Pandemic InfluenzaOverview and Current Planning

Considerations

State of Connecticut Department of Public Health

Albert L. Geetter, MDSection Chief

Office of Public Health Preparedness

Definitions

Bird Flu/Avian Influenza

o Domestic Poultry

o Migratory Waterfowl

Pandemic Influenza

H1 N1H2 N2H3 N3H4 N4H5 N5H6 N6H7 N7H8 N8H9 N9H10H11H12H13H14H15

Natural hosts of influenza viruses

Haemagglutinin subtype Neuraminidase subtype

Implications

Novel Virus

lack of immune “experience”

PATHOGENICITY

VS

TRANSMISSABILITY

Transmissability

Reassortment via Antigenic Shift•Human and Avian recombinant

in “other” species.

Mutation via Antigenic Drift•Internal Genetic Adaptive Change

Avian-human pandemic

reassortant virus

Avianvirus

Human virus

Avian reassortant

virus

Avianvirus

Reassortment

in hogs

Reassortment

in humans

Generation of Pandemic Influenza

Reassortment is where a human & other animal

strains can mix and form a new strain

Children/Teenagers 29%

Adults 59%

Seniors 12%

Demographics

Glass, RJ, et al. Local mitigation strategies for pandemic influenza. NISAC, SAND Number: 2005-7955J

School

Household

Workplace

Likely sites of transmission

Who Infects Who?To Children To Teenagers To Adults To Seniors Total From

From Children 21.4 3.0 17.4 1.6 43.4

From Teenagers 2.4 10.4 8.5 0.7 21.9

From Adults 4.6 3.1 22.4 1.8 31.8

From Seniors 0.2 0.1 0.8 1.7 2.8

Total To 28.6 16.6 49.0 5.7

Current WHO Statistics

Total Human Cases: 387*Total Human Deaths: 245*Total Avian (waterfowl /domestic)

Deaths: > 500 MillionViral etiologyCulling*Politically Driven estimates

Pandemic Influenza: Background & Assumptions

• Novel virus, fully susceptible population, efficient and sustained human to human spread – “1918-like” pandemic would result in ~2 million deaths in US– Vaccine (pandemic strain) likely delayed or not available– Antivirals may be insufficient quantity, ineffective and/or difficult to

distribute in a timely way– Epidemic over a large geographic area affecting a large proportion of the

population

Pandemics of the 20th Century

• The "Spanish influenza", between 1918 to 1919, was due to an A/H1N1 virus related to porcine influenza

• The "Asian influenza", between 1957 to 1958, was due to an A/H2N2 virus

• The "Hong Kong influenza", between 1968 to 1969, was due to an A/H3N2 virus.

20th Century Influenza Pandemics

• 1968-69 “Hong Kong flu,” (H3N2)– 34,000 US deaths (1-4 million worldwide)

• 1957-58 “Asian flu,” (H2N2)– 70,000 US deaths (1-4 million worldwide)

• 1918-19 “Spanish flu,” (H1N1)– >600,000 US deaths (20-100 M worldwide)– 30-40% infected– 2.5% overall mortality– Most deaths among young, healthy adults

Projected GDP Loss From Severe Pandemic: $10.1 Billion

Projected GDP Percent Loss from Severe Pandemic: 5.23 percent

Ranking of Percentage Losses Out of 50 States (Highest = 1): 46

Projected Losses Due to Workforce Absenteeism and Deaths: $ 5 billion

Projected Losses to State Industries: $3.2 billion

Projected Losses Due to Potential Drop in Trade: $1.9 billion

Projected Lives Lost: 29,000

Projected Number of Illnesses: 1,039,000

Pandemic Severity Index

1918

Category 5

Category 4

Category 3

Category 2Category 1

Pandemic Severity Index

March 1918“On March 30, 1918, the occurrence of eighteen cases of influenza of severe type, from which three deaths resulted was reported at Haskell, Kansas.” Public Health Reports, March, 1918September 1918“This epidemic started about four weeks ago, and has developed so rapidly that the camp is demoralized and all ordinary work is held up till it has passed....These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they very rapidly develop the most viscous type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves. We have been averaging about 100 deaths per day, and still keeping it up. There is no doubt in my mind that there is a new mixed infection here, but what I don’t know.”A physician stationed at Fort Devens outside Boston, late September, 1918

Stages of a Pandemic

The World Health Organization (WHO) has developed a global influenza preparedness plan, which defines the stages of a pandemic, outlines the role of WHO, and makes recommendations for national measures before and during a pandemic. The phases are:

Interpandemic period

Phase 1 : No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low.

Phase 2: No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease.

•Antigenic Shift

•Antigenic Drift

Pandemic alert period

Phase 3: Human infection(s) with a new subtype but no human-to-human spread, or at most rare instances of spread to a close contact.

Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.

Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk).

Phase 6: Pandemic: increased and sustained transmission in general population.

Pandemic period

Government Response to a Disaster

FEMA

FBI

DoD DoT

DoE

EPA

USDA

AITNRL

PHHS

USAMRIID DHHS

ATSDR

NMRI

NIH

CDC

SBCCOMC/B-RRT

?

