Avian Influenza: Bird of a Different Feather A Primer to Pandemic Influenza Preparedness
Office of Surveillance and Public Health PreparednessHouston Department of Health and Human Services
Agenda • Medical overview
• Business continuity planning
• What HDHHS is doing
Medical Overview
Types of Influenza• Seasonal Influenza: Annual event (type A and type B strains)
– 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 Influenza: flu in bird populations (wild and domestic)– Avian flu is caused by influenza viruses that occur naturally among
wild birds. The H5N1 type A variant is deadly to domestic fowl and can be transmitted from birds to humans. There is no human immunity and no vaccine is available.
• Pandemic Influenza: a new type A strain that causes serious illness and death, and spreads easily from person to person worldwide – 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.
Seasonal Influenza • Viral Infection of the respiratory tract
• Occurs seasonally
• Three types A, B and C
• Particular nomenclature
• Originates in wild aquatic birds
• Evades immunity through drift and shift
Big dropletsfall on peoplesurfaces bed clothes
Courtesy of CDC
Pathology of Influenza Infection
1. Binding to Sialic Acid 2. Entering Cell 3. Replication 4. Release From Cell
Clinically Relevant Influenza Viruses
Type A Potentially severe illness
Epidemics and pandemics
Rapidly changing
Type B Usually less severe illness
Epidemics
More uniform
Type C Usually mild or asymptomatic illness
Minimal public health impact
Antigenic Drift
RNARNA
HemagglutininHemagglutinin
NeuraminidaseNeuraminidaseAntibodiesAntibodies Sialic AcidSialic Acid
Antigenic Shift
Avian Influenza • Influenza A subtype
• Designated H5N1
• Related to bird migratory patterns, smuggling and travel
• Presence of the virus does not signal avian pandemic
• Human infections related to close contact
• No evidence of sustained human-to-human transmission
Pandemic Influenza • Global outbreak of disease that occurs when a new
influenza A virus appears or “emerges” in the human population
• May be of avian origin
• Caused by new subtypes that have never circulated among people, or by subtypes that have not circulated among people for a long time
• Characterized as highly contagious, spreading from person to person, worldwide and causes social and economic disruption
• Occurs approximately three times every century
20th Century Influenza Pandemics
H3N2
1920 1940 1960 1980 2000
H1N1 H1N1
H2N2
1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”
20-40 million deaths 1 million deaths 1 million deaths
Influenza Statistics • 5% to 20% of population every year
• >200,000 hospitalizations due to complications
• 10,000 deaths per epidemic are common
• 20,000 to 40,000 deaths during recent epidemics
MMWR. 2000;49:1.
Economic Cost of Influenza• Total annual costs of influenza are estimated at $14.6
billion in the US
• 10%: Direct costs of increased medical care
• 90%: Indirect costs (lost productivity, employee absenteeism)
American Lung Association. Fact Sheet – Influenza. Available at http://www.lungusa.org/diseases/influenza_factsheet.html.
Surveillance• Three systems coordinated by the CDC
– Pneumonia and influenza deaths
– Influenza-like illnesses
– Physician reporting
• Syndromic surveillance
Pneumonia and Influenza Mortality in 122 US Cities
CDC. 1999-2000 influenza season summary. Available at: http://www.cdc.gov/ncidod/diseases/flu/bigpi.htm.
Signs and Symptoms of Influenza• Sudden fever, usually over 100°F
• Muscle aches and pains
• Nasal congestion
• Dry cough
• Chills and/or sweats
• Headache
• Sore throat
• Potentially severe, persistent malaise
• Substernal soreness, photophobia, and ocular problems
Nasopharynx
Trachea
Risk Factors for Influenza Complications (CDC)• Age 50 yrs
• Residence in nursing home/chronic care facilities
• Chronic pulmonary disease (eg, asthma, COPD)
• Chronic cardiovascular disease
• Chronic metabolic diseases, renal dysfunction, hemoglobinopathy
• Immunosuppression
• Long-term aspirin therapy (ages 6 mos-18 yrs)
• Second or third trimester pregnancy
MMWR. 2000;49:6-7.
