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INFLUENZA From Routine Response to Pandemic Preparedness

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Title: INFLUENZA From Routine Response to Pandemic Preparedness


1
INFLUENZAFrom Routine Responseto Pandemic
Preparedness
2
Case
  • It is mid-December
  • A 35 year-old-man, previously healthy, presents
    to the Emergency Department (ED) with a one day
    history of fever, severe myalgias, dry cough, and
    retro-orbital pain

3
Case (contd)
  • He can barely sit up to be examined
  • He is a healthcare worker
  • Received influenza vaccine last year
  • No history of international travel or animal
    exposure
  • He is febrile, tachycardic, and appears toxic

4
Case (contd)
  • Over the course of the shift, the ED physician
    sees several cases with similar complaints. Some
    require IV fluids, some are admitted, some sent
    home.
  • ED physician calls the local health department
    and learns that other EDs in the area are seeing
    an unusual number of patients with fever,
    myalgias, cough and weakness.
  • Beds on the floors quickly fill. Backup nursing
    staff are being called in. The physician
    covering the next shift shows up sick and is sent
    home by the ICP.

5
Case (contd)
  • At the same time, the local TV station calls the
    ED and urgently requests an interview in order to
    prepare for a news story that evening

6
Case (contd)
  • Is it an outbreak? Is it a routine influenza
    season?
  • What other infectious diseases could present
    similarly?
  • What is the role of the healthcare provider in
    recognition and reporting, as well as in a
    multidisciplinary response?
  • If situation became markedly worse / evolved into
    a mass casualty event, how would the health care
    system respond?

7
INFLUENZA Objectives
  • Discuss influenza epidemiology and virology
  • Describe the 3 systems for influenza surveillance
  • Discuss primary prevention and treatment options
  • Review changes in recommendations for the 2004-05
    season, given shortage of vaccine
  • Review the risk of influenza pandemics
  • Understand flu as a model for bioterrorism and
    other public health disaster planning

8
INFLUENZA Clinical Features
  • Typical symptoms fever, chills, myalgias, sore
    throat, cough, retro-orbital pain
  • Most symptoms resolve in a week, cough may
    persist for more than one week
  • Symptoms may be prolonged in immunosuppressed
    hosts
  • Childrens max temp tends to be higher. Febrile
    seizures can occur

9
INFLUENZA Complications
  • Very young and elderly ? 65 y and those with
    underlying illness
  • Sinusitis, otitis, exacerbation of COPD,
    bronchitis, bronchiolitis, croup
  • Primary viral pneumonia 3-5 days,
  • Superimposed bacterial pneumonia -- 5-10 days

10
INFLUENZA Non-Pulmonary Complications
  • Myositis, rhabdomyolysis rare, reported mostly
    in children
  • Cardiac - Myocarditis, pericarditis
  • Toxic shock syndrome
  • Nervous system
  • Transverse myelitis
  • Guillain-Barrè Syndrome
  • Encephalitis in children lt 5y Japan
  • Encephalitis lethargica temporally associated
    with 1918 pandemic
  • Reyes Syndrome

11
INFLUENZA EPIDEMIOLOGY AND VIROLOGY
  • Including Avian Flu and
  • Potential Pandemic Viruses

12
INFLUENZA Epidemiology (contd)
  • Incubation period 1-4 days
  • Virus first detected just before onset of
    illness. Virus usually not detected after 5 - 10
    days.
  • More prolonged shedding in children,
    immunosuppressed hosts
  • Transmission via respiratory droplets
  • person to person,
  • direct contact,
  • aerosols--sneezing, coughing, etc.

