Influenza Jeffrey S. Duchin, M.D. Chief, Communicable Disease Control, Epidemiology and Immunization Section, Public Health - Seattle & King County Division of Allergy and Infectious Diseases, University of Washington What’s New and What’s Relevant in ?

Outbreak of Avian Influenza A (H5N1)  WHO: H5N1 poses a considerable human public health risk –Widespread, outbreak not controlled –Mutates rapidly, propensity to acquire new genes –Increasing host range –Directly infects humans  Since December 2003 –At least 122 human cases –62 deaths from Vietnam, Thailand, Cambodia and Indonesia  WHO Pandemic Alert: Stage 3 (of 6)

The influenza pandemic of killed more humans than any other disease in a period of similar duration in the history of the world.* The influenza pandemic of *Alfred W. Crosby; America’s Forgotten Pandemic: The Influenza of 1918, Cambridge University Press, 1989

Deaths By Week due to Pneumonia & Influenza October 1918 through March Philadelphia, PA Population: 1,761,371 Total deaths: 15,785 Deaths from the influenza pandemic of

Poll A. All B. Most C. Some D. None What portion of the recently released national pandemic influenza plan have you read?

Pandemic Influenza Planning  Little warning between onset of pandemic and arrival in U.S.  Attack rate 30%: 90 million persons clinically ill  45 million persons require outpatient medical care  865,000–9.9 million persons hospitalized  128,750-1,485,000 persons require ICU care  64, ,500 require mechanical ventilation  209, million deaths  Economic cost estimate: $181 billion for moderate pandemic Potential Impact of Pandemic Influenza in the U.S.

Pandemic Influenza Planning Potential Impact of Pandemic Influenza in the U.S.  Vaccine and antiviral drugs will be in short supply.  Healthcare workers and other first responders will be at higher risk of exposure and illness than the general population.  Risk of sudden shortages of key personnel in critical community services –Healthcare, police, fire, utilities, transportation workers, air traffic controllers, etc. Expect 6-8 month lag-time for vaccine availability.

Role of Local Public Health  Surveillance –Early detection, characterize epidemiology, monitor impact  Distribution of antiviral drug stocks and vaccine  Provide guidance on clinical management & infection control  Implement community containment strategies –Assure legal preparedness  Communication to public  Facilitate healthcare system planning and response  Psychological and social support to emergency responders

Surveillance: Pandemic Alert Period Clinical Criteria for Influenza-Like Illness (ILI)  Temperature of >38°C (>100.4°F) plus  Cough or  Sore throat or  Shortness of breath >38°C >100.4°F

Surveillance: Pandemic Alert Period Who to Identify and Test  Hospitalized patients with severe ILI (including pneumonia) AND who meet epidemiologic criteria  Non-hospitalized patients with ILI with strong epidemiologic suspicion of exposure –e.g., direct contact with ill poultry in an affected area, or close contact with a known or suspected human case of novel influenza

Surveillance: Pandemic Alert Period Epidemiologic Criteria  Travel or occupational risks within 10 days of symptom onset  Travel risks –Visited or lived in an area affected by highly pathogenic avian influenza A outbreaks in domestic poultry or where a human case of novel influenza has been confirmed and either –had direct contact with poultry OR –had close contact with a person with confirmed or suspected novel influenza or severe unexplained respiratory illness Useful websites to stay current: OIE ( WHO ( and CDC (

Surveillance: Pandemic Alert Period Epidemiologic Criteria (cont.)  Direct contact with poultry is defined as: –touching birds (well-appearing, sick, or dead) or –touching poultry feces or surfaces contaminated with feces or –consuming uncooked poultry products (including blood) in an affected area  Close contact with a person from an infected area with confirmed or suspected novel influenza is defined as: –being within 3 feet (1 meter) of that person during their illness

