H5N1, H1N1, and Pandemic Influenza An Update

1. H5N1, H1N1, and Pandemic InfluenzaAn Update Eden V. Wells, MD, MPH Michigan Department of Community Health

2. Outline • Novel Strain H5N1- Brief Update • Novel Strain H1N1-Update • Pandemic Influenza Planning-Michigan • Pan Flu Planning for You

3. 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

4. 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

5. 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

6. Current U.S. Status, H5N1 • No current evidence in U.S. of highly pathogenic H5N1 in: • Wild birds • Domestic poultry • Humans

7. 2009 Novel Influenza A (H1N1) The 21st Century’s first influenza pandemic

8. 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

9. 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.

10. World Health H1N1, as of August 2009

11. US Epidemiology H1N1August 2009

12. Mortality by Age, US,as of August 1, 2009

13. US Epidemiology, as of August 2009 • “More than one million people became ill with novel H1N1 flu between April and June 2009.”- cdc.gov

14. 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.

15. As of July 9, 2009: confirmed cases MI Epidemiology, as of July 2009

16. 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.

17. Planning for an Impending Pandemic The Role of Public Health

18. 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

19. America’s deaths from influenza were greater than the number of U.S. servicemen killed in any war Thousands Civil WWI 1918-19 WWII Korean Vietnam War Influenza War War Pestronk, Robert

21. Categories of Pandemic Strength

22. Estimated Impact of a Future Pandemic in Michigan (*Michigan figures developed with Flu-Aid 2.0 software, CDC)

23. 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

24. Public Health Containment Tools-Pandemic Flu Legal authority to Implement Public Health Measure resides equally in all 45 MI Local HD Health Officers • Vaccine • Antivirals • Treatment • Prophylaxis • Infection Control • Social Distancing MI PUBLIC HEALTH CODE Similar but multi-jurisdictional authority resides with State Health Officer

25. Menu of Public Health Actions, circa 1918 9. Mandatory or recommended use of masks in public10. Closing or discouraging the use of public transit systems11. Restrictions on funerals, parties, and weddings12. Restrictions on door-to-door sales13. Community-wide curfew measures and business closures14.  Social distancing strategies for those encountering others 15. Public health risk communication measures 16. Declaration of public health emergency. • Making influenza a reportable disease2. Isolating sick individuals3. Quarantine of households with sick individuals4. School closure5. Protective sequestration of children or adults6. Cancellation of worship services7. Closure of public gathering places [e.g., saloons, theatres, etc.]8. Staggered business hours to decrease congestion on trams, etc. Hatchett, et al, PNAS, May 1, 2007

26. 1918 Flint Journal Headlines Slide courtesy of Robert Pestronk

27. Michigan Pandemic Planning Coordination of state and local responses

28. 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

29. Keweenaw 44 % 8 • 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 7 6 3 2n 1 5 2 s

30. Preparedness Planning • “All Hazards”-Pandemic Flu an excellent example • Basis of all plans is a strong Continuity of Operations Plan

31. 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 • … West Nile Virus Hotline1-888-354-5500 ext 7850 or734-240-7850 Avian Influenza Hotline1-888-354-5500 ext 7878 or734-240-7878

32. The Role for the Community Responder Pandemic Influenza

33. 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

34. 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)

35. 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

36. 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

37. 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

38. 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

39. Tools for the First Responder • Surveillance • Community Mitigation • Social Distancing • Infection Control, based on Risk Assessment • Vaccination • Communication

40. Surveillance • MDCH, local health departments, tribes • Emergency Departments • Schools • Pharmacies • Hospitals • sentinel laboratories and physicians • local health departments • www.michigan.gov/flu

41. 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

42. 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.

43. 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

44. 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.

48. 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.

49. 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)

50. 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