# Presentation: 472132

## Critical Infrastructure Groups Inter-meeting Work Group Summary

- Joint ACIP/NVAC Meeting on Pandemic Influenza Vaccine Prioritization
- Atlanta, GA
- June 15-16, 2005

## Participants

- Ban Allos, ACIP
- Carolyn Bridges, NIP, CDC
- Dale Brown,  DHS
- Louisa Chapman, NIP, CDC
- Elizabeth Falcone, NVPO
- Kathy Gensheimer, CSTE
- Penina Haber, OD, CDC
- Paul Hightower, DHS
- Arnold Kaufman, NCEH, CDC

- Max Kiefer, NIOSH, CDC
- Teri Palermo, NIOSH, CDC
- Ben Schwartz, NVPO
- Ray Strikas, NIP, CDC
- Marion Warwick, DHS
- David Weissman, NIOSH, CDC
- Pascale Wortley, NIP, CDC

## Goals of Group	

- Define groups essential to maintenance of critical infrastructure in the U.S.:
- That would be part of influenza pandemic response and/or
- Whose function may be substantially impacted by a pandemic
- Healthcare workers considered by separate work group so not included
- Identify proportions of persons within each group that would highest priority for vaccination (still in progress)
- Prioritize among the groups, if possible

## Overall Goals for Pandemic Planning

- First, to minimize severe morbidity and mortality
- Second, to preserve functioning of critical infrastructure and minimize economic loss

## Process Taken by Group

- Developed a list of assumptions on impact of a pandemic
- Reviewed data on size and functions of critical infrastructure groups based on earlier work based on sources from:
- White House, The National Strategy for the Physical Protection of Critical Infrastructures and Key Assets, February 2003
- Congressional Research Service, Critical Infrastructures:  What Makes an Infrastructure Critical? January 2003
- New data from the Department of Homeland Security
- Public Health Agency of Canada’s influenza pandemic plan
- Considered
- Experiences from recent table top exercises from non-influenza-related events
- Relative paucity of information in essential services functions in prior pandemics
- Major changes in business practices that may make systems more vulnerable

## What is Critical Infrastructure?

- The framework of independent networks and systems comprising identifiable industries, institutions and distribution capabilities that provide a reliable flow of products and services essential to the defense and economic security of the U.S., smooth functioning of government at all levels, and society as a whole.
- President’s Commission on Critical Infrastructure Protection, 1997

## Key Assumptions I

- Influenza vaccine is primary means of influenza prevention
- Overall goal of vaccine program will be to vaccinate all in U.S. who desire vaccination
- HOWEVER, vaccine supply likely to be limited at least at the beginning of a pandemic

## Key Assumptions II

- Prioritized those functions that would most directly be involved in pandemic response, support maintenance of the healthcare system, and maintain public safety and functioning of critical infrastructure

## Key Assumptions III

- Vaccine production and use
- Time from candidate vaccine strain to first doses likely 6 or more months
- Current U.S. production capacity 5 M doses per week
- 2 doses/person likely needed
- Dept of Defense likely will be high priority for vaccination 0.5 M-1.5 M persons
- Thus, need for rationale, explicit prioritization of vaccine

## Key Assumptions IV

- Health impact of a pandemic
- 25% (range in working age 20-30% most likely) of persons may become ill in major wave
- Additional persons will need to be home to care for ill family members
- Outbreak period in a community 6-8 weeks per wave with possibly >1 wave in a community
- Illness duration preventing work for uncomplicated case 5 days
- Rates and age distribution of influenza-related hospitalizations and deaths may vary substantially from 1918 to 1968 scenario
- 1-10% ill persons may be hospitalized
- 0.1–1% ill persons may die

## Principles for Prioritization of Vaccine Among Key Resource Workers in Critical Infrastructure Groups

- The epidemiology of the next pandemic may dictate alteration of prioritization recommendations
- Local needs and preferences may also alter prioritization at local level
- Vaccination strategies must be feasible to implement and rationale used for decision clearly explainable
- Because preventing severe illness and death is the first goal, critical infrastructure groups most directly tied to this goal were prioritized
- Also, groups critical to maintenance of critical infrastructure prioritizes to meet secondary goal of pandemic planning

## Major Limitation

- Very little information on impact of prior pandemics on critical infrastructure outside of healthcare sector
- Because of changes in business management practices, particularly in past decade, experience from prior pandemics may have less relevance

