H5N1, H1N1, and Pandemic Influenza

An Update

Eden V. Wells, MD, MPH

Michigan Department of

Community Health

Outline Novel Strain H5N1- Brief Update

Novel Strain H1N1-Update

Pandemic Influenza Planning-Michigan

Pan Flu Planning for You

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

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

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

Current U.S. Status, H5N1

No current evidence in U.S. of highly pathogenic H5N1 in:

– Wild birds

– Domestic poultry

– Humans

2009 Novel Influenza A (H1N1)

The 21st Century’s first influenza pandemic

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

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.

World Health H1N1, as of August 2009

US Epidemiology H1N1August 2009

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

US Epidemiology, as of August 2009

“More than one million people became ill with novel H1N1 flu between April and June 2009.”- cdc.gov

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.

MI Epidemiology, as of July 2009

As of July 9, 2009: confirmed cases

Variables Total pH1N1 (%) (n=489)

Hospitalized pH1N1 (n=110)

Nonhospitalized pH1N1 (n=325)

Gender

Females Males

Unknown

227 (46.4)260 (53.2)

2 (0.4)

59 (53.6)51 (46.4)

0

143 (44.0)

180 (55.4)2 (0.6)

Average age (yrs) 18.0 25.4 15.8

Median age (yrs) 14.0 18.0 13.0

Age group 0-4 yrs 5-24 yrs 25-49 yrs 50-64 yrs 65+ yrsAge range (yrs)

58 (11.9)326 (66.7)77 (15.7)23 (4.7)5 (1.0)0.2─87

9 (8.2)55 (50.0)28 (25.5)14 (12.7)

4 (3.6)0.3─87

45 (13.8)230 (70.8)40 (12.3)

9 (2.8)1 (0.3)0.2─79

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.

Planning for an Impending Pandemic

The Role of Public Health

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

0

100

200

300

400

500

600

700

800

900

America’s deaths from influenza were greater than the number of U.S.

servicemen killed in any war

Civil WWI 1918-19 WWII Korean Vietnam

War Influenza War War

Thousands

Pestronk, Robert

Categories of Pandemic Strength

Estimated Impact of a Future Pandemic in Michigan

(*Michigan figures developed with Flu-Aid 2.0 (*Michigan figures developed with Flu-Aid 2.0 software, CDC)software, CDC)

Gross Attack Rate 35%

Health Outcome

Moderate(1957 / 68-like)

Severe(1918-like)

Minimum Maximum Minimum Maximum

Illness 3.4 million 3.4 million 3.4 million 3.4 million

Outpatient medical care

1.4 million 2.6 million 1.3 million 2.2 million

Hospitalization 14,000 51,000 120,000 420,000

Death 5,000 15,000 43,000 126,000

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

Public Health Containment Tools-Pandemic Flu

Vaccine

Antivirals– Treatment

– Prophylaxis

Infection Control

Social Distancing

Legal authority to Implement Public Health Measure

resides equally in all 45 MI Local HD

Health Officers

Similar but multi-jurisdictional

authority resides with State Health Officer

MI PUBLIC HEALTH CODE

Menu of Public Health Actions, circa 1918

1.Making influenza a reportable disease

2. Isolating sick individuals

3. Quarantine of households with sick individuals

4. School closure

5. Protective sequestration of children or adults

6. Cancellation of worship services

7. Closure of public gathering places [e.g., saloons, theatres, etc.]

8. Staggered business hours to decrease congestion on trams, etc.

9. Mandatory or recommended use of masks in public

10. Closing or discouraging the use of public transit systems

11. Restrictions on funerals, parties, and weddings

12. Restrictions on door-to-door sales

13. Community-wide curfew measures and business closures

14.  Social distancing strategies for those encountering others

15. Public health risk communication measures 16. Declaration of public health emergency.Hatchett, et al, PNAS,

May 1, 2007

1918 Flint Journal Headlines

Slide courtesy of Robert Pestronk

Michigan Pandemic Planning

Coordination of state and local responses

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

Keweenaw44 %

8

7

36

15 2 s2n

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

Preparedness Planning “All Hazards”-

Pandemic Flu an excellent example

Basis of all plans is a strong Continuity of Operations Plan

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• …

Avian Influenza Hotline1-888-354-5500 ext 7878 or734-240-7878

West Nile Virus Hotline1-888-354-5500 ext 7850 or734-240-7850

The Role for the Community Responder

Pandemic Influenza

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

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)

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

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

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

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

Tools for the First Responder

Surveillance Community Mitigation

– Social Distancing– Infection Control, based on Risk Assessment

Vaccination Communication

Surveillance MDCH, local health departments, tribes

– Emergency Departments– Schools– Pharmacies– Hospitals– sentinel laboratories and physicians– local health departments

www.michigan.gov/flu

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

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.

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

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.

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.

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)

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

References

Mivolunteerregistry.org Local Health Department Michigan Department of Community

Health (www.michigan.gov/flu) WHO www.who.int CDC www.cdc.gov DHHS (www.pandemicflu.gov)

(CHECKLISTS)

Acknowledgements

Howard Markel, University of Michigan Medical School

Several slides courtesy of:– Robert Pestronk – Christi Carlton, MDCH