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Improving Responses to
Public Health Threats:
Lessons from Influenza and Ebola
RADM Stephen C. Redd, MD
Director, Influenza Coordination Unit
October 16, 2014
Agenda
Avian influenza, 2005–2009
 Response
 Exercises and After-Action Reviews
H1N1, 2009–2010
 Response
 After Action Review
Ebola, 2014
 Situation update
 Response
2
BIRD FLU
2005–2009 Response
Centers for Disease Control and Prevention
Office of Public Health Preparedness and Response
3
Headlines, 2006
4
5
6
National Strategy
Pandemic Plans




National Strategy for Pandemic
Influenza
National Strategy for Pandemic
Influenza: Implementation Plan
HHS Pandemic Influenza Plan
HHS Implementation Plan
7
CDC Influenza Pandemic Operations Plan
Training and Exercise Plan
Senior Leader
OPLAN Seminar
Briefings/Seminars
28 Sep
Influenza Pandemic OPLAN
Training/Exercise Methods Include:
AAR
Tabletop Discussion (informal walk-thru and discussion)
DEOC Working
Level Workshop
Workshops and Functional Drills (step-by-step
rehearsal by phases/stages)
4 Oct
Full Scale Exercises
AAR
Functional Exercise –
Internal, Full Staff
Division Director, CIO
OPLAN Seminar
AAR
31 Jan-1 Feb 07
AAR
17 Oct
AAR
Advanced Tabletop:
Preparation for Full
Exercise
Basic Functional Level Drills
(6 Functional Areas)
27 Oct – 1 Dec
8 Dec (Half Day)
Full Scale Exercise –
Internal/External
April 07 (72 Hrs)
AAR
Internal Degraded
Operations Exercise
2-4 Hours Each
AAR
Final AAR
& Report
May 07 (Full Day)
AAR
8
After Action Review




Morning meeting after exercise
Review from each functional area:
 What worked well (to sustain)
 What needs improvement
Written report produced
 Overview of exercise
 Task list
Tracking of improvement
9
Real-life Practice
• May 2006: H5N1 cluster, Indonesia
• March 2007: US traveler, New York
• Dec 2007: Pakistani traveler, New York
10
Capabilities Developed to Prepare for an
Influenza Pandemic





Surveillance plans
Diagnostic test development / deployment
Vaccine development / deployment
Antiviral stockpiling / guidance development
Community mitigation measures




School closure guidance
Planning for airport screening
Infection control guidance
Communication planning and training
11
Pre-H1N1 Exercise Highlights


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
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Organization of leadership team
Span of control
Established daily rhythm
Communication with state health departments
Structured decision making
Fusion meeting
Communication on countermeasure development and
delivery
12
H1N1
2009–2010 Response
Centers for Disease Control and Prevention
Office of Public Health Preparedness and Response
13
Detection of Novel Swine Influenza

First case—April 15,2009



Second case—April 17, 2009





10 year old boy
Identified as part of a clinical trial of a
prototype diagnostic device
9 year old girl
Identified as part of CDC border flu
surveillance
MMWR Dispatch—April 21, 2009
Texas cases—April 22
Mexico cases—April 23
1
2
Southern California, US
14
Virology 2008-10 Influenza Seasons
> 700,000 specimens tested
12000
90
80
70
10000
60
8000
6000
4000
50
199,887
specimens
tested
40
Percent Positive
Number of Positive Specimens
14000
100
30
20
2000
10
0
0
2008
B
A(H3)
Percent Positive
2009
Week Number
A(Subtyping not performed)
A(Unable to Subtype)
A(H1)
A(2009 H1N1)
15
Estimated H1N1 cases by week, 2009-10
8,000,000
7,000,000
Estimated Cases
6,000,000
5,000,000
4,000,000
3,000,000
2,000,000
1,000,000
0
10/3
10/17
10/31
11/14
11/28
12/12
12/26
1/9
1/23
2/6
2/20
3/6
Week
16
Characteristics of 2009 H1N1 Influenza Pandemic in the US
April 15, 2009–April 10, 2010
Approximate rate per 100,000 population
Deaths
12,470 (8.9K – 19.3K)
Hospitalizations
274,000 (195K – 403K)
Cases
≥65
50-64
25-49
5-24
Age groups
0-4
61,000,000 (43M – 89M)
17
Estimated H1N1 Cases and Vaccine Doses
Distributed
14,000,000
Cases and Doses Distributed
12,000,000
vaccine doses
10,000,000
8,000,000
cases
6,000,000
4,000,000
2,000,000
0
10/3
10/17
10/31
11/14
11/28
12/12
12/26
1/9
1/23
2/6
2/20
3/6
Week
18
2009 H1N1 Achievements




Rapidly identified novel influenza virus
Developed and distributed diagnostic reagents within
weeks of detection
Vaccinated approx 80m US residents
Increased use of antiviral drugs for severely ill
19
Learning from the 2009 Pandemic




Preparation paid dividends
Vaccine production inadequate
 Time to sufficient quantities
 Understanding what was available
 Communicating the uncertainty
Everyday systems work best
Importance of communications
20
Shared Capabilities





