Pandemic Influenza Larimer County Community Leaders Awareness Meeting

Pandemic Influenza Larimer County Community Leaders Awareness Meeting Dec. 6, 2005

Larimer County in 1918 n County n Fort population about 27, 000 Collins population 8, 700 n Loveland population about 5, 000

Social Environment in 1918 n Most residents involved in agriculture, directly or indirectly n World War I was the major news story n There was rationing of coal, fuel, food and other items needed for war effort n Red Cross was very active in community, supporting war effort

Outbreak begins in military training camps Deaths occurring in training camps in East were reported in local newspapers n Numerous Larimer County enlistees/ draftees were among the fatalities (4 from Camp Dix, NJ in 1 wk. ) n

Spreading to Civilians Larimer County residents were aware of growing, alarming deaths among civilians in Eastern cities n First cases in CO in Boulder; army trainees on College campus. (First cases in FC at Ag College) n

Flu shut down schools and businesses Loveland schools closed on Oct. 8 n Fort Collins closed schools on Oct. 10 n They would not reopen until Dec. 30

1918 Flu killed young adults n Highest number of deaths were in the in late teens through the mid 30’s

By the end of the outbreak n Overall, there were 67 deaths in Loveland, a town of 5, 000 in a 15 week period. n This represented an overall death rate of 1. 3% of the population.

Why are we concerned today?

“We at WHO believe that the world is now in the gravest possible danger of a pandemic" Shigeru Omi, World Health Organization , 2005

Pandemic influenza is the“the most important threat that we are facing right now. “ Julie Gerberding, CDC director, 2005

“It will be absolutely essential that local communities are well prepared, have a plan, and have sorted out who will be responsible for what. ” Michael Leavitt, U. S. HHS director

“Localities should be prepared to rely on their own resources to respond. ” U. S. draft pandemic influenza plan, 2005

Influenza n Outbreaks yearly, usually in winter months n Illness more severe for very young, elderly, or those with pre-existing health conditions n Yearly, 5 -20% of population get the flu n Annually causes >200, 000 hospitalizations in US n 36, 000 deaths yearly in US

Influenza Prevention n Yearly influenza shot n Avoid those who are ill n Wash your hands n Antivirals (in special circumstances) If you are ill--don’t come to work, cover coughs and sneezes.

Influenza Virus types – Type A: Infects humans and other animals § More severe illness § Causes regular epidemics; can cause pandemics – Type B: Infectious only to humans § Causes epidemics, but less severe illness

n Influenza A is subtyped by surface Influenza proteins – Hemagglutinin (H) § 16 different types § Helps virus enter cells – Neuraminidase (N) § 9 different types § Helps virus leave cell to infect others

Influenza n All known subtypes of Influenza A found in birds - 144 possible combinations of H’s and N’s n H 5 and H 7 cause severe outbreaks in birds n Human disease usually due to H 1, H 2, H 3 and N 1 and N 2.

Influenza The flu virus constantly changes n When it does, vaccines will be less efficient n Immune system may be unable to recognize new virus – No immunity in population for new virus —potential for pandemic

Vaccine Development Inactivated trivalent vaccine (killed vaccine) n 2 A, 1 B n Effectiveness of vaccine depends on “match” between circulating strains and those in vaccine n 2005– 2006 Influenza Season A/New Caledonia/20/99 -like A/California/7/2004 -like (H 1 N 1) (H 3 N 2) Influenza Protection B/Shanghai/361/2002 -like

Influenza—Vaccine Production n Flu vaccines first produced in 1940 s n 2 manufacturers in US for flu vaccine n 80 million doses produced by late September n 6 -9 months to produce vaccine

Influenza Pandemics n What is a Pandemic? – Outbreak in wide geographic area (global) – Effects large # of people with serious illness – Usually a new virus or one which population has not had exposure in a long time – May have rapid spread – May occur in waves

Seasonal Flu vs Pandemic Flu Seasonal n Occurs every year Occurs during winter (usually Dec-Mar) n Most recover in 1 -2 weeks without tx n Very young, very old, ill most at risk of serious illness n n n Pandemic Occurs infrequently (3 per century) Occurs any time of year Some may not recover, even with tx People of all ages may be at risk

Pandemic Influenza n Past Pandemics: – 1968 Hong Kong Flu (H 3 N 2) – 1957 Asian Flu (H 2 N 2) – 1918 Spanish Flu (H 1 N 1)

1918 -1919 influenza pandemic § Worst of past century § Estimated 20 -40% of world population ill § 40 -50 million people died worldwide § 600, 000 or more deaths in US § High mortality in young adults

Why did young people die? n Over-reaction by the immune system called “cytokine storm” n Those with the strongest immune systems affected n Older people and youngest often die of bacterial pneumonia complicating flu -treatable now with antibiotics n Even in 2005, no good treatment for “cytokine storm. ”

There are severe pandemics and mild pandemics

Infectious Disease Deaths 1900’s Deaths per 100, 000 per year 1957 1918 1968

Pandemics can last for months and come in waves

H 5 N 1 Avian Influenza n Hong Kong 1997 – 18 human cases, 6 deaths – 1. 4 million birds destroyed n Dec. 2003: Asia – Ongoing extensive outbreak in poultry – Limited human to human transmission – 125 human cases, 64 fatal n July-Aug 2005 Kazakhstan, Russia n October 2005 Turkey, Romania, Russia

H 5 N 1 Symptoms n Symptoms (human) – Fever – Shortness of breath – Cough – Pneumonia – Acute Respiratory Distress – Diarrhea, sometimes severe – Life-threatening complications

Transmission of flu virus n Incubation period of 1 -4 days for regular flu - not clear if H 5 N 1 might be longer n Can be communicable to others 24 hours before symptoms begin - and up to 5 days or more after onset (adults) or 10 or more days (children) n Usually spread through respiratory droplets or contaminated objects. May also be airborne, and perhaps thru feces.

