Pandemic Influenza Avian Influenza Seasonal Influenza

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Pandemic InfluenzaAvian InfluenzaSeasonal
Influenza

• Sandi Henley, RN, CIC
• Texas Department of State Health Services
• Health Service Region 7
• Temple, Tx

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Flu Terms Defined

• Seasonal (or common) flu is a respiratory illness
  that can be transmitted person to person. Most
  people have some immunity, and a vaccine is
  available.
• Avian (or bird) flu (AI) is caused by influenza
  viruses that occur naturally among wild birds.
  Low pathogenic AI is common in birds and causes
  few problems. Highly pathogenic H5N1 is deadly to
  domestic fowl, can be transmitted from birds to
  humans, and is deadly to humans. There is
  virtually no human immunity and human vaccine
  availability is very limited.
• Pandemic flu is virulent human flu that causes a
  global outbreak, or pandemic, of serious illness.
  Because there is little natural immunity, the
  disease can spread easily from person to person.
  Currently, there is no pandemic flu.

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A new Influenza?

• Pandemic ( worldwide) epidemic of a new
  influenza virus
• New virus ? Most people will have no immunity
• Higher disease attack rates higher death rates
  than seasonal or normal influenza

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Characteristics of the Flu

• Spread by respiratory droplets
• Can also be spread as an aerosol or on inanimate
  objects
• Contagious within a
• day or 2 of exposure
• Flu virus mutates more
• effectively than any
• other human infection.

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Past influenza pandemics

• Pandemic flu is unpredictable, like the flu virus
  itself
• 1968-69 Hong Kong flu
• 34,000 deaths in US
• 1957-58 Asian flu
• 70,000 deaths in US
• 1918-1919 Spanish flu
• gt500,000 deaths in US
• Worst case scenario

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Waves of Disease

• Pandemic ? rapid spread around world in repeating
  waves
• 1918 waves circled globe in 6-9 months

United Kingdom experience Jordan E, American
Medical Association, 1927
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1918 Spanish Influenza

• Approximately 20 Approximately 20-40 million
  people died 40 million people died worldwide, and
  over 500,000 in US. Most who died were in the
  prime of their who died were in the prime of
  their lives

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Pandemic Influenza

• Approximately every 30 years a new strain of
  human influenza appears
• No one on the planet has protection against the
  new strain
• This produces a pandemic
• Some pandemics are more severe than others

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High death rate among young adults

• Influenza pneumonia mortality per 100,000
  person, by age group

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Characteristics of the 1918Influenza

• Produced sudden and severe lung disease
• High mortality in the young and healthy
• Worldwide 35-50 infectivity. 2-5 mortality
  rate (.02 normal year).

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H5N1 Influenza

• A new strain of bird flu
• Rare but severe associated human disease (over
  50 mortality)
• Large outbreaks in domestic chickens, ducks and
  migratory birds
• Mutation of the virus over time
• Those mutations may be allowing this bird disease
  to more easily infect humans

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Characteristics of current H5N1(Avian) Influenza
in humans

• Sudden and severe lung disease
• High mortality in the young and healthy
• Multi-organ failure

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Worrisome Changes

• New animal species becoming infected with H5N1
• Ducks asymptomatically shed virus
• Mutations on the H receptor allowing greater
  affinity for humans (similar mutations to those
  seen in the 1918 virus)
• Recent person to person transmission
• More cases more opportunity for mutation

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Human to human spread

• The ability of H5N1 to spread human to human in a
  sustained fashion is the sign of an impending
  pandemic
• WHO, CDC, varying estimates of human to human
  spread 3 to 30 instances recorded.

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What are the concerns?

• Extremely disruptive
• Worker absenteeism
• Lost productivity
• Unable to get/transport supplies raw materials
• Uncertain infrastructure
• Fuel utilities telecom info technology
• Public safety personnel public services
• Food medicine suppliers
• Increased demands on health care infrastructure
  workforce
• Reduced tourism, travel, entertaining, hotels
• No help from other areastheyre affected

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• Does
• H5N1
• avian influenza

?

