100 Years Since 1918 Are We Ready for the Next PandemicDaniel B Jernigan MD MPHDirector Influenza DivisionCenters for Disease Control and PreventionInfluenza DivisionToday146s AgendaRemembering the 19 ID: 887483
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1 Influenza Division 100 Years Since 1918:
Influenza Division 100 Years Since 1918: Are We Ready for the Next Pandemic? Daniel B. Jernigan, MD MPHDirector, Influenza DivisionCenters for Disease Control and Prevention Influenza Division Today’s Agenda Remembering the 1918 pandemicReviewing current influenza threatsEvaluating pandemic readinessGathering input on 1918 comm
2 emoration activities Influenza Signific
emoration activities Influenza Significant Annual Burden of Influenza in Humans https ://www.cdc.gov/flu/about/disease/201516.htm ; http ://www.who.int/immunization/topics/influenza/en ; Iuliano et al Lancet 2017 12,000 56,000140,000 710,0009.2M DeathsSevere CasesHospitalizationsCases291,000 646,000 3M to 5M United States Global Inf
3 luenza Division Shift: Reassortment of
luenza Division Shift: Reassortment of Influenza Viruses Humanadapted viruses can arise from reassortment to cause efficient and sustained transmissionFour pandemics in last 100 years Avian or Swine Influenza Virus Human Influenza Virus ReassortedInfluenza Virus with Pandemic Potential Influenza Division Influenza A Viruses Since 191
4 8 Pandemic(1918Estimated US Deaths= 675,
8 Pandemic(1918Estimated US Deaths= 675,000Pandemic(1968Estimated US Deaths100,000andemic(2009)Estimated US Deaths12,500GlezenWP. EpidemiolRev. 1996. **Shrestha SS. Clinical Infectious Diseases 2011. H1N1H2N2H3N2H1N1H1N1 Pandemic(1957Estimated US Deaths,000 All four pandemics in last 100 years have had some genes that originated fr
5 om avian influenza viruses Influenza Div
om avian influenza viruses Influenza Division 1918 Influenza Pandemic Influenza Division 1918: Crowding Facilitated Transmission Industrialization and war response added to urban overcrowdingSoldiers in crowded camps�100K in tents in US18 record cold winterAligneAJPH Barry The Great Influenza 2005 Influenza Division 1918: War
6 time Movement Aided Transmission Massive
time Movement Aided Transmission Massive troop movementFrom towns to training bases, to Europe10,000 men shipped to France every day in summer 1918Unprecedented troop movement allowed infection to move from camp to camp www.museumsyndicate.com/item.php?item=56784www.dailyherald.com/article/20140628/news/140629223 Influenza Division Fi
7 rst Published Cases in US Public Health
rst Published Cases in US Public Health Reports, April 1918 Site of emergence purported in Haskell KS in U.S.‘Spanish Flu’ not because Spain was source, but because Spain was a noncombatant and others refused to admit having casesPublic Health Reports Influenza Division The Dawn of Modern Medicine Causative agent (virus) un
8 known, no flu treatment or prevention, f
known, no flu treatment or prevention, flu transmission poorly understoodCause of influenza attributed in 1892 by Pfeiffer to be a bacillus HaemophilusinfluenzaeFew vaccines:typhoid, cholera, plagueOnly palliative therapies:Aspirin, quinine, opium, ammonium, iodine, turpentine, beef teaSevere shortage of medical personnel�30% o
9 f physicians working for the military&#x
f physicians working for the military� 9,000 nurses deployed overseas PfeifferByerlyPublic Health Reports 2010; Keeling Public Health Reports 2010 Influenza Division Signs and Symptoms of 1918 Pandemic Classic flu symptoms in mostPneumonia in 1020% of cases‘Purple Death’ often in 24 hrs“They very rapidly develop
10 the most vicious type of pneumonia that
the most vicious type of pneumonia that has ever been seen.”“Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the colouredmen from the white.”“It takes special trains to carry away the dead. For several days there were no coffins and the bodies piled up something f
11 ierce.” “Bodies stacked in the
ierce.” “Bodies stacked in the morgue from floor to ceiling like cord wood.”Barry The Great Influenza Shanks 2015 Influenza Division Fatality of 1918 Flu Three pandemic waves with high fatalityEstimated 50M deaths globallyFive times the military losses of WWIDepressed overall average life expectancy by 12 yearsTaubenber
12 gerand MorensEID 2006Johnson Bull. Hist.
