# Presentation: 690108

**Pandemic Preparedness**
- Nicole M. Smith, PhD, MPH, MPP
- Centers for Disease Control and Prevention_ _

## Overview

- Review federal pandemic plans
- National strategy
- Planning assumptions
- Discuss domestic surveillance objectives

## Seasonal influenza viruses
Are a public health problem every year
Circulate throughout the human population
Spread easily from person to person

Avian influenza A (H5N1) viruses
Devastating global outbreak in poultry
Cause severe but rare human infections
Do not spread easily from person to person

Pandemic influenza viruses
Appear in the human population periodically
H5N1 is a likely candidate, but is not a pandemic virus yet

- Are a public health problem every year
- Circulate throughout the human population
- Spread easily from person to person
- Avian influenza A (H5N1) viruses
- Devastating global outbreak in poultry
- Cause severe but rare human infections
- Do not spread easily from person to person
- Pandemic influenza viruses
- Appear in the human population periodically
- H5N1 is a likely candidate, but _is not a pandemic virus yet_

**Seasonal, Avian, and Pandemic Influenza**

## Seasonal Influenza

**Seasonal Influenza**
**Preparedness**

**Pandemic Influenza**
**Preparedness**

## Concerns about Pandemic Influenza

- Rapid global spread (morbidity and mortality)
- Shortages and delays – vaccines and antiviral medications
- Increases burden on hospitals and outpatient care systems
- Disrupts national and community infrastructures

## Federal Pandemic Plans

**National Strategy for Pandemic Influenza**
**Homeland Security Council Implementation Plan for the National Strategy for Pandemic Influenza**
**HHS Pandemic Influenza Plan**
**Strategic Plan**
**Public Health Guidance for State and Local Partners**
**HHS Operational Plan (incl. continuity of operations**

## Goals of the National Strategy

- Stopping, slowing, or otherwise limiting the spread of a pandemic to the US;
- Limiting the domestic spread, and mitigating disease, suffering, and death; and
- Sustaining infrastructure and mitigating impact to the economy and functioning of society.

## Pillar One:  Preparedness and Communication

- Planning for a pandemic
- Communicating expectations and responsibilities
- Producing and stockpiling vaccines, antivirals, and medical material
- Establishing distribution plans for vaccines and antivirals
- Advancing scientific knowledge and accelerating development

**Notes:**
The National strategy serves as the framework for US planning efforts and is supported by three “pillars”.

Pillar One reflects activities that should be undertaken before a pandemic to ensure preparedness, including communicating roles and responsibilities to all levels of government, the private sector and individuals.

Planning:
Federal implementation plans
Work thru multilateral orgs to support plans in other countries
Work with states and localities
Build on existing mechanisms to recruit and deploy health, medical and veterinary providers within/across jurisdictions

Comm:
Ensure clear, effective, and coordinated risk communication domestically and internationally before and during a pandemic
Provide guidance to private sector and critical infrastructure re: their response role
Provide guidance to individuals re; infection control behaviors to adopt pre-pandemic/severe influenza season
Provide guidance and support to poultry, swine, and related industries re: their role in responding to an outbreak of avian influenza; ensuring protection of workers; public education campaigns to minimize risk of infection from animal products.

Producing and stockpiling:
-Encourage nations to develop on production capacity and stockpiles; est. regional resources
Encourage and subsidize state-based stockpiles of antivirals
Establish domestic production capacity and stockpiles

Distribution plans
-Establish plans
Develop and revise prioritization schemes

Advance knowledge:
Research and develop vaccines, antivirals, adjuvants, and diagnostics incl. cell culture tech for vax production

## Pillar Two: Surveillance and Detection

- Ensuring rapid reporting of outbreaks
- Using surveillance to limit spread

**Notes:**
Establish a surveillance and detection system that allows us to activate response plans before a pandemic virus is introduced in the US; activate additional surveillance systems; and initiate vaccine production and administration.

Rapid reporting:
-Work through IPAPI (Int’l Partnership on Avian and Pandemic Influenza) to ensure transparency, scientific cooperation and rapid reporting
Support development of proper scientific and epi expertise in affected regions
Support development and sustainment of lab capacity to provide rapid confirmation
Advance mechanisms for real-time clinical surveillance (EDs, ICUs, and labs)
Develop and deploy rapid diagnostics with greater sensitivity
Expand domestic livestock and wildlife surveillance activities to ensure early warning

Limit spread:
-Rapidly share info on travelers who may be infected or exposed
-Develop and exercise mechanisms to provide active and passive surveillance during an outbreak
-Expand and enhance mechanisms for screening and monitoring animals susceptible to viruses with pandemic potential
-Develop screening and monitoring mechanisms and agreements to control travel and shipping of potentially infected products to and from affected regions

