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Pandemic Influenza Planning An Evolution to the Approach for National Communicable Disease Emergencies Dr. Theresa Tam Manager, Respiratory Infections Section Immunization and Respiratory Infections Division Health Canada Santé Canada Teleclass, Association of Local Public Health Agencies, October 21, 2003 Outline Background on influenza virus and pandemics Evolution of the Canadian Pandemic Influenza Plan How the Canadian plan and processes were used during the H5N1 and SARS response How the Plan will be modified: successes, challenges and lessons learnt from SARS model for communicable disease emergency response plans Health Canada Santé Canada Influenza Virus The Pandemic Agent Influenza Virus: orthomyxoviridae RNA virus, 8 segments mutate or recombine resulting in new viral strains Lipid membrane contains two spike glycoproteins: • haemagglutinin • neuraminidase Health Canada Santé Canada ABC of Influenza Virus Influenza A (avian, humans, swine, equine, marine mammals) 15 hemagglutinin subtypes current human strains H1N1 (H1N2) H3N2 Influenza B (humans) Influenza C (humans, swine) Health Canada Santé Canada The natural hosts of influenza A Antigenic Shift and Drift Antigenic drift: a gradual change in the hemagglutinin and/or the neuraminidase proteins when the virus goes through a series of minor mutations and evolves over time (Influenza A & B) Antigenic shift: an abrupt and major change in the hemagglutinin and/or the neuraminidase proteins resulting in the sudden appearance of a new influenza virus subtype (Influenza A) Health Canada Santé Canada Influenza Pandemics: How Do They Occur? Type A Type B Annual Flu ANTIGENIC SHIFT Novel virus No resistance Human to human transmission Illnesses and deaths Health Canada Santé Canada PANDEMIC Pandemic Influenza What is it? Why plan for it? What can be done to prepare for it? Health Canada Santé Canada Pandemic Influenza History Spanish Flu 1918 Asian Flu 1957 Hong Kong Flu 1968 Pandemic scares: Swine Flu 1976 Hong Kong Avian Flu 1997 and 2003 Health Canada Santé Canada Each Pandemic is Different Year Interval(yrs) Subtype 1889 1918 1957 1968 1977 Health Canada -29 39 11 9 Santé Canada H3N2 H1N1 H2N2 H3N2 H1N1 Severity moderate severe severe moderate mild Pandemic Influenza What We Know and the Uncertainties Another influenza pandemic is INEVITABLE Timing and epidemiology UNPREDICTABLE SHORT LEAD TIME presence in Canada < 3 months (much shorter?) 1st peak in illness within 5-7 months Outbreaks will occur SIMULTANEOUSLY in multiple locations, in multiple waves Health Canada Santé Canada Influenza Pandemics: Then and Now Increase in world population and changing demographics (e.g. immunocompromised hosts) Jets may spread the disease very rapidly in hours or days In developed countries Improved medical care, antibiotics for secondary infections Vaccines and antivirals for prophylaxis Antiviral drugs for treatment Health Canada Santé Canada Pandemic Influenza Estimating the Impact In Canada, if vaccine is unavailable, EXPECT: Health Resource 11,000 to 58,000 deaths Scarcity 34,000 to 138,000 hospitalizations 2 to 5 million outpatients economic costs Societal health care: $330M to $1.4B Disruption societal: $5B to $38B Health Canada Santé Canada Recent Experience with Avian Influenza 1997 H5N1 in Hong Kong 18 cases and 6 deaths Mass culling of poultry International demand for antiviral drugs 2003 H5N1 in China/Hong Kong Two persons with confirmed infection; two fatalities H7N7 in the Netherlands One death and > 80 cases of mild disease in humans associated with affected poultry farms Human to human spread Health Canada Santé Canada Pandemic Influenza Planning & preparing to better manage tomorrow’s pandemic consequences ... today Health Canada Santé Canada Preparedness Activities: International Global Agenda for Influenza Surveillance and Control (WHO) Major Themes 1. Improvement in the quality and coverage of virological and epidemiological influenza surveillance 2. Improvement in the understanding of health and economic burden of influenza, including benefits from epidemic control and pandemic preparedness Health Canada Santé Canada Global Agenda for Influenza Surveillance and Control (WHO) Major Themes 3. Expansion in the use of existing vaccines, particularly in developing countries and in high-risk groups and acceleration in the introduction of new vaccines 4. Increase in national and global epidemic and pandemic preparedness, including vaccine and pharmaceutical supplies Health Canada Santé Canada Global Influenza Surveillance Network Virological surveillance 110 national influenza laboratories 1 lab/country >1 lab/country 4 regional reference centres WHO Global Agenda, May 2002 To expand the existing laboratory surveillance network and increase disease surveillance for influenza control and pandemic preparedness. Health Canada Santé Canada Rationale for Strengthening International Influenza Surveillance Surveillance of human, wild and domestic animal populations in high risk areas is key to: vaccine development development of an early warning system for viruses with pandemic potential Areas where birds, pigs and humans live in close proximity are high risk environments for antigenic drift and shift. Health Canada Santé Canada WHO Pandemic Phases Phase 0, Level 0 - Inter-Pandemic period