June 23, 2009

By Molly Carbajal, Sal Murillo

Kelle Remmel and Annamaria Swardenski

Pan Flu Preparedness

Seasonal, Swine, Avian, and Pandemic Influenza

•Seasonal influenza•Winter months in temperate zones; year-round activity in the tropics•Influenza A and/or B

•Swine influenza•Influenza A infection in pigs•Rarely infects humans

•Avian influenza•Literally, “bird flu” - natural influenza A disease affecting birds•May occasionally or “accidentally” infect humans - not the natural host

•Pandemic influenza•Novel influenza strain, human population is immunologically naïve•Efficient human-to-human transmission•Widespread (global) epidemics

Influenza virus types

•Influenza A•Human and animal reservoirs•Subtypes classified by properties of surface proteins hemagglutinin (H) and neuraminidase (N)•Current human subtypes: H1N1, H1N2, H3N2•Epidemics and pandemics

•Influenza B•Humans only reservoir•Epidemics, not pandemics

•Influenza C•Not associated with epidemics

Influenza Virus Nomenclature

Type of nuclear material

Hemagglutinin

Neuraminidase

Virus type

Geographic origin

Strain number

Year of Isolation

Virus subtype

A/California/07/04-like (H3N2)

Influenza Virus Nomenclature

Influenza virus

exposure illness

Incubation: 1-4 days(average 2 days)

Communicability: 3-8 days(1 day before to 3-7 days after sx)

Mode of transmission: primarily close contact via large dropletsi.e., coughing, sneezing, talking; fomites may play a role

Influenza virus

• Click to edit Master text styles

Seasonal Influenza Symptoms• Rapid onset of:

– Fever– Chills– Body aches– Sore throat– Dry cough– Runny nose– Headache

• Children may have GI symptoms

Seasonal Influenza is a serious illness

• Annual deaths: 36,000*• Hospitalizations: >200,000** Average annual national estimates during the 1990’s

• Who is at greatest risk for serious complications?– persons 65 and older– persons with chronic diseases– infants– pregnant women– nursing home residents

Swine as Middle Man?

• Reassortment between human viruses and animal viruses may be facilitated by 3rd species susceptible to both viruses– Pigs have both human-

specific and avian-specific receptors on their respiratory epithelium

HumanHuman virusvirus

ReassortantReassortantvirusvirus

Non-humanNon-humanvirusvirus

Mechanisms of Influenza Virus Mechanisms of Influenza Virus Antigenic “Shift”Antigenic “Shift”

DIRECTDIRECT

Conditions favorable for antigenic shift• Humans living in close

proximity to domestic poultry and pigs

• Humans (as well as pigs) might serve as “mixing vessel” – Mounting evidence

that some avian flu subtypes circulating in bird populations can reassort in humans

Conditions favorable for antigenic shift

Conditions favorable for antigenic shift

Pandemic Influenza

– Novel influenza strain, to which human population has no or little immunity

– Efficient human-to- human transmission

– Pandemic literally means Global Spread

Avian Influenza

• Normally infects only birds and pigs, not humans

• Wild migratory birds are natural reservoir for influenza A, transmit viruses to domestic poultry

• Domestic poultry (chickens, turkeys) highly susceptible, high mortality rate

Avian Influenza: transmission to humans• Hong Kong, 1997: first documented human

infection with avian influenza (H5N1)– Severe respiratory illness in 18 people; 6 deaths

• Response: rapid destruction of Hong Kong’s entire poultry population of 1.5 million birds (during Chinese New Year!!!)

