Pandemic Influenza A Local Perspective Pandemic Influenza A Local Perspective David Goodfriend, MD,MPH, Director Loudoun County Health Department [email protected].

Pandemic Influenza Pandemic Influenza A Local PerspectiveA Local Perspective

David Goodfriend, MD,MPH, DirectorLoudoun County Health Department

[email protected] 20, 2007

Why Are We Why Are We Here?Here?

• An influenza pandemic is different from other public health disasters:

− Simultaneous outbreaks can occur across many regions

− Sharing of human resources or supplies from other communities is less likely

• Key elements that will affect the public include:− Human Impact

• Pandemics disproportionately affect younger people• Potential for high levels of:

Sickness and death Disruption of critical services Economic loss

− Business Continuity (COOP)− Communication

Impact on Impact on Business Business FunctionsFunctions

•Key Assumptions:− Economic impact nationwide could range from $71.3 to $166.5 billion− The epidemic could persist for two months or longer− Psychological impacts on the workforce will be extreme− Community containment measures may be

implemented to minimize spread

Will Return:Will Return:

SEP MAR

DEC

JUN

Pandemic Pandemic InfluenzaInfluenza

1918 Influenza 1918 Influenza PandemicPandemic

• Spread around the globe in 4 - 6 months • Death rate 25-times higher than previous

epidemics• 40 – 100 million people died worldwide • Majority of deaths were in persons 18 to

40 years old

1918 Flu in the Washington 1918 Flu in the Washington AreaArea

(from the Washington Post, October 4-11, 1918)(from the Washington Post, October 4-11, 1918)

“Theaters Closed to Stay Influenza…Movies and

Public Dance Halls also in [Closure] Order,

Churches Next Likely”

“Pandemic Extends from Coast to Coast”

“Shortage of Coffins and Grave Diggers”

“Universities Close Classes”

“Ban on Public Funerals”

“2,174 New Cases Reported in City”

“Stagger Hours for Food and Fuel”

Excess US Deaths in Excess US Deaths in Previous Influenza Previous Influenza

PandemicsPandemics•1918-19: 500,000 - 650,000

Ten times as many Americans died of flu than died in WW I

•1957-58: 70,000•1968-69: 40,000•Typical annual influenza season: 36,000

DefinitionsDefinitions•EPIDEMIC:EPIDEMIC: An increase in disease above what is normally expected

•PANDEMIC:PANDEMIC: A worldwide epidemic

Influenza Influenza ClarificationClarification

• Seasonal Influenza:Seasonal Influenza:− A contagious respiratory illness caused by various

influenza viruses creating a public health problem every year

− Viruses circulate throughout the human population− Spread easily from person to person

• Avian Influenza A (H5N1):Avian Influenza A (H5N1):− Devastating global outbreak in poultry− Causes severe but rare human infections− Does NOT spread easily from person to person

• Pandemic Influenza:Pandemic Influenza:− Currently there is no pandemic of influenza − Appears in the human population periodically− H5N1 is a likely candidate, but is not a pandemic virus to

date− Wide geographic spread

VirusesVirusesType Characteristics

AA

• Affects Multiple Species including humans

• Avian Influenza is type A

• Most Virulent Virus: Although not all strains cause clinical disease

• Classified by surface antigens into subtypes: Hemagglutinin (H),

Neuraminidase (N)

• Composed of 8 segments of RNA: Segments make it easier for

‘reassortment’ to occur

BB

• Mostly in humans

• Not categorized into subtypes

• Common and less severe then A

• Epidemics occur less often than A

• Human seasonal vaccine: Two strains of type A; one strain of type B

CC

• Humans and swine

• Rare, with mild to no symptoms

• By age 15, most people have antibodies

Pandemic PhasesPandemic Phases1 Inter-pandemic

phase

Low risk of human cases

2 New virus in animals; no human cases

Higher risk of human cases

3 Pandemic alert No or very limited human-to-human

transmission

4 Virus causes human cases

Evidence of increased human-to-human

transmission

5 Evidence of significant human-to-human

transmission

6 Pandemic Efficient & sustained human-to-human

transmission

You Are You Are HereHere

Situation Report: Avian Situation Report: Avian InfluenzaInfluenza

Widespread and spreading prevalence in migratory birds; broad host range

Continued outbreaks among domestic poultry

Mammalian infection (cats, pigs, tigers, ferrets) lethal

Virus is evolving

Sporadic human cases • Mostly in young and healthy persons• 317 human cases, 191 deaths (~60% mortality

rate) • Rare person-to-person transmission

Sustained and rapid person-to-person transmission

H5N1 Status -- June H5N1 Status -- June 20072007

Cumulative Confirmed Human Cases of Cumulative Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to Avian Influenza A/(H5N1) Reported to

WHOWHOas of June 29, 2007as of June 29, 2007

Total number of cases includes number of deaths.WHO reports only laboratory-confirmed cases

