An Overview of Pandemic
Influenza Planning
in the United States
NAPHSIS Annual Meeting
June 7, 2006
David K. Shay
Influenza Division
Centers for Disease Control and Prevention
www.pandemicflu.gov www.cdc.gov/flu
New Viruses Emerge, and
Pandemics Happen
H9*
1998 1999
2003
H5*
1997 2003-2006
H7*
1980 1996 2002
2003 2004
H1
H3
H2
H1 1977
1915 1925 1935 1945 1955 1965 1975 1985 1995 2005
1918 1957 1968 *Avian Flu
Spanish Asian Hong Kong
Influenza Influenza Influenza
H1N1 H2N2 H3N2
www.pandemicflu.gov www.cdc.gov/flu
Avian Influenza A(H5N1)
Why is Concern High?
• Impact on animals and economy
– Lethal to poultry, and mammals infected
– Present in waterfowl; shed in feces
– Already has had a major economic impact
impact on humans
• Causes severe human disease
– Might evolve to become easily transmissible
– No H5N1 vaccine commercially available
– Limited supplies of expensive antivirals
www.pandemicflu.gov www.cdc.gov/flu
Pandemic Planning Must Occur
in Many Sectors
• Federal government
• State and local governments
• Healthcare Systems
• Businesses and private sector
• Individuals and families
www.pandemicflu.gov www.cdc.gov/flu
National Strategy for
Pandemic Influenza
• Issued by President Bush in
November 2005
• Guides U.S. preparedness and
response by outlining responsibilities
– Individuals
– Industry
– State/local governments
– Federal government
• March 2006: Homeland Security
Council Implementation Plan
www.pandemicflu.gov www.cdc.gov/flu
Goals of the National Strategy
• Stop, slow, or otherwise limit the spread of
a pandemic to the United States
• Limit the domestic spread, and mitigate
disease, suffering, and death
• Sustain infrastructure and mitigate impact
to the economy and functioning of society
www.pandemicflu.gov www.cdc.gov/flu
Pillars of the National Strategy
• Pillar 1: Preparedness and Communication
– Ensure preparedness
– Communicate roles and responsibilities
• Pillar 2: Surveillance and Detection
– Systems that provide continuous situational awareness
– Ensure earliest warning possible
• Pillar 3: Response and Containment
– Limit the spread of the outbreak
– Mitigate the health, social and economic impact
www.pandemicflu.gov www.cdc.gov/flu
Department of Health and
Human Services (HHS)
Pandemic Influenza Plan
• Released November 2005
• Supports the National Strategy
• Outlines key roles of HHS and its
agencies
• Doctrine for health sector
preparedness and response
• Public health guidance for state and
local partners
• HHS Operational Plan will be
released soon
www.pandemicflu.gov www.cdc.gov/flu
Planning Assumptions
• All will be susceptible to infection with the
pandemic virus due to lack of existing immunity
• The clinical attack rate might approach 30%, and
50% of persons who become ill will seek
healthcare
• Each wave of infections in a community will last
for approximately 6-8 weeks; 2 or 3 waves
possible
• Groups at higher risk for severe disease/death
cannot be predicted in advance, and may not
correspond to those for seasonal influenza (eg,
elderly and those with comorbid conditions)
www.pandemicflu.gov www.cdc.gov/flu
Burden of Pandemic Influenza
• 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
Moderate (1957-like) Severe (1918-like)
Illness 90 million (30%) 90 million (30%)
Outpatient medical
45 million (50%) 45 million (50%)
care
Hospitalization 865,000 9,900,000
ICU care 128,750 1,485,000
Mechanical ventilation 64,875 745,500
Deaths 209,000 1,903,000
www.pandemicflu.gov www.cdc.gov/flu
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
www.pandemicflu.gov www.cdc.gov/flu
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
www.pandemicflu.gov www.cdc.gov/flu
HHS Pandemic Influenza
Doctrine: Saving Lives
Slow spread, decrease illness and death, buy time
• Antiviral treatment and isolation
• Quarantine for those exposed
• Social distancing Unprepared
• Vaccination Impact
Prepared
Weeks