## Pillar Three: Response and Containment

- Containing outbreaks
- Leveraging national medical and public health surge capacity
- Sustaining infrastructure, essential services and the economy
- Ensuring effective risk communication

**Notes:**
Containing:
Encourage all levels of government (domestically and internationally) to take appropriate and lawful action to contain an outbreak within their borders
Use governmental authorities to limit non-essential movement into and out of areas where an outbreak occurs
Provide guidance to all levels of gov’t on the range of options for infection control and containment (incl. non-pharmaceutical/PH interventions)
Emphasize roles and responsibilities of the individual

Leveraging:
-Impl state and local PH and med surge plans; leveragge all federal facilities, personnel and response capabilities
-Activate plans to distribute medical countermeasures from SNS and other distn centers
-Address barriers to the flow of personnel across state and local jurisdictions to meet local shortfalls
-Determine spectrum of surge capacity activities that the military and other gov’t entities may be able to support

Sustaining infrastructure:
-Encourage development of coordination mechanisms across industries
-Provide guidance to activate contingency plans to ensure worker protection, delivery of essential goods and services, and sectors remain functional despite significant and sustained worker absenteeism

Ensuring communication:
Ensure the timely, clear, and coordinated messages are delivered by trained spokespersons at all levels of gov’t
Work with state and local gov’ts to develop guidelines to assure the public of the safety of the food supply and mitigate the risk of exposure from wildlife

## WHO Phases and US Stagesof a Pandemic

| WHO Phases |  |  | US Stages |  |
| --- | --- | --- | --- | --- |
| Inter-Pandemic Period

(New virus in animals, no human cases) | Low risk of human cases | 1 | 
0 | 
New domestic animal outbreak in at-risk country |
|  | Higher risk of human cases | 
2 |  |  |
| Pandemic Alert

(New virus causes human cases) | No or very limited human-human transmission | 3 |  |  |
|  |  |  | 1 | Suspected human outbreak overseas |
|  | Evidence of increased human-human transmission | 4 | 2 | Confirmed human outbreak overseas |
|  | Evidence of significant human-human transmission | 5 |  |  |
| Pandemic Period | Efficient and sustained human-human transmission | 6 | 3 | Widespread human outbreaks in multiple locations overseas |
|  |  |  | 4 | First human case in North America |
|  |  |  | 5 | Spread throughout US |
|  |  |  | 6 | Recovery and preparation for subsequent waves |

**Notes:**
The planning efforts are based WHO phases and US stages that are linked to the characteristics of a new influenza virus and its spread throughout the population.

The US would initiate pandemic response actions at Phase 4, when epidemiological evidence of two generations of human-to-human transmission of a new influenza virus is documented anywhere in the world.

Stage 0 objectives (WHO 1, 2, or 3): Track outbreaks until control/resolution; provide coordination mechanisms, logistical support, and technical guidance; monitor for reoccurrence of disease.

Stage 1 objectives (WHO 3): Rapidly investigate and confirm or refute reports of human-to-human transmission; initiate coordination mechanisms and logistical support that will be necessary if an outbreak is confirmed.

Stage 2 objectives (WHO 4 or 5): Contain the outbreak to the affected region(s) and limit potential for spread to the US; activate the domestic public health and medical response.
 Stage 3 objectives (WHO 6): Delay the emergence of pandemic influenza in the US and North American populations; ensure the earliest warning possible of the first case(s) in North America; prepare our domestic containment and response mechanisms.

Stage 4 objectives (WHO 6): Contain the first cases on the continent with slowing of first and subsequent pandemic waves of spread; antiviral treatment and prophylaxis; and, implement the national response.

Stage 5 objectives (WHO 6):  Support community responses to the extent possible to mitigate illness, suffering and death; preserve the functioning of critical infrastructure and mitigate impact to the economy and functioning of society.

Stage 6 objectives (WHO 6 or 5):  Return all sectors to a pre-pandemic level of functioning as soon as possible; prepare for subsequent waves of pandemic.

## Planning Assumptions in the US (l)

- The seasonality of a pandemic cannot be predicted with certainty.
- Susceptibility to pandemic influenza will be universal.
- Overall, 30% of the population will become ill.
- 50% of those who are ill will seek outpatient medical care.
- The number of hospitalizations and deaths will depend on the virulence of the pandemic virus.
- Risk groups for severe and fatal infections cannot be predicted with certainty.

