1. Health System Response to Pandemic Influenza: A Clinician's Perspective Mary M. Klote, MD Walter Reed Army Medical Center

2. Disclosures Financial: None The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of the Army, Department of Defense, or US Government.

3. WHO 2005 Plan Revised from 1999 –Redefined the phases to more clearly aid in coordination of containment of the disease –Potentially allow for increased lead time for vaccine development WHO/CDS/CSR/GIP/2005.5

4. WHO Phases Interpandemic Period Phase 1 - Animal infection - low risk to humans Phase 2 - Animal infection - risk to humans -------------------------------------------------------- Pandemic Alert Period Phase 3 - Close contact human transmission Phase 4 - Increased transmission Phase 5 - Virus adapting and spreading -------------------------------------------------------- Pandemic Period Phase 6 - Generalized transmission

5. Phase Subcategories Planning and Coordination (PC) Situation Monitoring and Assessment (MA) Prevention and Containment (PreCon) Health System Response (HSR) WHO/CDS/CSR/GIP/2005.5

6. Phase 1 WHO Goal To promote contingency planning by health-care systems for response to an influenza pandemic. WHO/CDS/CSR/GIP/2005.5

7. Who to Vaccinate Tiered vaccine structure? –1 st responders Their families? –Healthcare workers –Other Hospital/clinic employees –City/County Service Workers Waste removal Electrical Water

8. Contingencies to Consider Delivery of Quality Immunizations: – Immunization techniques – Record keeping – Adverse event tracking – Legal Regulations MMWR Mar 2000 – Report of NVAC

9. Contingencies to Consider Delivery Teams: – Right combination of skills Administrative Technical – Right place – Right time – Right equipment

10. Contingencies to Consider Method of Delivery: –“Push Out” Send teams to communities –Security –Vaccine storage –“Pull In” Centralized locations –Security –Staffing –Transport of vaccinees

11. Contingencies to Consider Hospital Manning –Who will come to work? –How much of your staff works at another hospital part-time? –Will you allow anyone to go home? –Where will you house them? –How will you feed them?

12. Contingencies to Consider Surge capacity –How many patients can your hospital hold? –How many ventilators? Are you prepared for family members to “bag” patients? –How many in your morgue? –Scrubs? –Linen? –Cleaning supplies? –Regulated Medical Waste Bags? Sharps containers?

13. Contingencies to Consider Security –Access to Hospital Staff Patients Visitors –“Quarantine” Wards –Triage outside of hospital

14. Managing the Unexpected Adverse Events –Swine Flu experience –Myopericarditis with Smallpox Vaccine

15. Questions?

16. Phase 1 Objectives WHO To develop strategies and procedures to coordinate the rapid mobilization and deployment of global resources to foci of infection during a pandemic alert period (PC). Promote increased use of seasonal vaccine (PreCon) Resolve impediments to vaccine development, production and access (PreCon) National To develop effective mechanisms for mobilization and rapid deployment of resources to areas of need (PC). Share specimens for virus characterization and vaccine development (PreCon) Increase availability of vaccine (PreCon) Develop criteria for use of seasonal and pandemic vaccine (PreCon) Anticipate need for pandemic vaccine development (PreCon)

17. Phase 2 Objectives WHO To consider the development of a human vaccine against the new strain.(PreCon) National

18. Phase 3 Objectives WHO To enhance development or adjustment of diagnostic reagents and vaccines. (MA) To facilitate planning for pandemic vaccine development. (PreCon) National To increase readiness for possible pandemic vaccine development. (PreCon)

19. Phase 4 Overarching Goal Vaccine Development

20. Phase 4 Objectives WHO To enhance development or adjustment of diagnostic reagents and vaccines. (MA) To promote development and prepare for production of pandemic vaccine. (PreCon) To deploy pandemic vaccine to foci of disease, if appropriate and available. (PreCon) National To increase readiness for pandemic vaccine production and deployment (PreCon) To gain early experience in pandemic vaccine use under field conditions (if clinical trial lots are available) (PreCon)

21. Phase 5 Objectives WHONational To support preparations for large-scale pandemic vaccine production and licensing, and prepare for deployment as supplies become available. (PreCon) To gain early experience in pandemic vaccine use under field conditions (if clinical trial lots areavailable).(PreCon)

22. Phase 6 Objectives WHO To promote rational access to finite resources, including vaccines and other pharmaceutical supplies (when available) (PC) To promote maximum production and rational use of pharmaceuticals, e.g. vaccines and antivirals. (PreCon) National To ensure rational access to finite national resources, including pharmaceutical supplies and (when available) vaccine. (PC) To minimize morbidity and mortality through the rational use of available pharmaceuticals, e.g. vaccines and antivirals. (PreCon)