Challenges in Delivering Pandemic Vaccine from a City Health Department Perspective 43nd National Immunization Conference Fernando A. Guerra, M.D., M.P.H. Director of Health San Antonio Metropolitan Health District http://www.sanantonio.gov/health/

Objectives What can we expect in a Pandemic? Discuss the major challenges faced by a city health department 2

What does that mean for the 1 What does that mean for the 1.5 million people in my community, or other local health departments? 3

HISTORY is the best predictor of the FUTURE 1918 Spanish Flu 1957 Asian Flu 1968 Hong Kong Flu Present or Future??? 4

Historical Precedence 1917 - 1918 Pandemic San Antonio had the highest morbidity rate of any city in the country 98% of households had at least one person infected > 50 % of the population fell ill 5

Avian Flu (H5N1) Pandemic Influenza is NOT 6 To that end, it’s critical to remind you that while we are concerned about Avian Influenza and we are tracking its spread, Avian Influenza is NOT pandemic influenza. Pandemic Influenza 6

Currently there is no pandemic flu. Avian flu is caused by avian influenza viruses occurring naturally among birds Occasionally infect humans Occasionally, a highly pathogenic strain emerges, such as H5N1 Seasonal flu is a contagious respiratory illness caused by influenza viruses infecting humans Generally, most susceptible to severe illness and death are very young and very old. Pandemic flu is a global outbreak of a highly pathogenic strain Spreads easily from person to person Otherwise healthy young adults severely affected. Currently there is no pandemic flu. 7

WHO Criteria for Pandemic Influenza The emergence of a disease (or strain/subtype) new to a population The agent infects humans, causing serious illness The agent spreads easily and sustainably among humans This distinction is extremely important. H5N1, or avian flu, fits the first two criteria, not the third. All cases of human infection have been associated with close contact with infected birds. If I get it, I can’t pass it on to you. The presence of H5N1 is an important public health concern, but it is not going to affect the population the way a pandemic would. 8

Challenges for a City Health Department Minimize serious illness, hospitalizations, and mortality Implement control measures Developing and preserving critical infrastructure/workforce Variety of health department capacities Minimizing social disruption Latency in viral identification/vaccine development Surveillance 9

Surveillance Systems to Monitor and Detect Influenza Syndromic Surveillance Monitor School Absenteeism Over the counter drug sales Sentinel Clinics One of the key components of any plan is surveillance. SAMHD conducts a number of different surveillance systems to monitor and detect influenza activity in San Antonio/Bexar County. At present we obtain numbers of absentees from one school district. Kids are the first to get sick, and before they see their doctor they stay home from school. Kids are also infectious for longer and shed more virus. We are expanding this to include school districts throughout the city. HEB drugstores reports sales weekly of over the counter drugs. This is another clue to illness in the community before people are sick enough to see their doctor or go to hospital. Flu is currently not a reportable disease required by state law. Instead, we have 13 clinics throughout the city which report flu like illness. We obtain a sample from the patient which is then sent to the state labs for testing. 10

Surveillance Systems Flu-like illness reports from Texas Med Clinics Redbat ER Syndromic Surveillance Texas Med Clinics and soon, University Health Services, provide us data weekly on the number of patients presenting with flu-like illness. In each hospital ER there’s a system in place where the symptoms are entered into a program which is then submitted to our Epidemiology division on a daily basis. Taken together, these systems allow us to detect flu-like illness throughout the community before it becomes a large scale epidemic. 11

Challenges for a City Health Department (cont’d.) Identifying and responding to the needs of vulnerable populations Comorbidities Disabled Intellectually compromised Elderly and dependent Maintaining an adequate Stockpile Supplies Vaccine/ Anti-virals Shelf Life Storage Maintaining adequate funding and resources Prioritizing and Rationing??? Establishing MOUs with municipalities and school districts Oath of Office Selecting POD/Vaccine Facilities Other models, i.e. drive-thru/mobile sites 12

Challenges for a City Health Department (cont’d.) 2-wave “Epi Curve” Maintaining a supply of well-trained staff and volunteers to deliver and administer vaccine Public Health vs. Hospital Credentialing Multi-agency coordination and collaboration (ICS) Engaging the public General information; Informed consent; user-friendly documents Discrepancy of Categorization of Pandemic Influenza phases, i.e. WHO vs. U.S. Federal agencies 14

Federal Government Response Stages Pandemic Phases WHO Phases Federal Government Response Stages INTER-PANDEMIC PERIOD 1 Low risk of human cases New domestic animal outbreak in at-risk country 2 Higher risk of human cases   PANDEMIC ALERT PERIOD 3 Human infection with a new subtype, but no human-to human spread Suspected human outbreak overseas 4 Evidence of increase of human-to-human spread (small clusters) Confirmed human outbreak 5 Evidence of increased human- to-human spread (large clusters) PANDEMIC PERIOD 6 Efficient and sustained transmission in human population Widespread human outbreaks in multiple locations overseas First human case in North America Spread throughout United States Recovery and preparation for subsequent waves

“The greatest challenge for us is the unknown……” F.A. Guerra, M.D., M.P.H. 16