Dr Wells -- Pandemic Flu

Avian and Pandemic Influenza Where are we now? (May 2008) Eden V. Wells, MD, MPH Michigan Department of Community Health

Outline  Avian Update  Pan Flu Planning Update  State Operational Response Planning

Avian Influenza The “Bird Flu”

Images from: http://www.usda.gov/oc/photo

Species Affected Genetic Reservoirs

H3, H7

H1, H2, H3 H5N1

Intermixing

H3 Commercial, LBMs Others

H1-12 H14-15

H1-2, 4-7, H9-13, 15-16

Other Aquatic Birds? H1, H3

H10 H1, H3, H4, H7, H13

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 Pandemic criteria – New strain – Causes severe illness in humans – Sustained transmission from person to person

Countries with H5N1 in Poultry (OIE)

January 1, 2008- May 14, 2008

Pandemicflu.gov

Areas with high overlapping concentrations of Humans and Poultry (UN World Food Program, 5/24/06)

Humans at Risk  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

Clinical features specific to H5N1 (WHO, 2/06)  Unusually aggressive course – Rapid progression (avg. of 5 days) with a high fatality rate

 Early symptoms – – – – – –

High fever (usually > 38º C) Influenza-like symptoms Diarrhea (often watery) and/or vomiting Abdominal or chest pain Hemorrhage from the gums May have no respiratory symptoms or develop acute encephalitis

 3-13 days: Severe lower respiratory disease – Dyspnea – Inspiratory crackles; hoarse voice – Variable sputum/respiratory secretions (sometimes hemorrhagic)

 Always see a 1º viral pneumonia that is unresponsive to antibiotics  Commonly see multiorgan dysfunction

Implications for Human Health  Asian Strain H5N1 in humans more aggressive than seasonal flu strains – – – –

Severe clinical course Rapid deterioration High fatality Low transmissibility human-to-human

 Incubation may be longer than seasonal influenza – Seasonal influenza: 2-3 days – H5N1: possibly up to 10 days

 More studies needed

When to test for H5N1 (CDC Recommendations, 6/7/06) The patient must meet all of the following criteria:  Has an illness that requires hospitalization or is fatal AND

 has or had a documented temperature of ≥38°C (≥100.4° F) AND  has radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established AND  has at least one potential exposure within 10 days of symptom onset (next slide)

When to test for H5N1 – Potential Exposures (CDC Recommendations, 6/7/06) 1. History of travel to a country with influenza H5N1 documented in poultry, wild birds, and/or humans, AND had at least one of the following potential exposures during travel: • • • • •

direct contact with (e.g., touching) sick or dead domestic poultry. direct contact with surfaces contaminated with poultry feces. consumption of raw or incompletely cooked poultry or poultry products. direct contact with sick or dead wild birds suspected or confirmed to have influenza H5N1. close contact (within 1 meter) of a person who was hospitalized or died due to a severe unexplained respiratory illness.

2. Close contact (within 1 meter) of an ill patient who was confirmed or suspected to have H5N1. 3. Worked with live influenza H5N1 virus in a laboratory.

H5N1 Specimen Collection Protocols (MDCH, 8/5/06 and CDC, 6/7/06) •Get BOE approval for testing at (517) 335-8165. •Preferred specimens •Oropharyngeal (OP) swabs •Bronchoalveolar lavage (BAL) *A high-risk aerosol-generating procedure; use proper infection control precautions

•Tracheal aspirate •Nasal or nasopharyngeal (NP) swabs are acceptable but less preferred •Postmortem: Paraffin-embedded or formalin-fixed respiratory tissues

•Timing of specimen collection •First 3 days of illness onset is ideal •Collect serial samples over several days from several sites •Swabs should have a Dacron tip (not calcium or cotton) and an aluminum or plastic shaft (not wooden). •Specimens should be placed at 4°C immediately after collection.

Human-to Human TransmissionStill Unsustained Examples:  Pakistan- Oct/Nov 2008 – 4 cases: 2 recovered- 2 fatal  Indonesia-2006 – 3 clusters 2005 (NEJM Volume 355:2186-2194 Nov 2006 Number 21)  Viet Nam-2005

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Clusters of human H5N1 cases range from 2-8 cases Identified in most countries that have reported H5N1 cases Most of the cluster cases occurred in blood-related family members in same household If such clusters are related to genetic or other factors currently unknown. Limited human-to-human transmission of H5N1 virus cannot be excluded in some clusters “diagnosis of exclusion”

cdc,gov

Antivirals for H5N1 Adamantanes:  Resistant: Clades 1, 2 (80%)  Sensitive: Clades 2.2, 2.3 Neuraminadases*:  “…all viruses demonstrated similar sensitivity to zanamivir, but compared with the 2004 clade 1 viruses, the Cambodian 2005 viruses were 6-fold less sensitive and the Indonesian clade 2 viruses were up to 30-fold less sensitive to oseltamivir.

