Preparing for the NextPreparing for the NextInfluenza PandemicInfluenza Pandemic

Susan E. Tamblyn, MD, DPH, FRCPCSusan E. Tamblyn, MD, DPH, FRCPCMedical Officer of HealthMedical Officer of HealthPerth District Health UnitPerth District Health Unit

November 15, 2002November 15, 2002University of TorontoUniversity of Toronto

contact: tamblyn@pdhu.on.cacontact: tamblyn@pdhu.on.ca

Learning ObjectivesLearning ObjectivesAt the end of this educational session, participants At the end of this educational session, participants should be able to:should be able to:

1. describe influenza pandemics and their potential 1. describe influenza pandemics and their potential impactimpact

2. discuss the role played by international, federal, 2. discuss the role played by international, federal, provincial and local agencies in planning for and provincial and local agencies in planning for and responding to an influenza pandemicresponding to an influenza pandemic

3. discuss current status of strategies for surveillance, 3. discuss current status of strategies for surveillance, vaccines and antivirals, health services planning, vaccines and antivirals, health services planning, emergency response, and communicationsemergency response, and communications

4. create an effective local pandemic plan4. create an effective local pandemic plan

Why Focus on Pandemic Planning?Why Focus on Pandemic Planning?

• next influenza pandemic could to be associated with next influenza pandemic could to be associated with highhigh mortality, morbidity and societal disruption mortality, morbidity and societal disruption

worldwideworldwide

• emergency will be complex, rapidly evolving and emergency will be complex, rapidly evolving and provoke public alarmprovoke public alarm

• too late at its onset to take many steps to lessen its too late at its onset to take many steps to lessen its impactimpact

• planning will enhance capacity to respond to other planning will enhance capacity to respond to other public health emergencies (including bioterrorism) and public health emergencies (including bioterrorism) and improve response to annual flu epidemicsimprove response to annual flu epidemics

Influenza 101Influenza 101

•• of the 3 influenza types (A, B and C), only influenza A of the 3 influenza types (A, B and C), only influenza A is associated with pandemicsis associated with pandemics

•• influenza A subtypes are classified by their surfaceinfluenza A subtypes are classified by their surface proteins: haemagglutinin (H) and neuraminidase (N)proteins: haemagglutinin (H) and neuraminidase (N)

•• 15H and 9N subtypes known15H and 9N subtypes known

• humans affected mainly by H subtypes 1-3humans affected mainly by H subtypes 1-3

•• aquatic birds are the reservoir for all subtypesaquatic birds are the reservoir for all subtypes

Where Do Influenza Epidemics Where Do Influenza Epidemics Originate?Originate?

• • evidence suggests most epidemics emerge from Chinaevidence suggests most epidemics emerge from China

• • close mingling of ducks, pigs, humans allows close mingling of ducks, pigs, humans allows reassortment of viruses reassortment of viruses

• • minor changes called “drift”; if big enough result in minor changes called “drift”; if big enough result in new epidemicnew epidemic

• • at unpredictable intervals, major changes called “shift” at unpredictable intervals, major changes called “shift” occur that result in a pandemic (3-4 per century)occur that result in a pandemic (3-4 per century)

Source: Nature Medicine 1998; 4:1122-3.

Source: Nature Medicine 1998; 4:1122-3.

Setting for a PandemicSetting for a Pandemic

•• emergence of an influenza A subtype with a emergence of an influenza A subtype with a new / different haemagglutininnew / different haemagglutinin

•• high proportion of susceptible people in the high proportion of susceptible people in the populationpopulation

•• high person-to-person transmission of high person-to-person transmission of the new virus, with accompanying human the new virus, with accompanying human diseasedisease

History ofHistory ofInfluenza PandemicsInfluenza Pandemics

YearYear Influenza A StrainInfluenza A Strain

18471847 ??

