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Emergency Health and Nutrition Training

Emergency Health and Nutrition Training. Pandemic Influenza. Epidemiology, Prevention, Treatment, History, & Current Threat. Last Updated June 18, 2007. Three Different Kinds of Influenza. Pandemic Influenza “A Pandemic”. Avian Influenza “Bird Flu”. Seasonal Influenza “The Flu”.

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Emergency Health and Nutrition Training

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  1. Emergency Health and Nutrition Training Pandemic Influenza Epidemiology, Prevention, Treatment, History, & Current Threat Last Updated June 18, 2007

  2. Three Different Kinds of Influenza Pandemic Influenza “A Pandemic” Avian Influenza “Bird Flu” Seasonal Influenza “The Flu” Related to each other, but public health implications of each is very different

  3. Influenza Type A Virus – The Cause of All Avian & Pandemic Flu & Much of the Seasonal Flu Hemagglutinin (H) protein facilitates viral attachment onto our cells for invasion & replication Neuraminidase (N) protein facilitates virus detachment

  4. (type A) H16XXXXXX

  5. Origin of Pandemic Influenza (All human flu pandemics come from bird flu by 1 of 2 mechanisms) Migratory water birds H 1-16 Domestic pig N 1-9 Domestic birds

  6. Circulating Seasonal Influenza A Sub-Typesfrom Pandemics of the 20th Century 1918/19 1957/58 1968/69 ~2 million deaths ~1 milliondeaths 40-100 million deaths H3N2 Seasonal Flu H2N2 H1N1 Seasonal Flu H1N1 Seasonal Flu 1920 1940 1960 1980 2000 4 pandemics since 1889, with 11 to 39 years (average ~30 years)between each = ~3.3% annual risk of pandemic onset (but likely higher now)

  7. Camp Funston, Kansas, March 1918: Sadly, the comparatively benign first wave was not at all predictive of what was to come

  8. (John Barry. The Great Influenza.)

  9. “In Philadelphia the number of dead quickly overwhelmed the city’s ability to handle bodies. It was forced to bury people, without coffins, in mass graves and soon began using steam shovels to dig the graves.” (John Barry, The Great Influenza)

  10. Published Pandemic Mortality Estimates for Selected Countries (Johnson NPAS & Mueller J. Bulletin of the History of Medicine (2002) 76:105-15) (1918: 28% of current global population. http://birdfluexposed.com/resources/NIALL105.pdf) British isles: 249,000 Russia/USSR: 450,000 Canada: 50,000 Japan: 388,000 Afghan.: 320,000 Spain: 257,000 USA: 675,000 Egypt: 139,000 Philip.: 94,000 Bangl./ India/ Pak.: 18.5 million Guatemala: 49,000 Nigeria: 455,000 Kenya: 150,000 Indonesia: 1.5 million Brazil: 180,000 Australia: 15,000, in 1919 only South Africa: 300,000 Chile: 35,000 Global Total: 50 – 100 million (WHO: 40 million +)

  11. typical for seasonal flu (Also had some shift in deaths to younger adults in 1957 & 1968) U.S. life expectancy dropped by 12 years

  12. Modes of Person-to-Person Transmission: • Large droplets from coughing, sneezing, & talking, to other’s eyes, nose, or mouth; • Contact: direct(hand-to-hand) & indirect (hand-to-surface-to-hand – less common?); • ? Airborne / aerosol / droplet Courtesy of CDC

  13. Decent Understanding of Modes of Transmission Led to Non-Pharmaceutical Interventions But Guidance in the US was Inconsistent & Communities Made Very Different Decisions

  14. Gunnison, Colorado 1 of 7 U.S. towns & residential institutions to escape the 2nd wave • Non-Pharmaceutical Interventions • Barricades on roads for 4 months; • Rail travel restricted; • Quarantine of arrivals to county, & jailing of those in violation; • Isolation of suspected cases; • Schools & all institutions closed; • No public gatherings, per state law Flu Cases: 0 in town; 2 in county Flu Deaths: 0 in town; 1 in county

  15. Flu: From 1 to a cluster of 15 cases in 9 days, & 2,047 by Day 30! Explosive flu outbreaks are due to this short generation time (due to short incubation period & peak infectivity early in illness.) (For SARS, Ro = 3, v = 9 days: From 1 to 4 cases in 9 days, & 40 by Day 30) (Reproductive Number: R0 for flu = 1.5 – 3.0, but higher in closed settings & among children.)

