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Influenza Pandemic Training


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Title: Influenza Pandemic Training

Influenza Pandemic Training
  • Preparing for the Worse

By Magdy Akladios, PhD, PE, CSP, CPE, CSHM
What is a Pandemic?
  • The word "pandemic" is used to describe a disease
    that affects people on a worldwide scale.
  • Flu pandemics have occurred roughly every 20 to
    30 years throughout history, the most serious
    being the misnamed
  • "Spanish flu" of 1918
  • "Asian flu" of 1957
  • "Hong Kong flu" of 1968

What is an Epidemic?
  • Epidemic a disease attacking or affecting many
    individuals in a community or a population

Conditions Resulting in a Pandemic
  1. The emergence of a new flu strain
  2. The ability of that strain to infect humans and
    cause serious illness
  3. The ability to spread easily among humans

Seasonal Fluvs.Pandemic Flu
Seasonal Flu
  • Outbreaks follow predictable seasonal patterns
  • Usually some immunity built up from previous
  • Healthy adults usually not at risk for serious
  • Vaccine developed based on known flu strains
  • Adequate supplies of anti-virals are usually
    available and can usually meet public and patient
  • Average US deaths approximately 36,000/yr
  • Symptoms include
  • Fever, cough, runny nose, muscle pain.
  • Deaths often caused by complications, such as

Impact of Seasonal Flu
  • Generally causes modest impact on society (e.g.,
    some school closing, encouraging people who are
    sick to stay home)
  • Manageable impact on domestic and world economy

Pandemic Flu
  • Occurs rarely (only 3 times in 20th century -
    last in 1968)
  • No previous exposure (little or no preexisting
  • Healthy people may be at increased risk for
    serious complications
  • Health systems may be overwhelmed
  • Vaccine probably would not be available in the
    early stages of a pandemic (effective antivirals
    may be in limited supply)
  • Number of deaths could be high
  • Symptoms may be more severe and complications
    more frequent

Impact of a Pandemic
  • May cause major impact on society
  • Widespread restrictions on travel
  • Closings of schools and businesses
  • Cancellation of large public gatherings
  • Potential for severe impact on domestic and world

The State of Your Health Texas
Adult Health Indicators
  • Percentage of Adults with Asthma (2004)
  • TX 12.8 US 13.2
  • Percentage of Adults with Diabetes (2004)
  • TX 7.6 US 7.0
  • Percentage of Adults with Obesity (2004)
  • TX 25.8 US 23.2
  • Percentage of Adults with Hypertension (2003)
  • TX 24.6 US 24.8
  • Estimated New Cancer Cases (2005)
  • TX 86,880 US 1,372,910
  • Estimated Persons Living With AIDS (2004 Yr End)
  • TX 29,891 US 415,193
  • Cumulative Number AIDS Cases (2004 Yr End)
  • TX 64,479 US 918,286
  • Human West Nile Cases (2005 Cases as of 5/06)
  • TX 195 US 2,983

Child Health Indicators
  • of Children Estimated Lifetime Prevalence of
    Childhood Asthma (2003)
  • TX 13.1 US 12.4
  • of Children Overweight High School Students
  • TX 13.9 US 11.1
  • of Fully Immunized Children Aged 19-35 Months
  • TX 72.5 US 80.9
  • Infant Mortality Per 1,000 Live Births (2004)
  • TX 6.1 US 6.6
  • of Low Birth-weight Babies (2003)
  • TX 7.9 US 7.9

Other Public Health Indicators
  • Number of Primary Care Health Professions
    Shortage Areas (As of 9/30/05)
  • TX 346 US 4,577
  • Receipt of CDC Environmental Public Health
    Tracking Grant
  • TX None US 21

Who is most at Risk for Pandemic Flu?
Pandemic Flu
  • A flu pandemic occurs when a new flu virus
    against which the human population has no
    immunity appears.
  • This results in several, simultaneous epidemics
    worldwide with enormous numbers of infections and

What Helps Spread a Pandemic?
  • With the increase in global transport and
    communications, as well as urbanization and
    overcrowded conditions, epidemics due to the new
    flu virus are likely to quickly take hold around
    the world.