DHS

A tale of two citiesPhiladelphia & St. Louis

• In St. Louis, when the first cases of disease among civilians were reported on October 5, city authorities moved quickly to introduce a wide range of measures designed to promote "social distancing," implementing these measures within two days.

A Tale of Two CitiesPhiladelphia & St. Louis

• Philadelphia's officials response to the news of the pandemic was to downplay its significance. They allowed large public gatherings to continue taking place - most notably a city-wide parade on September 28, 1918.

• Bans on public gatherings, school closures and other NPI's did not begin to be implemented until October 3.

Philadelphia 1918 War Bond Parade

Philadelphia & St Louis

• Philadelphia experienced a peak weekly death rate of 257 per 100,000 people and an overall death count of 719 per 100,000.

• St. Louis showed much lower totals, with a weekly mortality peak of just 31 per 100,000 and a final mortality count of 347 per 100,000.

Shelter in PlaceFoodWaterFlashlight Battery/Crank Powered RadioCooking UtensilSterno Powered Fondue PotCell PhoneWritten Contact ListPrescriptions Allotment Resupply 80% of production-outsourced

Current Programs in Development

Surveillance Response/Activation/Mitigation

Surge Triage Alternate Care Sites Antiviral Distribution Vaccine Development Non Pharmaceutical Intervention1. Cough Etiquette

2. Hand Washing 3. Social Distancing 4. Shelter in Place

Legal Ethical Recovery Restoration

Two Tamiflu with “jimmies”

....please

Hmmm.... Taste just

like Relenza

Use of Antivirals to Blunt a Pandemic

1. Delay disease transmission and outbreak peak2. Decompress peak burden on healthcare infrastructure3. Diminish overall cases and health impacts

Done in combination with non-drug interventions

DailyCases

#1

#2

#3

Days since First Case

Pandemic outbreak:No intervention

Pandemic outbreak:With intervention

Vaccine (pandemic strain) likely delayed or not available

– Antivirals may be insufficient quantity, ineffective and/or difficult to distribute in a timely way

– Epidemic over a large geographic area affecting a large proportion of the population

Hospitals-32

Total Staffed Beds~7294

Professional Staff~14,077

Support Staff~47,425

Operational Considerations

Maximum surge rate: 48-72 hours

Expected staff depletion rate: 30-40%

Attack Rate 30%

Connecticut Population~3.5 Million

Acutely Ill ~1 Million

Morbidity

Pandemic Mortality Rate1-2%

projected 10,000-20,000 Deathsover a 10-12 week period

Pandemic Mortality Rate = 1-2%

10,000 – 20,000 projected pandemic deaths

5,500 – 6,600 ‘statistically expected’ deaths

TOTAL DEATHS 15,500 – 26,600

Management Categories

Critical Personnel

Essential Personnel

Support Personnel

Substitution

Sentinel Events

Impending Capacity Overload

Staff absence from assigned duties

ED Surge

Simultaneous Cessation of all Elective Procedures

Activate Staff: Notification, Call-down Reassignment from elective to acute care duties

Furlough, Early Discharge, of Non-Acute Patients

Designate % In-house Bed Capacity for Acute Viral Respiratory Syndrome Patients

Initial Response

Professional Staffing

Community Health Organizations

Local Health Departments

MRC

ESARVHP

Administrative Issues

ACH Oversight of all Non-Medical Aspects of ACF Operations

ACF to Operateas a Satellite of a Designated ACHunder its DPH licensure

Insurance Billing for Services Rendered under ACH Licensure

ACF/TC Activation

Predetermined Site Selection in concert with area ACH, Regional Emergency

Response and local Chief Elected Officials

Mobile Field Hospital Activation to provide 25 bed TC for each of the five DEMHS

regions

ACF Functional ElementsFree Standing“Hard” Shelter

HVACFoodRehydrationBeddingShowers Water intake

Sewage facilities Oral pharmaceuticals Temporary morgue capacity Ease of vehicle access Communications capability Basic medical/nursing care

Proximity but not contiguity to ACH’s and TC’s, to avoid aggregation of individuals seeking medical care

TC Functions

All 911 calls regarding acute respiratory syndrome will result in diversion to a

regional TC for evaluation

Risk communication to public will encourage private transport of similarly

ill individuals to the TC

Triage Classification

Acutely Ill, requiring transport to ACH as bed becomes available

Clinically Subacute Illness, requiring ACF support

Ill individuals who can remain at home

Worried Well

Expectant

Mortuary Operations

ACH, ACF and TC

On premises identification and body storage to be an oversight function of

the OCME and DMORT Teams

Declaration to deactivate the ACF/TC module

will be at the discretion of DPH Commissioner

in concert with ACH/DMAT/TC Administrators

Recovery

Procedure

Patient discharge/transfer per ACH protocols

Administrative and medical support personnel return to pre-event clinical duties

DMAT deconstruction and storage of MFH modules

Pharmaceutical cache returned to point of origin

Questions

Comments