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H5N1, H1N1, and Pandemic Influenza An Update

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H5N1, H1N1, and Pandemic Influenza An Update Eden V. Wells, MD, MPH Michigan Department of Community Health 2009 Novel Influenza A (H1N1) The 21st Century s first ... – PowerPoint PPT presentation

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Title: H5N1, H1N1, and Pandemic Influenza An Update


1
H5N1, H1N1, and Pandemic InfluenzaAn Update
  • Eden V. Wells, MD, MPH
  • Michigan Department of
  • Community Health

2
Outline
  • Novel Strain H5N1- Brief Update
  • Novel Strain H1N1-Update
  • Pandemic Influenza Planning-Michigan
  • Pan Flu Planning for You

3
Avian Influenza A (H5N1)
  • Discovered in Hong Kong, 1997
  • Now multiple epizootics worldwide
  • Still has not entered the Western Hemisphere
  • Still has not met WHO criteria for pandemic
  • New strain
  • Causes severe illness in humans
  • Sustained transmission from person to person

4
Humans at Risk-H5N1
  • Transmission from birds to humans does not occur
    easily
  • Contact with feces or secretions from infected
    birds
  • Risk with butchering, preparing, defeathering of
    infected birds
  • NOT transmitted through cooked food
  • All age groups affected
  • Higher rate lt 40 years
  • MF-0.9
  • Case fatality remains 63
  • Median duration of illness
  • hospitalization 4 days
  • death 9 days
  • Clinical features
  • Asymptomatic infection not common

5
Human Vaccine for Avian H5N1
  • Human H5N1 vaccine approved by FDA
  • US has advance-ordered 20,000,000 doses
  • Current US Strategic National Stockpile (SNS)
  • Clades 1, 2.1, 2.2, 2.3
  • currently (April 29, 2008) contains enough H5N1
    vaccine for 12 million to 13 million people
  • assuming two 90-microgram (mcg) doses per person
  • Potential adjuvants (AL-OH, oil/water,etc)
  • May not match strain that causes pandemic
  • Seasonal influenza vaccine does not protect
    against H5N1 strain

6
Current U.S. Status, H5N1
  • No current evidence in U.S. of highly pathogenic
    H5N1 in
  • Wild birds
  • Domestic poultry
  • Humans

7
2009 Novel Influenza A (H1N1)
  • The 21st Centurys first influenza pandemic

8
2009 Novel Influenza A (H1N1)
  • April 2009, Mexico and SE California
  • Rapid spread through Mexico and US
  • May 2009, Spread throughout World
  • WHO Pandemic Phase 6 June 2009

9
Transmission
  • Transmitted human-to-human
  • Transmitted similar as seasonal influenza
  • Exposure to nearby coughing or sneezing
  • Contact with contaminated surfaces
  • Incubation unknown and could range from 1-7
    days, and more likely 1-4 days
  • Infectious period unknown-
  • one day before to 7 days following illness onset
  • Children, especially younger children, maybe
    infectious up to 10 days.

10
World Health H1N1, as of August 2009
11
US Epidemiology H1N1August 2009
12
Mortality by Age, US,as of August 1, 2009
13
US Epidemiology, as of August 2009
  • More than one million people became ill with
    novel H1N1 flu between April and June 2009.-
    cdc.gov

14
US Epidemiology,as of August 2009
  • Secondary attack rate (SAR) of H1N1 for household
    contacts
  • For acute-respiratory-illness (ARI two or more of
    the following symptoms fever, cough, sore
    throat, and runny nose)-18 to 19
  • 8 to 12 for influenza-like-illness (ILI- fever
    and cough or sore throat)
  • Slightly lower than seasonal influenza SAR
  • US Case fatality rate ? lt0.1
  • Greater disease burden on people younger than 25
    years of age than older people.

15
MI Epidemiology, as of July 2009
  • As of July 9, 2009 confirmed cases

16
Antiviral Resistance (as of August 2009)
  • Antiviral resistance pandemic (H1N1) virus
  • Six oseltamivir resistant pandemic (H1N1) 2009
    influenza viruses
  • Denmark
  • Hong Kong SAR
  • Japan
  • Canada
  • Three were from patients in Japan.
  • All six patients had received oseltamivir with
    the exception of one and have recovered well.
  • All resistant viruses had the characteristic
    mutation at position 274/275 associated with
    resistance.

