Influenza Pandemic Training

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Influenza Pandemic Training

• Preparing for the Worse

By Magdy Akladios, PhD, PE, CSP, CPE, CSHM
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Introduction
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Objectives
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What is a Pandemic?

• The word "pandemic" is used to describe a disease
  that affects people on a worldwide scale.
• Flu pandemics have occurred roughly every 20 to
  30 years throughout history, the most serious
  being the misnamed
• "Spanish flu" of 1918
• "Asian flu" of 1957
• "Hong Kong flu" of 1968

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What is an Epidemic?

• Epidemic a disease attacking or affecting many
  individuals in a community or a population
  simultaneously

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Conditions Resulting in a Pandemic

1. The emergence of a new flu strain
2. The ability of that strain to infect humans and
   cause serious illness
3. The ability to spread easily among humans

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Seasonal Fluvs.Pandemic Flu
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Seasonal Flu

• Outbreaks follow predictable seasonal patterns
• Usually some immunity built up from previous
  exposure
• Healthy adults usually not at risk for serious
  complications
• Vaccine developed based on known flu strains
• Adequate supplies of anti-virals are usually
  available and can usually meet public and patient
  needs
• Average US deaths approximately 36,000/yr
• Symptoms include
• Fever, cough, runny nose, muscle pain.
• Deaths often caused by complications, such as
  pneumonia

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Impact of Seasonal Flu

• Generally causes modest impact on society (e.g.,
  some school closing, encouraging people who are
  sick to stay home)
• Manageable impact on domestic and world economy

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Pandemic Flu

• Occurs rarely (only 3 times in 20th century -
  last in 1968)
• No previous exposure (little or no preexisting
  immunity)
• Healthy people may be at increased risk for
  serious complications
• Health systems may be overwhelmed
• Vaccine probably would not be available in the
  early stages of a pandemic (effective antivirals
  may be in limited supply)
• Number of deaths could be high
• Symptoms may be more severe and complications
  more frequent

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Impact of a Pandemic

• May cause major impact on society
• Widespread restrictions on travel
• Closings of schools and businesses
• Cancellation of large public gatherings
• Potential for severe impact on domestic and world
  economy

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The State of Your Health Texas
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Adult Health Indicators

• Percentage of Adults with Asthma (2004)
• TX 12.8 US 13.2
• Percentage of Adults with Diabetes (2004)
• TX 7.6 US 7.0
• Percentage of Adults with Obesity (2004)
• TX 25.8 US 23.2
• Percentage of Adults with Hypertension (2003)
• TX 24.6 US 24.8
• Estimated New Cancer Cases (2005)
• TX 86,880 US 1,372,910
• Estimated Persons Living With AIDS (2004 Yr End)
• TX 29,891 US 415,193
• Cumulative Number AIDS Cases (2004 Yr End)
• TX 64,479 US 918,286
• Human West Nile Cases (2005 Cases as of 5/06)
• TX 195 US 2,983

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Child Health Indicators

• of Children Estimated Lifetime Prevalence of
  Childhood Asthma (2003)
• TX 13.1 US 12.4
• of Children Overweight High School Students
  (2003)
• TX 13.9 US 11.1
• of Fully Immunized Children Aged 19-35 Months
  (2004)
• TX 72.5 US 80.9
• Infant Mortality Per 1,000 Live Births (2004)
• TX 6.1 US 6.6
• of Low Birth-weight Babies (2003)
• TX 7.9 US 7.9

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Other Public Health Indicators

• Number of Primary Care Health Professions
  Shortage Areas (As of 9/30/05)
• TX 346 US 4,577
• Receipt of CDC Environmental Public Health
  Tracking Grant
• TX None US 21

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Who is most at Risk for Pandemic Flu?
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Pandemic Flu

• A flu pandemic occurs when a new flu virus
  against which the human population has no
  immunity appears.
• This results in several, simultaneous epidemics
  worldwide with enormous numbers of infections and
  deaths.

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What Helps Spread a Pandemic?

