1. Local and Global Public Health Links: Preparation for an Influenza Pandemic
Nicole J. Cohen, MD, MSc
Chicago Department of Public Health
The University of Chicago’s Summer Institute for Educators
June 29, 2006

2. Influenza Virus Three types of influenza virus: A, B, C
Only influenza A and B viruses cause significant disease and epidemics in humans

3. Influenza A Viruses
Classified into subtypes based on two surface proteins, hemagglutinin (HA) and neuraminidase (NA)
16 HAs and 9 NAs in total
Currently in humans:
H1N1
H3N2

4. Influenza A Susceptible Hosts

5. Influenza B Viruses
No subtypes
Infect humans almost exclusively

7. Avian Influenza Infection of bird with influenza A virus
Different strains from the ones that cause human infections annually
Occurs naturally
High vs low pathogenicity viruses
Highly contagious among bird populations
Usually spread from wild birds to domestic poultry
May be carried by birds without causing disease
May cause severe illness and/or death among birds
Rarely infects humans

8. Symptoms of Avian Influenza in Humans
Wide range of symptoms depending on type of virus
Typical flu symptoms (fever, cough, sore throat, muscle aches)
Conjunctivitis (eye infection)
Viral pneumonia
Severe respiratory illness
May be life threatening

9. H5N1 Influenza Virus 1996 First identified in a goose in China
1997 First human cases in Hong Kong
18 confirmed cases, 6 deaths
150 million chickens slaughtered to control outbreak
2/2003 Two cases in a Hong Kong family who traveled to mainland China

12. Current Situation Human Cases -- June 20, 2006
Azerbaijan
Cambodia
China
Djibouti
Egypt
Indonesia
Iraq
Thailand
Turkey
Viet Nam
228 Cases
130 deaths
Death rate approximately 50%

15. How avian influenza infects people
Virus present in respiratory secretions and feces of infected birds
Human infection has resulted from
Close contact with infected birds
Contact with or consumption of raw poultry products
Contact with contaminated surfaces (feces)
Generally has not spread from person to person
Has been suggested in several small family clusters after extremely close contact with sick person
Has not spread beyond one person
Has not spread to health care workers

17. How human influenza spreads
Respiratory droplets
Coughing, sneezing
Spreads through close contact (less than 3 feet)
Prevent by “covering cough”, wearing masks in medical situations
Hand contamination then touching eyes, nose, or mouth
Direct contact e.g. shaking hands with infected person
Contact with objects contaminated by influenza viruses (e.g. doorknobs, phones)
Prevent by hand hygiene, gloves in medical situations

18. H5N1: Is there a vaccine? A vaccine against H5N1 is under development
Not commercially available
Annual influenza vaccine does not protect against H5N1

19. H5N1: Is treatment available?
Most H5N1 viruses are resistant to older class of antivirals (amantadine and rimantadine)
May be treated with newer antivirals Tamiflu® or Relenza®
Effectiveness is not known
Some resistance to Tamiflu® has been identified

20. Advice for Travelers
CDC has not recommended that the general public avoid travel to any of the countries affected by avian influenza
Receive routine flu vaccine (if available) prior to departure
If traveling to any country with a known outbreak of H5N1 influenza
Avoid poultry farms
Avoid contact with animals in live food markets
Avoid contact with any surfaces that appear to be contaminated with feces from poultry or other animals

21. Advice for Travelers
Practice careful hand hygiene, especially after handling raw poultry
It is safe to eat poultry or eggs that have been properly handled and cooked
Monitor your health for 10 days after returning
Seek medical attention if symptoms of fever or respiratory illness develop

23. Pandemic Influenza Worldwide outbreak of a novel (new) influenza virus
Occurs infrequently and at irregular intervals
Unpredictable
Potential for substantial impact
Morbidity (illness) and mortality (death)
Social disruption
Economic costs

24. 20th Century Influenza Pandemics
: “Spanish Flu” (H1N1)
> 500,000 US deaths
> 20 million deaths worldwide
: “Asian Flu” (H2N2)
70,000 US deaths.
: “Hong Kong Flu” (H3N2)
34,000 US deaths

