Avian Influenza and Response Planning in Tennessee

1
Avian Influenza andResponse Planning in Tennessee

• Barton Warner, MD
• Regional Health Officer
• Mid-Cumberland Region
• Tennessee Department of Health

2
Objectives

• Introduction to pandemic influenza
• H5N1 avian influenza (bird flu)
• Planning assumptions and principles
• National (HHS)
• Tennessee

3
Definition of terms

• Isolation separating sick people from healthy
• Quarantine separating healthy people exposed to
  a disease from others and observing long enough
  to determine if they will become ill or not
• Endemic disease that is always present
• Epidemic a higher than normal number of cases of
  a disease in a human population (outbreak)
• Pandemic an epidemic that is worldwide (rare)
• HIV/AIDS
• Influenza (under special circumstances)

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The Nature of Influenza Virus How it is spread

• Different kinds of influenza viruses infect
  humans and animals (types A and B)
• The natural hosts of influenza A viruses are
  water fowl (e.g., ducks)
• Infected birds shed virus in their feces and
  respiratory secretions
• Influenza spreads among humans by
• Close contact (lt6 feet) with a sick person who is
  coughing or sneezing, or
• Touching a surface contaminated by infected
  respiratory secretions and touching mouth, nose
  or eyes.

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The Nature of Influenza VirusChanges over time

• Type A subtypes are named after two viral surface
  proteins hemagglutinin (H)-(16 subtypes) and
  neuraminidase (N)-(9 subtypes), e.g., Type A H3N2
  or H5N1
• Of the many subtypes, few cause human illness
• Influenza A viruses in people and animals
  perpetually mutate
• Gradual Antigenic Drift ? Routine Seasonal
  Flu
• Dramatic Antigenic Shift ? Pandemic Flu

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Mechanisms of Antigenic Shift
Non-human virus
Human virus
Reassortant Virus 1957, 1968
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Pandemics of the 20th Century Estimated U.S. and
Global Mortality
Emergency hospital during 1918 influenza
epidemic, Camp Funston, Kansas
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1918 Pandemic Nashville

• 155,000 people lived in Nashville
• The local outbreak lasted September through
  October
• The city hospital filled quickly
• A severe shortage of doctors and nurses prevented
  establishing temporary hospitals
• Many of the ill were cared for at home

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1918 Pandemic Nashville Public Health Responses

• Public gatherings were canceled by public health
  order on October 7
• Included theaters, dance halls, pool parlors,
  other places of amusement
• City schools were closed October 8
• Ministers asked not to hold worship services
• Street cars ordered to run with windows open
• No quarantine orders were issued, though most
  people stayed home because of fear or illness

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1918 Pandemic NashvilleResolution

• Schools and businesses reopened November 1
• By the end of the 6-week outbreak
• About 40,000 had fallen ill
• 468 people (1.2) died (US average was gt2)
• 41 of the dead were 20-39 years old
• 28 of the dead were less than 10 years old
• Officials believed that identifying the ill
  quickly and delivering care at home improved
  patient outcomes

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Incidents of human infection with animal viruses
are increasingly frequent
2006 H5N1 Avian virus
2005 H5N1 Avian virus
2004 H7N1 Avian virus

2004 H7N3 Avian virus
2004 H5N1 Avian virus
2003 H7N7 Avian virus
2003 H5N1 Avian virus
1999 H9N2 Quail virus
1997 H5N1 Avian virus
1995 H7N7 Duck virus
1993 Swine/avian recombinant
1988 H1N1 Swine virus
1986 H1N1 Swine virus
1976 H1N1 Swine flu
Timeline of human infection with novel influenza
viruses (since the 1968 pandemic)
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H5N1 Avian Influenza (Bird Flu)

• First caused illness in people in 1997
• Hong Kong 18 sick, 6 died
• Stopped after all poultry in Hong Kong were
  slaughtered
• In 2003, H5N1 outbreaks in poultry began (and
  continue), resulting in the death or slaughter of
  millions of birds in several Asian countries
• More poultry outbreaks ? more chances to mutate
  and begin spreading person to person
• Migratory birds spread H5N1 to new locations

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Animal Cases 12-1-03 To 5-5-06