• With the increase in global transport and
  communications, as well as urbanization and
  overcrowded conditions, epidemics due to the new
  flu virus are likely to quickly take hold around
  the world.

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Pandemic Dark History
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A Lesson from the Past

• Pandemics are a reality. Health records show at
  least 10 influenza pandemics over the past 300
  years
• 1732-1733
• 1781-1782
• 1800-1802
• 1830-1833
• 1847-1848
• 1857-1858
• 1889-1900
• 1918-1919
• 1957-1958
• 1968-1969  

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NUMBER OF DEATHS IN MOST RECENT PANDEMICS

• US Deaths
• 1918/19 500,000
• 1957/58 70,000
• 1968/69 34,000
• Worldwide Deaths
• 1918/19 40,000,000
• 1957/58 1,000,000-2,000,000
• 1968/69 700,000

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"Spanish flu" Pandemic of 1918

• Over 40 million people perished worldwide
• Age range of fatalities 15 to 35 years, mostly
  healthy
• 99 of deaths occurred in people younger than 65
  years

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The Effects of the 1918 Pandemic on Texas

• Reports of pandemic fears preceded the disease
  into Texas by about two weeks.
• But by September 23, there were definite accounts
  of it near Austin and Dallas.
• On October 4th, 35 counties were reporting the
  presence of influenza, with anywhere from one to
  2,000 cases per county.
• El Paso imposed a quarantine.
• The Dallas Morning News declared that surviving
  the pandemic required "medical attention, good
  nursing, fresh air, nutritious food, plenty of
  water, and cheerful surroundings."
• The Texas State Board of Health offered schools
  several suggestions on ways to prevent flu
  outbreaks.
• By the end of October, over 106,000 Texans in the
  state's urban centers had been afflicted.
• Over 2,100 had died.

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The Bad News

• If a pandemic strikes, it will come to Texas.

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"Hong Kong flu Pandemic of 1968

• This was a much "milder" flu pandemic
• It killed 1 million people across the globe

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Pandemic Impact on the US
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Economic Impact

• flu pandemic may strike in waves, each of which
  could last up to 6 8 weeks
• An especially severe pandemic could lead to
  widespread illness, a large number of deaths, and
  significant economic loss
• Everyday life would be disrupted because so many
  people in so many places would become seriously
  ill at the same time.
• Impact could range from school and business
  closings to the interruption of basic services as
  public transportation and food delivery.

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How would a Pandemic Impact the US Economy?

• A pandemic could deliver a "shock" to the
  economy, with immediate demand- and supply-side
  effects, as well as longer-term supply-side
  effects.
• The general slowdown in economic activity would
  reduce gross domestic product (GDP).
• Business confidence would be dented
• The supply of labor would be restricted

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More Impact on US Economy

• Supply chains would be strained as transportation
  systems were disrupted
• Default rates on consumer and business debt would
  rise
• The stock market would initially fall and rebound
  later
• A serious recession in the US economy with
  immediate costs ranging from 500 billion 675
  billion.

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Predictions from Financial Leaders

• WBB Securities LLC predictions
• A one-year economic loss of 488 billion
• A permanent economic loss of 1.4 trillion
• Congressional Budget Office predictions
• A 675 billion hit to the US economy
• World Bank predictions
• Cost on global economy 800 billion a year

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Impact on Health Services

• A substantial portion of the world's population
  would require medical care
• Healthcare facilities would be overwhelmed,
  creating a strain on hospital staff, and a
  shortage of beds, ventilators, and other
  supplies.
• To cope with the demand, "surge capacity" at
  nontraditional sites, such as schools, may need
  to be created.
• The need for vaccine is likely to outstrip supply
  and the supply of antiviral drugs is also likely
  to be inadequate early in a pandemic.
• Difficult decisions would need to be made
  regarding who gets these vaccines and antivirals.

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How Real is this Threat?
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What is the Likelihood of a 2007 Pandemic?

• The evolution of flu viruses cannot be predicted.
  