Country

2003 2004 2005 2006 2007 Total

CasesDeat

hsCases

Death

s

Cas

es

Death

s

Case

s

Deat

hs

Case

s

Deat

hs

Case

s

Deat

hs

Azerbaijan 0 0 0 0 0 0 8 5 0 0 8 5

Cambodia 0 0 0 0 4 4 2 2 1 1 7 7

China 1 1 0 0 8 5 13 8 3 2 25 16

Djibouti 0 0 0 0 0 0 1 0 0 0 1 0

Egypt 0 0 0 0 0 0 18 10 19 5 37 15

Indonesia 0 0 0 0 20 13 55 45 26 22 101 80

Iraq 0 0 0 0 0 0 3 2 0 0 3 2

Laos 0 0 0 0 0 0 0 0 2 2 2 2

Nigeria 0 0 0 0 0 0 0 0 1 1 1 1

Thailand 0 0 17 12 5 2 3 3 0 0 25 17

Turkey 0 0 0 0 0 0 12 4 0 0 12 4

Viet Nam 3 3 29 20 61 19 0 0 2 0 95 42

Total 4 4 46 32 98 43 115 79 54 33 317 191

The DiseaseThe Disease

Droplets

Influenza Influenza (Flu)(Flu)

•SymptomsSymptoms −Sudden headache−Dry cough−Runny nose−Sore throat−Muscle aches (myalgia)−Fatigue/malaise−Fever up to 104°F (40°C)

•Incubation - 24 to 72 hours•Most people feel better within days •Fatigue and cough can last for 2+ weeks•Patients most infectious 24 hours before symptoms

Viral ‘Shedding’• The incubation period can vary from 1 to 4 days, but symptoms normally

appear 2 days after exposure to the virus.

• Patients are most infectious 24 hours prior to the onset of symptoms.

• Viral shedding, the period when persons are contagious, lasts 5 to 7 days in adults.

• Persons can also be infected from environmental surfaces contaminated from infected respiratory secretions.

• The virus can survive outside a host cell for up to 48 hours on nonpenetrable surfaces and up to 12 hours on cloth, tissue, or paper.

Treatment or Treatment or Prophylaxis ?Prophylaxis ?

• Antivirals− Adamantanes (Amantadine, Rimantadine)− Neuraminadase inhibitors (Zanamivir, Oseltamivir)

• Therapy more efficient than prophylaxis in preventing adverse health outcomes− Uses less drug− Focuses on those who are ill and will directly benefit from

medication

• Prophylaxis more effective than therapy in maintaining quality health care and public safety− Prevents absenteeism from fear of illness− Prevents time lost from work while ill

Lessons From Past Lessons From Past PandemicsPandemics

• Large variations in mortality, severity of illness, pattern of illness, and age groups

• Rapid surge in number of cases over brief period of time (weeks)

• Tend to occur in waves - subsequent waves may be more or less severe

Key Lesson – UnpredictabilityKey Lesson – Unpredictability

PREPAREDNESSPREPAREDNESS

Surveillance:Surveillance: Seasonal Seasonal Influenza-Like-Illness Influenza-Like-Illness

TrendsTrends

Animal SurveillanceAnimal Surveillance

• Federal monitoring programs−Poultry farm surveillance

• State programs−Wild bird surveillance−Dead bird surveillance

• Local surveillance−Dead bird surveillance

Role of Public Health in Role of Public Health in PandemicsPandemics

FEDERAL

•DHHS Pandemic Influenza Plan, 11/2005•Development of laboratory tests and reagents•Development of reference strains for vaccines•Vaccine evaluation and licensure•Recommendations on target populations and priorities•Deployment of federally purchased vaccine•Mass vaccination clinic guidelines•Evaluation of vaccine safety

STATE(Response Plan – 2002, revised 3/2006)

•Surveillance

•Community Disease Control

•Immunization

•Antiviral medications

•Public Information

•Medical Care Planning

•Public Health Laboratory

•Infection Control

•Clinical Guidance

•Maintenance of Essential Health and Medical Services

•Travel associated risk

•Workforce Support

Role of County in Pandemic:Role of County in Pandemic: LocalLocal

• All Response is local!

• Loudoun Pandemic Flu Preparedness Task Force

• Craft Public Messages

• Recruit Medical Reserve Corps members

• Develop Plan (available on www.loudoun.gov/flu)

• Exercise Plan− July 2006: ‘Flu the COOP’ – tested county business

continuity− October 2006: ‘Code Flu 06’ - exercise of mass

prophylaxis POD plan− 2007: Alternate Care; Non-Medical POD exercise

Role of County in Pandemic:Role of County in Pandemic: LocalLocal

• Seminars & Educational Outreach

Meetings− County and Town government organizations− Medical offices− Private businesses (Nissan North America, AOL, Costco,

Lufthansa, Lockheed Martin, etc.)− First responders (police, fire, EMS)− Public and private schools, PTA's− Retirement communities and senior centers− Homeowners associations− Fraternal and civic organizations− Health fairs

