Conference sponsored by:

Center for Biosecurity of UPMC

Deutsche Bank

The Contingency Planning Exchange

New York City's Avian Influenza Response Plan
Isaac Weisfuse, M.D., M.P.H., Deputy Commissioner, New York City Department of Health and Mental Hygiene

Speaker biography  |  Slide thumbnails  |  Slide show  |  Video

What I wanted to do was talk about some [of our] planning assumptions in New York City, what our preparedness plans are like, and what we feel that businesses, at least in New York City, can do. Some of the information on businesses may not be necessarily translatable to other cities, so if you are from another city, it may be something that you need to look into with your local or state or provincial health department.

In looking at the potential impact on the City of New York, we have used some software that's been provided, called FluSurge, and we can debate the attack rates for a long time, but we tend to look at it in intervals, if you will. So we're looking at attack rates of between 15% and 35%, which would mean somewhere between 1.2 and 2.8 million folks in the City of New York infected, with the corresponding intervals or spread of outpatient visits, 60,000 to 280,000 hospitalizations and 12,000 to 141,000 deaths.

Again, we could really debate a lot of these assumptions, but I think this gives you a sense of the kind of assumptions that we are going on. So we're talking about a true public health emergency by any stretch of the imagination in the city.

We've also had some other planning assumptions, and I want to go down to the last bullet. There is just no way that we can think of to keep a pandemic from coming to and being spread in New York.

We don't think that that is realistic, at this stage in our knowledge and at this stage in the amount of pharmaceuticals or countermeasures there are to keep it from coming from New York. Again, at this stage -- and it may be different a year from now -- we don't think the vaccine will be likely for six months or more, and when a vaccine is available we'll probably need two doses [for each vaccinee].

As you've heard before, there's a limited supply of antivirals in the United States, both in the strategic national stockpile and in the private sector, and that these scarce resources, as was alluded to before, will likely dictate that the product will be available only for treatment and not for prophylaxis.

And that is an issue that local and state health departments wrestle with a lot and then finally, and again this is what's been alluded do, is that it will be very important. Everything that public health can do is dependent on the maintenance of potential services.

So, public safety, the medical system, and the socioeconomic system have to be up and running for us to have really any kind of major impact on the course of such a pandemic. So it is a public health emergency, but it really is a societal emergency, and we need these other factors that keep our city safe and distribute goods to be operating as well.

Now, in preparing for this talk, I realized that a lot of the work that we've been doing here in the City of New York on public health emergency preparedness in the last couple years actually really does apply to avian flu. So let me give you a couple of examples.

I'll go through some of them in a little bit more detail. But we have worked very hard on creating a cutting edge surveillance system in the city to alert us at the earliest possible moment when there is a spread of a disease, whether it's a naturally occurring disease or whether it's an attack from a bioterrorism agent. And I'll give you some examples of that.

We've worked very hard at increasing, since our anthrax attacks in 2001, our laboratory capacity and we recently opened a 20,000 square foot biosafety level III laboratory that we didn't have before. It greatly augments our capabilities in that respect.

Last year, with the flu vaccine scarcity, we operated flu PODs. PODs are points of distribution sites, and we did that on purpose. Well, first of all, we had flu vaccine scarcity, so that we didn't do on purpose, so let me correct that. But we decided to put together these POD sites because if we ever had to do the real thing in a pandemic flu situation, we wanted to learn from that experience.

And we really did a lot along those lines. We gave out in excess of 30,000 flu vaccines. Many were to elderly people. We had people in wheelchairs, people on stretchers coming to our sites and that was invaluable [in terms of testing the capabilities of the PODs]. In addition to giving out a good service, that was a valuable experience in dealing with many vulnerable populations.

I'll talk a little bit about provider outreach and community outreach. We have a lot of backups. I've sort of termed this "backup planning," and I guess I was influenced by Hurricane Katrina. But we have a lot of backup plans in case facilities or equipment go down, so that we can continue on in our work.

And then we've worked very [closely] in the last couple years with the 70 or so acute care hospitals in New York City to make sure that we have good communication systems with them, and that we are furthering their work in getting ready for a pandemic or a bioterrorism event or some sort of other terrorist event.

Along those lines, the New York State Department of Health has created a software program called HERDS, which allows us a way to assess what's going on in the hospitals, minute by minute or day by day, in terms of numbers of beds vacant, number occupied, staff that are there, medical equipment, etc. We've practiced that and drilled it a number of times with our New York City hospitals.

Let me give you a sense more of the surveillance. This is a slide that I think gives you a feel for what we call syndromic surveillance. This is something that we have throughout the city, and we're looking to come up with the earliest indication of a problem in the city and each day we get downloads from hospitals to help us look at that.

So, in this slide, rather than waiting for somebody who's really sick with that severe illness, that red graph, we hope to identify people at the very onset of their symptoms so that we can identify problems in the city as quickly as possible. And we have syndromic surveillance systems for emergency department visits, for ambulance runs. We have an agreement with large pharmaceutical companies to look at their sales, and we look at employee absenteeism in several places as well.

This is a little bit of an old slide, but it gives you a sense of our coverage. Right now, probably 80% of all ED visits in the city are monitored on a daily basis, so we get an electronic download every day and can look at that. We do that seven days a week to try to see what's going on in the city and the hope is that this will help us identify pandemic flu.