17
Planning for an Impending Pandemic
  • The Role of Public Health

18
20th Century Influenza Pandemics
  • 1918 1919, Spanish Flu (H1N1)
  • Influenza A H1N1 viruses still circulate today
  • US mortality approx. 500,000
  • 1957-58, Asian Flu (H2N2)
  • Identified in China (February 1957) with spread
    to US by June
  • US mortality 69,800
  • 1968-69, Hong Kong Flu (H3N2)
  • Influenza A H3N2 viruses still circulate today
  • First detected in Hong Kong (early 1968) and
    spread to US later that year
  • US mortality 33,800

19
Americas deaths from influenza were greater than
the number of U.S. servicemen killed in any war
Thousands
Civil WWI 1918-19 WWII
Korean Vietnam War
Influenza War War

Pestronk, Robert
20
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21
Categories of Pandemic Strength
22
Estimated Impact of a Future Pandemic in Michigan

(Michigan figures developed with Flu-Aid 2.0
software, CDC)
23
Public Health Leads
  • International World Health Organization
  • United States Centers for Disease Control and
    Prevention, DHHS
  • Michigan Michigan Department of Community Health
  • County Local Health Department/Jurisdiction

24
Public Health Containment Tools-Pandemic Flu
Legal authority to Implement Public Health
Measure resides equally in all 45 MI Local HD
Health Officers
  • Vaccine
  • Antivirals
  • Treatment
  • Prophylaxis
  • Infection Control
  • Social Distancing

MI PUBLIC HEALTH CODE
Similar but multi-jurisdictional authority
resides with State Health Officer
25
Menu of Public Health Actions, circa 1918
9. Mandatory or recommended use of masks in
public10. Closing or discouraging the use of
public transit systems11. Restrictions on
funerals, parties, and weddings12. Restrictions
on door-to-door sales13. Community-wide curfew
measures and business closures14.  Social
distancing strategies for those encountering
others 15. Public health risk communication
measures 16. Declaration of public health
emergency.
  • Making influenza a reportable disease2.
    Isolating sick individuals3. Quarantine of
    households with sick individuals4. School
    closure5. Protective sequestration of children
    or adults6. Cancellation of worship
    services7. Closure of public gathering places
    e.g., saloons, theatres, etc.8. Staggered
    business hours to decrease congestion on trams,
    etc.

Hatchett, et al, PNAS, May 1, 2007
26
1918 Flint Journal Headlines
Slide courtesy of Robert Pestronk
27
Michigan Pandemic Planning
  • Coordination of state and local responses

28
All-Hazard Preparedness
  • Since 9/11, enhanced infrastructure for emergency
    response
  • Requirement for coordinated hospital and first
    responder actions
  • Public healths enhanced role in emergency
    management
  • A need to integrate community response
  • Continuity of business planning
  • Continuity of operations planning

29
Keweenaw
44
8
  • Regional Bio-Defense Networks
  • Coordinate health care, state and local public
    health, and emergency management partners
  • 100 Federally funded
  • CDC Cooperative Agreement
  • HRSA Cooperative Agreement

7
6
3
2n
1
5
2 s
30
Preparedness Planning
  • All Hazards-Pandemic Flu an excellent example
  • Basis of all plans is a strong Continuity of
    Operations Plan

31
Preparedness-LocalAll Emergencies are Local
  • All 45 local health departments
  • Health Officer with legal authorities
  • Medical Director
  • Emergency Preparedness Coordinator
  • Immunization Staff
  • Communicable Disease Staff
  • Coordination of plans
  • Partnerships
  • Emergency Management
  • Businesses
  • Community/organizations
  • Schools
  • Healthcare

West Nile Virus Hotline1-888-354-5500 ext 7850
or734-240-7850
Avian Influenza Hotline1-888-354-5500 ext 7878
or734-240-7878
32
The Role for the Community Responder
  • Pandemic Influenza

33
How it will happen
  • Public health surveillance
  • Disease detection
  • Warnings, declarations, and orders
  • Staged countermeasures initiated
  • Requests from local health departments initiated
  • Local hospitals overwhelmed
  • Rapid, repeated cycles of illness and death
  • Loss of response staff
  • Burn-out of disease and staff
  • Clean up

34
Things to do now at work
  • Assure staff are vaccinated for flu each year
  • Assure other vaccinations are up-to-date
  • Plan for loss of staff and use of volunteers
  • Get to know your local health department and
    tribal leaders
  • Review inter/intra-agency planning documents and
    checklists
  • Participate in exercises train, emphasize
    leadership shift
  • Practice staying home when sick
  • Practice healthy hygiene

Robert Pestronk, Genesee Cty)
35
Emotional Impacts
  • Reacting to inconsistent information
  • Fear of exposure/infection
  • Massive loss and grief
  • Exposure to traumatic images
  • An inability to see loved ones
  • Not being able to say good-bye to those who may
    die in the hospital or while separated from
    family.

