1. Estimating the Potential Economic Impact of the Next Influenza Pandemic upon Belize Paul Edwards – MOH Belize Rony Maza – PAHO/WHO Belize San Jose, Costa Rica December 16, 2005

2. Age GroupPopulation 0-14 yrs 115,795 15-59 yrs 150,250 + 60 yrs 16,555 Belize’s Population, by Age Country Information

3. Country Information-Cont. Source: CSO mid-year estimates, Belize 2004. Total licensed non-ICU beds: 418 % licensed non-ICU beds staffed:100% Total staffed non-ICU beds: 418 Total licensed ICU beds: 12 % licensed ICU beds staffed:100% Total Staffed ICU beds: 12 Total number of ventilators: 4 % ventilators available:100% Total number of ventilators available: 4 Basic Hospital Resources

4. Results: Potential Impact on Belize of the Next Influenza Pandemic: 1960s/70s Scenario Population: Numbers and distribution by age and risk group Risk groups 0-14 yrs15-59 yrs60+ yrs Totals% total Non-high risk*108,385128,6149,933246,93287% High risk*7,41021,6366,62235,66813% Totals115,795150,25016,555282,600100% Note: High risk refers to pre-existing medical conditions (e.g., asthma, diabetes, heart and lung conditions) that increase risk of influenza-related adverse health outcome

5. Deaths: By age group Gross attack rateDistribution of deaths by risk group Age groups 15 %25%35% high risk % all deaths 0-14 yrsmost likely2340-14 yrs1%3% min12215-59 yrs54%62% max25425960+ yrs29%36% 15-59 yrsmost likely4778110Totals84%100% min71116 max88147206 60+ yrsmost likely274563 min264461 max345679 TOTALSmost likely76126177 min345779 max147245344 Results: Potential Impact on Belize of the Next Influenza Pandemic: 1960s/70s Scenario – Cont’d

6. Results: Potential Impact on Belize of the Next Influenza Pandemic: 1960s/70s scenario – Cont’d Hospitalizations: By age group Distribution of hospitalizations by risk group Gross attack rate Age groups15%25%35% % high risk % all hospital 0-14 yrsmost likely3254760-14 yrs2%8% Min162737 15-59 yrs 11%73% Max13622731860+ yrs12%19% 15-59 yrsmost likely278463648Totals25%100% Min5186120 Max303505707 60+ yrsmost likely72121169 Min5286121 Max91152213 TOTALmost likely382638893 Min119199278 Max5308841,238

7. Results: Potential Impact on Belize of the Next Influenza Pandemic: 1960s/70s Scenario – Cont’d Outpatients: By age group Gross attack rateDistribution of outpatients by risk group Age group15%25%35% high risk % all outpatient 0-14 yrsmost likely10,27317,12123,9700-14 yrs5%44% Min8,58214,30420,02515-59 yrs7%50% Max11,96319,93927,91560+ yrs2%6% 15- 59yrsmost likely11,59319,32227,050Totals14%100% Min8,32413,87319,422 max17,69529,49241,288 60+ yrsmost likely1,2852,1422,999 min1,2132,0212,830 max1,9953,3254,655 TOTALmost likely23,15138,58554,019 min18,11930,19842,277 max31,65352,75673,858

8. Total Estimates, per Health Outcome, from two Scenarios of Potential Impact of Next Influenza Pandemic in Belize: Most likely (min, max) Health Outcome Scenario 1960s/70s † Scenario tipo-1918 ‡ Gross attack rate 35%* Deaths 177 (79-344) 1,456 (657-2,820) Hospitalization 893 (278-1,238) 7,336 (7,280-10,181) Outpatient 54,019 (42,277-73,858) 49,565 (47,250-50,035) Ill without medical care 43,821 (23,470-56,276) 40,553 (38,659-40,938) Outpatient + ill without medical care 90,118 (85,909-90,973)

9. Demand for Hospital-based Resources: 1960/70s Scenario: 35% Attack Rate: 8 Weeks Duration Pandemic Influenza Impact / Weeks12345678910 Hospital AdmissionWeekly admissions61102152193 15210261 Peak admissions/day 30 Hospital Capacity # of influenza patients in hospital45751121421471299965 % of hospital capacity needed11% 18 % 27 % 34 % 35 % 31 % 24 % 16 % ICU Capacity # of influenza patients in ICU919303943413323 % of ICU capacity needed76% 162 % 248 % 328 % 355 % 345 % 274 % 189 % Ventilator Capacity # of influenza patients on ventilators510152021 1611 % usage of ventilator 114 % 243 % 372 % 492 % 532 % 518 % 412 % 284 % Deaths # of deaths from influenza 11182734 271811 # of influenza deaths in hospital 7121924 19127

10. Hospital Admissions by Week: 1960/70s Scenario: Hospital Admissions (most likely, min, max weekly admissions): 8 weeks duration

