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North Florida Region
Domestic Security Task Force
Setting the Pace for Florida's Leadership
11/292/05 Version 3.3
Pandemic Influenza Workshop
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Pandemic Influenza Workshop Objectives
Prior Planning Prevents Pandemic Pandemonium
• Raise awareness about impact of pandemic flu on the health care system and the community as a whole. • Increase understanding of the responsibilities of all community partners. • Determine the adequacy of current plans to address the range of anticipated events. • Identify gaps in coordination among community partners. • Promote planning continuity among all community partners.
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Education Format:
• Influenza Virus Characteristics
• History
• Surveillance
• Planning
Pandemic Influenza Workshop Format
Prior Planning Prevents Pandemic Pandemonium
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Exercise Format:
• Interactive Tabletop
• 3 Modules
•Prepare, Respond, Recover, Mitigate
• Hot Wash
• Action Plan
Prior Planning Prevents Pandemic Pandemonium
Pandemic Influenza Workshop Format
5Prior Planning Prevents Pandemic Pandemonium
Pandemic: An infectious disease epidemic that affects people worldwide or over an extensive geographical area.
Pandemic Definition
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Primitive “life” form
Only one function: Replication
Influenza Virus Characteristics
Prior Planning Prevents Pandemic Pandemonium
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Influenza Virus Infection
Prior Planning Prevents Pandemic Pandemonium
Stellenbosch University, Tygerberg, South Africa
Virus slips in RNA issues orders Viruses break out
High efficiency High mutation rate Confuses body defenses
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Virus Exchange Program
Wild Birds -- Chickens
Chickens -- Humans
Chickens -- Pigs
Pigs -- Humans
Humans -- Humans
Influenza Virus Characteristics
Prior Planning Prevents Pandemic Pandemonium
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H5N1 Outbreak in Birds12/2003 – 03/2006
Countries Affected (confirmed in poultry)
December 2003-March 2006 Source: World Health Organization
Cambodia China Indonesia Croatia Slovakia
Kuwait Japan Russia Kazakhstan Switzerland
Korea (Rep. of) Thailand Vietnam Ukraine Hungary
Romania Turkey Mongolia Malaysia Albania
Iraq* Nigeria Bulgaria Greece Poland
Italy Iran India Egypt Pakistan*
Austria Azerbaijan Germany France Serbia & Montenegro*
Bosnia* Laos* Slovenia Niger Burkina Faso
* - Only H5 confirmed, neuraminidase not determined
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Direct – Viral particles are contained in droplets resulting from an uncovered sneeze or cough.
Breathing them in can result in an infection.
Influenza Virus Transmission
Prior Planning Prevents Pandemic Pandemonium
During a sneeze, millions of tiny droplets of water, mucus, and virus particles are expelled at 200 mph.
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Indirect – Viral particles may survive for a short time on many surfaces (hands, door knobs, phones). Touching these surfaces may transmit infection through eyes, nose, or mouth.
Influenza Virus Transmission
Prior Planning Prevents Pandemic Pandemonium
What precaution do these transmissions suggest?
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History
“No disease the world has ever known even remotely resembles the great influenza epidemic of 1918. Presumed to have begun when sick farm animals infected soldiers in Kansas, spreading and mutating into a lethal strain as troops carried it to Europe, it exploded across the world with unequaled ferocity and speed. It killed more people in twenty weeks than AIDS has killed in twenty years; it killed more people in a year than the plagues of the Middle Ages killed in a century. Victims bled from the ears and nose, turned blue from lack of oxygen, suffered aches that felt like bones being broken, and died. In the United States, where bodies were stacked without coffins on trucks, nearly seven times as many people died of influenza as in the First World War.”
