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An Overview of Pandemic Influenza Planning in the United States

NAPHSIS Annual MeetingJune 7, 2006

David K. ShayInfluenza Division

Centers for Disease Control and Prevention


New Viruses Emerge, and Pandemics Happen

H1

H1H3

H2

H7*

H5*

H9*

1918Spanish

Influenza H1N1

1957Asian

Influenza H2N2

1968Hong Kong

Influenza H3N2

1980

1997

1915

*Avian Flu

2003 2004

1977

1996

2002

1925 1935 1945 1955 1965 1975 1985 1995 2005

2003-2006

1998

19992003


Avian Influenza A(H5N1)Why is Concern High?

• Impact on animals and economy– Lethal to poultry, and mammals infected– Present in waterfowl; shed in feces– Already has had a major economic impact

impact on humans

• Causes severe human disease– Might evolve to become easily transmissible– No H5N1 vaccine commercially available– Limited supplies of expensive antivirals


Pandemic Planning Must Occur in Many Sectors

• Federal government

• State and local governments

• Healthcare Systems

• Businesses and private sector

• Individuals and families


National Strategy for Pandemic Influenza

• Issued by President Bush in November 2005

• Guides U.S. preparedness and response by outlining responsibilities– Individuals– Industry– State/local governments– Federal government

• March 2006: Homeland Security Council Implementation Plan


Goals of the National Strategy

• Stop, slow, or otherwise limit the spread of a pandemic to the United States

• Limit the domestic spread, and mitigate disease, suffering, and death

• Sustain infrastructure and mitigate impact to the economy and functioning of society


Pillars of the National Strategy

• Pillar 1: Preparedness and Communication– Ensure preparedness– Communicate roles and responsibilities

• Pillar 2: Surveillance and Detection– Systems that provide continuous situational awareness– Ensure earliest warning possible

• Pillar 3: Response and Containment– Limit the spread of the outbreak – Mitigate the health, social and economic impact


Department of Health and Human Services (HHS)

Pandemic Influenza Plan• Released November 2005• Supports the National Strategy• Outlines key roles of HHS and its

agencies• Doctrine for health sector

preparedness and response• Public health guidance for state and

local partners• HHS Operational Plan will be

released soon


Planning Assumptions• All will be susceptible to infection with the

pandemic virus due to lack of existing immunity• The clinical attack rate might approach 30%, and

50% of persons who become ill will seek healthcare

• Each wave of infections in a community will last for approximately 6-8 weeks; 2 or 3 waves possible

• Groups at higher risk for severe disease/death cannot be predicted in advance, and may not correspond to those for seasonal influenza (eg, elderly and those with comorbid conditions)


Moderate (1957-like) Severe (1918-like)

Illness 90 million (30%) 90 million (30%)

Outpatient medical care

45 million (50%) 45 million (50%)

Hospitalization 865,000 9,900,000

ICU care 128,750 1,485,000

Mechanical ventilation 64,875 745,500

Deaths 209,000 1,903,000

• 50% or more of those who become ill will seek medical care• Number of hospitalizations and deaths will depend on the

virulence of the pandemic virus

Burden of Pandemic Influenza


Pandemic Influenza Doctrine:Saving Lives

• A threat anywhere is a threateverywhere

• Quench first outbreaks: detect andcontain where it emerges, if feasible

– International collaborations – Frontline detection and response; rapid laboratory diagnosis – Isolation / quarantine / antiviral prophylaxis / social distancing / animal culling


Pandemic Influenza Doctrine: Saving Lives

Prevent or at least delay introduction into the

United States

• May involve travel advisories, exit or entry

screening

• For first cases, may involve isolation / short-term

quarantine of arriving passengers


HHS Pandemic Influenza Doctrine: Saving Lives

Slow spread, decrease illness and death, buy time

• Antiviral treatment and isolation

• Quarantine for those exposed

• Social distancing

• Vaccination

Weeks

Impact

Prepared

Unprepared


HHS Pandemic Influenza Doctrine: Saving Lives

Clearly communicate to the public

• Prepare people with information

• Encourage action steps to prepare now

• Provide updates when new information emerges

• Use trusted messengers

• Coordinate to ensure consistent messages

• Address rumors and inaccuracies


A Network of Shared Responsibility

• Local - state - federal • Domestic – international• Public – private• Multi-sector• Animal – human• Health protection –

homeland security – economic protection

Healthcare

DeliverySystem

Federal Partners

Education System

Business & Workers

Local /State /Federal Public HealthSystem


• State and Local• Business• Preschool• Schools (K-12)• Colleges & Universities• Faith-based & Community

Organizations

• Physician Offices and Ambulatory Care

• Home Health• Emergency Medical

Services• Travel Industry• Individuals


Countermeasures: Vaccines, Antivirals, and

Medical Supplies

Strategic National

Stockpile


H5N1 Vaccine

• Prototype vaccine developed by the National Institutes of Health

• Based on a H5 strain isolated in Viet Nam last year

• Elicits an antibody response but requires large dose

• 40 million doses (to protect 20 million people) being stockpiled


Challenges for Pandemic Vaccination

• Expand production of current (egg-based) vaccine • Evaluate dose-sparing technology

(adjuvants, intramuscular vs. intradermal route)• Accelerate development of modern (non-egg) vaccines • Target new antigens


Influenza Antivirals

• Goal: treatment courses in the Strategic National Stockpile (SNS) for 25%

• Current status of SNS – 5.1 million Tamiflu (oseltamivir) treatment

courses– 84,000 Relenza (zanamivir) treatment courses

• Additional orders have been placed• Accelerate development of promising new

antiviral candidates


Health Protection at the Frontline:

Local, County, and State Public Health Departments


Seasonal Influenza Preparedness

Pandemic Influenza Preparedness

Preparing for a pandemic now means: •Putting into place methods to follow influenza, ie, public health surveillance

•Improving measures to control influenza•Modern seasonal influenza vaccine for all who need it

•New antiviral drugs for prevention and treatment


Critical Role of Surveillance Data

• Response will require easily interpretable, up-to-date information

• CDC anticipates that at a minimum, the Federal, State, and local responses will require– Mortality rates (overall and pneumonia/influenza) by

state– Hospitalization rates, for some states or large

communities

• Data sufficient to conduct assessments of ‘countermeasures’ in several sites


Hospitalizations• Current systems

– Emerging Infections Program & New Vaccine Surveillance Network

• Children-only systems at present• Sites in 11 states

• Additional data sources– Expanded EIP: Inclusion of adults, special studies– Vaccine Safety Datalink– BioSense real-time hospitalization data– Hospital capacity

• Exploring use of a HAvBED-like system that accepts bed census data from existing systems


Mortality

• Current– 122 Cities Mortality Reporting System– Pediatric mortality reporting is a nationally

notifiable condition– NCHS mortality files

• Additional – Exploring timely reporting of all deaths


Enhancement of Public Health Surveillance Systems

• Highest priority systems– Electronic laboratory data exchange

• Rapid 2-way exchange of patient-level data– Electronic death reporting

• Early use of mortality data submitted by funeral directors

• Benefits– Build public health reporting systems that would have

multiple uses– Use existing electronic data– Allow sub-state level analysis


Infectious Disease Mortality, United States--20th Century

Armstrong, et al. JAMA 1999;281:61-66.


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