Transcript Public Health Roles and Responsibilities

DC Department of Health
Pandemic Influenza
Preparedness
(All Hazards Preparedness)
Public Health Roles and Responsibilities
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Assure Availability of Healthcare Operations
Community Preparedness and Leadership
Surveillance & Clinical Laboratories
Public Health Partners
Infection Control and Clinical Guidelines
Vaccine Distribution & Antiviral Drug Distribution
Community Disease Control and Prevention
Public Health Communications
Workforce Support
Fiscal Resources
Public Health Response Cycle
Continuity of Operations
Prophylaxis
Immunization / Treatment
Infection Control Guidelines
Medical Surge
Quarantine / Isolation
Surveillance
Surveillance
Education / Risk Communication
Pre-Event
During
Plan Improvement
Recovery
Consequence
Management
Implementation
Response
Exercise
Train
Mitigate
Plan
Plan Development
Post-Event
Assessments and Planning
• Pandemic Influenza Coordinating Committee
– Strategic Priorities
– Accountability and Responsibility for Key Stakeholders
• Plan
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NIMS Compliant
Regionally Coordinated
Special Needs Populations
Requests for Resources outside Jurisdiction
• Legal Authority
– Public Health Emergency Declaration
– “Law Enforcement” Definition
• Workforce Support
Communications
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Surveillance and Rapid Reporting
PHIN Certification
Community Education
Risk Communication
Interoperability / Regional Partnership
Health Alert Network
Medical Surge
• Specialty Care Beds <50%
• Primary Care Clinics
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Alternate Care Sites
Pre-hospital Triage
Medical Shelter
SNS Point of Distribution
Long term Care Facilities
Academic Health Centers
Protection of the Healthcare Workforce
Medical Supply
Mortuary Services
Isolation and Quarantine
• Legal Authority
– Enforcement
• Trigger Point and Release Point
– Effective vs. Ineffective
• Social Distancing
– Mental Health Impact
– Economic Impact
Mass Prophylaxis
• Scarce Resource Distribution
• Special Needs Populations
• 48 Hour Delivery
– Institutional Model
– Manpower Resources
• Immunizations/Anti-virals
– Training
– Education
• Security
Policy Development on Antiviral Drug Use and
Stockpiling of Antiviral Drugs
Proposed
policy
Estimate of
material
needs
“Proposed”
guidance
Stakeholder
engagement
Revised
“Interim”
guidance
• Meetings with State/local govt,
healthcare, emergency services,
business, labor
• Report to HHS leadership
• Consideration in decision-making
Background on Antiviral Drug Use
Strategies
• Current strategies: containment & early treatment
• Rationale for reconsideration
– Allowed by increased manufacturing capacity
– Recognizes potential value of prophylaxis to 1) maintain healthcare
and other critical services; 2) reduce rates of illness as part of
community mitigation
• Interagency working group on antiviral drug use
– Representatives from Federal agencies, State/local/tribal public
health
– Consider drug effectiveness & resistance, mathematical modeling
results, potential absenteeism & continuity of operations, ethics &
values, and stakeholder preferences
Antiviral Working Group Assumptions
• Severe pandemic (PSI 5)
• Community mitigation reduces attack rate from 30% to 15%
• No accurate point-of-care (POC) diagnostic test
• 35% positive predictive value (PPV) of clinical diagnosis
• 60% of cases treated and household members receive
prophylaxis
• Community outbreaks last 12 weeks
• No vaccine effect for first pandemic wave
• Single pandemic wave for antiviral requirements
Definition of Antiviral Strategies
Strategy
Definition
Treatment (Rx)
Twice daily dosing for 5 days begun within
48 hrs of illness onset
Outbreak
prophylaxis
Once daily dosing triggered by the onset
and continued for the duration of a
community outbreak (up to 12 wks)*
Post-exposure
prophylaxis (PEP)
Once daily dosing for 10 days begun within
48 hrs of exposure to a case
# regimens
1
up to 8
1
*FDA approval of oseltamivir is for up to 6 wks prophylaxis. The working
group recommends that longer durations be given for outbreak prophylaxis,
as needed, under an EUA. Studies of longer
oseltamivir prophylaxis are ongoing.
Antiviral Drug Use Strategies
Population
Current strategies
• Containment
• Ill persons
Proposed strategies
• Front-line healthcare &
emergency service workers
• Other healthcare workers
• Household contacts of cases
• Unique/specialized critical workers
• Immunocompromised persons
• Outbreak control in closed settings
Antiviral drug
strategy
Est. number of
regimens
(millions)
Rx, Px
Rx
6
75
Outbreak Px
86
PEP
PEP
Outbreak Px
PEP
PEP
17
88
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5
Rx = Treatment; Px = Prophylaxis; PEP = Post-exposure prophylaxis
Rationale for Prophylaxis of Healthcare
Workers who have Patient Contact
• Reduce occupational risk of infection
– Limited data suggest an increased HCW risk
– Duty of care and reciprocity principle
• Reduce absenteeism from illness & fear of infection
– Increased healthcare burden & limited surge capacity
– Singapore HCW model suggests prophylaxis may reduce peak
absenteeism due to illness from ~10% to ~2%
– Surveyed HCWs report being more likely to work if protected
• Reduce transmission to patients (and co-workers)
– Studies in acute and long-term care show protecting HCWs protects
their contacts
Antiviral Prophylaxis in the
Emergency Services Sector?
