Transcript Intro to Influenza - Larimer County, Colorado

Pandemic Influenza
Influenza
Outbreaks yearly, usually in winter months
 Illness more severe for very young, elderly,
or those with pre-existing health conditions
 Yearly, 5-20% of population get the flu
 Annually causes >200,000 hospitalizations
in US
 36,000 deaths yearly in US

Influenza Prevention
 Yearly
influenza shot
 Avoid those who are ill
 Wash your hands
 Antivirals (in special circumstances)
If you are ill--don’t come to work, cover
coughs and sneezes.
Influenza Virus types
– Type A: Infects humans and other animals
 More severe illness
 Causes regular epidemics; can cause
pandemics
– Type B: Infectious only to humans
 Causes epidemics, but less severe illness
Influenza

Influenza A is
subtyped by surface
proteins
– Hemagglutinin (H)
 16 different types
 Helps virus enter
cells
– Neuraminidase (N)
 9 different types
 Helps virus leave
cell to infect others
Influenza

All known subtypes of Influenza A found in
birds

H5 and H7 cause severe outbreaks in birds

Human disease usually due to H1, H2, H3
and N1 and N2.
Influenza
The flu virus constantly changes

When it does, vaccines will be less
efficient

Immune system may be unable to
recognize new virus
– No immunity in population for new
virus—potential for pandemic
Vaccine Development
Inactivated trivalent vaccine (killed vaccine)
 2 A, 1 B
 Effectiveness of vaccine depends on “match”
between circulating strains and those in vaccine

2005–2006 Influenza Season
A/New Caledonia/20/99-like
A/California/7/2004-like
B/Shanghai/361/2002-like
Surveillance on
circulating strains
Prior Year
January
Selection of
specific strains
February
March
Preparation
and distribution
of virus stock to
manufacturers
April
Seed pools
inoculated into
eggs
n engl j med 351;20
www.nejm.org november 11, 2004
May
Harvest and
concentration
of fluids
June
July
Vaccine inactivated
and purified
August
Vaccine blended,
content verified
September
Packaging, labeling,
delivery
October
n engl j med351;20
www.nejm.org november 11, 2004
Influenza—Vaccine Production
 Flu
vaccines first produced in 1940s
 2 manufacturers in US for flu vaccine
 80 million doses produced by late
September
 6-9 months to produce vaccine
Influenza Pandemics

What is a Pandemic?
– Outbreak in wide geographic area
(global)
– Effects large # of people with serious
illness
– Usually a new virus or one which
population has not had exposure in a
long time
– May have rapid spread
– May occur in waves
Seasonal Flu vs Pandemic Flu
Seasonal
 Occurs every year
Occurs during winter
(usually Dec-Mar)
 Most recover in 1-2
weeks without tx
 Very young, very old,
ill most at risk of
serious illness





Pandemic
Occurs infrequently
(3 per century)
Occurs any time of
year
Some may not
recover, even with tx
People of all ages
may be at risk
Pandemic Influenza
 Past
Pandemics:
–1968 Hong Kong Flu (H3N2)
–1957 Asian Flu (H2N2)
–1918 Spanish Flu (H1N1)
1918-1919 influenza pandemic
Worst of past century
Estimated 20-40% of world
population ill
40-50 million people died
worldwide
600,000 or more deaths in US
High mortality in young adults
Loveland, 1917 & 1918
Deaths by age, influenza/pneumonia (Sept - Dec)
18
16
14
Deaths
12
10
8
6
4
2
0
0-4
Age
5-14
15-24
25-34
35-44
1917 (Sept-Dec)
45-54
55-64
1918 (Sept-Dec)
65-74
over 75
Why did young people die?
Over-reaction by the immune system
called “cytokine storm”
 Those with the strongest immune systems
affected
 Older people and youngest often die of
bacterial pneumonia complicating flu -treatable now with antibiotics
 Even in 2005, no good treatment for
“cytokine storm.”

There are
severe pandemics and
mild pandemics
Infectious Disease Deaths 1900’s
Deaths per 100,000 per year
1957
1918
1968
Pandemics can last for
months and come in
waves
612
O
ct
13
-1
9
O
ct
20
O
-2
ct
6
27
-N
ov
N
2
ov
3N
N
ov
ov
9
10
-N
N
ov
ov
16
17
-N
ov
N
ov
23
24
-N
ov
D
30
ec
1D
D
ec
ec
7
87
-D
ec
D
ec
14
15
-D
ec
D
ec
21
22
-D
ec
D
29
ec
30
-J
an
Ja
4
n
5Ja
Ja
n
11
n
12
-J
an
Ja
18
n1
9Ja
n2
Ja
5
n
26
-F
eb
Fe
1
b
2Fe
b
8
O
ct
Deaths
Loveland, Oct 1918 - Feb 1919
Flu/Pneumonia Deaths by week
18
2
17
16
14
12
10
8
8
6
5
4
3
5
3
3
2
1
Week
5
4
3
2
2
2
1
1
0
0
H5N1 Avian Influenza

