Intro to Influenza

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Pandemic Influenza Larimer County Community
Leaders Awareness Meeting Dec. 6, 2005
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Larimer County in 1918

• County population about 27,000
• Fort Collins population 8,700
• Loveland population about 5,000

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Social Environment in 1918

• Most residents involved in agriculture, directly
  or indirectly
• World War I was the major news story
• There was rationing of coal, fuel, food and other
  items needed for war effort
• Red Cross was very active in community,
  supporting war effort

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Outbreak begins in military training camps

• Deaths occurring in training camps in East were
  reported in local newspapers
• Numerous Larimer County enlistees/ draftees were
  among the fatalities (4 from Camp Dix, NJ in 1
  wk.)

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Spreading to Civilians

• Larimer County residents were aware of growing,
  alarming deaths among civilians in Eastern
  cities
• First cases in CO in Boulder army trainees on
  College campus. (First cases in FC at Ag College)

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Flu shut down schools and businesses

• Loveland schools closed on Oct. 8
• Fort Collins closed schools on Oct. 10
• They would not reopen until Dec. 30

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1918 Flu killed young adults

• Highest number of deaths were in the in late
  teens through the mid 30s

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By the end of the outbreak

• Overall, there were 67 deaths in Loveland, a town
  of 5,000 in a 15 week period.
• This represented an overall death rate of 1.3 of
  the population.

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Why are we concerned today?
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We at WHO believe that the world is now in the
gravest possible danger of a pandemic"

• Shigeru Omi, World Health Organization , 2005

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Pandemic influenza is thethe most important
threat that we are facing right now.

• Julie Gerberding, CDC director, 2005

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• It will be absolutely essential that local
  communities are well prepared, have a plan, and
  have sorted out who will be responsible for
  what.
• Michael Leavitt, U.S. HHS director

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• Localities should be prepared to rely on their
  own resources to respond.
• U.S. draft pandemic influenza plan, 2005

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Influenza

• Outbreaks yearly, usually in winter months
• Illness more severe for very young, elderly, or
  those with pre-existing health conditions
• Yearly, 5-20 of population get the flu
• Annually causes gt200,000 hospitalizations in US
• 36,000 deaths yearly in US

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Influenza Prevention

• Yearly influenza shot
• Avoid those who are ill
• Wash your hands
• Antivirals (in special circumstances)
• If you are ill--dont come to work, cover
  coughs and sneezes.

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Influenza Virus types

• Type A Infects humans and other animals
• More severe illness
• Causes regular epidemics can cause pandemics
• Type B Infectious only to humans
• Causes epidemics, but less severe illness

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Influenza

• Influenza A is subtyped by surface proteins
• Hemagglutinin (H)
• 16 different types
• Helps virus enter cells
• Neuraminidase (N)
• 9 different types
• Helps virus leave cell to infect others

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Influenza

• All known subtypes of Influenza A found in birds
  - 144 possible combinations of Hs and Ns
• H5 and H7 cause severe outbreaks in birds
• Human disease usually due to H1, H2, H3 and N1
  and N2.

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Influenza

• The flu virus constantly changes
• When it does, vaccines will be less efficient
• Immune system may be unable to recognize new
  virus
• No immunity in population for new viruspotential
  for pandemic

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Vaccine Development

• Inactivated trivalent vaccine (killed vaccine)
• 2 A, 1 B
• Effectiveness of vaccine depends on match
  between circulating strains and those in vaccine

20052006 Influenza Season
A/California/7/2004-like
A/New Caledonia/20/99-like
(H3N2)
(H1N1)
Influenza Protection
B/Shanghai/361/2002-like
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InfluenzaVaccine Production

• Flu vaccines first produced in 1940s
• 2 manufacturers in US for flu vaccine
• 80 million doses produced by late September
• 6-9 months to produce vaccine

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Influenza Pandemics

• What is a Pandemic?
• Outbreak in wide geographic area (global)
• Effects large of people with serious illness
• Usually a new virus or one which population has
  not had exposure in a long time
• May have rapid spread
• May occur in waves

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Seasonal Flu vs Pandemic Flu

• Seasonal
• Occurs every year
• Occurs during winter (usually Dec-Mar)
• Most recover in 1-2 weeks without tx
• Very young, very old, ill most at risk of serious
  illness

• Pandemic
• Occurs infrequently(3 per century)
• Occurs any time of year
• Some may not recover, even with tx
• People of all ages may be at risk

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Pandemic Influenza

• Past Pandemics
• 1968 Hong Kong Flu (H3N2)
• 1957 Asian Flu (H2N2)
• 1918 Spanish Flu (H1N1)

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1918-1919 influenza pandemic

• Worst of past century
• Estimated 20-40 of world population ill
• 40-50 million people died worldwide
• 600,000 or more deaths in US
• High mortality in young adults

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Why did young people die?

• Over-reaction by the immune system called
  cytokine storm
• Those with the strongest immune systems affected
• Older people and youngest often die of bacterial
  pneumonia complicating flu -- treatable now with
  antibiotics
• Even in 2005, no good treatment for cytokine
  storm.

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There are severe pandemics and mild pandemics
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Infectious Disease Deaths 1900s
Deaths per 100,000 per year
1957
1968
1918
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Pandemics can last for months and come in waves
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H5N1 Avian Influenza

• Hong Kong 1997
• 18 human cases, 6 deaths
• 1.4 million birds destroyed
• Dec. 2003 Asia
• Ongoing extensive outbreak in poultry
• Limited human to human transmission
• 125 human cases, 64 fatal
• July-Aug 2005 Kazakhstan, Russia
• October 2005 Turkey, Romania, Russia

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H5N1 Symptoms

• Symptoms (human)
• Fever
• Shortness of breath
• Cough
• Pneumonia
• Acute Respiratory Distress
• Diarrhea, sometimes severe
• Life-threatening complications

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Transmission of flu virus

• Incubation period of 1-4 days for regular flu -
  not clear if H5N1 might be longer
• Can be communicable to others 24 hours before
  symptoms begin - and up to 5 days or more after
  onset (adults) or 10 or more days (children)
• Usually spread through respiratory droplets or
  contaminated objects. May also be airborne, and
  perhaps thru feces.

