Avian Influenza: What it Means to an Environmental Health Specialist

1. Avian Influenza: What it Means to an Environmental Health Specialist Larry D. Michael, RS, MPH Program Manager Dairy and Food Protection Branch NCDENR Had an option to discuss pandemic influenza, Avian Influenza, and the public health implications of both or the risk of H5N1 in food. All of these scenarios impact environmental health, so I decided to address all of these issues in this presentation.Had an option to discuss pandemic influenza, Avian Influenza, and the public health implications of both or the risk of H5N1 in food. All of these scenarios impact environmental health, so I decided to address all of these issues in this presentation.

2. Overview Pandemic Influenza Why the Concern? Current Status of Avian Influenza Public Health Impact Avian Influenza and Poultry Consumption What Should You Do?

3. Pandemic Influenza Worldwide epidemics Potential excess death and illness Multiple waves possible Six to eight weeks long What about pandemic influenza? A pandemic is a worldwide epidemic. With pandemics, there is potential for enormous numbers of deaths and illnesses. Pandemic influenza can occur at any time during the year; a typical wave of activity will last from 6-8 weeks and subsequent waves are possible. (may occur 3-9 months after the first wave). This chart shows pandemic waves in Great Britain during the 1918-1919 pandemic (describe if time allows: note how first wave occurred in summer, followed by a very severe second wave the following fall and winter, then a third wave later in the winter and early spring).What about pandemic influenza? A pandemic is a worldwide epidemic. With pandemics, there is potential for enormous numbers of deaths and illnesses. Pandemic influenza can occur at any time during the year; a typical wave of activity will last from 6-8 weeks and subsequent waves are possible. (may occur 3-9 months after the first wave). This chart shows pandemic waves in Great Britain during the 1918-1919 pandemic (describe if time allows: note how first wave occurred in summer, followed by a very severe second wave the following fall and winter, then a third wave later in the winter and early spring).

4. Pandemic �Prerequisites� New flu virus emerges New flu virus causes disease in humans Novel virus can be efficiently transmitted person to person What does it take for a pandemic to occur? First, a new influenza virus emerges. It may emerge from mutations in an avian flu strain�this is why we in public health are watching the bird flu issues closely. Second, this new virus must be able to cause disease in humans. The final prerequisite is that the new virus must spread easily from person to person. While the bird flu strain called H5N1 has met the first two requirements, it hasn�t yet become able to spread easily between people. What does it take for a pandemic to occur? First, a new influenza virus emerges. It may emerge from mutations in an avian flu strain�this is why we in public health are watching the bird flu issues closely. Second, this new virus must be able to cause disease in humans. The final prerequisite is that the new virus must spread easily from person to person. While the bird flu strain called H5N1 has met the first two requirements, it hasn�t yet become able to spread easily between people.

5. Avianflu.gov WHO Pandemic Alert Phase The US would initiate pandemic response actions at Phase 4, when epidemiological evidence of two generations of human-to-human transmission of a new influenza virus is documented anywhere in the world. The US would initiate pandemic response actions at Phase 4, when epidemiological evidence of two generations of human-to-human transmission of a new influenza virus is documented anywhere in the world.

6. This graph shows the impact of the 1918 Spanish flu on mortality rates in the United States. Overall in the 20th century, the mortality rate due to infectious diseases declined significantly. However the mortality rate due to infectious diseases doubled in 1918 because of the Spanish flu pandemic.This graph shows the impact of the 1918 Spanish flu on mortality rates in the United States. Overall in the 20th century, the mortality rate due to infectious diseases declined significantly. However the mortality rate due to infectious diseases doubled in 1918 because of the Spanish flu pandemic.

7. If the worst would occur, consider how quickly this would spread throughout the world. Note the difference between 1918 and now�Think about the fact that when you go out to eat at a restaurant, you�re likely to be sitting next to someone who just came from some other part of the world. If they�re from China and coughing� A good example, in Spring 2003, SARS traveled to 5 countries within 24 hours after emerging from rural China.If the worst would occur, consider how quickly this would spread throughout the world. Note the difference between 1918 and now�Think about the fact that when you go out to eat at a restaurant, you�re likely to be sitting next to someone who just came from some other part of the world. If they�re from China and coughing� A good example, in Spring 2003, SARS traveled to 5 countries within 24 hours after emerging from rural China.

