H5N1, H1N1, and Pandemic Influenza An Update Eden V. Wells, MD, MPH Michigan Department of Community Health
Dec 26, 2015
H5N1, H1N1, and Pandemic Influenza
An Update
Eden V. Wells, MD, MPH
Michigan Department of
Community Health
Outline Novel Strain H5N1- Brief Update
Novel Strain H1N1-Update
Pandemic Influenza Planning-Michigan
Pan Flu Planning for You
Avian Influenza A (H5N1)
Discovered in Hong Kong, 1997 Now multiple epizootics worldwide Still has not entered the Western Hemisphere Still has not met “WHO” criteria for pandemic
– New strain– Causes severe illness in humans– Sustained transmission from person to person
Humans at Risk-H5N1 Transmission from birds to humans does not
occur easily– Contact with feces or secretions from infected birds– Risk with butchering, preparing, defeathering of infected
birds– NOT transmitted through cooked food
All age groups affected– Higher rate < 40 years– M:F=-0.9
Case fatality remains ~ 63% Median duration of illness
– hospitalization 4 days– death 9 days
Clinical features – Asymptomatic infection not common
Human Vaccine for Avian H5N1
Human H5N1 vaccine approved by FDA US has advance-ordered 20,000,000 doses Current US Strategic National Stockpile (SNS)
– Clades 1, 2.1, 2.2, 2.3– currently (April 29, 2008) contains enough H5N1 vaccine for 12
million to 13 million people– assuming two 90-microgram (mcg) doses per person – Potential adjuvants (AL-OH, oil/water,etc)
May not match strain that causes pandemic Seasonal influenza vaccine does not protect
against H5N1 strain
Current U.S. Status, H5N1
No current evidence in U.S. of highly pathogenic H5N1 in:
– Wild birds
– Domestic poultry
– Humans
2009 Novel Influenza A (H1N1)
The 21st Century’s first influenza pandemic
2009 Novel Influenza A (H1N1)
April 2009, Mexico and SE California
Rapid spread through Mexico and US
May 2009, Spread throughout World
WHO Pandemic Phase 6 June 2009
Transmission Transmitted human-to-human Transmitted similar as seasonal influenza
– Exposure to nearby coughing or sneezing– Contact with contaminated surfaces
Incubation: unknown and could range from 1-7 days, and more likely 1-4 days
Infectious period: unknown-– one day before to 7 days following illness onset– Children, especially younger children, maybe infectious up
to 10 days.
World Health H1N1, as of August 2009
US Epidemiology H1N1August 2009
Mortality by Age, US,as of August 1, 2009
US Epidemiology, as of August 2009
“More than one million people became ill with novel H1N1 flu between April and June 2009.”- cdc.gov
US Epidemiology,as of August 2009
Secondary attack rate (SAR) of H1N1 for household contacts– For acute-respiratory-illness (ARI two or more of the
following symptoms: fever, cough, sore throat, and runny nose)-18 % to 19%
– 8% to 12% for influenza-like-illness (ILI- fever and cough or sore throat)
– Slightly lower than seasonal influenza SAR– US Case fatality rate: ? <0.1%
Greater disease burden on people younger than 25 years of age than older people.
MI Epidemiology, as of July 2009
As of July 9, 2009: confirmed cases
Variables Total pH1N1 (%) (n=489)
Hospitalized pH1N1 (n=110)
Nonhospitalized pH1N1 (n=325)
Gender
Females Males
Unknown
227 (46.4)260 (53.2)
2 (0.4)
59 (53.6)51 (46.4)
0
143 (44.0)
180 (55.4)2 (0.6)
Average age (yrs) 18.0 25.4 15.8
Median age (yrs) 14.0 18.0 13.0
Age group 0-4 yrs 5-24 yrs 25-49 yrs 50-64 yrs 65+ yrsAge range (yrs)
58 (11.9)326 (66.7)77 (15.7)23 (4.7)5 (1.0)0.2─87
9 (8.2)55 (50.0)28 (25.5)14 (12.7)
4 (3.6)0.3─87
45 (13.8)230 (70.8)40 (12.3)
9 (2.8)1 (0.3)0.2─79
Antiviral Resistance (as of August 2009)
Antiviral resistance pandemic (H1N1) virus Six oseltamivir resistant pandemic (H1N1) 2009
influenza viruses – Denmark– Hong Kong SAR– Japan – Canada
Three were from patients in Japan. All six patients had received oseltamivir with the
exception of one and have recovered well. All resistant viruses had the characteristic mutation at
position 274/275 associated with resistance.
