Preparing for a Influenza Preparing for a Influenza Pandemic in Utah Pandemic in Utah

Robert T. Rolfs, MD, MPHRobert T. Rolfs, MD, MPH

Utah Department of HealthUtah Department of Health

December 4, 2006December 4, 2006

About InfluenzaAbout Influenza

Viral illness - Influenza A, B, C Abrupt onset fever, chills, muscle aches, headache,

followed by cough, sore throat, nasal congestion 5-6 days restricted activity, 3 days lost from school

or work Transmission – person to person

Respiratory droplets, contaminated hands/surfaces, aerosol

Infectious – 1 day before to 5 days after illness onset Short time from infection to transmission leads to

rapid spread in community

Spread of an Infectious Disease

Generation Time

Days

11 22 33 44 55 66 77 88

SARS - Generation time = 8-10 days

Influenza - Generation time = 2-4 days

What is Seasonal Influenza?What is Seasonal Influenza?

““Annual” seasonal epidemicsAnnual” seasonal epidemics Attack rates average 5-20%Attack rates average 5-20% 20-40,000 deaths in U.S. annually20-40,000 deaths in U.S. annually Greatest effect on very young and Greatest effect on very young and

older adultsolder adults

Result of antigenic “drift”Result of antigenic “drift” Ongoing changes of influenza viruses Ongoing changes of influenza viruses

that allow people to be infected more that allow people to be infected more than oncethan once

Percentage of Visits for Influenza-Percentage of Visits for Influenza-like illness (ILI) Reported by like illness (ILI) Reported by

Sentinel ProvidersSentinel ProvidersUtah 2003-4, 2004-5 and 2005-06 Utah 2003-4, 2004-5 and 2005-06

seasonsseasons

0

2

4

6

8

10

12

10/810/22

11/511/19

12/312/17

12/311/14

1/282/11

2/253/11

3/25 4/8

Week Ending

%

tota

l vis

its f

or

ILI

2003-04 2004-05 2005-06 Utah Baseline

Influenza-associated Influenza-associated Hospitalizations Utah 2005-Hospitalizations Utah 2005-

2006*2006*

10.9

2.4

0.6 0.4 0.71.8

4.5

15.7

0

2

4

6

8

10

12

14

16

18

< 1 1 - 4 5 - 14 15 - 44 45 - 54 55 - 64 65 - 74 75 +

Age Group

Rat

e pe

r 10,

000

pers

ons

•Date as of March 1, 2006

0

1

2

3

4

5

6

7

8

9

10

Date

All

ca

us

e a

bs

en

tee

ism

pe

r 1

00

stu

de

nt-

da

ys

-0.1

0.1

0.3

0.5

0.7

0.9

1.1

1.3

1.5

ILI a

bs

en

tee

ism

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r 1

00

stu

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All Cause Absenteeism ILI Absenteeism

Student Absenteeism by WeekFigure 5. Rates for absences due to all causes and influenza-like illness (ILI)- Utah, 2005-2006 influenza season

Student Absenteeism RatesStudent Absenteeism Rates2005-2006 Influenza Season2005-2006 Influenza Season

Many varieties of influenza occur in Many varieties of influenza occur in birdsbirds Primarily affects wild aquatic birdsPrimarily affects wild aquatic birds Serious illness is unusual in wild birdsSerious illness is unusual in wild birds

Illness more severe in domestic Illness more severe in domestic poultry, classified based on severitypoultry, classified based on severity

Most avian influenza viruses don’t Most avian influenza viruses don’t infect humansinfect humans

Highly pathogenic avian influenza is Highly pathogenic avian influenza is not found in Utah at this timenot found in Utah at this time

Avian InfluenzaAvian Influenza

What is an Influenza What is an Influenza Pandemic?Pandemic?

Global outbreak of influenzaGlobal outbreak of influenza Appearance of new type of influenza A Appearance of new type of influenza A

virus to which people have no immunityvirus to which people have no immunity Can cause serious illness and spread Can cause serious illness and spread

rapidly from person to person worldwide.rapidly from person to person worldwide. Past pandemics have caused high levels Past pandemics have caused high levels

of illness, death, social disruption and of illness, death, social disruption and economic loss.economic loss.

PandemicPandemic StrainStrain Est. DeathsEst. Deaths

U.S.U.S.

Est. DeathsEst. Deaths

WorldwideWorldwide

Spanish Spanish

(1918-19)(1918-19)H1N1H1N1 ~650,000~650,000 ~50 million~50 million

Asian Asian

(1957-58)(1957-58)H2N2H2N2 ~70,000~70,000 > 1 million> 1 million

Hong Kong Hong Kong

(1968-69)(1968-69)H3N2H3N2 ~34,000~34,000 > 1 million> 1 million

Influenza Pandemics in the Influenza Pandemics in the 2020thth Century Century

Influenza pandemics – death Influenza pandemics – death rates by agerates by age

1918 Influenza PandemicDeath rates - United Kingdom, 1918-

19

Tauberberger JK, Morens DM. 1918 Influenza: the Mother of All Pandemics. EID 206;12(1). http://www.cdc.gov/ncidod/eid/vol12no01/05-0979.htm#Figure1

Iowa State gymnasium, converted into hospital,1918 flu epidemic

Spread of H2N2 in 1957Spread of H2N2 in 1957

1968 Pandemic – peak by 1968 Pandemic – peak by statestate

Sharrar RG. National influenza experience in the US, 1968-1969. Bull. WHO 1969;41:361-66.