• Hong Kong, Feb 2003: H5N1 reappears – 2 cases and 1 death

Avian Influenza: transmission to humans

Avian influenza (H5N1) in humans

• Current outbreak started in 2003 and is ongoing• H5N1 now endemic in many parts of Asian despite

culling• Mostly rural and periurban households with small flocks

of poultry• Few cases in commercial poultry workers, veterinarians

and healthcare staff• Most cases previously healthy children & young adults• Limited human to human spread• Unusually aggressive clinical course, with rapid

deterioration and a variety of presentations

Novel H1N1 Influenza(the virus formerly known as “swine flu”)• A new influenza virus spreading from person-to-

person• Originally called “swine flu” because many genes

similar to influenza A viruses in pigs in north America

• BUT, further study shows novel H1N1 is a “quadruple reassortant” virus– Two genes from pigs in Europe and Asia– Avian genes– Human genes

Years Flu Virus Mortality

1918-1919 “Spanish” Type A (H1N1) 550,000 US

1957-1958 “Asian” Type A (H2N2) 70,000 US

1968-1969 “Hong Kong” Type A (H3N2) 34,000 US

Influenza Pandemics in the 20th Century

Major Pandemic: Historical Clues

1918: ‘Spanish’ Flu•20-40 million deaths worldwide

• targeted young, healthy adults: rapid death from respiratory failure

•Several waves: next older patients

•-Clinical attack rate: 25-40%•-Case fatality rate: 2-4%•-H1N1 highly virulent strain

Nature 10/05: Speculated high pathogenicity of 1918 strain likely due to human-adapted mutation in avian virus, rather than reassortant

Major Pandemic: Historical Clues

Major Pandemic: Historical Clues

Major Pandemic: Historical Clues

Major Pandemic: Historical Clues

Major Pandemic: Historical Clues

America’s deaths from 1918 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

0

100

200

300

400

500

600

700

800

900

Pandemic Influenza - Phases

Pandemic Influenza - Phases

Impact to the Healthcare System

• Extreme staffing and bed shortages

• Hospitalizations-61,000 to 143,000

• Shortage of key supplies and critical equipment

• Majority of ill taken care of at home by family members

• Demand will outpace supply for months

• Vaccine not available for 6-8 months

• Anti-virals in short supply

• Morgues, medical examiner and mortuary services overwhelmed

25-35% of total population will become illIn Santa Clara County 450,000 to 620,000

Pandemic Preparedness

"For the first time in human history, we "For the first time in human history, we have a chance to prepare ourselves for have a chance to prepare ourselves for a pandemic before it arrives…it is a pandemic before it arrives…it is incumbent upon the global community incumbent upon the global community to act now."to act now."

-Dr. Margaret Chan-Dr. Margaret Chan

WHO director, Communicable DiseasesWHO director, Communicable Diseases

• How can we educate ourselves and our community about Pan Flu?

• What about those who may have special needs?

Pan Flu and CBOs

• What did we learn from the recent Swine Flu outbreak?

• What info was most needed in your communities?

• Were you able to get what info you needed

• Advance Practice Center models and info to share

Community Education Tips

Designed to

Provide hands-on tools, training materials, preparedness and response resources to assist Community-based Organizations (CBOs)

Prepare CBO agencies, staff and clients for a pandemic influenza outbreak

Pan Flu Preparedness KitFor Community Based Organizations

Origin and Funding

Santa Clara County Public Health Department

For distribution to local CBOs

Developed specifically for organizations in Santa Clara County

SCCO Pan Flu PlanningHistorical Highlights 2004-05 – Formalized planning efforts began.

Workgroups were convened to address specific components in our county’s plan

2006 – Pandemic Flu Forum for Community Stakeholders was held. Unveiled draft of County’s Response Plan and requested feedback from participants

2007 – Contracted with CADRE/VCSV to develop: Pandemic Influenza Preparedness Planning: A Guide for Community Organizations Serving Vulnerable Populations in Santa Clara County

SCCO Pan Flu Planning

Obtained local funding:

- ICC supplies

- Mass media campaign for public awareness

- Workforce training DSW’s

Pandemic Influenza Preparedness for Schools Plan was developed

Advanced Practice Center (APC) toolkits created out of the ICC planning efforts and school plan: www.sccphd.org/APC

Santa Clara County Pan Flu Preparedness & Response Plan

The purpose of the plan is to:

1. Serve as a planning guide for the Public Health Department and other county departments.

2. Provide guidance and tools to partners in the community.

3. Guide activities to educate and prepare the general public.

Santa Clara County Pan Flu Preparedness & Response Plan

The intention of this planning effort is to minimize the impact of pandemic influenza in our community and protect the public’s health.