Slide information extracted from UNC webinar
January 2008 Mental Health Aspects of Pandemic
Flu Preparedness Patricia Watson, Ph.D. National
Center for PTSD
36
Social Impacts
  • Isolation/quarantine (home care)
  • Social distancing (comfort)
  • School dismissal (child care)
  • Closing places of assembly (social support)

Slide information extracted from UNC webinar
January 2008 Mental Health Aspects of Pandemic
Flu Preparedness Patricia Watson, Ph.D. National
Center for PTSD
37
Supporting First Responders
  • Illness and death among colleagues and family
    members
  • Fear of contagion and/or of transmitting disease
    to others
  • Shock, numbness, confusion, or disbelief extreme
    sadness, grief, anger, or guilt exhaustion
    frustration
  • Sense of ineffectiveness and powerlessness
  • Difficulty maintaining self-care activities
    (e.g., getting sufficient rest)
  • Prolonged separation from family

DHHS Pandemic Plan 2005
38
Support of First Responders
  • Concern about children and other family members
  • Constant stress and pressure to keep performing
  • Domestic pressures caused by school dismissals,
    disruptions in day care, or family illness
  • Stress of working with sick or agitated persons
    and their families and/or with communities under
    quarantine restrictions
  • Concern about receiving vaccines and/or antiviral
    drugs before other persons

39
Tools for the First Responder
  • Surveillance
  • Community Mitigation
  • Social Distancing
  • Infection Control, based on Risk Assessment
  • Vaccination
  • Communication

40
Surveillance
  • MDCH, local health departments, tribes
  • Emergency Departments
  • Schools
  • Pharmacies
  • Hospitals
  • sentinel laboratories and physicians
  • local health departments
  • www.michigan.gov/flu

41
Community Mitigation
  • Attempt to keep children in school
  • Schools may consider temporary dismissal
  • Virus severity, or uncontrolled transmission
  • Do NOT go to work or school if sick!
  • Social distancing
  • Infection Control
  • Medical intervention, if necessary
  • Antivirals for at-risk individuals
  • Hospital surge responses

42
Vaccination
  • H1N1 vaccination planning currently evolving
  • Public and private sector delivery
  • Target groups different from seasonal flu
  • Pregnant women
  • Household contacts and caregivers for children
    younger than 6 months of age
  • Healthcare and emergency medical services
    personnel
  • All people from 6 months through 24 years of age
  • Persons aged 25 through 64 years who have health
    conditions associated with higher risk of medical
    complications from influenza.

43
Communications
  • Streamlined, unified- federal, state, local
  • Primary federal websites
  • www.flu.gov
  • http//www.cdc.gov/h1n1flu/
  • Primary state website
  • michigan.gov/flu
  • Alternate routes
  • Twitter
  • Facebook
  • Regular media calls and updates

44
Health Alert System
  • The Michigan Health Alert Network (MIHAN) is a
    secure, Internet-based, emergency notification
    system
  • The MIHAN contains over 4,000 participants
  • local health departments
  • Hospitals
  • Clinics
  • Critical first responders across the state
  • Michigan's state governmental agencies.

45
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46
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47
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48
Things to do now at home
  • Get family members vaccinated each year
  • Practice healthy hygiene
  • Plan how you will care for someone in your
    household who becomes sick if you are called to
    work.

49
Practice Healthy Hygiene
  • Clean hands often
  • Wash with soap and water or
  • Clean with hand sanitizer
  • Cover mouth and nose when you sneeze or cough and
    clean hands afterwards
  • Keep hands away from face
  • Stay away from people who are sick
  • Single use tissue

Robert Pestronk, Genesee Cty)
50
Summary
  • Knowledge about novel influenza evolving
  • Pan flu risks persist-
  • regardless of H5N1 activity,
  • especially due to H1N1 activity
  • Pan flu planning
  • Is extremely comprehensive
  • Is extensive coordination
  • Enhances collaboration
  • Means new partnerships
  • Assists in planning for other events
  • Is NECESSARY

51
References
  • Mivolunteerregistry.org
  • Local Health Department
  • Michigan Department of Community Health
    (www.michigan.gov/flu)
  • WHO www.who.int
  • CDC www.cdc.gov
  • DHHS (www.pandemicflu.gov) (CHECKLISTS)

52
Acknowledgements
  • Howard Markel, University of Michigan Medical
    School
  • Several slides courtesy of
  • Robert Pestronk
  • Christi Carlton, MDCH
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