Avian Influenza H5N1Avian Influenza H5N1

1997 – Hong Kong outbreak1997 – Hong Kong outbreak 18 persons hospitalized & 6 deaths18 persons hospitalized & 6 deaths Live bird markets, controlled by destruction of Live bird markets, controlled by destruction of

poultry (>1.5 million)poultry (>1.5 million) 2003 Re-emerged in China, Vietnam, 2003 Re-emerged in China, Vietnam,

Thailand, KoreaThailand, Korea Poultry outbreaks and human casesPoultry outbreaks and human cases

2005 – 20062005 – 2006 Ongoing poultry outbreaks & human infectionsOngoing poultry outbreaks & human infections 11stst human-to-human transmission human-to-human transmission Wild birds, other mammals found infectedWild birds, other mammals found infected Spread to Eurasia, Africa, and EuropeSpread to Eurasia, Africa, and Europe

Avian Influenza (H5N1)Avian Influenza (H5N1)Human disease 2003-Human disease 2003-

20062006 Human cases – 258 cases with 154

deaths > 50% case fatality rate

How people get it Direct contact with poultry Very limited person-to-person spread

Effective person-to-person spread is not occurring at this time

Human cases are from Dec. 26, 2003 through November 29, 2006

Avian Influenza H5N1Avian Influenza H5N1Human Cases – 2003-2006 *Human Cases – 2003-2006 *CountryCountry 20032003 20042004 20052005 20062006 Total Cases Total Cases

(Deaths)(Deaths)

AzerbaijanAzerbaijan 88 8 (5)8 (5)

DjiboutiDjibouti 11 1 (0)1 (0)

EgyptEgypt 1515 15 (6)15 (6)

IraqIraq 33 3 (2)3 (2)

TurkeyTurkey 1212 12 (4)12 (4)

CambodiaCambodia 44 22 6 (6)6 (6)

ChinaChina 88 1212 21 (14)21 (14)

IndonesiaIndonesia 1717 5353 72 (55)72 (55)

ThailandThailand 1717 55 33 25 (17)25 (17)

VietnamVietnam 33 2929 6161 93 (42)93 (42)

* Human cases through October 16, 2006

Nations With Confirmed Cases H5N1 Avian Nations With Confirmed Cases H5N1 Avian InfluenzaInfluenza(July 7, 2006)(July 7, 2006)

www.pandemicflu.gov (accessed October 22, 2006)

Avian Influenza (H5N1) Avian Influenza (H5N1) 20062006

Unprecedented animal epidemicUnprecedented animal epidemic Poultry or wild bird outbreaks in > 53 nations Poultry or wild bird outbreaks in > 53 nations

in Asia, Africa, Europein Asia, Africa, Europe Unlike most avian influenza, it has Unlike most avian influenza, it has

infected people causing severe illnessinfected people causing severe illness Have conditions been met for a pandemic?Have conditions been met for a pandemic?

Novel antigens – no human immunity - Novel antigens – no human immunity - YesYes Serious human infection – Serious human infection – YesYes Effective person-to-person spread – Effective person-to-person spread – Not yetNot yet

Will it cause a pandemic?Will it cause a pandemic? We don’t know We don’t know

Another Another pandemic pandemic willwill occur somedayoccur someday

Pandemic Influenza ImpactPandemic Influenza ImpactUtah ProjectionsUtah Projections

Moderate Pandemic1957/1968-like

Severe Pandemic1918-like

Illness (30%) 759,000 759,000

Outpatient Care (50%)

379,000 379,000

Hospitalizations 7,280 83,550

ICU Care 1,090 12,520

Ventilator 550 6360

Death 1,750 15,930

Projections are based on the U.S. estimates included in the HHS Pandemic Influenza Plan, and based on Utah 2005 population estimate (2,529,000); these estimates don’t account for age differences in populations

Pandemic Influenza Pandemic Influenza ProjectionsProjections

Utah – Moderate (1957/68-like)Utah – Moderate (1957/68-like)

225

375

562

712 712

562

375

225

0

200

400

600

800

1,000

1,200

week 1 week 2 week 3 week 4 week 5 week 6 week 7 week 8

Pati

en

ts

Wkly Admissions

# pts in hospital

# pts in ICU

# pts on ventilator

At peak – 150 admissions per day

Pandemic Influenza Pandemic Influenza ProjectionsProjections

Utah – Severe (1918-like)Utah – Severe (1918-like)

