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Pandemic Influenza Overview and Current Planning Considerations. State of Connecticut Department of Public Health Albert L. Geetter, MD Section Chief Office of Public Health Preparedness. Pandemic Influenza. Definitions Bird Flu/Avian Influenza Domestic Poultry Migratory Waterfowl

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Pandemic Influenza Overview and Current Planning Considerations

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Pandemic InfluenzaOverview and Current Planning Considerations

State of Connecticut

Department of Public Health

Albert L. Geetter, MD

Section Chief

Office of Public Health Preparedness

Pandemic Influenza


  • Bird Flu/Avian Influenza

    • Domestic Poultry

    • Migratory Waterfowl

  • Pandemic Influenza

  • Implications

    • Novel Virus

      • lack of immune “experience”


    • Transmissability

    • Reassortment via Antigenic Shift

    • Human and Avian recombinant

    • in “other” species.

    • Mutation via Antigenic Drift

    • Internal Genetic Adaptive Change



    Avian reassortant



    in humans





    Avian-human pandemic

    reassortant virus


    in hogs

    Generation of Pandemic Influenza

    Reassortmentis where a human & other animal strains can mix and form a new strain




    Who Infects Who?

    Likely sites of transmission

    Children/Teenagers 29%

    Adults 59%

    Seniors 12%


    Glass, RJ, et al. Local mitigation strategies for pandemic influenza. NISAC, SAND Number: 2005-7955J

    Current WHO Statistics

    • Total Human Cases: 387*

    • Total Human Deaths: 245*

    • Total Avian (waterfowl /domestic) Deaths: > 500 Million

      • Viral etiology

      • Culling

      • *Politically Driven estimates

    Pandemic Influenza: Background & Assumptions

    • Novel virus, fully susceptible population, efficient and sustained human to human spread

      • “1918-like” pandemic would result in ~2 million deaths in US

      • Vaccine (pandemic strain) likely delayed or not available

      • Antivirals may be insufficient quantity, ineffective and/or difficult to distribute in a timely way

      • Epidemic over a large geographic area affecting a large proportion of the population

    Pandemics of the 20th Century

    • • The "Spanish influenza", between 1918 to 1919, was due to an A/H1N1 virus related to porcine influenza

    • • The "Asian influenza", between 1957 to 1958, was due to an A/H2N2 virus

    • • The "Hong Kong influenza", between 1968 to 1969, was due to an A/H3N2 virus.

    20th Century Influenza Pandemics

    • 1968-69 “Hong Kong flu,” (H3N2)

      • 34,000 US deaths (1-4 million worldwide)

    • 1957-58 “Asian flu,” (H2N2)

      • 70,000 US deaths (1-4 million worldwide)

    • 1918-19 “Spanish flu,” (H1N1)

      • >600,000 US deaths (20-100 M worldwide)

      • 30-40% infected

      • 2.5% overall mortality

      • Most deaths among young, healthy adults

    Projected GDP Loss From Severe Pandemic: $10.1 Billion

    Projected GDP Percent Loss from Severe Pandemic: 5.23 percent

    Ranking of Percentage Losses Out of 50 States (Highest = 1): 46

    Projected Losses Due to Workforce Absenteeism and Deaths: $ 5 billion

    Projected Losses to State Industries: $3.2 billion

    Projected Losses Due to Potential Drop in Trade: $1.9 billion

    Projected Lives Lost: 29,000

    Projected Number of Illnesses: 1,039,000

    Pandemic Severity Index


    Category 5

    Category 4

    Category 3

    Category 2

    Category 1

    Pandemic Severity Index

    March 1918

    “On March 30, 1918, the occurrence of eighteen cases of influenza of severe type, from which three deaths resulted was reported at Haskell, Kansas.” Public Health Reports, March, 1918

    September 1918

    “This epidemic started about four weeks ago, and has developed so rapidly that the camp is demoralized and all ordinary work is held up till it has passed....These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they very rapidly develop the most viscous type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves. We have been averaging about 100 deaths per day, and still keeping it up. There is no doubt in my mind that there is a new mixed infection here, but what I don’t know.”

    A physician stationed at Fort Devens outside Boston, late September, 1918

    Stages of a Pandemic

    The World Health Organization (WHO) has developed a global influenza preparedness plan, which defines the stages of a pandemic, outlines the role of WHO, and makes recommendations for national measures before and during a pandemic. The phases are:

    Page last modified on October 17, 2005

    Interpandemic period

    Phase 1 : No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low.

    Page last modified on October 17, 2005

    • Phase 2: No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease.

      • Antigenic Shift

      • Antigenic Drift

    Page last modified on October 17, 2005

    Pandemic alert period

    Phase 3: Human infection(s) with a new subtype but no human-to-human spread, or at most rare instances of spread to a close contact.

    Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.

    Page last modified on October 17, 2005

    Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk).

    Page last modified on October 17, 2005

    Pandemic period

    Phase 6: Pandemic: increased and sustained transmission in general population.