Prevention and Treatment
• Vaccination
• Antivirals
Inactivated Influenza Virus Vaccine
Content Updated yearly to protect againstanticipated strains, consists of type A (2)
and type B (1)
Process Grown in embryonated chicken eggs and formalin inactivated
Live Attenuated Influenza Vaccine (LAIV) • Licensed for use in the U.S. begins in 2003
• The protective mechanisms are not completely understood
• Children and adults can shed vaccine viruses for >2 days after vaccination
• Advantages include:
– Induce a broad mucosal and systemic immune system
– Acceptability of an intranasal route of administration
Influenza Virus Vaccine• Efficacy
– Varies with age and immunocompetence
– Depends on match between projected vs actual strains
• Children/Teens– Stimulates high HA-inhibition antibody titers
– Prevents infection
• Elderly– Produces lower HA-inhibition antibody titers
– May not eliminate URTI susceptibility
– May reduce LRTI morbidity/mortality
MMWR. 2000;49:5.
Effectiveness of Influenza Vaccine• Most effective (70%-90%) in preventing illness in persons
aged <65 yrs
• 30%-40% in preventing illness in frail elderly
• Overall significantly protects against the severe complications of influenza: hospitalizations and death
Get the Influenza Vaccine• October through November in the Fall
• Only one shot is needed for older children and adults
• Two does may be required for unvaccinated children aged less than nine years
Who Should Receive Influenza Vaccine (CDC) • Persons aged 50 yrs
• Persons at increased risk (age 6 mos)
• Hospital and outpatient employees
• Nursing home employees with patient contact
• Home health care providers working with high-risk persons
• Household members of high-risk persons
• Pregnant women in 2nd or 3rd trimester
• Persons desiring to avoid influenza infection
MMWR. 2000;49:6-7.
Side Effects of the Influenza Vaccine• Soreness at injection site (common, mild, and transient)
• Systemic and febrile reactions, esp in young children (infrequent)
• Immediate hypersensitivity reactions to egg protein (rare)
• Guillain-Barré syndrome (rare)
MMWR. 2000;49:11-12.
Who Should Not Receive the Vaccination • An allergic reaction to chicken eggs (welts, tongue
swelling, difficulty breathing, loss of blood pressure, etc.)
• A previous serious reaction to an influenza shot
• A rare paralytic disorder called Guillain-Barré Syndrome which was thought to be cause by a pervious influenza shot
• A current illness with fever
Treating Influenza with Antivirals
Influenza A Influenza A and B
•Amantadine
•Rimantadine
•Zanamivir
•Oseltamivir Phosphate
What To Do If You Develop Influenza • If symptoms present less than two days, discuss specific
antiviral treatment with your physician
• For fever and muscle aches:
• Aspirin if you are 18 years of age or older
• Or Acetaminophen
• Or Ibuprofen
• Liquids and nutrition
• Rest
• See your physician if symptoms worsen
Prevention: Simple Steps• Vaccine
• Hygiene
• Public Health Measures
1. Cover Your Cough.
2. Wash Your Hands.
3. Get your seasonal flu shot.
4. Keep all your immunizations current.
Business Continuity Planning
Goals• Containment of disease
• Reduction of the impact by controlling the spread of disease
• Maintenance of essential services
People
Information
Operation
Customers
Organization
Reputation
Evaluation• Identification of essential business activities
• Mitigation of business / economic disruptions
• Minimizing illness
Strategy• Communication
• Containment
• Continuity
Communication
Programs
Materials
Strategies
Communication Plan
Internal Communication / Education
Insurers
Health Plans
Other Business Entities
PH Agencies
Healthcare Providers
External Coordination
Containment • Restrict workplace entry
• Emphasize personal hygiene
• Social distancing
• Manage staff
Cover Your Cough • Cover nose and mouth when sneezing
• Use a tissue and dispose once used
• Keep hands away from nose, mouth and eyes
• Ask people to do the same
Hand Washing • The most important action can do
• Soap and water (10-20 seconds)
• Alcohol-based sanitizer (15 seconds)
Work Place Disinfectant• Influenza viruses inactivated by alcohol or chlorine
• Surfaces touched by hands should be cleansed daily
• 1:5 dilution of hospital grade bleach
• Granular chlorine
• 70% isopropyl alcohol
• 60% ethyl alcohol
Social Distancing• Avoid face-to-face meetings
• Avoid congregations
• 3 Feet rule
• Ghost shifts
Manage Staff• Encourage, manage and track influenza vaccination
• Establish healthcare resources
• Flexible scheduling
• Encourage working from home
• Oversee travel
Continuity• Identification of core people and skills
• Business planning for absence
• Knowledge management
