Avian Influenza Bird of a Different Feather A

Avian Influenza: Bird of a Different Feather A Primer to Pandemic Influenza Preparedness Office of Surveillance and Public Health Preparedness Houston Department of Health and Human Services

Agenda • Medical overview • Business continuity planning • What HDHHS is doing

Medical Overview

Types of Influenza • Seasonal Influenza: Annual event (type A and type B strains) – Seasonal (or common) flu is a respiratory illness that can be transmitted person to person. Most people have some immunity, and a vaccine is available. • Avian Influenza: flu in bird populations (wild and domestic) – Avian flu is caused by influenza viruses that occur naturally among wild birds. The H 5 N 1 type A variant is deadly to domestic fowl and can be transmitted from birds to humans. There is no human immunity and no vaccine is available. • Pandemic Influenza: a new type A strain that causes serious illness and death, and spreads easily from person to person worldwide – Pandemic flu is virulent human flu that causes a global outbreak, or pandemic, of serious illness. Because there is little natural immunity, the disease can spread easily from person to person. Currently, there is no pandemic flu.

Seasonal Influenza • Viral Infection of the respiratory tract • Occurs seasonally • Three types A, B and C • Particular nomenclature • Originates in wild aquatic birds • Evades immunity through drift and shift

Pathology of Influenza Infection 1. Binding to Sialic Acid 2. Entering Cell 3. Replication 4. Release From Cell

Clinically Relevant Influenza Viruses Type A Potentially severe illness Epidemics and pandemics Rapidly changing Type B Usually less severe illness Epidemics More uniform Type CUsually mild or asymptomatic illness Minimal public health impact

Antigenic Drift RNA Hemagglutinin Neuraminidase Antibodies Sialic Acid

Antigenic Shift

Avian Influenza • Influenza A subtype • Designated H 5 N 1 • Related to bird migratory patterns, smuggling and travel • Presence of the virus does not signal avian pandemic • Human infections related to close contact • No evidence of sustained human-to-human transmission

Pandemic Influenza • Global outbreak of disease that occurs when a new influenza A virus appears or “emerges” in the human population • May be of avian origin • Caused by new subtypes that have never circulated among people, or by subtypes that have not circulated among people for a long time • Characterized as highly contagious, spreading from person to person, worldwide and causes social and economic disruption • Occurs approximately three times every century

20 th Century Influenza Pandemics 1918: “Spanish Flu” 1957: “Asian Flu” 20 -40 million deaths 1968: “Hong Kong Flu” 1 million deaths H 3 N 2 H 2 N 2 H 1 N 1 1920 H 1 N 1 1940 1960 1980 2000

Influenza Statistics • 5% to 20% of population every year • >200, 000 hospitalizations due to complications • 10, 000 deaths per epidemic are common • 20, 000 to 40, 000 deaths during recent epidemics MMWR. 2000; 49: 1.

Economic Cost of Influenza • Total annual costs of influenza are estimated at $14. 6 billion in the US • 10%: Direct costs of increased medical care • 90%: Indirect costs (lost productivity, employee absenteeism) American Lung Association. Fact Sheet – Influenza. Available at http: //www. lungusa. org/diseases/influenza_factsheet. html.

Surveillance • Three systems coordinated by the CDC – Pneumonia and influenza deaths – Influenza-like illnesses – Physician reporting • Syndromic surveillance

Pneumonia and Influenza Mortality in 122 US Cities CDC. 1999 -2000 influenza season summary. Available at: http: //www. cdc. gov/ncidod/diseases/flu/bigpi. htm.

Signs and Symptoms of Influenza • Sudden fever, usually over 100°F • Muscle aches and pains • Nasal congestion • Dry cough • Chills and/or sweats • Headache • Sore throat • Potentially severe, persistent malaise • Substernal soreness, photophobia, and ocular problems Nasopharynx Trachea

Risk Factors for Influenza Complications (CDC) • Age 50 yrs • Residence in nursing home/chronic care facilities • Chronic pulmonary disease (eg, asthma, COPD) • Chronic cardiovascular disease • Chronic metabolic diseases, renal dysfunction, hemoglobinopathy • Immunosuppression • Long-term aspirin therapy (ages 6 mos-18 yrs) • Second or third trimester pregnancy MMWR. 2000; 49: 6 -7.

