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Information about Pandemic Influenza

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Information about Pandemic Influenza Harvey Kayman, MD, MPH, PHMO III California Department of Public Health Division of Communicable Disease Control – PowerPoint PPT presentation

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Title: Information about Pandemic Influenza


1
Information about Pandemic Influenza
  • Harvey Kayman, MD, MPH, PHMO III
  • California Department of Public Health
  • Division of Communicable Disease Control
  • Immunization Branch

2
Objectives
  • Learn about Pandemic Influenza
  • Learn how to prevent, protect, and mitigate
  • Learn what challenges we face

3
The three criteria of a Pandemic
  • Ability to isolate a new influenza virus from a
    human.
  • Can be spread from human to human.
  • Spreads worldwide.

4
An influenza A pandemic
  • is a global disease outbreak.
  • occurs when there is little or no immunity to
    that strain of influenza in the human population.
  • causes serious illness, and can sweep through
    populations.

5
Seasonal versus Pandemic Influenza
  • Drift Slight changes-H3N2 to new H3N2Seasonal
    Influenza
  • Shift Big changes-
  • H5N1 appears in Humans
  • Pandemic Influenza

6
The AVIAN H5N1 virus has raised concerns about a
potential human pandemic because
  • It is especially virulent.
  • It is being spread by migratory birds and
    transported domestic poultry.
  • It can be transmitted from birds to mammals and
    in some limited circumstances to humans.

7
The origins of influenza A virus
  • Human influenza A viruses start as avian (bird)
    influenza viruses

Migratory water birds
Humans and other animals
Domestic birds
8
Rapid Worldwide Spread
  • The entire world population is susceptible to a
    pandemic with a new strain of virus.
  • Countries can delay arrival of the virus.

9
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10
Pandemics are not new
  • Pandemics since, at least, the sixteenth century.
  • The 1918 Spanish flu, is generally regarded as
    the most deadly disease event in human history.

11
History of PI Deaths in the 20th century
  • 1918 PI-500,000 U.S. deaths and up to 40 million
    deaths worldwide.
  • 1957 PI-70,000 U.S. deaths and 1-2 million deaths
    worldwide.
  • 1968 PI-34,000 U.S. deaths and 700,000 deaths
    worldwide

12
History of PI in the 20th century
13
Flu after WW I
  • While most deaths from seasonal influenza occur
    in the very young or very old, the deaths from
    this pandemic were primarily in those aged 15-35,
    with 99 of deaths in those under 65.

14
Case-fatality rates (panel C, solid line 1918-19
dotted line-usual seasonal flu
15
Waves of severe illness
  • Pandemics occur in waves of sickness, and the
    virus may increase in potency between outbreaks.
  • The mortality rate of the pandemic of 1918-1919
    increased tenfold with the arrival of the second
    wave.
  • Waves generally last two to three months.

16
Three pandemic waves weekly combined flu and
pneumonia mortality, U K, 19181919 (21).
17
Characteristics
  • The influenza virus mutates and evolves often
    during Pandemics and between seasons.
  • Illness is more severe if the virus attaches to
    lung tissue and causes an extreme immune
    response.

18
Contagiousness
  • The typical period between infection and the
    onset of symptoms is two days
  • Persons who have become ill may transmit the
    infection as early as one day before the onset of
    symptoms
  • The risk of infection is greatest the first two
    days of illness
  • Children play a substantial role in the
    transmission of influenza

19
Potential Risk Factors for Humans
  • Slaughtering,
  • De-feathering, or
  • Preparing sick poultry for cooking
  • Playing with or holding diseased or dead poultry
  • Handling fighting cocks or ducks that appear to
    be well and
  • Consuming raw or undercooked poultry or poultry
    products NEJM 2008358261-73.(1/17/08)

20
High death rates may be largely determined by
four factors
  • (1) the number of people who become infected
  • (2) the virulence of the virus
  • (3) the underlying characteristics and
    vulnerability of affected populations and
  • (4) the degree of effectiveness of preventive
    measures.