8. Avian Influenza (AI)�Bird Flu� Migratory waterfowl are the natural reservoir Carry virus in intestines Virus shed in feces and respiratory secretions Usually do not get sick Many more flu types Source of potential pandemic strains Now let�s talk a little about avian influenza (or bird flu). You�ll hear more about it later in detail. Migratory birds are the natural reservoir for all known subtypes of avian influenza. They carry the virus in their intestines and shed the virus in both their feces and their respiratory secretions. Usually, they serve as carriers of the disease without getting sick themselves. One important issue with avian influenza is its potential to mutate and cause human pandemic flu.Now let�s talk a little about avian influenza (or bird flu). You�ll hear more about it later in detail. Migratory birds are the natural reservoir for all known subtypes of avian influenza. They carry the virus in their intestines and shed the virus in both their feces and their respiratory secretions. Usually, they serve as carriers of the disease without getting sick themselves. One important issue with avian influenza is its potential to mutate and cause human pandemic flu.

9. Pandemic influenza viruses Appear in the human population periodically H5N1 is a likely candidate, but is not a pandemic virus yet Antigenic drift Genetic composition of the viruses change as they mutate in their replications Antigenic shift Reassortment of genetic material from two different species as virus subtypes merge. Why the Concern over H5N1? Viruses change or mutate in one of two ways. They can randomly mutate over time in a natural selection process (antigenic drift) or they can combine with other viruses to produce new viral strains (antigenic shift). With respect to shift, the concern is that H5N1 will infect a cell that is also infected with a human flu virus. Once together in that cell, the two viruses could swap genetic material to create a new virus that is lethal and transmissible to humans.Viruses change or mutate in one of two ways. They can randomly mutate over time in a natural selection process (antigenic drift) or they can combine with other viruses to produce new viral strains (antigenic shift). With respect to shift, the concern is that H5N1 will infect a cell that is also infected with a human flu virus. Once together in that cell, the two viruses could swap genetic material to create a new virus that is lethal and transmissible to humans.

10. Key Prevention Method!

11. Avianflu.gov Nations w/ Confirmed Cases H5N1 What�s the most likely route? According to Dr. David Marshall (State Vet), it will spread E to W (instead of N to S) across the major flyways. Illegal transport and intentional acts are the most likely ways we�ll see it in US.What�s the most likely route? According to Dr. David Marshall (State Vet), it will spread E to W (instead of N to S) across the major flyways. Illegal transport and intentional acts are the most likely ways we�ll see it in US.

12. Federal Pandemic Plans National Strategy for Pandemic Influenza Homeland Security Council Implementation Plan for the National Strategy for Pandemic Influenza HHS Pandemic Influenza Plan Strategic Plan Public Health Guidance for State and Local Partners HHS Operational Plan (incl. continuity of operations

13. NC Pandemic Influenza Plan Communicable Disease Control Section, DHHS http://www.epi.state.nc.us/epi/gcdc/pandemic.html Plan focuses largely on planning and surveillance at this point. Have isolated people from other countries. Plan focuses largely on planning and surveillance at this point. Have isolated people from other countries.

14. Planning Assumptions in the US Susceptibility to pandemic influenza will be universal. Overall, 30% of the population will become ill. 50% of those who are ill will seek outpatient medical care. The number of hospitalizations and deaths will depend on the virulence of the pandemic virus. Current mortality rate=60% 1918 Spanish Flu=5%Current mortality rate=60% 1918 Spanish Flu=5%

15. CDC US Burden of Influenza Seasonal >200,000 hospitalizations 36,000 deaths Pandemic

16. North Carolina Impact In all likelihood, a flu pandemic will result in large numbers of people getting sick with the flu. More people will also need to go to the hospital compared to the regular flu season. And more people may die from flu during a pandemic compared to the regular flu season. This table shows you an estimate of the number of North Carolinians who see their doctor, get hospitalized, or die from the regular flu each season. Of these 1,100 deaths, the vast majority occur in people over the age of 65 years. In contrast, a moderate pandemic wave lasting approximately eight weeks could result in 1.6 million people going to the doctor, 29,000 people hospitalized and almost 7,000 people dying. A severe pandemic like the Spanish flu of 1918 could cause even more deaths and hospitalizations, maybe 10 times more. A pandemic flu could also result in a larger number of younger people dying compared to the regular flu. In all likelihood, a flu pandemic will result in large numbers of people getting sick with the flu. More people will also need to go to the hospital compared to the regular flu season. And more people may die from flu during a pandemic compared to the regular flu season. This table shows you an estimate of the number of North Carolinians who see their doctor, get hospitalized, or die from the regular flu each season. Of these 1,100 deaths, the vast majority occur in people over the age of 65 years. In contrast, a moderate pandemic wave lasting approximately eight weeks could result in 1.6 million people going to the doctor, 29,000 people hospitalized and almost 7,000 people dying. A severe pandemic like the Spanish flu of 1918 could cause even more deaths and hospitalizations, maybe 10 times more. A pandemic flu could also result in a larger number of younger people dying compared to the regular flu.

