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Update on Pandemic Influenza Response Strategies

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NIAC analysis of critical infrastructure (CI) for a U.S. pandemic ... Advisory committee input (ACIP, NVAC & NIAC) Antiviral drugs and. potential expansion ... – PowerPoint PPT presentation

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Title: Update on Pandemic Influenza Response Strategies


1
Update on Pandemic Influenza Response Strategies
Ben Schwartz, M.D. National Vaccine Program
Office, DHHS
2
Issues to address Whats new in national
planning?
  • Community mitigation guidance and the pandemic
    severity index (PSI)
  • Pandemic vaccine prioritization
  • Antiviral drug strategies

3
Public health and community mitigation strategies
1
  • Objectives
  • 1 - delay outbreak
  • 2 - diminish peakburden
  • 3 - decrease overallillness rate
  • Strategies
  • Personal hygiene handwashing cough etiquette
  • Social distancing
  • Community-based interventions

Daily Cases
Unmitigated outbreak
2
Mitigated outbreak
3
Days since first case
4
Community-Based Interventions Targeted Layered
Containment
  • Interventions targeted to commonsettings of
    disease transmission(households, schools,
    workplaces,and communities)
  • Components
  • Isolate cases voluntary quarantineof case
    households
  • Close schools keep children home
  • Cancel public gatherings
  • Social distancing in communities and at
    workplaces
  • Federal guidance posted at www.pandemicflu.gov

5
Pandemic influenza mortality A tale of two
cities, 1918
6
Modeled Impacts of Community Mitigation on
Pandemic Mortality
NPI Non-pharmaceutical Intervention Rx
treatment PEP post-exposure prophylaxis
U.S. national planning assumptions for pandemic
severity intervention at 1 community attack
rate 60 case ascertainment and
treatment/household prophylaxis 30 compliance
with voluntary quarantine 25 effectiveness of
antiviral Rx to prevent death modeling by N.
Ferguson, Imperial Col, London
7
Critical success factors for community mitigation
  • Timing
  • Interventions need to be implemented early before
    infection is widespread (lt1 of population ill)
  • Compliance (modeling estimates)
  • Keeping kids from re-congregating when dismissed
    from school (30 90)
  • Case isolation and voluntary household quarantine
    (30 90)
  • Reducing contacts in workplaces and communities
    (50)
  • Ability to mitigate adverse secondary
    consequences
  • E.g., work loss from closing schools impacts on
    school lunch program, etc.

8
Pandemic Severity Index
  • Defines severity based on case fatality rate
  • Isolation and case treatment recommended at all
    PSI
  • Other interventionsbased on PSI
  • PSI 5/4 recommend
  • PSI 3/2 consider
  • PSI 1 generally not recommend

9
Availability and prioritization of pandemic
vaccine
10
Pandemic vaccine supply
  • Pandemic vaccine first available at 20 weeks
    after identification of the pandemic virus
  • Monthly increments depend on production capacity
    and ability to decrease antigen content by use of
    adjuvants to stimulate immunity

11
Interagency pandemic vaccine prioritization
working group
  • Participants from federal agencies
  • Process included
  • Presentation and discussion of ethical issues
  • Presentations on key issues and by key
    stakeholders
  • Consideration of ACIP/NVAC recommendations
  • Consideration of National Infrastructure Advisory
    Council recommendations on critical
    infrastructure
  • Public engagement meetings
  • Stakeholder meeting
  • Decision analysis process
  • Written comments

12
NIAC analysis of critical infrastructure (CI) for
a U.S. pandemic
  • Request for analysis from Secs. Leavitt
    Chertoff
  • Issues considered
  • Critical functions of CI and key resource (KR)
    sectors (maintain national homeland security
    ensure economic survival maintain health
    welfare)
  • Interdependencies between sectors
  • Workforces needed to maintain critical functions
  • Process
  • Survey of CI/KR operators review of existing
    data and plans, interviews of subject matter
    experts

www.dhs.gov/niac
13
Identifying critical employee groups Sector
detail all sectors, all tiers
Critical Employees Tiers 1 -3 Banking Finance
1,562,000 Chemical 322,618 Commercial
Facilities 84,000 Communications
796,194 Electricity 375,000 Emergency Services
1,997,583 Food and Agriculture
750,000 Healthcare 6,999,725 Information
Technology 2,358,800 Nuclear 86,000 Oil and
Natural Gas 328,674 Postal and Shipping
464,744 Transportation 198,387 Water and
Wastewater 608,000 TOTAL 16,931,725
  • Notes
  • Numbers include Tier 1, Tier 2, and Tier 3
    essential employees.
  • State and local government numbers removed from
    gross and priority workforce numbers.