Surveillance: Pandemic Alert Period Epidemiologic Criteria (cont.)  Occupational risks –persons who work on farms or live poultry markets –Persons who process or handle poultry infected with known or suspected avian influenza viruses –workers in laboratories that contain live animal or novel influenza viruses –healthcare workers in direct contact with a suspected or confirmed novel influenza case

Pandemic Influenza Vaccination  Vaccine delivery - central preventive strategy  A second dose after 30 days will likely be required  Short time frame for vaccine delivery, distribution, and administration  Severe or moderate shortage will likely exist  Security issues

Pandemic Influenza Vaccination Strategies  Define priority groups for early vaccination*  Increase pneumococcal vaccine coverage before pandemic *NOTE: detailed outline groups are available in complete slide set on NWCPHP website

Antiviral Agents  May help decrease transmission in specific settings –Most useful before vaccine available  Prevention of infection (prophylaxis): 70-90% effective  Treatment: neuraminidase inhibitors may reduce severe complications of influenza –Start within 48 hours of symptom onset –Emergence of resistance  Supply will be severely limited so define priority –Cumulative number in priority groups 1-5: 33.9 million persons –Cumulative number in priority groups 1-10: million persons –Treatment versus prophylaxis (6-8 week course)

Healthcare System Emergency Preparedness  Severe pandemic = prolonged mass casualty event  Extreme stress on healthcare system –Will last for weeks to months –Up to 1/3 of workforce may be out: staff shortages –Shortages of ICU beds, ventilators, critical care needs –Shortages of drugs and other supplies –Mass fatality situation –Disruption of critical infrastructure & essential services

 Hospitals should work with other local hospitals, community organizations (e.g., social service groups), and the local health department to coordinate healthcare activities in the community.  HHS plan available at: From: HHS Pandemic Influenza Plan: Healthcare Planning Healthcare System Emergency Preparedness

Poll As we prepare for pandemic influenza, my jurisdiction has worked least with the following group: A. Hospitals B. Schools C. Businesses D. Law Enforcement

Healthcare System Emergency Preparedness  Implement new patient triage, evaluation, admission and clinical management procedures –Screen all referrals for admission: no direct admits –Limit or cancel elective admissions and surgeries –Early discharge of patients: role of home healthcare agencies –Standardized evaluation and management protocols  Use surgical ambulatory care centers for necessary surgeries  Coordinate with outpatient and home health organizations  Expand bed capacity  Have staffing plans to meet increased demand for services  Define critical staff for preventive interventions From: HHS Pandemic Influenza Plan: Healthcare Planning

Healthcare System Emergency Preparedness  Need a standardized, coordinated and equitable healthcare system response  Requires uniform understanding (and application) of definitions and “triggers” for: –Canceling elective admissions and surgery –Early discharge of patients –Application of “altered standards of care” in mass casualty event: Utilization/rationing of critical care resources –Antiviral drug and vaccine use –Implementation and utilization of community-based surge capacity/facilities

King County Healthcare System Pandemic Influenza Taskforce  Public Health sponsored half-day meeting in March 2005 with healthcare system stakeholders to discuss pandemic influenza  Broad participation from hospitals, outpatient care organizations, community clinics, specialty professional organizations, emergency managers  Discussed existing preparedness plans for pandemic influenza and identified healthcare system gaps

King County Healthcare System Pandemic Influenza Taskforce Recommendations  Standardized, cooperative, integrated healthcare system approach is essential  Need to identify healthcare system executives with whom public health leadership can consult rapidly to address priority emergency response issues of relevance to the healthcare system

 Need efficient, coordinated communication –Coordinate mass casualty response –Facilitate optimal resource management –Assess and monitor impact on healthcare facilities –Provide unified medical system interface with EOC/Incident management system –Communicate information related to clinical management, vaccine, antiviral drugs, community containment measures King County Healthcare System Pandemic Influenza Taskforce Recommendations