17. In North Carolina� 290,000 Needing hospitalization How many licensed and staffed beds in NC? Between 2,600 and 6,100 will need ventilation equipment How many ventilators do we have? NC has 20,639 licensed and staffed beds at 124 hospitals Ventilators�2,000 Presents and ethical dilemmaNC has 20,639 licensed and staffed beds at 124 hospitals Ventilators�2,000 Presents and ethical dilemma

18. CDC Planning Assumptions in the US The typical incubation period for influenza averages 2 days.� Persons who become ill may transmit infection for one-half to one day before the onset of illness. On average about 2 secondary infections will occur as a result of transmission from someone who is ill.� In an affected community, a pandemic outbreak will last about 6 to 8 weeks.� Work/school absenteeism may be as high as 40% at the peak. At least two pandemic disease waves are likely.�

19. Potential Strategies to Decrease the Impact of a Pandemic Antiviral treatment and isolation Quarantine for those exposed Social distancing Vaccine when available

21. St. Louis

22. Is Avian Influenza a Concern in Food?

23. Overreaction?

24. What if H5N1 Made it to the US (No Human Cases)? Survey in NE USA 46% would stop buying/eating poultry 25% would reduce buying/eating poultry 27% would keep buying/eating 2% don�t know

25. Value of Poultry to NC Primary production of poultry is worth approximately 2.7 Billion to the state. Approximately 16 Billion when you add the entire poultry food chain (processing, marketing, transportation, restaurants, etc.) Nearly 20% of NC population works in an agriculture/food-related job. Think about the infrastructure�the tax base�this would affect everyone.Think about the infrastructure�the tax base�this would affect everyone.

26. Is Poultry Safe? Food products of concern Raw Poultry Raw Eggs No documented cases of Avian Influenza from eating poultry products Extensive monitoring and control program Chance of AI entering poultry products for human consumption�you have a better chance of getting hit by debris from outer space. Dr. Steven Wells, Director, Meat and PoultryChance of AI entering poultry products for human consumption�you have a better chance of getting hit by debris from outer space. Dr. Steven Wells, Director, Meat and Poultry

27. Approved Source Inspected by NCDA & Consumer Services, Meat and Poultry Inspection Service USDA USDA Poultry Inspection Legend USDA Red Meat Inspection Legend Inspection LegendsInspection Legends

28. Asian Sources Restrictions on live birds, poultry and poultry products from Asian countries Processed poultry is not imported from Asia.

29. Birds on a Two-wheeler

30. Lack of Hygiene

31. Asian Wet Market

32. Intermingling

34. Slaughtering/Selling in Same Area

35. What�s the Worst-case Scenario? Finding it in Food? Sustained Person-to-Person Transmission of H5N1?

36. Proper Cooking Will Kill H5N1

37. What Now? Vaccination Good personal hygiene Stay home if ill Develop a COOP at work Educate Stay informed Get involved Promote seasonal vaccination Restaurants are going to be asked about this�. Promote seasonal vaccination Restaurants are going to be asked about this�.

38. Pandemic Flu Planning Two weeks supply of water and food Fluids with electrolytes RTE canned meats, fish, fruits, vegs, soups Protein or fruit bars Dry cereal or granola Peanut butter or nuts Dried fruit Pet food How many days supply of food at the store? Last year during Thanksgiving, people getting shot over Playstation�How many days supply of food at the store? Last year during Thanksgiving, people getting shot over Playstation�

39. Pandemic Flu Planning Prescription and nonprescription drugs Soap/hand sanitizing gel Thermometer Flashlight Batteries Portable radio Manual can opener Toilet paper

40. Online Resources www.who.org www.cdc.gov www.ncpublichealth.com These online resources are good sources of information on seasonal, avian and pandemic influenza. Here is the website address for the state plan and the email address if you have any comments or questions about the NC plan.These online resources are good sources of information on seasonal, avian and pandemic influenza. Here is the website address for the state plan and the email address if you have any comments or questions about the NC plan.

42. Dairy and Food Protection Branch Larry Michael (919) 715-0927 Larry.Michael@ncmail.net