• This makes it difficult to know if or when a
  virus might mutate to become easily transmittable
  among humans.
• Therefore, it is impossible to say when another
  pandemic will arise, or whether it will be mild
  or severe.
• However, the World Health Organization (WHO)
  asserts that once a virus allows for efficient
  human-to-human transmission, a pandemic can
  occur.

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A Wide Range of Estimates

• Experts' range 2 million to gt 50 million
• All of these predictions are scientifically
  grounded
• Some estimates are based on extrapolations from
  past pandemics
• The most precise predictions are based on the
  1968 pandemic, but even in this case estimates
  are 1 million 4 million deaths
• Similarly, based on the number of deaths from the
  1918 Spanish flu pandemic, estimates are 20
  million gt50 million
• The specific characteristics of a future pandemic
  virus cannot be predicted. It may affect 20 --
  50 of the total population

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Best case scenarios of the next pandemic2 to 7
million people could die, and tens of millions
would require medical attention worldwide
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High Mortality Rates

1. Number of people who become infected
2. Virulence of the virus
3. Underlying characteristics and vulnerability of
   affected populations
4. Availability and effectiveness of preventive
   measures

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2 Scenarios for the Potential Impactof a Flu
Pandemic on the US
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Moderate (1958/68-like)

• Illness 90 million (30)
• Outpatient medical care 45 million (50)
• Hospitalization 865,000
• ICU care 128,750
• Mechanical ventilation 64,975
• Deaths 209,000

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Severe (1918-like)

• Illness 90 million (30)
• Outpatient medical care 45 million (50)
• Hospitalization 9,900,000
• ICU care 1,465,000
• Mechanical ventilation 742,500
• Deaths 1,903,000

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A Pandemic is due soonThe question is not if,
but when
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What Interventions Might Reduce the Impact of a
Pandemic?
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Overview

• Depending on the contagiousness of the virus, a
  variety of approaches could reduce the number of
  flu cases to fewer than that of an annual flu
  season.

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Method

• The scientists simulated a virtual outbreak on
  computers at the Los Alamos National Laboratory

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1st, With No Interventions

• The results showed that, with NO intervention, a
  pandemic flu with low contagiousness could peak
  after 117 days and infect about 33 of the US
  population.
• A highly contagious virus could peak after 64
  days and infect about 54 of the population.

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2nd, a Variety of Scenarios
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Possible Scenarios

• The researchers tested different interventions
• distributing antiviral treatments to infected
  individuals and others near them to reduce
  symptoms and susceptibility
• vaccinating people, possibly children first, with
  either 1 or 2 shots of a vaccine not well matched
  to the strain that may emerge
• social distancing, such as restricting travel and
  quarantining households and closing schools

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Interventions w/a less contagious virus

• Utilize the 3 most effective single measures
  included
• Distributing several million courses of antiviral
  treatment to targeted groups 7 days after a
  pandemic alert
• School closures and
• and vaccinating 10 million people per week with
  1 dose of a poorly matched vaccine.
• The results also showed that vaccinating school
  children first is more effective than random
  vaccination when the vaccine supply is limited.
• Regardless of contagiousness, social distancing
  measures, alone, had little effect.

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Interventions w/a highly contagious virus

• All single-intervention strategies left nearly
  half the population infected.
• In this instance, the only measures that reduced
  the number of cases to below the annual flu rate
  involved a combination of at least three
  different interventions, including a minimum of
  182 million courses of antiviral treatment.

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Decline in Travel and Leisure Activities

• International travel would dramatically decline
  as people avoided flu "hotspots
• Governments may restrict travel
• People would quarantine themselves by staying at
  home more

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More on Travel and Leisure Activities

• Nonessential activities requiring social contact
  would be sharply curtailed, leading to
  significant declines in retail trade
• People would avoid public places, such as
  shopping malls, community centers, places of
  worship, and public transit
• Attendance at theaters, sporting events, museums,
  and restaurants would decline

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Schools and Business Would Suffer

• Many schools would close
• And if they didnt, attendance would fall
  dramatically as parents keep their children at
  home
• Large-scale school closings would lead to a spike
  in workplace absences because parents would stay
  home to care for their children even if they were
  not sick
• The impact on businesses of all kinds due to
  employee absenteeism would be dramatic

