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Public Testimony- Avian and Pandemic Flu
New York City Department of Health & Mental Hygiene
Office of Communications

Testimony
of
Isaac Weisfuse, M.D., M.P.H.
Deputy Commissioner
Division of Disease Control,
New York City Department of Health and Mental Hygiene


before
The New York City Council
Committees on
Health
and
Public Safety

on

Avian and Pandemic Flu


November 17, 2005
City Hall

Good morning Chairpersons Quinn and Vallone and members of the New York City Council Committees on Health and on Public Safety. I am Dr. Isaac Weisfuse, Deputy Commissioner of Disease Control for the New York City Department of Health and Mental Hygiene (DOHMH). Thank you for inviting us to discuss the City's preparations for responding to an influenza pandemic. Although this issue has been in the headlines only recently, we in the Department have been working on our plan for over a year.

Influenza
Influenza is a serious viral disease, and every year in the United States, an average of five to 20 percent of the population gets the flu, more than 200,000 people are hospitalized from its complications, and; about 36,000 people die. An average of 2,500 New Yorkers die from influenza and pneumonia each year, the vast majority over the age of 65. Influenza strains vary annually, which is why the composition of the vaccine is different every year, and why we need annual shots. Such vaccinations protect us only against the strains of influenza circulating that year. Pandemic flu is potentially more dangerous than the annual flu. Pandemics occur when the genetic structure of proteins on the surface of the virus change suddenly, and since most people have no prior immunity to the pandemic virus, it can cause more severe disease in all age groups, and may be easily transmitted person-to-person. There have been three flu pandemics in the past 100 years, in 1918, 1957 and 1968. The 1918 "Spanish flu" pandemic caused severe morbidity and mortality, while subsequent pandemics were milder. We estimate that more than 40,000 New Yorkers died during the successive waves of the 1918 pandemic.
Avian influenza
Currently, we are concerned about the H5N1 virus, known as "avian flu," as a potential cause of the next flu pandemic. The virus is being spread among domestic and migratory birds across Asia, and recently has been detected in Europe; more than a hundred million birds have died or been culled as a result of this infection. The H5N1 virus has infected humans, and the death rate for those people known to be infected has been extraordinarily high-50 percent. However, as of November 15, only 126 humans have been infected. This is a relatively small number given the geographic extent of the avian influenza outbreak, the many different bird species, and the high population density in some of the affected countries. In such areas it is common for people to have very close contact with poultry. Fortunately, this virus is not yet easily transmitted among humans-nearly all human cases to date have had direct contact with infected birds. Only a handful-one or two cases-of human- to-human transmission are suspected, with no evidence of community-wide transmission. However, if the virus mutates to become easily transmissible among humans, it would likely develop pandemic potential.

Many uncertainties surround avian flu, and we do not know whether the usual characteristics of spread that we see with human flu viruses will occur with avian flu. Will it ever become easily transmissible among humans, and if it does, when might this happen? If this happens, will it cause severe morbidity and mortality? Finally, to what antiviral agents will it be susceptible, or resistant? Even though we do not yet have the answers to these questions, we must continue to prepare for the possibility of an avian flu pandemic.

Planning for Pandemic Influenza
City government and society will play critical roles in responding to a pandemic flu, and we have long been working on a plan to detect and respond to pandemic influenza. We have held, and continue to schedule, meetings with a variety of agencies and businesses to discuss refinements in their basic emergency and business continuity plans necessitated by a pandemic flu. Over the next three weeks, the New York City Office of Emergency Management (OEM) will host a meeting with all City agencies, and has arranged a meeting with City businesses. Since 9/11, we have had extensive discussions with City hospitals about emergency preparedness, and have been working closely with them to improve and coordinate the City's public health emergency response planning. In September, we conducted a citywide tabletop drill on pandemic influenza for all City hospitals in which OEM, the City's Fire and Police Departments, the Health and Hospitals Corporation (HHC), the Office of the Chief Medical Examiner (OCME), and the Greater New York Hospital Association (GNYHA) as well as the State, participated.