• Africa
• Burkina Faso, Cameroon, Cote dIvoire, Egypt,
  Niger, Nigeria, Sudan
• East Asia the Pacific
• Cambodia, China, Hong Kong, Indonesia, Japan,
  Korea, Laos, Malaysia, Mongolia, Myanmar,
  Thailand, Vietnam
• Europe Eurasia
• Albania, Austria, Bosnia-Herzegovina, Bulgaria,
  Croatia, Czech Republic, Denmark, France,
  Germany, Greece, Hungary, Italy, Poland, Romania,
  Russia, Serbia-Montenegro, Slovakia, Sweden,
  Switzerland, Turkey, Ukraine, United Kingdom
• Near East
• Iran, Iraq, Israel, Jordan
• South Asia
• Afghanistan, Azerbaijan, India, Kazakhstan,
  Georgia, Pakistan

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Human H5N1 2003-2006

• First wave
• Thailand, Vietnam
• Second wave
• Thailand, Vietnam
• Third wave
• Thailand, Vietnam, Indonesia, Cambodia, China,
  (2006)Turkey, Azerbaijan, Djibouti, Egypt, Iraq

WHO July 4, 2006
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Human Cases 1-1-04 To 6-30-06

• East Asia and the Pacific
• Cambodia, China, Indonesia, Thailand,
  Vietnam
• Europe and Eurasia
• Turkey, Azerbaijan
• Near East
• Iraq
• Africa
• Egypt, Djibouti

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Human H5N1 cases (6-30-06)

• Average age 20 years (range 3 months - 75
  years)
• Half have died
• Half of cases lt20 years old
• 90 of cases lt40 years old

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Human H5N1 cases (6-30-06)

• Age Group
• lt10 years
• 10-19 years
• 20-39 years
• 40-49 years
• 50 years

• Case Fatality Rate
• 42
• 73
• 62
• 45
• 18

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Human H5N1 cases

• Most were bird-to-human transmission
• Previously healthy children, young adults
• Direct contact with sick/dead poultry or feces
• A few cases ate dish with uncooked duck blood
• No risk from eating properly cooked poultry/eggs
• Rare transmission from one person to another
• No sustained human-to-human transmission
• No evidence of genetic changes to make it spread
  easily in people

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3 ½ year-old Thai boy feeds ducks on a duck farm
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Global Status of Current Pandemic Threat

• World Health Organization (WHO) defines 3 major
  periods (broken into 6 phases) of increasing
  human infection with new flu virus
• Interpandemic (no human infection) (Phases 1,2)
• Pandemic Alert (limited human infection) (Phases
  3-5)
• Pandemic (widespread human infection) (Phase 6)
• We are at Pandemic Alert (Phase 3)
• Isolated human infections with a novel influenza
  strain H5N1 with no (or rare) person-to-person
  transmission.

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Will H5N1 become the next pandemic?

• Impossible to know
• H5N1 activity unprecedented and worrisome
• Infections in other mammals and humans
• Persistent outbreaks (endemic) in Asian poultry
• Spread through migratory birds
• Risk to people exists as long as it continues to
  infect birds with human contact
• If not H5N1, then another will come
• The prudent time to plan is now

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HHS Assumptions The Objectives of Pandemic
Planning and Response

• Primary objective
• Minimize sickness and death
• Secondary objectives
• Preserve functional society
• Minimize economic disruption
• There is no consensus on the proper order of
  these assumptions

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Assumptions about Disease Transmission (1)

• No one is immune 30 of population will become
  ill
• Most will become ill 2 days (range 1-10) after
  exposure
• People may be contagious up to 24 hours before
  illness begins
• People are most contagious the first 2 days of
  illness
• Sick children (and immunocompromised) are more
  contagious than adults
• On average, each ill person infects 2 or 3 others
  (if no precautions are taken)

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Assumptions about Disease Transmission (2)

• Pandemics move through community in waves
• Each wave will last 6-8 weeks
• There will be at least 2 waves, likely
  separated by months
• The entire pandemic period (all waves) will last
  about 18 months to 2 years
• Disease may break out in multiple locations
  simultaneously

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Hospital and Business Assumptions (during entire
pandemic period)

• Hospital demands
• Estimate gt25 more patients than normal needing
  hospitalization during a local wave
• Absenteeism
• During a 6-8 week wave, at any one time, 40 of
  employees may be absent because of illness, fear
  of illness, or to care for an ill person

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Medical Burden in Tennessee (pop. 6 million)
(HHS Plan Estimates)
HHS recommends that states plan for severe
scenario
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Tennessee Pandemic Planning

