1. Influenza: Facing New Global Challenges Howard Steinberg, Health Officer Morris County Office of Health Management

2. Overview Interim Pandemic Planning Seasonal, Avian and Pan Flu Infection Control Surveillance Planning Public Information

6. Community Mitigation Strategy by Pandemic Severity

10. Characteristics of Seasonal Influenza  Occurs annually – October through April  More than 36,000 deaths and 200,000 hospitalizations annually in US  Elderly, immunocompromised and young children most vulnerable  Largely preventable through vaccine

11. Influenza Viruses Three types (A,B,C) –Type A Can infect humans and a variety of animals (birds, pigs, horses) Wild birds are the natural reservoir Divided into subtypes (HA and NA) Greatest risk for epidemic/pandemic

12. Influenza Viruses –Type B Humans – only known reservoir Not classified into subtypes Can cause epidemics but not pandemics –Type C Humans and swine– known reservoirs Mild illness in humans without seasonality Not classified into subtypes Does not cause epidemics/pandemics

13. Influenza A H #N # 1-16 1-9

14. Antigenic Shift and Drift Shift (Type A only) –Major changes new subtype –Exchange of gene segments –May cause pandemic –Example: H3N2 replaced H2N2 in 1968 Occurs infrequently Drift (Types A and B) –Minor change, within subtype –Gradual accumulation of amino acid changes in HA and/or NA –May cause epidemic –Example: drifted A/H3N2/Fujian circulated A/H3N2/Panama (vaccine strain 2003/4) Occurs continuously Cox NJ, Subbarao K. Lancet 1999;354:1277-82.

15. Characteristics of Avian Flu Bird flu (H5N1) Migratory waterfowl are carriers Virus passed to domestic poultry flocks

16. Transmission to humans Person-to-person transmission not confirmed High death rate

18. Characteristics of Pandemic Influenza Needs to meet 3 criteria –New strain of virus –Ability to cause serious disease and death in humans –Easy person-to-person spread

19. Pandemic Impact

20. Pandemics 1918 Spanish Flu H1N1 500,000 US 1957 Asian Flu H2N2 70,000 US 1968 Hong Kong H3N2 34,000 US

21. Challenges Health Care Social Personal

22. Health Care Challenges Don’t know which people the virus will affect the most Vaccines will not be available in the early stages of pandemic Health care workforce will be sick along with everyone else Health care system will be overwhelmed

23. Societal Challenges Maintaining essential community services and business Distributing limited amounts of medications and vaccines Maintaining civil order

24. Personal Challenges Protecting self and family Attending school/work Obtaining goods, services and necessities Maintaining daily life activities Obtaining medical care Traveling Obtaining reliable information

26. Pandemic Influenza Preparedness

27. Worldwide Watch Animal Health –World Organization for Animal Health (OIE) –United Nations Food and Agriculture Organization (UNFAO) Human Health –World Health Organization (WHO) –Centers for Disease Control & Prevention (CDC)

28. Governmental Preparedness FEDERAL LEVEL: CDC assisting with monitoring efforts worldwide Federal strategic plan and pandemic influenza plan developed CDC recommending that each state develop its own plan

29. Governmental Preparedness STATE LEVEL: Continually updating and expanding our influenza pandemic plan Continually developing public information materials Developing guidelines for NJ hospitals Regularly updating DHSS website Exercising plans Surveillance

30. Governmental Preparedness LOCAL LEVEL: Pandemic plans part of local emergency preparedness plans LINCS agencies (county and city based) coordinate local preparedness efforts NJ Medical Reserve Corps

31. Healthcare System Preparedness Developing preparedness plans Enhancing infection control procedures Stockpiling supplies Cross training staff Conducting exercises

32. School Preparedness Schools Open Schools Closed

33. What can you do? Prepare now – “Ready Together NJ” Emergency Pocket Guide: Morris County Know where to get reliable information as the incident unfolds Follow instructions provided by governmental public health authorities

34. Infection Control Measures practiced by healthcare personnel to decrease transmission and acquisition of infectious agents.

35. Background Each year nearly 22 million school days are lost to the common cold alone. Research shows that when students practice health habits, they miss fewer days of school.

