# Presentation: 090518

## Joint ACIP/NVAC Meeting in Pandemic Influenza Vaccine Prioritization
And Antiviral Medication Prioritization
Marriot Century Center Hotel
Atlanta, GA
June 15-16, 2005

- And Antiviral Medication Prioritization
- Marriot Century Center Hotel
- Atlanta, GA
- June 15-16, 2005

## Introductions

- Basic charge of group
- Timeline and process for moving recommendations along
- Include work of subgroups
- Basic starting assumptions
- Information on
- Number of persons by group compared with vaccine
- Impact on workers
- Basic assumptions from Canadian plan
- Questions for group
- Agreement on starting assumptions?
- With list of main groups, are we missing any?
- How will main groups be prioritized?
- How will subgroups be prioritized?

## Goal of Meeting	

- Develop list of groups to be prioritized for influenza vaccine and antiviral medications
- Rank order larger groups
- Sub-prioritization with groups, when possible
- Consider relationship of vaccine and antiviral strategies
- Meeting summaries to be presented to full ACIP and NVAC

## Timeline and Process

- April 20, 2005 – 1st meetings of vaccine and antivirals working groups
- May through mid-June – work done by inter-meeting work groups
- Impact
- Healthcare workers
- Critical infrastructure
- Ethics
- June 15-16
- ACIP/NVAC joint vaccine group and NVAC antivirals groups meet together for 1st half of June 15, then separate meetings to discuss prioritization and strategies
- Summaries of meetings developed

## Timeline and Process

- June 22, 2-4 PM
- Conference call with NVAC Pandemic Influenza Working Group to review summaries from June 15-16 meetings and make additional comments
- Other from vaccine and antivirals working groups invited to join as able
- June 30
- Present summary to full ACIP in Atlanta
- ACIP to offer additional comments and endorsement of vaccine prioritization
- Brief presentation on antivirals prioritization and vaccine purchase option

## Timeline and Process

- July 19
- Conference call to vote on
- Vaccine prioritization (ACIP voting members and Ex-officio members plus full NVAC)
- Antivirals and vaccine purchase and distribution options (full NVAC)
- August 1
- Recommendations from NVAC and ACIP sent to Secretary Leavitt by August 1st through NVPO office

## Overall Goals for Pandemic Planning

- First, to minimize severe morbidity and mortality
- Second, to preserve functioning of critical infrastructure and minimize economic loss
- Rank order not explicitly stated in U.S. pandemic plan.
- Is there agreement on the rank order of these goals?

## Key Assumptions I

- Health impact of a pandemic
- 25-30% (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

## Key Assumptions II

- 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
- Antiviral medication availability
- Stockpile likely also limited
- Thus, need for rationale, explicit prioritization of vaccines and antiviral medications needed
**However, any prioritization scheme may require modification based on epidemiology of a new pandemic**

## Possible Priority Groups

**	****	****	****	****	****	****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**

## 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

## Days Lost from Work due to Pandemic Influenza

- Xinzhi Zhang, M.D., Ph.D.
- Martin I. Meltzer, Ph.D., M.S.

## Methods and Inputs Considered

- Modeled lost work days from illness using FluAid and FluSurge
- Population size by age group based on 2000 Census
- Inputs:
- Days lost from work due to illness
- by different triage (death, hospitalization, outpatient, self-cured) and age group
- Days lost from work due to caring for family member
- by different triage and age group
- Other assumptions
- employment rate, marriage rate, work day per month
- Assumed outbreak period 8 weeks and 25% influenza illness rate as base-case

## Days lost from work due to pandemic influenza (8 week outbreak, 

| Work Day Loss | Scenario A | Scenario B | Scenario C | Scenario D | Scenario E |
| --- | --- | --- | --- | --- | --- |
| Most Likely |  130,672,484  | 180,997,758 | 231,014,228 | 219,828,718 | 269,845,189 |
| Minimum |  110,435,229  | 160,598,429 | 210,704,491 | 199,235,607 | 249,341,669 |
| Maximum |  161,643,371  | 211,905,239 | 261,829,971 | 250,758,015 | 300,682,747 |

**Days lost from work due to pandemic influenza (8 week outbreak, **
**25% attack rate)**

**Scenario A: work loss for Caring 10, 7, 3, 1; work loss for illness 40, 7, 3, 1**
**Scenario B: work loss for Caring 10, 7, 3, 1; work loss for illness 40, 10, 5, 3**
**Scenario C: work loss for Caring 10, 7, 3, 1; work loss for illness 40, 12, 7, 5**
**Scenario D: work loss for Caring 12, 10, 5, 3; work loss for illness 40, 10, 5, 3**
**Scenario E: work loss for Caring 12, 10, 5, 3; work loss for illness 40, 12, 7, 5**

## Scenario E (10%)

- Scenario A (4.8%)

## Limitations

- Assumptions of work day loss for caring and illness fall into a large range
- Largely unknown from literature
- For interpandemic influenza, lost work days per illness-like illness average 1 day in US studies
- Assumptions of distribution of days lost from work may not reflect the real situation (e.g. community, enterprise etc.)

## Reference

- Meltzer MI, Cox NJ, Fukuda K. The economic impact of pandemic influenza in the United States: implications for setting priorities for intervention. Emerg Infect Dis 1999;5:659-71. Available on the Web at: _[http://www.cdc.gov/ncidod/eid/vol5no5/meltzer.htm](http://www.cdc.gov/ncidod/eid/vol5no5/meltzer.htm)_
- Meltzer MI, Cox NJ, Fukuda K. Modeling the economic impact of pandemic influenza in the United States: implications for setting priorities for intervention. Background paper; 1999. Available on the Web at: _[http://www.cdc.gov/ncidod/eid/vol5no5/melt_back.htm](http://www.cdc.gov/ncidod/eid/vol5no5/melt_back.htm)_
- Meltzer MI, Shoemake H, Kownaski M. FluAid 2.0: a manual to aid state and local-level public health officials plan, prepare, and practice for the next influenza pandemic. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2000.
- Zhang X, Meltzer MI, Wortley P. FluSurge2.0: a manual to assist state and local public health officials and hospital administrators in estimating the impact of an influenza pandemic on hospital surge capacity (Beta test version). Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2005.

## Questions for Group to Consider During Meeting

- Is there general agreement on starting assumptions?
- With list of main groups, are we missing any?
- How will main groups be prioritized?
- How will subgroups be prioritized?

## Agenda

- Reports from inter-meeting work groups
- Impact
- Healthcare workers
- Community Services
- Ethics
- Split into vaccine and antivirals groups
- Vaccine group
- Day 1
- Additional information on possible vaccine strategies
- Discussion
- Day 2
- Information from antivirals group
- Further discussion and drafting of summary

## Acknowledgments

- Intermeeting work group participants and coordinators
- Robin Jones, Mollie Ergle, Andrea Hatchet and Emma English for help with meeting logistics and preparation of materials
- ESD/NIP/CDC and NVPO for meeting funding

## Extras

## Slide 22

## Slide 23