Planning for an Impending Pandemic
The Role of Public Health
20th Century Influenza Pandemics
1918 – 1919, “Spanish Flu” (H1N1)– Influenza A H1N1 viruses still circulate today– US mortality: approx. 500,000+
1957-58, “Asian Flu” (H2N2)– Identified in China (February 1957) with spread to US by
June– US mortality: 69,800
1968-69, “Hong Kong Flu” (H3N2)– Influenza A H3N2 viruses still circulate today– First detected in Hong Kong (early 1968) and spread to
US later that year– US mortality: 33,800
0
100
200
300
400
500
600
700
800
900
America’s deaths from influenza were greater than the number of U.S.
servicemen killed in any war
Civil WWI 1918-19 WWII Korean Vietnam
War Influenza War War
Thousands
Pestronk, Robert
Categories of Pandemic Strength
Estimated Impact of a Future Pandemic in Michigan
(*Michigan figures developed with Flu-Aid 2.0 (*Michigan figures developed with Flu-Aid 2.0 software, CDC)software, CDC)
Gross Attack Rate 35%
Health Outcome
Moderate(1957 / 68-like)
Severe(1918-like)
Minimum Maximum Minimum Maximum
Illness 3.4 million 3.4 million 3.4 million 3.4 million
Outpatient medical care
1.4 million 2.6 million 1.3 million 2.2 million
Hospitalization 14,000 51,000 120,000 420,000
Death 5,000 15,000 43,000 126,000
Public Health Leads International: World Health Organization
United States: Centers for Disease Control and Prevention, DHHS
Michigan: Michigan Department of Community Health
County: Local Health Department/Jurisdiction
Public Health Containment Tools-Pandemic Flu
Vaccine
Antivirals– Treatment
– Prophylaxis
Infection Control
Social Distancing
Legal authority to Implement Public Health Measure
resides equally in all 45 MI Local HD
Health Officers
Similar but multi-jurisdictional
authority resides with State Health Officer
MI PUBLIC HEALTH CODE
Menu of Public Health Actions, circa 1918
1.Making influenza a reportable disease
2. Isolating sick individuals
3. Quarantine of households with sick individuals
4. School closure
5. Protective sequestration of children or adults
6. Cancellation of worship services
7. Closure of public gathering places [e.g., saloons, theatres, etc.]
8. Staggered business hours to decrease congestion on trams, etc.
9. Mandatory or recommended use of masks in public
10. Closing or discouraging the use of public transit systems
11. Restrictions on funerals, parties, and weddings
12. Restrictions on door-to-door sales
13. Community-wide curfew measures and business closures
14. Social distancing strategies for those encountering others
15. Public health risk communication measures 16. Declaration of public health emergency.Hatchett, et al, PNAS,
May 1, 2007
1918 Flint Journal Headlines
Slide courtesy of Robert Pestronk
Michigan Pandemic Planning
Coordination of state and local responses
All-Hazard Preparedness
Since 9/11, enhanced infrastructure for emergency response
Requirement for coordinated hospital and first responder actions
Public health’s enhanced role in emergency management
A need to integrate community response Continuity of business planning Continuity of operations planning
Keweenaw44 %
8
7
36
15 2 s2n
Regional Bio-Defense Networks
Coordinate health care, state and local public health, and emergency management partners
100% Federally funded– CDC Cooperative
Agreement– HRSA Cooperative
Agreement
Preparedness Planning “All Hazards”-
Pandemic Flu an excellent example
Basis of all plans is a strong Continuity of Operations Plan
Preparedness-Local“All Emergencies are Local”
All 45 local health departments:
– Health Officer with legal authorities
– Medical Director– Emergency Preparedness
Coordinator– Immunization Staff– Communicable Disease Staff
– Coordination of plans– Partnerships
• Emergency Management• Businesses• Community/organizations• Schools• Healthcare• …
Avian Influenza Hotline1-888-354-5500 ext 7878 or734-240-7878
West Nile Virus Hotline1-888-354-5500 ext 7850 or734-240-7850
The Role for the Community Responder
Pandemic Influenza
How it will happen
Public health surveillance Disease detection Warnings, declarations, and orders Staged countermeasures initiated Requests from local health departments initiated Local hospitals overwhelmed Rapid, repeated cycles of illness and death Loss of response staff Burn-out of disease and staff Clean up
Things to do now at work Assure staff are vaccinated for flu each year Assure other vaccinations are up-to-date Plan for loss of staff and use of volunteers Get to know your local health department and tribal
leaders Review inter/intra-agency planning documents and
checklists Participate in exercises: train, emphasize
leadership shift Practice staying home when sick Practice healthy hygiene
Robert Pestronk, Genesee Cty)
Emotional Impacts Reacting to inconsistent information
Fear of exposure/infection
Massive loss and grief
Exposure to traumatic images
An inability to see loved ones
Not being able to say “good-bye” to those who may die in the hospital or while separated from family.