Hong Kong 1997
– 18 human cases, 6 deaths
– 1.4 million birds destroyed

Dec. 2003: Asia
– Ongoing extensive outbreak in poultry
– Limited human to human transmission
– 125 human cases, 64 fatal
July-Aug 2005 Kazakhstan, Russia
 October 2005 Turkey, Romania, Russia

H5N1 Symptoms

Symptoms (human)
– Fever
– Shortness of breath
– Cough
– Pneumonia
– Acute Respiratory Distress
– Diarrhea, sometimes severe
– Life-threatening complications
Concern with Avian Influenza
Virus mutates rapidly
 Has shown ability to acquire genes from
viruses infecting other species
 H5N1 has acquired some of genetic
changes in the 1918 virus associated with
human-human transmission
 Causes severe disease in humans
 High fatality rate

Current H5N1 cases
in Vietnam, Thailand, Cambodia, & Indonesia as of 11/1/05
Date of
Total
Case-fatality
onset
cases
deaths
rate
Dec 2003Mar 2004
35
24
69%
July 2004 October
2004
9
8
89%
Dec 2004
to date
78
30
38%
Total
122
62
51%
What might happen in a
severe pandemic?
If it happens soon…..
There will be little or no vaccine until
6 - 9 months after the outbreak begins
 There will be very limited supplies of
antiviral medicines for treatment (for 1%
of populations, perhaps less).
 All communities hit a about the same time
 We need a plan for the short-term that
assumes no effective shots or Rx