Concern with Avian Influenza n Virus mutates rapidly n Can acquire genes from viruses infecting other species n H 5 N 1 has acquired some of genetic changes in the 1918 virus associated with human-human transmission n Causes severe disease in humans n High fatality rate

Are we more or less at risk today compared to 1918?

Why at LESS risk in 2005 n Antibiotics for bacterial pneumonia complications of influenza n Some antiviral medicines n IV fluids, ventilators n Greater ability to do surveillance, confirm diagnosis of flu

Why at LESS risk in 2005 n Rapid means of communications internet, TV, radio, email n More effective personal protective equipment n Fewer people living in each household and more rooms.

Why at MORE risk in 2005 n. A lot more international travel n 10 times more people in Larimer County, contact with far more people daily n Very little surge capacity in health care today n Greater reliance on health professionals

Why at MORE risk in 2005 n More elderly and immunecompromised people in population n Much less self-sufficient than in 1918’s (households and businesses) n Today’s society not used to rationing, sacrifice, compared to war-time 1918.

Why at MORE risk in 2005 n Far more manufactured goods and raw materials come from distant areas, especially Asia n “Just-in-time” ordering of needed supplies instead of warehousing critical items on site

Overall, are we at more or less risk? n Up to individuals, communities, states, and nations to decide as they plan for a possible pandemic

What might happen in a severe pandemic?

If it happens soon…. . n There will be little or no vaccine until 6 - 9 months after the outbreak begins n There will be very limited supplies of antiviral medicines for treatment (for 1% of populations, perhaps less). n All communities hit a about the same time n We need a plan for the short-term that assumes no effective shots or Rx

What might occur n Health system could be overwhelmed n Essential services could be at risk (fuel, power, water, food, etc. ) n “Just-in-time” supply lines could be disrupted n High mortality rates could occur n Social disruption could occur

Considerations for preparedness

Can we maintain our utilities? n Recent disasters have showed us the need for water, power, telecommunications, heat in an emergency n Could they operate with 50% of staff? n Do they stockpile materials and parts to ensure operation for 90 -120 days?

Who will provide health care? n Health workers will be disproportionately exposed and may become ill n Some will not show up due to fear n Some will not be able to leave sick family members, children out of school n Little or no surge capacity; nursing shortage; future of Medical Reserve

Will transportation/trade problems impact food supply? n Typical household has food on hand to last 3 days. n Few families have emergency reserves for a prolonged period n Low-income least able to set supplies aside for an emergency n Prices may rise quickly in emergency.

Who will help us? n Little or no state and federal assistance n Local government also limited in what it can do to assist citizens n Churches, neighbors, friends and families would need to help each other n Vulnerable groups would need extra assistance n Advance planning and stockpiling of necessities could help.

What public agencies and businesses can do as employers

Maintain Essential Services n Halt non-essential activities and redeploy staff to fill vacancies in critical services. n Cross train: Make sure all critical functions can be done by several different people.

Maintain Essential Services n Create written instructions/ procedures for critical processes that can be carried out by others n If possible, keep essential supplies/ parts stockpiled in advance to maintain services.

Increase Social Distance n Determine how to provide services with less person-to-person contact whenever possible n Increase telecommuting if possible n Use phone, web, virtual conferences to replace face-to-face meetings n Waive non-critical policies if they force in-person contact

Decrease contact exposures n Increase cleaning/sanitizing of locks/ doorknobs, faucet and toilet handles, shared keyboards, telephones, other equipment n Vacuuming/sweeping infectious particles may stir up

Decrease contact exposures n Use/provide tissues, hand sanitizers, disposable gloves if available (All could be scarce during a pandemic) n Increasing humidity may reduce virus

Provide Personal Protective Equipment n Need will vary with type business n Will be difficult to obtain in a pandemic - need to secure in advance n Masks (N 95 or better) may reduce exposure, but are difficult to wear for prolonged time or if employee has health problems.

Teach protective actions n Hand washing without recontamination n Covering cough, not using hands n Avoid putting hands to face, mouth, nose, eyes. n Staying home if any signs of illness

Prepare Communications Plan n How will key managers communicate among themselves n How will information be conveyed to customers? n How will information be conveyed to employees? n How will employees know who to call in specific situations?

Prepare for difficult HR issues n If offices are closed, will staff be paid? n If staff are needed, can they refuse to come to work? n If required to report, what protective equipment, if any, will be provided? n Can employer force someone who may be ill NOT to work? (Employees without sick leave may try to work while ill. )

Prepare for difficult HR issues n If an employee is required to work with ill people and becomes ill, is it a worker’s comp situation?

How Ready Are We? Used with permission of the Minneapolis Star-Tribune

"Every day a pandemic doesn't happen is another day we have to prepare. ” --Michael Osterholm