Pandemic InfluenzaPandemic Influenza Perspectives from Federal and Perspectives from Federal and

State Public Health State Public Health

DateDate

PresenterPresenter North Carolina Division of Public HealthNorth Carolina Division of Public Health

ObjectivesObjectives

Review influenza basicsReview influenza basics Assess current pandemic threatAssess current pandemic threat Describe pandemic planning in the Describe pandemic planning in the

United States and in North CarolinaUnited States and in North Carolina

Flu Basics: Flu Basics: Viral InfectionViral Infection

FeverFever HeadacheHeadache Muscle achesMuscle aches Extreme Extreme

fatiguefatigue Dry coughDry cough Sore throatSore throat Runny or Runny or

stuffy nosestuffy noseCDC Public Health Image Library

Flu ComplicationsFlu Complications

BronchitisBronchitis PneumoniaPneumonia DehydrationDehydration Worsening of chronic illnessWorsening of chronic illness Sinus or ear problems in childrenSinus or ear problems in children Death Death

• ~65/100,000 infections~65/100,000 infections• 80-90% >65 y/o80-90% >65 y/o

Seasonal Influenza: Key FactsSeasonal Influenza: Key Facts

TransmissionTransmission “ “Respiratory droplets”Respiratory droplets”• An infected person infects ~1.5—3 othersAn infected person infects ~1.5—3 others

Incubation PeriodIncubation Period 1 to 5 days from exposure1 to 5 days from exposure Contagious PeriodContagious Period

• 1-2 days before illness begins*1-2 days before illness begins*• 4-5 days after onset 4-5 days after onset

TimingTiming• Seasonal flu: Wintertime peak Seasonal flu: Wintertime peak • Occasional importation from Southern hemisphere Occasional importation from Southern hemisphere • Pandemic: anytimePandemic: anytime

*low likelihood of transmission*low likelihood of transmission

Avian Influenza H5N1: Key FactsAvian Influenza H5N1: Key Facts

Transmission to humans: RareTransmission to humans: Rare • Extensive contact with infected birdsExtensive contact with infected birds

ContagiousnessContagiousness • Very rarely spread between humansVery rarely spread between humans• Spread among birds: increasingSpread among birds: increasing

Birds and poultry in Southeast Asia, Asia, Birds and poultry in Southeast Asia, Asia, Indonesia, Europe, Africa, Middle East…Indonesia, Europe, Africa, Middle East…

SeveritySeverity• Of 281 people infected with H5N1 Avian Of 281 people infected with H5N1 Avian

Flu, 169 (60%) have diedFlu, 169 (60%) have died

Pandemic Influenza: Key FactsPandemic Influenza: Key Facts

Pandemic = worldwide epidemicPandemic = worldwide epidemic• New influenza virus New influenza virus No immunity No immunity• Spreads from person-to-personSpreads from person-to-person

Presumed to be like seasonal flu: respiratory Presumed to be like seasonal flu: respiratory dropletsdroplets

• Can cause severe diseaseCan cause severe disease Incubation PeriodIncubation Period

• Presumed like seasonal flu: 1 to 5 days Presumed like seasonal flu: 1 to 5 days Contagious PeriodContagious Period

• Presumed to be similar to seasonal flu Presumed to be similar to seasonal flu TimingTiming

• Waves that last weeks and could begin anytimeWaves that last weeks and could begin anytime

Influenza ImpactsInfluenza Impacts

Type of InfluenzaType of Influenza

ImpactImpact SeasonalSeasonal AvianAvian PandemicPandemic

Frequency Frequency AnnualAnnual RareRare ~3 - 5 per ~3 - 5 per centurycentury

% Infected% Infected 3030 <0.01<0.01 30-5030-50

% Fatal% Fatal ~0.05~0.05 >60>60 < 0.1 - > 2.0< 0.1 - > 2.0

Influenza CountermeasuresInfluenza Countermeasures

Counter-Counter-measuresmeasures SeasonalSeasonal AvianAvian PandemicPandemic

VaccineVaccine ++++ -- +/-+/-

Anti-viralsAnti-virals ++++ ++ +/-+/-

Non-Non-Pharmaceutical Pharmaceutical Interventions Interventions (NPIs)(NPIs)

++++ +/-+/- ++++

Week 1 = early January Week 52 = late December

Seasonal Flu in NCINFLUENZA SURVEILLANCE, NC 2006-2007

Influenza-Like Illness in Sentinel Site Patients (Solid Line)Comparative prior years, Dashed Lines

-- Data available as of 21 March, 2007 --

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20

WEEK #

% I.

L.I.

