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Pandemic Influenza *** Governor’s Taskforce for Pandemic Influenza Preparedness

Pandemic Influenza *** Governor’s Taskforce for Pandemic Influenza Preparedness. Robert T. Rolfs, MD, MPH Utah Department of Health September 7, 2006. Topics. About Influenza Seasonal Influenza Avian Influenza (AI) Pandemic Influenza Pandemic Preparedness Policy Issues for Taskforce.

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Pandemic Influenza *** Governor’s Taskforce for Pandemic Influenza Preparedness

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  1. Pandemic Influenza***Governor’s Taskforce for Pandemic Influenza Preparedness Robert T. Rolfs, MD, MPH Utah Department of Health September 7, 2006

  2. Topics • About Influenza • Seasonal Influenza • Avian Influenza (AI) • Pandemic Influenza • Pandemic Preparedness • Policy Issues for Taskforce Credit: L. Stammard, 1995

  3. Influenza Virus

  4. About Influenza • Viral illness – types A, B and C • Influenza A – typed by surface antigens • Haemagglutinin (H1-H16) • Neuraminidase (N1-N9) • Clinical illness • Incubation period* = 1-2 days • Abrupt onset fever, chills, muscle aches (myalgia), headache, followed by cough, sore throat, nasal congestion • 5-6 days restricted activity, 3 days lost from school or work * Incubation period = time from infection to onset of symptoms

  5. About InfluenzaTransmission • Person to person • Respiratory droplets (5-10 µm) • Contaminated hands and surfaces • Short distance airborne transmission ? • Infectious period • 1 day before to 5 days after onset* • Peak viral shedding in 24-48 hrs after illness onset • Rapid spread of influenza epidemics • Short incubation period (1-2 days) • Peak infectiousness at onset of illness * Shedding can be longer in children and those with impaired immune response

  6. About Influenza:How the Virus Changes • Influenza viruses are prone to genetic change • Antigenic drift • Progressive, smaller changes that allow virus to continue to spread • Reason vaccines need to change from year-to-year • Antigenic shift • Appearance of new, very different virus • People have not been exposed and immune system doesn’t recognize virus or provide protection

  7. What is Seasonal Influenza? • “Annual” seasonal epidemics • Attack rates average 5-20% • Estimated 20-40,000 deaths in U.S. annually • Greatest effect on very young and older adults • Result of antigenic “drift” • Ongoing changes of influenza viruses that allow people to be infected more than once

  8. Percentage of Visits for Influenza-like illness (ILI) Reported by Sentinel ProvidersUtah 2003-4, 2004-5 and 2005-06 seasons

  9. Influenza-associated Hospitalizations Utah 2005-2006* • Date as of March 1, 2006

  10. AVIAN INFLUENZA

  11. What is Avian Influenza?“Bird Flu” • Many varieties of influenza occur in birds • Primarily affect wild aquatic birds • Serious illness is unusual in wild birds • Illness more severe in domestic poultry, classified based on severity • Low pathogenic (LPAI) • High pathogenic (HPAI) • Most avian influenza viruses don’t infect humans * Only H5 and H7 cause HPAIV

  12. Avian Influenza in Utah • Currently, highly pathogenic influenza is not found in the Utah bird population • The dangerous highly pathogenic avian influenza A (H5N1) has not been detected in the US • The consequences of an outbreak could be severe to the poultry industry which generates >$100 million a year and employs hundreds.

  13. What is Pandemic Influenza? • Global outbreak of influenza • Caused by appearance of new type of influenza A virus to which people have no immunity • Can cause serious illness and spread rapidly from person to person worldwide. • Past pandemics have caused high levels of illness, death, social disruption and economic loss.