14
Public engagement and stakeholder meetings
  • Objective Consider goals of pandemic vaccination
    and assign values to each
  • Approach
  • Background presentations
  • Group discussions
  • Electronic voting (rating of goals on 7-point
    scale)
  • Participants
  • Las Cruces NM 108 persons culturally diverse
  • Nassau Co., NY 130 persons many older persons
  • DC 90 persons government, CI sectors,
    community organizations

15
Value of pandemic vaccination goals public(Las
Cruces, Nassau Co.) and stakeholder (DC) meeting
results (7-point scale)
16
Key outcomes of public engagement and stakeholder
meetings
  • Consistency in most highly rated goals
  • Values underlying those goals were
  • Maintaining critical societal functions
  • Protecting those who would help others during the
    pandemic
  • Protecting children as our future
  • Key messages
  • Balance vaccine use to achieve multiple pandemic
    response goals
  • Consider multiple factors in defining higher
    priority groups

17
Next steps
  • Public announcement of draft guidance
  • Obtain comments and finalize prioritization
    guidance
  • Stakeholder meetings
  • Public engagement meetings
  • Web-based public engagement
  • Written comments (Federal Register
    pandemicflu.gov)
  • Advisory committee input (ACIP, NVAC NIAC)

18
Antiviral drugs and potential expansion of
prophylaxis strategies
19
Current antiviral drug use strategies and
stockpiling
  • Primary strategy is early treatment
  • Meets expectations of clinicians and patients
  • Effective in reducing duration and severity of
    illness
  • Stockpiling
  • Target of 81 M regimens
  • 75 M treatment 6 M quenching international and
    domestic outbreaks
  • Federal purchase of 50 M and State purchase of 31
    M regimens with federal cost share
  • In early 2007, about 50 M regimens in hand or
    ordered
  • DOD, VA, and private sectors also stockpiling

20
Reassessment of antiviral drug use strategies
stockpile targets
  • Allowed by increased production of antiviral
    drugs
  • Possible need for prophylaxis to maintain health
    care and other critical infrastructures
  • MD health dept survey only 54 indicated they
    would report to work in a pandemic
  • Community mitigation guidance suggests value of
    household post-exposure prophylaxis (PEP)

21
Interagency working group on antiviral prophylaxis
  • Representatives from federal agencies, State
    local public health (ASTHO, NACCHO), IHS
  • Objective to develop guidance on antiviral
    prophylaxis for policy consideration
  • Consider prophylaxis strategies target groups
    by antiviral drug availability
  • lt 75 M regimens retain focus on treatment
  • No limit on supply

22
Potential impacts of household post-exposure
prophylaxis (PEP)
1.8 M
  • Impact on illness and death may be
    substantial
  • May improve compliance with other
    mitigation strategies
  • Caveats
  • Estimates are based on models and assumptions
  • Assumption of 60 cases treated and 100 of
    family members prophylaxed at 24 hrs not
    currently feasible

Deaths (thousands)
.5 M
.35 M
.24 M
U.S. national planning assumptions for pandemic
severity intervention at 1 community attack
rate 60 case ascertainment and
treatment/household prophylaxis 30 compliance
with voluntary quarantine 25 effectiveness of
antiviral Rx to prevent death modeling by N.
Ferguson, Imperial Col, London
23
Potential barriers to effectively implementing
household PEP
  • Case detection and diagnosis
  • Proportion and timing of cases presenting to HCW
  • Diagnostic strategy
  • POC testing not sensitive withhold Rx for a
    negative test?
  • ILI diagnosis has a low PPV lt35 for annual
    influenza
  • Dispensing antiviral medications
  • Capacity and timeliness
  • Pharmacy practice guidelines
  • Validation
  • Education and compliance

24
Other potential settings and strategies for
antiviral prophylaxis
25
Implementation Issues for Workplace PEP
  • Target groups
  • E.g., all HCWs or CI workers or only critical
    workers?
  • PEP process
  • Timeliness of case detection
  • Need for investigation
  • Definition of exposed contacts
  • Approach to antiviral drug dispensing
  • Role of health department vs occupational health
  • Estimated burden and antiviral drug requirement
  • Base on mitigated or unmitigated pandemic?