1889 - 18901889 - 1890 H2N2H2N2

1899 - 19001899 - 1900 H3N2H3N2

1918 - 19191918 - 1919 H1N1H1N1 Spanish fluSpanish flu

19571957 H2N2H2N2 Asian fluAsian flu

19681968 H3N2H3N2 Hong Kong fluHong Kong flu

(1977(1977 H1N1)H1N1)

Observations from Previous Observations from Previous PandemicsPandemics

•• 1-6 months warning from first global alert to 1-6 months warning from first global alert to local outbreakslocal outbreaks

•• 1st wave often out-of-season, lasts 6-8 weeks 1st wave often out-of-season, lasts 6-8 weeks (peak at 3-4 weeks)(peak at 3-4 weeks)

•• 2nd wave 3-9 months later; may be more 2nd wave 3-9 months later; may be more severesevere

•• 3rd wave may also occur3rd wave may also occur

Pandemic Epidemiology IIPandemic Epidemiology II

• many hospitalizations and deaths will be in young, many hospitalizations and deaths will be in young, previously healthy peoplepreviously healthy people

• percentage of deaths < age 65:percentage of deaths < age 65:19181918 99%99%19571957 36%36%19681968 48%48%

• pneumonia deaths predominated in 1918pneumonia deaths predominated in 1918(both primary viral and secondary bacterial)(both primary viral and secondary bacterial)

• in 1957 & 1968, cardiovascular and other in 1957 & 1968, cardiovascular and other complications accounted for about half of deathscomplications accounted for about half of deaths

Pandemic MortalityPandemic Mortality

No. of deathsNo. of deaths Death rateDeath rateWorldwideWorldwide CanadaCanada per 100,000 per 100,000 pop.pop.

1918-191918-19 40-50 m40-50 m 50-60,00050-60,000 218218

19571957 > 1 m> 1 m 7,0007,000 2222

19681968 3,0003,000 1414

Pandemic Impact in OntarioPandemic Impact in Ontario• up to 8 million people will be infected (up to 75%)up to 8 million people will be infected (up to 75%)

• 1.6 - 4 million will be clinically ill (up to 38%)1.6 - 4 million will be clinically ill (up to 38%)

• 0.7 - 1.8 million will require outpatient care0.7 - 1.8 million will require outpatient care(up to 17%)(up to 17%)

• 12 - 32,000 will require hospitalization12 - 32,000 will require hospitalization(up to 0.3%)(up to 0.3%)

• 3,000 - 12,000 deaths (up to 0.1%)3,000 - 12,000 deaths (up to 0.1%)

(Extrapolated from CDC estimates)(Extrapolated from CDC estimates)

1976 “Swine Flu” Lessons (H1N1)1976 “Swine Flu” Lessons (H1N1)

•• decision-making processdecision-making process

• mass vaccination programmass vaccination program

• unexpected vaccine adverse events unexpected vaccine adverse events (GBS)(GBS)

• need for domestic vaccine securityneed for domestic vaccine security

• led to first Canadian pandemic planled to first Canadian pandemic plan

1997 “Hong Kong Incident” Lessons 1997 “Hong Kong Incident” Lessons (H5N1)(H5N1)

• avian source – significant lab biosafety avian source – significant lab biosafety issues; control issuesissues; control issues

• difficulties in vaccine productiondifficulties in vaccine production

• communications were over-riding concerncommunications were over-riding concern

• wake-up call worldwide for pandemic wake-up call worldwide for pandemic planningplanning

Discussion & QuestionsDiscussion & Questions

WHO’s Role in InfluenzaWHO’s Role in Influenza• 50+ years of surveillance activities:50+ years of surveillance activities:

-- 4 WHO collaborating centres4 WHO collaborating centres -- 112 national influenza labs112 national influenza labs

-- collaborating centre for animal influenzacollaborating centre for animal influenza virusesviruses

• determine composition for annual vaccinesdetermine composition for annual vaccines

• Pandemic Preparedness Plan (1999)Pandemic Preparedness Plan (1999)

• WHO Global Strategy (2002)WHO Global Strategy (2002)