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Pandemic influenza
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All strains of influenza begin inbirds
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H5N1 avian influenza

• H5N1current epidemic avian flu strain
• Highly pathogenic avian influenza (HPAI)
• Continuous circulation in Asia since 2003
• Historically unprecedented avian pandemic
• Magnitude duration of pandemic in birds
• Virus is changing

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H5N1 avian influenza(Nations with confirmed
cases as of November 12, 2007)
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H5N1 avian influenza

• Before 1997, H5 influenza virus never infected
  humans
• Now
• Human cases from close exposure to ill birds
• No sustained human-to-human transmission
• Few cases, but high fatality (gt50)
• 229 cases 131 deaths, World Health
  Organization, July 4, 2006
• Treatment primarily supportive
• Antivirals (Tamiflu Relenza)

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Is H5N1 a pandemic virus?

• 3 requirements
• v Novel strain - new H /or N subtype
• v Causes significant disease in humans
• NO Consistent human-to-human transmission
• Avian H5N1 influenza virus is not a pandemic
  virus - but it might become one

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Cumulative Number of Confirmed Human Cases of
Avian Influenza A/(H5N1)
November 12, 2007
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Stage ONew Domestic Animal Outbreak in At-Risk
Country

• Goals
• Provide coordination, support, technical guidance
• Track outbreaks to resolution
• Monitor for reoccurrence of disease
• Actions
• Support coordinated international response
• Prepare to deploy rapid response team and
  materiel
• Offer technical assistance, encourage information
  sharing
• Policy Decisions
• Deployment of countermeasures

WHO Phase 1 or 2 Inter-Pandemic Period
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Stage 1Suspected Human Outbreak Overseas

• Goals
• Rapidly investigate and confirm or refute
• Coordination and logistical support
• Actions
• Initiate dialogue with WHO
• Deploy rapid response team
• Amplify lab-based and clinical surveillance to
  region
• Prepare to implement screening and/or travel
  restrictions from affected area
• Policy Decisions
• Pre-positioning of U.S. contribution to
  international stockpile assets
• Use of pre-pandemic vaccine

WHO Phase 3 Pandemic Alert Period
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Stage 2Confirmed Human outbreak Overseas

• Goals
• Contain outbreak and limit potential for spread
• Activate domestic medical response
• Actions
• Declare Incident of National Significance
• Support international deployment of
  countermeasures
• Implement layered screening measures activate
  domestic quarantine stations
• Prepare to limit domestic ports of entry
• Prepare to produce monovalent vaccine
• Policy Decisions
• Contribution to countermeasures for affected
  region
• Entry/exit screening criteria isolation/quarantin
  e protocols
• Diversion of trivalent vaccine production to
• monovalent
• Revise prioritization and allocation of pandemic
• vaccine and antiviral medications

WHO Phase 4 or 5 Pandemic Alert Period
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Stage 3Widespread Outbreaks Overseas

• Goals
• Delay emergence in North America
• Ensure earliest warning of first case(s)
• Prepare domestic containment and response
  mechanisms
• Actions
• Activate domestic emergency medical personnel
  plans
• Maintain layered screening measures at borders
• Deploy pre-pandemic vaccine and antiviral
  stockpiles divert to monovalent vaccine
  production
• Real-time modeling heighten hospital-based
  surveillance
• Prepare to implement surge plans at Federal
  medical facilities
• Policy Decisions
• Prioritize efforts for domestic preparedness and
  response

WHO Phase 6 Pandemic Period
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Stage 4First Human Case in North America

• Goals
• Contain first cases in North America
• Antiviral treatment and prophylaxis
• Implement national response
• Actions
• Ensure pandemic plans activated across all levels
• Limit non-essential domestic travel
• Deploy diagnostic reagents for pandemic virus to
  all laboratories
• Continue development of pandemic vaccine
• Antiviral treatment and targeted antiviral
  prophylaxis
• Policy Decisions
• Revision of prioritization and allocation scheme
  for pandemic vaccine

