Pandemic Preparedness: People, Plans, Products, and Practice. Julie Louise Gerberding, MD, MPH

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1 Pandemic Preparedness: People, Plans, Products, and Practice Julie Louise Gerberding, MD, MPH

2 The Burden of Influenza 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

3 Pandemics Do Happen! H9 * H1 H2 H3 H1 H7 * H5 * Spanish Influenza H1N Asian Influenza H2N Hong Kong Influenza H3N2 * Avian Flu

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

5 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 Illness Outpatient medical care Hospitalization ICU care Mechanical ventilation Deaths Moderate (1957-like) 90 million (30%) 45 million (50%) 865, ,750 64, ,000 Severe (1918-like) 90 million (30%) 45 million (50%) 9, 900,000 1,485, ,500 1,903,000

6 Pandemic Strain Emergence: Direct Infection Direct Avian Human Infection Avian virus Human virus Avian Reservoir

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

8 Addressing Local Practices

9 H5N1 Influenza Evolves Hemagglutinin Genetic Changes Hong Kong48697 Hong Kong53897 Hong Kong15697 CkHong Kong22097 Hong Kong CkCambodia013LC2b05 VietnamJP1405 VietnamJPHN VietnamJP CkVietnam104 CambodiaJP52a05 CkMalay sia CkThailand104 Thailand35304 Prachinburi Vietnam Vietnam VietnamHN Thailand1604 blhdgullhong Kong12103 Clade 1' Hong Kong CkIndonesia504 CkIndonesia703 CkHong KongYU DkKulonProgoBBVET904 QaCirebonBBVET105 Indonesia505 Indonesia705 Indonesia605 CkBrebesBBVET205 CkKulonprogoBbv etxii104 BarheadedGsQinghai1205 BarheadedGsQinghai6505 TurkeyTurkey CkKoreaES03 CkYamaguchi704 CkYunan49305 DkGuangxi1304 CkGuangdong19104 DkChinaE CkGuangdong17804 whooperswanmongolia MG24405 Clade 1 Clade GsGuangdong397 GsGuangdong

10 Situation Report: Avian Influenza 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

health sector pandemic preparedness and response Public Health

11 HHS Pandemic Influenza Plan 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

12 Pandemic Influenza Doctrine: Saving Lives A threat anywhere is a threat everywhere! 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

13 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-term quarantine of arriving passengers

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

15 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 Unprepared Vaccine when available Impact Local decisions Prepared Weeks

16 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

17 CDC Prepares: United States

18 FY04 Quarantine Stations Field Epidemiology / Laboratory Training Programs CDC Field Stations International Business Connectivity New CDC Sentinel Sites New Quarantine Stations New International LRN Sites New CDC Sentinel Sites CDC s Global Health Protection Network Global Health Protection Network D A T A E X C H A N G E Bio Sense & Biointelligence Center FY04 Laboratory Response Network (LRN) National Clinical Lab Orders DoD/VA Dx & Rx Records Biowatch Data OTC Drug Sales Private Clinical Care Expanded Real-Time LRN Data New Data Streams FY06 FY06

19 CDC Prepares: International Workforce

20 CDC Prepares: Global Communications

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

22 Vaccine Supply and Demand: Unpredictable Doses Produced Millions Doses Distributed

23 Vaccine Production and Use: U.S Seasonal Influenza Doses Produced (millions) Doses Distributed (millions) > 80 so far

24 Millions Influenza Vaccine Recommendations: Expanding the Market mos.old years Household contacts Health care workers Nursing home residents Pregnant women <65 years with a high risk condition

25 Influenza Antiviral Treatments Stockpile Tamiflu: 4.3 million courses in Strategic National Stockpile with an additional 1 million courses by end of January 2006 Strategy Procure 81 million courses of antivirals 6 million courses to be used to contain an initial U.S. outbreak 75 million courses to treat up to 25 percent of U.S. population Accelerate development of promising new antiviral candidates

26 Overcoming Challenges to Pandemic Vaccine Expand production of current (egg-based) vaccine Evaluate dose-sparing technology (adjuvants, intramuscular vs. intradermal route) Accelerate development of modern (non-egg) vaccines Target new antigens

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

28 Pandemic Influenza Checklists State and Local Business Preschool Schools (K-12) Colleges & Universities Faith-based & Community Organizations Physician Offices and Ambulatory Care Home Health Emergency Medical Services Travel Industry Correctional Facilities

29 Protecting Your Business Plan for impact on business Protect employees and customers Establish policies Allocate resources Engage employees Coordinate with external organizations

30 Influenza Preparedness: Return on Investment Save lives during seasonal influenza Modern seasonal influenza vaccine for all who need it New antiviral drugs for prevention and treatment Ensure health protection from other threats Peace of mind Seasonal Influenza Preparedness Pandemic Influenza Preparedness

31 Complacency is the enemy of health protection!

Tuberculosis and Travel

Tuberculosis and Travel Nicole J. Cohen, MD TB Morbidity & Mortality Review February 18, 2014 National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine U.S.