13
INFLUENZA Epidemiology (contd)
  • Attack rates 10-20 general population,
  • selected populations 40-50
  • Typical Season 200,000 hospitalizations and
    36,000 deaths
  • INFLUENZA IS THE SINGLE MOST COMMON VACCINE
    PREVENTABLE DISEASE

14
INFLUENZA Epidemiology (contd)
  • Epidemics
  • Begin abruptly
  • Peak 2-3 weeks, last 5-6 weeks
  • Severity of outbreak
  • Virulence of strain
  • Mismatch between vaccine strain andcirculating
    strain
  • Susceptibility of population
  • Influenza is predictably unpredictable

15
Transmission electron micrograph of influenza A
virus, late passage. Source CDC/Dr. Erskine
Palmer
16
INFLUENZA Virology
  • Family orthomyxoviridae
  • Enveloped viruses 80-120 nm, negative stranded
    RNA with 8 different segments. Allows for
    genetic reassortment when gt1 virus infects a
    single cell
  • Types A, B, and C Significant differences in
    structure, genetics, organization, host range,
    epidemiologic and clinical characteristics
  • Covered with surface projections or spikes --
    Hemagglutinin and neuraminidaseused to subtype
    influenza A virus types.

Source Aventis Pasteur
17
INFLUENZA Virology (contd)
  • Named by type / place isolated / culture / yr
    isolation
  • A/Fujian/411/2002 (H3N2)
  • B/Shanghai/361/2002-like

SourceAventis Pasteur
18
INFLUENZA Virology (contd)
  • Influenza A
  • Occurs in humans, pigs, horses, birds, and
    certain marine mammals
  • Human disease historically linked to H1 - H3 and
    N1 - N2
  • All human pandemics have been due to Influenza A
  • Avian flu viruses are Influenza A viruses
    (H1-H15 N1-N9) H5 and H7 typically cause
    severe outbreaks in birds

19
INFLUENZA Virology (contd)
  • Amazing ability to change
  • Antigenic Drift (A and B)
  • Comparatively minor antigenic change
  • Why we need a new vaccine each year
  • Causes epidemics a higher than normal level in
    the population, usually much higher than endemic,
    and usually short-term
  • Antigenic Shift (A only)
  • Major antigenic change
  • Leads to pandemicsnovel strain, little immunity,
    epidemic spreading between continents

20
INFLUENZA Virology / Epidemiology
  • Hypothesis that all mammalian influenza viruses
    derive from avian influenza reservoir
  • Influenza viruses replicate in intestinal tract,
    excreted in feces of birds
  • Many birds infected by virus shed into water

21
INFLUENZA Virology / Epidemiology
  • Link Between Avian and Mammalian Influenza
  • Transmission of avian influenza viruses to
    mammals including pigs and horses probably by
    direct transmission and fecal contamination of
    water
  • After transmission to pigs, horses, or humans,
    method of spread of influenza mainly respiratory
  • Avian influenza outbreaks and human disease
    1997-2004

22
Vietnamese woman selling chickens at market. Food
and Agriculture Organization, U.N.
23
INFLUENZA Epidemiology (contd)
  • 2003-04 Avian flu outbreaks (genetic. distinct
    H5N1)
  • S. Korea, Japan, Cambodia, Laos, Vietnam,
    Thailand, Indonesia, China, Malaysia
  • As of Oct 4, 2004
  • 27 cases and 20 deaths in Vietnam
  • 16 cases and 11 deaths in Thailand
  • Suspect one person to person transmission in a
    family
  • No sustained person to person transmission to
    date
  • Concern is for a genetic reassortment allowing
    high transmissibility person to person.

24
Whats needed for a pandemic strain?
  • Novel virus (little to no immunity)
  • Capable of causing disease in humans
  • Highly pathogenic / virulent
  • Capable of sustained person to person transmission

25
(No Transcript)
26
INFLUENZA Epidemiology (contd)
  • 6 billion chickens and 850 million ducks in SE
    Asia
  • China and Thailand account for 15 of the worlds
    poultry shipments
  • In many SE Asian countries, 80 of poultry is in
    small backyard farms (poultry, swine, humans,
    etc.)
  • Since late 2003, 200 million birds have been
    culled or died
  • Economic impact
  • could exceed 12 billion (Chinese Academy of
    Social Sciences)
  • Marked on individual farmers already at low
    income

27

INFLUENZA SURVEILLANCE
28
INFLUENZA Surveillance Systems
  • First Method Increased deaths
  • 122 US Cities Pneumonia and Influenza Mortality
    Surveillance (CDC)