Components of the Global AgendaComponents of the Global Agenda

A.A. Strengthen epidemiological & virologicalStrengthen epidemiological & virologicalsurveillancesurveillance

B.B. Increase knowledge on health & economic Increase knowledge on health & economic burden of diseaseburden of disease

C.C. Increase influenza vaccine useIncrease influenza vaccine use

D.D. Accelerate national and international action Accelerate national and international action on pandemic preparednesson pandemic preparedness

D.D. Accelerate national and international action on Accelerate national and international action on pandemic preparednesspandemic preparedness

1.1. increase awareness of the need for pandemic increase awareness of the need for pandemic planningplanning

2.2. accelerate development and implementation of accelerate development and implementation of national pandemic plansnational pandemic plans

3.3. enhance use of vaccine and antivirals in the enhance use of vaccine and antivirals in the interpandemic periodinterpandemic period

4.4. develop strategies for use of vaccines and antivirals develop strategies for use of vaccines and antivirals and securing adequate supplies in a pandemicand securing adequate supplies in a pandemic

5.5. advocate research on pandemic viruses, vaccines, advocate research on pandemic viruses, vaccines, antivirals and other control measuresantivirals and other control measures

WHO’s Role in a PandemicWHO’s Role in a Pandemic

• task force to assist in viral and epidemiologic task force to assist in viral and epidemiologic studiesstudies

• heightened surveillance through WHO networkheightened surveillance through WHO network

• official declaration of the pandemicofficial declaration of the pandemic

• preparation of seed strains and reagents for preparation of seed strains and reagents for vaccine developmentvaccine development

• advice on response, including use of vaccines advice on response, including use of vaccines and antiviralsand antivirals

WHO Response PhasesWHO Response Phases

Phase 0Phase 0 -- interpandemic activitiesinterpandemic activities

Phase 0, Phase 0, Preparedness Level lPreparedness Level l -- new strain in human casenew strain in human case

Phase 0, Phase 0, Preparedness Level 2Preparedness Level 2 -- human infection confirmed (2 or more)human infection confirmed (2 or more)

Phase 0, Phase 0, Preparedness Level 3Preparedness Level 3 -- human transmission confirmedhuman transmission confirmed

Phase 1Phase 1 -- onset of pandemiconset of pandemic

Phase 2Phase 2 -- regional & multi-regional epidemicsregional & multi-regional epidemics

Phase 3Phase 3 -- end of 1end of 1stst pandemic wave pandemic wave

Phase 4Phase 4 -- 22ndnd or later waves or later waves

Phase 5Phase 5 -- end of the pandemicend of the pandemic

Some Global RealitiesSome Global Realities• pandemic could emerge in China where pandemic could emerge in China where surveillance and info sharing is still weaksurveillance and info sharing is still weak

• rapid dissemination through air travelrapid dissemination through air travel

• developing countries will be as hard hit as developing countries will be as hard hit as elsewhere – maybe worseelsewhere – maybe worse

• no antivirals unless stockpiledno antivirals unless stockpiled

• vaccines will not be available for 6 or morevaccines will not be available for 6 or moremonthsmonths

Global Realities IIGlobal Realities II

• countries with vaccine manufacturers may countries with vaccine manufacturers may nationalize suppliesnationalize supplies

• only 8 countries have domestic vaccine only 8 countries have domestic vaccine manufacturermanufacturer

• current production serves < 5% of world current production serves < 5% of world populationpopulation

• about 30 countries have pandemic plansabout 30 countries have pandemic plans

Vaccine & Antiviral StrategiesVaccine & Antiviral Strategies

Key points from recent WHO consultation:Key points from recent WHO consultation:

• expect shortages of both vaccines and antiviralsexpect shortages of both vaccines and antivirals

• wise use follows goals and priorities chosen by a countrywise use follows goals and priorities chosen by a country

• probably need 2 doses of vaccine for a naïve populationprobably need 2 doses of vaccine for a naïve population

