pandemic preparedness: pigs, poultry, and people versus plans, products, and practice julie l....
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PandemicPreparedness:
Pigs, Poultry, and Peopleversus
Plans, Products, and PracticeJulie L. Gerberding, MD, MPH
DirectorCenters for Disease Control and Prevention
AdministratorAgency for Toxic Substances and Disease Registry
Atlanta, GA
The Burden of Influenza
Seasonal Influenza
• Globally: 250,000 to 500,000 deaths each year
• In the United States each year:– 36,000 deaths
– >200,000 hospitalizations
– $37.5 billion in economic costs from influenza and pneumonia
Pandemic Influenza
• An ever-present threat
Pandemics Do Happen!
H1
H1H3
H2
H7*
H5*
H9*
1918SpanishInfluenza
H1N1
1957Asian
Influenza H2N2
1968Hong KongInfluenza
H3N2
1980
1997
1915
*Avian Flu
2003 2004
1977
1996 2002
1925 1935 1945 1955 1965 1975 1985 1995 2005
2003-2006
1998 1999
2003
Bacteriologic Findings Among Patients with Influenzal Pneumonia 1918-1919
Stevens KM. NEJM. 1976;1363-66.
Sputum Blood
S. pneumoniae 1230/1609 (76%) 78/1507 (4.9%)
S. aureus 133/1485 (9%) 0/1535
Beta-hemolytic strep 254/2077 (12%) 32/1587 (2%)
H. Influenzae 436/729 (60%) 1/1400 (.1%)
Potential Causes of Shock and Death
• Exacerbation of undiagnosed underlying conditions
• Coincidental occurrence of an unrelated problem
• Influenza pneumonia
• Secondary bacterial pneumonia
• Toxic shock syndrome/endotoxemia
• Hypersensitivity response
• Myopericarditis
• Cytokine-induced shock syndrome
H5N1 Influenza Severe Pneumonia - Vietnam 2004
Hien TT et al. New England J Med. 2004;350:1179-1188.
DAY 5 DAY 7 DAY 10
Planning Assumptions: Health Care
Moderate (1957-like) Severe (1918-like)Illness 90 million (30%) 90 million (30%)
Outpatient medical care 45 million (50%) 45 million (50%)
Hospitalization 865,000 9,900,000
ICU care 128,750 1,485,000
Mechanical ventilation 64,875 745,500
Deaths 209,000 1,903,000
• 50% or more of those who become ill will seek medical care
• Number of hospitalizations and deaths will depend on the virulence of the pandemic virus
Addressing Local Practices
Direct Avian – Human Infection
Human virus
Avian Reservoir
Pandemic Strain Emergence:Direct Infection
Avian virus
Avian Reservoir
Avian virus
Human virus
Pandemic Strain Emergence: Reassortment of Influenza A Viruses
other mammals?New
reassorted virus
Clade 1
Clade 2
H5N1 InfluenzaEvolves
HemagglutininGeneticChanges Clade 1'
CkCambodia013LC2b05 VietnamJP1405
VietnamJPHN3032105 VietnamJP420705
CkVietnam104 CambodiaJP52a05
CkMalaysia585804 CkThailand104 Thailand35304
Prachinburi623104 Vietnam120304
Vietnam119404 VietnamHN3040805
Thailand1604
blhdgullHong Kong12103 Hong Kong21303
DkKulonProgoBBVET904 QaCirebonBBVET105
Indonesia505 Indonesia705
Indonesia605 CkBrebesBBVET205
CkKulonprogoBbvetXii104 CkIndonesia504
CkIndonesia703 CkHong KongYU32403
BarheadedGsQinghai1205 BarheadedGsQinghai6505
TurkeyTurkey105 whooperSwanMongolia
MG24405 CkKoreaES03
CkYamaguchi704 CkYunan49305
DkGuangxi1304 CkGuangdong19104
DkChinaE319203 CkGuangdong17804
Hong Kong48697 Hong Kong53897
Hong Kong15697 CkHong Kong22097
Hong Kong48397
GsGuangdong397 GsGuangdong196
99
99
100
98
95
100
100
91
99
99
94
99
100
93
88
99
0.005
Situation Report: Avian Influenza Widespread and spreading prevalence in migratory birds;
broad host range
Continued outbreaks among domestic poultry
Mammalian infection (cats, pigs, etc.) lethal
Virus is evolving
Sporadic human cases (>140 reports to date)– Most in young and healthy– Case-fatality 50%– Rare person-to-person transmission
Sustained and rapid person-to-person transmission
HHS Pandemic Influenza Plan
• Support the National Strategy for Pandemic Influenza
• Outlines planning assumptions and doctrine for health sector pandemic preparedness and response
• Public Health Guidance for State and Local Partners
• 11 Supplements with detailed guidance
Pandemic Influenza Doctrine: Saving Lives
• A threat anywhere is a threateverywhere!