WHO Phase 6 Pandemic Period
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Stage 5Spread Throughout the United States

• Goals
• Support community response
• Preserve critical infrastructure
• Mitigate illness, suffering, and death
• Mitigate impact to economy and society
• Actions
• Maintain overall situational awareness
• Evaluate epidemiology provide guidance on
  community measuresDeploy vaccine if available
  prioritization guidance
• Sustain critical infrastructure, support health
  and medical systems, maintain civil order
• Provide guidance on use of key commodities
• Policy Decisions
• Federal support of critical infrastructure and
  availability of key goods and services
• Lifting of travel restrictions

WHO Phase 6 Pandemic Period
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Bottom Line

• The safest place to be during an Influenza
  pandemic is at home

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Arguments for Closing Schools

• Children are the primary source of influenza in
  the household
• They are in very close contact at school
• Children are more susceptible to the flu
• They shed more virus and for longer period of
  time.
• Historical evidence of mitigation (school closure
  and child immunizations) affecting community
  transmission

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Secondary consequencesof school closures

• Economic impact to families
• Economic impact to society
• Disruption of school meal programs
• Disproportionate burden on vulnerable populations
• Need to weigh these against consequences of an
  unmitigated pandemic

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PreparednessWhere do we stand?

• No ready-to-use H5N1 vaccine
• Antivirals
• Limited supply of Tamiflu
• Production in next 10 years will treat only 20
  of world population
• Unclear if Tamiflu will work for treatment
• Not enough available to use for prevention

WHO Phase 4 or 5 Pandemic Alert Period
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Preparedness strategies

• Heightened surveillance
• Immediate response at 1st sign of an outbreak
• Respond to limit and confine outbreak
• Buy time to make vaccine and take other actions
• Applies to both humans and birds

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Control strategies

• Isolation quarantine
• Non-pharmaceutical
  approaches
• Cough hand hygiene
• Travel restrictions
• Social distancing
• Eliminate mass gatherings
• Close schools, theaters, etc.
• General public wears masks

www.pbs.org/wgbh/amex/influenza/
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Next Steps

• Assume schools will close early in a pandemic
• Need to identify vulnerable populations
• Need to assess needs for those populations
• Need to prepare for distance learning over a
  sustained period of time
• Need to plan for the needs of your staff

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What should you be doing?Prepare your family

• Store a two week supply of food.
• Have nonprescription drugs and other health
  supplies on hand.
• Teach your children and model the behavior
• To wash hands frequently with soap and water
• To cover coughs and sneezes with tissues
• To stay away from others as much as possible if
  they are sick
• To stay home from work and school if sick.
• Talk with family members and loved ones about how
  they would be cared for if they got sick, or what
  will be needed to care for them in their home.

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Reducing the Effects

• Encourage hand and respiratory hygiene for all
• Seasonal influenza Vaccine
• Policies that encourage ill people to stay home
• Adopt strong reporting and surveillance practices
  during seasonal flu

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Why?

• A strong network of prepared people, families,
  and organizations is vital to a communitys
  successful response to pandemic influenza.

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What else should you do?

• Get flu shots every year to your entire staff.
• Develop adequate stockpiles in case of supply
  chain disruption.
• Plan for personnel decreases and novel ways to
  accomplish your objectives.

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Interim Pre-pandemic Planning Guidance Community
Strategy for Pandemic Influenza Mitigation in the
United States
CDC guidelines on actions, designed primarily to
reduce contact between people, that community
government and health officials can take to try
to limit the spread of infection should a
pandemic flu develop. Appendixes 5, 6, and 7
contain information for childcare programs,
elementary schools, and colleges and
universities.

• http//www.pandemicflu.gov/plan/community/commitig
  ation.html