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How would a Pandemic Impact my Organization?
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Lost Employee Productivity

• Increase in absenteeism due to illness, caring
  for sick, and social distancing policies could
  reach 40 during peaks
• Risk that some companies do not have capacity to
  support increases in telecommuting

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Disruption of Supply Chains

• Disruption of transportation networks that limit
  ability to receive and distribute goods

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Operations and Facilities Shutdown

• Increase in absenteeism due to illness, caring
  for sick, and social distancing policies could
  reach 40 during peaks
• Inability to maintain operations because of
  shortages of staff, shortages of supplies, or a
  slowdown in servicing utilities
• Closure of facilities due to implementation of
  policies to contain the pandemic (e.g., social
  distancing)
• School closings would likely happen very early in
  a pandemic and could occur on short notice

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Drop in Demand for Products and Services

• Certain companies will see drops in demand for
  products and services
• Reduction in customer base due to illness
• Customers likely to avoid public shopping areas,
  restaurants, entertainment facilities, etc
• Potential decline in income and discretionary
  spending as businesses are forced to halt
  operations
• Closure of facilities due to implementation of
  policies to contain the pandemic (e.g., social
  distancing)

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Is the World Prepared?

• The answer is NO
• Despite the advance warning, the world is ill
  prepared to defend itself against a flu pandemic.
• WHO has urged all countries to develop
  preparedness plans, but only around 40 have done
  so.
• WHO has further urged countries with adequate
  resources to stockpile antiviral drugs nationally
  for use at the start of a pandemic.
• Under the current situation, most developing
  countries may have limited access to vaccines and
  antiviral drugs throughout the duration of a
  pandemic.

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How to Prepare your Organization?
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Planning

• Develop an internal pandemic planning taskforce
• Review the CDC checklists to include as part of
  your organization's pandemic plan
• Engage your business continuity/preparedness
  department to expand their mission to include
  pandemic planning
• Work with a business preparedness advisory
  organization to assist you in preparing your
  organization for an influenza pandemic

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10 Steps your Organization Can Take Now
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Step 1

• Check that existing contingency plans are
  applicable to a pandemic.
• In particular, check to see that core business
  activities can be sustained over several weeks.

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Step 2

• Plan accordingly for interruptions of essential
  governmental services like sanitation, water,
  power, and disruptions to the food supply.

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Step 3

• Identify your company's essential functions and
  the individuals who perform them.
• The absence of these individuals could seriously
  impair business continuity.

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Step 4

• Build in the training redundancy necessary to
  ensure that their work can be done in the event
  of an absentee rate of 25 to 30.

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Step 5

• Maintain a healthy work environment by ensuring
  adequate air circulation and posting tips on how
  to stop the spread of germs at work.

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Step 6

• Promote hand and respiratory hygiene.
• Ensure wide and easy availability of
  alcohol-based hand sanitizer products.

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Step 7

• Determine which outside activities are critical
  to maintaining operations and develop
  alternatives in case they cannot function
  normally.
• For example, what transportation systems are
  needed to provide essential materials?
• Does the business operate on "just in time"
  inventory or is there typically some reserve?

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Step 8

• Establish or expand policies and tools that
  enable employees to work from home with
  appropriate security and network access to
  applications.

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Step 9

• Expand online and self-service options for
  customers and business partners.
• Tell the workforce about the threat of pandemic
  flu and the steps the company is taking to
  prepare for it.
• In emergencies, employees demonstrate an
  increased tendency to listen to their employer,
  so clear and frequent communication is essential.

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Step 10

• Update sick leave and family and medical leave
  policies and communicate with employees about the
  importance of staying away from the workplace if
  they become ill.
• Concern about lost wages is the largest deterrent
  to self-quarantine.