• Tennessee pandemic response plan first published
  1999
• New plan, near completion, reflects the new
  federal guidelines issued November 2005
• Pandemic planning committee of 50 members from
  government and non-governmental representatives
  of potentially affected sectors
• The new plan will be a component of the Tennessee
  Emergency Management Plan (TEMP)

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The Plan - Core Sections

• Ethics Principles
• Disease Surveillance
• Laboratory
• Hospital
• Vaccine
• Antiviral
• Community Intervention
• Communications
• Workforce Public Social Support

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Section 1 Ethics and Principles

• Examples of ethical challenges
• Healthcare providers personal risks
• Restrictions of individual liberties
• Allocation of scarce resources
• Outlines criteria for policies
• Feasible
• Evidence-based
• Consistent with federal guidelines
• Highlights important values and guidelines for
  ethical decision-making process

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Sections 2 and 3 Disease Surveillance and
Laboratory

• Expansion of the Sentinel Provider Network is
  beginning
• Year-round weekly reporting of influenza-like
  illness to monitor trends collect cultures
• Other systems
• Variety of regional systems
• School absenteeism
• Hospital surveillance
• State laboratory
• Able to test human specimens with PCR culture

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Section 4 Hospital Planning

• First portion contains hospital planning
  recommendations
• The federal hospital preparedness checklist is
  attached
• A comprehensive resource list for hospitals is
  attached

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Section 4 Supplement 1Infection Control

• Controlling the spread of infection in hospitals
  is a key to reducing mortality
• Provides an index of infection control procedures
  and recommendations
• First portion during Pandemic Alert, before a
  pandemic begins
• Second portion adapted to the Pandemic

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Section 4 Supplement 2Hospital-Based
Surveillance

• Critical for situational awareness and
  appropriate resource allocation
• Daily reporting once pandemic underway
• Sample questions provided (questions to be turned
  on/off as needed)
• Reporting through Hospital Resource Tracking
  System (HRTS) once available

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Section 4 Supplement 3Hospital Surge Capacity

• Provides recommendations for assessing and
  increasing bed availability during pandemic wave
• Primary health priority will be to provide
  existing hospitals and outpatient facilities the
  resources necessary to function optimally
• Staff credentialing and altered standards of care
  will need to be addressed
• Temporary inpatient healthcare facilities not
  recommended as part of pandemic response

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Section 4 Supplement 4Ethical Allocation of
Scarce Resources

• Addresses one of the most difficult dilemmas in a
  pandemic
• Illustrates how scarce resources may be allocated
  using ventilators as example

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Vaccine and Antivirals Solutions of the future,
but little help now

• Pandemic influenza vaccine
• Limited production
• Research underway
• Priority groups
• Antiviral drugs
• Limited production
• Priority groups
• Usefulness?

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Section 5 Vaccine

• State will follow federal vaccine priorities
• Prioritization of recipients will not be
  determined until a US pandemic is imminent
• Focus for state planning is on how to administer
  vaccine to each group, irrespective of ultimate
  sequence
• Vaccine will be administered by public health
  personnel over months
• Vaccine tracking through federal database or
  through Immunization Registry

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Estimated Current US Annual Domestic Production
of Pandemic Influenza Vaccine Supply,
Capacity, and Need

People vaccinated (Millions)
2 doses/person

• A Current stockpile
• B Stockpile with current production
• C Current annual domestic capacity
• - Assumes all capacity dedicated to pandemic
  vaccine
• - Assumes NO annual influenza vaccine
• D National need

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HHS vaccine priority groups eligible over one
year of production at current capacity
(Populations are national estimates)

• 1a. Military (up to 1.5 million persons)
• 1. Vaccine manufacturers (40,000 persons)
• 2. Healthcare workers with direct patient care
  (8-9 million persons)
• 3. Persons as highest risk for complications (26
  million persons)

Current capacity 14 million persons per year
of production
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Section 6 Antiviral Medication

• Effectiveness and optimal dose still unknown
• Federal stockpile now at gt5 million treatment
  courses goal 81 million treatment courses
• Strategic National Stockpile will store and
  distribute these medications
• Antivirals will be administered to hospitalized
  patients

42
HHS antiviral priority groups eligible with
current national stockpile

• 1a. Military (as needed)
• 1. Patients admitted to hospitals (est. 10
  million)

Current stockpile 4.3 million courses
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Section 7 Community Intervention

• Once pandemic begins in the US, gatherings of
  gt10,000 persons subject to suspension
• Other policies implemented in affected county and
  adjacent counties when
• Disease is detected and surveillance systems
  indicate community spread

