Improving Responses to Public Health Threats: Lessons from Influenza and Ebola RADM Stephen C. Redd, MD Director, Influenza Coordination Unit October 16,

Improving Responses toPublic Health Threats:

Lessons from Influenza and Ebola

RADM Stephen C. Redd, MDDirector, Influenza Coordination Unit

October 16, 2014

Agenda

2

Avian influenza, 2005–2009 Response Exercises and After-Action Reviews

H1N1, 2009–2010 Response After Action Review

Ebola, 2014 Situation update Response

Centers for Disease Control and Prevention

Office of Public Health Preparedness and Response

BIRD FLU

2005–2009 Response

3

Headlines, 2006

4

5

6

National Strategy Pandemic Plans

National Strategy for Pandemic Influenza

National Strategy for Pandemic Influenza: Implementation Plan

HHS Pandemic Influenza Plan

HHS Implementation Plan

7

CDC Influenza Pandemic Operations Plan Training and Exercise Plan

Influenza Pandemic OPLAN

Senior Leader OPLAN Seminar

28 Sep

DEOC Working Level Workshop

4 Oct

Advanced Tabletop: Preparation for Full Exercise

8 Dec (Half Day)

Internal Degraded Operations Exercise

May 07 (Full Day)

Basic Functional Level Drills (6 Functional Areas)

27 Oct – 1 Dec

2-4 Hours Each

Full Scale Exercise – Internal/External

April 07 (72 Hrs)

Training/Exercise Methods Include:Briefings/Seminars

Tabletop Discussion (informal walk-thru and discussion)

Workshops and Functional Drills (step-by-step rehearsal by phases/stages)

Full Scale Exercises

Final AAR & Report

Division Director, CIO OPLAN Seminar

17 Oct

AAR

AAR

AAR

AAR

AAR

AAR

AAR

AAR

Functional Exercise – Internal, Full Staff

31 Jan-1 Feb 07

8

After Action Review

Morning meeting after exercise Review from each functional area:

What worked well (to sustain) What needs improvement

Written report produced Overview of exercise Task list

Tracking of improvement

9

Real-life Practice

• May 2006: H5N1 cluster, Indonesia

• March 2007: US traveler, New York

• Dec 2007: Pakistani traveler, New York

10

Surveillance plans Diagnostic test development / deployment Vaccine development / deployment Antiviral stockpiling / guidance

development Community mitigation measures

School closure guidance Planning for airport screening

Infection control guidance Communication planning and training

Capabilities Developed to Prepare for an Influenza Pandemic

11

Pre-H1N1 Exercise Highlights

Organization of leadership team Span of control Established daily rhythm Communication with state health

departments Structured decision making Fusion meeting Communication on countermeasure

development and delivery

12

Centers for Disease Control and Prevention

Office of Public Health Preparedness and Response

H1N1

2009–2010 Response

13

Detection of Novel Swine Influenza

First case—April 15,2009 10 year old boy Identified as part of a clinical trial

of a prototype diagnostic device Second case—April 17, 2009

9 year old girl Identified as part of CDC border

flu surveillance MMWR Dispatch—April 21,

2009 Texas cases—April 22 Mexico cases—April 23

1 2

Southern California, US

14

0

10

20

30

40

50

60

70

80

90

100

0

2000

4000

6000

8000

10000

12000

14000

Per

cent

Po

sitiv

e

Num

ber

of P

osi

tive

Spe

cim

ens

Week NumberB A(Subtyping not performed) A(H1)A(H3) A(Unable to Subtype) A(2009 H1N1)Percent Positive

199,887specimens

tested

2008 2009

> 700,000 specimens tested

Virology 2008-10 Influenza Seasons

15

10/3

10/10

10/17

10/24

10/31

11/7

11/14

11/21

11/28

12/5

12/12

12/19

12/26

1/2 1/9 1/16

1/23

1/30

2/6 2/13

2/20

2/27

3/6 3/13

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

Week

Es

tim

ate

d C

as

es

Estimated H1N1 cases by week, 2009-10

16

Characteristics of 2009 H1N1 Influenza Pandemic in the US

April 15, 2009–April 10, 2010

0-4

5-24

25-4

9

50-6

4

≥65

Cases61,000,000 (43M – 89M)

Hospitalizations274,000 (195K – 403K)

Deaths12,470 (8.9K – 19.3K)

App

roxi

mat

e ra

te p

er 1

00,0

00 p

opul

atio

n

Age groups

17

10/3

10/10

10/17

10/24

10/31

11/7

11/14

11/21

11/28

12/5

12/12

12/19

12/26

1/2 1/9 1/16

1/23

1/30

2/6 2/13

2/20

2/27

3/6 3/13

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

Estimated H1N1 Cases and Vaccine Doses Distributed

Week

Ca

se

s a

nd

Do

se

s D

istr

ibu

ted

cases

vaccine doses

18

2009 H1N1 Achievements

Rapidly identified novel influenza virus Developed and distributed diagnostic

reagents within weeks of detection Vaccinated approx 80m US residents Increased use of antiviral drugs for severely

ill

19

Learning from the 2009 Pandemic

Preparation paid dividends Vaccine production inadequate

Time to sufficient quantities Understanding what was available Communicating the uncertainty