Prior Planning Prevents Pandemic Pandemonium
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History – Some Statistics
Death Toll Worldwide: 40 - 100 Million
Death Toll US: 650,000
Normal Season Flu Death Toll: 36,000
Normal Sean Flu Hospitalizations: 200,000
Most Susceptible Population Age: 15-34
Number of Flu-Orphans in NYC: 21,000
Prior Planning Prevents Pandemic Pandemonium
I had a little bird
His name was Enza
I opened up the window
And Influenza
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History -- Pandemic Spread
• Exceptionally Virulent Strain
• New and Rapid Population Mixing (Training Camps)
• WWI Overseas Deployments
• Initial Lack of Communications (Sedition Act)
• Quarantine – None early on
• Weak Public Health Infrastructure
Prior Planning Prevents Pandemic Pandemonium
Liberty Bond Rally
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History – Other Pandemics
1957 Asian Flu -- US Deaths 69,800
1968 Hong Kong Flu – US Deaths 33,800
Pandemic Flu Scares:
1976 Swine Flu
1977 Russian Flu
1997 -1999 Avian Flu
Non-Flu Scare: SARS Multi-Country Outbreak
Prior Planning Prevents Pandemic Pandemonium
SARS Precautions
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Inter-Pandemic Period – Phases 1 and 2
Inter-Pandemic Period – Phases 1 and 2
•No new influenza virus•Develop plans and exercise them•Educate the public (throughout all phases)•Vaccinate public•Surveillance
Prior Planning Prevents Pandemic Pandemonium
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Pandemic Alert Period – Phase 3
The phase we are currently in
Pandemic Alert Period—Phase 3
•Human infection with a new subtype•No human to human spread
•Monitor the situation via surveillance systems and communication with Florida DOH•Communicate with community partners
Prior Planning Prevents Pandemic Pandemonium
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Pandemic Alert Period – Phase 3
The phase we are currently in
Prior Planning Prevents Pandemic Pandemonium
• Pandemic Alert Period—Phase 3 Actions– Stockpile masks, hand-sanitizer, anti-virals– Nationally—encouraging the development of
vaccine– Nationally—develop more rapid testing
methods– State-Increase surge capacity of laboratories
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Human Cases of H5N1 Avian Flu 2003-2006
Country Total Cases Deaths
Indonesia 29 22
Cambodia 4 4
Thailand 22 14
Vietnam 93 42
China 15 10
Turkey 12 4
Iraq 2 2
Azerbaijan 7 5
Egypt 7 (4 initial confirmation only) 4
Jordan 2 (initial confirmation only)
Total 193 107
As of 04/04/06 Source: World Health Organization (laboratory confirmed cases)
55%
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Pandemic Alert Period – Phase 4
Prior Planning Prevents Pandemic Pandemonium
• Pandemic Alert Period—Phase 4– Limited human to human transmission
• Isolate / treat the sick
• Vaccinate / treat close contacts
• Encourage self-quarantine
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Pandemic Alert Period – Phase 5
Prior Planning Prevents Pandemic Pandemonium
• Pandemic Alert Period—Phase 5– Larger clusters but still localized– Adjust and maximize resources—questionable use of
points of distribution (drugs are trickling in)– If available deploy prototype vaccine
• Questionable use of points of distribution• Decision on who to vaccinate (ethics?)
– Assess staffing issues– Travel restrictions– Social distancing
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Pandemic Alert Period – Phase 6
Prior Planning Prevents Pandemic Pandemonium
• Pandemic Period-Phase 6– Increased and sustained transmission– Alternative treatment sites– Ventilator decisions– State resources for aid– Continue risk management– Maintain surveillance, including deaths
• Morgue surge capacity• Funeral supplies may be limited
25Prior Planning Prevents Pandemic Pandemonium
• Sentinel physicians – how many are in your county?
• ESSENCE – influenza symptoms, patient load, etc.
• BIOSENSE – military hospitals• EpiCom• Vital Statistics – death rates• School absenteeism
Human Surveillance
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• Sentinel Physicians
• Hospitals
• County Health Departments
• Department of Health and Private Labs
• Department of Agriculture and Consumer Services
• Centers for Disease Control and Prevention (CDC)
• World Health Organization (WHO)
Communication! – Communication! – Communication!
Surveillance Partners
Prior Planning Prevents Pandemic Pandemonium
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Between Waves
Prior Planning Prevents Pandemic Pandemonium
• Between waves– Ensure staff recovery– Re-stock supplies/medications– Lessons learned to improve
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Current Situation -- Avian Flu – Phase 3:
• Bird to Human transmission still very rare
•Vaccine in development for birds for H5N1
•Vaccine in development for H5N1 for humans – this is not the same as a human to human virus we are planning for
• Human to Human transmission even more rare
•We can’t develop a vaccine until we know the human to human strain
• Will this be the “Big One”?
Influenza H5N1 – Avian Flu
Prior Planning Prevents Pandemic Pandemonium
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Request to Fund – National Strategy
Prior Planning Prevents Pandemic Pandemonium
DOH – 12/5/05
• Global surveillance $ 251 million• Vaccine technology $ 2.8 billion • Purchase medication • and vaccines $ 800 million• Vaccine for HHS $ 1.5 billion• Stockpile anti-virals $ 1.0 billion• Emergency preparedness $ 644 million• Total $ 7.1 billion
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The thing to Keep in Mind for Now:
Influenza H5N1 – Avian Flu
Prior Planning Prevents Pandemic Pandemonium
NOT Recommended.