Slide information extracted from UNC webinar January 2008“Mental Health Aspects of Pandemic Flu Preparedness” Patricia Watson, Ph.D.National Center for PTSD
Social Impacts Isolation/quarantine (home care)
Social distancing (comfort)
School dismissal (child care)
Closing places of assembly (social support)
Slide information extracted from UNC webinar January 2008“Mental Health Aspects of Pandemic Flu Preparedness” Patricia Watson, Ph.D.National Center for PTSD
Supporting First Responders Illness and death among colleagues and family
members Fear of contagion and/or of transmitting disease
to others Shock, numbness, confusion, or disbelief;
extreme sadness, grief, anger, or guilt; exhaustion; frustration
Sense of ineffectiveness and powerlessness Difficulty maintaining self-care activities (e.g.,
getting sufficient rest) Prolonged separation from family
DHHS Pandemic Plan 2005
Support of First Responders Concern about children and other family
members Constant stress and pressure to keep performing Domestic pressures caused by school
dismissals, disruptions in day care, or family illness
Stress of working with sick or agitated persons and their families and/or with communities under quarantine restrictions
Concern about receiving vaccines and/or antiviral drugs before other persons
Tools for the First Responder
Surveillance Community Mitigation
– Social Distancing– Infection Control, based on Risk Assessment
Vaccination Communication
Surveillance MDCH, local health departments, tribes
– Emergency Departments– Schools– Pharmacies– Hospitals– sentinel laboratories and physicians– local health departments
www.michigan.gov/flu
Community Mitigation Attempt to keep children in school
– Schools may consider temporary dismissal– Virus severity, or uncontrolled transmission
Do NOT go to work or school if sick! Social distancing Infection Control Medical intervention, if necessary
– Antivirals for at-risk individuals– Hospital surge responses
Vaccination H1N1 vaccination planning currently evolving Public and private sector delivery Target groups different from seasonal flu:
– Pregnant women – Household contacts and caregivers for children younger
than 6 months of age – Healthcare and emergency medical services personnel– All people from 6 months through 24 years of age – Persons aged 25 through 64 years who have health
conditions associated with higher risk of medical complications from influenza.
Communications
Streamlined, unified- federal, state, local Primary federal websites
– www.flu.gov– http://www.cdc.gov/h1n1flu/
Primary state website– michigan.gov/flu
Alternate routes:– Twitter– Facebook
Regular media calls and updates
Health Alert System
The Michigan Health Alert Network (MIHAN) is a secure, Internet-based, emergency notification system
The MIHAN contains over 4,000 participants– local health departments– Hospitals– Clinics– Critical first responders across the state– Michigan's state governmental agencies.
Things to do now at home
Get family members vaccinated each year
Practice healthy hygiene Plan how you will care for someone in
your household who becomes sick if you are called to work.
Practice Healthy Hygiene Clean hands often
– Wash with soap and water or
– Clean with hand sanitizer Cover mouth and nose when you sneeze
or cough and clean hands afterwards Keep hands away from face Stay away from people who are sick Single use tissue
Robert Pestronk, Genesee Cty)
Summary Knowledge about novel
influenza evolving Pan flu risks persist-
– regardless of H5N1 activity, – especially due to H1N1
activity
Pan flu planning – Is extremely comprehensive– Is extensive coordination– Enhances collaboration– Means new partnerships– Assists in planning for other
events– Is NECESSARY
References
Mivolunteerregistry.org Local Health Department Michigan Department of Community
Health (www.michigan.gov/flu) WHO www.who.int CDC www.cdc.gov DHHS (www.pandemicflu.gov)
(CHECKLISTS)
Acknowledgements
Howard Markel, University of Michigan Medical School
Several slides courtesy of:– Robert Pestronk – Christi Carlton, MDCH