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“Influenza Pandemic Preparedness for

Clinicians on the Frontline”CAPT HA C. TANG, DO US Public Health Service

Adjunct Associate Clinical Professor of Dartmouth Medical School, Community/Family Medicine Dept.

Deputy Chief of Family Medicine Department at TCRHCCArizona Osteopathic Medical Association

April 14, 2019

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Co-AuthorsReasol A. Chino, PharmD, BCACPCommander, US Public Health ServiceAssistant Director of Pharmacy Tuba City Regional Health Care Corp

Sita Marie Shablack, PharmDLT, US Public Health Service Advance Practice Pharmacist I

Disclaimers-Do not speak for the IHS or the USPHS

-No profits or financial gain

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“What are you going to do in an influenza pandemic?”

Objectives

1. History and lessons of past pandemics2. How and when a pandemic can take

place?3. What a bad pandemic scenario looks like?4. What frontline providers can do to blunt

the impact of an influenza pandemic

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21st Century Epidemics/Pandemics

SARS pandemic 2002-2003 Re-emergence of H5N1 HPAI virus

2003 (1997 first emergence) H1N1 influenza pandemic 2009 Ebola of 2014 West Africa MERS in Middle East, to South Korea Zika virus in the Americas 2016

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Influenza Basics

Human influenza A and B viruses cause seasonal epidemics

Influenza B viruses are not divided into subtypes

Influenza type C infections cause a mild respiratory illness

Influenza Basics

The Influenza A virus subtypes are labeled according to an • H (hemagglutinin) (H1 to H16) • N (neuraminidase) (N1 to N9)• Pandemic potential

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Updates for 2015-2017

-HPAI H7N9 Feb 2017-An HPAI H5N2 virus was detected in a wild duck in the United States. -H7N8 in Indiana farm-H7N3 avian flu in Mexican poultry- H5N2 in Taiwanese chickens-H5N1 affecting more farms in Nigeria.

Recent Pandemic History

The "Spanish flu", 1918–1919, 500 millions infected

The "Asian Flu", 1957–58, 2 millions The "Hong Kong Flu", 1968–69, 1

million H1N1 Pandemic of 2009- 284,000

deaths

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A letter from a physician wrote on the 1918 pandemic

“It is only a matter of a few hours then until death comes [...]. It is horrible. We have been averaging about 100 deaths per day [...]. Pneumonia means in about all cases death [...]. We have lost an outrageous number of Nurses and doctors. It takes special trains to carry away the dead.”

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Recent Pandemic History in US

H1N1 2009 to 2010 over 12 months 60.8 million cases 274,304 hospitalizations 12,469 deaths Fatality rate at 0.02%

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H7N9 Avian Influenza?

-Now on a fifth epidemic since March 2013

-1600 infections -30% to 40% fatality-Limited person-to-person spread of this

virus have been identified in China,

-having the greatest potential to cause a pandemic

Socioeconomic toll?

-$4 trillions US consumers nonmortgage debt

-$1.4 trillions student debt, 11% deliquent

-$21.2 trillions national debt, another $7 trillions in 10 years.

-Global debt at $247 trillions, exceeding 318%

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Socioeconomic toll?

-Societies and countries tend to recover from pandemics well

-At individual levels-life long-Foster children-400,000

When can a pandemic occur?

A new influenza virus subtype It must infect humans and cause

illness It must spread easily and sustainably

among humans

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What are the pathways for an influenza

pandemic?

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What frontline providers can do to blunt the impact of an influenza pandemic?

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Strategic National Stockpile-since 2002- $7 billions dollarsStockpiled products include:

AntibioticsChemical antidotesAntitoxinsVaccinesAntiviral drugsPersonal protective equipmentVentilatorsOther medical supplies

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“A number of surveys have found that 16%–33% of HCWs may not report to work in the event of an influenza pandemic”

According to CDC on Emerging Diseases Article, “Pandemic (H1N1) 2009 Risk for Frontline Health Care Workers,” Volume 17, Number 6—June 2011

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HHS Influenza Pandemic Plan 2017 Update

1. Surveillance, epidemiology,& lab activities

2. Community mitigation measures

3. Medical countermeasures;

4. Health care system preparedness and response activities

HHS Influenza Pandemic Plan 2017 Update

1. Communications and public outreach;

2. Scientific infrastructure and preparedness;

3. Domestic and international response policy, incident management, and global partnerships and capacity building.

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What is the likely scenario of an Influenza

Pandemic at ground zero?

Ventilator ICU Bed Capacity in US? Our nation has only 105,000 ventilators as of 2005, per NEJM

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Comparison of tools available to fight the next Influenza

Pandemic

1918 Spanish Flu 21st Century

No antivirals No ventilatorsNo antibiotics1/3 of HCWs died?Majority young 20-40s yrs of age

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1918 Spanish Flu 21st Century

No antivirals No ventilatorsNo antibiotics1/3 of HCWs died?

No antivirals ?No ventilatorsNo antibiotics?1/3 of HCWs will not show up for work

What are our defenses? -Infection Control -Pharmacotherapy -Vaccine -Social Distancing

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Ground zero How do we manage overwhelming

influx of patients?

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Inpatient setting

-Central strategy: Triage early

Must have separate housing units for confirmed and yet-to-be confirmed

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Call for Ethics Committee

-To decide who meets the criteria for intubation and to be ventilated

-If limited antivirals, prioritize -Triage those deemed to be

Expectant Suspected vs confirmed influenza

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Why Influenza tend to be more prevalent in colder climates?

-Transmission of infection was most efficient when the humidity was 20-35%;

-It was blocked at 80% humidity.

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Outpatient setting

-Early spot and control dissemination -Hospital wide enforcement of “proper” use of masks

-Consider humidity of 80% of all waiting areas

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Influenza Treatment

-Tamiflu(oseltamivir) and Relenza(zanamivir)

-Rapivab(Peramivir) in IV only -Xofluza (baloxavir marboxil) Oct 24, 2018

-Supportive care -Aggressive bacterial treatment as

needed

Vaccine Production Options

-Egg based -Cell culture -Recombinant DNA

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Public health response goals

-Goal to contain outbreak as much and early possible

-Massive vaccination campaign to follow

-Prophylaxis with antivirals

Summary

Influenza viruses are the most adaptable and deadly

Our defenses are weaker than we hope for

The key is how well hospitals handle sentinel cases

Swift public health response