Background and Threshold for Epidemic Diagnosis
29
INFLUENZA Surveillance Systems
  • Second Method Sentinel Providers
  • Office visits for Influenza like Illness
    (Health Departments and CDC)
  • Sentinel Provider Offices visits for
    influenza like illnesses -- fever sore throat
    or cough without another identified cause
  • 1000 Sentinel Providers nationally (70 in WV)

30
WV Sentinel Provider Network Influenza-like
Illness (ILI) Reporting

31
INFLUENZA Surveillance Systems
  • Third Method Laboratory Surveillance-WV

WV data 2003-04
WV data 2002-03
32
INFLUENZA Surveillance Systems
  • Third Method Laboratory Surveillance--WHO

33
INFLUENZA PREVENTION AND TREATMENT

34
INFLUENZA Management (contd)
  • Primarily symptomatic, including hydration
  • Antivirals Adamantanes
  • Amantadine, rimantidine decrease duration of
    symptoms by 50 if initiated within lt 48 hours in
    trials
  • Decrease in viral shedding
  • Appearance and transmission of resistant virus
  • Side effects predominantly CNS type, amantadine
    greater than rimantidine

35
INFLUENZA Management (contd)
  • Side effects Neuraminidase Inhibitors
  • Oseltamivir nausea, vomiting, headache, cough
  • Zanamivir not recommended for COPD, asthma
    because of bronchospasm
  • No controlled trials comparing neuraminidase
    inhibitors to adamantanes

36
CDC Interim Recommendations on use of Antiviral
Medications for the 2004-05 Influenza Season
  • TREATMENT
  • Any person experiencing a potentially
    life-threatening influenza-related illness
  • Any person at high risk for serious complications
    of influenza and who is within the first 2 days
    of illness onset
  • Interim Guidelines not intended to guide the use
    of these medications in other situations, such as
    outbreaks of avian influenza.

37
CDC Interim Recommendations on use of Antiviral
Medications for the 2004-05 Influenza Season
  • PROPHYLAXIS--Antivirals
  • Institutional Outbreaks
  • Other High Risk Individuals exposed to influenza
  • CDC encourages the use of amantadine or
    rimantadine for chemoprophylaxis and use of
    oseltamivir or zanamivir for treatment as
    supplies allow

38
INFLUENZA PREVENTION
  • VACCINE
  • Inactivated Influenza Vaccine
  • Live Attenuated Influenza Vaccine
  • 2004-05 Vaccine Recommendations
  • Future directions

39
INFLUENZA PREVENTION (contd)
  • INACTIVATED INFLUENZA VACCINE
  • First developed in US by Armed
  • Services 1940s
  • Made of split viruses or viral subunits
    containing hemaglutinin and neuraminidase
  • Contain 2 type A viruses and 1 type B virus
  • Try to match what will most likely be in
    circulation each season

Source CDC
40
INFLUENZA PREVENTION (contd)
  • INACTIVATED INFLUENZA VACCINE
  • WHO convenes meeting to determine vaccine
    composition (Feb Northern Hemisphere Sept
    Southern)

SourceWHO
41
INFLUENZA PREVENTION (contd)
  • INACTIVATED INFLUENZA VACCINE
  • Strains circulating detected by WHO Global
    Surveillance Network (since 1948)
  • Serologic studies to determine antigenicity
  • 4-6 month egg based manufacturing process
  • 18 Manufacturers worldwide
  • 2 licensed in US in 2004

SourceAventis Pasteur
42
INFLUENZA PREVENTION (contd)
  • LIVE ATTENUATED INFLUENZA VACCINE
  • FluMist, produced by MedImmune
  • Produced by reassortant gene technology
  • Viruses express contemporary influenza vaccine
    antigens
  • Administered by
  • nasal spray

Source CDC
43
INFLUENZA VACCINE 2004-05 SEASON
  • Contamination limited to a few lots reported by
    Chiron Corporation (Summer, 2004)
  • The UK Regulatory Agency (MHRA) suspended
    Chirons license to manufacture Fluvirin vaccine
    for 3 months (Liverpool facility)
  • On October 5, 2004, Chiron informed CDC that none
    of its influenza vaccine (48 million doses)
    would be available for distribution this season

44
2004-05 INFLUENZA SEASON (contd)
  • Influenza Vaccine Shortage
  • Reduction in vaccine supply by about 50
  • Available doses in the U.S.
  • 58 million doses of inactivated vaccine
  • About 3 million doses of Live Attenuated Vaccine