Are we more or less at
risk today compared to
1918?
Why at LESS risk in 2005
 Antibiotics
for bacterial pneumonia
complications of influenza
 Some antiviral medicines
 IV fluids, ventilators
 Greater ability to do surveillance,
confirm diagnosis of flu
Why at LESS risk in 2005
 Rapid
means of communications internet, TV, radio, email
 More effective personal protective
equipment
 Fewer people living in each
household and more rooms.
Why at MORE risk in 2005
A
lot more international travel
 10 times more people in Larimer
County, contact with far more people
daily
 Very little surge capacity in health
care today
 More elderly and immunecompromised people in population
Why at MORE risk in 2005
 Much
less self-sufficient than in
1918’s (households and businesses)
 Far more manufactured goods and
raw materials come from distant
areas, especially Asia
 “Just-in-time” ordering of needed
supplies instead of warehousing
critical items on site
Why at MORE risk in 2005
 Unlike
1918, today’s society not used
to rationing, sacrifice.
(In 1918, because of WWI, fuel, coal,
and food were already being rationed,
and community groups, like the Red
Cross, were very active supporting
the war effort)
Overall, are we at more or less
risk?
 Up
to individuals, communities,
states, and nations to decide as they
plan for a possible pandemic
What might occur - fictional but
possible
 Closing
of borders, shutting down
trade
 Fuel shortages/restrictions due to 
in oil imports
 Closing of schools, events, and
businesses where large numbers of
people congregate
 Businessses/workers upset about loss
of income
What might occur
 High
mortality, especially among young
adults
 People working at home when possible;
others taking paid or unpaid leave
 Absenteeism of 30% to 50%
 High numbers of cases, hospitalizations,
and deaths
What might occur
 Not
enough hospital beds, health care
workers, or ventilators
 High numbers of cases and
hospitalizations. Death rates - 2.5%
 Death rate for pregnant women is 20%
 Inadequate amounts of antiviral meds,
leading to violence at treatment sites
What might occur
 Sick
people who live alone, or with
small children only, in dire straits
 Young children trying to take care of
sick parents, with no support
 Children neglected because parent(s)
too sick to provide care
 Orphaned children whose parent(s)
have died
What might occur
 Mortuaries
and crematoria unable to
keep up with deaths
 Funeral home workers unwilling to
handle corpses of influenza patients
 Makeshift hospitals established in
churches and schools
 Shortages of fuel, food, essential
supplies; prices skyrocket.
What might occur
 Utilities
having trouble with staff
shortages, inability to replace supplies
and parts. Spot failures occurring.
 Care shifted from hospitals to being
taken care of by family/friends/people
in neighborhood.
 Some neighborhoods organized,
collaborative; others disorganized
with individuals hoarding
What might occur
 Protective
face masks that sold for $1
are now going for $20 each
 Sanitizers and chlorine are sold out of
the stores
 Availability of other Rx drugs is reduced
 Flu outbreak severe in detention center,
with 1/2 the usual number of staff
What might occur
 Courts
largely shut down; no one
willing to serve on a jury
 Fear, distrust, mourning/depression,
are widespread
 Church facilities are closed when
people most need spiritual comfort
 Some flee cities to National Forests to
wait out the outbreak
What might occur
 In
the end, after several waves and
3-4 months, the outbreak is declared
to be over in Larimer County.
 Over 80,000 became ill and over
2,000 deaths occurred in about 12
weeks.
 Great economic loses from closed
businesses.
What might occur
 12,000
needed hospitalization,
although many were cared for in the
community
 With the completion of McKee’s new
wing AND the completion of Medical
Center of the Rockies, Larimer County
will have about 635 licensed hospital
beds.
Considerations for
preparedness
Can we maintain our utilities?
 Recent
disasters have showed us the
need for water, power, telecommunications, heat in an emergency
 Can they operate with 50% of staff?
 Do they stockpile materials and parts
to ensure operation for 90-120 days?
Will transportation/trade
problems impact food supply?
 Typical
household has food on hand
to last 3 days.
 Few families have emergency
reserves for a prolonged period
 Low-income least able to set supplies
aside for an emergency
 Prices will rise quickly in emergency.
Who will provide health care?
 Health
workers will be disproportionately exposed and may become ill
 Some will not show up due to fear
 Some will not be able to leave sick
family members, children out of
school
 Little or no surge capacity; nursing
shortage; ? future of MRC?
Who will help us?
 Little
or no state and federal assistance
 Local government also limited in what it
can do to assist citizens
 Churches, neighbors, friends and
families will need to help each other out
 Vulnerable groups will need extra
assistance
 Advance planning and stockpiling of
necessities could help.
What County Depts and
businesses can do
Maintain Essential Services
 Halt
non-essential activities and redeploy staff to fill vacancies in critical
services.
 Cross
train: Make sure all critical
functions can be done by several
different people.
Maintain Essential Services
 Create
written instructions/
procedures for critical processes that
can be carried out by others
 If
possible, keep essential supplies/
parts stockpiled in advance to
maintain services.
Increase Social Distance
 Determine
how to provide services
with less person-to-person contact
whenever possible
 Increase telecommuting/Citrix access
 Use phone, web, virtual conferences
to replace face-to-face meetings
 Waive non-critical policies if they
force in-person contact (WIC, FP)
Decrease contact exposures
 Increase
cleaning/sanitizing of locks/
doorknobs, faucet and toilet handles,
shared keyboards, telephones, other
equipment [Vacuuming/sweeping
may stir up infectious particles]
 Use/provide tissues, hand sanitizers,
disposable gloves if available (All
could be scarce during a pandemic)
 Increasing humidity may reduce virus
Provide Personal Protective
Equipment
 Need
will vary with type business
 Will be difficult to obtain in a
pandemic
 Masks (N95 or better) may reduce
exposure, but are difficult to wear for
prolonged time or if employee has
health problems.
Teach protective actions
 Hand
washing without
recontamination
 Covering cough, not using hands
 Avoid putting hands to face, mouth,
nose, eyes.
 Staying home if any signs of illness
Prepare Communications Plan
 How
will key managers communicate
among themselves
 How will information be conveyed to
customers?
 How will information be conveyed to
employees?
 How will employees know who to call
in specific situations?
Prepare for thorny HR issues
 If
offices are closed, will staff be paid?
 If staff are needed, can they refuse to
come to work?
 If required to report, what protective
equipment, if any, will be provided?
 Can employer force someone who may
be ill NOT to work? (Employees without
sick leave may try to work while ill.)
Prepare for thorny HR issues
 If
an employee is required to work
with ill people and becomes ill, is it
a worker’s comp situation?
Some County-specific issues
 Vital
stats-Issuing death certificates additional assistance may be needed
 Coroner’s office issues - volume,
unclaimed bodies, etc.
 Clarification of legal issues - both
county attorney and district attorney
 Child protection issues when parents
too ill to care for children
Some County-specific issues
 IT
assistance may be needed to rapidly
deploy systems to track cases
 Human Services - many low income
may have trouble with getting food
 Detention center - potential for
outbreaks in close quarters
 Fairgrounds - Events and conventions
cancelled. Other use of buildings?
Some County-specific issues
 Solid
Waste - Disposal of household
infectious waste issues
 Fleet - May assist with transportation
needs/fuel
 Workforce center - may be source to
recruit workers or volunteers
 Community Corrections - similar issues
with other residential facilities
Some County-specific issues
 Parks
- may be dealing with
campers/poachers on county lands;
may help supplement law enforcement
 Sheriff - Challenges of maintaining law
and order in face of fear, shortages,
decreased staff
How Ready Are We?
Used with permission of the Minneapolis Star-Tribune