Now, it works in the sense that every year New York City, like every place else in the United States, has an influenza epidemic and usually syndromic surveillance efforts from the emergency departments are the first to pick up any indication that flu is in the city. So we have several years' worth of experience in looking at flu ED visits in the city, and our hope is to find out, as early as possible, if there is any kind of problem with pandemic flu in the city.

We also rely very heavily on traditional surveillance. With traditional surveillance, we say that our physicians are our eyes and ears, and just to point that out, in 2001 all the anthrax cases that were reported in New York City came through traditional surveillance. So that's an important point that we're working on as well.

A couple of other generic foundations. One is that we have tried very hard to integrate mental health approaches into all of our work. We know from Hurricane Katrina, from PTSD following the World Trade Center disaster, that mental health is clearly a critical part of what a public health response should be.

We work very hard with some of the mental health providers, for example, in the city, so that they can feel prepared to take care of their vulnerable populations at the time of a crisis, so the most vulnerable in our society are not left adrift in terms of having people who can take care of them, as an example of one of our mental health approaches.

We've done a lot of work on communications. We have done a lot of media and risk communication training.

We have something called the "Health Alert Network" for providers that is an electronic messaging system that is open to all New York State licensed professionals who register with us and any company who has an employee health program. It should be a requirement that if you have any of those folks, licensed professionals, that they be on our HAN. That should be something that you today. I'll give you some instructions about how to do that.

We've also deepened our ties with the ethnic media. You know that New York City is a city of immigrants. There are many languages spoken, and we worked very hard to extend our roots into many different communities to get messages out. So it's not just the mainstream media that we try to work on.

We've also done a very good job at trying to develop a contact mailing list, which is growing every day, where we try to get messages out to people on a variety of health issues and that would be of use in case there was an emergency.

I'm not going to go through all the specific avian flu surveillance mechanisms we have, but just getting a little bit more specific on avian flu, we have a couple things going, listed here. Some of it, that nontraditional surveillance that I talked about, that's located on the bottom, to help us pinpoint if avian flu is in the city. You know, a pandemic doesn't necessarily mean that it'll be avian flu, but any increase in flu activity in the city, so we have some specific issues around avian flu.

We've also worked, as I said, very hard with our hospital systems to look at surge capacity, and we have plans and ideas. We recently had a tabletop on September 9 with all the hospitals in the city, talking about avian flu and talked about the "creation of beds" to be able to deal with that surge in hospitalizations.

I won't go on in great detail on it, but obviously one of the issues will be communication with the public: When to go to the hospital, when not to go to the hospital, so we don't overburden the hospital system. We have a superb medical care system in the City of New York, but we need to protect them and make sure they're dealing with appropriate patients.

We also worked with our Office of Chief Medical Examiner. There have been allusions to great, large mortality rates, and I've talked to them about their service plans for dealing with remains of people who die from pandemic flu, and that plan is in place.

Under discussion are issues such as Tamiflu policies, community controls, and city respirator capacities. We're going to be looking at what our capacity is for respirators and ventilators in the city and whether we should augment that capacity. Because, if you look at the clinical literature, from people who died in Southeast Asia, many of these folks died of an overwhelming immunologic reaction and would need to be supported throughout their hospitalization. And one way to do that would be important, would be respirators, but if you run out of respirators you lose your ability to do that.

Let talk a little bit about businesses: You know clearly I said that one issue is the essential services that businesses provide, and we're talking kind of basic here, but food, water, electricity, fuel are all critical for us getting our job done, for the hospitals getting their job done.

I'm not a businessman, and maybe this is something all businesses at this point do, but this issue of the just-in-time inventory control and some of the essentials are something that businesses really need to look at to keep our city running.

What should you tell your employees? Well, from my perspective, if your employees are residents or work in the City of New York, the better your employees are doing, the better I'm doing. So one suggestion is dealing with telecommuting, sort of decreasing the burden on the transportation infrastructure, make sure that you have the IT infrastructure for telecommuting.

In SARS, we read that some businesses split essential employees into home and work teams, so if one team had a problem, the other team could come in. And obviously online transactions are something that we think is very important for some of these essential services.

I get my pharmaceuticals delivered to me by mail after I register online. Hey, I'd like to be able to offer that to the entire City of New York for anybody with pharmaceutical needs. I mean, we're not stuck in 1918 is my mantra. 1918 was bad, but there's been significant progress on a number of fronts, and we ought to figure out what that progress is and use it to our advantage.

In terms of public health and your business, obviously keeping your employees well informed, and reinforcing during a time of a pandemic those really boring messages of public health, about covering your mouth and nose when you sneeze or cough. I talked about the HAN, the Health Alert Network that your employee health director should be required to sign up with our HAN, and there are HAN equivalents in every state.

We also have a Medical Reserve Corp. That is something that we'd like people to look into as well, and you can access both at the website shown, and I believe this will be put up as well.

Finally, we have a number of public/private initiatives through our New York City Office of Emergency Management. A number of them are here. One is something on the bottom called "Ready New York" that should be in the hands of every one of your employees. It has to do with emergency preparedness for people and for families.

We have programs to allow people to get credentialing so they can go into places where they need to go and also, information about current events in the city through corp.net.

Just a reminder: We get flu every year. We have an influenza outbreak every year. That's the normal state of events. If there's enough vaccine -- and the vaccine supply is a little bit iffy today -- but it's a good time, if you're having flu vaccination sessions, to also educate your folks about avian flu.

I realize I went through very fast. I hope I kept to the time limit, and I will be around to answer questions. If something comes up, that we run out of time, I'd be happy to answer questions by e-mail. Thank you.

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