Pandemic Response Briefing to Business &

Community LeaderScenario time: Oct 24

Group 2

Tammy Hunt

David Broudy

Outline1. The challenge

Without intervention:

• 800K - 9.6M Hospitalizations• 18-42M outpatient visits• 80K - 285K deaths

2. Epidemiology: Breaking the cycle of transmission

3. What is to be done? A strategy for communities

Why Multnomah Co should support community interventions• Medical measures may be delayed• Efficacy of vaccine and antivirals unknown• Infection Control Measures are effective• History of 1918 Pandemic supports aggressively

limiting assemblage– The longer you wait to intervene, the worse the effects

of the epidemic

• Working together and building our community is good for business and good public health

Social Distancing and Infection Control

• Social Distancing (Contact Interventions) – School closure– Work closure (telecommuting) – Cancellation of public gatherings

• Infection Control (Transmission Interventions)– Facemasks– Cough etiquette– Hand hygiene

Non-pharmaceutical Interventions

• Ill persons should be isolated (home vs hospital)• Voluntary home quarantine for household contacts• Social distancing measures

– School closures may have profound impact– Keep your business going by allowing employees

to work from home– Cancellation of public events

• Individual infection control measures work– Hand washing and cough etiquette for all– Mask use for ill persons, PPE stratified by risk– Disinfection of environmental surfaces as needed

Community-Based Interventions

1. Delay disease transmission and outbreak peak2. Decompress peak burden on healthcare infrastructure3. Diminish overall cases and health impacts

DailyCases

#1

#2

#3

Days since First Case

Pandemic outbreak:No intervention

Pandemic outbreak:With intervention

Susceptible to Targeted Attack

Susceptible to Targeted Attack

Effect of R 0 on Epidemic Curve

Eubank S, personal communication

A Tale of Many Cities:What Does History Teach Us?

"...Spanish influenza is now present and probably will become epidemic in the City of St. Louis. In view of this proclamation, and under the authority vested in me by the City Charter of the City of St. Louis, after such proclamation in order to prevent all unnecessary public gatherings through the medium by which this disease is disseminated, I hereby order that all theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions to be at once closed and discontinued until further notice." --Mayor Henry Keil (October 7, 1918)

Liberty Loan ParadeSeptember 28, 1918

The drastic actions of Mayor Keil were sensible considering by October 7th, 167,000 cases had broken out, with 4,910 deaths, across the eastern United States. Mayor Keil's actions perhaps spared St. Louis of the worst outbreaks.

For instance for the October 10-November 2 time frame the following deaths were reported:

New York, 16,705 Boston, 3,694

Philadelphia, 12,162 Chicago, 7,405;

Baltimore, 3,507 St. Louis 784.

Weekly mortality data provided by Marc Lipsitch (personal communication)

1918 Weekly Excess Death Rate by City

0

0.002

0.004

0.006

0.008

0.01

0.012

0.014

0.016

0.018

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

Ex

ce

ss

De

ath

Ra

te Baltimore

Boston

Minneapolis

Philadelphia

Pittsburgh

St. Louis

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

es /

100

,000

Po

pu

lati

on

(A

nn

ual

Bas

is)

PhiladelphiaSt. Louis

1918 Age-specific Attack Rates

McLaughlin AJ. Epidemiology and Etiology of Influenza. Boston Medical and Surgical Journal, July 1920.

Why close schools?

• In 1918 the “spanish flu” had an unusually high attack rate among younger people

• Small children are efficient incubators and spreaders of infectious diseases

• Preventing the spread of the flu among children will reduce spread to families

• Reducing serious illness and death among working age adults will reduce impact on economy

• Flattening the epidemiology curve will allow distribution of scarce resources over longer periods.

To Children To Teenagers To Adults To Seniors Total From

From Children 21.4 3.0 17.4 1.6 43.4

From Teenagers 2.4 10.4 8.5 0.7 21.9

From Adults 4.6 3.1 22.4 1.8 31.8

From Seniors 0.2 0.1 0.8 1.7 2.8

Total To 28.6 16.6 49.0 5.7

Children/Teenagers 29%

Adults 59%

Seniors 12%

Demographics

Glass, RJ, et al. Local mitigation strategies for pandemic influenza. NISAC, SAND Number: 2005-7955J

School

Household

Workplace

Likely sites of transmission

Who Infects Whom?

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

MONTREAL 11.5%

SAN FRANCISCO 8.8%

ST. LOUIS 2.2%

Model Predictions – 1918 InterventionsRo = 2.1, 2% case fatality rate

Model Predictions – 1918 InterventionsRo = 2.1, 2% case fatality rate

Intervention DelaySensitivity

*Scenarios Attack Rate (%) Deaths

No intervention 46.8 80,405

Intervention at 12% 27.7 47,511

Intervention at 8% 23.9 41,045

Intervention at 2% 9.7 15,782

Intervention at 1% 5.3 9,107

Intervention at 1% w/ TARP

Case Rx, HH Px2.9 4,889

*Longini model for Chicago pop 8.8M, NPI intervention TLC w 30% compliance HH-Q

Acknowledgements

• Many of these slides are from a presentation by Martin Cetron, MD, Div Global Migration and Immigration, CDC

• Thanks to Subject Matter Expert for Group 2:– Chris Felstadt– Norm Nedell– Peter Rigby– Karen Pendelton– Matt Bernard– Diane Bonne, Facilitator

• Martin, MD• Director, Division of Global Migration and Quarantine

• Centers for Disease Control and \, MD• Director, Division of Global Migration and Quarantine

• Centers for Disease Control and, MD

Director, Division of Global Migration and QuarantineCenters for Disease Control and Prevention