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Concern with Avian Influenza

• Virus mutates rapidly
• Can acquire genes from viruses infecting other
  species
• H5N1 has acquired some of genetic changes in the
  1918 virus associated with human-human
  transmission
• Causes severe disease in humans
• High fatality rate

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Are we more or less at risk today compared to
1918?
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Why at LESS risk in 2005

• Antibiotics for bacterial pneumonia complications
  of influenza
• Some antiviral medicines
• IV fluids, ventilators
• Greater ability to do surveillance, confirm
  diagnosis of flu

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Why at LESS risk in 2005

• Rapid means of communications - internet, TV,
  radio, email
• More effective personal protective equipment
• Fewer people living in each household and more
  rooms.

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Why at MORE risk in 2005

• A lot more international travel
• 10 times more people in Larimer County, contact
  with far more people daily
• Very little surge capacity in health care today
• Greater reliance on health professionals

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Why at MORE risk in 2005

• More elderly and immune-compromised people in
  population
• Much less self-sufficient than in 1918s
  (households and businesses)
• Todays society not used to rationing, sacrifice,
  compared to war-time 1918.

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Why at MORE risk in 2005

• Far more manufactured goods and raw materials
  come from distant areas, especially Asia
• Just-in-time ordering of needed supplies
  instead of warehousing critical items on site

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Overall, are we at more or less risk?

• Up to individuals, communities, states, and
  nations to decide as they plan for a possible
  pandemic

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What might happen in a severe pandemic?
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If it happens soon..

• There will be little or no vaccine until 6 - 9
  months after the outbreak begins
• There will be very limited supplies of antiviral
  medicines for treatment (for 1 of populations,
  perhaps less).
• All communities hit a about the same time
• We need a plan for the short-term that assumes no
  effective shots or Rx

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What might occur

• Health system could be overwhelmed
• Essential services could be at risk (fuel, power,
  water, food, etc.)
• Just-in-time supply lines could be disrupted
• High mortality rates could occur
• Social disruption could occur

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Considerations for preparedness
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Can we maintain our utilities?

• Recent disasters have showed us the need for
  water, power, telecommuni-cations, heat in an
  emergency
• Could they operate with 50 of staff?
• Do they stockpile materials and parts to ensure
  operation for 90-120 days?

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Who will provide health care?

• Health workers will be disproportion-ately
  exposed and may become ill
• Some will not show up due to fear
• Some will not be able to leave sick family
  members, children out of school
• Little or no surge capacity nursing shortage
  future of Medical Reserve

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Will transportation/trade problems impact food
supply?

• Typical household has food on hand to last 3
  days.
• Few families have emergency reserves for a
  prolonged period
• Low-income least able to set supplies aside for
  an emergency
• Prices may rise quickly in emergency.

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Who will help us?

• Little or no state and federal assistance
• Local government also limited in what it can do
  to assist citizens
• Churches, neighbors, friends and families would
  need to help each other
• Vulnerable groups would need extra assistance
• Advance planning and stockpiling of necessities
  could help.

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What public agencies and businesses can doas
employers
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Maintain Essential Services

• Halt non-essential activities and re-deploy staff
  to fill vacancies in critical services.
• Cross train Make sure all critical functions can
  be done by several different people.

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Maintain Essential Services

• Create written instructions/ procedures for
  critical processes that can be carried out by
  others
• If possible, keep essential supplies/ parts
  stockpiled in advance to maintain services.

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Increase Social Distance

• Determine how to provide services with less
  person-to-person contact whenever possible
• Increase telecommuting if possible
• Use phone, web, virtual conferences to replace
  face-to-face meetings
• Waive non-critical policies if they force
  in-person contact

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Decrease contact exposures

• Increase cleaning/sanitizing of locks/ doorknobs,
  faucet and toilet handles, shared keyboards,
  telephones, other equipment
• Vacuuming/sweeping may stir up infectious
  particles

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Decrease contact exposures

• Use/provide tissues, hand sanitizers, disposable
  gloves if available (All could be scarce during a
  pandemic)
• Increasing humidity may reduce virus

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Provide Personal Protective Equipment

• Need will vary with type business
• Will be difficult to obtain in a pandemic - need
  to secure in advance
• Masks (N95 or better) may reduce exposure, but
  are difficult to wear for prolonged time or if
  employee has health problems.

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Teach protective actions

• Hand washing without recontamination
• Covering cough, not using hands
• Avoid putting hands to face, mouth, nose, eyes.
• Staying home if any signs of illness

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Prepare Communications Plan

• How will key managers communicate among
  themselves
• How will information be conveyed to customers?
• How will information be conveyed to employees?
• How will employees know who to call in specific
  situations?

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Prepare for difficult HR issues

• If offices are closed, will staff be paid?
• If staff are needed, can they refuse to come to
  work?
• If required to report, what protective
  equipment, if any, will be provided?
• Can employer force someone who may be ill NOT to
  work? (Employees without sick leave may try to
  work while ill.)

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Prepare for difficult HR issues

• If an employee is required to work with ill
  people and becomes ill, is ita workers comp
  situation?

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How Ready Are We?
Used with permission of the Minneapolis
Star-Tribune
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"Every day a pandemic doesn't happen is another
day we have to prepare. --Michael
Osterholm