21
H5N1 Cases and Deaths as of May, 2008 WHO
22
Potential need for care in USA
Characteristic Moderate Severe
Ill 90 million 90 million
in OPD 45 million 45 million
need Hospital 1 million 10 million
need ICU 125,000 745,000
Ventilators 65,000 745,000
of Deaths 200,000 2 million
23
Citizens develop strategies for action In Kansas
City 2008
  • Most people know very little about pandemic flu.
  • Workshop participants grappled with the question
    of how to inform people of the need to prepare
    for pandemic flu in a way that would encourage
    action.
  • One KC Voice Pandemic Flu Citizen Engagement
    Project 2008

24
Barriers to preparation
  • The need to earn a paycheck.
  • No sense of urgency, and no perceived incentives
    for action.
  • Few neighborhood, church and school leaders are
    involved in preparing for pandemic flu.
  • People will disregard health department
    advisories if they feel they need to care for
    children or parents.
  • One KC Voice Pandemic Flu Citizen Engagement
    Project 2008

25
Protective and Mitigating responses
  • Cross sector planning and collaboration including
    governmental preparedness
  • Cross boundary planning and collaboration
  • Adopt unified command structure, and vocabulary
    using Incident Command System
  • Improve and expand training systems
  • Legal issues and legal system

26
Obtain and Track Impact of the Pandemic
(Surveillance)
  • Detect initial cases of PI
  • Identify virus and treatment susceptibility in
    Laboratory
  • Improve electronic data reporting system to
    track
  • Attack rates
  • Rates of influenza hospitalization
  • Case fatality rates
  • Isolated and quarantined persons, treatment and
    support.

27
Protective and Mitigating responses
  • Vaccine
  • Antiviral medications
  • Other medications to reduce inflammation ??
  • Personal protective equipment Masks and
    respirators, etc.

28
ImmunizationN Engl J Med 2008358261-73.
  • Safe and immunogenic inactivated H5 vaccines have
    been developed.
  • Decisions regarding the use of vaccine before a
    pandemic and stockpiling require complex
    riskbenefit and costbenefit analyses
  • Effects on the seasonal capacity of vaccine
    production, timing and cause of the next
    influenza pandemic are unknown, and
  • Unclear if immunization of large populations
    could have adverse consequences.

29
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30
Anti-Viral Drug treatment
  • Early treatment with oseltamivir (Tamiflu) is
    recommended,
  • Rx may improve survival,
  • Optimal dose and duration of therapy uncertain.
  • Mortality remains high despite oseltamivir
  • Late initiation of therapy a major factor.
  • N Engl J Med 2008358261-73.

31
Initiate Social Distancing
  • Dismiss students
  • Cancel large gatherings
  • Restrict mall usage and business activities.
  • Restrict travel on public transportation.

32
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33
Communications
  • Improve risk communication, both to and from
    constituents.
  • Improve interoperable communications networks
    between State, public health, health care
    community, EMS,
  • 9-1-1, emergency management, public safety etc.

34
Protective and Mitigating responses
  • Prepare for security and law enforcement
    challenges.
  • Prepare for ethical challenges and the least
    unfair resource allocation.
  • Prepare for spiritual challenges on population
    and personal levels.

35
Protective and Mitigating responses
  • Anticipate concerns and needs of at-risk
    individuals and populations.
  • Attend to Mental Health/Disaster mental health
    system design.

36
Assessment and Concerns
  • Assess available work capacities, commodities,
    equipment, and personnel for all sectors.
  • Improve Health Care system SURGE capacity
  • Create protocols to expand healthcare services

37
Ports of Entry
  • Develop a port of entry (POE) communicable
    disease response plan for locations with a
    Quarantine Station --which includes ill passenger
    assessment and isolation procedures
  • Ready legal orders for detention, isolation,
    quarantine, and conditional release of passengers
    or crew members
  • Prepare for serious mental health challenges at
    Ports of Entry.

38
Community disease containment
  • WHO recommendations
  • advise ill people to remain at home
  • use measures to increase social distance
  • mask use by the public should be based on risk
    routine mask use should be permitted, but not
    required
  • hand hygiene and respiratory hygiene/cough
    etiquette should be strongly encouraged

39
Community disease containment
  • Although nonpharmaceutical interventions may be
    the only interventions available for community
    disease containment early in a pandemic, the
    effectiveness of such interventions has not been
    well studied

40
Health Care Systems Overloaded
  • Infection and illness rates may soar.
  • A substantial percentage of the worlds
    population will likely require some form of
    medical care.
  • Nations are unlikely to have the staff,
    facilities, equipment and hospital beds needed to
    cope with large numbers of people who suddenly
    fall ill.

41
Medical Supplies Inadequate
  • The need for vaccine is likely to outstrip
    supply.
  • The need for antiviral drugs is also likely to be
    inadequate early in a pandemic, so will need to
    be allocated.
  • Difficult decisions will need to be made
    regarding who gets antiviral drugs and vaccines.