Phase 0, Level 1 - Novel virus identification in a human Phase 0, Level 2 - Human infection confirmed Phase 0, Level 3 - Human-to-Human transmission confirmed Phase 1 - Pandemic confirmed Phase 2 - Outbreaks in multiple geographic areas Phase 3 - End of first wave Phase 4 - Second or later waves Phase 5 - Post-Pandemic / Recovery Health Canada Santé Canada International Pandemic Preparedness Development of pandemic plans Approximately 30 countries worldwide have a plan Use of the WHO Pandemic Phases improves communication and consistency Requires national coordination and agreement on goals of pandemic preparedness and response National surveillance for influenza-like illness and influenza viruses Vaccine strategies Development of Stockpiles / Antiviral strategy Health Canada Santé Canada Preparedness Activities Canada Overall Goal of Pandemic Preparedness and Response First, to minimize serious illness and overall deaths, and second to minimize societal societal disruption among Canadians as a result of an influenza pandemic. Health Canada Santé Canada Pandemic Planning Milestones 1998-2002 Post H5N1 outbreak in Hong Kong First national meeting (Jan. 2000) Federal/Provincial/Territorial Working Agreement (Mar. 2001) Pandemic vaccine contract (Sep. 2001) Pandemic Influenza Committee (PIC) (Mar. 2002) Extensive stakeholder consultations on the Canadian Pandemic Influenza Plan (Summer 2002) Health Canada Santé Canada Pandemic Planning in Evolution 2003 “Exercised” pandemic plan structures & processes H5N1 in Hong Kong and H7N7 in Netherlands SARS outbreak other emergency exercises TOPOFF2 Global Mercury – international communications Incorporating SARS lessons learnt Health Canada Santé Canada Overview of the Plan Executive Summary Overview I. INTRODUCTION List of Annexes Goal of Influenza Pandemic Preparedness and Response II. BACKGROUND Overview of the Plan Epidemiology of Pandemic Influenza Roles and Responsibilities Estimated Impact of an Influenza The Pandemic Influenza Committee Pandemic on Canadians The Pre-Pandemic Period Terminology The Pandemic Period Pandemic Phases The Post-Pandemic Period List of Abbreviations Legal Issues III. PREPAREDNESS SECTION Ethical Issues Introduction (to Preparedness Section) Components of the Preparedness Section Surveillance and Lab Testing Vaccine Programs Antivirals Health Services Emergency Planning Emergency Services Public Health Measures IV. RESPONSE SECTION Communications Introduction (to Response Section) Planning Activities by Components Phased Approach Pandemic Planning Checklists Experience to Date WHO Phases Key Response Activities by Pandemic Phase V. RECOVERY SECTION In development Health Canada Santé Canada VI. ANNEXES National Working Groups Pandemic Influenza SARS Surveillance and epidemiology Laboratory testing Vaccines Antivirals (Special Access Program) Public Health Measures Communication Health Services Resource Management Health Canada Santé Canada Non-Traditional Sites and Workers Mass fatalities Clinical Care Infection Control SARS: Recognition and Response 14 Feb: Official confirmation of outbreak of atypical pneumonia with 305 cases and 5 deaths, Guangdong 19 Feb: Hong Kong SAR, 2 cases of influenza A/H5N1 Canada’s Pandemic Influenza Committee activated FluWatch surveillance system on alert Pandemic surveillance protocol developed Communications strategy and fact sheets 12 March: 1st WHO global alert for atypical pneumonia 13 March: Health Canada advised of cases of atypical pneumonia in Ontario and British Columbia Health Canada Santé Canada Issues, What Issues? Health Canada Santé Canada Successes Pandemic influenza structures and processes were successfully translated to respond to SARS Early phases of the national pandemic influenza response tested and applied to another emerging infectious disease Disease control measures, despite uncertainties, appear to have been largely effective Rapid knowledge generation and translation through existing networks for influenza and new partnerships international and national laboratory, epidemiology and clinical care experts worked together National health crisis communications network worked well Health Canada Santé Canada Key Challenges Insufficient public health infrastructure, policies, procedures and legislation to support public health action at all levels Lack of infrastructure and processes for real time data sharing Time lag in epidemiologic data generation and application of evidence to public health action Making decisions on public health measures with insufficient evidence Health Canada e.g. travel-related interventions Santé Canada Key Challenges Laboratory testing over-testing and inability to prioritise specimens research versus public health needs Use of surveillance case definitions for clinical purposes Retrospective epidemiologic linkage of cases Communicating the progress and impact of the epidemic to decision makers and the public Health Canada National and international inconsistency in case definitions Santé Canada Lessons Learned: Coordination and Operations Clear command structure required Provinces without well developed pandemic plans had to create structures immediately to deal with health emergency Dedicated team leadership is essential Need to strengthen human resource planning and surge capacity in emergency plans Psycho-social support: post traumatic