Chance Favors the Prepared Community:

Preparing for a Flu Pandemic

February 14, 2007Mark J. Levine, MD MPH

BIRD FLU PANDEMIC?

Influenza Virus

Single-stranded RNA virus

Surface membrane spiked with 2 types of protein– Hemagglutinin

(H)– Neuraminidase

(N)

Influenza Virus Composition

Type of nuclear material

Virus type

Geographic origin

Strain number

Year of Isolation

Virus subtype

A/Beijing/32/92 (H3N2)

Hemagglutinin

Neuraminidase

“The pandemic clock is ticking, we just don’t know what

time it is”

E. Marcuse

Pandemic influenza: definition

Pandemic influenza, or flu, is a global outbreak of disease that occurs when a new influenza A virus appears in humans, causes serious illness and then spreads easily from person to person.

“A pandemic is the viral equivalent of a perfect storm. There are three essential conditions, which rarely converge, and

they are impossible to predict.”

Michael Specter, The New Yorker

The three conditions…

1. A new subtype that has not infected people in the past

2. Causes severe illness in people

3. Sustained transmission from person to person

Emergence of pandemic strain = most significant public health emergency caused by a naturally occurring pathogen

Timeline of Emergence of Timeline of Emergence of Influenza A Viruses in HumansInfluenza A Viruses in Humans

1918 1957 1968 1977 19971998/9

2003

H1

H1

H3H2

H7H5H5

H9

SpanishInfluenza

AsianInfluenza

RussianInfluenza

AvianInfluenza

Hong KongInfluenza

Effects of Typical Flu Season (U.S.)

5-20% ill

200,000 hospitalizations

36,000 deaths

Impact of Past Influenza Pandemics/Antigenic Shifts

Pandemic, or Antigenic

Shift

Excess Mortality

Populations Affected

1918-19(A/H1N1)

500,000 Persons <65 years

1957-58(A/H2N2)

70,000 Infants, elderly

1968-69(A/H3N2)

36,000 Infants, elderly

Moderate (1957-like)

Severe (1918-like)

Illness 90 million (30%) 90 million (30%)

Outpatient medical care

45 million (50%) 45 million (50%)

Hospitalization 865,000 9,900,000

ICU care 128,750 1,485,000

Mechanical ventilation

64,875 745,500

Deaths 209,000 1,903,000

Planning Assumptions:• 30% attack rate• 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

Pandemic Prediction: U.S.A.

Moderate (1957-like)

Severe (1918-like)

Illness 360,000 (30%) 360,000 (30%)

Outpatient medical care

180,000 (50%) 180,000 (50%)

Hospitalization 3,460 39,600

ICU care 519 5,940

Mechanical ventilation

260 2,970

Deaths 836 7,612

Planning Assumptions:• 30% attack rate• 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

Pandemic Prediction: Central Region

Standard operations

Expanded capacity-

Out of hospital

3200 3900

????

0 days 10 days

Sudden surge from a immediate event

Standard operations

Expanded capacity-

Out of hospital

3200 3900

????

0 days 10 days- 3 months

Biological attack or Pandemic ?

Care in the community

Slowly growing surge from a rolling event:

The Influenza Pandemic of 1918-191925-30 percent of the world’s population fell ill

500,000 deaths in the US

25-30 percent of the world’s population fell ill

500,000 deaths in the US

25-30 percent of the world’s population fell ill

500,000 deaths in the US

1918 Pandemic

Avian Influenza H5N1as of February 7, 2007

55 countries with documented H5N1 avian influenza in bird populations

11 countries with documented human cases of H5N1

Nations With Confirmed Cases

H5N1 Avian Influenza (Feb ‘07)

Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO as of

02/06/07

Country 2003 2004 2005 2006 2007Tota

l

cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths

Azerbaijan 0 0 0 0 0 0 8 5 0 0 8 5

Cambodia 0 0 0 0 4 4 2 2 0 0 6 6

China 1 1 0 0 8 5 13 8 0 0 22 14

Djibouti 0 0 0 0 0 0 1 0 0 0 1 0

Egypt 0 0 0 0 0 0 18 10 2 2 20 12

Indonesia 0 0 0 0 19 12 56 46 6 5 81 63

Iraq 0 0 0 0 0 0 3 2 0 0 3 2

Nigeria 0 0 0 0 0 0 0 0 1 1 1 1

Thailand 0 0 17 12 5 2 3 3 0 0 25 17

Turkey 0 0 0 0 0 0 12 4 0 0 12 4

Viet Nam 3 3 29 20 61 19 0 0 0 0 93 42

Total 4 4 46 32 97 42 116 80 9 8 272 166

Integrated Planning for a

Large Scale Health Emergency

The Public Health SystemThe Public Health System

MCOs

Home Health

Parks

Economic Development

Mass Transit

Employers

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory Facilities

Hospitals

EMS Community Centers

Doctors

Health Department

Churches

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

Accountants!

National Preparedness

CommunityPreparedness

Business and Organizational Preparedness

Individual and Family Preparedness

Pandemic Flu Preparedness for Individuals and

Families

http://www.pandemicflu.gov

Pandemic Flu Preparedness for

Businesses

http://www.pandemicflu.gov

In a Pandemic…

Despite all preparedness efforts, Virginia will not be spared from a flu pandemic.

AllAll businesses, hospitals and government agencies will feel the effects of a pandemic.

Ten to 25 percent of the workforce may be ill at any one time.

Unlike other disasters, a flu pandemic will touch every population in every part of the country. Moving operations to another location may not be a viable option.

