Responding to Pandemics and Emerging Infectious Diseases: Lessons Learned from the AAP and CDC Partnership Eric Dziuban, MD, DTM, CPH, FAAP Acting Branch Chief, Child Development and Disability Branch Division of Human Development and Disability National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Liaison to the AAP Disaster Preparedness Advisory Council Meg Fisher, MD, FAAP Infectious Disease Pediatrician, RWJ Barnabas Health Member, AAP Disaster Preparedness Advisory Council
SESSION PURPOSE To share the lessons learned from the AAP and CDC partnership on select outbreaks, and describe how these experiences can inform future strategies for addressing emerging infections and outbreaks.
OBJECTIVE #1 Describe how the CDC and AAP partnership on the H1N1 pandemic, Ebola, and Zika virus public health emergencies led to changes in pediatric preparedness
OBJECTIVE #2 Detail the role of public health and pediatricians in improving disaster preparedness to increase physician awareness, understanding, and ability to respond
OBJECTIVE #3 Identify specific strategies and highlight how coalitions can improve infectious disease preparedness and response through sharing of stories and examples
H1N1, Ebola, and Zika
H1N1 INFLUENZA
Began in April 2009 2009 H1N1 VIRUS PANDEMIC SUMMARY World Health Organization declared an end in August 2010 CDC estimated between 151,700 and 575,400 deaths worldwide, 32% of deaths in the United States were 0-17 years old Source: https://www.cdc.gov/h1n1flu/pediatric/
Activities: AAP/CDC weekly calls Triage algorithm for children AAP pediatricians on CDC COCA calls, HHS webinars, media briefings High-level stakeholder meetings Pediatrician input on interim guidance 10 state pediatric/public health teams attended collaborative meeting 2009 H1N1 VIRUS PANDEMIC AAP AND CDC COLLABORATION Source: https://www.cdc.gov/h1n1flu/pediatric/
2009 H1N1 VIRUS PANDEMIC AAP AND CDC COLLABORATION AAP identified experts (24 staff and 13 pediatricians) to oversee response efforts CDC established a pediatric desk in the Emergency Operations Center AAP updated its Web page for members each day Strong connections established with groups like AMA, ASPR, FEMA, and HHS, as well as the National Commission on Children and Disasters
2009 H1N1 VIRUS PANDEMIC AAP AND CDC COLLABORATION Overarching Challenges: Evolving clinical guidance (not vetted with users) Unclear expectations during the public health emergency Managing information overload Offices ran out of fax paper, phones rang continuously Challenge in addressing questions of worried well Vaccine distribution issues Need to analyze data, findings, and recommendations quickly Increased workload resulting from the pandemic Consolidating and sharing information with others in a manner that met their needs
2009 H1N1 VIRUS PANDEMIC AAP AND CDC COLLABORATION Other issues: Communication/guidance with federal agencies and public health was challenging to follow, comprehend Increase in patient loads for practices created challenges, and plans were not created ahead of time (well child exams post-phoned) Vaccine distribution unclear, understaffed Source: http://content.time.com/time/covers/asia/0,16641,20090824,00.html
2009 H1N1 VIRUS PANDEMIC LESSONS LEARNED AND OUTCOMES Vaccine availability and distribution (outside the medical home) for children caused issues for typical vaccinators/pediatricians Vaccine availability for health care professionals (37%) was low due to lack of availability Public perception of the safety of the H1N1 vaccine = low vaccination rates in children
2009 H1N1 VIRUS PANDEMIC SELECT RECOMMENDATIONS Include pediatric leaders and experts in planning and response efforts Establish pediatric public health partnerships and identify opportunities to enhance communications Promote the essential role of the medical home in serving as the central place for primary care delivery Engage in follow-up discussions regarding improved strategies for distributing and administering vaccine or other pediatric countermeasures Support development of a comprehensive pediatric pandemic response plan across lead federal agencies and pediatric organizations
ENHANCING PEDIATRIC PARTNERSHIPS TO PROMOTE PANDEMIC PREPAREDNESS AAP/CDC meeting with 10 state teams Each team included pediatricians and public health, including a primary care provider First time that AAP/CDC used this approach Pediatric Preparedness Resource Kit