  14. Pandemic Influenza in the 20th Century

  15. Influenza pandemics – death rates by age

  16. 1918 Influenza PandemicDeath rates - United Kingdom, 1918-19 Tauberberger JK, Morens DM. 1918 Influenza: the Mother of All Pandemics. EID 206;12(1). http://www.cdc.gov/ncidod/eid/vol12no01/05-0979.htm#Figure1

  17. Spread of H2N2 in 1957

  18. Aug 30-Oct 17, 1968 July 17 – Hong Kong Sept 2 – 1st US cases Late Sept/Oct - civilian outbreaks AK, PR Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  19. Week 40-42, 1968 3rd wk Oct – 1st civilian outbreak in continental U.S. - Needles CA 35-40% affected Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  20. Week 45, 1968 Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  21. Week 46, 1968 Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  22. Week 47, 1968 Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  23. Week 49, 1968 Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  24. Week 50, 1968 Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  25. Week 52, 1968 50 states affected in ~ 2 months after 1st civilian outbreak in CA Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  26. 1968 Pandemic – peak by state Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

  27. CURRENT SITUATION www.pandemicflu.gov (accessed September 5, 2006)

  28. Avian Influenza H5N12003 - present • 1996 – initial outbreak in Hong Kong, 18 hosp & 6 deaths • 2003-2004 • poultry outbreaks in China, Viet Nam, Thailand, Korea • Human cases in Hong Kong, Viet Nam, Thailand • 2005 • Ongoing poultry outbreaks & human infections in 5 nations • 1st human-to-human transmission • Wild birds found to be infected • Spread to Eurasia • 2006 - Rapid spread into Africa and Europe

  29. Avian Influenza (H5N1) 2003-2006 • Epizootic (animal epidemic) of unprecedented scope • Poultry or wild bird outbreaks in 53 nations* in Asia, Africa, Europe • Death or destruction of hundreds of million birds • Spread by migratory birds and shipment of poultry and related products Poultry outbreaks as of June 29, including current and controlled outbreaks

  30. Avian Influenza (H5N1) Human disease 2003-2006 • Human cases – 241 cases with 141 deaths • > 50% case fatality rate • How people get it • Direct contact with poultry • Very limited person-to-person spread • Effective person-to-person spread is not occurring at this time Human cases are from Dec. 26, 2003 through August 23, 2006

  31. Avian Influenza H5N1Human Cases & Deaths, 2003-2006 * 2006 Cases/Deaths through July 4, 2006

  32. Nations With Confirmed Cases H5N1 Avian Influenza(July 7, 2006) www.pandemicflu.gov (accessed July 12, 2006)

  33. Avian Influenza (H5N1)The Next Pandemic? • Have conditions been met for a pandemic? • Novel antigens – no human immunity - Yes • Human infection – Yes • Causes serious illness - Yes • Effective person-to-person spread – No

  34. A PANDEMIC TODAY WHAT IT MIGHT LOOK LIKE

  35. Pandemic Influenza ImpactUtah Projections Projections are based on the U.S. estimates included in the HHS Pandemic Influenza Plan, and based on Utah 2005 population estimate (2,529,000); these estimates don’t account for age differences in populations

  36. Pandemic Influenza ProjectionsUtah – Moderate (1957/68-like) At peak – 150 admissions per day

  37. Pandemic Influenza ProjectionsUtah – Severe (1918-like) At peak – 1700 admissions per day

  38. Pandemic InfluenzaExamples of Community Impact • High absenteeism rates at work/school • Illness, caring for dependents, limiting transmission • Possible school closures • Event cancellations – concerts, meetings, conventions, etc. • Travel restrictions and decreased tourism • Economic impact on business • Shortages of supplies • Difficulty keeping police, fireman, doctors, nurses, and other critical service providers working • Hospitals full – delayed care for routine or even urgent illnesses

  39. Pandemic InfluenzaPublic Health Capacity • Public health has changed since Sept 11, 2001 and subsequent anthrax attacks • All Hazards Disaster Planning • Epidemiology & Disease Surveillance • Laboratory Testing • Information & Communication Systems • Stockpiles and Mass Vaccination Capability • Effective Risk Communication • Training & Exercises • Hospital Preparedness