## US Burden of Influenza

**Seasonal**
**>200,000 hospitalizations**
**36,000 deaths**
**Pandemic**

|  | 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 |

## Planning Assumptions in the US (ll)

- The typical incubation period for influenza averages 2 days.
- Persons who become ill may transmit infection for one-half to one day before the onset of illness.
- On average about 2 secondary infections will occur as a result of transmission from someone who is ill.
- In an affected community, a pandemic outbreak will last about 6 to 8 weeks.
- Work/school absenteeism may be as high as 40% at the peak.
- At least two pandemic disease waves are likely.

## Potential Strategies to Decrease the Impact of a Pandemic

**Prevent or delay introduction, slow spread (Buy time)**
**Decrease illness and death**
**Antiviral treatment and isolation for people with illness**
**Quarantine for those exposed**
**Social distancing**
**Vaccine when available**

**Weeks**

## Potential Implications of Public Health Control Measures

- Support needed for people who are isolated or quarantined
- Limitations on travel due to restrictions, advisories, and screening measures
- Limitations on public gatherings
- Changes in the workplace to avoid disease
- Worker absenteeism due to school closures
- Vaccine initially limited to priority groups
- Antivirals reserved for containment

## Surveillance Objectives

- Ensure laboratory, epidemiologic, and clinical systems are in place.
- Detect and investigate initial human cases/clusters of H5N1/influenza virus subtypes with pandemic potential.
- Determine and track trends in the impact of disease in affected areas.
- Monitor changes in circulating influenza viruses and assess effectiveness of treatment guidelines, vaccines, antivirals, and public health interventions.

**Notes:**
Ensure that sensitive and comprehensive laboratory, epidemiologic, and clinical systems are in place to reliably detect and monitor the occurrence of pandemic influenza in each phase.

Reliably detect and investigate initial cases/clusters of HPAI disease or disease associated with other influenza virus subtypes with pandemic potential.

Determine and track trends in the impact of disease in affected areas.

Assess effectiveness of treatment guidelines, vaccines, antivirals, and public health interventions; use the data to inform decisionmaking.

Monitor antigenic and genetic changes in circulating influenza viruses, including the prevalence of antiviral resistance. 

## Establish and Enhance Systems to Detect and Monitor the Pandemic

- Provide standardized influenza reagents for influenza testing and research.
- Promote development, evaluation, licensure, and use of point of care rapid diagnostic tests.
- Train epidemiologists and other public health professionals in response and investigation methods.
- Create and update protocols for investigating and reporting suspect and confirmed cases.
- Ensure health care providers and the public are aware of case identification, reporting and appropriate utilization of health services.

**Notes:**
Reagents are being developed and distributed domestically and globally – discuss new H5N1 assay recently approved by FDA.

Need more sensitive and specific point of care tests.

Response training helps build domestic capacity, and also a cadre that can provide TA for other countries.

Need info about what’s happening in other countries (eg. Clinical presentation) to help guide our own case definitions and case investigation approaches.

Protocols incl. surveillance methods, case definitions, questionnaires, data analysis plans, and specimen collection/handling/testing guidelines for investigating and reporting suspect and confirmed cases.

## Detect and Investigate Initial Cases and Clusters (l)

- Continue routine surveillance for influenza.
- WHO and NREVSS collaborating labs
- Sentinel providers surveillance network
- 122 cities mortality reporting system
- Pediatric deaths
- EIP and NVSN

**Notes:**
World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) Collaborating Laboratories: Each week approximately 130 US WHO and NREVSS collaborating laboratories report the total number of specimens received for respiratory virus testing and the number of positive isolations of influenza A (H1N1), A (H3N2), A (not subtyped), or B.  WHO collaborating laboratories report these data by age group ( in years, < 1, 1-4, 5-24, 25-44, 45-64,  65, or unknown).  The laboratories participating are in state or local health agencies, universities, and hospitals. 

US Influenza Sentinel Providers Surveillance Network:  Each week from October through May, approximately 1,300 healthcare providers report the number of patient visits for the week and the number of those patients examined for influenza‐like illness by age group in years (0-4, 5-24, 25-64,  65). A subset of the providers continue to report year-round. The participating healthcare provider may collect nasal and throat swabs for virus isolation. 

122 Cities Mortality Reporting System:  Each week throughout the year the vital statistics offices of 122 cities report the total number of death certificates filed due to all causes for that week and the number of deaths for which pneumonia or influenza was mentioned in any position on the certificate.  A seasonal baseline is calculated, and if the proportion of pneumonia and influenza (P&I) deaths for a given week exceeds the baseline value for that week by a statistically significant amount, then influenza‐related deaths are said to be above the epidemic threshold.

Influenza-associated pediatric mortality:  Influenza-associated pediatric mortality is a newly added nationally notifiable condition. Laboratory-confirmed influenza-associated deaths in children less than 18 years old are reported through the Nationally Notifiable Disease Surveillance System.

