• Combination of pressure points.
Holding and Burial sites
• Limited capacity to hold the deceased prior to
funerals at hospital mortuaries, public
mortuaries, in private homes and funeral parlors.
• Use of refrigerated vehicles and trailers?
• Cemetery managers should plan for alternative
ways of providing graves.
• Move to provision of common graves?
• Common graves should be deep enough to
allow for additional family burials.
Time to prepare
• While no one can state with
complete certainty that a
pandemic will occur, the signs
point to it being a prudent time to
begin careful and thorough
preparation.
•
•
•
•
Business Continuity Planning
and Pandemic Influenza in
Europe (Coker report 2008):
Demonstrate Leadership &
Commitment
Develop Business Continuity
Plans (BCP)
Identify Risks and Quantify
Impacts
Provide Information, education
and communication
Business Continuity Planning
and Pandemic Influenza in
Europe (Coker report 2008):
• Attend to Occupational Health
and Safety
• Review Human Resource Policies
• Assess the resiliency of supply
chain
• Ensure continued access to
financial resources
COLLABORATION AND
COORDINATION (Coker report 2008):
• Sharing of best practices with
business partners, the community
and within the industries must be
encouraged
• Public-private collaboration must
be facilitated
COLLABORATION AND
COORDINATION (Coker report 2008):
• The allocation and commitment of
specific resources to pandemic
preparedness and response have
to be considered as a crucial
component of the planning
PUTTING PLANS INTO
ACTION (Coker report 2008):
• Whenever it is possible, every employer
should test the effectiveness of their plans
• RECOVERY PLANNING
• There is an urgent need to encourage
organizations to prepare for the recovery
and this area should be addressed in all
organizational guidance
•
An Analysis of Independent Sector and National Governments’ Guidance.
Alexandra Conseil, Sandra Mounier-Jack and Dr. Richard Coker (London School
of Hygiene and Tropical Medicine (LSHTM), 6/12/08)
www.lshtm.ac.uk/ecohost/flupanbcp
35
Number of themes covered (overall and by area)
30
25
20
15
10
5
0
IE MT ES UK PT CH FR
SE NL FL RO AT BG NO DK T R BE CY EE CZ DE EL HU IT
LV LT LU PL
SL
Countries
Area 1. Leadership and Commitment
Area 2. Risk Assessment and Impact Quantification
Area 3. Information, Education and Communication
Area 4. Occupational Health and Safety
Area 5. Human Resources Issues
Area 6. Operational Continuity
Area 7. Putting Plans into Action
Area 8. Recovery Planning
Area 9. Collaboration and Coordination
SK
WHO tests capacity to respond
• Exercise in Vancouver, B.C. (6/08) was
designed and conducted to test how well
the WHO can use the new International
Health Regulations.
• A global health treaty that requires
countries to report disease outbreaks that
might have international ramifications.
Los Alamos mathematical model
uses anomaly detection
• Identifies subtle changes in
epidemiological data.
• Uses far less data over shorter time
frames, not huge amounts of data for
accuracy,
• Can be used on data from a handful
of infected people in a remote village.
General Resources
• Links to Additional Information
• http://www.pandemicflu.gov/ (managed by
the Department of Health and Human
Services)
• http://www.cdc.gov/flu/avian/ (managed by
the Centers for Disease Control and
Prevention)
Resources for this presentation
• http://www.medicalreservecorps.g
ov/File/MRC_Pandemic_Influenza
_Planning_Guidance.pdf
• http://www.flcourts.org/gen_public
/emergency/index.shtml).