Prevention and Treatment • Vaccination • Antivirals

Inactivated Influenza Virus Vaccine Content Updated yearly to protect against anticipated strains, consists of type A (2) (1) Process Grown in embryonated chicken eggs and formalin inactivated and type B

Live Attenuated Influenza Vaccine (LAIV) • Licensed for use in the U. S. begins in 2003 • The protective mechanisms are not completely understood • Children and adults can shed vaccine viruses for >2 days after vaccination • Advantages include: – Induce a broad mucosal and systemic immune system – Acceptability of an intranasal route of administration

Influenza Virus Vaccine • Efficacy – Varies with age and immunocompetence – Depends on match between projected vs actual strains • Children/Teens – Stimulates high HA-inhibition antibody titers – Prevents infection • Elderly – Produces lower HA-inhibition antibody titers – May not eliminate URTI susceptibility – May reduce LRTI morbidity/mortality MMWR. 2000; 49: 5.

Effectiveness of Influenza Vaccine • Most effective (70%-90%) in preventing illness in persons aged <65 yrs • 30%-40% in preventing illness in frail elderly • Overall significantly protects against the severe complications of influenza: hospitalizations and death

Get the Influenza Vaccine • October through November in the Fall • Only one shot is needed for older children and adults • Two does may be required for unvaccinated children aged less than nine years

Who Should Receive Influenza Vaccine (CDC) • Persons aged 50 yrs • Persons at increased risk (age 6 mos) • Hospital and outpatient employees • Nursing home employees with patient contact • Home health care providers working with high-risk persons • Household members of high-risk persons • Pregnant women in 2 nd or 3 rd trimester • Persons desiring to avoid influenza infection MMWR. 2000; 49: 6 -7.

Side Effects of the Influenza Vaccine • Soreness at injection site (common, mild, and transient) • Systemic and febrile reactions, esp in young children (infrequent) • Immediate hypersensitivity reactions to egg protein (rare) • Guillain-Barré syndrome (rare) MMWR. 2000; 49: 11 -12.

Who Should Not Receive the Vaccination • An allergic reaction to chicken eggs (welts, tongue swelling, difficulty breathing, loss of blood pressure, etc. ) • A previous serious reaction to an influenza shot • A rare paralytic disorder called Guillain-Barré Syndrome which was thought to be cause by a pervious influenza shot • A current illness with fever

Treating Influenza with Antivirals Influenza A and B • Amantadine • Zanamivir • Rimantadine • Oseltamivir Phosphate

What To Do If You Develop Influenza • If symptoms present less than two days, discuss specific antiviral treatment with your physician • For fever and muscle aches: • Aspirin if you are 18 years of age or older • Or Acetaminophen • Or Ibuprofen • Liquids and nutrition • Rest • See your physician if symptoms worsen

Prevention: Simple Steps • Vaccine • Hygiene • Public Health Measures 1. Cover Your Cough. 2. Wash Your Hands. 3. Get your seasonal flu shot. 4. Keep all your immunizations current.

Business Continuity Planning

Goals • Containment of disease • Reduction of the impact by controlling the spread of disease • Maintenance of essential services Reputation People Organization Information Customers Operation

Evaluation • Identification of essential business activities • Mitigation of business / economic disruptions • Minimizing illness

Strategy • Communication • Containment • Continuity

Communication Programs Materials Strategies Insurers Health Plans Healthcare Providers PH Agencies Communication Plan Other Business Entities Internal Communication / Education External Coordination

Containment • Restrict workplace entry • Emphasize personal hygiene • Social distancing • Manage staff

Cover Your Cough • Cover nose and mouth when sneezing • Use a tissue and dispose once used • Keep hands away from nose, mouth and eyes • Ask people to do the same

Hand Washing • The most important action can do • Soap and water (10 -20 seconds) • Alcohol-based sanitizer (15 seconds)

Work Place Disinfectant • Influenza viruses inactivated by alcohol or chlorine • Surfaces touched by hands should be cleansed daily • 1: 5 dilution of hospital grade bleach • Granular chlorine • 70% isopropyl alcohol • 60% ethyl alcohol

Social Distancing • Avoid face-to-face meetings • Avoid congregations • 3 Feet rule • Ghost shifts