Emerging Infections Program (EIP):  The EIP Influenza Project conducts surveillance for laboratory-confirmed influenza related hospitalizations in persons less than 18 years of age in 57 counties covering 11 metropolitan areas of 10 states (San Francisco CA, Denver CO, New Haven CT, Atlanta GA, Baltimore MD, Minneapolis/St. Paul MN, Albuquerque NM, Albany NY, Rochester NY, Portland OR, and Nashville TN). Cases are identified by reviewing hospital laboratory and admission databases and infection control logs for children with a documented positive influenza test conducted as a part of routine patient care.
New Vaccine Surveillance Network (NVSN):  The New Vaccine Surveillance Network (NVSN) provides population-based estimates of laboratory-confirmed influenza hospitalization rates for children less than 5 years old residing in 3 counties: Hamilton County OH, Davidson County TN, and Monroe County NY. Children admitted to NVSN hospitals with fever or respiratory symptoms are prospectively enrolled and respiratory samples are collected and tested by viral culture and RT-PCR. NVSN estimated rates are reported every 2 weeks.

But we recognize that our routine system may not pick up initial cases, therefore need for enhanced surveillance, especially given potential for H5N1 introduction among birds and travelers.

## Detect and InvestigateInitial Cases and Clusters (ll)

- Continue enhanced surveillance for H5N1 human cases.
- Monitor health status of travelers from affected areas
- Conduct active surveillance among persons exposed to H5N1 infected birds
- Establish and initiate surveillance for illness and infection among health care workers
- Continue surveillance among laboratory workers

**Notes:**
Guidance to state, local, and tribal public health entities; providers and the public
re signs/symptoms and epidemiologic profile of possible cases/clusters, and reporting mechanisms

## Detect and InvestigateInitial Cases and Clusters (lll)

- Investigate identified human cases and clusters.
- Describe clinical features
- Assess risk factors
- Effectiveness of/compliance with guidance for personal protective equipment)
- Develop recommendations to prevent further spread of disease to humans
- Prevention measures,
- Case management, and
- Risk communication messages

## Determine and Track Trends in the Impact of Disease

- Track number of hospitalizations and deaths.
- Monitor workplace safety and continuity of operations in critical infrastructure functions, including health care sector.
- Assess need for changes in disease containment and medical countermeasure strategies.

**Notes:**
Surveillance and Monitoring ~ BioSense
Outpatient ILI:
Sentinel providers
Emergency departments
DoD
VA
AAFP
Inpatient ILI: 
BioSense ADT
Verispan
NAHDO
NHDS
Deaths: 
122 Cities
 NCHS
State electronic reporting
Pediatric deaths
Laboratory reporting:
WHO and NREVSS
Quest
Visualization and analysis data: 
Clinical lab data (e.g., Quest)
Characterization of the pandemic
Assessment of status of critical infrastructure
Evaluation of the impact on the health and health care system
Effectiveness of public health interventions:
Modeling:

## Monitor Changes in the Virus and Assess Effectiveness of Interventions

- Monitor changes in the virus
- Conduct epidemiologic studies linked with laboratory data to assess/monitor:
- Treatment guideline effectiveness
- Vaccine effectiveness
- Antiviral effectiveness and resistance

**Notes:**
Utilize the Emerging Infections Program influenza project, the New Vaccine Surveillance Network, Marshfield Clinic Research Foundation, and/or other sites to conduct epidemiologic studies to assess/monitor treatment guidelines, vaccine effectiveness, antiviral effectiveness and resistance, and effectiveness of public health interventions.
- Develop (pilot test, and implement) protocols and process for active population-based hospitalization surveillance including specimen collection and virologic testing from a subset of hospitalized patients in all age groups in a limited number of sites.

## Pandemic Influenza Planning Healthcare Checklists

- Emergency Medical Service and Medical Transport
- Home Health Care Services
- Hospitals
- Long-Term Care and Other Residential Facilities
- Medical Offices and Clinics

## Seasonal Influenza

**Seasonal Influenza**
**Preparedness**

**Pandemic Influenza**
**Preparedness**

## Seasonal Protections Are Important Now and Good Practice for a Pandemic

-  Promote seasonal vaccination
-  Encourage good personal hygiene
-  Support staying home if ill
-  Stay informed

## Summary

- A pandemic will place incredible demands on the healthcare system
- Pandemic preparedness actions must begin now
- Be familiar with national, state, and local plans
- Early detection of initial cases/clusters is essential
- Know reporting guidelines
- Monitoring the impact of the pandemic will be critical
- Assist federal, state, and local officials

## For more information

- _[www.pandemicflu.gov](http://www.pandemicflu.gov/)_
- _www.cdc.gov/flu_

**For more information**

## Thank You