31Pandemic Pandemonium
The Clock is Ticking….
We just don’t know what time it is.
Surveillance Urgency
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• We will have an epidemic soon of a strain of influenza to which none of us is immune.
• We will likely have only a short window between when the strain is clearly causing disease and when it starts causing widespread disease where we live.
• Vaccine likely won’t be available for 6 to 9 months after the epidemic starts.
• Supplies of anti-virals will be far less than needed for total-population coverage or even coverage of high-priority groups.
Planning Assumptions
Prior Planning Prevents Pandemic Pandemonium
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Predicted Morbidity Range for Palm Beach County
• 35% Attack Rate
Predicted Mortality Rate for Palm Beach County•5% of those infected
Planning Assumptions
Prior Planning Prevents Pandemic Pandemonium
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Planning Assumptions
Prior Planning Prevents Pandemic Pandemonium
Palm Beach Population 1.2 Million
Attack Rate 35% 420,000
Seeking Treatment 75% 315,000
Hospitalization Rate 10% 31,500
Mechanical Ventilation 7.5% 23,625
Fatality Rate 5% 21,000
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• Once the pandemic takes hold, we have to assume that there will be little to No Help from the national or state level – not just for days, but for weeks, and perhaps months.
• We have to assume that every county and every community will be pretty much on its own in an influenza pandemic.
• County Health Department will have ICS Lead.
Planning Assumptions
Prior Planning Prevents Pandemic Pandemonium
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• When a vaccine first becomes available, who should get it?
• How should we use the limited supplies of antiviral medications? (Tamiflu – 10 doses in five days. Must be taken within 48 hours.)
• Given lack of vaccines and anti-virals, how do we approach reducing illness and death?
• What is the right balance among minimizing health burden, economic damage, and societal damage?
Planning Questions
Prior Planning Prevents Pandemic Pandemonium
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Can we hold the fort till we can get vaccine?
• The longer we can delay the onset of the epidemic in our community, the more illness we can prevent.
• This will require vigorously applying measures that have limited effectiveness and a strong and continuous, risk communication campaign directed to all of our citizens.
Planning – More Questions
Prior Planning Prevents Pandemic Pandemonium
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The placement of sick persons with specific infectious illness in separate rooms from those who are healthy. This is usually voluntary and may be at their own home or at a hospital
Planning – Isolation
Prior Planning Prevents Pandemic Pandemonium
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Usually voluntary, but the FDOH Secretary may declare a public health emergency and issue a quarantine order to separate and restrict movement of people who have been exposed to an infectious agent, and may therefore become infectious
Planning – Quarantine
Prior Planning Prevents Pandemic Pandemonium
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• Isolate the sickVoluntary or legally
mandated?
• Quarantine well, exposed persons
Voluntary or legally mandated?
• Limit personal interactionse.g., close schools and
day-care, stop large public gatherings
Planning – Options for Disease Prevention
Prior Planning Prevents Pandemic Pandemonium
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• Change social norms about self-quarantine, personal hygiene, shaking hands, and masks.
• Advise travel restrictions.
• Home management of uncomplicated influenza
-- Recognition of complications
-- Management of complicated patients
Planning – Behavioral Modification
Social Marketing
Prior Planning Prevents Pandemic Pandemonium
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• Stigmatization of vulnerable groups
• Equity in access to care and in application of isolation and quarantine
• Civil liberties balanced with effective disease control
• Potential for civil disorder and vigilante actions
• Trust in government and health care system institutions, especially if initial measures seem to fail
• Long-term stress and behavioral health
Planning – Social Issues
Prior Planning Prevents Pandemic Pandemonium
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• Cost of care and cost of providing preventive measures.
• Impact on essential services and general productivity of widespread illness – e.g., 10% of workforce out sick continuously for many weeks.
• Curtailment of business travel, shopping, and entertainment venues.
• Shipment of goods, including food, fuel, and essential supplies
Planning – Economic Issues
Prior Planning Prevents Pandemic Pandemonium
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• Lots and lots of issues and opportunities with risk communication
• Prompt, accurate, clear
• Acknowledge uncertainties
• Provide frequent updates as new info becomes available
• Manage the level of expectations
Planning – Communications Issues
Prior Planning Prevents Pandemic Pandemonium
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• For Unusual death in domestic birds call:
•USDA – Veterinary Services for Florida at
1-866-536-7593
•The Florida Department of Agriculture recommends that you contact your local agriculture extension at Broward County Fish and Game – Non-Game Division 561-625-5122 – Sharon Hood
•The Florida Dept of Agriculture / Division of Animal Industry can be reached at 850-410-0900
Communications
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