• Includes EMS, fire departments, law enforcement
• Risk of occupational exposure and infection varies
• Rationale for prophylaxis
– Reduce absenteeism and maintain essential services
– PPE may be less effective in a field setting
– Reciprocity principle
Prophylaxis for other
Critical Infrastructure Personnel
• Recommended for small cadre with individual skills and
experience that make them irreplaceable
• Continuity of operations planning expected for CI sector
businesses generally
– Various approaches to protect workers
– May choose to include prophylaxis
– HHS guidance will be available
Post-exposure Prophylaxis (PEP) for Household
Contacts of Ill Persons
• Household contacts are at increased risk of influenza
infection
• PEP is effective in reducing illness
– For individuals – ~70 – 90% effective in reducing illness in
household contacts
– In communities – based on results of mathematical models
Modeled Impact of PEP on Pandemic
Influenza Illness Rate
Influenza illness attack rate
NPI = Non-pharmaceutical interventions; Rx = treatment;
PEP = Household post-exposure prophylaxis
35
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- 50%
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- 8%
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Baseline
NPI + Rx
NPI + Rx + PEP
See Community Mitigation Guidance; impact of PEP based on model by N. Ferguson
Uncertainties and Risks
• Estimated requirements based on assumptions
– PPV of a clinical influenza diagnosis
– Effectiveness of community mitigation
– Duration of community outbreaks
• Ability to implement interventions
– IOM study pending on implementation and best-practices
• Antiviral resistance
– Less likely with prophylaxis than treatment
• New technologies may be developed
– Point-of-care diagnostic test; new antiviral drugs
Shared Responsibility for Implementation
• What is the role of government, organizations, employers,
and individuals in…
– Purchase and stockpiling?
– Identifying workers to receive prophylaxis?
– Dispensing?
• If organizations and HCWs are responsible…
– How effectively is the guidance likely to be implemented?
– What barriers may limit the ability of public health agencies,
healthcare providers and organizations to implement the guidance?
– What can the Federal government do to help overcome those
barriers?
Proposed Considerations for
Antiviral Drug Stockpiling by
Employers
In Preparation for an Influenza
Pandemic
Draft Guidance for Stakeholder Discussion
Proposed Guidance
• Encourage employers to consider stockpiling antiviral
drugs for use during an influenza pandemic as a part
of comprehensive pandemic planning
Role of Businesses/Employers in
Pandemic Planning and Response
• Protect employees' health and safety
• Maintain business continuity
• Preserve function of critical infrastructure
How can private sector caches complement
public sector stockpiles to improve
community response?
Employers may choose to purchase antiviral drugs
for stockpiling for several reasons:
• Assure early treatment to employees who are ill;
• Provide pre-exposure prophylaxis for employees:
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probable occupational exposure/risk to ill persons,
essential to a business’ operations,
certain critical infrastructure workers, or
all of workforce (and possibly their families);
• Provide post-exposure prophylaxis following household*
or workplace exposure; and
• Protect overseas employees and operations where U.S.
government pandemic response activities will not reach.
* As described by the Community Mitigation Guidance
Special considerations for U.S. businesses
with overseas operations
• “American citizens should take note that the
Department of State cannot provide Americans
traveling or living abroad with medications or
supplies even in the event of a pandemic.”
• “U.S. embassies and consulates do not have
supplies of this drug [oseltamivir (Tamiflu ®)] for use
by private American citizens abroad.”
For more information see:
http://www.travel.state.gov/travel/tips/health/health_1181.html
Key Issues for Employer Planning for
Antiviral Stockpiles
• Plan for collaboration with State/local public health
• Comply with State/Federal prescribing and dispensing
laws and regulations
• Consider ethical and equity concerns
• Develop stockpiling and dispensing models
– Utilize existing health care or pharmacy facilities (preferred)
– Contract with a wholesale drug distributor
– Stockpile onsite by businesses
– Dispense pre-pandemic
• Educate employees and families
Final thoughts
• Guidance does not establish the requirement or
expectation that all businesses/employers stockpile
antiviral drugs.
• If antivirals are stockpiled, assure drugs are used:
• As part of a comprehensive pandemic planning strategy in
conjunction with other measures (e.g. Community
Mitigation measures, PPE, hand hygiene)
• In compliance with State laws and regulations
• With consideration to ethical issues
• In coordination with State and local pandemic plans
Summary
• We’re not there yet.
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Making progress
2008 is Critical Year
Plans need to be exercised across all sectors
Science advancements are key
• Immunization
• Anti-virals
– Private Sector & Community Preparedness is vital
Questions
Beverly Pritchett
Senior Deputy Director
Health Emergency Preparedness and Response Administration
DC Department of Health
202/671-4222
[email protected]