  40. Pandemic InfluenzaPlanning Assumptions • Simultaneous outbreaks across Utah and U.S. • Limited ability to share resources across jurisdictions • In a given community, the epidemic will last 6-8 weeks • No vaccine for first 6-8 months and shortages after that • Shortages of antiviral medications and probably of antibiotics and other medical supplies • Illness rates and absenteeism of 25% or more • Need for care may exceed capacity of health care system

  41. Pandemic Influenza PlanA Roadmap • Identified what public health needs to do • Surveillance, containment, communications, state and local coordination, infection control • Pandemic Influenza Workgroup • Planning and activities in 12 Local Health Departments • Identified where we need help • Governor’s Taskforce to address key policy questions • Too big for (any) government alone • Will require efforts of entire community

  42. Utah Pandemic PlanIssues for Governor’s Taskforce • Credible and effective decision-making • Capacity of health care system • Maintaining essential business and community services • Support for people confined by illness or to limit spread • Antiviral stockpile and use • Vaccine priorities

  43. Governor’s TaskforceIssue 1: Effective & Credible Decision-making • A pandemic will severely stress society and pose challenges for governments and other entities. • Difficult decisions that will greatly affect people’s lives • Allocating scarce resources (e.g., medical care, vaccine) • Closing schools and cancelling events • Restricting travel and other usual activities • Trust in decision-making processes can affect community cooperation, cohesion, and resilience • Existing legal authority may not be adequate to support effective response during a pandemic

  44. Governor’s TaskforceIssue 2: Adequacy of Health Care Surge Capacity • A pandemic could severely stress or overwhelm the capacity of health care system. • Health care system has limited excess capacity and limited ability to expand that capacity • It may be impossible to meet usual standards of care • Need to protect integrity of health care system and of providers during and after pandemic

  45. Governor’s TaskforceIssue 3: Maintaining Essential Business and Community Services • A pandemic can disrupt business operations and provision of essential services in several ways. • Businesses will need to operate with diminished workforce, and with travel and gathering restrictions • Just-in-time supply lines are vulnerable to disruption during a pandemic with global impact • Fear and uncertainty • Police, fire, EMS, and other providers of essential community services will be challenged to maintain essential services

  46. Governor’s TaskforceIssue 4: Support for those Confined by Illness or to Limit Spread • Both the ill and their caregivers may need support, including: • Information, supplies, childcare, basic needs (e.g., food), financial assistance, mental health care, medical care. • The impact and need for support will be greatest for those who are most vulnerable due to preexisting illness, poverty, or social or physical isolation. • Social service agencies and voluntary organizations may be overwhelmed by need for services and will themselves face the challenges of the pandemic

  47. Governor’s TaskforceIssue 5: Antiviral medications – Stockpile, Management and Use • Antiviral medications can prevent and treat influenza. • Efficacy for a pandemic strain is uncertain, but it is generally believed they would help. • Availability during a pandemic will require stockpile • Funding needs to be identified to purchase stockpile • If a pandemic doesn’t occur during usable life of the medications, the medications could go unused. • Priorities must be set for appropriate use of stockpiled antiviral medications and mechanisms established to adjust those priorities if needed.

  48. Governor’s TaskforceIssue 6: Vaccine Management and Use • Vaccine would be the most effective tool against a pandemic virus • Unlikely to be available initially • When available, supply will be insufficient • Priorities must be set for appropriate use and a mechanism established to adjust priorities if necessary.

  49. Pandemic and Avian InfluenzaAdditional information Utah http://www.pandemicflu.utah.gov U.S. http://www.pandemicflu.gov John M. Barry The Great Influenza: The Epic Story of the Deadliest Plague In History Neustadt R, Fineberg H The Epidemic that Never Was: Policy-making and the Swine Flu Affair

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