October 7, 2005
Epi Update Managing Staff:
"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."
Foege WH., International
Journal of Epidemiology 1976; 5:29-37
Response Planning Critical to
At a heavily attended one-day summit organized by the Department of Health Division of Emergency Management and the Bureau of Epidemiology, speakers at the Tampa Airport Marriott on September 13 emphasized multiple reasons for increased vigilance and thorough planning to effectively meet the challenges presented by an influenza pandemic.
In recent years a number of concerns have been raised by the public health community, international and domestic, regarding the readiness of medical professionals and first responders to counter a worldwide pandemic. Three incidents have tested the world in the last century: the "Spanish" influenza of 1918, which cost approximately 50 million lives worldwide; and the 1957 Asian and 1968 Hong Kong flu epidemics. According to a Florida Department of Health draft White Paper prepared and released earlier this month by a technical assistance group, the span between flu pandemics during the 20th century was 11 to 39 years. Because 37 years have passed since the last incident, experts anticipate an occurrence in this decade. Planning would be an essential element in keeping the morbidity and mortality rates at a minimum.
Fortunately, the state of Florida has already complied with a Department of Homeland Security directive which requires states to adopt the National Incident Management System (NIMS) for measures taken in preparation for, during and after emergencies. One of the components of NIMS is adoption of the Incident Command System by all responders, including non-government organizations. Florida has accomplished this task also, and updated its comprehensive emergency management plan as well.
Seven regional domestic security task force health co-chairs have brought cohesion to the planning process across the state. During the Tampa summit, an afternoon breakout session provided attendees the opportunity to provide input to their co-chairs, and become familiar with what has already been accomplished. Regions are identified by starting at the Panhandle with Region 1; the Big Bend area as Region 2; the NE area as Region 3; the Tampa Bay area as Region 4; the east coast as Region 5; the SW coast as Region 6; and Palm Beach County and further south as Region 7. People interested in becoming more involved in the emergency planning process should contact the chairpersons listed below:
Region 1: John Lanza
Jaime Forth is managing editor of Epi Update and can be reached at 850.245.4444, ext. 2440.
In separate addresses to the audience gathered at the Airport Marriott in Tampa Dr. Bill Tynan, medical director for the Office of Public Health Preparedness and Dr. John Sinnott, director of the Division of Infectious Disease and Tropical Medicine at the University of South Florida emphasized the enormous threats posed by a pandemic and the challenges in responding.
In his presentation, Sinnott began by outlining the basics: Influenza A is highly infectious and has a very short incubation period; is spread between people through droplet nuclei; kills through viral and secondary bacterial pneumonia, both of which congest the airways until breathing becomes impossible. A medium-level pandemic could nationally result in 150,000 dead, with 500,000 hospitalized with another 33 million sickened. The current vaccine is not effective, nor is the antiviral Amantadine.
Bill Tynan provided details of the White Paper which makes planning recommendations for the state's response to pandemic influenza. Although not a comprehensive document or a strategic overview, the paper does identify critical operational priorities which need to be addressed by epidemiologists, state laboratories, county health departments, public health veterinarians and ethicists before an emergency strikes.
Of special concern to public health officials is the genetic shift in circulating influenza viruses that would lead to a pandemic, because it would introduce a viral sub-type to which no one has developed immunity. With no time to manufacture a vaccine in response, the highly infectious virus would spread quickly because of increased travel, crowded daycare and nursing home facilities, no appropriate vaccine, and resistance to antiviral medications among other circumstances.
Working hand-in-hand with other disciplines, the role of epidemiologists in this scenario would be to detect and track the size and direction of the epidemic, and collect and analyze real-time data about the virus and effectiveness of control measures. Public health veterinarians would assess and respond to incidents of suspected transmission between humans and other species, and develop occupational safety guidelines for workers who interact with animals that might be infected. Ethicists would contribute to the effort by protecting public health and individual rights and determining the most equitable way to allocate resources. Laboratorians would be responsible for surveilling changes in the antigenic shift and drift of influenza strains, tracing second wave cases and unusual presentations, and identifying non-influenza causes of flu-like illnesses. County health department personnel would collaborate in identifying vaccine efficacy and population groups at greatest risk of morbidity and mortality. Because the disease would be active all over Florida at the same time, implementing control measures would be largely a local responsibility.