2003-2004

2004-2005

2005-2006

2006-2007

Week 1 = early January Week 52 = late December

Sentinel and Emergency Department Surveillance in NC

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

WEEK#

%IL

I

ED

SPN

(WK # 20= May 19, 2006)(WK # 40=Oct 7 2006)

Prevention of Seasonal InfluenzaPrevention of Seasonal Influenza

Annual vaccination Annual vaccination • InjectionInjection

InactivatedInactivated

• Nasal mist Nasal mist Live attenuatedLive attenuated

Prophylactic medicinesProphylactic medicines Avoid ill personsAvoid ill persons Respiratory hygiene & Respiratory hygiene &

etiquette: “Cover your etiquette: “Cover your cough”cough”

southbirminghampct.nhs.uk

Pandemic Influenza EmergencePandemic Influenza Emergence

Novel virusNovel virus Human-to-human transmissionHuman-to-human transmission

• ““RR00” = number of people an infected ” = number of people an infected person infectsperson infects

Severity of illnessSeverity of illness• Case fatality ratio (CFR)Case fatality ratio (CFR)

Pandemic Influenza EmergencePandemic Influenza Emergence

Novel virusNovel virus Human-to-human transmissionHuman-to-human transmission

• ““RR00” = number of people an infected ” = number of people an infected person infectsperson infects

Severity of illnessSeverity of illness• Case fatality ratio (CFR)Case fatality ratio (CFR)

Pandemic SeverityPandemic Severity

CDC Pandemic Severity Index

•Basis: Case Fatality Ratio

•Category 1 “Mild”

•Category 5 “Catastrophic”

Pandemics of the 20Pandemics of the 20thth Century Century

YearYear US US MortalityMortality

1918-191918-19 “Spanish flu”“Spanish flu” 550,000550,000

1957-58 1957-58 “Asian”“Asian” 69,80069,800

1968-69 1968-69 “Hong Kong”“Hong Kong” 33,80033,800

1977-78 1977-78 “Russian”*“Russian”* 8,3008,300

*Novel virus that didn’t cause a pandemic

Pandemic InfluenzaPandemic Influenza

Multiple waves possibleMultiple waves possible• Six to eight weeksSix to eight weeks

Weekly combined influenza and pneumonia mortality, United Kingdom, 1918–1919.

-JK Taubenberger and DM Morens. 1918 Influenza: the Mother of All Pandemics. EID, Jan. 2006

Does Age Matter?Does Age Matter?

Age at death, per 100,000 persons in each age group, United States, 1911–1918

-JK Taubenberger and DM Morens.1918 Influenza: the Mother of All Pandemics. EID, Jan. 2006

Pandemic Flu Vaccine and DrugsPandemic Flu Vaccine and Drugs

VaccineVaccine• Delayed productionDelayed production• May require two dosesMay require two doses

DrugsDrugs• Supplies: limitedSupplies: limited• Distribution: unfamiliarDistribution: unfamiliar

PrioritizationPrioritization rationing rationing fear… fear…

Pandemic Influenza Pandemic Influenza PlanningPlanning

Federal and State PerspectivesFederal and State Perspectives

Overall GoalsOverall Goals

ReduceReduce deaths deaths

ReduceReduce illnesses illnesses

ReduceReduce social social disruptiondisruption

Current Pandemic Planning AssumptionsCurrent Pandemic Planning Assumptions

We’ll have some noticeWe’ll have some notice Don’t expect federal or state “rescue”Don’t expect federal or state “rescue” Duration of event: weeks to monthsDuration of event: weeks to months Absenteeism Absenteeism

• Plan for 30-40% for at least 2 weeksPlan for 30-40% for at least 2 weeks VaccineVaccine

• Late, limitedLate, limited Anti-viralsAnti-virals

• Insufficient stockpile for preventive treatmentInsufficient stockpile for preventive treatment• Sufficient for some treatmentSufficient for some treatment

Federal and State Public Health RolesFederal and State Public Health Roles

Leadership—in collaboration with Leadership—in collaboration with emergency managementemergency management

Information—regular updates, interim Information—regular updates, interim guidance guidance

Coordination—with multiple agencies and Coordination—with multiple agencies and jurisdictions, e.g. counties, state agenciesjurisdictions, e.g. counties, state agencies

Evaluation—measure interventions’ effectsEvaluation—measure interventions’ effects

Public Health’s Legal AuthoritiesPublic Health’s Legal Authorities

CDC CDC State Public Health State Public Health County or City Health County or City Health DepartmentsDepartments

Federal—guidance onlyFederal—guidance only• www.pandemicflu.govwww.pandemicflu.gov• www.cdc.govwww.cdc.gov

State—guidance and legal authority State—guidance and legal authority • www.epi.state.nc.us/epi/gcdc/pandemic.htmlwww.epi.state.nc.us/epi/gcdc/pandemic.html

County/Local Health Departments—where guidance County/Local Health Departments—where guidance and legal authority meet real peopleand legal authority meet real people