• monovalent vaccine to be usedmonovalent vaccine to be used

• options to improve immunity include whole cell vaccines options to improve immunity include whole cell vaccines and use of adjuvantsand use of adjuvants

Vaccine & Antiviral Strategies IIVaccine & Antiviral Strategies II

• antiviral use is totally dependent on stockpilesantiviral use is totally dependent on stockpiles

• options are prophylaxis (PEP or during full options are prophylaxis (PEP or during full pandemic wave) and/or treatmentpandemic wave) and/or treatment

• need to avoid amantadine / rimantadine for need to avoid amantadine / rimantadine for treatmenttreatment

• issues of sharing with “have not” countriesissues of sharing with “have not” countries

Discussion & QuestionsDiscussion & Questions

Pandemic Planning in CanadaPandemic Planning in Canada

• ongoing activity for 20 yearsongoing activity for 20 years

• major revisions under way since Hong Kong incidentmajor revisions under way since Hong Kong incidentin 1997in 1997

• federal/provincial planning meetings held in 1999 and federal/provincial planning meetings held in 1999 and 2000 provincial / local planning2000 provincial / local planning

• F/P/T agreement led to establishment of PIC (Pandemic F/P/T agreement led to establishment of PIC (Pandemic Influenza Committee) and funding of a vaccine strategyInfluenza Committee) and funding of a vaccine strategy

• challenge now to integrate with bioterrorism planning challenge now to integrate with bioterrorism planning

Canadian Pandemic Influenza PlanCanadian Pandemic Influenza Plan

Plan will have three sections:Plan will have three sections:

• preparedness sectionpreparedness section – developed by CIDPC – developed by CIDPC now out for reviewnow out for review

• responseresponse – being developed by CIDPC and CEPR – being developed by CIDPC and CEPR

• recoveryrecovery – not yet developed – not yet developed

Framework for Planning & ResponseFramework for Planning & ResponseKey sections:Key sections:

• SurveillanceSurveillance• AntiviralsAntivirals• Health Services Emergency PlanningHealth Services Emergency Planning• Emergency Planning & ResponseEmergency Planning & Response• CommunicationsCommunications

Plan describes components and key planning Plan describes components and key planning activities (checklists) and has annexes and guidelines.activities (checklists) and has annexes and guidelines.

Canadian Pandemic Response GoalCanadian Pandemic Response Goal

• to reduce influenza morbidity and to reduce influenza morbidity and mortality and minimize societal disruption mortality and minimize societal disruption

among Canadians by providing access to among Canadians by providing access to appropriate prevention, care and treatmentappropriate prevention, care and treatment

SurveillanceSurveillance• objectives are to detect emergence, spread and objectives are to detect emergence, spread and

impact of novel strains in Canadaimpact of novel strains in Canada

• may include special studies at borders and major may include special studies at borders and major points of arrivalpoints of arrival

• early need to identify population susceptibility early need to identify population susceptibility to new strainto new strain

• both virologic and activity surveillance, both virologic and activity surveillance, including outbreak investigation and real-time including outbreak investigation and real-time

mortality trackingmortality tracking

Surveillance – Local ResponsibilitiesSurveillance – Local Responsibilities

• advance planning for activity monitoringadvance planning for activity monitoringeg sentinel physicians, school or workplaceeg sentinel physicians, school or workplaceabsenteeism, emergency room visitsabsenteeism, emergency room visits

• virologic surveillance will be directed by the virologic surveillance will be directed by the province – to include resistance monitoringprovince – to include resistance monitoring

• need rapid flow and analysis of dataneed rapid flow and analysis of data

• local epidemiologic picture triggers other response local epidemiologic picture triggers other response eg antiviral prophylaxis, hospital responseeg antiviral prophylaxis, hospital response

VaccinesVaccines• Canada has a pandemic contract with Shire to Canada has a pandemic contract with Shire to develop capacity to produce enough vaccine for develop capacity to produce enough vaccine for

whole population (includes continuous availability whole population (includes continuous availability of fertilized eggs)of fertilized eggs)

