pandemic influenza. influenza outbreaks yearly, usually in winter months outbreaks yearly, usually...
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Pandemic Influenza
InfluenzaInfluenza
Outbreaks yearly, usually in winter Outbreaks yearly, usually in winter monthsmonths
Illness more severe for very young, Illness more severe for very young, elderly, or those with pre-existing health elderly, or those with pre-existing health conditionsconditions
Yearly, 5-20% of population get the fluYearly, 5-20% of population get the flu Annually causes >200,000 Annually causes >200,000
hospitalizations in UShospitalizations in US 36,000 deaths yearly in US36,000 deaths yearly in US
Influenza PreventionInfluenza Prevention
Yearly influenza shotYearly influenza shot Avoid those who are illAvoid those who are ill Wash your handsWash your hands Antivirals (in special circumstances)Antivirals (in special circumstances)
If you are ill--don’t come to work, cover If you are ill--don’t come to work, cover coughs and sneezes.coughs and sneezes.
Influenza Virus typesInfluenza Virus types
– Type AType A: Infects humans and other : Infects humans and other animalsanimals
More severe illnessMore severe illnessCauses regular epidemics; can cause Causes regular epidemics; can cause pandemicspandemics
– Type BType B: Infectious only to humans: Infectious only to humansCauses epidemics, but less severe Causes epidemics, but less severe illnessillness
InfluenzaInfluenza Influenza A is subtyped Influenza A is subtyped
by surface proteinsby surface proteins– Hemagglutinin (H)Hemagglutinin (H)
16 different types16 different types Helps virus enter cellsHelps virus enter cells
– Neuraminidase (N)Neuraminidase (N) 9 different types9 different types Helps virus leave cell Helps virus leave cell
to infect othersto infect others
InfluenzaInfluenza
All known subtypes of Influenza A All known subtypes of Influenza A found in birdsfound in birds
H5 and H7 cause severe outbreaks in H5 and H7 cause severe outbreaks in birdsbirds
Human disease usually due to H1, Human disease usually due to H1, H2, H3 and N1 and N2.H2, H3 and N1 and N2.
InfluenzaInfluenza
The flu virus constantly changesThe flu virus constantly changes
When it does, vaccines will be less When it does, vaccines will be less efficient efficient
Immune system may be unable to Immune system may be unable to recognize new virusrecognize new virus– No immunity in population for new No immunity in population for new
virus—potential for pandemicvirus—potential for pandemic
Vaccine DevelopmentVaccine Development Inactivated trivalent vaccine (killed vaccine)Inactivated trivalent vaccine (killed vaccine) 2 A, 1 B2 A, 1 B Effectiveness of vaccine depends on “match” Effectiveness of vaccine depends on “match”
between circulating strains and those in vaccinebetween circulating strains and those in vaccine
(H3N2)(H1N1)
Influenza
Protection
A/California/7/2004-like
B/Shanghai/361/2002-like
2005–2006 Influenza Season
A/New Caledonia/20/99-like
Prior Year
January
February
March
April
Surveillance on circulating strains
Selection of specific strains
Preparation and distribution of virus stock to manufacturers
Seed pools inoculated into
eggs
n engl j med 351;20 www.nejm.org november 11, 2004
May
June
July
August
September
October
Harvest and concentration
of fluids
Vaccine inactivated and purified
Vaccine blended, content verified
Packaging, labeling, delivery
n engl j med351;20 www.nejm.org november 11, 2004
Influenza—Vaccine Influenza—Vaccine ProductionProduction
Flu vaccines first produced in Flu vaccines first produced in 1940s1940s
2 manufacturers in US for flu 2 manufacturers in US for flu vaccinevaccine
80 million doses produced by 80 million doses produced by late September late September
6-9 months to produce vaccine6-9 months to produce vaccine
Influenza PandemicsInfluenza Pandemics What is a Pandemic?What is a Pandemic?