Pandemic Dark History
A Lesson from the Past
  • Pandemics are a reality. Health records show at
    least 10 influenza pandemics over the past 300
  • 1732-1733
  • 1781-1782
  • 1800-1802
  • 1830-1833
  • 1847-1848
  • 1857-1858
  • 1889-1900
  • 1918-1919
  • 1957-1958
  • 1968-1969  

  • US Deaths
  • 1918/19 500,000
  • 1957/58 70,000
  • 1968/69 34,000
  • Worldwide Deaths
  • 1918/19 40,000,000
  • 1957/58 1,000,000-2,000,000
  • 1968/69 700,000

"Spanish flu" Pandemic of 1918
  • Over 40 million people perished worldwide
  • Age range of fatalities 15 to 35 years, mostly
  • 99 of deaths occurred in people younger than 65

The Effects of the 1918 Pandemic on Texas
  • Reports of pandemic fears preceded the disease
    into Texas by about two weeks.
  • But by September 23, there were definite accounts
    of it near Austin and Dallas.
  • On October 4th, 35 counties were reporting the
    presence of influenza, with anywhere from one to
    2,000 cases per county.
  • El Paso imposed a quarantine.
  • The Dallas Morning News declared that surviving
    the pandemic required "medical attention, good
    nursing, fresh air, nutritious food, plenty of
    water, and cheerful surroundings."
  • The Texas State Board of Health offered schools
    several suggestions on ways to prevent flu
  • By the end of October, over 106,000 Texans in the
    state's urban centers had been afflicted.
  • Over 2,100 had died.

The Bad News
  • If a pandemic strikes, it will come to Texas.

"Hong Kong flu Pandemic of 1968
  • This was a much "milder" flu pandemic
  • It killed 1 million people across the globe

Pandemic Impact on the US
Economic Impact
  • flu pandemic may strike in waves, each of which
    could last up to 6 8 weeks
  • An especially severe pandemic could lead to
    widespread illness, a large number of deaths, and
    significant economic loss
  • Everyday life would be disrupted because so many
    people in so many places would become seriously
    ill at the same time.
  • Impact could range from school and business
    closings to the interruption of basic services as
    public transportation and food delivery.

How would a Pandemic Impact the US Economy?
  • A pandemic could deliver a "shock" to the
    economy, with immediate demand- and supply-side
    effects, as well as longer-term supply-side
  • The general slowdown in economic activity would
    reduce gross domestic product (GDP).
  • Business confidence would be dented
  • The supply of labor would be restricted

More Impact on US Economy
  • Supply chains would be strained as transportation
    systems were disrupted
  • Default rates on consumer and business debt would
  • The stock market would initially fall and rebound
  • A serious recession in the US economy with
    immediate costs ranging from 500 billion 675

Predictions from Financial Leaders
  • WBB Securities LLC predictions
  • A one-year economic loss of 488 billion
  • A permanent economic loss of 1.4 trillion
  • Congressional Budget Office predictions
  • A 675 billion hit to the US economy
  • World Bank predictions
  • Cost on global economy 800 billion a year

Impact on Health Services
  • A substantial portion of the world's population
    would require medical care
  • Healthcare facilities would be overwhelmed,
    creating a strain on hospital staff, and a
    shortage of beds, ventilators, and other
  • To cope with the demand, "surge capacity" at
    nontraditional sites, such as schools, may need
    to be created.
  • The need for vaccine is likely to outstrip supply
    and the supply of antiviral drugs is also likely
    to be inadequate early in a pandemic.
  • Difficult decisions would need to be made
    regarding who gets these vaccines and antivirals.