• expedited approval mechanisms and clinical trial expedited approval mechanisms and clinical trial protocols are under developmentprotocols are under development

• need to monitor uptake, adverse events and vaccine need to monitor uptake, adverse events and vaccine effectivenesseffectiveness

• national priorities for vaccine usenational priorities for vaccine use

Priority Groups for VaccinationPriority Groups for Vaccination

1.1. Health care workersHealth care workers

2.2. Essential service workersEssential service workers

3.3. Persons at high risk of severe or fatal outcomesPersons at high risk of severe or fatal outcomes• long term care facilitieslong term care facilities• NACI high riskNACI high risk• seniorsseniors• children < 2children < 2• pregnant womenpregnant women

4. Healthy adults4. Healthy adults

5. Children 2-18 years5. Children 2-18 years

Vaccines – Local ResponsibilitiesVaccines – Local Responsibilities

• plan to vaccinate whole population with 2 plan to vaccinate whole population with 2 doses a month apartdoses a month apart

• might or might not be able to use family doctors might or might not be able to use family doctors as vaccinators (not during wave of illness)as vaccinators (not during wave of illness)

• develop generic mass vaccination plan, using develop generic mass vaccination plan, using universal flu experience and Waterloo and universal flu experience and Waterloo and Alberta reportsAlberta reports

• plan tracking of uptake, adverse eventsplan tracking of uptake, adverse events

AntiviralsAntivirals• Canada’s antiviral strategy and stockpile is not Canada’s antiviral strategy and stockpile is not

yet approvedyet approved

• antivirals will likely be our only intervention for antivirals will likely be our only intervention for the first wavethe first wave

• antiviral distribution will be controlled, probably antiviral distribution will be controlled, probably through public healththrough public health

• need to monitor uptake, adverse events, need to monitor uptake, adverse events, resistance and effectivenessresistance and effectiveness

Priority Groups for AntiviralsPriority Groups for Antivirals

1.1. treatment of persons hospitalized for flutreatment of persons hospitalized for flu

2.2. treatment of high risk persons in communitytreatment of high risk persons in community

3.3. prophylaxis of health care workersprophylaxis of health care workers

4.4. outbreaks in LTCFoutbreaks in LTCF

5.5. prophylaxis of essential service workersprophylaxis of essential service workers

6.6. prophylaxis of other hospitalized patientsprophylaxis of other hospitalized patients

7.7. prophylaxis of high risk persons in communityprophylaxis of high risk persons in community

8.8. treatment of ill persons (not high risk)treatment of ill persons (not high risk)

AssumptionsAssumptions• prophylaxis is for six weeks –prophylaxis is for six weeks –

triggered by arrival of flu in local areatriggered by arrival of flu in local area

• treatment is for five daystreatment is for five daysand only for persons ill < 48 hoursand only for persons ill < 48 hours

• amantadine is used only for prophylaxis amantadine is used only for prophylaxis (to prevent development of resistance)(to prevent development of resistance)

• neuraminidase inhibitors are used for neuraminidase inhibitors are used for treatmenttreatment

Antivirals – Local PlanningAntivirals – Local Planning• develop mass distribution plan for public health develop mass distribution plan for public health

controlled drug (can be generic – anthrax etc)controlled drug (can be generic – anthrax etc)

• potential scenarios:potential scenarios:

- hospitals dispense for patient and health care - hospitals dispense for patient and health care worker prophylaxis (pharmacy committee worker prophylaxis (pharmacy committee control)control)

- Health Unit or community pharmacy clinics for - Health Unit or community pharmacy clinics for ESW’s and other HCW’sESW’s and other HCW’s

- selected pharmacies for Rx courses- selected pharmacies for Rx courses

Health Services Emergency PlanningHealth Services Emergency Planning• problems – no surge capacity, shortage of problems – no surge capacity, shortage of personnel at time of high demand and increased personnel at time of high demand and increased

risk of infectionrisk of infection

• extensive clinical guidelines have been developed:extensive clinical guidelines have been developed:clinical managementclinical managementtriagetriageresource managementresource managementmass casualtiesmass casualtiesnon-traditional sites and workersnon-traditional sites and workersinfection controlinfection control