Jennifer L. McKimm-Breschkin,* Paul W. Selleck,† Tri Bhakti Usman,‡ and Michael A. Johnson† EID Volume 13, Number 9–September 2007 Reduced Sensitivity of Influenza A (H5N1) to Oseltamivir

Human Vaccine for Avian H5N1  Human H5N1 vaccine approved by FDA  US has advance-ordered 20,000,000 doses  Current US 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

H5N1 viruses Vaccines being made from Clade 1 and 2 viruses •Clinical trials •Stockpiles Clade 1: • Human- Cambodia, China, Hong Kong, Viet Nam, Thailand • Avian-Cambodia, Viet Nam Clade 2.1: • Avian and human- Indonesia Clade 2.2: • Avian- outbreaks in over 60 countries Antigenic and genetic characteristics of H5N1 viruses and candidate H5N1 vaccine viruses developed for potential use as human vaccines WHO, February 2008

Antigenic and genetic characteristics of H5N1 viruses and candidate H5N1 vaccine viruses developed for potential use as human vaccines WHO, February 2008

Current U.S. Status  No current evidence in U.S. of highly pathogenic H5N1 in: – Wild birds – Domestic poultry – Humans

What is the H5N1 Pandemic Risk?  Three conditions must be met for a pandemic to start: – Emergence of a new influenza subtype – The strain infects humans causing serious illness – Spreads easily between humans

 A pandemic will impact ALL sectors of Michigan society

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

WHO Phases and Federal Stages    

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Stage 0: New Domestic Animal Outbreak in At-Risk Country Stage 1: Suspected Human Outbreak Overseas Stage 2: Confirmed Human Outbreak Overseas Stage 3: Widespread Human Outbreaks in Multiple Locations Overseas Stage 4: First Human Case in North America Stage 5: Spread throughout United States Stage 6: Recovery and Preparation for Subsequent Waves

Categories of Pandemic Strength

Estimated Impact of a Future Pandemic in Michigan 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

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

Leads for Public Health  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 MI PUBLIC HEALTH CODE Similar but multi-jurisdictional authority resides with State Health Officer

Public Health:NonPharmaceutical Interventions  Social distancing  Respiratory/Cough etiquette  Infection Control – Droplet /Airborne Precautions

 Isolation  Quarantine

Public Health Measures  Isolation – Ill persons with contagious diseases – Usually in hospital, but can be in home or in a dedicated area  Quarantine – Restriction of movement select exposed, not ill, person(s) – Home, institutional, or other forms (“work quarantine”) – Voluntary vs. compulsory

Public Health Measures  Social Distancing interventions to prevent contact: – School closures – Cancellation of public gatherings – Worksite closures (computing,etc)

 Infection Control interventions to prevent transmission: – Masks – Hand hygiene

Number of Daily Cases

Goals of Community Measures

Pandemic Outbreak: No No Community Community Measures Used

1

Delay onset of outbreak

2

Reduce the peak burden on hospitals/infrastructure

3

Pandemic Outbreak: With Measures Taken

Days Since First Case

Decrease a) number of cases of death and illness and b) overall health impact

Draft- MI Public Health Interventions

State-Level Preparedness Michigan’s Draft Pandemic Influenza State Operational Plan

Emergency Management & Homeland Security Division

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Responsible to coordinate state and federal resources to assist local government in response and relief activities in the event of an emergency or disaster.

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Responsible for the coordination of homeland security initiatives and several federal grants, as directed by the U.S. Department of Homeland Security.

Pre-positioning MedPack for Special Events

Bill Fales, Region 6 L. Scott, MDCH

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

Keweenaw 44 %

 Regional Bio-Defense Networks

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 Coordinate health care, public health and emergency management partners  100% Federally funded – CDC Cooperative Agreement – HRSA Cooperative Agreement

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Regional Medical Bio-Defense Networks Keweenaw 44 %

