Pandemic Preparedness: Pigs, Poultry, and People versus Plans, Products, and Practice

1. PandemicPreparedness:Pigs, Poultry, and PeopleversusPlans, Products, and Practice Julie L. Gerberding, MD, MPH Director Centers for Disease Control and Prevention Administrator Agency for Toxic Substances and Disease Registry Atlanta, GA

2. Seasonal Influenza Globally: 250,000 to 500,000 deaths each year In the United States each year: 36,000 deaths >200,000 hospitalizations $37.5 billion in economic costs from influenza and pneumonia Pandemic Influenza An ever-present threat The Burden of Influenza

3. Pandemics Do Happen! H9* 1998 1999 H5* 2003 1997 2003-2006 H7* 1980 1996 2002 2003 2004 H1 H3 H2 H1 1977 1915 1925 1935 1945 1955 1965 1975 1985 1995 2005 1957 Asian Influenza H2N2 1918 Spanish Influenza H1N1 1968 Hong Kong Influenza H3N2 *Avian Flu

4. Bacteriologic Findings Among Patients with Influenzal Pneumonia 1918-1919 Stevens KM. NEJM. 1976;1363-66.

5. Potential Causes of Shock and Death • Exacerbation of undiagnosed underlying conditions • Coincidental occurrence of an unrelated problem • Influenza pneumonia • Secondary bacterial pneumonia • Toxic shock syndrome/endotoxemia • Hypersensitivity response • Myopericarditis • Cytokine-induced shock syndrome

6. H5N1 Influenza Severe Pneumonia - Vietnam 2004 DAY 5 DAY 7 DAY 10 Hien TT et al. New England J Med. 2004;350:1179-1188.

7. Planning Assumptions: Health Care • 50% or more of those who become ill will seek medical care • Number of hospitalizations and deaths will depend on the virulence of the pandemic virus

9. Addressing Local Practices

10. Direct Avian – Human Infection Human virus Pandemic Strain Emergence:Direct Infection Avian virus Avian Reservoir

11. New reassorted virus other mammals? Pandemic Strain Emergence: Reassortment of Influenza A Viruses Human virus Avian virus Avian Reservoir

12. H5N1 InfluenzaEvolves HemagglutininGeneticChanges CkCambodia013LC2b05 VietnamJP1405 VietnamJPHN3032105 VietnamJP420705 CkVietnam104 Clade 1 CambodiaJP52a05 CkMalaysia585804 CkThailand104 Thailand35304 99 Prachinburi623104 Vietnam120304 Vietnam119404 88 VietnamHN3040805 Thailand1604 Clade 1' 93 blhdgullHong Kong12103 Hong Kong21303 DkKulonProgoBBVET904 100 QaCirebonBBVET105 Indonesia505 Indonesia705 Indonesia605 91 100 CkBrebesBBVET205 CkKulonprogoBbvetXii104 CkIndonesia504 94 CkIndonesia703 Clade 2 CkHong KongYU32403 BarheadedGsQinghai1205 BarheadedGsQinghai6505 100 TurkeyTurkey105 99 whooperSwanMongolia MG24405 95 CkKoreaES03 CkYamaguchi704 99 CkYunan49305 DkGuangxi1304 CkGuangdong19104 DkChinaE319203 99 CkGuangdong17804 99 Hong Kong48697 Hong Kong53897 Hong Kong15697 CkHong Kong22097 98 99 Hong Kong48397 GsGuangdong397 GsGuangdong196 100 0.005

13. Widespread and spreading prevalence in migratory birds; broad host range Continued outbreaks among domestic poultry Mammalian infection (cats, pigs, etc.) lethal Virus is evolving Sporadic human cases (>140 reports to date) Most in young and healthy Case-fatality 50% Rare person-to-person transmission Sustained and rapid person-to-person transmission Situation Report: Avian Influenza

