““PandemicsPandemics””(And Other Reasons To(And Other Reasons To

Never Leave Your House)Never Leave Your House)Tuesday, May 20, 2008Tuesday, May 20, 2008

Stephen G. Jones, MDStephen G. Jones, MD

““This is the single greatest threat to our This is the single greatest threat to our society todaysociety today””

-- M. OsterholmM. Osterholm

Natural Medical ThreatsNatural Medical ThreatsFlu PandemicsFlu PandemicsSARSSARSWest Nile VirusWest Nile VirusHIVHIVEmerging New Infectious DiseasesEmerging New Infectious Diseases

Environmental ThreatsEnvironmental Threats

TobaccoTobaccoUV RadiationUV RadiationRadonRadonPollutionPollutionGlobal WarmingGlobal Warming

Man Made ThreatsMan Made Threats

Bioterror (Anthrax, SmallpoxBioterror (Anthrax, Smallpox……))Nuclear Nuclear Toxins Toxins Global WarmingGlobal Warming

GoalsGoals1) Understanding the Threat1) Understanding the Threat

2) What to Expect2) What to Expect

3) Preparedness3) Preparedness

Some BackgroundSome BackgroundEpidemicEpidemic

Outbreak among Outbreak among ““Particular" population.Particular" population.

PandemicPandemicOutbreak across Outbreak across ““EntireEntire”” populationpopulation..

PandemicsPandemics

10 Pandemics past 300 Years10 Pandemics past 300 Years

Past CenturyPast Century1918 (Spanish Flu)1918 (Spanish Flu)1957 (Asian Flu)1957 (Asian Flu)1968 (Hong Kong)1968 (Hong Kong)1976 (Swine Flu)*1976 (Swine Flu)*

1918 Spanish Flu1918 Spanish Flu50 Million Deaths Worldwide50 Million Deaths Worldwide**675,000 Deaths USA675,000 Deaths USA8 Million Deaths in Spain8 Million Deaths in Spain25% World Population Affected25% World Population Affected2.5% Kill Rate2.5% Kill Rate

**NoteNote: : World Population wasWorld Population was1/3 that of today!1/3 that of today!

The BeginningThe Beginning………………..March 11, 1918March 11, 1918

Pvt. Albert Gitchell (Case #1)Pvt. Albert Gitchell (Case #1)100 more before noon100 more before noonBad Flu Bad Flu –– Very ContagiousVery ContagiousNot Deadly Not Deadly -- Yet Yet

A Few Weeks Later...A Few Weeks Later...1.5 Million Soldiers Crossed Atlantic1.5 Million Soldiers Crossed AtlanticFlu Mutated Flu Mutated –– Now A Killer!Now A Killer!More Dead from Flu than WWIMore Dead from Flu than WWISoldiers Brought Killer Flu HomeSoldiers Brought Killer Flu Home

19181918Life Expectancy PlungedLife Expectancy Plunged

20 Years!20 Years!

The The ““Cruelest MonthCruelest Month”…”…..

October 1918October 1918

NYC NYC –– 851 People Died in One Day851 People Died in One DayPhiladelphia Philadelphia –– 700x Normal Death Rate700x Normal Death RateAge 21Age 21--29 Most Vulnerable29 Most VulnerableRan Out of Coffins!Ran Out of Coffins!195,000 Americans Died195,000 Americans Died

QuestionQuestion

Why was this flu different Why was this flu different and so bad?and so bad?

Understanding InfluenzaUnderstanding Influenza

Italian Derivation Italian Derivation –– ““InfluenceInfluence””New Strain Each Year (New Strain Each Year (““DriftDrift””))Pandemic Year (Pandemic Year (““ShiftShift””))

““Understanding The LingoUnderstanding The Lingo””

WhatWhat’’s this s this ““H5N1H5N1”” stuff? stuff?

Understanding FluUnderstanding FluN = NeuramidinaseN = Neuramidinase

H = HemagluttinH = Hemagluttin

NeuraminidaseNeuraminidase

HemagglutininHemagglutinin

Flu Virus SurfaceFlu Virus Surface

““M2M2””

Flu VirusFlu Virus

NeuraminidaseNeuraminidase

HemagglutininHemagglutinin

ExamplesExamplesH1N1 H1N1 (Spanish Flu)(Spanish Flu)H3N2 H3N2 (Hong Kong)(Hong Kong)H5N1 H5N1 (Avian Flu)(Avian Flu)

Adapted from Levine AJ. Viruses. 1992;165, with permission.Adapted from Levine AJ. Viruses. 1992;165, with permission.

