Epidemiology and Surveillance: Lessons from Past Pandemics Arnold S. Monto, MD Professor of Epidemiology University of Michigan School of Public Health.

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Presentation transcript:

Epidemiology and Surveillance: Lessons from Past Pandemics Arnold S. Monto, MD Professor of Epidemiology University of Michigan School of Public Health Founding Director University of Michigan Bioterrorism Preparedness Initiative Ann Arbor, MI

Basic Questions When will the virus arrive and spread? How long from the source? What will the principal age and other risk groups be? How many will be affected? –Morbidity? –Mortality?

Source of Pandemic Viruses Pandemic Years Influenza A Subtype Viral Change H1N1Mutation from Avian Virus 2 kinds identified H2N2Reassortment 3 segments from Avian Virus H3N2Reassortment 2 segments from Avian Virus

Effects of Past Pandemics on the US Source: NVPO. Pandemic Years Estimated US Deaths Influenza A Subtype Populations at Greatest Risk ,000H1N1Young; healthy adults ,000H2N2Infants; elderly ,000H3N2Infants; elderly

The 1918 Pandemic in Asia and Africa: Influenza-Associated Deaths Asia –India: 12.5 million deaths (higher than bubonic plague) –Japan: 257,000 deaths –Rest of Asia: 3,000,000 deaths Africa –Union of South Africa: 139,471 deaths out of 6,100,000 population –Madagascar: 114,000 deaths out of 3,250,000 population Jordan, ED. Epidemic Influenza, AMA. Chicago, 1927.

Review of Past Pandemics Age Specificity:Age Specificity: Traditional view:Traditional view: “U” or “J” shaped curves in most pandemics; “W” shaped curve in Variations:Variations: —Reports from UK of high mortality in young adults – Sparing of elderly in 1918 – Relatively higher death rates in young adults in more recent pandemics Will past history predict the future?Will past history predict the future?

Pneumonia and Influenza Mortality in Influenza Pandemics *Modified from Dauer & Serfling. Am Rev Resp Dis. 1961; 83:15-28.

Age-Specific Influenza Death Rates Among Females in England and Wales, 1918 Nguyen-Van-Tam, JS, et al. Vaccine. 2003;21: 

1957

Influenza Attack Rates by Age in Tangipahoa Parish, Louisiana: August, 1957 Langmuir AD. Am Rev Resp Dis. 1961;83:5.

1968

Weekly Incidence of Influenza-like Diseases in Hong Kong: June to September 1968 JuneJuly Aug.Sept. *Cockburn et al. Origin and progress of the Hong Kong Influenza epidemic. Bull. Wld Hlth Org. 1969;41: Week Ending

Peak Influenza Activity in the US by State and Week: Oct.Nov.Dec.Jan.Feb. *Sharrar RG. National Influenza Experience in the USA, Bull. Wld Hlth Org. 1969;41: Week Beginning

Number of Episodes of Illness, Healthcare, Utilization, and Death Associated with Moderate and Severe Pandemic Influenza Scenarios* Characteristic Moderate (1958/68-Like) Severe (1918-Like) Illness90 million (30%) Outpatient Medical Care45 million (50%) Hospitalization865,0009,900,000 ICU Care128,7501,485,000 Mechanical Ventilation64,875742,500 Deaths209,0001,903,000 *Estimates based on extrapolation from past pandemics in the United States. Note that these estimates do not include the potential impact of interventions not available during the 20 th century pandemics. Source: NVPO.

Conclusions The 1918 outbreak was unique in terms of numbers of persons involved and age groups affected. There is a question as to whether affected young adults disproportionately. It is difficult from historic records to document the presence or effect of the 1918 virus before the second wave. Once that wave began, it spread quickly. The 1957 virus probably spread for at least 6 weeks in China, starting in February, before emerging. It affected South America before spreading to North America in the early autumn. The spread of the 1968 virus was well documented from Hong Kong in July. The peak in the US was December-January. Numbers affected in the future will be based on multiple factors currently unknown, and any estimates must be viewed as provisional.