45
(No Transcript)
46
ESTIMATING VACCINE NEED
  • 2002-03 SEASON
  • Estimated at risk population 84.9 million
  • Other targeted pop 102.9 million
  • Total target group 187.8 million
  • vaccinated varied widely
  • Children with chronic illness 10
  • gt65 year olds 66
  • Est. 57.6 doses administered
  • 2004-05 SEASON
  • Target group narrowed to 98.2 million
  • Estimate vaccine acceptance rate (5 increase
    demand) 42.8 million

47
Priority Groups For Influenza Vaccination,
2004-2005
  • Children 6-23 months of age
  • Adults gt65 years
  • Persons 2-64 years of age with underlying chronic
    medical conditions
  • Women who will be pregnant during influenza
    season

MMWR 200453(39)923-4
48
Inactivated Influenza VaccineRecommendations
  • Persons with the following chronic illnesses
    should be considered for inactivated influenza
    vaccine
  • pulmonary (e.g., asthma, COPD)
  • cardiovascular (e.g., CHF)
  • metabolic (e.g., diabetes)
  • renal dysfunction
  • hemoglobinopathy
  • immunosuppression, including HIV infection

MMWR 200453 (RR-6)1-40
49
Priority Groups For Influenza Vaccination,
2004-2005
  • Residents of nursing homes and long-term care
    facilities
  • Children 6 months-18 years of age on chronic
    aspirin therapy
  • Healthcare workers with direct, face-to-face
    patient contact
  • Household contacts and out-of-home caregivers of
    children aged lt6 months

MMWR 200453(39)923-4
50
Who Should NOT Receive Influenza Vaccine This Year
  • Healthy persons 2-64 years of age
  • Household contacts of high-risk persons EXCEPT
    children lt6 months of age
  • Providers of essential community services
  • Foreign travelers
  • Students

except those who are in a priority group because
of age or medical condition
51
Prevention and Control of Influenza in Healthcare
Facilities
  • The most important measure to protect patients
    from influenza in a healthcare setting is
    vaccination of both patients and healthcare
    workers
  • In a vaccine shortage situation vaccination of
    HCWs becomes even more critical
  • In 2002, only 38 of HCWs were vaccinated!

52
Influenza Vaccination of Healthcare Workers
  • Reduces influenza-related death among nursing
    home residents
  • Reduces overall illness in nursing home residents
  • Reduces illness and illness-related absenteeism

Reference Improving Influenza Vaccination Rates
in Healthcare Workers. Strategies to Increase
Protection for Workers and Patients. Available at
www.nfid.org
53
Influenza Vaccination of Children 2004-05
  • Current influenza vaccine not licensed for
    children lt6 months of age
  • 2 doses separated by gt1 month recommended for
    children lt9 years who are receiving influenza
    vaccine for the first time
  • Children being vaccinated for the first time last
    year who only received 1 dose should receive 1
    dose this year and in subsequent years

54
Influenza Vaccination of Children 2004-05
  • Do NOT reserve vaccine for second doses for
    children being vaccinated for the first time this
    year
  • Children should be vaccinated (first or second
    dose) on a first-come, first-served basis

55
Live Attenuated Influenza Vaccine (LAIV)
(FLUMIST) Indications
  • Healthy persons 549 years of age
  • Household contacts of persons at increased risk
    of complications of influenza
  • for 2004-05, just household contacts of those lt6
    months of age
  • Health care workers

Persons who do not have medical conditions that
increase their risk of complications of influenza
56
Live Attenuated Influenza VaccinePersons Who
Should NOT Be Vaccinated
  • Children lt5 years of age
  • Persons gt50 years of age
  • Persons with underlying medical conditions
  • asthma, reactive airways disease or other chronic
    pulmonary condition
  • cardiovascular disease
  • metabolic diseases (e.g. diabetes)
  • renal disease
  • hemoglobinopathy (e.g. sickle cell disease)

