[your facility’s name/logo here] Preparing For Pandemic Flu

1. [your facility’s name/logo here]Preparing For Pandemic Flu What our healthcare workers need to know Influenza virus, X 500,000

2. Acknowledgements These training materials were developed by Kay Koelemay, MD and Jeffrey Duchin, MD Public Health – Seattle & King County with support from the University of Washington and The National Institutes of Health Region X Center of Excellence for Biodefense and Emerging Infectious Diseases Questions? Public Health 206-296-4774

3. User’s Guide • Seven separate modules • The Basics 21 slides • Government Agencies 10 slides • Decision-Makers and Authorities 14 slides • How is Seasonal Flu Transmitted? 16 slides • Pandemic Flu and Your Job 11 slides • Infection Control and Patient Care: What Do I Wear? 26 slides • Influenza Preparedness Plan 36 slides

4. User’s Guide • Modules are designed to be customized with facility-specific information for training health care providers and non-clinical staff regarding facility pandemic planning • Modules can also be used for self-study • Notes provide additional talking points • Review questions follow several modules • May customize with facility-specific questions • Presenters should review to be sure information in the presentation is current

5. BIRD FLU

6. Pandemic Influenza The basics Module 1

7. Human Influenza • “Seasonal” influenza • three types: A, B, and C • 3 influenza viruses currently circulate worldwide: • 2 type A strains (currently H1N1 and H3N2) • 1 type B strain • adults may have partial immunity (protection) to seasonal flu • have had past infections with related flu viruses • no pre-existing immunity to a new virus that is dramatically different from past viruses

8. I N F L U E N Z A What Do the “H” and “N” Mean?Proteins on the surface of the virus Hemagglutinin (HA) (15 types exist in nature) Neuraminidase (NA) (9 types exist in nature) Genes

9. Human InfluenzaTransmission • Influenza spreads readily from person to person • primarily thought to spread by respiratory droplets • lesser role for airborne spread and indirect contact • May be transmitted from infected persons who appear well (mild or asymptomatic infection) • Short incubation period – average 2 days (range 1-4 days) • May be spread 24 hours before onset of symptoms and during the symptomatic period http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm

10. Human InfluenzaVaccine • Influenza virus is continually changing • allows it to evade the immune system • Flu vaccine must be made yearly • based on best projection of the types of influenza virus that will be circulating • ~36,000 Americans die each year from flu-related causes • All healthcare workers should get the annual influenza vaccination http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5408a1.htm

11. Avian Influenza: Bird Flu • Influenza A viruses infect birds = “avian influenza” or “bird flu” • can be mild or severe in birds • usually do not cause human disease • Highly pathogenic avian influenza A (H5N1) has infected birds in more than 50 countries since ‘97 • Not currently present in birds in North America

12. Current Outbreak of Avian Influenza A (H5N1)

13. Current Outbreak: Avian Influenza A (H5N1) • 12 countries have reported human cases • all cases involved close contact with infected poultry or ill family members • no sustained person-to-person transmission • mortality rate is high in human avian flu infections • remains very difficult for humans to get • is still a disease of birds

14. Avian Influenza A (H5N1) in Humans

15. Exposure to Avian Influenzain Southeast Asia

16. Current Outbreak of Avian Influenza A (H5N1) • There is NO current human influenza pandemic • The United States and many other countries are preparing for a possible severe influenza pandemic because: • the avian influenza (bird flu) outbreak is widespread and not able to be controlled • the virus can infect humans and cause severe illness • an avian influenza virus evolved to cause a catastrophic human pandemic in 1918

17. Pandemic Influenza • A new strain of influenza can evolve • when an avian virus mutates or changes • from a combination of an avian and human virus • If the new strain infects humans and is able to spread easily from person to person: • humans would have little or no immunity • it would rapidly travel around the world and cause high levels of disease and death • “Pandemic” = global outbreak of disease • occur naturally at variable intervals • are not always severe