Early planning and training will be essential to an effective response to a health threat of the magnitude presented by a worldwide pandemic. For a copy of the draft White Paper, contact your regional chair or Dr. Dian Sharma at 850.245.4444, ext. 4411.
An eight-member panel discussion facilitated by Dr. Jennifer Bencie Fairburn at the day-long summit summarized many of the issues at stake during a major public health event. Contributing to the discussion were:
Phil Amuso, PhD, HCLD (ABB), Assistant Bureau
Chief and Laboratory Director
T.T. Belcoure, MS, Administrator
Lynne Drawdy, Strategic Planning Coordinator
Richard Hopkins, MD, MSPH, Medical
Disease Epidemiology Section
Lillian Stark, PhD, MPH, MS, Virology
Bill Tynan, MD, MPH, Medical Director
Guided by audience questions and comments, the panel addressed rationing, isolation and quarantine, risk communications and vaccines in an hour-long discussion centered on managing a large-scale response to a pandemic.
Planning. Dr. Tynan noted that it's incumbent upon regions to include all aspects of their communities in the planning process, channeled by consensus. Questions concerning the closure of public facilities should be addressed by regions.
Surveillance. Some of the complexities were outlined by the panel's medical epidemiologist, Dr. Richard Hopkins, who pointed out that county health departments bear the burden of detecting the earliest cases and developing a clear protocol. "Our existing surveillance methods are not designed to identify every single flu case," he said. "They are designed to document where influenza activity starts, peaks and ends. New methods are needed to detect all cases of imported influenza early in a pandemic."
Tom Belcoure noted that travel presented a challenge to the tracking of respiratory diseases. "Within a week of hearing about SARS in China," he said, "we found cases in Florida that were a direct link." Phil Amuso noted that the surge of tests through state laboratories in the first stages of an epidemic can be managed by including hospitals as partners.
Communications. Stark prompted CHD staff members to be aware of the need for testing by the five state labs, and to know the routes in advance for forwarding specimens. Ethicist Robert Hood encouraged planners to think about communications with physicians and county health departments in the early stages of a crisis. He also promoted developing a list of social merit criteria beforehand, so issues such as triage and justification for target groups selected for vaccines could be addressed while there was adequate time for debate.
Rationing. Tynan reminded attendees that no states have stockpiled antivirals yet. "There may be some large orders," he said, "but allocations to states will be dictated by population." Drawdy commented that in the past few years the focus has been on national preparation for terrorist events, but we're now moving past that toward regional emergency plans.
Isolation and quarantine. Belcoure reminded others of the differences between isolation and quarantine and that for the most part Americans are a compliant society, but some are not, and planners need to address that eventuality.
Vaccines. Current procedure using the chicken egg method means a six month minimum wait; more efficient use of novel cell lines has not been approved by the FDA. When it comes to decisions such as identifying who should receive vaccinations, Hopkins enunciated the bottom line: science can help inform actions, but the conversation should turn on fundamental values of the community at hand.
When the 1957 and 1968 flu pandemics occurred, vaccines were developed too late to have any impact on the outcome. The US government has plans to avoid that scenario in this generation, with a nearly $13 million contract already signed for the manufacture and stockpile of a vaccine to match the H5N1 flu virus. Announcement of the purchase came just a month after the secretary of the Department of Health and Human Services released the department's draft preparedness plan for combating a flu epidemic.
That was last year. Earlier this month, The US government announced the signing of a $100 million contract between the National Institute of Allergy and Infectious Diseases and Medimmune, a US company that makes an inhaled flu vaccine, to work cooperatively in research and development of vaccines for avian flu. Secretary of Health and Human Services Mike Leavitt pointed out during the September 28 announcement that the agreement would "help speed the process of developing vaccines" needed to fight an outbreak if there is a rapid spread of avian flu through the human population. Reverse genetics will be used to create the vaccines.
Vaccine is not an effective treatment for
avian flu. Yet it can, if given ahead of time, reduce the effects of the flu in persons who
are at medical risk for complications such as the elderly, the immune
compromised, and the very young.