gerand MorensEID 2006Johnson Bull. Hist. Med 2002 ; Patterson Bull. Hist. Med 1991; Guyer Pediatrics 2000 Influenza Division The 1918 Influenza Virus Johan Hultinat permafrost gravesite, BrevigMission AK Hultinreturns to gravesite for frozen lung tissue Hultinunable to grow live 1918 virus in lab Taubenbergerat AFIP begins sequencing
13 the 1918 virus genes Tumpey at CDC resc
the 1918 virus genes Tumpey at CDC rescues 1918 virus in high containment lab CDC shows 1918 virus causes severe pneumonia in mice and identifies the genes responsible for high virulenceTaubenbergerScience1997, Tumpey Science Influenza Division Human Cases of Reported Novel Influenza A Infection, 1959Includes Avian H4, H5, H6, H7, H9
14 , H10 & Swine H1, H3 (not H1N1pdm09)Year
, H10 & Swine H1, H3 (not H1N1pdm09)Year of Onset 1959 to 2017�30 fold increase from 1990’s to 2000’sNumber of Human Cases 0100200300400500600 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 Novel Influenza Infection
15 Reports are Increasing Freidl, Meijer,
Reports are Increasing Freidl, Meijer, deBruinet al Euro Surveill2014; Cumulative case counts of H5N1 from WHO and Chinese provincial reports Influenza Division Avian Influenza A(H7N9)in Asia Influenza Division Avian Influenza H7N9 and Pandemic Potential Influenza Division 20040060080010001200140016002003/042004/052005/062006/072007
16 /082008/092009/102010/112011/122012/1320
/082008/092009/102010/112011/122012/132013/142014/152015/162016/17 Number of Human Infections Year (Season)Cumulative Number of Human Infections of Avian InfluenzaA(H5N1) and A(H7N9) by Season A(H5N1) A(H7N9) H7N9 and H5N1 Human Cases Influenza Division H7N9 Characteristics Severe human infections90% developed pneumonia70% admitted to
17 ICU40% diedClusters of infection35 repo
ICU40% diedClusters of infection35 reported but sustained humantohuman transmissionwave viruses changedIncreased cases and geographic spreadGenetic drift requiring new vaccine developmentSubset of viruses now highly pathogenic in poultry H7N9 patient in Hubei province, 2017. STAT. The Next Pandemic:Are We Ready? Influenza Division Pa
18 ndemic Readiness World more crowded, mor
ndemic Readiness World more crowded, more connected, and the worlds of humans and animals are increasingly convergingIf 1918 pandemic were to occur today, it could result in tens of millions Infection in 2030% of global populationPotential disruption of transportation and supply chainsFood, Energy, Medical SuppliesPotential disruption
19 of healthcare servicesPotential high ec
of healthcare servicesPotential high economic costs$181B estimated for pan flu pandemic*SARS cost $30 billion in only 4 months HHS Pandemic Influenza Plan 2017 Update Influenza Division Pandemic Readiness Surveillance, Epidemiology, and Laboratory Activities Community Mitigation MeasuresMedical Countermeasures: Diagnostic Devices, Va
20 ccines, Therapeutics, and Respiratory De
ccines, Therapeutics, and Respiratory Devices Health Care System Preparedness and Response ActivitiesCommunications and Public OutreachScientific Infrastructure and PreparednessDomestic and International Response Policy, Incident Management and Global Partnerships and Capacity Building HHS Pandemic Influenza Plan Influenza Division Su
21 rveillance and Diagnostic Readiness Stre
rveillance and Diagnostic Readiness StrengthsExpanded global surveillance and reagent distribution for fluGreatly improved domestic flu surveillanceNextgeneration sequencing at CDC of all flu viruses receivedGapsInadequate surveillance in birds and swine‘Data Deserts’ in Africa and many developing countries Influenza Divisio
22 n Treatment and Clinical Care StrengthsA
