Pandemic Planning: Worthy Endeavor or Waste of Time? Pandemic Flu Symposium Saratoga, NY November 8, 2006 Anita L. Barkin, DrPH, MSN,CRNP Carnegie Mellon University ab4x@andrew.cmu.edu Purpose • Discuss the importance of planning • Identify the challenges to planning • Describe specific areas that should be included in planning – Meeting the health and safety needs of students – Addressing planning issues for the campus-wide response Why plan? • More effective response to any public health emergency • Pandemics are a part of human history • H5NI is endemic in the bird population and shares some of the characteristics of the H1N1 which was responsible for 1918-1920 Pandemic • There will be little time to act once the event starts Pandemic Threat • Condition One – Novel virus • Condition Two – Crosses species – Humans, pigs, tigers, cats • Condition Three – Efficient, persistent human-to-human transmission • Reassortment • Mutation Pandemics • Ten recorded over past 300 years – Range between events 10-49 years, average 24 – No predictable pattern • Three in the past century – 1957-58 – reassortment event – 1967-68 – reassortment event – 1918-20 – mutation event with markers similar to those found in birds Pandemic Influenza in the 20th Century Seasonal vs Pandemic Flu • Seasonal influenza – Peaks usually December thru March in North America – 36,000 deaths/200,000 hospitalizations/yr – Frail, elderly and very young – U shaped distribution • Pandemic influenza – Rapid, global spread among humans – No seasonal preference – Comes in waves – Total duration a year or more – Millions of deaths Pandemic influenza: 2nd waves • 1918: three waves over a 18 month period – The second and third waves were worse than the first • 1957: second wave began 3 months after peak of the first wave • 1968: second wave began 12 months after peak of the first wave Concerns about H5N1 • Highly pathogenic strain that has persisted in the bird population despite culling of millions of domestic and wild birds. • New role of migratory birds as an additional, significant source of international infection during 2005 • Crossed species infecting 42 animal species beyond birds including humans • Limited human-to-human transmission has occurred Similarities to 1918 • High mortality rate – Appears to have W shaped mortality curve • Has the same protein tag – NS1 protein found in H1N1 and H5N1 only ones alike out of 169 viruses – Increased level of tumor necrosis factor alpha assoc with tissue destruction – Cascade leading to cytokine storm ->ARD America’s deaths from influenza were greater than the number of U.S. servicemen killed in any war Planning Assumptions • Attack rate - 25%-50% • Sickness rate 4%-12% – Normal flu is 5-10% • Absenteeism – 25%-35% for 5-8 days over a 3 month period • Difficult to impossible to travel • Disruptions and shortages of fuel, food stuffs, health care Clinical Features • Aggressive clinical course with concentration in previously healthy children and young adults • Current features – Virus can survive in environment 6-35 day • droplet infection • depending on temperature – Incubation period in humans ranges from 2-17 days • 7 day range current WHO standard for observation Clinical Features (con’t) • High fever, bodyaches, malaise • Diarrhea, vomiting and abdominal pain in some cases • Respiratory distress within 4-13 days of onset – Pneumonia consistent feature in severe cases • Multi-organ failure Treatment • Oseltamivir and Zanavir – Prior to outbreak in Turkey, most patients treated late in disease – Early detection with treatment is stressed – Recommendations on optimum dosing and duration of treatment continue – Expensive, production capacity limited • Antibiotics – Not effective in treating pneumonia Vaccine • Clinical trials ongoing • Adjuvant that allows for effective delivery and adequate immune response using smaller doses of vaccine developed • New technologies for vaccine development continue to be explored • Will not be available at the start of pandemic and there will not be sufficient amounts to vaccinate everyone Goal of Public Health: Slow down spread • Isolation of the sick • Quarantine of the exposed • Protective sequestration – Isolating a community before illness enters • Social Distancing – Actions taken to discourage close social contact between individuals • Public education – Accurate, clear – Consistent with those being given by other public health authorities Liberty Loan Parade - Philadelphia September 28, 1918 Influenza control: Isolation • Influenza isolation precautions* – Private room or with other influenza patient – Negative air pressure room, or placed with other suspected influenza cases in area of hospital with independent air supply – Masks for HCW entering room – Standard droplet precautions (hand washing, gloves, gown and eye protection) Influenza control: Quarantine • Challenges – short incubation period for influenza – a large proportion of infections are asymptomatic – clinical illness from influenza infection is non specific • Not used during annual epidemics • Could potentially slow onset of a pandemic before sustained person-to-person transmission has been established Social Distancing Strategies • Perceived risk influences behavior • No group gatherings including classes, worship services, athletic events, cafeteria style eating • Risky to use public transportation- defer travel • People can work alone in spaces, drive in their own cars Social Distancing Strategies con’t • Maintain working distances of 4-6 feet • Implement a shift schedule • Do not share equipment (eg. computer keyboards, telephones) • Meet/counsel by phone or video conferencing, avoid face-to-face meetings Issues of School Closure • Perceived risk will influence behavior – Will people show up for work/class? – What level of absenteeism will force closure? • Pulling the trigger early may helps schools meet the demands of the few instead of the many – Issues with waiting: • Students may become ill, require care and not be able to go home. • Schools will be straining to meet needs while experiencing shortages of staff and supplies. – Issues with calling it early: • Social disruption School closure • Defining closure – Lock down of buildings? – Cancellation of classes and students are sent home? – Research continues? • Stages of closure or curtailment of activities may make more sense. Challenges to Planning • Requires multi-faceted, multi-departmental effort over time • Deficits in knowledge – When? H5N1? – Gaps in our understanding of viruses – Gaps in our understanding of which strategies are most effective Challenges to Planning • Considering the what ifs – we can’t send all students home? – we have students who are ill and the local health systems are overwhelmed? – we must work with a reduced staff? • Allocation of resources – Stockpile goods? How much? – Questions of ethical nature Planning in the Present • Based on current knowledge and understanding • Inclusive, collaborative • Plans must be flexible, adaptable, resilient • Plans must be tailored to the particular type of institution • Plans must be tested and rehearsed Determining triggers for Moving Plans to Action • Short window for critical decision making. • Reducing the number of students on campus may be best strategy. – Resources/expectations for care/support • Once closed…when do you reopen? – 8-12 weeks to avoid resurgence of illness – Define closing – no classes? No research? Lock down of all buildings? Levels of Emergency Response • WHO - 6 response levels • Carnegie Mellon - 3 response levels – Level One • Pre-event planning to first case of human-to-human transmission – Level Two • Suspected/confirmed cases of sustained human-to-human transmission anywhere in the world – Level Three • Suspected/confirmed cases in the United States Key Considerations • Identify essential functions and personnel. – Depth charting • Identify appropriate channels of communication and chain of command within your institution. • Establish communications with key external partners including government agencies, local health authorities and hospital/health systems. “The pandemic clock is ticking, we just don’t know what time it is” E. Marcuse Time well spent • Pandemic flu will occur • Advanced planning will be crucial • Planning will be useful for any public health or campus-wide emergency • Individual and family emergency planning is critical • Community welfare will be commensurate with preparedness and commitment Resources • Posted on American College Health Association website – Resources and B.Board are in place for questions/suggestions • CSHEMA – www.cshema.orgn • General guidelines, educational materials, health care precautions – www.pandemicflu.gov – www.pandemicflu.gov/plan/maskguidance.html Q & A