Everyday systems work best Importance of communications

20

Communications Within government With partners With the public

Infection control Travel issues Coordination with State and Local Health

authorities (and political leadership) Potential for societal impacts

Shared Capabilities

21

Plan for Addressing Key Items for Improvement

22

AAR Policy Meeting with CDC

Director

June 28, 2010

In Progress Reviews

May, June, July (State/Local), August & November 2009

January & February (State/Local) 2010

Summary Reports from States on AAR/IP progress

November 30, 2010

Task Force & Senior Leader

AARs

March - May 2010

Response Begins

April 2009

AAR/Improvement Plan Final Draft

July 15, 2010

CDC AAR Conference -

Update on CDC Improvement Plan

Progress

November 15, 2010

PHER-required AARs due from

States

July 31, 2010

2011-2012Reports on

improvement plan activities

Final improvement plan approved by

response leadership

Sep 15, 2010

H1N1 Response After Action Reviews

23

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Key Items for ImprovementPandemic Preparedness Continues: Plan, Exercise and

Refine PlansVaccine

ProductionModernize and increase speed of vaccine production

Laboratory Diagnostics

Communications

Antiviral Drug Distribution

Staffing

Infection Control

Modeling

Improve lab diagnostics, including next generation serologic testing and more sensitive point-of-care testing

Clearly define and express severity for seasonal and pandemic influenza

Leverage existing commercial drug distribution to efficiently distribute antivirals

Effectively manage the emergency response staffing

Improve infection control, especially respiratory protection

Integrate statistical modeling into the response

BudgetIncrease proactive budget planning to facilitate fast, efficient use of resources

2014 Ebola Outbreak Response

West Africa

Centers for Disease Control and Prevention

Office of Public Health Preparedness and Response

EBOLA

2014 Ebola Outbreak

25

First discovered in 1976 near the Ebola River in the Democratic Republic of the Congo

Family of zoonotic RNA viruses Filoviridae

Historically, death rates for Ebola 50%-90%

History of Ebola

The 2014 outbreak is the largest Ebola outbreak in History and the world’s first Ebola epidemichttp://www.cdc.gov/vhf/ebola/outbreaks/2014-west-

africa/distribution-map.html

26

Ebola Cases and Deaths

*Data based on joint Ministry of Health/WHO Situation Reports † Includes only confirmed cases‡Data based on WHO Situation Reports

SitRep Date

Cases Deaths

Total Confirmed Total HCW Total

Guinea* 11 Oct 1441 1164 75† 831

Liberia 09 Oct 4190 948 204 2400

Sierra Leone 11 Oct 3187 2792 129‡ 1173

Total 8818 4904 408 4404

27

Total Number of EVD Cases by Week Reported in Situation Reports

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 400

500

1000

1500

2000

2500

3000

3500

4000

4500

Guinea Sierra Leone Liberia

Epidemiologic Week 2014

Num

ber o

f Cas

es

Epidemiologic weeks 13-40 correspond to 24 Mar–4 Oct

Liberia week 40 may not be complete

28

Interrupt Ebola transmission in West Africa Case identification, isolation and care Contact identification and monitoring Transmission risk factor identification and

mitigation HCW protection and infection control Funeral and burial safe practices

Prevent Ebola transmission to other countries Prevention of undiagnosed cases entering

unaffected countries Prevention of transmission from diagnosed

cases during and after repatriation

Ebola Response Priority Objectives

29

US Government Strategy

Encourage International Participation

Control the Outbreak

Build Long-term Capacity to Detect

and Respond

Mitigate Secondary Impacts

30

Challenges in West Africa

Epicenter of epidemic in remote, tri-country border area, rapid spread in urban areas

Institutions of government still being strengthened

Weak health and public health systems Lack of even basic resources Poor communications (limited cell phone,

radio coverage, internet service) Divisions within societies recovering from

war Misconceptions about disease and low

levels of literacy

31

Laboratory Testing Capacity

Sierra Leone 300 specimens per day

Liberia 350 specimens per day

Guinea 100 specimens per day

* Lab Partners in West Africa include: US CDC, NIH, China CDC, Institute Pasteur, Canada, CDC, NIH, US Navy, US Army, Russia, European Consortium, South Africa

32

Recent Developments: Texas Cases Texas case #1

First domestically-diagnosed Ebola patient confirmed 9/30/14

Visited ER, evaluated and sent home on 9/26/14 14 person CDC team provided support with contact

identification and tracing and infection control—48 contacts tracked

Texas case #2 Diagnosed 10/12/14 Isolated within 90 minutes of reporting symptoms Provided patient care to case #1, not a contact between

2 ER visits Review of infection control procedures Few contacts, but over 70 health care workers being

monitored Texas case #3

Tested positive for Ebola on 10/15/14 33

Domestic Preparedness:Airport Screenings

Entry screening of passengers arriving from affected countries JFK: New York-JFK, NY (10/12/14) IAD: Washington-Dulles, VA EWR: Newark, NJ ORD: Chicago-O’Hare, IL ATL: Atlanta, GA

Account for 94% of all passengers arriving from Liberia, Sierra Leone, and Guinea

Procedure Visual assessment Questions about symptoms Temperature measurement Questions about exposure

34

Applying Lessons Learned from Influenza Responses

Structure of response leadership Importance of communication

Potential for misinformation / distrust CDC product is information and guidance No vaccine or specific therapeutic agent Critical role for meticulous infection control Community mitigation measures

35

Preparing for Emergencies of Infectious Diseases

Global detection and response is key Plan and exercise for greatest threats

(pandemic influenza) Recognize the need for speed and scale Communication capacity

36

Questions?

37