n Treatment and Clinical Care StrengthsAntiviralsIncreased availability of antiviralsOseltamivir, Zanamivir, Peramivir, LaninamivirStockpiles maintained in some countries for use in emergencyGapsNeed better performing antiviralsNeed reusable respiratory protective devices and better ventilator accessHealthcare system could get overwhe
23 lmed in a severe pandemic Influenza Divi
lmed in a severe pandemic Influenza Division Vaccine Readiness StrengthsImproved virologic forecasting New vaccine technologies availableSynthetic biology for making vaccine virusesCellgrown vaccinesRecombinant protein vaccinesMore manufacturing capacity availableNew programs for introducing vaccine for lowmidincome countriesGaps Take
24 s too long to have vaccine available for
s too long to have vaccine available for pandemic response Need better current vaccines as we work toward a truly “universal” vaccine Influenza Division Pandemic Planning and Response StrengthsBetter tools for responding to a pandemicSeverity Assessment FrameworkCommunity Mitigation Guidance for use of nonpharmaceutical inte
25 rventionsGapsMost countries do not have
rventionsGapsMost countries do not have robust pandemic plans and very few exercise response effortsOnly a third of all countries are prepared to meet Global Health Security / WHO readiness targetsReed EID 2013; Qualls MMWR 2017 Conclusions Influenza viruses are constantly changing, requiring ongoing surveillance and frequent vaccine
26 virus changesPandemics vary in severity1
virus changesPandemics vary in severity1918 pandemic was exceptionally severeA similar pandemic today would cause significant illness and deathNumber of detected emerging novel influenza viruses is increasing, requiring ongoing laboratory and epidemiologic investigations for risk assessmentsEfforts to improve pandemic readiness and re
27 sponse are underway, however, many gaps
sponse are underway, however, many gaps remain Commemoration Objectives & Resources Influenza Division Underscore continued threat of pandemic influenzaHighlight public health achievements in influenza preparedness and responseIdentify pandemic flu preparedness gaps, areas in need of further investment Empower people to act in order t
28 o decrease their risk of seasonal and pa
o decrease their risk of seasonal and pandemic influenzaImportance of vaccinationKnow the actions they can take to protect their health in the event of a pandemic (i.e., personal, organizational, and community) Communication Objectives Influenza Division Use 1918 commemoration as a platform for collective public health preparedness me
29 ssagingHowCommunication: collaborate wit
ssagingHowCommunication: collaborate with CDC and each other on creative communications activitiesEvents: incorporate 1918 messaging into conferences, meetings, press events, etc.Other creative ideas: share with us and we’ll help spread the word What Can Partners Do? Influenza Division 1918 commemoration web page Master key poi
30 ntsInfographics Digital timeline (1918 t
ntsInfographics Digital timeline (1918 to present)Support for your ideas on how to commemorate with communications, events, or in other waysCDC examples of activities include: Hosting a 1918 Symposium with Emory University, Rollins School of Public HealthIntegrating 1918 into conferences, presentations, plenary sessions, and publicati
31 ons Resources for Partners Influenza Div
ons Resources for Partners Influenza Division Contact us with: Followup questions Your 1918 events to add to our calendar Requests for CDC support, such as:Assistance connecting with other partnersCommunication resourcesCommemoration event assistanceStart the conversation we look forward to engaging with you! Share your ideas: 1918fl