dr wells -- pandemic flu

8/14/2019 Dr Wells -- Pandemic Flu

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Avian and Pandemic

Influenza

Where are we now?(May 2008)

Eden V. Wells, MD, MPH

Michigan Department of

Community Health


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Outline

Avian Update

Pan Flu Planning Update

State Operational Response Planning


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Avian InfluenzaThe Bird Flu

Images from: http://www.usda.gov/oc/photo


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Species Affectedpecies AffectedGenetic Reservoirs

Intermixing

H1, H3

H1, H2, H3

H3, H7

Commercial,LBMsOthers

H1-12H14-15

H1-2, 4-7,H9-13, 15-16

H10

H1, H3, H4, H7,

H13

Other AquaticBirds?

H5N1

H3


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Avian Influenza A (H5N1)

Discovered in Hong Kong, 1997

Now multiple epizootics worldwide

Still has not entered the WesternHemisphere

Still has not met WHO Pandemic criteria

New strain Causes severe illness in humans

Sustained transmission from person to person


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Countries with H5N1 in Poultry(OIE)

January 1, 2008- May 14, 2008


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Pandemicflu.gov


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Areas with high overlapping

concentrations of Humans and Poultry

(UN World Food Program, 5/24/06)


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Humans at Risk

Transmission from birds to humans does not occureasily 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


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Clinical features specific to

H5N1 (WHO, 2/06) Unusually aggressive course

Rapid progression (avg. of 5 days) with a high fatality rate

Early symptoms High fever (usually > 38 C) Influenza-like symptoms Diarrhea (often watery) and/or vomiting

Abdominal or chest pain

Hemorrhage from the gums May have no respiratory symptoms or develop acute encephalitis

3-13 days: Severe lower respiratory disease

Dyspnea Inspiratory crackles; hoarse voice

Variable sputum/respiratory secretions (sometimes hemorrhagic)

Always see a 1 viral pneumonia that is unresponsive to antibiotics Commonly see multiorgan dysfunction


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Implications for Human Health

Asian Strain H5N1 in humans more aggressive thanseasonal flu strains Severe clinical course

Rapid deterioration

High fatality Low transmissibility human-to-human

Incubation may be longer than seasonal influenza Seasonal influenza: 2-3 days

H5N1: possibly up to 10 days More studies needed


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When to test for H5N1(CDC Recommendations, 6/7/06)

The patient must meet all of the following criteria:

Has an illness that requires hospitalization or is fatal

AND has or had a documented temperature of 38C (100.4 F)

AND

has radiographically confirmed pneumonia, acute respiratory

distress syndrome (ARDS), or other severe respiratory illnessfor which an alternate diagnosis has not been established

AND

has at least one potential exposure within 10 days of

symptom onset (next slide)


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When to test for H5N1 Potential Exposures(CDC Recommendations, 6/7/06)

1. History of travel to a country with influenza H5N1 documented in poultry,

wild birds, and/or humans, AND

had at least one of the following potential exposures during travel:

direct contact with (e.g., touching) sick or dead domestic poultry.

direct contact with surfaces contaminated with poultry feces.

consumption of raw or incompletely cooked poultry or poultry products.

direct contact with sick or dead wild birds suspected or confirmed to have

influenza H5N1.

close contact (within 1 meter) of a person who was hospitalized or died due to asevere unexplained respiratory illness.

2. Close contact (within 1 meter) of an ill patient who was confirmed or

suspected to have H5N1.

3. Worked with live influenza H5N1 virus in a laboratory.


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H5N1 Specimen Collection Protocols(MDCH, 8/5/06 and CDC, 6/7/06)

Get BOE approval for testing at (517) 335-8165.

Preferred specimensOropharyngeal (OP) swabs

Bronchoalveolar lavage (BAL)

*A high-risk aerosol-generating procedure; use proper infection control precautions

Tracheal aspirate

Nasal or nasopharyngeal (NP) swabs are acceptable but less preferred

Postmortem: Paraffin-embedded or formalin-fixed respiratory tissues

Timing of specimen collectionFirst 3 days of illness onset is ideal

Collect serial samples over several days from several sites

Swabs should have a Dacron tip (not calcium or cotton) and an aluminum or plastic shaft (not wooden).

