Pandemic influenza – preparing nowDr Chloe Sellwood PhD FRIPH

Pandemic Flu Lead, NHS London

Most experts believe that it is not a question of whether there will be another severe

influenza pandemic, but when

Sir Liam Donaldson, CMO

2002

• seasonal influenza• learning from previous pandemics• current threat from avian influenza • preparing for the next pandemic

– health

– wider society

Seasonal flu

• occurs every year winter

• affects up to 10% of the population

• the very young, the very old and people with certain chronic illness are most at risk

• annual vaccination available

• antiviral drugs available for the at risk (RCGP threshold)

Pandemic flu

• occurs about 3 times each century – at any time of the year

• may affect up to 50% of the population (up to 90% in closed communities)

• people of every age may be at risk

• vaccine won’t be available initially - in the first wave

• antiviral drugs are likely to be in limited supply; antibiotics, OTC meds, fluids…

Previous pandemics1920 1950 1980 2000

1918 1957A/H1N1

19681957A/H2N2

1968A/H3N2

A/H1N11977

Intervals:Shortest = 11 yearsLongest = 39 yearsCurrent = 40 years

PPPA/H3A/H2

A/H?N?20??

Spanish flu• 3 waves • <40m deaths worldwide, incl. ~200,000 xs UK civilian deaths

• mainly 20-50 year olds

Asian flu• worldwide: ~1.0m deaths•UK: 33,000 deaths, under 14’s and over 65’s

Hong Kong flu• worldwide: ~0.8–1.0m deaths• UK: 30,000 xs deaths (cf. 26,000 ’89/90), under 5’s and over 65’s

Geographic Spread: 1968-9

07/68

08/68

09/68

09/68

09/68

09/68

06/69

09/68

01/69

C.W. Potter, Textbook of Influenza, 1998

NOW: all major air hubs are less than 72 hrs apart…

Learning from previous pandemics• maximum recorded interval between pandemics is 39 years – it

could be soon (but it remains unpredictable)• the likely origin is south east Asia – but we can’t say for sure• global spread will be rapid – we either prepare now, or risk

being caught by surprise • may be several waves; first may be ‘milder’ than later waves• excess mortality and morbidity difficult to predict but may be

high (but not necessarily like 1918)• overall population clinical attack rate is likely to be 25-33%• there may be a shift towards younger age groups in terms of

severity and mortality• impact on public services for business continuity likely to be

considerable• impact on all organisations likely to be considerable

“Experts at WHO and elsewhere believe that the world is now closer to another influenza pandemic than at any time since 1968, when the last of the previous century's three pandemics occurred.” WHO

The world is presently in WHO Phase 3: a new influenza virus subtype is causing disease in humans, but is not yet spreading efficiently and sustainably among us.

Avian flu

• primarily a disease of birds – natural reservoir is wild aquatic birds

• most strains are relatively harmless (Low Pathogenic Avian Influenza)

• some strains are highly pathogenic (HPAI) and cause large outbreaks, especially in poultry, where death is rapid and near 100%

• A/H5N1 first appeared in Hong Kong in 1997, re-appeared in 2003

• has affected wild birds, poultry and some other mammals, including people

• wild and migratory birds are spreading infection

Live bird market China May 06, Defra

A/H5N1– the story so far• detected in birds in many countries – including UK

• millions of wild birds and poultry have died or been slaughtered

• virus has jumped directly from poultry to humans in 15 countries

• <400 human cases with 60% case fatality rate

• potential to mutate or mix with human virus to create new influenza virus against which there would be no immunity

• potential to cause the next pandemic…

• However, the next pandemic may be caused by a completely different subtype…

Potential impact to the UK• one or more national waves lasting ~15 weeks, local epidemics lasting

~8 weeks

• 25 – 50% population with symptoms

• 80,000 – 1,115,000 nationally needing hospital care

• 50,000 – 750,000 excess deaths nationally

• 15–20% absent from work at the peak, ?impact of schools closure

• £1,242 billion cost to society

Potential impact to London

CFR – case fatality rateRange of possible cases and excess deaths based on various permutations at case-fatality and clinical attack rates in a single wave. London figures based on ONS 2005 Mid-Year Population Estimates (rounded to nearest hundred), Borough based on typical size of 200,000.

Clinical Attack Rate

25% 35% 50%

National London Borough National London Borough National London Borough

Cases 15,000,000 1,880,000 50,000 21,000,000 2,632,000 70,000 30,000,000 3,760,000 100,000

CFR 0.4% 55,000 7,500 200 77,700 10,500 280 111,000 15,000 400

1.0% 150,000 18,800 500 210,000 26,300 700 300,000 37,600 1,000

1.5% 225,000 28,200 750 315,000 39,500 1,050 450,000 56,400 1,500

2.5% 375,000 47,000 1,250 525,000 65,800 1,750 750,000 94,000 2,500

Impact on health• staff will be ill and/or have personal responsibilities as carers

• supply chains could be disrupted

• transport disruptions could prevent staff coming into work

• hospitals will fill up quickly

• community services will need to care for people with a wider range of needs that usual – both health and social care