RECOMMENDATIONS: Preparedness and planning efforts should consider messaging and strategic communication as essential to response Preexisting and trusted collaborative relationships between public health and health care organizations form the basis of a strong communication system during an emergency It is important to minimize excessive, conflicting, confusing, or unnecessarily anxiety-provoking messages It is critical to ensure up front that children s needs are specifically addressed The AAP and CDC partnership during the pandemic was effective. It will be important to continue and expand a joint AAP/CDC response strategy
EBOLA
2014 EBOLA VIRUS OUTBREAK SUMMARY March 2014 to March 2016 Outbreak most prominent in W. Africa (Guinea, Liberia, and Sierra Leone) Index case is believed to be a 2-year-old child Total Cases: 28,652, Total Deaths: 11,325 More than 16,000 children lost parents or caregivers to Ebola Children accounted for one fifth of all confirmed cases of Ebola to date. Sources: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4418196/ https://www.unicef.org/emergencies/ebola/75941_76202.html and https://www.cbsnews.com/news/ebola-what-to-tell-kids/
2014 EBOLA VIRUS OUTBREAK AAP AND CDC COLLABORATION Early engagement between CDC and the AAP CDC Children s Preparedness Unit activated CDC and AAP collaboration on: 6 pediatric-focused guidance documents AAP Ebola Red Book chapter Children s hospital calls, webinars CDC pediatric inquiries phone line/email Parental presence recommendations
2014 EBOLA VIRUS OUTBREAK LESSONS LEARNED AND OUTCOMES Challenges: Common questions about parental presence were hard to answer given infection control requirements Issues around mistrust of healthcare providers and vaccines in West Africa caused issues for providers and public health to investigate cases and provide care PPE donning/doffing procedures
2014 EBOLA VIRUS OUTBREAK LESSONS LEARNED AND OUTCOMES Improvements since H1N1: Expanded team of clinicians/smes to help with response Recognition that taking the time to acquire feedback from AAP members was worthwhile and made the recommendations more effective Regular, ongoing, seamless AAP/CDC connection (including weekly AAP/CDC staff calls) AAP/CDC collaboration on guidance (pediatric SMEs consulted initially and during the development)
2014 EBOLA VIRUS OUTBREAK SELECT RECOMMENDATIONS Guidance development was quicker; urgent need for a fast-track process Emphasis on hospitals excluded primary care offices Need to address the stresses that response places on clinicians and responders Lack of guidance on parental presence at the bedside of a child with Ebola School guidance was offered; there was an over-reaction in some schools and no proposed strategy for addressing this Success of Regional Response Centers should be fostered beyond Ebola
ZIKA
2016 ZIKA VIRUS OUTBREAK SUMMARY Source: https://www.cdc.gov/vitalsigns/zika-babies/infographic.html
2016 ZIKA VIRUS OUTBREAK SUMMARY Source: https://wwwnc.cdc.gov/travel/files/zika-areas-of-risk.pdf
Zika Virus Timeline 2016 Local transmission in Florida, Texas, and outbreak in Puerto Rico 2015 2016 AAP funded to respond to Zika virus through guidance, outreach, and education 1952 First human cases of Zika detected - Zika Forest, Uganda 2015 Outbreak in Brazil 2016 CDC releases interim guidance for infants 1969-1983 Mosquitos carrying Zika move to Asia 2015 Scientists note neurological disorders in infants 2017 Analysis of the US and territories shows 5% of infants of women with Zika show abnormalities 2007 First large Zika outbreak in humans - Yap Islands 2008 First documented case of sexual transmission of Zika 2017 AAP/CDC Expert Forum and Updated Interim Guidance for infants Reference: http://www.who.int/emergencies/zika-virus/history/en/
AAP/CDC ZIKA RESPONSE PARTNERSHIP
AAP/CDC ZIKA RESPONSE: JULY 2016 EXPERT MEETING & SUBSEQUENT GUIDANCE Source: https://www.cdc.gov/mmwr/volumes/65/wr/mm6533e2.htm?s_cid=mm6533e2_w
AAP/CDC ZIKA RESPONSE: AUGUST 2017 EXPERT FORUM
AAP/CDC ZIKA RESPONSE: COMMUNICATION TOOLS
AAP NATIONAL LEVEL ZIKA RESPONSE: COMMUNICATION TOOLS
AAP/CDC ZIKA RESPONSE: PROVIDER EDUCATION
AAP/CDC ZIKA RESPONSE: PROVIDER EDUCATION
AAP/CDC ZIKA RESPONSE: CONNECTION TO PUBLIC HEALTH DEPARTMENTS AAP members joined site visits for the CDC Zika Pregnancy and Birth Defects Field Support to Local Health Departments in AZ, CA, DC, FL, IL, MS, NY, TX, UT, and VA