Health Services – Local PlanningHealth Services – Local Planning

• ideal is integrated response involving doctors, ideal is integrated response involving doctors, clinics, hospitals and CCACclinics, hospitals and CCAC

• establish plans for community clinics / triage establish plans for community clinics / triage sitessites

• establish hospital expansion plans / alternate establish hospital expansion plans / alternate sitessites

• clarify communication between health services clarify communication between health services and public healthand public health

Community Control MeasuresCommunity Control Measures

• general advice for publicgeneral advice for public

• emphasis on personal and hand hygieneemphasis on personal and hand hygiene

• community mask use felt ineffectivecommunity mask use felt ineffective

• effectiveness of closure of public places, effectiveness of closure of public places, including schools needs more studyincluding schools needs more study(modeling ?) (modeling ?)

CommunicationsCommunications

• federal communications plan still under federal communications plan still under developmentdevelopment

• expect templates, fact sheets, key messages, expect templates, fact sheets, key messages, guidelines, etcguidelines, etc

• secure web site will be usedsecure web site will be used

• essential to harmonize with all levels of essential to harmonize with all levels of government – consistent messaginggovernment – consistent messaging

Communications – Local PlanningCommunications – Local Planning

• develop public health emergency develop public health emergency communications plan (not just for pandemics)communications plan (not just for pandemics)

• identify stakeholders and communication identify stakeholders and communication strategies to reach themstrategies to reach them

• dispelling rumors and mythsdispelling rumors and myths

Emergency Planning and ResponseEmergency Planning and Response

• at all levels, need to dovetail with the emergency at all levels, need to dovetail with the emergency response system already in placeresponse system already in place

eg Emergency Management Ontarioeg Emergency Management Ontario

• maintaining essential services should be their key maintaining essential services should be their key responsibilityresponsibility

• highlight differences from otherhighlight differences from other emergencies – emergencies – prolonged emergency, little outside help, affects prolonged emergency, little outside help, affects people not infrastructurepeople not infrastructure

Emergency Response – Local PlanningEmergency Response – Local Planning

• engage local municipalities and emergency engage local municipalities and emergency control groups in pandemic preparednesscontrol groups in pandemic preparedness

• want pandemic annex for local planswant pandemic annex for local plans

• need way to coordinate county-wide or Health need way to coordinate county-wide or Health Unit-wide responseUnit-wide response

• establish triggers for moving to ECG control establish triggers for moving to ECG control (vs HU led) and declaring a local emergency(vs HU led) and declaring a local emergency

Creating a Local PlanCreating a Local Plan

Various approaches can work. Steps include:Various approaches can work. Steps include:

• raising awarenessraising awareness

• developing a plan to plan:developing a plan to plan:framework / timetableframework / timetable

• with appropriate stakeholders, developing with appropriate stakeholders, developing details for each componentdetails for each component

• writing up the planwriting up the plan

• exercises to test components of the planexercises to test components of the plan

Planning ProblemsPlanning Problems• working with committees vs internal planningworking with committees vs internal planning• who’s in charge?who’s in charge?

- what type of coordinating committee?- what type of coordinating committee?

- relationship with municipal ECG’s- relationship with municipal ECG’s

• finding time / talent to develop the planfinding time / talent to develop the plan

• lack of provincial planlack of provincial plan

Unresolved Provincial IssuesUnresolved Provincial Issues

• hospital preparednesshospital preparedness

• licensing issues / use of alternative licensing issues / use of alternative practitionerspractitioners

• stockpiling / distribution issuesstockpiling / distribution issues

• decisions on who will immunizedecisions on who will immunize

• surveillance / reporting requirementssurveillance / reporting requirements

Discussion & QuestionsDiscussion & Questions