26
Conclusions implications of new developments in
pandemic response planning
  • Plan implementation of community mitigation
  • Surveillance and triggers plans and materials
    for effective implementation mitigation of
    adverse consequences
  • Consider implications on planning of increased
    countermeasure supply and possible new strategies
  • Comments on strategies being considered are
    welcomed
  • Stay informed as policies are finalized
  • Work with partners to begin planning
    implementation

27
ESF 8 Pandemic Influenza Planning
  • Casey Wright, ScM
  • Office of the Assistant Secretary for
    Preparedness and Response
  • U.S. Department of Health and Human Services

28
Outline
  • Goals, strategies and framework for ESF 8
    response
  • Response missions, structure and ESF 8 op tempo

29
Goals for Managing a Pandemic
1. Delay disease transmission and outbreak
peak 2. Decompress peak burden on healthcare
infrastructure 3. Diminish overall cases and
health impacts
1
Pandemic outbreak No intervention
2
Daily Cases
Pandemic outbreak With intervention
3
Days since First Case
30
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31
HHS Missions at Stages 0 and 1
  • Stage 0
  • Ensure effective surveillance and reporting
    systems
  • Support antiviral and vaccine development and
    stockpiling
  • Assist State, local and Tribal and international
    partners in public health and medical response
    planning
  • Stage 1
  • Rapidly confirm or refute reports of efficient
    h2h2h transmission
  • Initiation of ESF 8 coordination mechanisms and
    logistical support

32
ESF 8 Missions at Stages 2 and 3
  • International Containment
  • Deployment of a Rapid Response Team
  • Deploy SNS to 62 project areas in phases
  • Deploy ESF 8 personnel to support screening,
    quarantine and isolation operations at aviation,
    land and maritime ports of entry
  • Activate EMG and deploy SHOs and IRCTs to JFOs

33
Regionally-Based JFO Areas of Responsibility
National SHO Dr. Kevin Yeskey
C
C SHO CAPT James Galloway
AK
ND
WA
MT
MN
ME
WI
SD
VT
OR
ID
NH
NY
WY
MI
MA
NE
IA
CT
RI
PA
OH
E
IL
NJ
A
IN
NV
MD
UT
KS
DE
CO
WV
E SHO RADM Patrick
OCarroll
DC
KY
CA
MO
VA
A SHO Dr. Pierre Noel
TN
NC
OK
NM
AZ
MS
SC
AR
AL
GA
TX
B
LA
B SHO CAPT Ali Khan
FL
D
D SHO RADM Ron Banks
REGION A Standard Federal Regions 12
(Boston/New York)
PR
VI
REGION B Standard Federal Regions 34
(Philadelphia/Atlanta)
REGION C Standard Federal Regions 58
(Chicago/Denver)
REGION D Standard Federal Regions 67
(Denton/Kansas City)
REGION E Standard Federal Regions 910
(Oakland/Bothell)
34
ESF 8 Pandemic Influenza Response Incident
Command Structure
Secretary
ASPR with EMG
Headquarters Level Activated at Stage
2 - 6
Op Divs Leadership (ACF, AoA, AHRQ, ATSDR, CDC,
CMS, FDA, HRSA, IHS, NIH, SAMHSA)
Staff Divs Leadership (IOS, ASAM, ASBTF, ASH,
ASL, ASPE, OSGASPA, OD, DAB, OCR, OIG, OMHA,
IGA, OGC)
--------------------------------------------------
--------------------------------------------------
--------------------------------------------------
--------------
5 FEMA PI Regions Activated at Stage 2 - 6
ESF 6 (Human Services)
--------------------------------------------------
--------------------------------------------------
--------------------------------------------------
--------------
State Level Activated at Stage 2 - 6
Information and Intelligence Sharing
HHS Senior Medical Officer
HHS Senior Medical Officer
HHS/CDC SMO or other ESF 8 LNO
HHS/CDC SMO or other ESF 8 LNO
HHS/CDC SMO or other ESF 8 LNO
35
ESF 8 Missions at Stage 4
  • Deploy ESF 8 personnel to support domestic
    containment in first affected communities
  • Attempt to delay progression with vigorous
    response to earliest cases
  • Technical advice on implementation of community
    mitigation strategies
  • Maintain ESF 8 presence at points of entry

36
ESF 8 Missions at Stages 5 and 6
  • Pull back majority of ESF 8 resources to support
    HHS business continuity
  • Secondary priorities include
  • Support to Federal healthcare infrastructures
  • Support to other critical infrastructures
  • Shift in focus the new C2 is Communication and
    Coordination with States, tribes and territories

37
Get Informed. Be Prepared
  • One-stop access to avian and pandemic flu
    information from the U.S. Government
  • Managed by the
  • U.S. Department of Health and Human Services