How Real is this Threat?
What is the Likelihood of a 2007 Pandemic?
  • The evolution of flu viruses cannot be predicted.
  • This makes it difficult to know if or when a
    virus might mutate to become easily transmittable
    among humans.
  • Therefore, it is impossible to say when another
    pandemic will arise, or whether it will be mild
    or severe.
  • However, the World Health Organization (WHO)
    asserts that once a virus allows for efficient
    human-to-human transmission, a pandemic can

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A Wide Range of Estimates
  • Experts' range 2 million to gt 50 million
  • All of these predictions are scientifically
  • Some estimates are based on extrapolations from
    past pandemics
  • The most precise predictions are based on the
    1968 pandemic, but even in this case estimates
    are 1 million 4 million deaths
  • Similarly, based on the number of deaths from the
    1918 Spanish flu pandemic, estimates are 20
    million gt50 million
  • The specific characteristics of a future pandemic
    virus cannot be predicted. It may affect 20 --
    50 of the total population

Best case scenarios of the next pandemic2 to 7
million people could die, and tens of millions
would require medical attention worldwide
High Mortality Rates
  1. Number of people who become infected
  2. Virulence of the virus
  3. Underlying characteristics and vulnerability of
    affected populations
  4. Availability and effectiveness of preventive

2 Scenarios for the Potential Impactof a Flu
Pandemic on the US
Moderate (1958/68-like)
  • Illness 90 million (30)
  • Outpatient medical care 45 million (50)
  • Hospitalization 865,000
  • ICU care 128,750
  • Mechanical ventilation 64,975
  • Deaths 209,000

Severe (1918-like)
  • Illness 90 million (30)
  • Outpatient medical care 45 million (50)
  • Hospitalization 9,900,000
  • ICU care 1,465,000
  • Mechanical ventilation 742,500
  • Deaths 1,903,000

A Pandemic is due soonThe question is not if,
but when
What Interventions Might Reduce the Impact of a
  • Depending on the contagiousness of the virus, a
    variety of approaches could reduce the number of
    flu cases to fewer than that of an annual flu

  • The scientists simulated a virtual outbreak on
    computers at the Los Alamos National Laboratory

1st, With No Interventions
  • The results showed that, with NO intervention, a
    pandemic flu with low contagiousness could peak
    after 117 days and infect about 33 of the US
  • A highly contagious virus could peak after 64
    days and infect about 54 of the population.

2nd, a Variety of Scenarios
Possible Scenarios
  • The researchers tested different interventions
  • distributing antiviral treatments to infected
    individuals and others near them to reduce
    symptoms and susceptibility
  • vaccinating people, possibly children first, with
    either 1 or 2 shots of a vaccine not well matched
    to the strain that may emerge
  • social distancing, such as restricting travel and
    quarantining households and closing schools

Interventions w/a less contagious virus
  • Utilize the 3 most effective single measures
  • Distributing several million courses of antiviral
    treatment to targeted groups 7 days after a
    pandemic alert
  • School closures and
  • and vaccinating 10 million people per week with
    1 dose of a poorly matched vaccine.
  • The results also showed that vaccinating school
    children first is more effective than random
    vaccination when the vaccine supply is limited.
  • Regardless of contagiousness, social distancing
    measures, alone, had little effect.

Interventions w/a highly contagious virus
  • All single-intervention strategies left nearly
    half the population infected.
  • In this instance, the only measures that reduced
    the number of cases to below the annual flu rate
    involved a combination of at least three
    different interventions, including a minimum of
    182 million courses of antiviral treatment.

Decline in Travel and Leisure Activities
  • International travel would dramatically decline
    as people avoided flu "hotspots
  • Governments may restrict travel
  • People would quarantine themselves by staying at
    home more

More on Travel and Leisure Activities
  • Nonessential activities requiring social contact
    would be sharply curtailed, leading to
    significant declines in retail trade
  • People would avoid public places, such as
    shopping malls, community centers, places of
    worship, and public transit
  • Attendance at theaters, sporting events, museums,
    and restaurants would decline

Schools and Business Would Suffer
  • Many schools would close
  • And if they didnt, attendance would fall
    dramatically as parents keep their children at
  • Large-scale school closings would lead to a spike
    in workplace absences because parents would stay
    home to care for their children even if they were
    not sick
  • The impact on businesses of all kinds due to
    employee absenteeism would be dramatic