www.pandemicflu.gov www.cdc.gov/flu
HHS 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
www.pandemicflu.gov www.cdc.gov/flu
A Network of Shared
Responsibility
• Local - state - federal
• Domestic – international
• Public – private Healthcare
Delivery
Federal
Partners
System
• Multi-sector Local /State /
Federal Public
• Animal – human Health
System
• Health protection – Business Education
homeland security – & Workers System
economic protection
www.pandemicflu.gov www.cdc.gov/flu
• State and Local • Physician Offices and
• Business Ambulatory Care
• Preschool • Home Health
• Schools (K-12) • Emergency Medical
• Colleges & Universities Services
• Faith-based & Community • Travel Industry
Organizations • Individuals
www.pandemicflu.gov www.cdc.gov/flu
Countermeasures: Vaccines,
Antivirals, and
Medical Supplies
Strategic
National
Stockpile
www.pandemicflu.gov www.cdc.gov/flu
H5N1 Vaccine
• Prototype vaccine developed by the
National Institutes of Health
• Based on a H5 strain isolated in Viet Nam
last year
• Elicits an antibody response but requires
large dose
• 40 million doses (to protect 20 million
people) being stockpiled
www.pandemicflu.gov www.cdc.gov/flu
Challenges for Pandemic
Vaccination
• 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
www.pandemicflu.gov www.cdc.gov/flu
Influenza Antivirals
• Goal: treatment courses in the Strategic
National Stockpile (SNS) for 25%
• Current status of SNS
– 5.1 million Tamiflu (oseltamivir) treatment
courses
– 84,000 Relenza (zanamivir) treatment courses
• Additional orders have been placed
• Accelerate development of promising new
antiviral candidates
www.pandemicflu.gov www.cdc.gov/flu
Health Protection at the
Frontline:
Local, County, and State Public
Health Departments
www.pandemicflu.gov www.cdc.gov/flu
Seasonal Influenza Preparedness
Pandemic Influenza Preparedness
Preparing for a pandemic now means:
• Putting into place methods to follow influenza,
ie, public health surveillance
• Improving measures to control influenza
• Modern seasonal influenza vaccine for all
who need it
• New antiviral drugs for prevention and
treatment
www.pandemicflu.gov www.cdc.gov/flu
Critical Role of Surveillance
Data
• Response will require easily interpretable, up-to-
date information
• CDC anticipates that at a minimum, the Federal,
State, and local responses will require
– Mortality rates (overall and pneumonia/influenza) by
state
– Hospitalization rates, for some states or large
communities
• Data sufficient to conduct assessments of
‘countermeasures’ in several sites
www.pandemicflu.gov www.cdc.gov/flu
Hospitalizations
• Current systems
– Emerging Infections Program & New Vaccine
Surveillance Network
• Children-only systems at present
• Sites in 11 states
• Additional data sources
– Expanded EIP: Inclusion of adults, special studies
– Vaccine Safety Datalink
– BioSense real-time hospitalization data
– Hospital capacity
• Exploring use of a HAvBED-like system that
accepts bed census data from existing systems
www.pandemicflu.gov www.cdc.gov/flu
Mortality
• Current
– 122 Cities Mortality Reporting System
– Pediatric mortality reporting is a nationally
notifiable condition
– NCHS mortality files
• Additional
– Exploring timely reporting of all deaths
www.pandemicflu.gov www.cdc.gov/flu
Enhancement of Public Health
Surveillance Systems
• Highest priority systems
– Electronic laboratory data exchange
• Rapid 2-way exchange of patient-level data
– Electronic death reporting
• Early use of mortality data submitted by funeral
directors
• Benefits
– Build public health reporting systems that would have
multiple uses
– Use existing electronic data
– Allow sub-state level analysis
www.pandemicflu.gov www.cdc.gov/flu
Infectious Disease Mortality,
United States--20th Century
Armstrong, et al. JAMA 1999;281:61-66.
www.pandemicflu.gov www.cdc.gov/flu
Questions?
www.pandemicflu.gov www.cdc.gov/flu