An Overview of Pandemic Influenza Planning in the United States

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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

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New Viruses Emerge, and Pandemics Happen
H9
1998
1999
H5
2003
1997
2003-2006
H7
1980
1996
2002
2003 2004
H1
H3
H2
H1
1977
1915
1925
1935
1945
1955
1965
1975
1985
1995
2005
1918 Spanish Influenza H1N1
1957 Asian Influenza H2N2
1968 Hong Kong Influenza H3N2
Avian Flu
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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

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Pandemic Planning Must Occur in Many Sectors

• Federal government
• State and local governments
• Healthcare Systems
• Businesses and private sector
• Individuals and families

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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

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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

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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

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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

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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)

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Burden of Pandemic Influenza

• 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

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Pandemic Influenza DoctrineSaving Lives

• A threat anywhere is a threateverywhere
• Quench first outbreaks detect andcontain where
  it emerges, if feasible
• International collaborations
• Frontline detection and response rapid
  laboratory diagnosis
• Isolation / quarantine / antiviral prophylaxis /
  social distancing / animal culling

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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

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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

Unprepared
Impact
Prepared
Weeks
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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

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A Network of Shared Responsibility

• Local - state - federal
• Domestic international
• Public private
• Multi-sector
• Animal human
• Health protection homeland security economic
  protection

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• 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

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Countermeasures Vaccines, Antivirals,
andMedical Supplies
Strategic National Stockpile
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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

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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

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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

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

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• 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

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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

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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

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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

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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

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Infectious Disease Mortality, United States--20th
Century
Armstrong, et al. JAMA 199928161-66.
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Questions?