How would a Pandemic Impact my Organization?
Lost Employee Productivity
  • Increase in absenteeism due to illness, caring
    for sick, and social distancing policies could
    reach 40 during peaks
  • Risk that some companies do not have capacity to
    support increases in telecommuting

Disruption of Supply Chains
  • Disruption of transportation networks that limit
    ability to receive and distribute goods

Operations and Facilities Shutdown
  • Increase in absenteeism due to illness, caring
    for sick, and social distancing policies could
    reach 40 during peaks
  • Inability to maintain operations because of
    shortages of staff, shortages of supplies, or a
    slowdown in servicing utilities
  • Closure of facilities due to implementation of
    policies to contain the pandemic (e.g., social
  • School closings would likely happen very early in
    a pandemic and could occur on short notice

Drop in Demand for Products and Services
  • Certain companies will see drops in demand for
    products and services
  • Reduction in customer base due to illness
  • Customers likely to avoid public shopping areas,
    restaurants, entertainment facilities, etc
  • Potential decline in income and discretionary
    spending as businesses are forced to halt
  • Closure of facilities due to implementation of
    policies to contain the pandemic (e.g., social

Is the World Prepared?
  • The answer is NO
  • Despite the advance warning, the world is ill
    prepared to defend itself against a flu pandemic.
  • WHO has urged all countries to develop
    preparedness plans, but only around 40 have done
  • WHO has further urged countries with adequate
    resources to stockpile antiviral drugs nationally
    for use at the start of a pandemic.
  • Under the current situation, most developing
    countries may have limited access to vaccines and
    antiviral drugs throughout the duration of a

How to Prepare your Organization?
  • Develop an internal pandemic planning taskforce
  • Review the CDC checklists to include as part of
    your organization's pandemic plan
  • Engage your business continuity/preparedness
    department to expand their mission to include
    pandemic planning
  • Work with a business preparedness advisory
    organization to assist you in preparing your
    organization for an influenza pandemic

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10 Steps your Organization Can Take Now
Step 1
  • Check that existing contingency plans are
    applicable to a pandemic.
  • In particular, check to see that core business
    activities can be sustained over several weeks.

Step 2
  • Plan accordingly for interruptions of essential
    governmental services like sanitation, water,
    power, and disruptions to the food supply.

Step 3
  • Identify your company's essential functions and
    the individuals who perform them.
  • The absence of these individuals could seriously
    impair business continuity.

Step 4
  • Build in the training redundancy necessary to
    ensure that their work can be done in the event
    of an absentee rate of 25 to 30.

Step 5
  • Maintain a healthy work environment by ensuring
    adequate air circulation and posting tips on how
    to stop the spread of germs at work.

Step 6
  • Promote hand and respiratory hygiene.
  • Ensure wide and easy availability of
    alcohol-based hand sanitizer products.

Step 7
  • Determine which outside activities are critical
    to maintaining operations and develop
    alternatives in case they cannot function
  • For example, what transportation systems are
    needed to provide essential materials?
  • Does the business operate on "just in time"
    inventory or is there typically some reserve?

Step 8
  • Establish or expand policies and tools that
    enable employees to work from home with
    appropriate security and network access to

Step 9
  • Expand online and self-service options for
    customers and business partners.
  • Tell the workforce about the threat of pandemic
    flu and the steps the company is taking to
    prepare for it.
  • In emergencies, employees demonstrate an
    increased tendency to listen to their employer,
    so clear and frequent communication is essential.

Step 10
  • Update sick leave and family and medical leave
    policies and communicate with employees about the
    importance of staying away from the workplace if
    they become ill.
  • Concern about lost wages is the largest deterrent
    to self-quarantine.