– Outbreak in wide geographic area (global)Outbreak in wide geographic area (global)– Effects large # of people with serious Effects large # of people with serious
illnessillness– Usually a new virus or one which Usually a new virus or one which
population has not had exposure in a long population has not had exposure in a long timetime
– May have rapid spreadMay have rapid spread– May occur in wavesMay occur in waves
Seasonal Flu vs Pandemic Seasonal Flu vs Pandemic FluFlu
SeasonalSeasonal Occurs every yearOccurs every year
Occurs during winter Occurs during winter (usually Dec-Mar)(usually Dec-Mar)
Most recover in 1-2 Most recover in 1-2 weeks without txweeks without tx
Very young, very Very young, very old, ill most at risk of old, ill most at risk of serious illness serious illness
PandemicPandemic Occurs infrequentlyOccurs infrequently
(3 per century)(3 per century) Occurs any time of Occurs any time of
yearyear Some may not Some may not
recover, even with recover, even with txtx
People of all ages People of all ages may be at riskmay be at risk
Pandemic InfluenzaPandemic Influenza
Past Pandemics:Past Pandemics:
– 1968 Hong Kong Flu (H3N2) 1968 Hong Kong Flu (H3N2) – 1957 Asian Flu (H2N2) 1957 Asian Flu (H2N2) – 1918 Spanish Flu (H1N1)1918 Spanish Flu (H1N1)
1918-1919 influenza 1918-1919 influenza pandemicpandemic
Worst of past centuryWorst of past centuryEstimated 20-40% of world Estimated 20-40% of world population illpopulation ill
40-50 million people died 40-50 million people died worldwideworldwide
600,000 or more deaths in US600,000 or more deaths in USHigh mortality in young adultsHigh mortality in young adults
Loveland, 1917 & 1918Deaths by age, influenza/pneumonia (Sept - Dec)
0
2
4
6
8
10
12
14
16
18
0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 over 75
Age
Dea
ths
1917 (Sept-Dec) 1918 (Sept-Dec)
Why did young people die?Why did young people die?
Over-reaction by the immune system Over-reaction by the immune system called “cytokine storm” called “cytokine storm”
Those with the strongest immune Those with the strongest immune systems affectedsystems affected
Older people and youngest often die Older people and youngest often die of bacterial pneumonia complicating of bacterial pneumonia complicating flu -- treatable now with antibioticsflu -- treatable now with antibiotics
Even in 2005, no good treatment for Even in 2005, no good treatment for “cytokine storm.”“cytokine storm.”
There are There are severe pandemics severe pandemics
and mild pandemicsand mild pandemics
Infectious Disease Deaths Infectious Disease Deaths 1900’s1900’s
1918
1957 1968
Deaths per 100,000 per year
Pandemics can last Pandemics can last for months and come for months and come
in wavesin waves
Loveland, Oct 1918 - Feb 1919Flu/Pneumonia Deaths by week
1
3
4
8
17
5
3 3
2
3
5 5
2
1
2 2
0
1
0
2
4
6
8
10
12
14
16
18
Oct 6
-12
Oct 1
3-19
Oct 2
0-26
Oct 2
7-Nov
2
Nov 3
-Nov
9
Nov 1
0-Nov
16
Nov 1
7-Nov
23
Nov 2
4-Nov
30
Dec 1
-Dec
7
Dec87
-Dec
14
Dec 1
5-Dec
21
Dec 2
2-Dec
29
Dec 3
0-Ja
n 4
Jan
5-Ja
n 11
Jan
12-J
an 1
8
Jan1
9-Ja
n25
Jan
26-F
eb 1
Feb 2
-Feb
8
Week
Dea
ths
H5N1 Avian InfluenzaH5N1 Avian Influenza
Hong Kong 1997Hong Kong 1997– 18 human cases, 6 deaths18 human cases, 6 deaths– 1.4 million birds destroyed1.4 million birds destroyed
Dec. 2003: AsiaDec. 2003: Asia– Ongoing extensive outbreak in poultryOngoing extensive outbreak in poultry– Limited human to human transmissionLimited human to human transmission– 125 human cases, 64 fatal125 human cases, 64 fatal
July-Aug 2005 Kazakhstan, RussiaJuly-Aug 2005 Kazakhstan, Russia October 2005 Turkey, Romania, RussiaOctober 2005 Turkey, Romania, Russia
H5N1 SymptomsH5N1 Symptoms
Symptoms (human)Symptoms (human)– FeverFever– Shortness of breathShortness of breath– CoughCough– PneumoniaPneumonia– Acute Respiratory DistressAcute Respiratory Distress– Diarrhea, sometimes severeDiarrhea, sometimes severe– Life-threatening complications Life-threatening complications