stress Health Canada Santé Canada Lessons Learned: Advance Planning Incident management structure used at Health Canada Coordination and Operations Technical (surveillance, epidemiology, public health guidelines etc.) Logistics Crisis communications Advance Planning Group needed Health Canada Santé Canada Lessons Learned: Disease Control Quarantine and isolation measures were generally acceptable to the public Cancellation of public gatherings will happen regardless of public health recommendations Multiple partners need to be involved in the implementation of public health measures Education and information dissemination media, NGOs, professional societies, businesses, schools… Blood and border issues will arise quickly Health Canada Santé Canada Lessons Learned: Surveillance Lack of integrated mechanisms and processes for surveillance Strengthen interface between hospital and public health Epidemiological, clinical and laboratory data linkage Establish case definitions with rationale Consistent use of definitions nationally AND strive for international consistency Pre-establish minimum dataset and data sharing agreements for emerging infectious diseases Establish mechanism and processes for alerting public health and health care providers in real time Health Canada Santé Canada Lessons Learned: Outbreak Investigation Enhance epidemiological capacity at all levels Improve ability to mobilize resources across jurisdictions multi-disciplinary outbreak investigation teams Clarify or establish roles and responsibilities and collaboration mechanisms for a multi-jurisdictional response Increase training programs, including short courses that can be rapidly implemented Health Canada Santé Canada Lessons Learned: Communication Pre-established national networks worked; need to strengthen international networks Establish communication processes that permit optimal use of all participants time Human resources needed to translate science (particularly epidemiology) into public information Potential for case counts to become politicized Perception IS reality Health Canada Santé Canada Lessons Learned: Infection Control in Acute Care Settings Lack of trained infection control personnel Varying capacity for surveillance and need to coordinate with public health Negative impact of intensive SARS infection control measures Health care worker well-being Increase in other nosocomial infections e.g. MRSA, VRE Missed or not reported tuberculosis cases Ongoing training needed e.g. how to put on / remove personal protective equipment Health Canada Santé Canada Lessons Learned: Health Services Pandemic influenza guidelines useful Resource management Managing hospital triaging and transfers Dedicated SARS units Lack of supplies Staff exhaustion Security requirements Non-traditional sites / workers Health Canada Sites administered through acute care setting City buses as screening units outside hospitals Lack of volunteers, no medical/nursing students Santé Canada Response to SARS vs Influenza Pandemics SARS Goal = Containment Flu Pandemic Goal = Reducing Morbidity and Mortality Major challenge to national capacity Health Canada Santé Canada Looking into the Future Canadian Pandemic Influenza Plan 2003 “Exercising” of the Plan Generic approach to communicable disease emergency plans Phase approach for advance planning Antiviral stockpile Strengthening pandemic preparedness in special populations: First Nations and Inuit, isolated communities Health Canada Santé Canada Preparedness Activities: Regional and Local Levels Within Canada… Most Provinces and Territories have developed plans for pandemic influenza Some provinces and territories are at the stage where they are testing their plans Local level planning is occurring Post-SARS high level of recognition for need for plans to mitigate the impact of pandemic influenza Health Canada Santé Canada Strategies for Local Planning Get all stakeholders involved Agree upon goals and objectives Divide and conquer suing existing expertise Consolidate and re-assess Incorporate lessons learned from other experiences that have “challenged” the system or facility – e.g. SARS Test and evaluate plan and revise as necessary Ongoing education of stakeholders, potential partners and public Health Canada Santé Canada References The BC Pandemic Influenza Preparedness Plan Minnesota Pandemic Influenza Prevention and Control Guidelines http://www.bccdc.org/content.php?item=150 http://www.health.state.mn.us/divs/idepc/diseases/flu/pande mic.html (includes Guide to Local Planning) WHO website on Global Agenda for Influenza Surveillance and Control <http://www.who.int/csr/disease/influenza/globalagen da/en/> Health Canada Santé Canada References Health Canada: FluWatch and SARS <http://www.hc-sc.gc.ca/> Special Issue: Influenza Vaccine.Vaccine Volume 21 (16) 1 May 2003. “The State of Infection Surveillance and Control in Canadian Acute Care Hospitals” Zoutman et al., AJIC, August 2003 Health Canada Santé Canada Acknowledgements The many Canadian experts in public health, epidemiology, infection control, infectious disease, laboratory sciences and communications who continue to contribute their time and expertise to - developing, implementing and evaluating our national SARS response - developing, reviewing and evaluating the Canadian Pandemic Influenza Plan Thank you Health Canada Santé Canada
