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Local and Global Public Health Links: Preparation for an Influenza Pandemic

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Title: Local and Global Public Health Links: Preparation for an Influenza Pandemic


1
Local and Global Public Health Links Preparation
for an Influenza Pandemic
  • Nicole J. Cohen, MD, MSc
  • Chicago Department of Public Health
  • The University of Chicagos Summer Institute for
    Educators
  • June 29, 2006

2
Influenza Virus
  • Three types of influenza virus A, B, C
  • Only influenza A and B viruses cause significant
    disease and epidemics in humans

3
Influenza A Viruses
  • Classified into subtypes based on two surface
    proteins, hemagglutinin (HA) and neuraminidase
    (NA)
  • 16 HAs and 9 NAs in total
  • Currently in humans
  • H1N1
  • H3N2

4
Influenza A Susceptible Hosts
5
Influenza B Viruses
  • No subtypes
  • Infect humans almost exclusively

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7
Avian Influenza
  • Infection of bird with influenza A virus
  • Different strains from the ones that cause human
    infections annually
  • Occurs naturally
  • High vs low pathogenicity viruses
  • Highly contagious among bird populations
  • Usually spread from wild birds to domestic
    poultry
  • May be carried by birds without causing disease
  • May cause severe illness and/or death among birds
  • Rarely infects humans

8
Symptoms of Avian Influenza in Humans
  • Wide range of symptoms depending on type of virus
  • Typical flu symptoms (fever, cough, sore throat,
    muscle aches)
  • Conjunctivitis (eye infection)
  • Viral pneumonia
  • Severe respiratory illness
  • May be life threatening

9
H5N1 Influenza Virus
  • 1996 First identified in a goose in China
  • 1997 First human cases in Hong Kong
  • 18 confirmed cases, 6 deaths
  • 150 million chickens slaughtered to control
    outbreak
  • 2/2003 Two cases in a Hong Kong family who
    traveled to mainland China

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12
Current Situation Human Cases -- June 20, 2006
  • Azerbaijan
  • Cambodia
  • China
  • Djibouti
  • Egypt
  • Indonesia
  • Iraq
  • Thailand
  • Turkey
  • Viet Nam

228 Cases 130 deaths Death rate approximately 50
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15
How avian influenza infects people
  • Virus present in respiratory secretions and feces
    of infected birds
  • Human infection has resulted from
  • Close contact with infected birds
  • Contact with or consumption of raw poultry
    products
  • Contact with contaminated surfaces (feces)
  • Generally has not spread from person to person
  • Has been suggested in several small family
    clusters after extremely close contact with sick
    person
  • Has not spread beyond one person
  • Has not spread to health care workers

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17
How human influenza spreads
  • Respiratory droplets
  • Coughing, sneezing
  • Spreads through close contact (less than 3 feet)
  • Prevent by covering cough, wearing masks in
    medical situations
  • Hand contamination then touching eyes, nose, or
    mouth
  • Direct contact e.g. shaking hands with infected
    person
  • Contact with objects contaminated by influenza
    viruses (e.g. doorknobs, phones)
  • Prevent by hand hygiene, gloves in medical
    situations

18
H5N1 Is there a vaccine?
  • A vaccine against H5N1 is under development
  • Not commercially available
  • Annual influenza vaccine does not protect against
    H5N1

19
H5N1 Is treatment available?
  • Most H5N1 viruses are resistant to older class of
    antivirals (amantadine and rimantadine)
  • May be treated with newer antivirals Tamiflu or
    Relenza
  • Effectiveness is not known
  • Some resistance to Tamiflu has been identified

20
Advice for Travelers
  • CDC has not recommended that the general public
    avoid travel to any of the countries affected by
    avian influenza
  • Receive routine flu vaccine (if available) prior
    to departure
  • If traveling to any country with a known outbreak
    of H5N1 influenza
  • Avoid poultry farms
  • Avoid contact with animals in live food markets
  • Avoid contact with any surfaces that appear to be
    contaminated with feces from poultry or other
    animals

21
Advice for Travelers
  • Practice careful hand hygiene, especially after
    handling raw poultry
  • It is safe to eat poultry or eggs that have been
    properly handled and cooked
  • Monitor your health for 10 days after returning
  • Seek medical attention if symptoms of fever or
    respiratory illness develop

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23
Pandemic Influenza
  • Worldwide outbreak of a novel (new) influenza
    virus
  • Occurs infrequently and at irregular intervals
  • Unpredictable
  • Potential for substantial impact
  • Morbidity (illness) and mortality (death)
  • Social disruption
  • Economic costs

24
20th Century Influenza Pandemics
  • 1918-1919 Spanish Flu (H1N1)
  • gt 500,000 US deaths
  • gt 20 million deaths worldwide
  • 1957-1958 Asian Flu (H2N2)
  • 70,000 US deaths.
  • 1968-1969 Hong Kong Flu (H3N2)
  • 34,000 US deaths