25. Influenza Pandemic 1918

26. How does a pandemic happen?
4 factors must be present:
Novel virus
Virus capable of causing disease in humans
Susceptible population
Virus that is transmissible from person to person
Current avian influenza outbreak is not a pandemic

27. Where do new influenza strains come from?
Mixing of human and animal influenza strains
Adaptation of an animal strain to allow person to person spread

28. WHO Pandemic Phases

29. Issues of Concern
Potential rapid worldwide spread due to global trade and international travel
Medical resources may be insufficient
Medical personnel at high risk of infection
Pandemic would likely be prolonged
Community infrastructure disruption
Major economic impact

30. Estimated Impact of “Medium-Level” Pandemic, US
As much as 35% of population could be affected
~ 47 million people
As many as 734,000 hospitalizations
As many as 207,000 deaths
Economic impact could range between $71.3 and $166.5 billion

31. On the bright side…
Pandemic influenza planning is occurring at the local, state, national and international levels
Surveillance for new influenza strains in birds and humans is ongoing to allow for early detection
Experience with SARS has led to increased awareness and preparedness to deal with global infectious disease emergencies
Medical care and isolation capabilities are more sophisticated than during 1918

32. Global Public Health Surveillance
International Health Regulations revised 2005
Defines Public Health Emergency of International Concern (PHEIC)
Contains a decision instrument to help countries determine whether reporting to WHO is necessary
Includes a list of diseases to be reported immediately, even if single case
Encourages countries to consult WHO for events that may be of public health relevance

34. Pandemic Influenza Planning
Goals
Limit total burden of disease (illness and death)
Decrease social disruption
Decrease economic loss
Engage all levels of health care system, public health, and emergency response
Include public and private sectors
Key similarities (and differences) between pandemic response and other health emergencies
Planning, resources, and implementation

35. Local Planning an Influenza Pandemic
Surveillance recommendations
Laboratory recommendations
Antiviral plan
Vaccine distribution plan
Containment including isolation and quarantine issues
Surge capacity, mortuary issues, and mass care
Communications
Public information
AIRIP = Acute Infectious Respiratory Illness Protocol

36. Vaccine and Antiviral Medications
Will probably not be available in early stages of a pandemic
Even when vaccine does become available, supplies will be limited
Prioritization will have to occur
Antiviral medications
Stockpiled supplies are limited but increasing
Resistance may be a problem

37. Controlling a Pandemic
Early identification and isolation of ill people will be critical
Close monitoring and possible quarantine of exposed contacts
Basic infection control measures
“Social Distancing”
Public transportation
Large gatherings/special events
Schools

38. Preventing Spread of Influenza
Preventing illness:
Wash your hands
Stay away from people who are sick
Get your flu vaccine!
If symptomatic with a respiratory illness:
“Cover Your Cough”
Wash your hands!
Don’t visit friends or family in hospital or a long term care facility
If diagnosed with influenza:
Don’t go to work or attend school while symptomatic

39. Corporate (Workplace) Preparedness
Encourage respiratory and hand hygiene in the workplace
Ensure appropriate hygiene supplies and facilities are available
Discourage employees diagnosed with influenza from working while symptomatic
Plan for functioning with high levels of absenteeism
Mechanisms for employees to work from home, if possible

40. Preparedness in Schools
Hygiene messages/posters
Disease surveillance
Systematic exclusion of sick students and staff
Consider the possibility of school closures
Who makes this decision?
Mandatory closures vs self-shielding behaviors
Continuity of education

43. Personal/Family Emergency Preparedness
Prepare a disaster supply kit for 3 days (general emergencies)
Create a Family Emergency Plan
Know where to access accurate information

44. Personal and Corporate Antiviral Stockpiles – A Bad Idea!!!
Depletion of resources from the public sector
Inadequate supplies for treatment and prophylaxis during seasonal influenza outbreaks
Potential for misuse (wasting) during non-influenza respiratory infections
Potential for development of resistance
Incomplete courses, incorrect dosing, sharing
Cost
Inequitable distribution of drug
Shelf life/expiration

45. For more information http://www.cdc.gov/flu/avian/ http://www.who.int