pandemic influenza a local perspective pandemic influenza a local perspective david goodfriend,...
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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…