Get the Facts, Not the Flu: Preparing Your Business for the Next

Pandemic

Catherine Slemp, MD, MPH

2006 Human Resources Summit and

Governor’s Safety Conference

November 1, 2006

Objectives / Overview

• Review Influenza Basics

• Putting Pandemics into Perspective

• Why the Concern Now (Avian Flu-H5N1)

• Discuss Pandemic Control Measures

• Implications for Business

• Pan Flu All Hazard Preparedness

• Incubation period ~1-4 days

• Transmission: Respiratorydroplet (coughing, sneezing); Contact? Aerosol?

• Seasonal Flu causes– 200,000 hospitalizations– 36,000 deaths / yr

• Flu Viruses are constantly changing, evolving, reassorting

INFLUENZA – Key Facts

Influenza Pandemic Viruses

Requirements:– A new influenza A subtype that can infect humans

AND– Causes serious illness

AND– Spreads easily from human-to-human

H5N1 meets the first two prerequisites,

but not the last

Next pandemic virus may or may not be due to a variation of current H5N1 virus

Putting Flu Pandemics in Perspective

Impact of 1918 Pandemic on US Life Expectancy

1918: heavy impact on young healthy adults –nation’s workforce

Daily Deaths in Ohio - 1918

Brodrick OL. Influenza and pneumonia deaths in Ohio in October and November, 1918. The Ohio Public Health Journal 1919;10:70-72.

West Virginia in 1918

The Bluefield TelegraphOct. 8, 1918

Flu stops court,BluefieldOct. 8, 1918

Huntington mayor diesOct. 19, 1918The New Dominion,

Morgantown, WVOct. 24th

Business

Court System

Local GovernmentNewspapers

COMMUNITY INFRASTRUCTURE

“Less than half a dozen families in Fayetteville have illness…Dr. Grose was one of the first victims….”Oct. 10, 1918, The Fayette Tribune

“The Mt. Hope-Kilsyth community is credited with over 500 cases and the death rate is on the increase….”Oct. 31, 1918, The Fayette Tribune

Why the Concern Now?

“AVIAN” OR “BIRD” FLU: THE H5N1 VIRUS

Update

As of 10/31/06: 256 cases; 152 deaths; most poultry related

H5N1 in Humans – 2003-2006

• As of October 31, 2006: 256 cases, 152 deaths (~60%)– Ten countries

• Sporadic, with occasional clusters

• Most had touched or handled sick poultry

• A few cases of probable, limited human-to-human transmission

• All lived in countries with poultry outbreaks

•

Sample Estimate of Morbidity/MortalityWest Virginia*

• Characteristic Moderate (1957-68-like) Severe (1918-like)• Illness 540,000 (30%) 540,000 (30%)• Outpatient 270,000 (50%) 270,000 (50%)• Hospitalization 5,314 60,813• ICU Care 791 9,123• Ventilators 399 4,558• Deaths 1,284 11,690

* based upon DHHS U.S. estimates applied to WV population numbers. These are in the absence of potential interventions.

Much we don’t know … about the next pandemic

• When will it occur?• Which virus will cause it, H5N1 or another?• Who will be most at risk (Elderly and infants? Healthy

adults? Children?)• How severe an illness will it cause?• Will there be multiple waves?• Will antiviral medication work?• How long until we have a vaccine?• What are the best control measures?

Understanding Disease Spread

Ro = 2R0 = 1

Ways to Increase “Social Distance”

Implement “Community Shielding” recommendations Close or alter high risk transmission environments e.g. schools,

daycare centers if supported by epidemiology Cancel large public gatherings (concerts, theaters) Minimize other exposures (markets, churches, public transit) Encourage ill and exposed persons to stay home (isolation and

quarantine) Encourage telecommuting; other worksite adaptations Scaling back or altered transportation services (holiday schedule)

Consider additional community measures COOP to minimize economic impact Distribution of surgical masks, barrier precautions, hand hygiene

Planning Pandemic Control Measures

Potential Tools in Our Toolbox• Our best countermeasure – vaccine – will probably be

unavailable during the first wave of a pandemic

• Antiviral treatment may improve outcomes but will have only modest effects on transmission

• Antiviral prophylaxis may have more substantial effects on reducing transmission

• Infection control and social distancing should reduce transmission, but strategy requires clarification

Community interventions

What does history and modeling tell us?

What planning can be done now?

Weekly mortality data provided by Marc Lipsitch (personal communication)

1918 Death Rates: Philadelphia v St. Louis

0

2000

4000

6000

8000

10000

12000

14000

16000

9/15

/22

9/22

/22

9/29

/22

10/6

/22

10/1

3/22

10/2

0/22

10/2

7/22

11/3

/22

11/1

0/22

11/1

7/22

11/2

4/22

12/1

/22

12/8

/22

12/1

5/22

12/2

2/22

12/2

9/22

Date

Dea

ths

Rat

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100

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PhiladelphiaSt. Louis

A Tale of Two CitiesA Tale of Two Cities

Value of combining strategies – Longini model

0

10

20

30

40

50

60

70

Clinical attack rate Antiviral stockpile needed

Base case (Ro=1.9)Generic social distancingSchool closureSchool closure + generic social distancing60% Case treatment + 60% household prophylaxis60% Case treatment + 60% household prophylaxis + 60% social prophylaxis (60% TAP)60% TAP + School closure + generic social distancing

Workplace / Classroom Social Density

http://buildingsdatabook.eren.doe.gov/docs/7.4.4.xls

11.7 feet 3.9 feet

7.8 feet

Elementary Schools

Hospitals

Offices

16.2 feet

Residences

Spacing of people: If homes were like schools

*Based on avg. 2,600 sq. ft. per single family home

Spacing of people: If homes were like schools

*Based on avg. 2,600 sq. ft. per single family home

66 million

18 million

9 million8 million5 million

Labor Status of Parents in U.S.