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Section 7 Community Intervention

• During local waves
• Suspend discretionary public gatherings of gt100
• Sit-down restaurants exempted
• Daycares (gt13 students) and schools K-12 closed
• Universities treated like rest of community not
  schools

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Section 7 Community Interventions Supplements

• Legal authority for public health actions
• Pre-pandemic case investigation is described
• Steps for interventions in pre-K through 12th
  grades
• Attachment with advice for colleges
• Attachment with advice for businesses

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Section 7 Supplement 4Special Populations

• Briefly addresses need to have plans for prisons
  and jails
• Nursing homes
• Priority is to isolate them, screen visitors,
  vaccinate staff
• Vaccination of residents not recommended
• Healthcare provision in the facility (difficulty
  in admitting patients because hospitals full)

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Section 8 Communications

• State pandemic website now up, will continue to
  expand
• Electronic update system for public and
  healthcare professionals under development
• Critical to coordinate messages at all levels to
  assure the public gets accurate and consistent
  clear information

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Section 9 Workforce and Public Social Support

• Plan for psychosocial and physical support
• Prolonged stressful working conditions
• Regional plans are recommended to list options
  for assistance in the local area (faith, medical,
  physical)
• Volunteer organizations active in disasters
  (VOAD) in most areas

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Regional Plan Purpose

• The purpose of the Regional Pandemic Influenza
  Response Plan is to support the local response to
  pandemic influenza.
• Coordination among pandemic response plans at
  the federal, state, and local level is a primary
  objective of all planning efforts

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Regional Plan Structure

• The regional plan will be structured like the
  state plan (the structure is outlined below). The
  rural regional plans will also have an annex
  (similar to an appendix) specific to each county
  with additional county-level response
  information, as needed.
• These annexes are likely to be more detailed for
  larger counties with major cities and less
  detailed for more rural counties without
  additional county resources to consider.

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County Annexes

• An annex for each county will be included that
  contains section headings that correspond to each
  of the regional operational sections. Annexes for
  sparsely populated counties are expected to be
  brief, while counties with major cities may
  require more county-specific detail.
• The role of county-specific support agencies
  expected to carry out essential roles during a
  pandemic response will be listed. Contact
  information for these agencies will be listed
  including the regional office for county agencies
  

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Support Agencies Examples

• Emergency Management Agency (office contact
  number for county and region)
• TEMA Regional Office Number (office contact
  number)
• State Homeland Security District number (office
  contact number)
• Board of Education Administration (s) (office
  contact number)
• State Department of Human Services Region (office
  contact number)
• Hospitals and bed capacity (ICU, ward,
  ventilators) and contact number
• Chamber of Commerce (office contact number)
• Emergency Medical Service (office contact number)
• Law Enforcement (Sheriff and/or municipal police
  office contact number)
• Media outlets
• County/City Mayors Office (office contact
  number)
• Red Cross Chapter (office contact number)
• Other local response agencies or organizations
  specific to the county

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County Operational Sections

• Continuity of Operations
• For County Health Department
• Disease Surveillance
• Describe county specific systems only
• Laboratory
• Additional info to the county only
• Healthcare Planning
• List the countys hospitals, contact information
  and information on their capacity here. Also
  describe any other key healthcare resources
  necessary for response and specific only to the
  county.

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County Operational Sections II

• Vaccine
• Provide any information specific to the county
  (e.g., if the county will have a vaccination
  site, provide details here).
• Antiviral
• County Specific info only

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County Operational Sections III

• Community Interventions
• Provide any county-specific information major
  county industry or higher education institutions,
  county-specific information for outbreak or
  suspect case reporting and response. Community
  interventions county procedures, roles, and
  responsibilities will be described here.
• Provide information on how schools in this county
  will be closed.
• Provide information on how the social distancing
  policies will be communicated in the county to
  affected businesses and the community.

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County Operational Sections IV

• Communications
• Provide any additional county-specific
  information on communication in the county
  (beyond what applies generally to the whole
  region), such as local media outlets.
• Workforce Psychosocial support
• List resources or methods for support in this
  county, if resources in addition to the regional
  resources are available to the county.

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Conclusions

• Influenza periodically causes pandemics
• State and regional pandemic response plans are
  important,
• but each
• family,
• community,
• healthcare facility
• and business should prepare
• Federal resources and planning checklists
  www.pandemicflu.gov

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Thanks for Your Attention

• Bart.Warner_at_state.tn.us
• Phone [phone]