2,576

4,294

6,441

8,158 8,158

6,441

4,294

2,576

0

2,000

4,000

6,000

8,000

10,000

12,000

week 1 week 2 week 3 week 4 week 5 week 6 week 7 week 8

Pati

en

ts

Wkly Admissions

# pts in hospital

# pts in ICU

# pts on ventilator

At peak – 1700 admissions per day

Pandemic InfluenzaPandemic InfluenzaExamples of Community ImpactExamples of Community Impact

High absenteeism rates at work/school (20-High absenteeism rates at work/school (20-40%)40%)

Possible school closuresPossible school closures Event cancellations – concerts, meetings, Event cancellations – concerts, meetings,

conventionsconventions Travel restrictions and decreased tourismTravel restrictions and decreased tourism Economic and business impactEconomic and business impact Shortages of suppliesShortages of supplies Difficulty keeping police & firemen, doctors, Difficulty keeping police & firemen, doctors,

nurses, and other critical service providers nurses, and other critical service providers workingworking

Hospitals full – delayed care for routine or Hospitals full – delayed care for routine or even urgent illnesseseven urgent illnesses

Pandemic InfluenzaPandemic InfluenzaStrengthening Public Health Strengthening Public Health

CapacityCapacity All Hazards Disaster PlanningAll Hazards Disaster Planning Epidemiology & Disease SurveillanceEpidemiology & Disease Surveillance Laboratory Testing & ResponseLaboratory Testing & Response Information & Communication SystemsInformation & Communication Systems Effective Risk CommunicationEffective Risk Communication Training & ExercisesTraining & Exercises Hospital PreparednessHospital Preparedness

Pandemic Influenza Pandemic Influenza PlanningPlanning

Some planning assumptionsSome planning assumptions Simultaneous outbreaks across Utah and U.S.Simultaneous outbreaks across Utah and U.S.

Limited ability to share resources across jurisdictionsLimited ability to share resources across jurisdictions In a given community, the epidemic will last 6-8 In a given community, the epidemic will last 6-8

weeksweeks No vaccine for first 6-8 months and shortages No vaccine for first 6-8 months and shortages

after thatafter that Shortages of antiviral medications and probably Shortages of antiviral medications and probably

of antibiotics and other medical suppliesof antibiotics and other medical supplies Illness rates and absenteeism of 25% or moreIllness rates and absenteeism of 25% or more Need for care may exceed capacity of health care Need for care may exceed capacity of health care

systemsystem

Pandemic Influenza PlanPandemic Influenza Plan

Utah Pandemic Influenza Plan – a Utah Pandemic Influenza Plan – a roadmaproadmap Identified what public health needs to doIdentified what public health needs to do

Pandemic influenza workgroupPandemic influenza workgroup Local health department planningLocal health department planning

Identified issues requiring broader input and Identified issues requiring broader input and help to addresshelp to address

Governor’s TaskforceGovernor’s Taskforce Too big for (any) government aloneToo big for (any) government alone

Local governments, faith-based & community Local governments, faith-based & community organizations, businesses, families, individualsorganizations, businesses, families, individuals

Pandemic Influenza Pandemic Influenza PreparednessPreparedness

Communications and coordinationCommunications and coordination Public/risk communicationsPublic/risk communications Agency/partner coordination and Agency/partner coordination and

communicationcommunication Health care surge capacityHealth care surge capacity Antiviral medication stockpileAntiviral medication stockpile Vaccine planningVaccine planning Maintaining essential servicesMaintaining essential services Supporting vulnerable populations & Supporting vulnerable populations &

essential respondersessential responders

Pandemic Influenza Pandemic Influenza PreparednessPreparedness

Community MitigationCommunity Mitigation Home isolationHome isolation Family quarantineFamily quarantine School closureSchool closure Cancellation of mass gatheringsCancellation of mass gatherings Social distancing and respiratory Social distancing and respiratory

hygienehygiene

Pandemic Preparedness in Pandemic Preparedness in SchoolsSchools

PlanningPlanning Maintaining core operations during pandemicMaintaining core operations during pandemic CommunicationCommunication

public health and other agencies/partnerspublic health and other agencies/partners students and parentsstudents and parents

Infection control policies, procedures, Infection control policies, procedures, suppliessupplies Keeping school safe, reducing spread of Keeping school safe, reducing spread of

influenzainfluenza Continuity of student learning & operationsContinuity of student learning & operations

School closure planningSchool closure planning

Pandemic and Avian Pandemic and Avian InfluenzaInfluenza

Additional informationAdditional informationUtah:Utah: http://www.pandemicflu.utah.govhttp://www.pandemicflu.utah.govHHS: HHS: http://www.pandemicflu.govhttp://www.pandemicflu.gov

John M. Barry The Great Influenza: The Epic John M. Barry The Great Influenza: The Epic Story of the Deadliest Plague In History Story of the Deadliest Plague In History

Neustadt R, Fineberg H. The Epidemic that Neustadt R, Fineberg H. The Epidemic that Never Was: Policy-making and the Swine Never Was: Policy-making and the Swine Flu AffairFlu Affair