• little scope for mutual aid (other than local)

Impact on business

• staff will be ill and/or have responsibilities as carers – up to 50% of your workforce off for 7-10 days over the pandemic, 20% at peak, more for small teams…

• schools likely to close – staff off to care for children

• expect transport disruptions to prevent staff coming into work

• it will not be ‘business as usual’…

UK planning – health• lead by the Department of Health, with

Cabinet Office lead for cross-government planning

• UK Influenza Pandemic National Framework published 11/07, covers role of NHS and DH responsibilities for policy, practice and logistics

• incorporates an escalating, graduated response based on WHO pandemic phases, and UK Alert Levels 1-4

• suite of supporting, area-specific guidance

www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/index.htm

The NHS in London

Reducing the impact through “defence in depth”…

Reducing death antibiotics, healthcare

Reducing spread hygiene, stay at home, school closures

Reducing infection vaccines

Reducing illness/ complications antiviral drugs, healthcare

Pandemic vaccine

• 4-6 months to produce a pandemic specific vaccine, longer for sufficient quantities to vaccinate all who want/ need it

• unlikely to be available during the early stages of the pandemic

• limited global production capacity• may need to prioritise the vaccine

when available• how many doses per person?• what about pre-pandemic

vaccination?

Antiviral drugs• March 2005: DH procured 14.6 million courses of oseltamivir

(Tamiflu®), enough to treat 25% of the UK population• Now: expanding stockpile to treat 50% of the UK population

• Prevents the virus from reproducing– reduces period of infectivity/symptoms by ~1 day– reduces secondary complications and therefore

reduces hospital admissions/ pressure on acute sector

• But:– effectiveness against a pandemic virus is unknown – must be taken within 48 hours of onset of symptoms (ideally

12 hrs) – so how to do this??

National Pandemic Flu Line Service• Access via web, automated telephony and 24x7 call centres• NHS number for UK nationals; ?foreign nationals• Basic Flu Line - algorithm to determine whether antivirals to be

allocated (URN / local collection point) or caller needs to see GP– FluLine Professional – health professionals– Stock Management System – maintain local supplies– Information Line – worried well

• If AVs appropriate – caller asked to direct Flu Friend to local collection point

• Next steps: increased language capabilities, and ?texting URNs to mobile phones?

• PCTs identifying antiviral collection points; but how will social care users access the flu line, or get their antivirals (will they have flu friends?)

Guidance relevant to Local Authorities

Cabinet Office• Guidance to local planners(

www.ukresilience.gov.uk/pandemicflu/guidance/regional_local.aspx)

DH• Guidance on the Management

of Death & Cremation Certification

• Ethical framework• HR (NHS guidance)• Social care(

www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/DH_093202)

Social care

• maintaining service – adult and children services

• increase in demand • identifying the existing vulnerable

and those who are newly vulnerable due to the pandemic

• supporting ‘informal’/private care• working with health

• London Development Centre workshop

Regional actionHealth• working with the DH to ensure consistency across the country

with other SHAs

• working across the NHS in London through the steering group and workstreams to ensure consistency of preparedness and service

Wider than health• working with London Resilience Team and others (HPA London,

DH etc), to ensure consistency across the region and across sectors– social care workshop – January – excess deaths workshop – February– IPC exercise – June– other meetings – London First, local resilience groups etc

Local action

• engage with staff at all levels – communication is essential

• engage with your partners/neighbours, particularly through the local Influenza Pandemic Committees – these should be meeting now to plan the response to a pandemic

• tailor existing plans to pandemic flu, and identify how flu planning can help wider emergency preparedness/ business continuity

• get involved – locally and regionally• it’s not all just about the health response…

Top tips…Now…• familiarise yourself with the national guidance (HSE guidance for

employers, UK Resilience www etc…)• practice good hand and respiratory hygiene• enable your staff to work from home (eg if schools close or they

need to care for a family member)• use existing BCP processes and adapt them to flu – what can you

do without for a day, a week, a month, a quarter…

When it happens…• go to work if you are well, but stay at home if you are ill with

pandemic flu – don’t spread it• remember it won’t be business as usual, it could last for up to 3

months, and all aspects of society will be disrupted …

www.ukresilience.gov.uk/pandemicflu/guidance/business.aspx

What can we all do?• Good hand and respiratory hygiene

• Identify a ‘Flu Friend’ and be a ‘Flu Friend’ for others

• Identify if/how you can work from home, can you work altered hours to avoid rush hour, or are there alternate ways to get to work…

• Stay at home if you are ill with pandemic flu

Catch it, bin it, kill it…

X

Dr Chloe Sellwood PhD FRIPHPandemic Flu Lead, NHS London Southside, 105 Victoria Street, London SW1E 6QT 020 7932 2633 Chloe.Sellwood@london.nhs.uk

Simon ColeSocial Care Lead, Pandemic Influenza Preparedness Programme Team Department of Health, Skipton House, 80 London Road, London SE1 6LH020 79725363 Simon.Cole@dh.gsi.gov.uk