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North Florida Region Domestic Security Task Force Pandemic Influenza Workshop Setting the Pace for Florida's Leadership 1 11/292/05 Version 3.3 Pandemic Influenza Workshop Objectives • Raise awareness about impact of pandemic flu on the health care system and the community as a whole. • Increase understanding of the responsibilities of all community partners. • Determine the adequacy of current plans to address the range of anticipated events. • Identify gaps in coordination among community partners. • Promote planning continuity among all community partners. Prior Planning Prevents Pandemic Pandemonium 2 Pandemic Influenza Workshop Format Education Format: • Influenza Virus Characteristics • History • Surveillance • Planning Prior Planning Prevents Pandemic Pandemonium 3 Pandemic Influenza Workshop Format Exercise Format: • Interactive Tabletop • 3 Modules •Prepare, Respond, Recover, Mitigate • Hot Wash • Action Plan Prior Planning Prevents Pandemic Pandemonium 4 Pandemic Definition Pandemic: An infectious disease epidemic that affects people worldwide or over an extensive geographical area. Prior Planning Prevents Pandemic Pandemonium 5 Influenza Virus Characteristics Primitive “life” form Only one function: Replication Prior Planning Prevents Pandemic Pandemonium 6 Influenza Virus Infection Virus slips in RNA issues orders Viruses break out High efficiency High mutation rate Confuses body defenses Stellenbosch University, Tygerberg, South Africa Prior Planning Prevents Pandemic Pandemonium 7 Influenza Virus Characteristics Virus Exchange Program Wild Birds -- Chickens Chickens -- Humans Chickens -- Pigs Pigs -- Humans Humans -- Humans Prior Planning Prevents Pandemic Pandemonium 8 H5N1 Outbreak in Birds 12/2003 – 03/2006 Countries Affected (confirmed in poultry) Cambodia China Indonesia Croatia Slovakia Kuwait Japan Russia Kazakhstan Switzerland Korea (Rep. of) Thailand Vietnam Ukraine Hungary Romania Turkey Mongolia Malaysia Albania Iraq* Nigeria Bulgaria Greece Poland Italy Iran India Egypt Pakistan* Austria Azerbaijan Germany France Serbia & Montenegro* Bosnia* Laos* Slovenia Niger Burkina Faso * - Only H5 confirmed, neuraminidase not determined December 2003-March 2006 Source: World Health Organization 9 10 Influenza Virus Transmission Direct – Viral particles are contained in droplets resulting from an uncovered sneeze or cough. Breathing them in can result in an infection. During a sneeze, millions of tiny droplets of water, mucus, and virus particles are expelled at 200 mph. Prior Planning Prevents Pandemic Pandemonium 11 Influenza Virus Transmission Indirect – Viral particles may survive for a short time on many surfaces (hands, door knobs, phones). Touching these surfaces may transmit infection through eyes, nose, or mouth. What precaution do these transmissions suggest? Prior Planning Prevents Pandemic Pandemonium 12 History “No disease the world has ever known even remotely resembles the great influenza epidemic of 1918. Presumed to have begun when sick farm animals infected soldiers in Kansas, spreading and mutating into a lethal strain as troops carried it to Europe, it exploded across the world with unequaled ferocity and speed. It killed more people in twenty weeks than AIDS has killed in twenty years; it killed more people in a year than the plagues of the Middle Ages killed in a century. Victims bled from the ears and nose, turned blue from lack of oxygen, suffered aches that felt like bones being broken, and died. In the United States, where bodies were stacked without coffins on trucks, nearly seven times as many people died of influenza as in the First World War.” Prior Planning Prevents Pandemic Pandemonium 13 History -- Images Prior Planning Prevents Pandemic Pandemonium 14 History – Some Statistics Death Toll Worldwide: 40 - 100 Million Death Toll US: 650,000 Normal Season Flu Death Toll: 36,000 Normal Sean Flu Hospitalizations: 200,000 Most Susceptible Population Age: 15-34 Number of Flu-Orphans in NYC: 21,000 I had a little bird His name was Enza I opened up the window And Influenza Prior Planning Prevents Pandemic Pandemonium 15 History -- Pandemic Spread • Exceptionally Virulent Strain • New and Rapid Population Mixing (Training Camps) • WWI Overseas Deployments • Initial Lack of Communications (Sedition Act) • Quarantine – None early on • Weak Public Health Infrastructure Liberty Bond Rally Prior Planning Prevents Pandemic Pandemonium 16 History – Other Pandemics 1957 Asian Flu -- US Deaths 69,800 1968 Hong Kong Flu – US Deaths 33,800 Pandemic Flu Scares: 1976 Swine Flu 1977 Russian Flu 1997 -1999 