A flu pandemic could cost the U. S. economy billions of dollars in lost productivity and medical expenses. During a pandemic, it will not be business as usual.

The number one thing you can do to

prepare for a pandemic is to learn as much as you can and personally plan

ahead of time

Local Emergency Planning and

Response Framework

Health Districts in Virginia

Preparing for Emergencies in the

Face of Uncertainty

Hope?

Hope is not a strategy…

Julie Gerberding, Director, Centers for Disease Control and Prevention

Chance Favors the Prepared Mind

Louis Pasteur

Chance Favors the Prepared

CommunityMark Levine

What is a

“Prepared Community?”

Incident Command Structure

Incident Commander

Planning Operations Logistics Finance/Admin

Safety Officer Public Information Officer

Liaison Officer

Division

Group

Unit

Supply Unit

Resource Unit

Food Unit

Unified Command(Representatives From Local

Jurisdictions)

Finance/ Administratio

n

LogisticsPlanningOperations

Unified Command

Components of Local Response

Communication/AwarenessSurveillance/InvestigationContainment/Control

– Distribution of antivirals/vaccineHealthcare Surge

Components of Local Response

Communication/AwarenessCommunication/AwarenessSurveillance/InvestigationContainment/Control

– Distribution of antivirals/vaccineHealthcare Surge

Communication/Awareness

Virginia Department of Health– http://www.vdh.virginia.gov/pande

micflu/

Henrico County Health

Department– http://www.co.henrico.va.us/health

/

CDC– Travel: http://www.cdc.gov/travel/– Avian flu: http://www.cdc.gov

/flu/avian/

Continued…

Education/Information Exchange– Public Health: Epi-X, CDC– Medical community: Public

Health Bytes•www.publichealthbytes.org

– General community: Promote individual/family preparedness•www.pandemicflu.gov•Media spots•Health Department Web site info

Components of Local Response

Communication/AwarenessSurveillance/InvestigationSurveillance/InvestigationContainment/Control

– Distribution of antivirals/vaccineHealthcare Surge

Surveillance and Detection

-current status-Surveillance is a routine

function of the Health Department and is always ongoing

Influenza surveillance is not something new and is already very extensive

Enhanced surveillance experience/process already in place

Additional Surveillance Efforts

Syndromic Surveillance– Surveillance for symptoms of

disease rather than actual cases– May detect a disease outbreak

sooner

Ongoing issues

Communication/AwarenessSurveillance/InvestigationContainment/ControlContainment/Control

– Infection Control measuresInfection Control measures– Distribution of antivirals/vaccineDistribution of antivirals/vaccine

Healthcare Surge

NPI

Summary of NPI

Isolation and treatment of people infected with pandemic flu strain

Voluntary home quarantine of members of households with pandemic flu strain

Social distancing – Children: school closure and out of

school social activity suspension– Adults: Cancellation of public

gatherings; alteration of workplace environments

CDC PandemicSeverity

Index

Meteorology Meteorology Geology

Saffir-Simpson

Hurricane Scale

FujitaTornado

Scale

RichterEarthquake

Scale

0 - 73 MPH 0 - 39 MPH 0  

Category 1 >74 MPH F0 40 - 72 MPH 1 No damage

Category 2 >96 MPH F1 73 - 112 MPH 2 No damage

Category 3 >111 MPH F2 113 - 157 MPH 3 Little damage

Category 4 >131 MPH F3 158 - 206 MPH 4 Light damage

Category 5 >155 MPH F4 207 - 260 MPH 5 Moderate damage

F5 261 - 318 MPH 6

Mod.-Heavy damage

F6 319 - 379 MPH 7 Heavy Damage

8 Very Heavy Damage

9 Total destruction

10 Unheard - never seen

  Pandemic Severity Index

Interventions by Setting 1 2 and 3 4 and 5

     

Home      

Voluntary isolation Recommend Recommend Recommend

Voluntary quarantine Generally not recommended

Consider Recommend

School      

Child Social Distancing      

School closure Generally not recommended

Consider: <= 4 weeks

Recommend: <= 12 weeks

Out of school activity restrictions Generally not recommended

Consider: <= 4 weeks

Recommend: <= 12 weeks

Workplace/Community      

Adult Social Distancing      

Decrease number of social contacts Generally not recommended

Consider Recommend

Increase distance between people Generally not recommended

Consider Recommend

Modify/Postpone public gatherings Generally not recommended

Consider Recommend

Modify workplace schedules Generally not recommended

Consider Recommend

Ongoing issues

Communication/AwarenessSurveillance/InvestigationContainment/Control

– Distribution of antivirals/vaccineHealthcare SurgeHealthcare Surge

HENRICO MEDICAL RESERVE CORPS

http://www.vdh.virginia.gov/LHD/henrico/myweb/mrc.asp

Goal of Planning for Large Scale

Health Emergencies

Enhance our capacity and ability to better perform our day to day tasks and build

capacity to ramp up for large scale health issues

Questions to AskHow will you maintain your business

operations when 10 to 25 percent of the workforce falls ill at one time?

How can you adapt your existing continuity of operations plans to reflect this kind of human resources impact?

How will you cope when the other businesses and suppliers you rely on experience the same absentee rates?

Continued…How will you adapt to disruptions in the

supply chain for the raw materials you need and how will you get your product to the consumer if your distribution network is hit with high absentee rates?

How can existing return-to-work and travel policies be adapted to control the spread of this virus among employees?

How will you limit the economic impact of a flu pandemic on your business?

Chance Favors the Prepared Mind

Louis Pasteur

Chance Favors the Prepared

CommunityMark Levine