## Two Main Tiers Defined I

- Tier one
- Persons working in influenza vaccine and antiviral medication production
- 10,000-20,000 persons
- Key government health decision makers
- principally those in executive branch of local/state/fed government who develop and implement health-related policy
- total number persons not yet determined
- Non-healthcare workers in public health needed to
- assess pandemic impact
- allocate resources
- develop and implement pandemic-related policy and guidance
- assist with distribution vaccine and antivirals
- total number of persons not yet determined

## Two Main Tiers Defined II

- Tier one, con’t
- Public safety workers (fire, police, correctional facility, dispatchers)
- Critical for responding to emergencies with health implications and likely to be called on to ensure order at vaccination/antiviral clinics and maintain public order
- Total number: 2,987,000
- Critical number: yet to be determined
- Utility service workers (water, power, sewage management)
- Provide essential services for healthcare system and all other sectors where loss of service would likely to contribute to additional illness and protect overall public safety and critical infrastructure
- Total number: 364,000
- Critical number:  yet to be determined

## Two Main Tiers Defined III

- Tier two
- Transportation workers to maintain critical supplies of food, water, fuel and medical materials or who are likely to transport healthcare workers and patients to medical facilities
- Total number: 3.8 million (DHS industry estimate including trucking, passenger ground transportation, rail and water transportation)
- Critical number: yet to be determined
- Telecommunications
- Essential for accessing and delivering healthcare and response to emergencies and maintenance of critical infrastructure
- Total number: 1.08 million
- Critical number:  yet to be determined

## Two Main Tiers Defined IV

- Tier two, con’t
- Mortuary services
- Deaths expected to rise.  Although probably little direct health impact, large delays in these services could have substantial social/psychological impact
- Total number:  61,780 persons
- Critical number: yet to be determined
- Waste management
- With large reductions in this service, could possibly create health hazards
- Total number: 321,190 persons
- Critical number: yet to be determined

## Two Main Tiers Defined V

- Tier two, con’t
- Judicial branches of government
- Some functioning needed for maintenance of community function
- Total number of persons: 72,980
- Critical number: yet to be determined
- Financial Services
- Some basic functioning necessary for maintenance critial societal service
- This sector has developed estimate of critical personnel to prevent financial system collapse
- Critical number: 1,000 persons

## Critical Infrastructure Groups Considered

**	****	****	****	****	****	****Personnel****	****Cumulative**
_**Element**_**	****	****	****	****	**_**(1,000’s)**_**	**_**total (1,000’s)**_
**Health care****	****	****	****	****11,830****	****	****11,830**
**Ambulatory services****	****	****	****     885****	****	****12,715**
**Vaccine and antivirals manu.****	****	****       20****	****	****12,735**
**Key Executive Branch personnel****	****         ****	****   ****?100****	****	****12,835**
**	****for health care decisions**
**Non-healthcare PH workers****	****	****   ****?200****	****	****13,035**
**Public safety****	****	****	****	****  2,987****	****	****16,022**
**Utilities****	****	****	****	****     ****	****     364****	****	****16,386**
**Transportation****	****	****	****	****  3,800****	****	****20,186**
**Telecommunications****	****	****	****  1,052****	****	****21,986**
**Funeral directors/embalmers****	****	****       62****	****	****21,238**
**Waste management****	****	****	****     321****	****	****21,559**
**Judiciary****	****	****	****	****       73****	****	****21,632**
**Financial industry****	****	****	****         1****	****	****21,633**
**High risk persons (all)****	****	****	****88,300**

## More Work to Be Done

- Critical infrastructure groups described in prioritization are grossly defined
- Additional evaluation needed to
- Further define specific sections of each group critical for maintenance of function
- Evaluate surge capacity
- Establish mechanisms for identifying these personnel and feasible means for vaccine and/or antiviral medication delivery
- Identify additional groups along supply chains that may also need to be prioritized (e.g. critical food groups needed to supply food for transportation)

## Other Recommendations

- Recommend federal support for expansion of U.S. influenza vaccine manufacturing capacity
- Evaluation of technologies to speed vaccine production and assess dose sparing strategies (e.g. use of adjuvants, intradermal delivery) also high priority to improve vaccine availability
- Set aside some vaccine and antivirals to vaccinate groups of workers who may need to respond to unforeseen emergencies

## Pandemic vaccination program progress toward meeting 80% goal 

- Pandemic vaccination program progress toward meeting 80% goal
- for target groups, assuming 5 million doses available per week**

- * Also, roughly equal to immunizing 80% of all children under the age of 18
- ** Assume no waste and all vaccine goes to target group

**No. doses for immunity**

**Vaccinated Population**** ****(cumulative millions)**

- High Risk Only

- HCW Only

- Pandemic begins ????

- High Risk + HCW

- Critical Infrastructure Only