18. Origins of Pandemic Influenza Belshe RB. N Engl J Med. 2005; 353:2209-11

19. ←SE ASIA

20. 20th Century Influenza Pandemics • 1918-19: “Spanish flu” A (H1N1) • most severe pandemic known • new influenza virus subtype emerged and spread around the globe in 4 - 6 months • 20-50 million deaths worldwide • 500 - 650,000 deaths in the U.S. • Ten times as many Americans died of influenza than died in World War I

21. 20th Century Influenza Pandemics • 1957-58 - “Asian flu” A (H2N2) • first identified in China in late Feb 1957 • spread to the U.S. by June (4 months) • 70,000 deaths in the U.S. • 1968-69 - “Hong Kong flu” A (H3N2) • detected in Hong Kong in early 1968 • spread to U.S. later that year. • 34,000 deaths in the U.S. • H3N2 continues to circulate

22. Influenza Pandemics: Summary • Pandemics vary in severity • Not possible to predict in advance how severe the next pandemic will be, but we know from history that they can be severe • Not possible to know in advance when the next pandemic will occur • When it does occur, it will spread rapidly

23. Potential Pandemic Impact: King County Adapted from Pandemic Influenza Response Plan, Public Health – Seattle & King County, available at: http://www.metrokc.gov/health/pandemicflu/plan/index.htm

24. WHO Pandemic Flu Phases ► Adapted from “National Strategy for Pandemic Influenza Implementation Plan,”http://www.whitehouse.gov/homeland/nspi_implementation.pdf

25. 1918 Influenza Pandemic Courtesy of the National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C

26. Review Questions: Module 1 • Pandemic flu and avian (bird) flu are the same. True False • Avian (bird) flu is easily transmitted to humans. True False • In the 20th Century there were 3 flu pandemics. True False • A severe influenza pandemic would have a major impact on the health care system True False

27. Government Agencies Roles and responsibilities Module 2

28. World Health Organization (WHO) • Monitors influenza activity and pandemic conditions worldwide • Issues guidelines for national pandemic planning and preparedness • Coordinates international activities • Declares the global pandemic phase • Formulates ethical guidance for pandemic planning (http://www.who.int/ethics/influenza_project/en/ )

29. U. S. Department of Health and Human Services (HHS) • Overall coordination of the public health and medical emergency response during a pandemic • Determines pandemic response stage for U.S., based on the WHO global phase

30. Centers for Disease Control and Prevention (CDC) • Guidance on disease control and prevention strategies • National surveillance and epidemiological activities • Strategic National Stockpile • Guidance on disease containment measures to reduce transmission (travel restrictions, social distancing, isolation & quarantine, etc.) • Health and medical guidance

31. Washington State Department of Health (WADOH) • Assures statewide planning and preparedness • State Public Health Lab is CDC Lab Response Network reference lab • Requests federal assistance through the Governor, including medication from the Strategic National Stockpile (SNS)

32. Public HealthSeattle & King County • Facilitates and coordinates countywide health response planning & preparedness • King County Healthcare Coalition • Coordination with emergency management response • Conducts local surveillance to monitor human disease • Provides local guidance for health and medical response

33. Public Health Seattle & King County • Provides guidelines for surveillance, clinical management, infection control, and disease containment strategies for local use • Provides updates about the local situation to guide local response efforts • Procures and manages governmental (public) antiviral and vaccine stockpiles • Provides communications to the public, healthcare providers, media, elected officials, business & community leaders throughout a public health emergency

34. King County Healthcare Coalition • Collaboration among Public Health, hospitals, ambulatory care facilities, other health agencies, and emergency management officials to improve response to health emergencies across all sectors of the healthcare system • Voluntary organization • Currently includes 28 healthcare organizations & agencies • Open to all health care organizations providing services in King County

35. Working Groups: Medical Directors Acute Care (Region 6 Committee) Critical Care Ambulatory Care Infectious Disease Legal Regional Medical Resource Center Call Center Project Alternate Care Facilities Future Planning: Workforce Issues & Medical Staffing Finance & Reimbursement Pediatric Care Long Term Care Palliative Care Healthcare Coalition Workgroups