25
Influenza Pandemic 1918
26
How does a pandemic happen?
  • 4 factors must be present
  • Novel virus
  • Virus capable of causing disease in humans
  • Susceptible population
  • Virus that is transmissible from person to
    person
  • Current avian influenza outbreak is not a pandemic

27
Where do new influenza strains come from?
  1. Mixing of human and animal influenza strains
  2. Adaptation of an animal strain to allow person to
    person spread

28
WHO Pandemic Phases
29
Issues of Concern
  • Potential rapid worldwide spread due to global
    trade and international travel
  • Medical resources may be insufficient
  • Medical personnel at high risk of infection
  • Pandemic would likely be prolonged
  • Community infrastructure disruption
  • Major economic impact

30
Estimated Impact of Medium-Level Pandemic, US
  • As much as 35 of population could be affected
  • 47 million people
  • As many as 734,000 hospitalizations
  • As many as 207,000 deaths
  • Economic impact could range between 71.3 and
    166.5 billion

31
On the bright side
  • Pandemic influenza planning is occurring at the
    local, state, national and international levels
  • Surveillance for new influenza strains in birds
    and humans is ongoing to allow for early
    detection
  • Experience with SARS has led to increased
    awareness and preparedness to deal with global
    infectious disease emergencies
  • Medical care and isolation capabilities are more
    sophisticated than during 1918

32
Global Public Health Surveillance
  • International Health Regulations revised 2005
  • Defines Public Health Emergency of International
    Concern (PHEIC)
  • Contains a decision instrument to help countries
    determine whether reporting to WHO is necessary
  • Includes a list of diseases to be reported
    immediately, even if single case
  • Encourages countries to consult WHO for events
    that may be of public health relevance

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34
Pandemic Influenza Planning
  • Goals
  • Limit total burden of disease (illness and death)
  • Decrease social disruption
  • Decrease economic loss
  • Engage all levels of health care system, public
    health, and emergency response
  • Include public and private sectors
  • Key similarities (and differences) between
    pandemic response and other health emergencies
  • Planning, resources, and implementation

35
Local Planning an Influenza Pandemic
  • Surveillance recommendations
  • Laboratory recommendations
  • Antiviral plan
  • Vaccine distribution plan
  • Containment including isolation and quarantine
    issues
  • Surge capacity, mortuary issues, and mass care
  • Communications
  • Public information

36
Vaccine and Antiviral Medications
  • Vaccine
  • Will probably not be available in early stages of
    a pandemic
  • Even when vaccine does become available, supplies
    will be limited
  • Prioritization will have to occur
  • Antiviral medications
  • Stockpiled supplies are limited but increasing
  • Resistance may be a problem
  • Prioritization will have to occur

37
Controlling a Pandemic
  • Early identification and isolation of ill people
    will be critical
  • Close monitoring and possible quarantine of
    exposed contacts
  • Basic infection control measures
  • Social Distancing
  • Public transportation
  • Large gatherings/special events
  • Schools

38
Preventing Spread of Influenza
  • Preventing illness
  • Wash your hands
  • Stay away from people who are sick
  • Get your flu vaccine!
  • If symptomatic with a respiratory illness
  • Cover Your Cough
  • Wash your hands!
  • Dont visit friends or family in hospital or a
    long term care facility
  • If diagnosed with influenza
  • Dont go to work or attend school while
    symptomatic

39
Corporate (Workplace) Preparedness
  • Encourage respiratory and hand hygiene in the
    workplace
  • Ensure appropriate hygiene supplies and
    facilities are available
  • Discourage employees diagnosed with influenza
    from working while symptomatic
  • Plan for functioning with high levels of
    absenteeism
  • Mechanisms for employees to work from home, if
    possible

40
Preparedness in Schools
  • Hygiene messages/posters
  • Disease surveillance
  • Systematic exclusion of sick students and staff
  • Consider the possibility of school closures
  • Who makes this decision?
  • Mandatory closures vs self-shielding behaviors
  • Continuity of education

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43
Personal/Family Emergency Preparedness
  • Prepare a disaster supply kit for 3 days (general
    emergencies)
  • Create a Family Emergency Plan
  • Know where to access accurate information

44
Personal and Corporate Antiviral Stockpiles A
Bad Idea!!!
  • Depletion of resources from the public sector
  • Inadequate supplies for treatment and prophylaxis
    during seasonal influenza outbreaks
  • Potential for misuse (wasting) during
    non-influenza respiratory infections
  • Potential for development of resistance
  • Incomplete courses, incorrect dosing, sharing
  • Cost
  • Inequitable distribution of drug
  • Shelf life/expiration

45
For more information
  • http//www.cdc.gov/flu/avian/
  • http//www.who.int
  • http//pandemicflu.gov/
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