• Quench first outbreaks: detect and contain where it emerges, if feasible
– International collaborations
– Frontline detection and response; rapid laboratory diagnosis
– Isolation / quarantine / antiviral prophylaxis / social distancing / animal culling
Pandemic Influenza Doctrine: Saving Lives
• Prevent or at least delay introduction into the United States
– May involve travel advisories, exit or entry screening
– For first cases, may involve isolation / short-termquarantine of arriving passengers
VT
ME
MANY
PA
NH
WV
VA
MD
NJ
RICT
AZ
IN
WI
KY
MI
OHIA
MN
MO
ILNE
KS
SD
ND
AL
TN
GA
SC
NC
AR
LA
MS
OKAtlanta
ChicagoSeattle
WY
ID
WA
AK
OR
MT
NVUT
NM
CO
East TX
Miami
FL
No.CA
So.CA
Los Angeles
San Francisco
Jurisdictions of 18 CDC quarantine and border health stations
DE
HI
Honolulu
Washington D.C.
El Paso
Houston
Newark
New York
Boston
GU
Minneapolis
Detroit*
Anchorage
San Diego
West TX
PR
CDC Station
Pandemic Influenza Doctrine: Saving Lives
• Slow spread, decrease illness and death, buy time
– Antiviral treatment and isolation for people with illness
– Quarantine for those exposed
– Social distancing
– Vaccine when available
– Local decisions Weeks
Impact
Prepared
Unprepared
Pandemic Influenza Doctrine: Saving Lives
• Clearly communicate to the public
– Prepare people with information
– Encourage action steps to prepare now
– Provide updates when new information emerges
– Use trusted messengers
– Coordinate to ensure consistent messages
– Address rumors and inaccuracies
Our Health Protection Preparedness SystemA NETWORK of Shared Responsibility!
• Local - state - federal
• Domestic – international
• Public – private
• Multi-sector
• Non-partisan
• Animal – human
• Health protection – homeland security – economic protection
HealthcareDeliverySystem
Federal Partners
Education System
Business & Workers
Local /State /Federal Public
HealthSystem
Countermeasures: Vaccines, Antivirals, and Medical Supplies
Strategic National Stockpile
www.pandemicflu.gov
Pandemic Influenza Checklists
• State and Local
• Business
• Preschool
• Schools (K-12)
• Colleges & Universities
• Faith-based & Community Organizations
• Physician Offices and Ambulatory Care
• Home Health
• Emergency Medical Services
• Travel Industry
Vaccine Production and Use: U.S Seasonal Influenza
Doses Produced (millions)
Doses Distributed (millions)
1980 15.7 12.4
1985 23.1 20.1
1990 32.3 28.3
1995 71.5 54.9
1999 77.2 76.8
2000 77.9 70.4
2001 87.7 77.7
2002 95.0 83.0
2003 86.9 83.1
2004 61.0 56.5
2005 86.0 > 80 so far
Vaccine Supply and Demand are Unpredictable U.S. Seasonal Influenza
0
10
20
30
40
50
60
70
80
90
100
1980 1985 1990 1995 2000 2001 2002 2003 2004 2005
Mill
ions
Doses Produced
Doses Distributed
020406080
100120140160180200
1964 1974 1984 1994 2004
Millio
ns
6-23 mos.old
50-64 years
Householdcontacts
Health careworkers
Nursing homeresidents
Pregnant women
<65 years with ahigh risk condition
>65 years
Influenza Vaccine Recommendations: Expanding
Immunization Programs: Some Key Differences
•Public Sector Financial Support
• Significant public sector support – VFC, 317, states
• Small financial risk to private providers for vaccine purchases
• Very limited; no ACIP ability to finance vaccine purchases
• Potentially large financial risks for providers for vaccine purchase(i.e., “reimbursement” model used)Control of
Vaccine• Large CDC/State roles • Small CDC/State roles
Access; number and public sector provider sites
• 45,000 VFC sites providing vaccinations year round (i.e., public clinics and private physicians)
• About 5,000 state and local health departments provide access to publicly purchased influenza vaccine
Assurance of vaccination (accountability) • CDC/States
• CMS/QIOs for some populations
• No clear lead for targeted high-risk adults for people <65 years old
Routine Childhood Adult
Pandemic Influenza Preparedness
Preparing for a pandemic now will mean:
• Lives saved during seasonal influenza
– Modern seasonal influenza vaccine for all who need it
– New antiviral drugs for prevention and treatment
• Community health protection from other threats
• Peace of mind
Preparedness Preparedness
www.cdc.gov
www.pandemicflu.gov
Complacency is the Enemy of Health Protection!