Many elements of our pandemic flu plan expand upon the emergency preparedness activities in which we have engaged over the past several years. These prior activities include a marked improvement in our infectious disease surveillance structure, improved relationships with medical providers and laboratories that have fostered disease reporting, the creation of the nation's most sophisticated syndromic surveillance system, building a City-financed, state-of-the-art bio-safety level three (BSL-3) containment laboratory, development and testing of points of distribution sites (PODS) for giving out antibiotics and vaccines, working with hospitals and primary care clinics on emergency preparedness and surge capacity, and improving our ability to communicate rapidly and effectively with the City's diverse populations.

As you know, the National Health and Human Services Pandemic Flu Plan, which took more than a decade to complete and comprises 396 pages, was released to the nation on November 1. We are currently reviewing and revising our plan in light of the release of the HHS Plan, which has many positive aspects. The release of the DOHMH pandemic flu plan will be early in 2006 with the understanding that this plan is a working document that will change over time.

The federal focus on the creation of pandemic influenza vaccine production capacity, as well as international surveillance and collaboration in outbreak investigations, makes sense; these are the national and international activities that must occur now. However, it is clear that the Administration's plan assumes a great deal of responsibility on the part of state and local governments, without matching resources, and we have expressed our concerns in this regard. One concern is whether the funding for the avian flu response will come at the expense of other crucial emergency preparedness activities. The plan also lacks clarity as to who will be paying for the proposed stockpiles of antiviral treatment, making it impossible to calculate what the City's financial burden will be. There is also insufficient attention to preventing the emergence of a pandemic strain through prevention activities overseas. It will be less costly and more effective to prevent a pandemic strain from evolving through global control measures than to treat a pandemic here.

The development of our plan rests upon certain realities, including the assumption that we will not be able to prevent pandemic flu from entering New York City, and, that once it arrives, we can only try to slow its transmission, but will not be able to halt it. If avian flu viruses behave the same as human viruses, people may be contagious with influenza virus prior to getting ill, and not all infected persons may become symptomatic; therefore, mass quarantine will not be effective in halting the spread of influenza. In addition, given the current state of vaccine manufacturing, an effective influenza vaccine against the pandemic strain may not be available until at least six months after the start of a pandemic. We will need to rely on providing good information to the public, paying close attention to infection control precautions such as respiratory etiquette, judicious use of any antiviral medications available to us, and hospital preparedness to deal with the expected surge in patients during the first wave of the pandemic, which based on history, may last eight or more weeks.

Influenza detection in birds and humans
Public health begins with surveillance. It is important to bear in mind that Asians who have become H5N1-infected have generally had direct contact with infected poultry. The risk to New Yorkers from infected wild birds, even if they did arrive here, would likely be very low, since there is minimal contact between wild birds and humans here in the City. Even if the virus was introduced to the poultry industry, it would not likely pose a substantial risk to New Yorkers, unless the virus were to mutate to become more transmissible among people. Our federal and State partners in agriculture are well-versed in responding to avian influenza outbreaks in poultry, and several large outbreaks of other types of avian influenza in U.S. flocks were successfully contained soon after they were identified.

Our ongoing human influenza surveillance would be enhanced at the first sign of a pandemic overseas, and greatly heightened if the outbreak reached New York. To monitor normal human influenza activity, an influenza sentinel provider surveillance network of clinical sites reports to us during each flu season on the number of patients seen with influenza- like illness, and also submits specimens to our Public Health Laboratory (PHL) for testing, to help us monitor which flu viruses are circulating here. Some of these sites already operate year-round, and if the pandemic threat started outside the traditional winter flu season, we would re-activate this system quickly. We also survey the 40 hospital and commercial laboratories licensed citywide for influenza testing to monitor the number of positive flu tests. In 2004, the New York State Department of Health (NYSDOH) required labs that are part of our Electronic Clinical Laboratory Reporting System (ECLRS) to report positive influenza tests. We track and provide public health consultation on nosocomial respiratory outbreaks in nursing homes. We receive data on influenza-related deaths for both adults and children, as well as all laboratory-confirmed influenza hospitalizations. Lastly, all influenza and pneumonia deaths are tracked weekly by our Office of Vital Statistics.