Human vs. AnimalsHuman vs. AnimalsSubtype Subtype Human SwineHuman Swine Horse BirdHorse BirdN1N1N2N2N3N3N4N4N5N5N6N6N7N7N8N8N9N9

Subtype Human Swine Horse BirdH1H1H2H2H3H3H4H4H5H5H6H6H7H7H8H8H9H9H10H10H11H11H12H12H13H13H14H14H15H15

Humans vs. AnimalsHumans vs. Animals

Adapted from Levine AJ. Viruses. 1992;165, with permission.

AVIAN FLUAVIAN FLU

How Flu Changes ItselfHow Flu Changes Itself

Increased Risk of MutationsIncreased Risk of Mutations

CHINACHINA 19681968 20062006

Human PopulationHuman Population 790 million 1.3 Billion790 million 1.3 Billion

Pig PopulationPig Population 5 million5 million 508 million508 million

Poultry PopulationPoultry Population 12 million12 million 13 Billion13 Billion

Migrating BirdsMigrating Birds

““AAHAAH--CHOOCHOO””Uh oh!Uh oh!

A Gathering Storm?A Gathering Storm?1918 Pandemic was a 1918 Pandemic was a ““BirdBird”” FluFluDo Conditions Favor Pandemic?Do Conditions Favor Pandemic?

US PreparednessUS PreparednessStrategic Plan Released 11Strategic Plan Released 11--0101--0505Preparedness Plan Released 5Preparedness Plan Released 5--0303--0606Vaccine Vaccine AntiAnti--viral Stockpilingviral Stockpiling

Federal Pandemic PlansFederal Pandemic Plans

National Strategy for National Strategy for Pandemic InfluenzaPandemic Influenza

HHS Pandemic Influenza HHS Pandemic Influenza PlanPlan

What About a Vaccine?What About a Vaccine?19501950’’s Eggs Egg--Based TechnologyBased Technology6 Month Production Lag6 Month Production LagCanCan’’t Make Until New Virus Appearst Make Until New Virus AppearsCanCan’’t Make Enought Make Enough…….Yet.YetNeed Two ShotsNeed Two Shots

Vaccine Target SitesVaccine Target Sites

NeuraminidaseNeuraminidase

HemagglutininHemagglutinin

UpdateUpdate……....

New Technology to Replace Old Egg New Technology to Replace Old Egg Base Vaccine (Cell Culture)Base Vaccine (Cell Culture)Ability to Ability to ““Scale UpScale Up”” ProductionProductionMore Pharmaceutical Buy InMore Pharmaceutical Buy InVaccine Liability ProtectionVaccine Liability ProtectionPrePre--Pandemic Vaccine Pandemic Vaccine

What About AntiWhat About Anti--Virals?Virals?

TamifluTamiflu RelenzaRelenza

“PlugPlug”” DrugsDrugs

Tamiflu BlocksTamiflu Blocks

UpdateUpdateIncreased ProductionIncreased ProductionNew Drugs in DevelopmentNew Drugs in Development

ButBut…………..Must Give in First 48 HoursMust Give in First 48 HoursUnsure How EffectiveUnsure How EffectiveResistanceResistance$$$$$$

Pandemic ScenariosPandemic ScenariosMODERATE (1957MODERATE (1957--like) SEVERE (1918like) SEVERE (1918--like)like)

ILLNESSILLNESS 90 Million (30%)90 Million (30%) 90 Million (30%)90 Million (30%)

HOSPITALIZATIONSHOSPITALIZATIONS 865,000865,000 9,900,0009,900,000

VENTILATORSVENTILATORS 64,87564,875 745,500745,500

DEATHSDEATHS 209,000209,000 1,903,0001,903,000

Ventilators in USVentilators in US

Total Available Total Available –– 105,000105,000

Average in Use Average in Use –– 75,00075,000Normal Flu Season Normal Flu Season –– 100,000100,000

American Lung Association. Fact Sheet American Lung Association. Fact Sheet –– Influenza. Influenza. Available at http://www.lungusa.org/diseases/influenza_factsheetAvailable at http://www.lungusa.org/diseases/influenza_factsheet.html.html.

Seasonal FluSeasonal Flu

14.6 Billion Dollars in Costs!14.6 Billion Dollars in Costs!10% 10% -- Direct Direct (medical care)(medical care)90% 90% -- Indirect Indirect (lost productivity,(lost productivity,

employee absenteeism)employee absenteeism)

Economic ImpactEconomic Impact

Seasonal FluSeasonal Flu

$14.6 Billion$14.6 Billion

Pandemic FluPandemic Flu

$800 Billion$800 Billion

Impact on Global EconomyImpact on Global Economy

$ 2 Trillion$ 2 Trillion($2,000,000,000,000)($2,000,000,000,000)