38
National Disaster Medical System
  • Current NDMS PI Overview

39
Briefing Overview
  • National Disaster Medical System
  • Alignment within HHS
  • Background and Origins
  • Structure and Components
  • Capabilities
  • NDMS Role in ESF8
  • Recent Deployments
  • 2004 Florida Hurricanes
  • 2005 Gulf Coast Hurricanes

40
NDMS in the HHS Organization
41
HHS Regional Offices
42
NDMS Background Origins
  • National Security Decision Directive 47 (NSDD-47)
  • Approved by the President (July, 1982)
  • Set forth Emergency Mobilization
  • Preparedness Principles for
  • National Security Emergencies
  • Domestic Emergencies

43
NSDD-47
Health
It is the policy of the United States to develop
systems and plans to ensure that sufficient
medical personnel, supplies, equipment, and
facilities will be available and deployed to meet
essential civilian and military health care needs
in an emergency.
44
National Disaster Medical System
A public / private sector partnership HHS DHS
DOD VA
  • A Nationwide Medical Response System to
  • Supplement state and local medical resources
    during disasters or major emergencies
  • Provide backup medical support to the military/
    VA medical care systems during an overseas
    conventional conflict

45
National Disaster Medical System
Major Components of NDMS
46
NDMS

3 Major Components of NDMS
Medical Response Lead HHS
Patient Evacuation Lead DoD
Definitive Care Lead DoD/VA
DoD Aeromedical Evacuation Primarily Fixed Wing
DoD/VA Federal Coordinating Centers
47
NDMS Medical Response
Lead Responsibility - HHS
  • Assist in Assessment of Health/Medical Needs
  • Provision of On-Scene Medical Services
  • Victim Identification/Mortuary Services
  • Veterinary Medical Services

48
NDMS Medical Response
Lead Responsibility - HHS
  • More than 9,000 personnel in the
  • System
  • Equipment and Supplies
  • Medical Team Caches
  • Veterinary Medical Assistance Team
  • Cache
  • Deployable Portable Morgue Units
  • Mobile Intensive Care Units

49
NDMS Medical Response
Disaster Medical Assistance Teams
Disaster Medical Assistance Teams
  • Groups of Intermittent Federal Employees who
    Volunteer to be on Designated Team for NDMS
  • Approximately 35 Persons per Team (deployed)
  • (gt 5,700 personnel currently enrolled in
    DMATs)
  • Variety of Health/Medical Skills
  • NDMS Teams are Sponsored by the U.S. Government
  • Team Originate from Community-Based Health
    Medical Organization

50
DMAT Functions
At Disaster Site
  • Triage
  • Primary Medical Care
  • Casualty Clearing/Staging

At Local NDMS Reception Area
  • Patient Reception

51
NDMS Specialty Teams
  • Pediatric
  • Burn
  • Disaster Mortuary Operational Response Teams
    (DMORTs)
  • Urban Search and Rescue Medical Team
  • Mental Health
  • Veterinary Medical Assistance Teams (VMATs)
  • National Medical Response Teams (NMRTs)
  • Medical Surgical Response Teams (MSuRTs)

52
DMAT and Specialty Teams
  • Members are Intermittent Federal Employees
  • (Public Law 107-188)
  • Importance of Federalization
  • Licensure / Certification
  • Liability
  • Compensation
  • USERRA Coverage

53
NDMS Response Teams
  • 35 Disaster Medical Assistance Teams - (Fully
    Operational/Operational)
  • 17 Disaster Medical Assistance Teams -
    (Augmentation/Developmental)
  • 4 National Medical Response Teams / WMD
  • 4 Burn Teams
  • 2 Pediatric Teams
  • 1 Crush Medicine Team
  • 3 International Medical / Surgical Teams
  • 2 Mental Health Teams
  • 4 Veterinary Medical Assistance Teams
  • Disaster Mortuary Operational Response Teams (1
    WMD)
  • National Pharmacist Response Teams
  • 10 National Nurse Response Teams
  • 1 Management Support Team(s)