PlanningPlanning

• Being Able to Work May Be Difficult or Impossible− Ask your employer how business will continue during a

pandemic − Discuss staggered shifts or working at home with your

employer − Discuss telecommuting possibilities and needs,

accessing remote networks, and using portable computers

− Discuss possible flexibility in leave policies − Discuss with your employer how much leave you can

take to care for yourself or a family member − Plan for possible loss of income if you are unable to

work or the company you work for temporarily closes

PlanningPlanning• Plan for the possibility that usual

services may be disrupted− Could include services provided by hospitals, other

healthcare facilities, banks, restaurants, government offices, telephone and cellular phone companies, and post offices

• Stores may close or have limited supplies − Planning checklists can help you determine what items

you should stockpile to help you manage without these services

• Transportation services may be disrupted and you may not be able to rely on public transportation − Plan to take fewer trips and store essential supplies

PlanningPlanning

• Public gatherings, such as volunteer meetings and worship services, may be canceled

• Prepare contact lists including conference calls, telephone chains, and email distribution lists, to access or distribute necessary information

• Consider that the ability to travel, even by car if there are fuel shortages, may be limited

PlanningPlanning

•Food and Water Supplies May Be Interrupted and Limited

−Temporary shortages could occur −You may also be unable to get to a store

•Food−Store 2 weeks of nonperishable food −Select foods that do not require refrigeration, preparation (including the use of water), or cooking−Insure that formulas for infants and any child's or older person's special nutritional needs are a part of your planning

•Water−Store two weeks of water, 1 gallon of water per person per day. (2 quarts for drinking, 2 quarts for food preparation/sanitation), in clean plastic containers −Avoid using containers that will decompose or break, such as milk cartons or glass bottles

Family Emergency Health Family Emergency Health Information SheetInformation Sheet

•Think ahead about issues that could affect you & your family

•If a mass vaccination clinic is set up you may need to provide medical histories.

•Example:

Family

Membe

r

Blood

Type

Allergies Past/Current

Medical

Conditions

Current

Medication

s &

Dosages

John O Neg Penicilli

n

High Blood

Pressure

Back

surgery

Lasix 20

mg daily

Aspirin 85

mg daily

Jane AB

Pos

None Pregnant Pre-natal

vitamin

daily

Suzy O Pos Milk

Eggs

Asthma Inhaler as

needed

Emergency Contacts Emergency Contacts FormFormContacts Name/Phone

NumberLocal Personal emergency contact

Out-of-town personal emergency contact

Hospitals near: Work

School

Home

Family physician(s)

Loudoun County Health Department

703-777-0234

www.loudoun.gov/flu

Pharmacy

School(s) contact & emergency information

Employer(s) contact & emergency number

PlanningPlanning

• Schools and Daycare Centers May Be Closed for an Extended Period of Time

• Talk to teachers, administrators, and parent-teacher organizations about your school's pandemic plan, and offer your help

• Plan now for children staying at home for extended periods of time, as school closings may occur along with restrictions on public gatherings, such as at malls, movie theaters

PlanningPlanning

• Medical Care for People with Chronic Illness Could be Disrupted − In a severe pandemic, hospitals and doctors'

offices may be overwhelmed. − If you have a chronic disease, such as heart disease, high

blood pressure, diabetes, asthma, or depression, you should continue taking medication as prescribed by your doctor.

− Make sure you have necessary medical supplies such as glucose and blood-pressure monitoring equipment.

− Talk to your healthcare provider to ensure adequate access to your medications.

− If you receive ongoing medical care such as dialysis, chemotherapy, or other therapies, talk with your health care provider about plans to continue care during a pandemic.

PlanningPlanning

• Stay Informed−Knowing the facts is the best preparation

• Identify sources you can count on for reliable information

• If a pandemic occurs, having accurate and reliable information will be critical

• Alert Loudoun (http://alert.loudoun.gov)−Check for information on your local and state

government Web sites −Listen to local and national radio, watch news

reports on television, and read your newspaper and other sources of printed and web-based information

−Talk to your local health care providers and public health officials

Strategies for Strategies for Preventing Preventing

Pandemic InfluenzaPandemic Influenza• Vaccination

−May not be widely available

• Early Detection &

Treatment−Surveillance−Antiviral drugs may be

limited or ineffective

• Infection Prevention Infection Prevention

& Control Measures& Control Measures

COVER YOUR COUGHCOVER YOUR COUGH

WASH YOUR HANDSWASH YOUR HANDS

STAY HOME WHEN STAY HOME WHEN SICKSICK

Infection Control StrategyInfection Control Strategy

REMEMBER…REMEMBER…• Prepare Family Emergency Plans, Ensure

Early Recognition of Staff/Family Members at Risk

• Prevent Transmission by implementing appropriate Infection Control Precautions

• Consult your local health department with suspect or actual cases

• More Information at: www.loudoun.gov/flu

• Submit additional thoughts or questions to [email protected] or call me at 703-771-5829

Questions…Questions…