Texas Pandemic Influenza Preparedness
Texas Pandemic Influenza Preparedness
Cynthia Morgan, PhD, RN
Pandemic Influenza Program Coordinator, Acting
Anita Wheeler, BSN, RN
School Nurse Consultant
AgendaAgenda
• Everything you wanted to know about pandemic influenza but couldn’t find anyone to ask
• What you can do to prepare your family
• What you can do to prepare your school
• What you can do to prepare your students & their families
Everything you wanted to know. . . Everything you wanted to know. . .
• Definitions• Examine reasons
pandemics occur• Look at the progress of
Avian H5N1 Influenza• Discuss why we are
concerned• Review current
prevention efforts• Consider the state of
the science
Avian vs Pandemic InfluenzaAvian vs Pandemic Influenza
Epidemiology of Avian flu in humansEpidemiology of Avian flu in humans
• Avian (Bird) Flu is a disease of birds
• All Avian Flu viruses are endemic in waterfowl & do not harm them
• Wild birds mix with domestic chickens in back yard farms
• Domestic chicken flocks mix in live poultry markets
• People mix with sick or dead chickens
• People catch Avian Flu
Seasonal vs Pandemic FluSeasonal vs Pandemic Flu
Seasonal• Annually• Known virus• Vaccine available
(usually)• High mortality
young & old esp. w/ health problems
Pandemic• Irregular intervals• Novel virus• No or mismatched
vaccine• High mortality in
20-50 year olds; mortality in young similar to seasonal flu
Pandemics of the 20th CenturyPandemics of the 20th Century
Year Name Strain Deaths
1918 Spanish H1N1 >50 million
(US 675,000)
1957 Asian H2N2 1 – 2 million
1968 Hong Kong H3N2 700,000
Natural hosts of influenza virusesHaemagglutinin subtype Neuraminidase subtype
H 1 H 2H 3H 4H 5H 6H 7H 8H 9
H 10H 11H 12H 13H 14H 15H 16
N 1N 2N 3N 4N 5N 6N 7N 8N 9
Composition of Seasonal VaccinesComposition of Seasonal Vaccines
• 2004 – 2005• A / New Caledonia / 99 / H1N1• A / Fugian / 02 / H3N2
• 2005 – 2006• A / New Caledonia / 99 / H1N1• A / California / 03 / H3N2
• 2006 – 2007 (recommended)• A / New Caledonia / 99 / H1N1• A / Wisconsin / 05 / H3N2
Pandemics of the 20th CenturyPandemics of the 20th Century
Year Name Strain Deaths
1918 Spanish H1N1 >50 million
(US 675,000)
1957 Asian H2N2 1 – 2 million
1968 Hong Kong H3N2 700,000
Antigenic changeAntigenic change
• Antigenic ‘drift’ occurs in HA and NA
• Associated with seasonal epidemics
• Continual development of new strains secondary to genetic mutations
• Antigenic ‘shift’ occurs in HA and NA
• Associated with pandemics
• Appearance of novel influenza A viruses bearing new HA or both HA & NA
HumanHuman virusvirus
ReassortedReassortedvirusvirus
Non-humanNon-humanvirusvirus
Mechanisms of Antigenic Shift
Direct Infection
Indirect Infection
Reassortment in humans
0
10
20
30
40
50
60
Countries with H5N1 Influenza in animals & humans
Countries with H5N1 Influenza in animals & humans
Countries with H5N1 influenza in animals
2003 2004 2005 2006Through June 15, 2006
2 1
11
2
18
5
51
10
Countries with H5N1 influenza in humans
Bird and Human Cases H5N1Bird and Human Cases H5N1
Bird Cases Human CasesJune 13, 2006
The H5N1 Flu Threat to HumansThe H5N1 Flu Threat to Humans
1. A new virus to which humans have no immunity - Yes
2. The virus causes significant human illness or death - Yes
3. The virus spreads easily from person-to-person – NO
The Avian Flu (H5N1) virus has 2 out of 3 of these today…
Why the Concern with H5N1?Why the Concern with H5N1?