Communications

Within government

With partners

With the public
Infection control
Travel issues
Coordination with State and Local Health authorities
(and political leadership)
Potential for societal impacts
21
Plan for Addressing
Key Items for Improvement
22
H1N1 Response After Action Reviews
In Progress Reviews
May, June, July (State/Local),
August & November 2009
Final improvement
plan approved by
response
leadership
January & February (State/Local)
2010
Response
Begins
Sep 15, 2010
Task Force &
Senior Leader
AARs
March - May 2010
April 2009
AAR Policy
Meeting with CDC
Director
PHER-required
AARs due from
States
July 31, 2010
2011-2012
CDC AAR
Conference Update on CDC
Improvement Plan
Progress
Reports on
improvement
plan activities
November 15, 2010
June 28, 2010
AAR/Improvement
Plan Final Draft
July 15, 2010
Summary Reports from
States on AAR/IP progress
November 30, 2010
23
Key Items for Improvement
Pandemic Preparedness Continues: Plan, Exercise and Refine Plans
Vaccine
Production
Laboratory
Diagnostics
Communications
Antiviral Drug
Distribution
Modernize and increase speed of vaccine production
Improve lab diagnostics, including next generation
serologic testing and more sensitive point-of-care testing
Clearly define and express severity for seasonal and
pandemic influenza
Leverage existing commercial drug distribution to
efficiently distribute antivirals
Staffing
Effectively manage the emergency response staffing
Infection
Control
Improve infection control, especially respiratory protection
Modeling
Integrate statistical modeling into the response
Budget
Increase proactive budget planning to facilitate fast,
efficient use of resources
24
2014 Ebola Outbreak Response
EBOLA
West Africa
2014 Ebola Outbreak
Centers for Disease Control and Prevention
Office of Public Health Preparedness and Response
25
History of Ebola


First discovered in 1976 near the Ebola River
in the Democratic Republic of the Congo
Family of zoonotic RNA viruses
 Filoviridae

Historically, death rates for Ebola 50%-90%

The 2014 outbreak is the
largest Ebola outbreak in
History and the world’s first
Ebola epidemic
http://www.cdc.gov/vhf/ebola/outbreaks/2014-westafrica/distribution-map.html
26
Ebola Cases and Deaths
SitRep
Date
Cases
Deaths
Total
Confirmed
Total HCW
Total
Guinea*
11 Oct
1441
1164
75†
831
Liberia
09 Oct
4190
948
204
2400
Sierra Leone
11 Oct
3187
2792
129‡
1173
8818
4904
408
4404
Total
*Data based on joint Ministry of Health/WHO Situation Reports
† Includes only confirmed cases
‡Data based on WHO Situation Reports
27
Total Number of EVD Cases by Week Reported in
Situation Reports
Guinea
Sierra Leone
Liberia
4500
Liberia week 40 may not be complete
4000
Number of Cases
3500
3000
2500
2000
1500
1000
500
0
13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Epidemiologic Week 2014
Epidemiologic weeks 13-40 correspond to 24 Mar–4 Oct
28
Ebola Response Priority Objectives


Interrupt Ebola transmission in West Africa
 Case identification, isolation and care
 Contact identification and monitoring
 Transmission risk factor identification and mitigation
 HCW protection and infection control
 Funeral and burial safe practices
Prevent Ebola transmission to other countries
 Prevention of undiagnosed cases entering unaffected
countries
 Prevention of transmission from diagnosed cases
during and after repatriation
29
US Government Strategy
Control the Outbreak
Mitigate Secondary
Impacts
Encourage International
Participation
Build Long-term Capacity
to Detect and Respond
30
Challenges in West Africa






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Epicenter of epidemic in remote, tri-country border
area, rapid spread in urban areas
Institutions of government still being strengthened
Weak health and public health systems
Lack of even basic resources
Poor communications (limited cell phone, radio
coverage, internet service)
Divisions within societies recovering from war
Misconceptions about disease and low levels of literacy
31
Laboratory Testing Capacity
Sierra Leone
300 specimens per day
Liberia
350 specimens per day
Guinea
100 specimens per day
* Lab Partners in West Africa include: US CDC, NIH, China CDC,
Institute Pasteur, Canada, CDC, NIH, US Navy, US Army, Russia,
European Consortium, South Africa
32
Recent Developments: Texas Cases

Texas case #1
 First domestically-diagnosed Ebola patient confirmed 9/30/14
 Visited ER, evaluated and sent home on 9/26/14
 14 person CDC team provided support with contact identification
and tracing and infection control—48 contacts tracked

Texas case #2






Diagnosed 10/12/14
Isolated within 90 minutes of reporting symptoms
Provided patient care to case #1, not a contact between 2 ER visits
Review of infection control procedures
Few contacts, but over 70 health care workers being monitored
Texas case #3
 Tested positive for Ebola on 10/15/14
33
Domestic Preparedness:
Airport Screenings

Entry screening of passengers arriving from affected
countries







JFK: New York-JFK, NY (10/12/14)
IAD: Washington-Dulles, VA
EWR: Newark, NJ
ORD: Chicago-O’Hare, IL
ATL: Atlanta, GA
Account for 94% of all passengers arriving from Liberia,
Sierra Leone, and Guinea
Procedure




Visual assessment
Questions about symptoms
Temperature measurement
Questions about exposure
34
Applying Lessons Learned from Influenza Responses


Structure of response leadership
Importance of communication
 Potential for misinformation / distrust




CDC product is information and guidance
No vaccine or specific therapeutic agent
Critical role for meticulous infection control
Community mitigation measures
35
Preparing for Emergencies of Infectious Diseases




Global detection and response is key
Plan and exercise for greatest threats (pandemic
influenza)
Recognize the need for speed and scale
Communication capacity
36
Questions?
37