Concern with Avian Concern with Avian InfluenzaInfluenza
Virus mutates rapidlyVirus mutates rapidly Has shown ability to acquire genes Has shown ability to acquire genes
from viruses infecting other speciesfrom viruses infecting other species H5N1 has acquired some of genetic H5N1 has acquired some of genetic
changes in the 1918 virus associated changes in the 1918 virus associated with human-human transmissionwith human-human transmission
Causes severe disease in humansCauses severe disease in humans High fatality rateHigh fatality rate
Current H5N1 casesin Vietnam, Thailand, Cambodia, & Indonesia as of 11/1/05
Case-fatalitycases deaths rate
Dec 2003-Mar 2004 35 24 69%July 2004 - October 2004 9 8 89%Dec 2004 to date 78 30 38%Total 122 62 51%
Date of onset
Total
What might happen What might happen in a severe in a severe pandemic?pandemic?
If it happens soon…..If it happens soon…..
There will be little or no vaccine until There will be little or no vaccine until 6 - 9 months after the outbreak begins6 - 9 months after the outbreak begins
There will be very limited supplies of There will be very limited supplies of antiviral medicines for treatment (for antiviral medicines for treatment (for 1% of populations, perhaps less).1% of populations, perhaps less).
All communities hit a about the same All communities hit a about the same timetime
We need a plan for the short-term that We need a plan for the short-term that assumes no effective shots or Rxassumes no effective shots or Rx
Are we more or less Are we more or less at risk today at risk today
compared to 1918?compared to 1918?
Why at LESS risk in 2005Why at LESS risk in 2005
Antibiotics for bacterial Antibiotics for bacterial pneumonia complications of pneumonia complications of influenzainfluenza
Some antiviral medicinesSome antiviral medicines IV fluids, ventilatorsIV fluids, ventilatorsGreater ability to do surveillance, Greater ability to do surveillance,
confirm diagnosis of fluconfirm diagnosis of flu
Why at LESS risk in 2005 Why at LESS risk in 2005
Rapid means of Rapid means of communications - internet, TV, communications - internet, TV, radio, email radio, email
More effective personal More effective personal protective equipmentprotective equipment
Fewer people living in each Fewer people living in each household and more rooms.household and more rooms.
Why at MORE risk in 2005Why at MORE risk in 2005
A lot more international travelA lot more international travel 10 times more people in Larimer 10 times more people in Larimer
County, contact with far more County, contact with far more people dailypeople daily
Very little surge capacity in health Very little surge capacity in health care todaycare today
More elderly and immune-More elderly and immune-compromised people in populationcompromised people in population
Why at MORE risk in 2005Why at MORE risk in 2005
Much less self-sufficient than in Much less self-sufficient than in 1918’s (households and businesses)1918’s (households and businesses)
Far more manufactured goods and Far more manufactured goods and raw materials come from distant raw materials come from distant areas, especially Asiaareas, especially Asia
““Just-in-time” ordering of needed Just-in-time” ordering of needed supplies instead of warehousing supplies instead of warehousing critical items on sitecritical items on site
Why at MORE risk in 2005Why at MORE risk in 2005
Unlike 1918, today’s society not Unlike 1918, today’s society not used to rationing, sacrifice.used to rationing, sacrifice.(In 1918, because of WWI, fuel, (In 1918, because of WWI, fuel, coal, and food were already being coal, and food were already being rationed, and community groups, rationed, and community groups, like the Red Cross, were very like the Red Cross, were very active supporting the war effort)active supporting the war effort)
Overall, are we at more or Overall, are we at more or less risk?less risk?