42
All Supplies Inadequate
  • A pandemic can create a shortage of hospital
    beds, ventilators and other supplies.
  • A pandemic can create a shortage of all
    commodities especially fuel, food, and
    essentials.
  • Surge capacity at non-traditional sites such as
    schools may be created to cope with demand.

43
Economic and Social Disruption
  • Travel bans, student dismissal, closure of
    businesses and cancellations of events could have
    major impact on communities and citizens.
  • Care for sick family members and fear of exposure
    can result in significant worker absenteeism.

44
Economic costs
  • According to the Congressional Budget Office, an
    outbreak on the scale of the 1918 pandemic could
    result in a loss of 5 of gross domestic product,
    or a national income loss of approximately 600
    billion dollars.

45
A Framework for Planners Preparing to Manage
Deaths
  • It is clear increased numbers of natural deaths
    in a potentially short period of time will place
    considerable pressure on all local Public
    Services providers.
  • Systems for receiving and disseminating
    information will need to be robust and capable of
    moving at a fast pace-tell it all, tell it
    truthfully and tell it quickly.
  • The Home Office Mass Fatalities Section
    (Pandemic Influenza Consultation) London
  • http//www.ukresilience.info/upload/assets/www.ukr
    esilience.info/flu_managing_deaths.pdf

46
Trigger Points for Different Ways of Working
  • Scale of increased deaths.
  • Limited storage space at local mortuaries and
    funeral parlors
  • Absenteeism.
  • How to complete death certificates.
  • Political policy formulation and implementation
    the activation of emergency regulations.
  • Combination of pressure points.

47
Holding and Burial sites
  • Limited capacity to hold the deceased prior to
    funerals at hospital mortuaries, public
    mortuaries, in private homes and funeral parlors.
  • Use of refrigerated vehicles and trailers?
  • Cemetery managers should plan for alternative
    ways of providing graves.
  • Move to provision of common graves?
  • Common graves should be deep enough to allow for
    additional family burials.

48
Time to prepare
  • While no one can state with complete certainty
    that a pandemic will occur, the signs point to it
    being a prudent time to begin careful and
    thorough preparation.

49
Business Continuity Planning and Pandemic
Influenza in Europe (Coker report 2008)
  • Demonstrate Leadership Commitment
  • Develop Business Continuity Plans (BCP)
  • Identify Risks and Quantify Impacts
  • Provide Information, education and communication

50
Business Continuity Planning and Pandemic
Influenza in Europe (Coker report 2008)
  • Attend to Occupational Health and Safety
  • Review Human Resource Policies
  • Assess the resiliency of supply chain
  • Ensure continued access to financial resources

51
COLLABORATION AND COORDINATION (Coker report
2008)
  • Sharing of best practices with business partners,
    the community and within the industries must be
    encouraged
  • Public-private collaboration must be facilitated

52
COLLABORATION AND COORDINATION (Coker report
2008)
  • The allocation and commitment of specific
    resources to pandemic preparedness and response
    have to be considered as a crucial component of
    the planning

53
PUTTING PLANS INTO ACTION (Coker report 2008)
  • Whenever it is possible, every employer should
    test the effectiveness of their plans
  • RECOVERY PLANNING
  • There is an urgent need to encourage
    organizations to prepare for the recovery and
    this area should be addressed in all
    organizational guidance
  • An Analysis of Independent Sector and National
    Governments Guidance. Alexandra Conseil, Sandra
    Mounier-Jack and Dr. Richard Coker (London School
    of Hygiene and Tropical Medicine (LSHTM),
    6/12/08) www.lshtm.ac.uk/ecohost/flupanbcp

54
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55
WHO tests capacity to respond
  • Exercise in Vancouver, B.C. (6/08) was designed
    and conducted to test how well the WHO can use
    the new International Health Regulations.
  • A global health treaty that requires countries to
    report disease outbreaks that might have
    international ramifications.

56
Los Alamos mathematical model uses anomaly
detection
  • Identifies subtle changes in epidemiological
    data.
  • Uses far less data over shorter time frames, not
    huge amounts of data for accuracy,
  • Can be used on data from a handful of infected
    people in a remote village.

57
General Resources
  • Links to Additional Information
  • http//www.pandemicflu.gov/ (managed by the
    Department of Health and Human Services)
  • http//www.cdc.gov/flu/avian/ (managed by the
    Centers for Disease Control and Prevention)

58
Resources for this presentation
  • http//www.medicalreservecorps.gov/File/MRC_Pandem
    ic_Influenza_Planning_Guidance.pdf
  • http//www.flcourts.org/gen_public/emergency/index
    .shtml).
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