AAP/CDC ZIKA RESPONSE: CAREGIVER EDUCATION
Activities AAP/CDC ZIKA RESPONSE: THE ROAD FORWARD Periodic survey of members Focus groups for obstetric and pediatric providers Suite of social media tools on prevention strategies for families Connect pediatricians to local Zika field assignees
2016 ZIKA VIRUS OUTBREAK LESSONS LEARNED AND OUTCOMES Importance of subspecialists contributions Strategies for providing a continuum of care across obstetrician, hospital, neonatologists, pediatric primary care Testing questions How to support provision of quality care for CWSHCN in an emergency, especially in underserved areas
The Role of Public Health and Pediatricians in Improving Disaster Preparedness
WHY THIS IS IMPORTANT: PREPARING FOR INFECTIOUS DISEASE THREATS IN THE FUTURE Source: http://healthyamericans.org/health-issues/wp-content/uploads/2017/02/tfah-2016-readyornot-final.pdf
PREPAREDNESS PAYS OFF ONLY IF: Pediatricians and pediatric office practices are prepared to assist children, families, and communities with disaster planning Children s needs are fully integrated/exercised into federal, state, and local plans for all hazards/emergencies having public health impact Pediatric/public health and other relationships are formed in advance Source: http://archive.knoxnews.com/news/local/treating-disease-and- disaster-retired-pediatrician-to-speak-on-missions-ep-917796161-353589831.html/
WHAT CAN (AND SHOULD) WE DO? Pediatrician input is key to advocate for the needs of children in national, state, local planning Pediatricians can offer to help with planning Public health, coalitions can invite pediatric involvement Ongoing education for pediatricians and others and others is critical in this area, so those who care for children can remain knowledgeable about what children need, especially regarding exposure to chemical, biological, radiologic, nuclear, explosive agents Encourage physicians to sign-up in advance to be credentialed to volunteer in a disaster DMAT/NDMS ESAR-VHP MRC
OPTIONS FOR PEDIATRIC INVOLVEMENT Take part in community and hospital drills and exercises Design a pediatric office disaster plan Develop disaster plans for child care programs, schools, and other community-based groups Help families develop their own plans Participate in and offer guidance to pediatric responder teams, medical volunteer programs, legislative initiatives Emphasize the importance of the AAP leadership role, and what members can add to state and local planning Develop or enhance communication strategies
ACTIVITIES TO INCREASE AWARENESS & PREPAREDNESS drills Exercises and drills Joint planning
How Coalitions Can Improve Infectious Disease Preparedness and Response
STRATEGIES Establish partnerships before the emergency happens Set roles and expectations ahead of time Use exercises or drills to prepare Establish systems and joint documents beforehand information sharing, role definitions, etc. Debrief following the event and coordinate recovery and resilience efforts
PREPAREDNESS CHECKLIST FOR PEDIATRIC PRACTICES
FAMILY READINESS KIT Key resource to assist families to prepare for emergencies and disasters Includes general guidelines for readiness that can be used in most situations Collaborative effort of the AAP COPEM, AAP DPAC, AAP SOEM, EMSC, and HRSA Available on the AAP Children & Disasters Web site (www.aap.org/disasters)
PEDIATRIC AND PUBLIC HEALTH EXERCISE TABLETOP Participants Public health representatives designated by the state CDC Public Health Emergency Preparedness (PHEP) grantees Pediatricians selected by the AAP Chapter
PEDIATRIC AND PUBLIC HEALTH TABLETOP EXERCISE Smallpox Scenario 5 modules Discussions Communication strategies Emergency response plans Policies and procedures Hotwash Feedback
2017 - ADAPTING AN IN-PERSON APPROACH INTO A VIRTUAL EXERCISE HOW WE DID IT
RESOURCES American Academy of Pediatrics, Children and Disasters https://www.aap.org/disasters Centers for Disease Control and Response, Children s Preparedness Unit https://www.cdc.gov/childrenindisasters/index.html AAP/CDC Pediatric Tabletop Exercises https://www.aap.org/en-us/advocacy-and-policy/aap-health- initiatives/children-and-disasters/pages/pediatric-and-public- Health-Tabletop-Exercise.aspx
Thank You! Questions? This webinar is supported by cooperative agreement number 5NU38OT000167-05, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the US Department of Health and Human Services.