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Preparations for a Potential Flu Pandemic
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A Federal Pandemic Plan is in Place

• The National Strategy for Pandemic Influenza,
  issued by President Bush on November 1, 2005,
  guides our nation's preparedness and response to
  a flu pandemic

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Intent of the Federal Plan

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

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Components of the HHS Plan

• The HHS Plan includes an overview of the threat
  of pandemic flu, a description of the
  relationship of this document to other federal
  plans, and an outline of key roles and
  responsibilities during a pandemic.
• In addition, the HHS Plan specifies needs and
  opportunities to build robust preparedness for
  and response to pandemic flu.
• The preparations made for a pandemic today will
  have lasting benefits for the future

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Antiviral Stockpiling is Crucial

• Major components of the critical preparedness and
  ready response actions include
• Intensifying surveillance and collaborating on
  containment measures - both international and
  domestic
• Stockpiling antivirals and vaccines, and working
  with industry to expand capacity for production
  of these medical countermeasures
• Creating a seamless network of federal, state and
  local preparedness, including increasing
  healthcare surge capacity
• Developing the public education and
  communications efforts that will be critical to
  keeping the public informed

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A Plan Based on Known Pandemic Principles

• Preparedness will require coordination among
  federal, state, and local government and partners
  in the private sector
• An informed and responsive public is essential to
  minimizing the health effects of a pandemic and
  the resulting consequences to society
• Domestic vaccine and production capacity
  sufficient to provide vaccine for the entire US
  population is critical
• Quantities of antiviral drugs sufficient to treat
  25 of the US population should be stockpiled.
• Sustained human-to-human transmission anywhere in
  the world will be the triggering event to
  initiate a pandemic response by the US
• When possible and appropriate, basic public
  health measures will be employed to reduce
  person-to-person viral transmission and to
  prevent or delay influenza outbreaks
• At the start of a pandemic, vaccine, which will
  initially be in short supply, will be procured
  and distributed to state and local health
  departments for immunization of predetermined
  priority groups
• At the onset of a pandemic, antiviral drugs from
  public stockpiles will be distributed to
  predetermined priority groups

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OSHA

• U.S. Department of Labor's OSHA Unveils New
  Guidance on Preparing Workplaces for Influenza
  Pandemic (released Feb 6, 2007)
• Assistant Secretary of Labor for Occupational
  Safety and Health, Edwin G. Foulke Jr. "In
  anticipation of a flu pandemic, our top priority
  is protecting the safety and health of America's
  working men and women

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Texas Preparations

• Texas received 5,875,044 in phase 1 funding from
  the U.S. Department of Health and Human Services
  (HHS) to use for pandemic planning activities.
• Texas will also receive additional funds of
  15,450,021 from the revised phase 2 of Health
  and Human Services local and state allocations.
• This amount is based on a formula adjusted for
  population.

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State Activities

• The state of Texas, HHS and other federal
  agencies held a pandemic planning summit on March
  27, 2006, with public health and emergency
  management and response leaders within the state.
• Texas Department of State Health Services
  developed a Pandemic Draft Plan
• Dallas County Health Human Services developed
  an Influenza Pandemic Plan
• Texas Department of State Health
  Servicesprovided information about Avian Flu

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Employers Responsibility under OSHA

• Under the Occupational Safety and Health Act of
  1970, employers are responsible for providing a
  safe and healthful workplace for their employees.
• OSHA's role is to assure the safety and health of
  America's working men and women by setting and
  enforcing standards providing training, outreach
  and education establishing partnerships and
  encouraging continual process improvement in
  workplace safety and health.

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Are People Out There Planning?
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How are Other Organizations Preparing?
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Pandemic Plans Generally Address

• Business continuity
• impact of absenteeism on operations, technology,
  travel
• Awareness/Education
• employee communication, educational materials
• Prevention
• promoting good health habits, procuring supplies
• Treatment
• purchasing antivirals for appropriate employees

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Examples of Plans
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HSBC27

• Developing "Remote Working" plans to operate
  under a flu pandemic scenario that would keep as
  many as 50 of its employees from being at work

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Deutsche Bank

• Taking measures to ensure that employees in
  infected zones don't transmit the disease to
  coworkers and preparing for the economic shocks
  triggered by a global pandemic