36. [your facility’s name/logo here]Healthcare Coalition Representatives • Executive member:__________________ • Work group members • Medical Directors WG:__________________ • Region 6 Committee:___________________ • Critical Care WG:______________________ • Infectious Disease WG:_________________ • Ambulatory Care WG:__________________ • Other:_______________________________

37. Decision-Makers and Authorities Who makes decisions in a large-scale health emergency? Module 3

38. Statutory Authority: Emergency Management • The County Executive and the heads of cities: • can proclaim emergencies and issue emergency orders in their jurisdictions • The Governor • can proclaim an emergency in all or part of the state and issue emergency orders • Emergency orders can include: • Curfews, closure of public places, closure of businesses • Such other orders as are necessary for the protection of life and property

39. Statutory Authority: Public Health • Health officials have broad authority and may act without a proclamation of an emergency. • The State Secretary of Health • advises Local Health Officers and could exercise direct authority in local matters, if necessary. • The Local Health Officer can take action to “…control and prevent the spread of any dangerous, contagious or infectious disease within his or her jurisdiction.”

40. Emergency Management and Public Health: Coordination • The heads of government and health officials have broad powers to protect the public • during an emergency, actions would be coordinated through incident command structures • The Local Health Officer is the only official who can order isolation and quarantine

41. Isolation and QuarantineIsolation • Separation and restricted movement of illpersons with contagious disease • often in a hospital setting • primarily applied on an individual level, but may be applied to populations • often voluntary, but may be mandatory • fundamental, commonly used public health practice (usually voluntary) • Prevents spread to others

42. Isolation and QuarantineQuarantine • Separation and restriction of movement of persons presumed to have been exposedto an infectious disease, but who are not yet ill • may be in home or residential facility • voluntary or mandatory • monitored for development of illness • lasts at least as long as the usual incubation period of the infection • Prevents spread to others

43. Quarantine: Statutory Authority 1 • Intrastate quarantine power (within the state) • Local and state public health officials have authority for quarantine when an infectious disease outbreak is confined within state borders • Considered a police power- an inherent authority to protect health and welfare of citizens • Reserved to states (10th Amendment)

44. Quarantine: Statutory Authority: 2 • Foreign and interstate quarantine • Considered essential in regulation of foreign and interstate commerce • Federal authority (Commerce Clause) • Limited to diseases named in Executive Order • CDC manages federal quarantine, with possible utilization of assets from other agencies • CDC may intervene in intrastate incidents if requested by state or if local control efforts are considered inadequate

45. Purpose of Quarantine: 1 • One of several “community containment” strategies to prevent spread of serious infectious diseases • Applied to persons who have been exposed (contacts) but are not ill • Designed to meet two objectives • Allow early recognition of symptoms as and as early treatment, if the exposed person becomes ill • Reduce transmission to others before illness has been clinically recognized

46. Purpose of Quarantine: 2 • Quarantine is more likely to be used: • when the disease is severe • when there are limited or no other treatments or prevention options (drugs, vaccine) • when the disease spreads easily or rapidly through populations • when appropriate resources are available to meet the needs of persons who are quarantined

47. Additional Potential Community Containment Strategies • Isolation for ill persons at home or in hospital • Home quarantine for household members of ill persons • Close schools and day care centers • Keep children and teens at home

48. Additional Potential Community Containment Strategies • Limit group/public assembly • Cancellation of large public events • Decrease mass public transit • Close public places where people gather • Restrict nonessential travel • Avoid close contact in public and at work (social distancing)

50. Review Questions: Module 3 1. Isolation is commonly used in hospitals for patients with certain infections. True False 2. Quarantine can be done at home. True False 3. A quarantine is separation and restriction of movement of well persons. True False 4. During a severe pandemic, schools may close and children and teens may need to stay home for months. True False