• Communication
Identification of Core People and Skills• What are the essential parts of the business
• Who are the core people required to keep the business running
• What are the core skills required
• Who are the back-ups
• Who will manage the pandemic component
Business Planning for Absence• What is the minimal number of staff required
• Where can additional staffing be found
• Can operations be shifted
• Plan for essential incidentals: food, water, gas
Knowledge Management• Develop a plan
• Key operating and emergency management information needs to be readily accessible
• Implement exercises and drills to practice
• Test plan regularly
Steps to Take During a Pandemic – Early Stages
hand sanitizers
surgical gloves
masks
disease transmission
hand hygiene
cough and sneeze etiquette
symptoms
policies
contact info
1. Provide 2. Remind 3. Implement
travel restrictions
4. Track
illness pattern
5. Inform
disease pattern
official recommendations
During a Pandemic • Implement flexible work schedules and telecommunicating plans
• Continually monitor supply chain
• Continually monitor ability to meet contractual commitments
• Continually re-stock hand sanitizers, masks, and gloves
• Follow directions of public health authorities
• Monitor CDC, WHO, and HDHHS official websites
• Make work place vaccination available if possible
• Communicate with customers, suppliers and employees
• Assess financial impact and communicate with markets
Maintenance of Essential Business Activities• Identification of core people and core skills
• Business planning for absence (for peak rate of 30-60%)
• Communication
• Knowledge management
• Short, medium and long term planning
• Reasonable risks to employees and others
• Deciding whether a workplace should stay open or close
Summary • Educate key stakeholders
• Develop and empower multi-disciplinary team
• Design a strategic comprehensive preparedness plan
• Implement surveillance program
• Execute with flexibility and responsiveness
Illness Surveillance
Business Operations
Facility Preparedness
Education & Communication
What HDHHS is Doing
Overview of Pandemic Influenza Preparedness • “The Plan” is to provide guidance for HDHHS and partners
on how to respond during three periods (WHO)
– Pre pandemic period
– Inter pandemic period
– Pandemic alert period
WHO Pandemic Phases
Inter-Pandemic Period Phase 1: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in humans, the risk of human infection or disease is considered low Phase 2: No new influenza virus subtypes have been detected in humans. However a circulating animal influenza virus subtype poses a substantial risk of human disease
Pandemic Alert Period Phase 3: Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact. Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk).
Pandemic Period Phase 6: Pandemic – increased and sustained transmission in the general population.
Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO as of 16 June 2006
Country
2003 2004 2005 2006 Total
cases deaths cases deaths cases deaths cases deaths cases deaths
Azerbaijan 0 0 0 0 0 0 8 5 8 5
Cambodia 0 0 0 0 4 4 2 2 6 6
China 0 0 0 0 8 5 11 7 19 12
Djibouti 0 0 0 0 0 0 1 0 1 0
Egypt 0 0 0 0 0 0 14 6 14 6
Indonesia 0 0 0 0 17 11 32 26 49 37
Iraq 0 0 0 0 0 0 2 2 2 2
Thailand 0 0 17 12 5 2 0 0 22 14
Turkey 0 0 0 0 0 0 12 4 12 4
Viet Nam 3 3 29 20 61 19 0 0 93 42
Total 3 3 46 32 95 41 83 53 227 129Total number of cases includes number of deaths.WHO reports only laboratory-confirmed cases.Latest data available online at:http://www.who.int/csr/disease/avian_influenza/country/en/
Emphasis of Pandemic Influenza Preparedness • Preventative measures
– Education
– Healthy practices
– Good hygiene
– Vaccination
Key Elements of Pandemic Influenza Preparedness • Planning, command and coordination
• Surveillance, investigation and protective public health measures
• Laboratory testing
• Infection control & containment
• Healthcare and emergency response
• Communication and public outreach
• Maintenance of essential business activities
What HDHHS Has Done • Planning command and control
• Surveillance, investigation and protective public health measures
• Laboratory testing
• Infection control & containment
• Healthcare and emergency response
Implications of Pandemic Influenza
• Shortage of Available Workers at ALL levels
• Disruptions in Supply Chains
• Behavioral Changes to Prevent Spread
• Increased Demand for Certain Services and Products
• Decreased Production
• Increased Illness and Loss of Life
State Normal School volunteers preparing food during 1918 influenza pandemic
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