Specimens should be placed at 4C immediately after collection.


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Human-to Human

Transmission-

Still UnsustainedExamples:

Pakistan- Oct/Nov 2008 4 cases: 2 recovered- 2

fatal

Indonesia-2006 3 clusters 2005 (NEJM

Volume 355:2186-2194

Nov 2006 Number 21)

Viet Nam-2005

Clusters of human H5N1 casesrange from 2-8 cases

Identified in most countries thathave reported H5N1 cases

Most of the cluster casesoccurred in blood-related familymembers in same household

If such clusters are related togenetic or other factors currentlyunknown.

Limited human-to-human

transmission of H5N1 viruscannot be excluded in someclusters

diagnosis of exclusion

cdc,gov


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Antivirals for H5N1Adamantanes:

Resistant: Clades 1, 2 (80%) Sensitive: Clades 2.2, 2.3

Neuraminadases*: all viruses demonstrated

similar sensitivity to zanamivir, butcompared with the 2004 clade 1viruses, the Cambodian 2005viruses were 6-fold less sensitiveand the Indonesian clade 2viruses were up to 30-fold less

sensitive to oseltamivir.

Jennifer L. McKimm-Breschkin,* Paul W. Selleck, Tri Bhakti Usman, and Michael A.

Johnson

EID Volume 13, Number 9September 2007Reduced Sensitivity of Influenza A (H5N1) to Oseltamivir


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Human Vaccine for Avian H5N1

Human H5N1 vaccine approved by FDA

US has advance-ordered 20,000,000 doses

Current US 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 protectagainst H5N1 strain


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H5N1 viruses

Antigenic and genetic characteristics of H5N1

viruses and candidate H5N1 vaccine viruses developed

for potential use as human vaccinesWHO, February 2008

Vaccines being made from Clade 1 and 2 virusesClinical trialsStockpiles

Clade 1:

Human- Cambodia, China, Hong Kong, Viet Nam, Thailand Avian-Cambodia, Viet Nam

Clade 2.1: Avian and human- Indonesia

Clade 2.2: Avian- outbreaks in over 60 countries


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Antigenic and genetic characteristics of H5N1

viruses and candidate H5N1 vaccine viruses developed

for potential use as human vaccinesWHO, February 2008


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Current U.S. Status

No current evidence in U.S. of highlypathogenic H5N1 in:

Wild birds

Domestic poultry

Humans


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What is the H5N1 Pandemic

Risk? Three conditions must be met for a pandemic

to start: Emergence of a new influenza subtype

The strain infects humans causing

serious illness

Spreads easily between humans

A pandemic will impact ALL sectors of

Michigan society


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Planning for an ImpendingPandemic

The Role of Public Health


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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

WHO Ph d F d l St


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WHO Phases and Federal Stages

Stage 0: New Domestic Animal

Outbreak in At-Risk Country Stage 1: Suspected Human

Outbreak Overseas

Stage 2: Confirmed HumanOutbreak Overseas

Stage 3: Widespread HumanOutbreaks in Multiple LocationsOverseas

Stage 4: First Human Case inNorth America

Stage 5: Spread throughoutUnited States

Stage 6: Recovery andPreparation for SubsequentWaves


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Categories of Pandemic

Strength


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Estimated Impact

of a Future Pandemic in

Michigan

(*Michigan figures developed with Flu-Aid 2.0(*Michigan figures developed with Flu-Aid 2.0software, CDC)software, CDC)

Gross Attack Rate 35%

Health OutcomeModerate

(1957 / 68-like)

Severe

(1918-like)

Minimum Maximum Minimum Maximum

Illness 3.4 million 3.4 million 3.4 million 3.4 million

Outpatientmedical 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


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Leads for Public Health

International: World Health Organization

United States: Centers for Disease Controland Prevention, DHHS

Michigan: Michigan Department of

Community Health

County: Local Health Department/Jurisdiction


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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 butmulti-jurisdictional

authority resides with

State Health Officer

MI PUBLIC HEALTH CODE


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Public Health:Non-

Pharmaceutical Interventions

Social distancing

Respiratory/Cough

etiquette Infection Control

Droplet /Airborne Precautions

Isolation

Quarantine


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Public Health Measures

Isolation

Ill persons with contagious diseases

Usually in hospital, but can be in home or in a

dedicated area

Quarantine

Restriction of movement select exposed, not ill,person(s)