• 1918 (H1N1) flu and H5N1 avian flu are the only “kissing cousins” among the 169 known avian flu viruses.
1918 Influenza Pandemic1918 Influenza Pandemic
• 20-40 million persons died worldwide, possibly more
• Death rate 25 times higher than previous epidemics
• 500-650,000 deaths in the U.S.: Ten times as many Americans died of flu than died in WW I
• The epidemic preferentially affected and killed younger, healthy persons
• The epidemic was so severe that the average life span in the U.S. was depressed by 10 years
MOST FATAL EVENTMOST FATAL EVENTIN THE LAST 300 YRSIN THE LAST 300 YRSMOST FATAL EVENTMOST FATAL EVENTIN THE LAST 300 YRSIN THE LAST 300 YRS
35
40
45
50
55
60
65
70
1900 1906 1912 1918 1924 1930 1936 1942 1948 1954 1960
Date
Age
U.S. LIFE EXPECTANCY AT BIRTH
1918 H5N1 Incident rate (0-75)1918 H5N1 Incident rate (0-75)
15 55
Case fatality rate comparison (0-75)Case fatality rate comparison (0-75)
15
55
Case fatality rate comparisonCase fatality rate comparison
Cytokine StormCytokine Storm
• Has been suggested as an explanation for the devastating nature of the 1918 flu
• Is an over reactive immune response that causes multiple organ system failure
• Evidence indicates H5N1 deaths are caused by this
Worst Case ScenarioWorst Case Scenario
Patient
Severe (1918-like)
National Texas
Number sick 150M 11.5M
Outpatient 75M (50%) 5.75M
Hospitalized 16.5M (11%) 1,265,000
ICU Care 2.5M (15%) 199,750
Ventilator 1.25M (50%) 94,780
Death 3.225M (2.15%) 247,250
Absenteeism 50% of workforce over 1 year
Pandemic wave mortalityPandemic wave mortality
Animal interventionAnimal intervention
Society during a pandemicSociety during a pandemic
• Healthcare system• Work• School• Travel• Supplies• Services
Prevention & Containment – NonpharmaceuticalPrevention & Containment – Nonpharmaceutical
• Public Health population focused measures
• Personal protective measures
• Business contingency planning
• Care of sick at home
Potential Community Measures to Decrease Transmission
Potential Community Measures to Decrease Transmission
• Travel advisories/limit travel to affected areas• Screening travelers from affected areas* • Limit large public gatherings; close schools• Encourage telecommuting• Limit availability of public transportation• Hand hygiene, respiratory hygiene/cough
etiquette• Quarantine of exposed persons*• Education to allow early identification and
isolation of cases*
* Note: Some measures may be most useful early in outbreak and with strains that are not efficiently transmitted
Evidence for use of masksEvidence for use of masks
• Limited evidence available on benefits of masks in preventing healthcare or community influenza transmission
• Use prudent at least in healthcare settings
• SARS studies have shown clear benefit mask use in healthcare setting
Influenza Antiviral Drug QuestionsInfluenza Antiviral Drug Questions
• How much supply will there be?• Will feds or state have control over
distribution decisions?
• How should it be used?
• Who should get it? • How can it be delivered? • Where does the $$ come from?
12/07?? 50 million courses
Influenza Antiviral Drug QuestionsInfluenza Antiviral Drug Questions
• How much supply will there be?• Will feds or state have control over
distribution decisions?• Where do the $$ come from?
• How should it be used?
• Who should get it? • How can it be delivered?
Influenza Vaccine QuestionsInfluenza Vaccine Questions
• When will it be available?• How much will there be?• How effective will it be?• Who will own it?• How should it be delivered? • Who should get it?• Who will pay for it?