For further reading on this topic, go to: http://www.healthday.com/view.cfm?id=528130
Across the Board:
Scientists and physicians from the Centers for Disease Control and Prevention, the World Health Organization, the National Institutes of Health and others have issued multiple concerns about avian flu. So far, it has been difficult to contract. So far, it has not spread readily between humans. Human cases have been reported in Vietnam, Cambodia, Thailand and Indonesia. Infection in birds has, however, spread from China to Vietnam to Thailand to Cambodia and lately into Russia and Europe, despite the culling of millions of birds to curb its proliferation. Dr. John Sinnott, in his address before the crowd gathered for the influenza summit in Tampa, said, "More and more, thoughts are spreading that something catastrophic is imminent."
In the July/August issue of Foreign Affairs, author Michael T. Osterholm describes what would happen if an influenza pandemic struck today. "...borders would close, the global economy would shut down, international vaccine supplies and health-care systems would be overwhelmed, and panic would reign. To limit the fallout, the industrialized world must create a detailed response strategy involving the public and private sectors."
As Osterholm envisioned, foreign trade and tourism would suffer greatly. According to Pat Smith, director of communications at Visit Florida, the state's tourism marketing corporation, the cost to our state's number one industry in an emergency would be enormous. "Approximately 76.8 million people visited the state last year," she said in a recent phone interview, "and they generated $58 billion in taxable sales." The corporation has worked closely with the governor's office to coordinate a generic crisis management plan that includes the most common types of disasters faced by Floridians. There is a $2 million emergency marketing fund in each fiscal budget and it was used after the 9/11 terrorist attacks seriously affected travel to Florida. The corporation countered with an aggressive marketing campaign that resulted in a successful economic recovery; but how does one plan for a virus that stops travel in its tracks because it spreads easily through packed planes? The impact on Canada's economy due to SARS was estimated at $419 million during the 6-month period. Pandemics normally run 12-36 months.
The ongoing impact on the poultry industry in less industrialized nations has been substantial: When the first human case was found in Hong Kong in 1997, all poultry on the island were killed. Then, in China, cases were reported in 2003. It spread into Vietnam in early 2004 followed by Cambodia and Thailand. In response, tens of millions of birds were slaughtered but the virus persisted. Laboratory results have shown that the flu which recently appeared in Russia is the same genetic sub-type of avian flu seen originally in China and Hong Kong.
In the United Kingdom, a contingency plan includes restricting travel, banning some leisure activities, and emergency service measures. The government has decided against stockpiling vaccines due to the ineffectiveness of the current vaccine against future strains of flu; instead, it will stockpile Tamiflu, the antiviral drug that works by treating the symptoms of influenza. Other European countries have also begun stockpiling reserves of antiviral drugs.
Since 2005, this highly pathogenic virus has expanded its range and as new cases occur, there are new opportunities for the virus to evolve into a strain that becomes fully transmissible between humans. When that happens, experts warn, the world had better be ready.
Disease Update September 18-24, 2005
*Seroconversion to undetermined flavivirus
Gadsden, Leon, Pasco, Polk, Pinellas and Suwannee Counties are currently under medical alert for mosquito-borne disease. Alachua and Hillsborough counties are currently under a medical advisory for mosquito-borne disease.
Dead birds should be reported to www.wildflorida.org/bird/. See the web page for more information at www.MyFloridaEH.com. The Disease Outbreak Information Hotline offers recorded updates on medical alerts status and surveillance at 888.880.5782.
The Bureau of Epidemiology encourages
Epi Update readers to not only register on the EpiCom system at
https://www.epicomfl.net but to sign up for features such as automatic
notification of certain events
contribute appropriate public health observations related
any suspicious or unusual occurrences or circumstances. EpiCom is the primary method of communication
between the Bureau of Epidemiology and other state medical agencies during emergency situations.
Christie Luce is administrator
of the Surveillance Systems Section in the Bureau of
Epidemiology. She can be reached at 850.245.4444, ext. 2450.
Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.
D'Juan Harris is a GIS
specialist in the Surveillance Systems Section of the Bureau of
Copyright©2005 State of Florida