4.8% World Gross Domestic Product4.8% World Gross Domestic Product

How Ready Are You?How Ready Are You?Business PreparednessBusiness Preparedness

Personal (Family) Personal (Family) PreparednessPreparedness

Pandemic Planning Pandemic Planning AssumptionsAssumptions

Susceptibility will be universalSusceptibility will be universal30% population will become ill30% population will become illSeasonality can not be predictedSeasonality can not be predictedOutbreak will last 6 to 8 weeksOutbreak will last 6 to 8 weeksTwo waves of Pandemic likelyTwo waves of Pandemic likely

Pandemic PlanningPandemic PlanningExpect 50% Workforce ReductionExpect 50% Workforce ReductionStockpile SuppliesStockpile SuppliesPlan Plan ““Work from HomeWork from Home”” StrategiesStrategies

Expect Client WithdrawalsExpect Client WithdrawalsAddress HR IssuesAddress HR Issues

Business Planning AssumptionsBusiness Planning Assumptions

Disruption of Essential Business ServicesDisruption of Essential Business Services(Transportation, Supply Chain, etc.)(Transportation, Supply Chain, etc.)

Disruption of Emergency ServicesDisruption of Emergency Services(Fire. Police, Healthcare)(Fire. Police, Healthcare)

Impact Will NOT be Local!Impact Will NOT be Local!

Planning AssumptionsPlanning Assumptions

Expect Highly Limited TravelExpect Highly Limited Travel

Organizational PreparednessOrganizational Preparedness

Have Plan in PlaceHave Plan in PlaceCommunicate and EducateCommunicate and EducateLeadershipLeadershipOperational FlexibilityOperational FlexibilityIdentify Mission Critical StaffIdentify Mission Critical StaffContinuity of Operations (COOP)Continuity of Operations (COOP)

Possible ScenariosPossible Scenarios30% Population Affected30% Population Affected40 40 --60% Abandon Workforce60% Abandon Workforce

1.9 Million Americans Dead1.9 Million Americans DeadUp to 360 Million Dead WorldwideUp to 360 Million Dead Worldwide

The The longer longer a business is out a business is out of serviceof service…………....the the lessless likely it will recover.likely it will recover.

Business PreparednessBusiness Preparedness

Flu ShotsFlu ShotsSick employees Sick employees –– GO HOME!GO HOME!Office HygieneOffice Hygiene

Personal PreparednessPersonal Preparedness

How Do I Protect My How Do I Protect My Family and Myself?Family and Myself?

How do you catch Flu?How do you catch Flu?

Keep Your FaceKeep Your FaceOut of Here!Out of Here!

Cox NJ, Fukuda K. Infect Dis Clin North Am. 1998;12:28.Cox NJ, Fukuda K. Infect Dis Clin North Am. 1998;12:28.

Signs and SymptomsSigns and SymptomsAbrupt onset Abrupt onset Fever (>100Fever (>100°°F) / Chills F) / Chills HeadacheHeadacheAchesAchesSore throatSore throatSevere FatigueSevere Fatigue

Being PreparedBeing Prepared

Personal PreparednessPersonal Preparedness““Social DistancingSocial Distancing””Get Flu ShotGet Flu ShotWash Hands / Alcohol GelsWash Hands / Alcohol GelsKeep Hands Away from FaceKeep Hands Away from Face

Personal PreparednessPersonal Preparedness““All Hazard PreparednessAll Hazard Preparedness””

Home SuppliesHome SuppliesCash at HomeCash at HomeMedicationsMedications

Maintain HealthMaintain Health

The Bad NewsThe Bad NewsPandemic is Coming!Pandemic is Coming!WeWe’’re Not Prepared re Not Prepared –– Yet!Yet!Young Seem Most VulnerableYoung Seem Most VulnerableNo Vaccine Available (1No Vaccine Available (1stst Wave)Wave)Cost Could Be StaggeringCost Could Be Staggering

The The ““GoodGood”” NewsNews

May Not Be So BadMay Not Be So BadMay Not Be Coming So SoonMay Not Be Coming So SoonWorld is Mobilizing World is Mobilizing –– Finally!Finally!Improving Vaccine TechnologiesImproving Vaccine Technologies

Modern Medicine Modern Medicine –– ItIt’’s not 1918!s not 1918!

Some Closing ThoughtsSome Closing ThoughtsTake Seriously But Keep In PerspectiveTake Seriously But Keep In PerspectivePrepare Prepare –– Have a Plan!Have a Plan!Hand Washing / Gel / Flu ShotHand Washing / Gel / Flu ShotCOOP COOP --Time Limited Event Time Limited Event

–– It WILL END!It WILL END!

The Only The Only PredictablePredictable ThingThingis a Pandemics is a Pandemics Unpredictability!Unpredictability!

More Questions?More Questions?

stephenj @ greenhosp . orgstephenj @ greenhosp . org

(203)(203)--863863--3415 (Office)3415 (Office)

THANK YOU!THANK YOU!