Current methodCurrent method
• 1950’s technology• Depends on
eggs and chicks• Shortages often
due to problems here
• Requires 4-6 months for vaccine production
Pandemic wave mortalityPandemic wave mortality
New methodNew method
• Cell cultures
• Less room
• More dependable
• Requires 4-6 weeks for vaccine production
Vaccine Consumption - 2000Vaccine Consumption - 2000
Source: WHO Global Influenza Program
Vaccine Production CapacityVaccine Production Capacity
Texas Plan Challenges InHealth Systems Response Texas Plan Challenges InHealth Systems Response
• Assuring essential workers are prophylaxed and/or vaccinated
• Surge Capacity• Emergency Systems for Advance
Registration of Volunteer Health Professionals Program (ESAR-VHP)
• Availability of PPE• Disaster Mental Health• Dead bodies
Texas Plan Challenges InCommunicationTexas Plan Challenges InCommunication
• Risk Communication• Pre-event message preparation for
the public• Educating decision makers• Communication technology• Interoperability
How can you prepare?How can you prepare?
• Visit the DSHS website at: www.dshs/state/tx/us
• Follow the Pandemic Influenza link to the state’s plan.
• Appendix F “Personal Protective Strategies
How can you prepare?How can you prepare?
• Get seasonal flu vaccine• Stay informed• Stockpile supplies, food, & some $$• Talk to MD and RPh about extra
routine meds• Don’t forget pets• Have a family plan• Know your business’ continuity plan
WebsitesWebsites
• http://www.pandemicflu.gov• http://www.cidrap.umn.edu/cidrap/• http://www.cidrap.umn.edu/services/
email/change• http://www.cdc.gov/flu/pandemic/• http://www.psandman.com/indxpand.htm• http://www.dshs.state.tx.us
Planning Takes Partnerships
Planning Takes Partnerships
Considerations in School Planning
Considerations in School Planning
▶THE ROLES OF SCHOOLS IN THE COMMUNITY
▶ COMMUNICATING/COORDINATING WITH PUBLIC HEALTH/GOVERNMENT OFFICIALS
▶ UPDATING SCHOOL CRISIS PLANS
▶ LEARNING ABOUT PREVENTING INFECTIONS
▶ EDUCATING PARENTS, KIDS, STAFF
▶ INFORMING/COUNTERING DISINFORMATION
▶ MAINTAINING THE LEARNING ENVIRONMENT
Local Planning Is Critical
Local Planning Is Critical
Planning must be broad/interactive/cross-cutting/coordinated: city government, civil
agencies health departments, community centers, medical providers,
businesses, schools, private/voluntary/faith based organizations
Resources to Assist in Crisis Planning
Resources to Assist in Crisis Planning
Federal and State Resources Focus on
Local Planning
Federal and State Resources Focus on
Local Planning
Mitigation and Prevention Activities
Mitigation and Prevention Activities
►►Liaison with state/local health Liaison with state/local health officialsofficials
►Clear Roles/responsibilities of staff
►Roles of school nurses
►Assign key roles
►Review health needs of students
►Improve health activities
Pandemic Preparedness
Pandemic Preparedness
►Update crisis plans
►Educate staff, students & parents
►Account for Procedures
►Delegate Crisis Communication/Authority
Local School ConsiderationsLocal School
Considerations►Maintain operations & the learning environment
►Triage/isolate students and staff
►Use good health practices: handwashing, disinfect, etc.
►Address misinformation
►Plan for school closure
►Disseminate community information
► Utilize schools as clinics, hospitals, morgues, vaccination sites or vaccine storage sites
School Houses were turned into temporary hospitals during the 1918 Influenza Pandemic
Pandemic Recovery Period
Pandemic Recovery Period
► Allocate time for recovery
► Involve kids & parents
► Counsel
► Debrief
► Plan anniversaries
► Facility remediation
School Specific Websites
School Specific Websites
• www.itsasnap.org/snap/about.asp• www.scrubclub.org/home.php• www.cdc.gov/flu/protect/covercough.htm• www.cdc.gov/germstopper/• www.pandemicflu.gov/plan/schoolchecklist.html• www.state.gov/m/a/os/c17204.htm• www.tea.state.tx.us/pandemic_spellingsltr.html
Questions?Questions?