These persons should receive inactivated
influenza vaccine
57
Live Attenuated Influenza VaccinePersons Who
Should NOT Be Vaccinated
  • Pregnant women
  • Persons immunosuppressed from disease (including
    HIV) or drugs
  • Children or adolescents receiving long-term
    therapy with aspirin or other salicylates
  • Severe (anaphylactic) allergy to egg or other
    vaccine components
  • History of Guillain-Barre syndrome

These persons should receive inactivated
influenza vaccine
58
Live Attenuated Influenza VaccineTransmission of
Vaccine Virus
  • Vaccinated children shed vaccine viruses for up
    to 3 weeks (mean, 7.6 days)
  • One documented instance of transmission of
    vaccine virus to a contact (in a daycare setting)
  • Transmitted virus remained attenuated
  • Frequency of shedding among adults unknown

59
Use of LAIV Among Healthcare Personnel
  • No data regarding transmission from adults
    vaccinated with LAIV to immunosuppressed persons
    (but no evidence of transmission during 2003-2004
    influenza season)
  • ACIP recommends that LAIV can be given to
    eligible HCWs except those who may expose
    severely immuno-suppressed persons

60
Use of LAIV Among Close Contacts of High Risk
Persons
  • Persons who receive LAIV should refrain from
    contact with severely immunosuppressed persons
    for 7 days after vaccination
  • Persons who receive LAIV need NOT be excluded
    from visitation of patients who are not severely
    immunosuppressed

MMWR 200453(RR-6)17
61
Influenza Prevention (contd)
  • INFLUENZA VACCINE FUTURE DIRECTIONS
  • Cell culture vaccines (non-egg reliant)
  • Injectable and intranasal
  • Intradermal administration? (NEJM 11/04)
  • Federal guarantees against financial risk?

Source CDC
62
Prevention Beyond Vaccine
  • Avoid close contact with people who are sick
  • Cover Your Cough
  • Frequent handwashing
  • Avoid touching eyes, nose or mouth
  • Antiviral drugs
  • Stay home when you are sick!

63
Influenza as a Model for Disaster Preparedness

64
The 1918 Spanish flu pandemic
National Museum of Health and Medicine, Armed
Forces Institute of Pathology
65
INFLUENZA History
  • Epidemics and pandemics
  • Most well known pandemic 1918-1919
  • 40-50 million deaths worldwide
  • Subsequent pandemics
  • 1957 Asian flu
  • 1968 Hong Kong flu
  • 1.5 million deaths
  • Economic impact estimated at 32 billion dollars

66
Images from the 1918 Influenza Epidemic National
Museum of Heath and Medicine
67
Images from the 1918 Influenza Epidemic National
Museum of Heath and Medicine
68
Images from the 1918 Influenza Epidemic National
Museum of Heath and Medicine
69
THE NEXT PANDEMIC?
  • Potential impact of next pandemic (CDC)
  • 2-7.4 million deaths globally
  • In high income countries
  • 134-233 million outpatient visits
  • 1.5-5.2 million hospitalizations
  • 25 increase demand for ICU beds, ventilators,
    etc.

70
Preparing for Health Disasters

71
World Trade Center Attack - September 11,
2001Emergency Response
72
Bioterrorism
Anthrax by MailOct. 2001
Salmonella to alter electionsOR 1984
Ricin -- Feb 2004
Risk of Smallpox?
Pneumonic Plague
73
INFLUENZA OR BIOTERRORISM?
  • Global travel rapid spread / little
    warning
  • Vaccines and antivirals in short supply
  • Medical facilities overwhelmed
  • Personnel shortages among essential community
    workers (including HCWs)
  • Longer impact than many disasters
  • Simultaneous impact in many communities
  • Disruptions in community infrastructure
    (utilities, transport, etc.)
  • Requires an intersector response

74
Commonalities
  • Good disease Surveillance is critical
  • Clinicians must be able to Recognize and Report
    to PH!
  • Laboratory Capacity is critical!
  • Contingency Planning is key
  • Incident Command Structures
  • Beds, vents, supplies
  • Health Care Personnel
  • Epi investigation drives control measures
  • Mass vaccination strategies
  • Communication to address changing situations
  • Mental Health Response
  • Coordinated Multidisciplinary Response
  • Etc.