Home, institutional, or other forms (work quarantine) Voluntary vs. compulsory


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Public Health Measures

Social Distancing interventions to preventcontact: School closures

Cancellation of public gatherings

Worksite closures (computing,etc)

Infection Control interventions to prevent

transmission: Masks Hand hygiene


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Delay onset of outbreak

Reduce the peak burden

on hospitals/infrastructure

Decrease a) number of

cases of death and

illness and b) overall

health impact

Days Since First Case

NumberofDa i

lyCases

Goals of Community Measures

PandemicOutbreak:

No CommunityMeasures Used

PandemicOutbreak:

With MeasuresTaken

Delay onset of outbreak

Reduce the peak burden

on hospitals/infrastructure

Decrease a) number of

cases of death and

illness and b) overall

health impact

2

1

3

PandemicOutbreak:

No CommunityMeasures Used

Draft MI Public Health Interventions


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Draft- MI Public Health Interventions


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State-Level Preparedness

Michigans Draft Pandemic

Influenza

State Operational Plan


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Emergency Management &

Homeland Security Division

Responsible to coordinate state and federal resources to assist local

government in response and relief activities in the event of an emergency or

disaster.

Responsible for the coordination of homeland security initiatives and several

federal grants, as directed by the U.S. Department of Homeland Security.


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Pre-positioning MedPack for

Special Events

Bill Fales, Region 6

L. Scott, MDCH


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All-Hazard Preparedness Since 9/11, enhanced infrastructure for emergency response

Requirement for coordinated hospital and first responder actions

Public healths enhanced role in emergency management

A need to integrate community response

Continuity of business planning

Continuity of operations planning

Keweenaw44 %


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Regional Bio-Defense

Networks

Coordinate health care,public health and

emergencymanagement partners

100% Federally funded CDC Cooperative

Agreement

HRSA CooperativeAgreement


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Regional Medical Bio-Defense

NetworksRegion 1: Region 5:Dan Young Bob DievendorfRegion 1 BT. Coordinator Region 5 BT. Coordinator4990 Northwind Ste. 240 1000 Oakland Dr.East Lansing, MI 48823 Kalamazoo, MI 49008Office: 517-324-4404 Office: 269-337-6549Fax: 517-324-4406 Fax: [email protected] [email protected] 2N: Region 6:

Gary Canfield Tim BulsonRegion 2N BT. Coordinator Region 6 BT. Coordinator2032 E. Square Lake Road, Ste. 200 678 Front NW Ste. 235Troy, MI 48085 Grand Rapids, MI 49504Office: 248-828-0180 Office: 616-451-8438

Fax: 248-828-0185 Fax: [email protected] [email protected] 2S: Region 7:Amy Beauregard Tres BrookeRegion 2S BT. Coordinator Region 7 BT. CoordinatorWayne Co. Health Adm. C/O Northwest Regional MCA33030 VanBorn Road 1105 Sixth StreetWayne, MI 48184 Traverse City, MI 49684Office: 734-727-8001 Office: 231-935-7846Office (24 hours): 734-727-7280 Fax: 231-935-7845Fax: 734-727-7110 [email protected]@waynecountyemd.com

Region 3: Region 8: Jim Brasseur Interim-Alyson SundbergRegion 3 BT. Coordinator Region 8 BT. Coordinator1600 N. Michigan Ave. 420 Magnetic StreetSaginaw, MI 48602 Marquette, MI 48955Office: 989-583-7938 Office: 906-225-7745Fax: 989-583-7930 Fax: [email protected] [email protected]

Keweenaw44 %

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Preparedness Planning

All Hazards-Pandemic Flu an excellent example

www.pandemicflu.gov

Business Continuity of Operations Clinics and Medical Offices

Family and individual preparedness

Home health care

Long-term facilities

Schools Health insurers

Basis ofallplans is a strong Continuity ofBusiness Plan (CBP)


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The Importance of Surveillance

Continuous global surveillance of influenza is

key

Rapid detection of unusual influenzaoutbreaks, isolation of possible pandemic

viruses and immediate alert to the WHO

system by national authorities is decisive for

mounting a timely and efficient response topandemics.