    Page last modified on October 17, 2005

    Government Response to a Disaster





















    A tale of two citiesPhiladelphia & St. Louis

    • In St. Louis, when the first cases of disease among civilians were reported on October 5, city authorities moved quickly to introduce a wide range of measures designed to promote "social distancing," implementing these measures within two days.

    A Tale of Two CitiesPhiladelphia & St. Louis

    • Philadelphia's officials response to the news of the pandemic was to downplay its significance. They allowed large public gatherings to continue taking place - most notably a city-wide parade on September 28, 1918.

    • Bans on public gatherings, school closures and other NPI's did not begin to be implemented until October 3.

    Philadelphia 1918 War Bond Parade

    Philadelphia & St Louis

    • Philadelphia experienced a peak weekly death rate of 257 per 100,000 people and an overall death count of 719 per 100,000.

    • St. Louis showed much lower totals, with a weekly mortality peak of just 31 per 100,000 and a final mortality count of 347 per 100,000.

    Shelter in Place

    • Food

    • Water

    • Flashlight

    • Battery/Crank Powered Radio

    • Cooking Utensil

      • Sterno Powered Fondue Pot

  • Cell Phone

  • Written Contact List

  • Prescriptions



    80% of production-outsourced

    • Current Programs in Development

    • Surveillance

    • Response/Activation/Mitigation

      • Surge

      • Triage

      • Alternate Care Sites

      • Antiviral Distribution

      • Vaccine Development

      • Non Pharmaceutical Intervention

        • Cough Etiquette

          2. Hand Washing

          3. Social Distancing

          4. Shelter in Place

    • Legal

    • Ethical

    • Recovery

    • Restoration

    The "Back-up Plan"

    Vaccine (pandemic strain) likely delayed or not available

    • Antivirals may be insufficient quantity, ineffective and/or difficult to distribute in a timely way

    • Epidemic over a large geographic area affecting a large proportion of the population


    • Total Staffed Beds~7294

    • Professional Staff~14,077

    • Support Staff~47,425

    Operational Considerations

    • Maximum surge rate: 48-72 hours

    • Expected staff depletion rate: 30-40%


    • Attack Rate 30%

    • Connecticut Population~3.5 Million

    • Acutely Ill ~1 Million

    Pandemic Mortality Rate1-2%

    • projected 10,000-20,000 Deathsover a 10-12 week period

    Pandemic Mortality Rate = 1-2%

    10,000 – 20,000 projected pandemic deaths

    5,500 – 6,600 ‘statistically expected’ deaths


    15,500 – 26,600

    Management Categories

    • Critical Personnel

    • Essential Personnel

    • Support Personnel

    • Substitution

    Sentinel Events

    • Impending Capacity Overload

    • Staff absence from assigned duties

    • ED Surge

    Initial Response

    • Simultaneous Cessation of all Elective Procedures

    • Activate Staff: Notification, Call-down Reassignment from elective to acute care duties

    • Furlough, Early Discharge, of Non-Acute Patients

    • Designate % In-house Bed Capacity for Acute Viral Respiratory Syndrome Patients

    Professional StaffingCommunity Health OrganizationsLocal Health DepartmentsMRCESARVHP

    Administrative Issues

    • ACH Oversight of all Non-Medical Aspects of ACF Operations

    • ACF to Operateas a Satellite of a Designated ACHunder its DPH licensure

    • Insurance Billing for Services Rendered under ACH Licensure

    ACF/TC ActivationPredetermined Site Selection in concert with area ACH, Regional Emergency Response and local Chief Elected OfficialsMobile Field Hospital Activation to provide 25 bed TC for each of the five DEMHS regions

    ACF Functional Elements

    • Sewage facilities

    • Oral pharmaceuticals

    • Temporary morgue capacity

    • Ease of vehicle access

    • Communications capability

    • Basic medical/nursing care

    • Free Standing“Hard” Shelter

      • HVAC

      • Food

      • Rehydration

      • Bedding

      • Showers

      • Water intake

    • Proximity but not contiguity to ACH’s and TC’s, to avoid aggregation of individuals seeking medical care

    TC FunctionsAll 911 calls regarding acute respiratory syndrome will result in diversion to a regional TC for evaluationRisk communication to public will encourage private transport of similarly ill individuals to the TC

    Triage Classification

    • Acutely Ill, requiring transport to ACH as bed becomes available

    • Clinically Subacute Illness, requiring ACF support

    • Ill individuals who can remain at home

    • Worried Well

    • Expectant

    Mortuary OperationsACH, ACF and TCOn premises identification and body storage to be an oversight function of the OCME and DMORT Teams


    Declaration to deactivate the ACF/TC module will be at the discretion of DPH Commissioner in concert with ACH/DMAT/TC Administrators


    • Patient discharge/transfer per ACH protocols

    • Administrative and medical support personnel return to pre-event clinical duties

    • DMAT deconstruction and storage of MFH modules

    • Pharmaceutical cache returned to point of origin



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