75
The Benefits of All Hazard PlanningBoth
require
  • Developing facility and jurisdictional plans
  • Defined command and coordination systems
    (facility and jurisdictional)
  • Strengthening Surveillance and Reporting
  • Strengthening Laboratory Capacity
  • Enhancing Epi Investigation Capacity
  • Planning for surge capacitybeds, personnel,
    supplies
  • Planning for Mass vaccination / prophylaxis
  • Workforce Training in advance and just in
    time.
  • Credentialing volunteers
  • Interagency and interjurisdictional MOUs
  • Building relationships and Exercising plans
    together

76
CDC and HRSA Preparedness Funds
  • HRSA Hospital Preparedness Program
  • Aimed at strengthening capacity of hospitals and
    the health care systems that support them in
    disaster response
  • CDC Preparedness and Response Program
  • Strengthening public health systems to address
    bioterrorism, infectious disease outbreaks, and
    other public health threats and emergencies

77
Health Care System Preparedness Program WV
Projects (HRSA)
  • Hospital and other facility bio plan template
    developed
  • Regional health care system plan development
  • HEICS Training
  • Communications equipment
  • Linking hospital labs to WVEDSSelectronic
    reporting
  • Education and Training
  • Isolation and Decontamination Capacity
  • Registering and Credentialing Volunteers
  • Etc.

78
PH Preparedness and Response Program (CDC)WV
Projects
  • Agency and jurisdictional planning
  • Strategic National Stockpile Receipt and
    Deployment
  • Mass vaccination / medication planning
  • Building surveillance and epi skills
  • BSL 3 Laboratory
  • Health Alert Network
  • Enhancing Risk Communication Skills
  • Workforce Education

79
WVU VMC Bioterrorism Continuing Education Grant
(HRSA)
  • WV Prepares Project
  • 3 online courses
  • Terrorism Recognition Reporting
  • Multidisciplinary Response
  • Acute Care of Patients from WMD Events

www.vmc.wvu.edu/hrsa/
80
Pandemic Preparedness
  • Strengthening virus surveillanceto detect novel
    strains and monitor impact
  • Research to enhance vaccine production / supply /
    delivery systems
  • Enhancing Antiviral Supply in SNS and setting
    priorities for its use
  • Strengthening annual vaccination programs
  • Assuring an adequate alert system

81
Pandemic Preparedness (contd)
  • Public Health System Planning SNS, Epi
    protocols, etc.
  • Health Care System Planning HEICS, infection
    control, bed / personnel / supplies surge
    capacity, triage sites, alternative sites, etc.
  • Building PartnershipsPublic Health, Clinical
    Medicine, Emergency Management, Law enforcement,
    etc.

82
INFLUENZA and DISASTER RESPONSE - SUMMARY
  • The changing nature of Influenza virus continues
    to pose a threat. The threat is global.
  • Extensive avian influenza activity does spread to
    humans and is now a serious concern.
  • Influenza provides a real life and anticipated
    situation for which we must plan. It is not
    unlike bioterrorism scenarios.
  • Global surveillance is critical for identifying
    new viruses, detecting outbreaks, tracking
    morbidity and mortality, determining vaccine
    composition, etc.

83
INFLUENZA and DISASTER RESPONSE Summary (contd)
  • We may not fully prevent illness and death from
    the next flu pandemic, however
  • With advance planning (agency, jurisdictional,
    and regional), much can be done to reduce its
    impact.
  • Get involved now!

84
Further Influenza Resources
  • http//www.cdc.gov/flu
  • (various materials on flu, training
    opportunities, etc.)
  • http//www.wvdhhr.org/Immunizations/
  • (fact sheets, press releases, etc.)
  • http//www.wvdhhr.org/IDEP/a-z/a-z-influenza.asp
  • (WV flu surveillance data and other items of
    interest)

85
Resources / Linking into WV Preparedness Efforts
  • Regional Health Care System Planning
  • Terry Shorr, WVBPH 304-558-1218
  • Amy Veazey, WVHA 304-344-9744
  • Local Jurisdictional Planning Contact your
    Local Health Department and Office of Emergency
    Services
  • WVU/VMC WV Prepares Courses www.vmc.wvu.edu/hrsa
    /
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