11. Pandemic Influenza Impact / Weeks12345678910 Hospital AdmissionWeekly admissions5018361,2531,587 1,253836501 Peak admissions/day 247 Hospital Capacity # of influenza patients in hospital3686149211,1671,2081,062814534 % of hospital capacity needed88%147%220%279%289%254%195%128% ICU Capacity # of influenza patients in ICU75159245323350341271187 % of ICU capacity needed627% 1329 % 2041 % 2696 % 2917 % 2838 % 2255 % 1557 % Ventilator Capacity # of influenza patients on ventilators388012216217517013593 % usage of ventilator940% 1993 % 3061 % 4043 % 4376 % 4257 % 3383 % 2336 % Deaths # of deaths from influenza 11182734 271811 # of influenza deaths in hospital 7121924 19127 Demand for Hospital-based Resources: 1918-type scenario: 35% attack rate: 8 weeks duration

12. Hospital admissions by week: 1918-type scenario: 35% attack rate (most likely, min, max weekly admissions): 8 wks duration

13. Workdays Lost due to an Influenza Pandemic: Two scenarios, 8 weeks duration, 35% attack rate † Workdays lost 1960s/70s scenario % all workdays full time* 1918-type scenario** % all workdays full time** Most Likely416,09912.3561,73416.6 Minimum382,73911.3516,69815.3 Maximum466,24913.8629,43618.6 * Percent of annual workdays, calculated as 132,821 fulltime equivalents employed of those aged 15-59 years age (88.4% of 150,250), multiplied by 250 workdays per year. † See Appendix III for details of methods and assumptions ** Estimated based on other studies which demonstrate a 30-40% increase for the 1918-type scenario as compared to the 1960/1970 scenario therefore an average of 35% was utilized

14. Economic Impact: Work-days Lost

15. Value of Lost Workdays Value of lost workdays Lost work days 1960s/70s scenario BZ$ 1918-type scenario BZ$ Most Likely 416,099days$25,964,577$35,052,179 Minimum 382,739$23,882,914$32,241,933 Maximum 466,249$29,093,938$39,276,816 GDP 2004 = $2,071,200,000 Workday lost equivalent to % GDP:1.251.69 Source: CSO: [GDP/(workforce X employment rate)]/250 work days/year= $62.4

16. Value of Direct Medical Care Direct Medical Costs BZ$ Health outcomes 1960s/ 70s scenario† 1918-type scenario Gross attack rate 35%* Gross attack rate 35% Deaths* $263,139.00$355,238 Hospitalized no ICU $827,220.00$1,116,747 Hospitalized ICU $23,865,141.00$32,217,940 Outpatients $34,417,666.00$46,463,849 Ill, no medical care $1,095,525.00$1,478,959 Totals$60,468,691.00$81,632,733 * Assumed 70% of deaths require medical care equivalent of 10 days ICU Source: # Cost per day** # of daysTotal Death177$212.387$263,138 Hospitalizat ion a.No ICU b.ICU 1016 779* 237* $212.38 5 10 $827,220 $23,865,140 Outpatient54,019$212.383$34,417,665 Ill no medical attention 43,821$212.380$1,095,525 TOTAL$60,468,691 * Total of 1016 (893 + (70% of 177) ** KHMH Budget $7M. Bed occupancy 78.5% of 115 beds (90.3). Therefore ($7M/90.3)/365=$212.38

17. MINISTRY OF HEALTH INFLUENZA PANDEMIC PREPAREDNESS PLAN NOVEMBER 2005 BELIZE 100 nm

18. Planning Process 1. National Committee established with technical sub-committees 2. 3 preparatory meetings organized 3. Meeting with stakeholders 4. Presentation to Cabinet and approval 5. Development of guidelines and SOPs

19. Background Information  Belize is free of both LPIA and HPIA  Surveillance in both poultry and wild birds

20. Factors Considered in Developing the Plan  Large population of migratory birds: 28% of bird species are migratory (from North and South America)  Significantly large poultry industry  3% of national population from Asian descent – who travel to and from affected areas  Importation of supplies/equipment from Asian countries  The longest distance migrant is the Arctic Terns. They migrate from the Arctic circle to Antarctica each year – an annual distance of approximately 25,000 miles.

21. Purpose and Objectives of the Plan Purpose: To protect the Belizean population from the predicted outbreak of the avian flu General Objective: To reduce the risk and the impact of the avian flu on the country Specific Objectives: Reduce opportunities for human infection Minimize the economic impact on the agricultural/poultry industry Strengthen early warning systems Control or delay spread at the source Reduce morbidity and mortality, and social disruption

22. PeriodsPhasesResponse Actions Pre-pandemicI.Virus confirmed in humans outside of Belize (bird to human transmission) II.Virus confirmed in humans in Belize (bird to human transmission) PandemicI.Human to Human transmission outside of Belize II.Human to human transmission in Belize Post PandemicI – The first wave of human to human transmission in Belize is controlled Response Periods and Phases

23. Budget Summary ComponentPrepandemicPandemicTotal IIII Planning & Coordination 13,0003,000--10,00026,000 Situation Monitoring & Assessment 22,5006,000 29,000 5,00062,500 Prevention & Control 143,50057,500120,000--321,000 Multisector Response 50040,000-----40,500 Communication34,00020,000 15,000--69,000 213,500 126,500164,000 15,000 340,000179,000519,000 66%34%

24. THANK YOU GRACIAS