Federal Guidance

•DHS/HHS/CDC—leadership

•All Federal Cabinet Level Agencies

•Justice

•Defense

•Commerce

•Treasury

State Guidance•Division of Public Health leadership

•Governor Executive Order: All executive level agencies to create pan-flu continuity of operations plans (COOPS)

How To Slow a Pandemic: How To Slow a Pandemic: Latest CDC GuidanceLatest CDC Guidance

1.1. Ill persons should be treated* and Ill persons should be treated* and stay away from othersstay away from others

2.2. Exposed persons should stay away Exposed persons should stay away from others and receive prophylaxis*from others and receive prophylaxis*

3.3. More ‘More ‘social distancesocial distance’ between ’ between children in schools and childcarechildren in schools and childcare

4.4. More social distance between adults More social distance between adults at work and playat work and play

*If sufficient medicine is available*If sufficient medicine is available

Delay and Limit New Cases

Time

Imp

act

No interventions

With interventions

Weekly mortality data provided by Marc Lipsitch (personal communication)

1918 Death Rates: Philadelphia v St. Louis

0

2000

4000

6000

8000

10000

12000

14000

16000

9/14

/191

8

9/21

/191

8

9/28

/191

8

10/5

/191

8

10/1

2/19

18

10/1

9/19

18

10/2

6/19

18

11/2

/191

8

11/9

/191

8

11/1

6/19

18

11/2

3/19

18

11/3

0/19

18

12/7

/191

8

12/1

4/19

18

12/2

1/19

18

12/2

8/19

18

Date

Dea

ths

Rat

es /

100

,000

Po

pu

lati

on

(A

nn

ual

Bas

is)

Philadelphia

St. Louis

St. LouisSt. Louis

St. Louis

0

2000

4000

6000

8000

10000

12000

14000

9/14

/191

8

9/21

/191

8

9/28

/191

8

10/5/

1918

10/12

/191

8

10/19

/191

8

10/26

/191

8

11/2/

1918

11/9/

1918

11/16

/191

8

11/23

/191

8

11/30

/191

8

12/7/

1918

12/14

/191

8

12/21

/191

8

12/28

/191

8

Date

De

ath

Ra

te /

10

0,0

00

Po

pu

lati

on

(A

nn

ua

l Ba

sis

)

First death recorded

Mayor closes “theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions until further notice”

Closing order withdrawn

Estimated attack rate before interventions:

2.2%

Source: Lipsitch M, Hatchett R, Mecher C

PittsburghPittsburgh

Pittsburgh

0

2000

4000

6000

8000

10000

12000

14000

9/14

/191

8

9/21

/191

8

9/28

/191

8

10/5/

1918

10/12

/191

8

10/19

/191

8

10/26

/191

8

11/2/

1918

11/9/

1918

11/16

/191

8

11/23

/191

8

11/30

/191

8

12/7/

1918

12/14

/191

8

12/21

/191

8

12/28

/191

8

Date

De

ath

Ra

te /

10

0,0

00

Po

pu

lati

on

(A

nn

ua

l Ba

sis

)

3.7%*

Estimated attack rate before interventions:

Theaters, saloons closed*

Sports suspended

Churches closedSchools, libraries closed

Source: Lipsitch M, Hatchett R, Mecher C

Non-Pharmaceutical InterventionsNon-Pharmaceutical Interventions“Social Distancing”“Social Distancing”

More distance between persons More distance between persons spread of spread of germs less likely germs less likely

More distance, fewer persons More distance, fewer persons reduced reduced “social density” “social density” fewer opportunities fewer opportunities

Examples:Examples: • Cancel indoor arena eventsCancel indoor arena events• Dismiss students from schoolsDismiss students from schools• Increase distance between workers/Limit Increase distance between workers/Limit

workplace interactionsworkplace interactions Tele-work, stagger schedules, Net-meetingsTele-work, stagger schedules, Net-meetings

Pandemic SeverityPandemic Severity

CDC’s Pandemic Severity Index

•Category 1 –mild

•Category 3 –moderate

•Category 5 –catastrophic

Interventions α Severity Index

•Category 1

•Ill persons stay home

•Schools generally not closed

•Category 5

•Almost everyone stays home!

Impact of an Influenza PandemicImpact of an Influenza PandemicUnited StatesUnited States

SeasonalSeasonal 1957-like1957-like 1918-like1918-like

IllnessesIllnesses 50-60 million50-60 million 90 million90 million 90 million90 million

Outpatient Outpatient visitsvisits

25 million25 million 45 million45 million 45 million45 million

Hospital Hospital visitsvisits

200,000200,000 865,000865,000

~5x~5x9.9 million9.9 million

~50x~50x

DeathsDeaths 36,00036,000 209,000209,000

~5x~5x1.9 million1.9 million

~50x~50x

Pandemic Impact in North CarolinaPandemic Impact in North Carolina

SeasonalSeasonalModerate Moderate

Pandemic*Pandemic*Severe Severe

Pandemic*Pandemic*

Doctor visitsDoctor visits 750,000750,000 1.6 million1.6 million 1.6 million1.6 million

Hospital visitsHospital visits 6,0006,000 35,00035,000 290,000290,000

DeathsDeaths 1,1001,100 7,9507,950 65,30065,300

* Based on CDC software FluAid 2.0: Assumes a 35% attack rate, NC population of 8.5 million people.