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Microsoft

• Issued all 1,200 employees at its Mountain View
  campus a bottle of hand sanitizer, with web link
  for info on Avian Flu.
• Installed hand sanitizer dispensers throughout
  its buildings

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Boeing

• Assembled a task force to examine business
  continuity issues and worker-protection plans
• Assessed minimum workers to conduct core
  activities.
• Estimated that non attendance rates of up to 30
• Exploring options to minimize operational
  disruptions (e.g., cross-training, reconfiguring
  shifts, virtual work)

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Virgin Atlantic

• Purchased 10,000 courses of TAMIFLU for
  employees, who frequently travel internationally

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What is the Role of Vaccination on Seasonal Flu?
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Seasonal Flu Vaccination

• Vaccination is one of the most effective ways to
  minimize suffering and death due to seasonal
  influenza.
• In fact, vaccination is universally regarded as
  the most important medical intervention for
  preventing seasonal influenza and reducing its
  health consequences.

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Flu Vaccines

• Flu vaccination is recommended for people who are
  at high risk for complications if they contract
  flu.
• It is also recommended for people aged 50 to 64,
  since one third of individuals in this age range
  have medical conditions that place them at
  increased risk for complications of flu.
• Flu vaccination is also recommended for those who
  will be in close contact with others at high risk
  for complications of flu.

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A Flu vaccination is not recommended for

• People lt 6-months old
• Individuals with severe allergies to chicken eggs
  
• Those who have had a severe reaction to flu
  vaccine in the past
• Anyone who has ever developed Guillain-Barré
  syndrome

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Vaccines in a Pandemic

• In a pandemic, it could take several months to
  develop an effective vaccine.
• Presently, there is NO commercially available
  vaccine to protect humans against potential
  pandemic strains.
• However, research studies to test potential
  vaccines to protect humans against pandemic flu
  are under way.

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Medical Treatment
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Antivirals

• There are two drugs that, if administered early
  enough post-infection, have been shown to reduce
  symptoms of influenza A and B in some infected
  humans.
• These drugs belong to a class of antiviral drugs
  known as "neuraminidase inhibitors."
• These antivirals can also be taken to prevent
  illness upon suspected exposure to the flu virus,
  before symptoms develop.
• The stockpiling of antivirals is a key component
  of the Federal Pandemic Preparedness Plan.

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TAMIFLU

• Two principal roles
• Prophylaxis - aimed at decreasing the likelihood
  of developing flu
• Treatment - aimed at reducing the duration of flu
  by 1.3 days
• Research has demonstrated the effectiveness of
  antivirals when used for both purposes.
• When used for treatment purposes, these drugs
  need to be administered within 48 hours after the
  onset of symptoms.

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How much Antiviral is Enough?
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Example

• Company XYZ employs 1,000 individuals and
  employees have on average 3 immediate family
  members (4,000 individuals) and are covering 40
  of this population

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Solution

• a
• a 40 x 4,000 individuals 1,600.
• b
• The company assumes that each individual will be
  provided 2 treatment courses (2 packs) and 2
  prevention courses (2 packs)
• b 4
• c
• The company assumes that the seasonal dosage will
  be used
• c 1
• d
• The company assumes that there will be two waves
  of a pandemic
• d 2
• Therefore, Order Quantity ( of packs) a x b x c
  x d 1,600 x 4 x 1 x 2 12,800 Packs

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In Conclusion
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Conclusion
Started Ended Years ? (Delta)
1732 1733 1 49
1781 1782 1 19
1800 1802 2 30
1830 1833 3 17
1847 1848 1 10
1857 1858 1 32
1889 1900 11 29
1918 1919 1 39
1957 1958 1 11
1968 1969 1 Next ???
2.3 26.22222
Next One 1994.222
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Pandemics are a reality

• Health records show at least 10 influenza
  pandemics over the past 300 years 
• On average we have a pandemic every 26 years
• The next one should have been in 1994-1995
• We are now 12-13 years overdue
• Therefore, be very prepared

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Questions??

• Thank you