 Technical experts must plan for specific priority needs including critical care and clinical management  Need mass fatality management plans  Need to include participation by non-hospital (community-based) healthcare assets –Home healthcare organizations –Healthcare for the Homeless –Association of Occupational Health Practitioners –Jail Health –Representative from long term care facilities King County Healthcare System Pandemic Influenza Taskforce Recommendations

 Priority areas: –Critical care surge capacity –Community pandemic planning and surge capacity  Vulnerable populations –Regulatory, licensing, and legal issues –Financial impact and implications –EMS response –Mass fatality planning King County Healthcare System Pandemic Influenza Taskforce Recommendations

Poll A. True B. False My jurisdiction is better prepared for pandemic influenza than what is being portrayed in the media.

Gaps in Healthcare System Response to Emergencies  The healthcare system is fragmented.  Planning by individual facilities is necessary but not sufficient for robust community emergency response.  Community-wide healthcare emergency response structures and plans are not sufficiently comprehensive to respond to major disasters.

 There is no forum for public officials and healthcare leaders to discuss policy issues.  In an emergency, there is no operational mechanism in place to coordinate response activities across healthcare organizations.  The linkages between the overall healthcare system and the emergency incident command structure need to be strengthened.  Emergency preparedness planning has focused primarily on hospitals. Gaps in Healthcare System Response to Emergencies (cont.)

Healthcare System Emergency Preparedness Healthcare Coalition  Strengthen the healthcare system’s emergency preparedness and response to all hazards  Increase medical surge capacity  Improve coordination and communication during emergency response

 Expand the health system’s emergency response capacity through regional agreements and plans  Coordinate the emergency response of health care organizations through effective communications  Integrate the health system’s response into the larger emergency response  Advise public officials on health policy matters during emergencies Healthcare Coalition (cont.)

 Coordinated action is more effective than multiple individual organizational efforts.  Cooperative agreements and plans promote the most effective use of resources.  Leadership and operational management must come from within the healthcare community. Healthcare Coalition (cont.)

Healthcare Coalition: Assumptions  Elected officials and the Health Officer have emergency powers to preserve the public health.  The use of emergency health powers, if necessary, will be more effective with advance planning and in timely consultation with healthcare leaders.

 Public health’s primary role in this context is to support and facilitate the healthcare system’s emergency preparedness planning and response. Healthcare Coalition: Assumptions (cont.)

Healthcare Coalition  Coalition model consistent with the HHS Medical Surge Capacity and Capability Handbook –(  Consistent with the requirements of the National Incident Management System (NIMS)  Similar coalitions have been formed and effectively used in emergency situations in other communities, including Minnesota, Washington DC, and Northern Virginia

Healthcare Coalition (cont.)  Hospitals  Large medical groups  Safety net healthcare organizations  Professional associations  Home health and long term care providers  Key stakeholders, e.g., EMS, Puget Sound Blood Center, Red Cross

Emergency Mgmt Response - Maintenance of Critical Services  Maintain essential services in both the health and non-health sectors  Impact of widespread absenteeism on human infrastructure responsible for critical community services  Identify essential services that, if interrupted, would pose a serious threat to public safety or significantly interfere with the ongoing response to the pandemic  Develop contingency plans to provide back- up of such services and/or replacement personnel

Pandemic Influenza Communication  Good communication can guide the public, media, and health care providers in responding appropriately and complying with exposure-control measures.  Provide accurate, consistent, and comprehensive information.  Address rumors, inaccuracies, and misperceptions promptly.  Coordinate messages.  Guide community members on actions to protect themselves, family members, and colleagues.  Contradictions and confusion can undermine public trust and impede control measures.

Healthcare System Emergency Preparedness Routine Circumstances Public health Healthcare system Hospitals Outpatient facilities Clinics Community health centers

Public healthHealthcare systemEmergency response Healthcare System Emergency Preparedness Outbreaks & Public Health Emergencies: Paradigm Shift