The plan is presented as eight critical capacity modules with each module including a set of actions that are critical to effective preparedness and response.

Santa Clara County Pan Flu Preparedness & Response Plan

♦ Eight critical capacity modules– Legal Authority– Surveillance – Healthcare Systems – Limiting the Spread of Disease – Clinical Guidelines and Disease Management – Public Education and Emergency Risk Communication– Psychosocial Support – Essential Services During Pandemic Influenza www.sccphd.org/panflu

SCCO Planning Efforts Continue

Building on the vulnerable population guidance developed in 2007, the SCCPHD contracted with Remmel Consulting to provide local CBO’s with a practical toolkit they could use in their plan flu planning efforts

Pan flu requires special planning since this event will be unlike anything most of us have ever experienced

Contents of the Kit

Pan Flu Preparedness and Response Guidance for Vulnerable Populations

Clipboard Checklist for CBO Pan Flu Preparedness

Training Kit – Intro to Pan Flu for CBOs

Training Kit – Pan Flu Tabletop Exercise for CBOs

Contents of the Kit (continued)

Risk communications materials for Clients and Consumers

Pan Flu Preparedness DVD Pan Flu Homecare Guide Germ Stop Kit USB drive with electronic copy of all

materials (including multi-lingual materials)

Pan Flu Guidance for CBOs

♦ Collaboration between SCCPHD, local emergency managers, CADRE Network, and mulititude of CBOs and FBOs

♦ To strengthen ability to prepare for and respond to pan flu, especially as it affects our most vulnerable residents

Guidance - Purpose

♦ Serve as a guide for local stakeholders and SCCPHD to increase coordination of services for vulnerable populations in a pandemic influenza outbreak

♦ Provide guidance and tools to CBOs to prepare for continuity of operations and service delivery to vulnerable populations in an outbreak

♦ Outline a countywide response strategy which integrates CBOs and FBOs as vital resources in responding to various needs of vulnerable populations in an outbreak

Guidance - Background

♦ Research of best practices and models throughout the country on planning for vulnerable populations in a pandemic

♦ Development, distribution and analysis of survey completed by 74 participants from 49 SCCO CBOs

Guidance - Identifying Strategies ♦ Large group meetings

with stakeholders such as SCCO Emergency Managers Association, EMAs VPOPs Committee, and CBOs that provide services to vpops

♦ Small group meetings with different CBO sectors (homeless service providers, food services like MOWs, clinics, etc) to identify specific issues and strategies for serving their client populations in a disaster

Clipboard Checklist Tool

♦ Designed to outline some key planning considerations CBOs should consider to prepare for and respond to pan flu

♦ Not designed to be comprehensive, but rather a quick start planning guide for agencies with limited time and resources

Clipboard

Training Kit – Intro to Pan Flu

Training Kit – Pan Flu Tabletop Exercise designed for CBOs

Home Care Guide

Individual/Household

Hand hygiene

Cough etiquette

Home isolation of ill

Home care plan

Cleaning/disinfecting

Facemasks/gloves

Emergency Preparedness Kit

The Home Care Guide for Pandemic Flu is available online:http://www.sccgov.org

Risk Communication

Practice, Prepare, and Help Limit the Spread of Disease

Wash your hands Practice Good Respiratory

Hygiene Cover your cough and sneezes

When sick, stay home and away from others

Don’t send sick kids to school or daycare

Avoid close contact with people who are sick

Stay Healthy!Stay Healthy!

Other Kit Items

Questions?

Molly Carbajal and Sal Murillo, SCCPHDMolly.carbajal@hhs.sccgov.org

Sal.Murillo@hhs.sccgov.org

Kelle Remmel, Remmel ConsultingKelleRemmel@gmail.com

Annamaria Swardenski, Swardenski ConsultingARSwardenski@gmail.com

Thank You