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60
Roles of Emergency Support Function 8
  • 1. Assessment of Public Health and Medical Needs
  • 2. Health Surveillance
  • 3. Medical Care Personnel
  • 4. Health/Medical Equipment and Supplies
  • 5. Patient Evacuation
  • 6. In-Hospital/Patient Care
  • 7. Safety and Security of Human Drugs,
    Biologics, Medical Devices, and Veterinary
    Drugs
  • 8. Blood and Blood Products
  • 9. Food Safety and Security
  • 10. Agriculture Safety and Security
  • 11. Worker Health/Safety
  • 12. All-Hazard Public Health and Medical
    Consultation, Technical Assistance,
  • and Support
  • 13. Behavioral Health Care
  • 14. Public Health and Medical Information
  • 15. Vector Control
  • 16. Potable Water/Wastewater Solid Waste
    Disposal
  • 17. Victim Identification/Mortuary Services
  • 18. Protection of Animal Health
    NDMS supported

61
Patient Evacuation
Lead Responsibility - DOD
  • Provide Patient Movement from the Disaster Area
  • Utilize All Types of Transportation
  • Primarily Relies on Aeromedical

62
Patient Movement
  • Coordinated inter-agency process
  • Identification of a need to move a patient
  • Admission of a patient at a destination
  • medical facility

63
NDMS Roles
  • Patient Stabilization
  • Staffing of Regional EVAC Points (REP)
  • Staffing of Patient Reception Areas (PRA)
  • Patient Preparation
  • Patient Regulation

64
Additional Transport Providers
  • ESF-8 Partners
  • Department of Transportation
  • General Services Administration
  • U.S. Postal Service
  • American Red Cross
  • Private Contractors

65
DOD Role
  • Support agency to ESF 8, Public Health and
    Medical Services
  • 1. Coordinate Patient Movement - DoD is lead for
    patient movement in collaboration with other
    federal agencies. Responsible for movement of
    patients on DoD resources.
  • Provides transportation assets, medical crews,
    patient regulating teams
  • Transportation medical assets include
  • Aero-medical Evacuation Kits
  • Patient Movement Equipment
  • Civilian Reserve Air Fleet in Homeland Incident

66
DOD Role (cont)
  • Coordinate Patient Movement (Cont)
  • Global Patient Movement Requirements Center
    (GPMRC) located at Scott AFB (OFallon, Illinois
    St. Louis area)
  • Performs Medical Regulating
  • Coordinates the Transportation - Bed plan
  • Transportation Command Regulating and Command and
    Control Evacuation System (TRAC ES)
  • Combines transportation, logistics, and clinical
    decision elements into seamless patient movement
    capable of assessing/prioritizing medical
    requirements, assigning proper resources
    distributing relevant data

67
DOD Role (cont)
  • TRANSCOM Regulating and Command Control
    Evacuation System (TRAC ES) Benefits
  • Seamless transition from peacetime to natural
  • disaster, contingencies and wartime
  • In-transit visibility of patient location and
    status
  • Integrates different modes of transportation
    (air/ground/sea) for patient movement
  • Advanced planning capabilities to develop
    precise plans and projections in resource
    constrained environments
  • Effective use of existing transportation
    resources
  • Projects limitations and patient movement
    bottlenecks
  • Situational awareness for patient recipient
    hospitals

68
NDMS Definitive Medical Care
Lead Responsibility - DOD/VA
  • Federal Coordinating Centers (FCCs)
  • Concentrated in Major Metropolitan Areas
  • Air Access
  • Available Hospital Support
  • Patient Reception and Distribution Capabilities

69
NDMS Definitive Medical Care
  • Network of approximately 1,800
  • non-Federal hospitals
  • Approximately 80,000 beds
  • 62 FCCs, which coordinate in
  • excess of 82 receiving areas

70
Federal Coordinating Centers
WA
AK
MT
ND
ME
MN
VT
OR
NH
WI
MA
SD
NY
RI
CT
ID
WY
MI
CA
IA
PA
NV
NJ
NE
OH
MD
DE
IL
UT
CO
WV
IN
KS
VA
MO
KY
NC
AZ
OK
NM
TN
SC
TX
AR
AL
MS
LA
GA
FL
USVI
HI
GUAM
PR
Army FCC Navy FCC Air Force FCC VA FCC
71
NDMS Participating Hospital Roles
  • Voluntary Commit Hospital Support to NDMS
  • Provide Bed Availability Information to Local
  • NDMS Federal Coordinating Center
  • Treat NDMS Patients
  • Participate in NDMS Exercises

72
NDMS Role in Pandemic Flu Outbreak
  • Members are Intermittent Federal Employees
    (Public Law 107-18)
  • However, team members are employed
  • in their communities
  • NDMS team members probably will be required
  • to perform their medical duties locally and
    not
  • be available for Feral activation

73
  • DOD and VA assets may be otherwise engaged
  • Other events may arise such as Hurricanes or
    earthquakes that require what resources that are
    available.

74
  • Questions?
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