Up to individuals, communities, Up to individuals, communities, states, and nations to decide as states, and nations to decide as they plan for a possible they plan for a possible pandemicpandemic
What might occur - fictional What might occur - fictional but possiblebut possible
Closing of borders, shutting down Closing of borders, shutting down tradetrade
Fuel shortages/restrictions due to Fuel shortages/restrictions due to in oil importsin oil imports
Closing of schools, events, and Closing of schools, events, and businesses where large numbers of businesses where large numbers of people congregatepeople congregate
Businessses/workers upset about Businessses/workers upset about loss of incomeloss of income
What might occurWhat might occur
High mortality, especially among High mortality, especially among young adultsyoung adults
People working at home when People working at home when possible; others taking paid or possible; others taking paid or unpaid leaveunpaid leave
Absenteeism of 30% to 50%Absenteeism of 30% to 50% High numbers of cases, High numbers of cases,
hospitalizations, and deathshospitalizations, and deaths
What might occurWhat might occur
Not enough hospital beds, health care Not enough hospital beds, health care workers, or ventilatorsworkers, or ventilators
High numbers of cases and High numbers of cases and hospitalizations. Death rates - 2.5%hospitalizations. Death rates - 2.5%
Death rate for pregnant women is 20%Death rate for pregnant women is 20% Inadequate amounts of antiviral meds, Inadequate amounts of antiviral meds,
leading to violence at treatment sitesleading to violence at treatment sites
What might occurWhat might occur
Sick people who live alone, or with Sick people who live alone, or with small children only, in dire straitssmall children only, in dire straits
Young children trying to take care Young children trying to take care of sick parents, with no supportof sick parents, with no support
Children neglected because Children neglected because parent(s) too sick to provide careparent(s) too sick to provide care
Orphaned children whose parent(s) Orphaned children whose parent(s) have diedhave died
What might occurWhat might occur
Mortuaries and crematoria unable Mortuaries and crematoria unable to keep up with deathsto keep up with deaths
Funeral home workers unwilling to Funeral home workers unwilling to handle corpses of influenza patientshandle corpses of influenza patients
Makeshift hospitals established in Makeshift hospitals established in churches and schoolschurches and schools
Shortages of fuel, food, essential Shortages of fuel, food, essential supplies; prices skyrocket.supplies; prices skyrocket.
What might occurWhat might occur Utilities having trouble with staff Utilities having trouble with staff
shortages, inability to replace supplies shortages, inability to replace supplies and parts. Spot failures occurring.and parts. Spot failures occurring.
Care shifted from hospitals to being Care shifted from hospitals to being taken care of by family/friends/people taken care of by family/friends/people in neighborhood.in neighborhood.
Some neighborhoods organized, Some neighborhoods organized, collaborative; others disorganized with collaborative; others disorganized with individuals hoarding individuals hoarding
What might occurWhat might occur Protective face masks that sold for $1 Protective face masks that sold for $1
are now going for $20 eachare now going for $20 each Sanitizers and chlorine are sold out of Sanitizers and chlorine are sold out of
the storesthe stores Availability of other Rx drugs is reduced Availability of other Rx drugs is reduced Flu outbreak severe in detention Flu outbreak severe in detention
center, with 1/2 the usual number of center, with 1/2 the usual number of staffstaff
What might occurWhat might occur Courts largely shut down; no one Courts largely shut down; no one
willing to serve on a jurywilling to serve on a jury Fear, distrust, mourning/depression, Fear, distrust, mourning/depression,
are widespreadare widespread Church facilities are closed when Church facilities are closed when
people most need spiritual comfortpeople most need spiritual comfort Some flee cities to National Forests Some flee cities to National Forests
to wait out the outbreakto wait out the outbreak
What might occurWhat might occur
In the end, after several waves and 3-In the end, after several waves and 3-4 months, the outbreak is declared to 4 months, the outbreak is declared to be over in Larimer County.be over in Larimer County.
