Avian Influenza: Bird of a Different Feather A Primer to Pandemic Influenza Preparedness

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Avian Influenza Bird of a Different Feather A
Primer to Pandemic Influenza Preparedness

• Office of Surveillance and Public Health
  Preparedness
• Houston Department of Health and Human Services

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Agenda

• Medical overview
• Business continuity planning
• What HDHHS is doing

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Medical Overview
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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.

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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

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Pathology of Influenza Infection
3. Replication
1. Binding to Sialic Acid
2. Entering Cell
4. Release From Cell
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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

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Antigenic Drift
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Antigenic Shift
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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

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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

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20th Century Influenza Pandemics
1918 Spanish Flu
1957 Asian Flu
1968 Hong Kong Flu
20-40 million deaths
1 million deaths
1 million deaths
H3N2
H2N2
H1N1
H1N1
1920 1940 1960 1980 2000
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Influenza Statistics

• 5 to 20 of population every year
• gt200,000 hospitalizations due to complications
• 10,000 deaths per epidemic are common
• 20,000 to 40,000 deaths during recent epidemics

MMWR. 2000491.
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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/di
seases/influenza_factsheet.html.
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Surveillance

• Three systems coordinated by the CDC
• Pneumonia and influenza deaths
• Influenza-like illnesses
• Physician reporting
• Syndromic surveillance

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Pneumonia and Influenza Mortality in 122 US Cities
CDC. 1999-2000 influenza season summary.
Available at http//www.cdc.gov/ncidod/diseases/f
lu/bigpi.htm.
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Signs and Symptoms of Influenza

• Sudden fever, usually over 100F
• 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

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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. 2000496-7.
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Prevention and Treatment

• Vaccination
• Antivirals

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Inactivated Influenza Virus Vaccine

• Content Updated yearly to protect
  against anticipated strains, consists of type A
  (2) and type B (1)
• Process Grown in embryonated chicken eggs and
  formalin inactivated

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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
  gt2 days after vaccination
• Advantages include
• Induce a broad mucosal and systemic immune system
• Acceptability of an intranasal route of
  administration

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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. 2000495.
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Effectiveness of Influenza Vaccine

• Most effective (70-90) in preventing illness in
  persons aged lt65 yrs
• 30-40 in preventing illness in frail elderly
• Overall significantly protects against the severe
  complications of influenza hospitalizations and
  death

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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

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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. 2000496-7.
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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. 20004911-12.
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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

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Treating Influenza with Antivirals
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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

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Prevention Simple Steps

• Vaccine
• Hygiene
• Public Health Measures
• Cover Your Cough.
• Wash Your Hands.
• Get your seasonal flu shot.
• Keep all your immunizations current.

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Business Continuity Planning
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Goals

• Containment of disease
• Reduction of the impact by controlling the spread
  of disease
• Maintenance of essential services

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Evaluation

• Identification of essential business activities
• Mitigation of business / economic disruptions
• Minimizing illness

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Strategy

• Communication
• Containment
• Continuity

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Communication
Internal Communication / Education
External Coordination
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Containment

• Restrict workplace entry
• Emphasize personal hygiene
• Social distancing
• Manage staff

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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

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Hand Washing

• The most important action can do
• Soap and water (10-20 seconds)
• Alcohol-based sanitizer (15 seconds)

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Work Place Disinfectant

• Influenza viruses inactivated by alcohol or
  chlorine
• Surfaces touched by hands should be cleansed
  daily
• 15 dilution of hospital grade bleach
• Granular chlorine
• 70 isopropyl alcohol
• 60 ethyl alcohol

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Social Distancing

• Avoid face-to-face meetings
• Avoid congregations
• 3 Feet rule
• Ghost shifts

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Manage Staff

• Encourage, manage and track influenza vaccination
• Establish healthcare resources
• Flexible scheduling
• Encourage working from home
• Oversee travel

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Continuity

• Identification of core people and skills
• Business planning for absence
• Knowledge management
• Communication

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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

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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

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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

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Steps to Take During a Pandemic Early Stages
1. Provide
2. Remind
3. Implement
4. Track
5. Inform
hand sanitizers surgical gloves masks
disease transmission hand hygiene cough and
sneeze etiquette symptoms policies contact info
travel restrictions
illness pattern
disease pattern official recommendations
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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

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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

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Summary

• Educate key stakeholders
• Develop and empower multi-disciplinary team
• Design a strategic comprehensive preparedness
  plan
• Implement surveillance program
• Execute with flexibility and responsiveness

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What HDHHS is Doing
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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

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WHO Pandemic Phases
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Cumulative Number of Confirmed Human Cases of
Avian Influenza A/(H5N1) Reported to WHO as of 16
June 2006
Total 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/

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Emphasis of Pandemic Influenza Preparedness

• Preventative measures
• Education
• Healthy practices
• Good hygiene
• Vaccination

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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

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What HDHHS Has Done

• Planning command and control
• Surveillance, investigation and protective public
  health measures
• Laboratory testing
• Infection control containment
• Healthcare and emergency response

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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

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State Normal School volunteers preparing food
during 1918 influenza pandemic
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Thank You !