1. Pandemic H1N1 Influenza:The California Experience Pandemic Influenza Summit II San Bernardino County Department of Public Health July 15, 2009

3. Pandemic Influenza Plan • Lengthy and detailed but no operational component • Assumptions: • Phase 6 Pandemic • Avian influenza model • H5N1 Avian Influenza virus • Person-to-person transmission • 1-2% fatality rate • 30-40% attack rate • Antiviral susceptibility

4. Seasonal Flu Occurs every year, usually in winter, in temperate climates Usually some immunity built up from previous exposure Healthy adults usually not at risk for serious complications Vaccine for seasonal flu is based on known virus strains Pandemic Flu Occur sporadically throughout history – 2-3 waves of 3-4 months- total duration up to 18 months Little or no pre-existing immunity Healthy people of all age groups may be at risk Vaccine probably will not be available in the early stages of a pandemic Seasonal flu vs. Pandemic flu

7. Baseline Assumptions at Onset of Pandemic H1N1, April 2009 • Novel H1N1 with swine, avian and human components never before seen in the world • Since novel, assume no one is immune • Potentially as severe as Avian Flu or 1918 • Since no direct swine contact, assume person-to-person spread • Mexico reported exacerbation of influenza with many deaths. Due to swine flu?

9. California Pandemic H1N1 Response - Chapter 1 • Joint Emergency Operation and Richmond Coordinating Center Activation • Daily local, state and federal conference calls • Healthcare Alerts and Guidance created • Daily media briefings • Aggressive Response Actions • Governor Proclamation of Public Health Emergency • Enhanced surveillance recommended statewide • Teams deployed to the field • Emergency purchase of lab equipment/reagents for 24 local and state public health laboratories • Swine Flu Hotline activated • Antiviral stockpiles deployed to LHDs

11. Key Aspects of California’s Response – Chapter 1 • Partnership between CDPH and LHD • Richmond Emergency Coordinating Center • Sentinel Physician Surveillance • Laboratory Regional Network (LRN) • VRDL • Field response • Response, calibrated to severity • Novel virus, yet mostly non-severe illnesses • Media and public reaction tempered

12. Trust for America’s Health ReportLessons Learned – Chapter 1 • Investments in pandemic planning and stockpiling antiviral medications paid off; • Public health departments did not have enough resources to carry out plans; • Response plans must be adaptable and science-driven; • Providing clear, straightforward information to the public was essential for allaying fears and building trust; • School closings have major ramifications for students, parents and employers;

13. Trust for America’s Health Report Lessons Learned, Chapter - 1, cont. • Sick leave and policies for limiting mass gatherings were also problematic; • Even with a mild outbreak, the health care delivery system was overwhelmed; • Communication between the public health system and health providers was not well coordinated; • WHO pandemic alert phases caused confusion; and • International coordination was more complicated than expected.

14. Trust for America’s Health Report Systemic Gaps – Chapter 1 • Maintaining the Strategic National Stockpile • Vaccine development, production, and distribution • Vaccinating all Americans • Planning and coordination • School closings, sick leave, and community mitigation strategies • Global coordination • Resources • Workforce • Surge capacity • Health care for uninsured and under-insured

16. Public Health ResponseChapter 2 How many cases of H1N1 infection have occurred in California as of last week? • 224,690 • 24,690 • 2,469 • 246 • None of the above • It does not matter

17. Public Health ResponseChapter 2 California (San Bernardino Co) Pandemic H1N1 infections as of 7/9/2009 • Total Cases: 2,469 (139) • Confirmed: 1,945 (134) • Hospitalizations: 287 ( 15) • Deaths: 32 ( 1)

19. California Pandemic (H1N1) cases by County, July 9, 2009

20. California Pandemic (H1N1) cases by Age, July 9, 2009

23. Public Health ResponseChapter 2 • The problem is far from over • Epidemiologic questions: • Ease of transmission? • Risk populations? • Virulence factors? • Severity? • Protective and risk factors? • Laboratory capacity • Ongoing testing, high volume • H1N1 genome changes? • Ongoing cluster and outbreak response • PH worker and HC provider safety • Vaccine production and distribution

24. H1N1 Vaccination Program Planning Assumptions • Configuration in each state and local jurisdiction determined by the target population • Limited amount of vaccine available initially • Vaccine might be adminstered in diverse settings • Severity of illness is unchanged from what has already been observed • Risk groups affected by this virus do not change significantly • Vaccine testing suggests safe and efficacious product • Adequate supplies of vaccine can be produced • No major antigenic changes are evident that would signal the lack of likely efficacy of the vaccines being produced

25. H1N1 Vaccination Program Planning Scenario 1 • Target population: • Students and staff (all ages) associated with schools (K-12th grade) and children (age ≥6 months) and staff (all ages) in child care centers • Primary vaccination venues:  • schools and child care centers • Goals: • Provide direct protection against illness among persons who have high attack rates of illness, reduce likelihood of outbreaks that may lead to disruptive school dismissals, reduce transmission from schools into homes and the community

26. H1N1 Vaccination Program Planning Scenario 2 • Target population: • Pregnant women, children 6 months – 4 years of age, new parents and household contacts of children <6 months of age. • Primary venues: • Provider offices, community clinics • Goal: • Reduce complications of novel H1N1 influenza among those vulnerable for serious complications of influenza; protect the youngest (<6 months) who are not themselves able to be vaccinated through immunization of their household contacts

27. H1N1 Vaccination Program Planning Scenario 3 • Target population: • Non-elderly adults (age <65 years) with medical conditions that increase the risk of complications of influenza • Primary venues: • Occupational settings, community clinics, pharmacies, providers’ offices • Goal: • Reduce risk of hospitalizations and deaths among persons with higher rates of these complications than the general population, and focus vaccine where its impact can be most beneficial for direct protection

28. H1N1 Vaccination Program Planning Scenario 4 • Target population: • Health care workers and emergency services sector personnel (regardless of age) • Primary venue: • Occupational settings, providers’ offices • Goal: • Reduce risk of illness, sustain health system functioning, and reduce absenteeism among front-line providers; reduce transmission from emergency services personnel and health care workers to patients; provide additional worker protection in settings of increased exposure

29. Summary • Successful response in chapter one • Pandemic H1N1 still causing morbidity and mortality in summer months • High likelihood of second more intense wave in fall • Significant challenges for chapter two • Public health and healthcare systems will be tested to the limit

30. Questions - Discussion