Over 80,000 became ill and over Over 80,000 became ill and over 2,000 deaths occurred in about 12 2,000 deaths occurred in about 12 weeks. weeks.
Great economic loses from closed Great economic loses from closed businesses. businesses.
What might occurWhat might occur
12,000 needed hospitalization, 12,000 needed hospitalization, although many were cared for in although many were cared for in the communitythe community
With the completion of McKee’s With the completion of McKee’s new wing AND the completion of new wing AND the completion of Medical Center of the Rockies, Medical Center of the Rockies, Larimer County will have about Larimer County will have about 635 licensed hospital beds.635 licensed hospital beds.
Considerations for Considerations for preparednesspreparedness
Can we maintain our Can we maintain our utilities?utilities?
Recent disasters have showed us Recent disasters have showed us the need for water, power, the need for water, power, telecommuni-cations, heat in an telecommuni-cations, heat in an emergencyemergency
Can they operate with 50% of staff?Can they operate with 50% of staff? Do they stockpile materials and Do they stockpile materials and
parts to ensure operation for 90-120 parts to ensure operation for 90-120 days?days?
Will transportation/trade Will transportation/trade problems impact food problems impact food
supply?supply? Typical household has food on hand Typical household has food on hand
to last 3 days.to last 3 days. Few families have emergency Few families have emergency
reserves for a prolonged periodreserves for a prolonged period Low-income least able to set Low-income least able to set
supplies aside for an emergencysupplies aside for an emergency Prices will rise quickly in Prices will rise quickly in
emergency.emergency.
Who will provide health Who will provide health care?care?
Health workers will be disproportion-Health workers will be disproportion-ately exposed and may become illately exposed and may become ill
Some will not show up due to fearSome will not show up due to fear Some will not be able to leave sick Some will not be able to leave sick
family members, children out of family members, children out of schoolschool
Little or no surge capacity; nursing Little or no surge capacity; nursing shortage; ? future of MRC?shortage; ? future of MRC?
Who will help us?Who will help us? Little or no state and federal assistanceLittle or no state and federal assistance Local government also limited in what it Local government also limited in what it
can do to assist citizenscan do to assist citizens Churches, neighbors, friends and Churches, neighbors, friends and
families will need to help each other outfamilies will need to help each other out Vulnerable groups will need extra Vulnerable groups will need extra
assistanceassistance Advance planning and stockpiling of Advance planning and stockpiling of
necessities could help.necessities could help.
What County Depts What County Depts and businesses can and businesses can
dodo
Maintain Essential ServicesMaintain Essential Services
Halt non-essential activities and Halt non-essential activities and re-deploy staff to fill vacancies in re-deploy staff to fill vacancies in critical services.critical services.
Cross train: Make sure all critical Cross train: Make sure all critical functions can be done by several functions can be done by several different people.different people.
Maintain Essential ServicesMaintain Essential Services
Create written instructions/ Create written instructions/ procedures for critical processes procedures for critical processes that can be carried out by othersthat can be carried out by others
If possible, keep essential If possible, keep essential supplies/ parts stockpiled in supplies/ parts stockpiled in advance to maintain services.advance to maintain services.
Increase Social DistanceIncrease Social Distance
Determine how to provide services Determine how to provide services with less person-to-person contact with less person-to-person contact whenever possiblewhenever possible
Increase telecommuting/Citrix accessIncrease telecommuting/Citrix access Use phone, web, virtual conferences Use phone, web, virtual conferences
to replace face-to-face meetingsto replace face-to-face meetings Waive non-critical policies if they Waive non-critical policies if they
force in-person contact (WIC, FP)force in-person contact (WIC, FP)
Decrease contact exposuresDecrease contact exposures Increase cleaning/sanitizing of locks/ Increase cleaning/sanitizing of locks/
doorknobs, faucet and toilet handles, doorknobs, faucet and toilet handles, shared keyboards, telephones, other shared keyboards, telephones, other equipment [Vacuuming/sweeping equipment [Vacuuming/sweeping may stir up infectious particles]may stir up infectious particles]
Use/provide tissues, hand sanitizers, Use/provide tissues, hand sanitizers, disposable gloves if available (All disposable gloves if available (All could be scarce during a pandemic)could be scarce during a pandemic)
Increasing humidity may reduce virusIncreasing humidity may reduce virus
Provide Personal Protective Provide Personal Protective Equipment Equipment
Need will vary with type businessNeed will vary with type business Will be difficult to obtain in a Will be difficult to obtain in a
pandemicpandemic Masks (N95 or better) may Masks (N95 or better) may
reduce exposure, but are difficult reduce exposure, but are difficult to wear for prolonged time or if to wear for prolonged time or if employee has health problems.employee has health problems.
