An Overview of Pandemic Influenza Planning in the United States NAPHSIS Annual Meeting June 7, 2006 David K. Shay Influenza Division Centers for Disease Control and Prevention

New Viruses Emerge, and Pandemics Happen H1 H3 H2 H7 * H5 * H9 * 1918 Spanish Influenza H1N Asian Influenza H2N Hong Kong Influenza H3N * Avian Flu

Avian Influenza A(H5N1) Why is Concern High? Impact on animals and economy –Lethal to poultry, and mammals infected –Present in waterfowl; shed in feces –Already has had a major economic impact impact on humans Causes severe human disease –Might evolve to become easily transmissible –No H5N1 vaccine commercially available –Limited supplies of expensive antivirals

Pandemic Planning Must Occur in Many Sectors Federal government State and local governments Healthcare Systems Businesses and private sector Individuals and families

National Strategy for Pandemic Influenza Issued by President Bush in November 2005 Guides U.S. preparedness and response by outlining responsibilities –Individuals –Industry –State/local governments –Federal government March 2006: Homeland Security Council Implementation Plan

Goals of the National Strategy Stop, slow, or otherwise limit the spread of a pandemic to the United States Limit the domestic spread, and mitigate disease, suffering, and death Sustain infrastructure and mitigate impact to the economy and functioning of society

Pillars of the National Strategy Pillar 1: Preparedness and Communication –Ensure preparedness –Communicate roles and responsibilities Pillar 2: Surveillance and Detection –Systems that provide continuous situational awareness –Ensure earliest warning possible Pillar 3: Response and Containment –Limit the spread of the outbreak –Mitigate the health, social and economic impact

Department of Health and Human Services (HHS) Pandemic Influenza Plan Released November 2005 Supports the National Strategy Outlines key roles of HHS and its agencies Doctrine for health sector preparedness and response Public health guidance for state and local partners HHS Operational Plan will be released soon

Planning Assumptions All will be susceptible to infection with the pandemic virus due to lack of existing immunity The clinical attack rate might approach 30%, and 50% of persons who become ill will seek healthcare Each wave of infections in a community will last for approximately 6-8 weeks; 2 or 3 waves possible Groups at higher risk for severe disease/death cannot be predicted in advance, and may not correspond to those for seasonal influenza (eg, elderly and those with comorbid conditions)

Moderate (1957-like)Severe (1918-like) Illness90 million (30%) Outpatient medical care 45 million (50%) Hospitalization865,0009,900,000 ICU care128,7501,485,000 Mechanical ventilation64,875745,500 Deaths209,0001,903,000 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 Burden of Pandemic Influenza

Pandemic Influenza Doctrine: Saving Lives A threat anywhere is a threat everywhere 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-term quarantine of arriving passengers

HHS Pandemic Influenza Doctrine: Saving Lives Slow spread, decrease illness and death, buy time Antiviral treatment and isolation Quarantine for those exposed Social distancing Vaccination Weeks Impact Prepared Unprepared

HHS 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

A Network of Shared Responsibility Local - state - federal Domestic – international Public – private Multi-sector Animal – human Health protection – homeland security – economic protection Healthcare Delivery System Federal Partners Education System Business & Workers Local /State / Federal Public Health System

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 Individuals

Countermeasures: Vaccines, Antivirals, and Medical Supplies Strategic National Stockpile

H5N1 Vaccine Prototype vaccine developed by the National Institutes of Health Based on a H5 strain isolated in Viet Nam last year Elicits an antibody response but requires large dose 40 million doses (to protect 20 million people) being stockpiled

Challenges for Pandemic Vaccination Expand production of current (egg-based) vaccine Evaluate dose-sparing technology (adjuvants, intramuscular vs. intradermal route) Accelerate development of modern (non- egg) vaccines Target new antigens

Influenza Antivirals Goal: treatment courses in the Strategic National Stockpile (SNS) for 25% Current status of SNS –5.1 million Tamiflu (oseltamivir) treatment courses –84,000 Relenza (zanamivir) treatment courses Additional orders have been placed Accelerate development of promising new antiviral candidates

Health Protection at the Frontline: Local, County, and State Public Health Departments

Seasonal Influenza Preparedness Pandemic Influenza Preparedness Preparing for a pandemic now means: Putting into place methods to follow influenza, ie, public health surveillance Improving measures to control influenza Modern seasonal influenza vaccine for all who need it New antiviral drugs for prevention and treatment

Critical Role of Surveillance Data Response will require easily interpretable, up-to- date information CDC anticipates that at a minimum, the Federal, State, and local responses will require –Mortality rates (overall and pneumonia/influenza) by state –Hospitalization rates, for some states or large communities Data sufficient to conduct assessments of ‘countermeasures’ in several sites

Hospitalizations Current systems –Emerging Infections Program & New Vaccine Surveillance Network Children-only systems at present Sites in 11 states Additional data sources –Expanded EIP: Inclusion of adults, special studies –Vaccine Safety Datalink –BioSense real-time hospitalization data –Hospital capacity Exploring use of a HAvBED-like system that accepts bed census data from existing systems

Mortality Current –122 Cities Mortality Reporting System –Pediatric mortality reporting is a nationally notifiable condition –NCHS mortality files Additional –Exploring timely reporting of all deaths

Enhancement of Public Health Surveillance Systems Highest priority systems –Electronic laboratory data exchange Rapid 2-way exchange of patient-level data –Electronic death reporting Early use of mortality data submitted by funeral directors Benefits –Build public health reporting systems that would have multiple uses –Use existing electronic data –Allow sub-state level analysis

Infectious Disease Mortality, United States--20 th Century Armstrong, et al. JAMA 1999;281:61-66.

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