Avian Flu SARS Precautions Non-Flu Scare: SARS Multi-Country Outbreak Prior Planning Prevents Pandemic Pandemonium 17 Inter-Pandemic Period – Phases 1 and 2 Inter-Pandemic Period – Phases 1 and 2 •No new influenza virus •Develop plans and exercise them •Educate the public (throughout all phases) •Vaccinate public •Surveillance Prior Planning Prevents Pandemic Pandemonium 18 Pandemic Alert Period – Phase 3 The phase we are currently in Pandemic Alert Period—Phase 3 •Human infection with a new subtype •No human to human spread •Monitor the situation via surveillance systems and communication with Florida DOH •Communicate with community partners Prior Planning Prevents Pandemic Pandemonium 19 Pandemic Alert Period – Phase 3 The phase we are currently in • Pandemic Alert Period—Phase 3 Actions – Stockpile masks, hand-sanitizer, anti-virals – Nationally—encouraging the development of vaccine – Nationally—develop more rapid testing methods – State-Increase surge capacity of laboratories Prior Planning Prevents Pandemic Pandemonium 20 Human Cases of H5N1 Avian Flu 2003-2006 Country Total Cases Deaths Indonesia 29 22 Cambodia 4 4 Thailand 22 14 Vietnam 93 42 China 15 10 Turkey 12 4 Iraq 2 2 Azerbaijan 7 5 Egypt 7 (4 initial confirmation only) 4 Jordan 2 (initial confirmation only) Total 193 107 As of 04/04/06 Source: World Health Organization (laboratory confirmed cases) 55% 21 Pandemic Alert Period – Phase 4 • Pandemic Alert Period—Phase 4 – Limited human to human transmission • Isolate / treat the sick • Vaccinate / treat close contacts • Encourage self-quarantine Prior Planning Prevents Pandemic Pandemonium 22 Pandemic Alert Period – Phase 5 • Pandemic Alert Period—Phase 5 – Larger clusters but still localized – Adjust and maximize resources—questionable use of points of distribution (drugs are trickling in) – If available deploy prototype vaccine • Questionable use of points of distribution • Decision on who to vaccinate (ethics?) – Assess staffing issues – Travel restrictions – Social distancing Prior Planning Prevents Pandemic Pandemonium 23 Pandemic Alert Period – Phase 6 • Pandemic Period-Phase 6 – Increased and sustained transmission – Alternative treatment sites – Ventilator decisions – State resources for aid – Continue risk management – Maintain surveillance, including deaths • Morgue surge capacity • Funeral supplies may be limited Prior Planning Prevents Pandemic Pandemonium 24 Human Surveillance • Sentinel physicians – how many are in your county? • ESSENCE – influenza symptoms, patient load, etc. • BIOSENSE – military hospitals • EpiCom • Vital Statistics – death rates • School absenteeism Prior Planning Prevents Pandemic Pandemonium 25 Surveillance Partners • Sentinel Physicians • Hospitals • County Health Departments • Department of Health and Private Labs • Department of Agriculture and Consumer Services • Centers for Disease Control and Prevention (CDC) • World Health Organization (WHO) Communication! – Communication! – Communication! Prior Planning Prevents Pandemic Pandemonium 26 Between Waves • Between waves – Ensure staff recovery – Re-stock supplies/medications – Lessons learned to improve Prior Planning Prevents Pandemic Pandemonium 27 Influenza H5N1 – Avian Flu Current Situation -- Avian Flu – Phase 3: • Bird to Human transmission still very rare •Vaccine in development for birds for H5N1 •Vaccine in development for H5N1 for humans – this is not the same as a human to human virus we are planning for • Human to Human transmission even more rare •We can’t develop a vaccine until we know the human to human strain • Will this be the “Big One”? Prior Planning Prevents Pandemic Pandemonium 28 Request to Fund – National Strategy • • • • • • • • Global surveillance Vaccine technology Purchase medication and vaccines Vaccine for HHS Stockpile anti-virals Emergency preparedness Total $ 251 million $ 2.8 billion $ 800 $ 1.5 $ 1.0 $ 644 $ 7.1 million billion billion million billion Prior Planning Prevents Pandemic Pandemonium DOH – 12/5/05 29 Influenza H5N1 – Avian Flu The thing to Keep in Mind for Now: NOT Recommended. Prior Planning Prevents Pandemic Pandemonium 30 Surveillance Urgency The Clock is Ticking…. We just don’t know what time it is. Pandemic Pandemonium 31 Pandemic Planning Prior Planning Prevents Pandemic Pandemonium 32 Planning Assumptions • We will have an epidemic soon of a strain of influenza to which none of us is immune. • We will likely have only a short window between when the strain is clearly causing disease and when it starts causing widespread disease where we live. • Vaccine likely won’t be available for 6 to 9 months after the epidemic starts. • Supplies