We have, since the H5N1 virus was first recognized in Asia in 1997, enhanced surveillance for suspect avian influenza cases among travelers returning from affected areas overseas. Through our health alert network (HAN), we advise New York City physicians on the clinical descriptions of avian flu, and instruct them on when and how to contact us regarding cases of concern and how to arrange testing through our Public Health Lab. Our poison control center provides 24/7 active physician back-up to the City's clinicians.

Our syndromic surveillance system uses existing electronic data sources along with clinical information to monitor for citywide trends and geographic clustering of disease syndromes; it includes emergency department data and EMS 911 ambulance dispatch data, as well as over-the-counter drug sale data. These systems have helped us identify the advent of regular flu each year.

Planning for possible response to a pandemic If a pandemic reaches New York City, our priority would shift to monitoring influenza-related hospitalizations and mortality, and identifying unusual epidemiologic or clinical features of the outbreak, such as antiviral resistance or unexpected complications. Furthermore, our sentinel sites and City virology laboratories could provide additional specimens to help track any changes in the pandemic strain. One of our primary roles would be to determine who is most vulnerable to the pandemic virus -to inform public health recommendations on treatment and prevention. We would prepare daily reports providing crucial data about how the pandemic is affecting New Yorkers to guide City leadership. Laboratory detection will be most critical to ensure early detection of the first clinical cases in New York City. Our Public Health Lab has the capability to test for avian flu; however, materials needed for such testing are currently in short supply nationwide, and we plan to address this issue with the Centers for Disease Control and Prevention (CDC). Equally important, the Public Health Lab will soon have the capability and capacity to "rule-out" avian flu from respiratory infections caused by other influenza and influenza-like viruses.

DOHMH works closely with hospitals to help them develop and refine their emergency response plans and increase surge capacity to accommodate more patients. All hospitals have emergency response plans for biologic emergencies; have developed and are now testing their screening and isolation procedures for persons entering the hospital's emergency department with fever and respiratory/ rash illnesses; and participated in a large DOHMH-sponsored citywide tabletop exercise on pandemic influenza on September 9. This citywide hospital exercise included more than 300 individuals from the medical and first responder community and simulated the issues that would need to be addressed at the hospital level in responding to a pandemic influenza outbreak.

During a pandemic, in coordination with the NYSDOH, OEM, HHC and GNYHA, we will monitor, through the NYSDOH Health Emergency Response Data System -- or HERDS -- hospitals' bed, staffing, equipment and supply capacities, to determine the ongoing impact on the city's hospitals and how best to allocate scarce resources. We will regularly communicate with hospitals, via teleconferences and electronic health alert updates, informing them about surveillance findings and providing them with the latest clinical advice. Through its automated electronic call-down system, DOHMH can contact hospital administrators to notify them of an urgent health alert or an upcoming teleconference. In addition to caring for sick patients, hospitals will need to report suspected and confirmed cases to DOHMH, transmit regular HERDS updates on hospital capacity, provide educational outreach and mental health support to their staffs, and institute facility-wide infection control precautions. DOHMH will be prepared to work with City hospitals on clinical indications for and distribution of antivirals when they become available through national, state or local stockpiles.

Pandemic flu is already presenting communications challenges. We are already working to inform New Yorkers about avian flu through frequent talks at community events and media interviews, and we participate in many educational forums on the issue. We are also developing and will widely distribute posters on respiratory and hand-washing etiquette.

If there is a pandemic, we will quickly provide accurate information, primarily through the news media, to keep New Yorkers well-informed about the progress of the disease, and about what measures they can take to protect themselves. Timely public information will also help minimize the impact on City hospitals, so that only those who need medical care will go to emergency departments for evaluations. Through 311, the Call Center, Lifenet, the Poison Control Center, and the Department's website, we will provide the most current information. Our Department also has a contact mailing list, which provides e-mail messages to New Yorkers who sign up to receive information on a variety of topics including emergency preparedness. New Yorkers can go to our website at www.nyc.gov/health to sign up for this service. As always, we will be sensitive to the diverse language needs of our City, and work with pre-identified organizations and media to reach those hard-to-reach groups.