Source: U.S. Census Bureau, Population Division, Current Population Survey, 2003 Annual Social and Economic Supplementhttp://www.census.gov/population/www/socdemo/hh-fam/cps2003.html

What are limits of this data?

• Observational data from 1918; data incomplete; cannot link cause and effect

• Modeling impact of different interventions. Useful, but

• Doesn’t yet incorporate impact of people’s behavioral responses to interventions

• Doesn’t incorporate secondary consequences of interventions (e.g., effects of school closure on education, workforce, etc.)

• Does help shape discussion.

A Targeted and Layered Approach

A Layered Approach

Individual / Household / Business

Hand hygieneCough etiquetteInfection controlLiving / working space adaptationIsolation of ill & designated care provider

Community

Isolation of illTreatment of illQuarantine of exposedProphylaxis of exposedSchool closureProtective sequestration of childrenSocial distancing

- Community- Workplace

Liberal leave policies

International

Containment-at-sourceSupport efforts to reduce

transmissionTravel advisoriesLayered screening of travelersHealth advisoriesLimited points of entry

Epidemiology Drives Approach(Targeted)

Mild Moderate SevereCase Fatality Rate ≤ 0.1% 0.1 - 0.5% ≥ 0.5%

Isolation Yes Yes Yes

Treatment Yes Yes Yes

Quarantine No ??? Yes

Prophylaxis High-risk individuals High-risk individuals Yes

School Closure Reactive Punctuated ??? Proactive

Protective sequestration High-risk individuals High-risk individuals Children

Community social distancing

High-risk individuals Encouraged Encouraged + selective closures

Workplace protections Encourage good hygiene

Social distancing Aggressive social distancing

Liberal leave policies Confirmed influenza Influenza-like illness ILI and/or sick family members

SAMPLE

Remember: We have a Tool Kit of Control Measures to Use

• Community Shielding (many methods)

• Hygiene measures

• Antivirals (treatment; prevention, if supplies sufficient)

• Vaccine

• Continuity of Operations Planning

Current Thoughts on Control Measures

• Earlier rather than later implementation of measures more likely to be effective

• Targeted and layered application of measures (e.g., combinations are more effective than a single measure at a time; scale response based on severity of pandemic)

• Communities must consider practicality and ethics of implementing any measure.– Transparency– Public discussion and dialogue– Planning– Coordination across jurisdictions

Tackling This from the Business Perspective

• Educate Leadership and Staff• COOP, COOP, COOP (Continuity of Operations)• Personnel Policies• Knowing your Workforce• Employee and Family Safety• Employee Communications• Contributions to / Participation in Community

Response

Interesting Correlation

Businesses truly embracing a culture of preparedness

High performing businesses everyday

Leadership

Imagination

Resiliency of Businesses and Communities

What does this take? (Now and when the time comes)

Contributors to Historical Analysis and Modeling

HSC/NSPI Writing Team

Richard Hatchett, MD

Carter Mecher, MD

Laura McClure, MS

CDR Michael Vineyard

NIH

James Anderson, PhD

Irene Eckstrand, PhD

Peter Highnam, PhD

Ellis McKenzie, PhDCDC

David Bell, MD

Martin Cetron, MD

Rachel Eidex, MD

Lisa Koonin, MN, MPH

Anthony Marfin, MD

Modelers

Joshua Epstein, PhD

Stephen Eubank, PhD

Neil Ferguson, PhD

Robert Glass, PhD

Betz Halloran, PhD

Nathaniel Hupert, MD

Marc Lipsitch, MD

Ira Longini, PhD

HSC

Rajeev Venkayya, MD

Ken Staley, MD, MPA

RTI

Philip Cooley, PhD

Diane Wagener, PhDUniversity of Michigan

Howard Markel, MD

Department of Education

Camille Welborn, MS

Department of Labor

Suey Howe, JD

Department of Finance - Canada

Steven James

Timothy Sargent

Department of the Treasury

Nada Eissa, PhD

Chris Soares, PhDJohn Worth, PhD

NVPO

Bruce Gellin, MD

Ben Schwartz, MD

NSC

Rita DiCasagrande, MS

CEA

Steven Braun, PhD

Get Informed, Be Prepared!

RESOURCES

WV Bureau for Public Health: http://www.wvflu.org

Your Local Health Department or Emergency Management Agency

USDHHS: http://www.pandemicflu.gov Seattle-King County Health:

http://www.metrokc.gov/health/pandemicflu/ CDC: www.cdc.gov