Region 1: Region 5: Dan Young Bob Dievendorf Region 1 BT. Coordinator Region 5 BT. Coordinator 4990 Northwind Ste. 240 1000 Oakland Dr. East Lansing, MI 48823 Kalamazoo, MI 49008 Office: 517-324-4404 Office: 269-337-6549 Fax: 517-324-4406 Fax: 269-337-6475 [email protected] [email protected]    Region 2N: Region 6: Gary Canfield Tim Bulson Region 2N BT. Coordinator Region 6 BT. Coordinator 2032 E. Square Lake Road, Ste. 200 678 Front NW Ste. 235 Troy, MI 48085 Grand Rapids, MI 49504 Office: 248-828-0180 Office: 616-451-8438 Fax: 248-828-0185 Fax: 616-451-8462 [email protected] [email protected]    Region 2S: Region 7: Amy Beauregard Tres Brooke Region 2S BT. Coordinator Region 7 BT. Coordinator Wayne Co. Health Adm. C/O Northwest Regional MCA 33030 VanBorn Road 1105 Sixth Street Wayne, MI 48184 Traverse City, MI 49684 Office: 734-727-8001 Office: 231-935-7846 Office (24 hours): 734-727-7280 Fax: 231-935-7845 Fax: 734-727-7110 [email protected] [email protected]    Region 3: Region 8: Jim Brasseur Interim-Alyson Sundberg Region 3 BT. Coordinator Region 8 BT. Coordinator 1600 N. Michigan Ave. 420 Magnetic Street Saginaw, MI 48602 Marquette, MI 48955 Office: 989-583-7938 Office: 906-225-7745 Fax: 989-583-7930 Fax: 906-225-3038 [email protected] [email protected]

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Preparedness Planning  “All Hazards”-Pandemic Flu an excellent example  www.pandemicflu.gov – – – – – – –

Business Continuity of Operations Clinics and Medical Offices Family and individual preparedness Home health care Long-term facilities Schools Health insurers

 Basis of all plans is a strong Continuity of Business Plan (CBP)

The Importance of Surveillance  Continuous global surveillance of influenza is key…  Rapid detection of unusual influenza outbreaks, isolation of possible pandemic viruses and immediate alert to the WHO system by national authorities is decisive for mounting a timely and efficient response to pandemics. World Health Organization

Pandemic Influenza Coordinating Committee (PICC)  Concept presented in September 2006  Purpose of the PICC – Assure pandemic influenza plans are being developed – Assure plans are coordinated – Assure plans involve all necessary areas

 Encompasses all state agencies

Pandemic Influenza Coordinating Committee (PICC) - Steering Group (A Representative from each State of Michigan Departments and Tribal)

Subcommittees Transportation/ Border •MDOT • DLEG • MDCH • MSP • MDA • Tribes • CDC Quarantine

Human Health •MDCH Core •Mental Health •Medicaid •OSE •LHDs •HRSA •DOC •DHS •Tribes

School/ Public Health Workgroup

Animal Health •AIIWG

PIO Meetings Liaison: James McCurtis, MDCH 3rdrd Party Payers Workgroup

Long-Term Care Workgroup

Pandemic Safe Work Practice Workgroup

Two Workgroups: •Legal Authority •Public Safety

Legal / Public Safety • Governor’s Legal • Homeland Security Advisor • MSP • DMVA • Attorney General • Civil Rights • Michigan Sheriff’s Association • MSU College of Law • Univ of Michigan • DMVA • DIT • DMB • MI Supreme Court • MALPH •Executive Office • Assoc of Chiefs of Police • Treasury

PICC Report • Presenting key recommendations: – Legal / Legislative – Community Preparedness • School • Business • At-Risk Populations

– Human Health – Protecting State employees

Recommendations of the Human Health Sub-committee    

Outreach to vulnerable populations Implementation of safe work practices Increase seasonal vaccination rates Involve third party payers / private insurers

OSHA Guidelines  February 2007  Understand risks to staff, patients, public  Educate!  DHHS Guidelines coming soon about use of masks for general public

State Operational Plan  Planning Guidance to States  Released March 13, 2008  Purpose- strategic framework to help the 50 states, DC and the 5 US territories to improve and maintain their operational plans for responding to and sustaining functionality during an influenza pandemic

SOP Strategic Goals  Goal A: Ensure continuity of ops for state agencies/state government  Goal B: Protect citizens  Goal C: Sustain/support 17 Critical infrastructure/key resource sectors

Goal A-Continuity of Ops  Continuing critical services and lifelines that citizens rely on for survival (eg, Medicaid, safe food and water, etc)  Must prepare for and exercise and improve comprehensive operational plans

Goal B- Protection of Citizens  State Government is conducting business as usual with functions such as CD surveillance  State is altering the way it conducts business to delay the introduction, slow the spread, or lessen the severity of pan flu

Goal C: CI/KR  Sustain and support 17 critical infrastructure and key resources  Redevelop and implement statewide CI/KR protection programs  Reflect and align with full spectrum of homeland security activities in National Infrastructure Protection Plan (NIPP)

State Operational Plans Due July 9, 2008 To be reviewed by DHHS/DHS SOP’s will be graded Future funding tied to grades State’s grades reported to Congress, with subsequent release to public  Ongoing activity- support to All Hazards     

Summary  Avian influenza epidemiology knowledge evolving  Pan flu risk persists regardless of H5N1 activity  Pan flu planning is – – – – –

Extremely comprehensive Extensive coordination Enhanced collaboration New partnerships To become supporting plan to All Hazards

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)