Before a vaccine is available, it is likely that we would have to consider some types of community measures to slow transmission of the virus. Much would depend on the epidemiologic and behavioral characteristics of the pandemic strain, including its dangerousness, the period of contagiousness, its incubation period, and populations most likely to be affected. The most basic community control measure for any respiratory disease outbreak, including human influenza, is to encourage respiratory hygiene. The best way to reduce human-to-human transmission of influenza is to observe these simple rules: Cover your cough and sneeze, and, to reduce many respiratory and other infections, wash your hands regularly and always before eating. These will be stressed to the general public repeatedly using a variety of communication measures.

New Yorkers with a cough and fever would be advised to stay home and avoid contact with others. Although there may be limited use of mandatory isolation and quarantine in the city for the initial travel-related cases at the earliest stages of a pandemic overseas, these measures will not play a role once the pandemic is present; they are impossible to implement and enforce, especially since the virus may be contagious before symptoms start.

A powerful image is a city full of people wearing masks. While influenza can be spread through a combination of contact and respiratory droplets, there is no hard evidence that face masks are effective in preventing its spread in community settings. The use of personal protective equipment such as surgical masks will be strongly encouraged in health care settings where contagious patients are being cared for. We will monitor how the pandemic strain is spreading and advise accordingly, but it is unlikely that either the World Health Organization (WHO) or the CDC will encourage wearing masks in public, though it is equally unlikely that anyone would forbid wearing masks.

Some of the most difficult community control measures cannot be decided in advance, because we do not know which groups will be most severely affected by a pandemic. The cancellation of large public gatherings, as well as school closures, could potentially be recommended, if these measures are deemed necessary based on the epidemiologic characteristics of the pandemic virus. Mass transit is a special concern, particularly informing riders about covering their mouth when they cough or sneeze, and staying home if they have cough with fever. Such measures will decrease the possibility that uninfected persons will come in contact with the infected, although, again, this should reduce, but will not eliminate transmission.

Our plan also addresses vaccine management. All pandemic flu planning assumes there would be a period of at least six months between a novel virus alert and the availability of a vaccine, that the vaccine would be released in stages, and that government will play a large role in its distribution. There would also be an intense need for public education about the vaccination program, and there will be priority groups that will need to be vaccinated first. Additionally, security will be needed for vaccine supplies. While the availability of vaccine may be incremental, and distribution will be through both the private and public sectors, the City has a plan that allows us to vaccinate its entire population through a system of 200 PODS. We have tested our POD plans several times in the past, and are constantly refining and improving the plan.

The drug Tamiflu®, a possible treatment for influenza, has received a great deal of attention recently; however it is not a panacea for avian flu. When used to treat seasonal flu patients within 48 hours of the onset of symptoms, the drug decreases the duration of illness and shedding of the virus, thereby decreasing transmission. However, there is no data on whether this drug might decrease illness duration or viral shedding in avian flu; the only data comes from studies of treatment for regular flu. Hence, the role of Tamiflu® for treatment of avian flu is unclear. Moreover, Tamiflu® is in short supply, and the company that makes it has limited capacity, and it will take several years to produce all of the drug currently on order.

The federal plan calls for Tamiflu® purchase to treat 25 percent of the U.S. population, which is consistent with the WHO's recommendation. The plan also recommends that states themselves stockpile the antiviral and bear much of the cost-a recommendation that is being hotly debated. Regardless of how this debate is resolved, during a flu pandemic the DOHMH would be responsible for distribution of antivirals to hospitals and health centers for use in the treatment of individuals with pandemic influenza infection.

The DOHMH takes pandemic flu very seriously, and our work builds upon the foundation of emergency preparedness activities in which we have been engaged for several years. We are working with our partners in City and State government and with the health care and business communities to help prepare for such an event. Our plans will need to be flexible, as we learn more about avian flu, and perhaps as more antivirals and vaccines become available in the future.

Finally, it is worth reminding everyone that influenza does come to New York City -- every year in fact. Although the current vaccine situation is not as good as we would like it to be, there is still plenty of time to get a flu shot, so protect yourselves against the regular influenza virus.

Thank you again for inviting us here today to discuss this important issue. I would be happy to answer any questions you may have.