Preparations for a Potential Flu Pandemic
A Federal Pandemic Plan is in Place
  • The National Strategy for Pandemic Influenza,
    issued by President Bush on November 1, 2005,
    guides our nation's preparedness and response to
    a flu pandemic

Intent of the Federal Plan
  • Stopping, slowing, or otherwise limiting the
    spread of a pandemic to the US
  • Limiting the domestic spread of a pandemic and
    mitigating disease, suffering, and death
  • Sustaining infrastructure and mitigating impact
    on the economy and the functioning of society

Components of the HHS Plan
  • The HHS Plan includes an overview of the threat
    of pandemic flu, a description of the
    relationship of this document to other federal
    plans, and an outline of key roles and
    responsibilities during a pandemic.
  • In addition, the HHS Plan specifies needs and
    opportunities to build robust preparedness for
    and response to pandemic flu.
  • The preparations made for a pandemic today will
    have lasting benefits for the future

Antiviral Stockpiling is Crucial
  • Major components of the critical preparedness and
    ready response actions include
  • Intensifying surveillance and collaborating on
    containment measures - both international and
  • Stockpiling antivirals and vaccines, and working
    with industry to expand capacity for production
    of these medical countermeasures
  • Creating a seamless network of federal, state and
    local preparedness, including increasing
    healthcare surge capacity
  • Developing the public education and
    communications efforts that will be critical to
    keeping the public informed

A Plan Based on Known Pandemic Principles
  • Preparedness will require coordination among
    federal, state, and local government and partners
    in the private sector
  • An informed and responsive public is essential to
    minimizing the health effects of a pandemic and
    the resulting consequences to society
  • Domestic vaccine and production capacity
    sufficient to provide vaccine for the entire US
    population is critical
  • Quantities of antiviral drugs sufficient to treat
    25 of the US population should be stockpiled.
  • Sustained human-to-human transmission anywhere in
    the world will be the triggering event to
    initiate a pandemic response by the US
  • When possible and appropriate, basic public
    health measures will be employed to reduce
    person-to-person viral transmission and to
    prevent or delay influenza outbreaks
  • At the start of a pandemic, vaccine, which will
    initially be in short supply, will be procured
    and distributed to state and local health
    departments for immunization of predetermined
    priority groups
  • At the onset of a pandemic, antiviral drugs from
    public stockpiles will be distributed to
    predetermined priority groups

  • U.S. Department of Labor's OSHA Unveils New
    Guidance on Preparing Workplaces for Influenza
    Pandemic (released Feb 6, 2007)
  • Assistant Secretary of Labor for Occupational
    Safety and Health, Edwin G. Foulke Jr. "In
    anticipation of a flu pandemic, our top priority
    is protecting the safety and health of America's
    working men and women

Texas Preparations
  • Texas received 5,875,044 in phase 1 funding from
    the U.S. Department of Health and Human Services
    (HHS) to use for pandemic planning activities.
  • Texas will also receive additional funds of
    15,450,021 from the revised phase 2 of Health
    and Human Services local and state allocations.
  • This amount is based on a formula adjusted for

State Activities
  • The state of Texas, HHS and other federal
    agencies held a pandemic planning summit on March
    27, 2006, with public health and emergency
    management and response leaders within the state.
  • Texas Department of State Health Services
    developed a Pandemic Draft Plan
  • Dallas County Health Human Services developed
    an Influenza Pandemic Plan
  • Texas Department of State Health
    Servicesprovided information about Avian Flu

Employers Responsibility under OSHA
  • Under the Occupational Safety and Health Act of
    1970, employers are responsible for providing a
    safe and healthful workplace for their employees.
  • OSHA's role is to assure the safety and health of
    America's working men and women by setting and
    enforcing standards providing training, outreach
    and education establishing partnerships and
    encouraging continual process improvement in
    workplace safety and health.