36. Planning Considerations Spread will likely be rapid and unpredictable Each wave of the virus may last 6-8 weeks each 40% of all children will be sick

37. What can you do to prevent the spread of influenza? –Cover your mouth and nose when you cough or sneeze –Avoid touching your face –Stay home if you are sick –Wash your hands frequently

38. Wash Your Hands! Use warm water and soap Rub hands vigorously for 20 seconds Wash palms, backs, wrists, under fingernails and between fingers Rinse off all soap Dry hands with paper towel Use the paper towel to turn off the faucet Use the paper towel to open the bathroom door

39. When should I wash my hands? When visibly soiled When contaminated with blood or bodily fluids After removing gloves

40. When should I wash, continued Before eating Before feeding others Prior to handling food After personal functions such as using the bathroom or blowing your nose

41. When to use antibacterial gels When hand hygiene is required and hands are not visibly soiled Between contacts with students After touching objects that have been in contact with sick people When you can’t wash your hands with soap and water

42. Use of antibacterial gels Apply to palm of one hand Rub hands together making sure to cover all surfaces of hands and fingers Rub until hands are dry

43. Germs Are Everywhere Age appropriate discussion of germs Invisible Present even though not seen

45. Investigative Questions How can disrupting the environmental conditions stop the spread of infectious disease? How can thorough hand washing limit the spread of infectious diseases?

46. Investigative Questions Are plans in place to send sick children home safely? What will be done if parents send sick children to school? How will you monitor how many children are sick? Is there a policy to isolate sick children?

47. Implications for Schools Children expected to have high rates of infection Schools may face closures or release of students Schools may be used as emergency facilities

48. Policy and Logistical Challenges School feeding Continuation of learning Need for comprehensive approach

49. Start Planning Now…Preparedness Evaluate supply policies and order supplies if needed (tissues, soap, antibacterial hand gel) Train teachers and staff on the risks and implications of a pandemic

50. Preparedness, Continued Create a surveillance system to help track student and staff absences Consider different mechanisms for delivering educational content if schools are closed for extended periods of time Test your plans and conduct tabletop exercises

51. Schools Can Start Planning Now…Response Activate Incident Command System Communicate with teachers, staff and parents –Messages MUST be clear and accurate Track absences in collaboration with your local health department

52. Response, Continued Promote infection control measures among and between students and staff Make necessary changes throughout the process

53. Schools Can Start Planning Now, Recovery Ensure appropriate environmental remediation of school facility if school was used as health care site or if there were sick children in school building Assess ongoing policies and practices

55. OBJECTIVES WHO phases of an Influenza pandemic Current surveillance in place to detect an influenza pandemic Surveillance in Schools.

56. UNIVERSAL PANDEMIC TERMINOLOGY PHASE 2 INTER PANDEMIC PERIOD PHASE 3 PHASE 4 PHASE 5 PHASE 6 PHASE 1 PANDEMIC ALERT PERIOD PANDEMIC PERIOD Increased and sustained transmission in general population No new influenza sub-type has been detected in humans. Human infection(s) with a new subtype, but no human-to-human spread or at most rare instances of spread to a close contact

57. INFLUENZA SURVEILLANCE Goals of public health surveillance Surveillance for influenza viruses (virologic surveillance) and Surveillance for influenza-associated illness and deaths (disease surveillance).

58. INFLUENZA SURVEILLANCE CONTD… Virology surveillance Laboratories NJDHSS CDC Detection of Illness Sentinel providers Sentinel labs Acute care hospitals OTC sales Schools Long term care facilities

59. INFLUENZA SURVEILLANCE AND SCHOOLS Inter pandemic and Pandemic alert period Participate in the weekly school absenteeism surveillance. Ask for the predominant reason for absenteeism (respiratory illness, gastrointestinal illness, fever, ILI.)

60. INFLUENZA SURVEILLANCE AND SCHOOLS Pandemic period Expanding the LHD surveillance network, increasing the number of schools and nursing homes surveyed. Implementation of a hospital based respiratory illness surveillance system. Implementation of an intra-state influenza and pneumonia mortality surveillance system. Emphasis placed on reporting any outbreak of ILI in nursing homes and other institutional setting.