of anti-virals will be far less than needed for totalpopulation coverage or even coverage of high-priority groups. Prior Planning Prevents Pandemic Pandemonium 33 Planning Assumptions Predicted Morbidity Range for Palm Beach County • 35% Attack Rate Predicted Mortality Rate for Palm Beach County •5% of those infected Prior Planning Prevents Pandemic Pandemonium 34 Planning Assumptions Palm Beach Population 1.2 Million Attack Rate 35% 420,000 Seeking Treatment 75% 315,000 Hospitalization Rate 10% 31,500 Mechanical Ventilation 7.5% 23,625 Fatality Rate 21,000 5% Prior Planning Prevents Pandemic Pandemonium 35 Planning Assumptions • Once the pandemic takes hold, we have to assume that there will be little to No Help from the national or state level – not just for days, but for weeks, and perhaps months. • We have to assume that every county and every community will be pretty much on its own in an influenza pandemic. • County Health Department will have ICS Lead. Prior Planning Prevents Pandemic Pandemonium 36 Planning Questions • When a vaccine first becomes available, who should get it? • How should we use the limited supplies of antiviral medications? (Tamiflu – 10 doses in five days. Must be taken within 48 hours.) • Given lack of vaccines and anti-virals, how do we approach reducing illness and death? • What is the right balance among minimizing health burden, economic damage, and societal damage? Prior Planning Prevents Pandemic Pandemonium 37 Planning – More Questions Can we hold the fort till we can get vaccine? • The longer we can delay the onset of the epidemic in our community, the more illness we can prevent. • This will require vigorously applying measures that have limited effectiveness and a strong and continuous, risk communication campaign directed to all of our citizens. Prior Planning Prevents Pandemic Pandemonium 38 Planning – Isolation The placement of sick persons with specific infectious illness in separate rooms from those who are healthy. This is usually voluntary and may be at their own home or at a hospital Prior Planning Prevents Pandemic Pandemonium 39 Planning – Quarantine Usually voluntary, but the FDOH Secretary may declare a public health emergency and issue a quarantine order to separate and restrict movement of people who have been exposed to an infectious agent, and may therefore become infectious Prior Planning Prevents Pandemic Pandemonium 40 Planning – Options for Disease Prevention • Isolate the sick Voluntary or legally mandated? • Quarantine well, exposed persons Voluntary or legally mandated? • Limit personal interactions e.g., close schools and day-care, stop large public gatherings Prior Planning Prevents Pandemic Pandemonium 41 Planning – Behavioral Modification Social Marketing • Change social norms about self-quarantine, personal hygiene, shaking hands, and masks. • Advise travel restrictions. • Home management of uncomplicated influenza -- Recognition of complications -- Management of complicated patients Prior Planning Prevents Pandemic Pandemonium 42 Planning – Social Issues • Stigmatization of vulnerable groups • Equity in access to care and in application of isolation and quarantine • Civil liberties balanced with effective disease control • Potential for civil disorder and vigilante actions • Trust in government and health care system institutions, especially if initial measures seem to fail • Long-term stress and behavioral health Prior Planning Prevents Pandemic Pandemonium 43 Planning – Economic Issues • Cost of care and cost of providing preventive measures. • Impact on essential services and general productivity of widespread illness – e.g., 10% of workforce out sick continuously for many weeks. • Curtailment of business travel, shopping, and entertainment venues. • Shipment of goods, including food, fuel, and essential supplies Prior Planning Prevents Pandemic Pandemonium 44 Planning – Communications Issues • Lots and lots of issues and opportunities with risk communication • Prompt, accurate, clear • Acknowledge uncertainties • Provide frequent updates as new info becomes available • Manage the level of expectations Prior Planning Prevents Pandemic Pandemonium 45 Communications • For Unusual death in domestic birds call: •USDA – Veterinary Services for Florida at 1-866-536-7593 •The Florida Department of Agriculture recommends that you contact your local agriculture extension at Broward County Fish and Game – Non-Game Division 561-625-5122 – Sharon Hood •The Florida Dept of Agriculture / Division of Animal Industry can be reached at 850-410-0900 46 QUESTIONS? ???????????????? Prior Planning Prevents Pandemic Pandemonium 47