World Health Organization

Pandemic Influenza


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Pandemic Influenza

Coordinating Committee

(PICC)

Concept presented in September 2006

Purpose of the PICC Assure pandemic influenza plans are being

developed

Assure plans are coordinated

Assure plans involve all necessary areas Encompasses all state agencies


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Pandemic Influenza Coordinating Committee (PICC)

- Steering Group -(A Representative from each State of Michigan Departments and Tribal)

Subcommittees

Legal / Public Safety

Governors Legal Homeland

Security Advisor

MSP DMVA Attorney General Civil Rights Michigan Sheriffs

Association MSU College of Law Univ of Michigan

DMVA DIT DMB MI Supreme Court MALPHExecutive Office Assoc of Chiefs of

Police

Treasury

Legal / Public Safety

Governors Legal Homeland

Security Advisor

MSP DMVA Attorney General Civil Rights Michigan Sheriffs

Association MSU College of Law Univ of Michigan

DMVA DIT DMB MI Supreme Court MALPHExecutive Office Assoc of Chiefs of

Police

Treasury

Animal Health

AIIWG

Animal Health

AIIWG

Two Workgroups:

Legal Authority

Public Safety

Two Workgroups:

Legal Authority

Public Safety

Transportation/

Border

MDOT DLEG

MDCH MSP MDA Tribes CDC

Quarantine

Transportation/

Border

MDOT DLEG

MDCH MSP MDA Tribes CDC

Quarantine

Human Health

MDCH CoreMental HealthMedicaid

OSELHDsHRSADOCDHSTribes

Human Health

MDCH CoreMental HealthMedicaid

OSELHDsHRSADOCDHSTribes

School/ Public

Health

Workgroup

School/ Public

Health

Workgroup

PIO Meetings

Liaison: James

McCurtis, MDCH

PIO Meetings

Liaison: James

McCurtis, MDCH

Pandemic Safe

Work Practice

Workgroup

Pandemic Safe

Work Practice

Workgroup

Long-Term Care

Workgroup

Long-Term Care

Workgroup

3rd Party Payers

Workgroup

3rd Party Payers

Workgroup


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PICC Report

Presenting key recommendations: Legal / Legislative

Community Preparedness School

Business

At-Risk Populations

Human Health Protecting State employees


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Recommendations of the

Human Health Sub-committee

Outreach to vulnerable populations

Implementation of safe work practices

Increase seasonal vaccination rates Involve third party payers / private

insurers


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OSHA Guidelines

February 2007 Understand risks

to staff, patients,public

Educate!

DHHSGuidelines

coming soonabout use ofmasks forgeneral public


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State Operational Plan

Planning Guidance to States

Released March 13, 2008

Purpose- strategic framework to help the50 states, DC and the 5 US territories toimprove and maintain their operationalplans for responding to and sustaining

functionality during an influenza pandemic


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SOP Strategic Goals

Goal A: Ensure continuity of ops for

state agencies/state government

Goal B: Protect citizens Goal C: Sustain/support 17 Critical

infrastructure/key resource sectors


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Goal A-Continuity of Ops

Continuing critical services and lifelines

that citizens rely on for survival (eg,

Medicaid, safe food and water, etc)

Must prepare for and exercise and

improve comprehensive operationalplans


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Goal B- Protection of Citizens

State Government is conducting

business as usual with functions such as

CD surveillance State is altering the way it conducts

business to delay the introduction, slow

the spread, or lessen the severity of panflu


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Goal C: CI/KR

Sustain and support 17 critical

infrastructure and key resources

Redevelop and implement statewideCI/KR protection programs

Reflect and align with full spectrum of

homeland security activities in NationalInfrastructure Protection Plan (NIPP)


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State Operational Plans

Due July 9, 2008

To be reviewed by DHHS/DHS

SOPs will be graded

Future funding tied to grades

States grades reported to Congress,

with subsequent release to public

Ongoing activity- support to All Hazards


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Summary

Avian influenza epidemiologyknowledge evolving

Pan flu risk persists regardless of H5N1activity

Pan flu planning is Extremely comprehensive

Extensive coordination

Enhanced collaboration

New partnerships

To become supporting plan to All Hazards


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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)

dr wells -- pandemic flu

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