Teach protective actionsTeach protective actions
Hand washing without Hand washing without recontaminationrecontamination
Covering cough, not using handsCovering cough, not using hands Avoid putting hands to face, Avoid putting hands to face,
mouth, nose, eyes.mouth, nose, eyes. Staying home if any signs of Staying home if any signs of
illnessillness
Prepare Communications Prepare Communications PlanPlan
How will key managers How will key managers communicate among themselvescommunicate among themselves
How will information be conveyed How will information be conveyed to customers?to customers?
How will information be conveyed How will information be conveyed to employees?to employees?
How will employees know who to How will employees know who to call in specific situations?call in specific situations?
Prepare for thorny HR issuesPrepare for thorny HR issues
If offices are closed, will staff be paid?If offices are closed, will staff be paid? If staff are needed, can they refuse to If staff are needed, can they refuse to
come to work?come to work? If required to report, what protective If required to report, what protective
equipment, if any, will be provided?equipment, if any, will be provided? Can employer force someone who may Can employer force someone who may
be ill NOT to work? (Employees without be ill NOT to work? (Employees without sick leave may try to work while ill.)sick leave may try to work while ill.)
Prepare for thorny HR issuesPrepare for thorny HR issues
If an employee is required to work If an employee is required to work with ill people and becomes ill, is itwith ill people and becomes ill, is ita worker’s comp situation?a worker’s comp situation?
Some County-specific issuesSome County-specific issues
Vital stats-Issuing death certificates - Vital stats-Issuing death certificates - additional assistance may be needed additional assistance may be needed
Coroner’s office issues - volume, Coroner’s office issues - volume, unclaimed bodies, etc.unclaimed bodies, etc.
Clarification of legal issues - both Clarification of legal issues - both county attorney and district attorneycounty attorney and district attorney
Child protection issues when parents Child protection issues when parents too ill to care for childrentoo ill to care for children
Some County-specific issuesSome County-specific issues
IT assistance may be needed to IT assistance may be needed to rapidly deploy systems to track casesrapidly deploy systems to track cases
Human Services - many low income Human Services - many low income may have trouble with getting foodmay have trouble with getting food
Detention center - potential for Detention center - potential for outbreaks in close quartersoutbreaks in close quarters
Fairgrounds - Events and conventions Fairgrounds - Events and conventions cancelled. Other use of buildings?cancelled. Other use of buildings?
Some County-specific issuesSome County-specific issues
Solid Waste - Disposal of household Solid Waste - Disposal of household infectious waste issuesinfectious waste issues
Fleet - May assist with transportation Fleet - May assist with transportation needs/fuelneeds/fuel
Workforce center - may be source to Workforce center - may be source to recruit workers or volunteersrecruit workers or volunteers
Community Corrections - similar Community Corrections - similar issues with other residential facilitiesissues with other residential facilities
Some County-specific issuesSome County-specific issues
Parks - may be dealing with Parks - may be dealing with campers/poachers on county campers/poachers on county lands; may help supplement law lands; may help supplement law enforcementenforcement
Sheriff - Challenges of maintaining Sheriff - Challenges of maintaining law and order in face of fear, law and order in face of fear, shortages, decreased staffshortages, decreased staff
How Ready Are We?How Ready Are We?
Used with permission of the Minneapolis Star-Tribune