14. Support the National Strategy for Pandemic Influenza Outlines planning assumptions and doctrine for health sector pandemic preparedness and response Public Health Guidance for State and Local Partners 11 Supplements with detailed guidance HHS Pandemic Influenza Plan

15. A threat anywhere is a threateverywhere! Quench first outbreaks: detect and contain where it emerges, if feasible International collaborations Frontline detection and response; rapid laboratory diagnosis Isolation / quarantine / antiviral prophylaxis / social distancing / animal culling Pandemic Influenza Doctrine: Saving Lives

16. Pandemic Influenza Doctrine: Saving Lives • Prevent or at least delay introduction into the United States • May involve travel advisories, exit or entry screening • For first cases, may involve isolation / short-termquarantine of arriving passengers

17. CDC Station Jurisdictions of 18 CDC quarantine and border health stations AK ME Minneapolis Seattle Anchorage Chicago VT NH WA Boston MA ND MT Detroit* NY MN CT RI MI WI New York NJ OR PA ID SD Newark WY MD DE IA OH NE IN No.CA WV IL Washington D.C. NV VA San Francisco UT KY CO MO KS NC TN SC So.CA OK AR Atlanta NM AZ Los Angeles AL GA MS San Diego LA West TX East TX El Paso FL Houston Miami Honolulu HI GU PR

18. Unprepared Impact Prepared Weeks Pandemic Influenza Doctrine: Saving Lives • Slow spread, decrease illness and death, buy time • Antiviral treatment and isolation for people with illness • Quarantine for those exposed • Social distancing • Vaccine when available • Local decisions

19. Pandemic Influenza Doctrine: Saving Lives • Clearly communicate to the public • Prepare people with information • Encourage action steps to prepare now • Provide updates when new information emerges • Use trusted messengers • Coordinate to ensure consistent messages • Address rumors and inaccuracies

20. Federal Partners Healthcare Delivery System Local /State / Federal Public Health System Business & Workers Education System Our Health Protection Preparedness SystemA NETWORK of Shared Responsibility! • Local - state - federal • Domestic – international • Public – private • Multi-sector • Non-partisan • Animal – human • Health protection – homeland security – economic protection

21. Countermeasures: Vaccines, Antivirals, and Medical Supplies Strategic National Stockpile

22. Physician Offices and Ambulatory Care Home Health Emergency Medical Services Travel Industry Pandemic Influenza Checklists • State and Local • Business • Preschool • Schools (K-12) • Colleges & Universities • Faith-based & Community Organizations www.pandemicflu.gov

23. Vaccine Production and Use: U.S Seasonal Influenza

24. Vaccine Supply and Demand are Unpredictable U.S. Seasonal Influenza 100 Doses Produced 90 80 70 Doses Distributed 60 Millions 50 40 30 20 10 0 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005

25. Influenza Vaccine Recommendations: Expanding

26. Routine Childhood Adult Immunization Programs: Some Key Differences • Significant public sector support – VFC, 317, states • Small financial risk to private providers for vaccine purchases • Very limited; no ACIP ability to finance vaccine purchases • Potentially large financial risks for providers for vaccine purchase(i.e., “reimbursement” model used) • Public Sector Financial Support Control of Vaccine • Large CDC/State roles • Small CDC/State roles Access; number and public sector provider sites • 45,000 VFC sites providing vaccinations year round (i.e., public clinics and private physicians) • About 5,000 state and local health departments provide access to publicly purchased influenza vaccine Assurance of vaccination (accountability) • CMS/QIOs for some populations • No clear lead for targeted high-risk adults for people <65 years old • CDC/States

27. Preparedness Preparedness Pandemic Influenza Preparedness • Preparing for a pandemic now will mean: • Lives saved during seasonal influenza • Modern seasonal influenza vaccine for all who need it • New antiviral drugs for prevention and treatment • Community health protection from other threats • Peace of mind

28. Complacency is the Enemy of Health Protection! www.cdc.gov www.pandemicflu.gov