Pandemic Influenza PlanningPandemic Influenza PlanningChallengesChallenges

Widespread eventWidespread event Long duration Long duration Uncertainties Uncertainties

• SeveritySeverity• Age-related impactsAge-related impacts• BlindersBlinders

Health services overwhelmedHealth services overwhelmed• Shortages likely Shortages likely ethical approaches needed ethical approaches needed

Medications, vaccinesMedications, vaccines EquipmentEquipment Hospital bedsHospital beds Personnel: ~30% absenteeism for 2 weeksPersonnel: ~30% absenteeism for 2 weeks

• Health care settings as sources of infection?Health care settings as sources of infection?

Planning Partners: No One UntouchedPlanning Partners: No One Untouched

HospitalsHospitals Emergency Emergency

management management agenciesagencies

Local and Local and regional public regional public healthhealth

Business SectorBusiness Sector

Schools and Schools and universitiesuniversities

Faith-basedFaith-based Other governmentOther government

In other words…In other words…

……everyone!everyone!

Goal: Continuity of Operations

Critical Infrastructure/Key ResourcesCritical Infrastructure/Key Resources

Private Sector FocusPrivate Sector Focus

Identify priorities Identify priorities Motivate action earlierMotivate action earlier Recognize differences Recognize differences

between traditional between traditional COOPS and Pan Flu COOPS and Pan Flu impactsimpacts• Longer durationLonger duration• AbsenteeismAbsenteeism

Prevention and PlanningPrevention and Planning

It Begins At HomeIt Begins At Home

The more you prepare yourself and The more you prepare yourself and your family, the more likely you can your family, the more likely you can fulfill roles in an emergencyfulfill roles in an emergency

Possible ScenarioPossible ScenarioFederal ResponseFederal Response

WHO “Phase 6”, Category 5 SeverityWHO “Phase 6”, Category 5 Severity• Sustained human-to-human transmission, Sustained human-to-human transmission,

high case fatality ratiohigh case fatality ratio Cases recognized in US Cases recognized in US President may proclaim State of President may proclaim State of

EmergencyEmergency DHS/CDC and all other Federal Agencies DHS/CDC and all other Federal Agencies

implement COOPsimplement COOPs Private sector partners encouraged to Private sector partners encouraged to

implement COOPsimplement COOPs MediaMedia

Possible ScenarioPossible ScenarioState ResponseState Response

Cases recognized in US including NCCases recognized in US including NC Governor proclaims State of Emergency, Governor proclaims State of Emergency,

ordersorders• Students: Students: dismissed from schoolsdismissed from schools• Mass gatherings: Mass gatherings: cancelledcancelled• Church services: Church services: discourageddiscouraged• Businesses: Businesses: continuity of operations planscontinuity of operations plans • Hospitals: Hospitals: surge capacity + COOPssurge capacity + COOPs

Division of Public Health and NC Emergency Division of Public Health and NC Emergency ManagementManagement• Activate COOPs, EOCs, JICActivate COOPs, EOCs, JIC• Work with CountiesWork with Counties

Counties: COOPs within their jurisdictions Counties: COOPs within their jurisdictions

The “Snow Day” ApproachThe “Snow Day” Approach--For 6-8 Weeks?For 6-8 Weeks?

Emergency EndsEmergency Ends

The pandemic wave passes throughThe pandemic wave passes through Public Health measures impactsPublic Health measures impacts

• Illnesses, deathsIllnesses, deaths• Other impacts, losses to business sectorOther impacts, losses to business sector

Plans refinedPlans refined Vaccine or anti-flu drugs become Vaccine or anti-flu drugs become

available???available???

Questions

Feedback

Thanks

Contact InfoContact Info

Brant Goode, RN/BSN, MPHBrant Goode, RN/BSN, MPHLCDR, USPHSLCDR, USPHSCDC Career Epidemiology Field OfficerCDC Career Epidemiology Field Officerassigned to assigned to North Carolina Division of Public HealthNorth Carolina Division of Public HealthPublic Health Preparedness and ResponsePublic Health Preparedness and Response919.715.6738 (office)919.715.6738 (office)919.715.4699 (fax)919.715.4699 (fax)406.360.5247 (mobile)406.360.5247 (mobile)brant.goode@ncmail.net orbrant.goode@ncmail.net orbgoode@cdc.govbgoode@cdc.gov