Are People Out There Planning?
How are Other Organizations Preparing?
Pandemic Plans Generally Address
  • Business continuity
  • impact of absenteeism on operations, technology,
  • Awareness/Education
  • employee communication, educational materials
  • Prevention
  • promoting good health habits, procuring supplies
  • Treatment
  • purchasing antivirals for appropriate employees

Examples of Plans
  • Developing "Remote Working" plans to operate
    under a flu pandemic scenario that would keep as
    many as 50 of its employees from being at work

Deutsche Bank
  • Taking measures to ensure that employees in
    infected zones don't transmit the disease to
    coworkers and preparing for the economic shocks
    triggered by a global pandemic

  • Issued all 1,200 employees at its Mountain View
    campus a bottle of hand sanitizer, with web link
    for info on Avian Flu.
  • Installed hand sanitizer dispensers throughout
    its buildings

  • Assembled a task force to examine business
    continuity issues and worker-protection plans
  • Assessed minimum workers to conduct core
  • Estimated that non attendance rates of up to 30
  • Exploring options to minimize operational
    disruptions (e.g., cross-training, reconfiguring
    shifts, virtual work)

Virgin Atlantic
  • Purchased 10,000 courses of TAMIFLU for
    employees, who frequently travel internationally

What is the Role of Vaccination on Seasonal Flu?
Seasonal Flu Vaccination
  • Vaccination is one of the most effective ways to
    minimize suffering and death due to seasonal
  • In fact, vaccination is universally regarded as
    the most important medical intervention for
    preventing seasonal influenza and reducing its
    health consequences.

Flu Vaccines
  • Flu vaccination is recommended for people who are
    at high risk for complications if they contract
  • It is also recommended for people aged 50 to 64,
    since one third of individuals in this age range
    have medical conditions that place them at
    increased risk for complications of flu.
  • Flu vaccination is also recommended for those who
    will be in close contact with others at high risk
    for complications of flu.

A Flu vaccination is not recommended for
  • People lt 6-months old
  • Individuals with severe allergies to chicken eggs
  • Those who have had a severe reaction to flu
    vaccine in the past
  • Anyone who has ever developed Guillain-Barré

Vaccines in a Pandemic
  • In a pandemic, it could take several months to
    develop an effective vaccine.
  • Presently, there is NO commercially available
    vaccine to protect humans against potential
    pandemic strains.
  • However, research studies to test potential
    vaccines to protect humans against pandemic flu
    are under way.

Medical Treatment
  • There are two drugs that, if administered early
    enough post-infection, have been shown to reduce
    symptoms of influenza A and B in some infected
  • These drugs belong to a class of antiviral drugs
    known as "neuraminidase inhibitors."
  • These antivirals can also be taken to prevent
    illness upon suspected exposure to the flu virus,
    before symptoms develop.
  • The stockpiling of antivirals is a key component
    of the Federal Pandemic Preparedness Plan.

  • Two principal roles
  • Prophylaxis - aimed at decreasing the likelihood
    of developing flu
  • Treatment - aimed at reducing the duration of flu
    by 1.3 days
  • Research has demonstrated the effectiveness of
    antivirals when used for both purposes.
  • When used for treatment purposes, these drugs
    need to be administered within 48 hours after the
    onset of symptoms.

How much Antiviral is Enough?
  • Company XYZ employs 1,000 individuals and
    employees have on average 3 immediate family
    members (4,000 individuals) and are covering 40
    of this population

  • a
  • a 40 x 4,000 individuals 1,600.
  • b
  • The company assumes that each individual will be
    provided 2 treatment courses (2 packs) and 2
    prevention courses (2 packs)
  • b 4
  • c
  • The company assumes that the seasonal dosage will
    be used
  • c 1
  • d
  • The company assumes that there will be two waves
    of a pandemic
  • d 2
  • Therefore, Order Quantity ( of packs) a x b x c
    x d 1,600 x 4 x 1 x 2 12,800 Packs

In Conclusion
Started Ended Years ? (Delta)
1732 1733 1 49
1781 1782 1 19
1800 1802 2 30
1830 1833 3 17
1847 1848 1 10
1857 1858 1 32
1889 1900 11 29
1918 1919 1 39
1957 1958 1 11
1968 1969 1 Next ???
2.3 26.22222
Next One 1994.222
Pandemics are a reality
  • Health records show at least 10 influenza
    pandemics over the past 300 years 
  • On average we have a pandemic every 26 years
  • The next one should have been in 1994-1995
  • We are now 12-13 years overdue
  • Therefore, be very prepared

  • Thank you