61. We’ve Got A Plan! And another plan too! 7/5/05 NJDHSS Influenza Pandemic Plan 11/1/05 National Strategy for Pandemic Influenza 11/23/05 Morris County Pandemic Influenza Preparedness and Response Plan 5/3/06 Implementation Plan for the National Strategy 10/31/06 Local Health Department Influenza Preparedness and Response Plan 1/07 (?)Revised NJDHSS Influenza Pandemic Plan 6/07 (?)Revised Morris County Pandemic Influenza Preparedness and Response Plan

63. Surveillance and Epidemiologic Response LEAD AGENCY – County Office of Health Management POSSIBLE LINKS TO YOUR SCHOOL Local Health Department’s (LHD) doing case/contact follow-up County Epidemiologist requesting attendance/sick data

65. Laboratory Diagnostics LEAD AGENCY – NJ Department of Health & Senior Services POSSIBLE LINKS TO YOUR SCHOOL LHD’s conducting sampling of contacts

66. Community Control and Response LEAD AGENCY – NJ Department of Health & Senior Services POSSIBLE LINKS TO YOUR SCHOOL Guidance on community gatherings Social Distancing Suggestions Procedures for disinfection Somebody* tells you to close the school *(NJDHSS, NJDOE, LHD, MCOHM, School Board, Governor)

67. What Do People Feel Inside When a Disaster Looms or Occurs? Psychological Barriers 1. Denial 2. Fear, anxiety, confusion, dread 3. Hopelessness or helplessness 4. Seldom panic 5. Flight or fight and paralysis

68. Communicating in a Crisis is Different In a CRISIS, all affected people: Take in information differently Process information differently Act on information differently

69. Communicating in a Crisis is Different Be first Be right Be credible

70. Messaging 27 – 9 -3 Simple messages that contain 3 sound bites, delivered in 9 seconds, with 27 words

71. 5 Communication Steps That Boost Operational Success 1. Execute a solid communication plan 2. Be the first source for information 3. Express empathy early 4. Show competence and expertise 5. Remain honest and open

72. Communicating In A Crisis Is Different Public must feel empowered – reduce fear and victimization Mental preparation reduces anxiety Taking action reduces anxiety Uncertainty must be addressed

73. 5 Key Elements To Build Trust 1. Express Empathy in first 30 seconds 2. Competence 3. Honesty 4. Commitment 5. Accountability

74. The STARCC Principle: How To Communicate Initially in a Crisis Your public messages in a crisis must be: Simple Timely Accurate Relevant Credible Consistent

75. What Reporters Want Every Crisis – no matter how catastrophic is predictable: –Who was hurt? –Who is at risk? –How can I protect myself/my family? –Where can I get more information? –When will I get more information? –Am I safe?

76. Who The Public Perceives As Credible Most Credible –Local Citizens perceived as neutral, respected, informed –Health/Safety Professionals (Nurses, MDs, Firefighters) –Professors/Educators (respected institutions) –Clergy –Non-profit Organizations –Media –Environmental/Advocacy Groups –Federal Government –State/Local Government –Industry –For Profit Groups Least Credible

77. Ten Rules for a Successful Interview 1.Be yourself 2.Know your message 3.Stick to your expertise 4.Don’t be afraid to say “I don’t know” 5.Avoid jargon

78. Public Health Communication Planning NJDHSS Office of Communications Morris County Office of Health Management: message out to partners and stakeholders: –County OEM, Administration –Municipal Health Departments –Mental health –Education –Community Organizations

79. Conclusions Flu pandemics are unpredictable We don’t know if the avian H5N1 virus will cause the next flu pandemic Flu pandemics can have serious impact on us, society, businesses and the health care system NJ governmental agencies are preparing for a potential flu pandemic

80. Conclusions cont. There are things that you can do NOW to prepare for a future flu pandemic Adopting health behaviors now can help reduce the spread of illness Know where to get the facts

81. Resources CDC –www.cdc.gov/fluwww.cdc.gov/flu –www.pandemicflu.govwww.pandemicflu.gov Department of Health and Senior Services –www.nj.gov/health/fluwww.nj.gov/health/flu –Ready Together NJ –Your County LINCS Site

82. Questions ?

83. Contact Information Howard Steinberg 973-631-5485 hsteinberg@co.morris.nj.us