Manage Staff • Encourage, manage and track influenza vaccination • Establish healthcare resources • Flexible scheduling • Encourage working from home • Oversee travel

Continuity • Identification of core people and skills • Business planning for absence • Knowledge management • Communication

Identification of Core People and Skills • What are the essential parts of the business • Who are the core people required to keep the business running • What are the core skills required • Who are the back-ups • Who will manage the pandemic component

Business Planning for Absence • What is the minimal number of staff required • Where can additional staffing be found • Can operations be shifted • Plan for essential incidentals: food, water, gas

Knowledge Management • Develop a plan • Key operating and emergency management information needs to be readily accessible • Implement exercises and drills to practice • Test plan regularly

Steps to Take During a Pandemic – Early Stages 1. Provide 2. Remind 3. Implement hand sanitizers disease transmission surgical gloves hand hygiene masks cough and sneeze etiquette symptoms policies contact info travel restrictions 4. Track 5. Inform illness pattern disease pattern official recommendations

During a Pandemic • Implement flexible work schedules and telecommunicating plans • Continually monitor supply chain • Continually monitor ability to meet contractual commitments • Continually re-stock hand sanitizers, masks, and gloves • Follow directions of public health authorities • Monitor CDC, WHO, and HDHHS official websites • Make work place vaccination available if possible • Communicate with customers, suppliers and employees • Assess financial impact and communicate with markets

Maintenance of Essential Business Activities • Identification of core people and core skills • Business planning for absence (for peak rate of 30 -60%) • Communication • Knowledge management • Short, medium and long term planning • Reasonable risks to employees and others • Deciding whether a workplace should stay open or close

Summary • Educate key stakeholders • Develop and empower multi-disciplinary team • Design a strategic comprehensive preparedness plan • Implement surveillance program • Execute with flexibility and responsiveness Education & Communication Business Operations Facility Preparedness Illness Surveillance

What HDHHS is Doing

Overview of Pandemic Influenza Preparedness • “The Plan” is to provide guidance for HDHHS and partners on how to respond during three periods (WHO) – Pre pandemic period – Inter pandemic period – Pandemic alert period

WHO Pandemic Phases Inter-Pandemic Period Phase 1: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in humans, the risk of human infection or disease is considered low Phase 2: No new influenza virus subtypes have been detected in humans. However a circulating animal influenza virus subtype poses a substantial risk of human disease Pandemic Alert Period Phase 3: Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact. Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk). Pandemic Period Phase 6: Pandemic – increased and sustained transmission in the general population.

Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H 5 N 1) Reported to WHO as of 16 June 2006 2003 Country cases 2004 deaths cases 2005 deaths cases 2006 deaths cases Total deaths cases deaths Azerbaijan 0 0 0 8 5 Cambodia 0 0 4 4 2 2 6 6 China 0 0 8 5 11 7 19 12 Djibouti 0 0 0 1 0 Egypt 0 0 0 14 6 Indonesia 0 0 17 11 32 26 49 37 Iraq 0 0 0 2 2 Thailand 0 0 17 12 5 2 0 0 22 14 Turkey 0 0 0 12 4 Viet Nam 3 3 29 20 61 19 0 0 93 42 Total 3 3 46 32 95 41 83 53 227 129 Total number of cases includes number of deaths. WHO reports only laboratory-confirmed cases. Latest data available online at: http: //www. who. int/csr/disease/avian_influenza/country/en/

Emphasis of Pandemic Influenza Preparedness • Preventative measures – Education – Healthy practices – Good hygiene – Vaccination

Key Elements of Pandemic Influenza Preparedness • Planning, command coordination • Surveillance, investigation and protective public health measures • Laboratory testing • Infection control & containment • Healthcare and emergency response • Communication and public outreach • Maintenance of essential business activities

What HDHHS Has Done • Planning command control • Surveillance, investigation and protective public health measures • Laboratory testing • Infection control & containment • Healthcare and emergency response

Implications of Pandemic Influenza • Shortage of Available Workers at ALL levels • Disruptions in Supply Chains • Behavioral Changes to Prevent Spread • Increased Demand for Certain Services and Products • Decreased Production • Increased Illness and Loss of Life

State Normal School volunteers preparing food during 1918 influenza pandemic

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