  16. Expect human cases in all areas with substantial human exposure to HPAI H5N1+ birds Expect human cases in all areas with substantial human exposure to H5N1 HPAI+ birds 313 lab.-confirmed cases with 191 deaths (61%) in 12 countries (So far, limited serological surveys suggest that sub-clinical infection & mild illness remain rare.)

  17. (Injectable Peramivir has completed phase-1 trials) Tamiflu! (oral) Ralenza (inhaled) (Older drugs) (Viral resistance to these is more common)

  18. WHO, May 2006: • “In patients with confirmed or strongly suspected H5N1 infection, clinicians should administer oseltamivir treatment as soon as possible (strong recommendation, very low quality evidence).” (Evidence = seasonal flu clinical trials in humans & H5N1 animal data). • “clinicians might administer a combination of neuraminidase inhibitor & M2 inhibitor” (weak recommendation, very low quality evidence).” (Resistance to Tamiflu is a concern.)

  19. Pandemic Flu Prevention & Treatment Challenge ~2 day incubation period for seasonal flu is expected for pandemic flu also High levels of virus, & some person-to-person transmission, 1 day before symptoms! Transmission up to 7 days after fever ends – longer in kids & immune suppressed Peak transmission

  20. Oseltamivir Therapy in H5N1Thailand and Vietnam, 2004-2005 • Tamiflu treatment often started late • Dosage too low? • Poor absorption of oral Tamiflu? • Course of treatment too short? • Some H5N1 resistance to Tamiflu Writing Committee. N Engl J Med. 2005;353:1374-1385.

  21. Case-Fatality by Age – WHO Data on 256 Confirmed Cases, 11/03 - 11/06 This “case-fatality distribution among H5N1 cases is reminiscent of those observed during previous pandemics, particularly in 1918” (WHO, June 2006, re. a similar distribution)

  22. H5N1 in Humans Remains Rare:Currently Implicated Exposures(Source of infection is unknown in many cases.Very few cases are in presumed high-risk groups: Commercial poultry workers, workers at live poultry markets, cullers, veterinarians, & health staff caring for patients without using protective equipment) Preparing or disposing of diseased birds Handling fighting cocks Some cases are in family clusters, some due to person-to-person transmission (genetics?) Handling poultry, esp. asymptomatic ducks Consuming uncooked duck blood (& undercooked poultry?)

  23. (http://birdflubook.com/resources/Ungchusak333.pdf) established in 1812January 27, 2005 vol. 352 no. 4 Probable Person-to-Person Transmission of Avian Influenza A (H5N1) Kumnuan Ungchusak, M.D., M.P.H., Prasert Auewarakul, M.D., Scott F. Dowell, M.D., M.P.H., Rungrueng Kitphati, M.D., Wattana Auwanit, Ph.D., Pilaipan Puthavathana, Ph.D., Mongkol Uiprasertkul, M.D., Kobporn Boonnak, M.Sc., Chakrarat Pittayawonganon, M.D., Nancy J. Cox, Ph.D., Sherif R. Zaki, M.D., Ph.D., Pranee Thawatsupha, M.S., Malinee Chittaganpitch, B.Sc., Rotjana Khontong, M.D., James M. Simmerman, R.N., M.S., and Supamit Chunsutthiwat, M.D., M.P.H. • Thailand, Sep. 2004: • 11 year old girl died in Kamphaeng Phet province without H5N1 test. • Mother visited daughter in hospital from BKK, H5N1+ without poultry exposure, & died. • Aunt H5N1+, recovered

  24. April /May 2006 Karo, N. Sumatra cluster • Limited WHO/MOH containment activities • No transmission beyond this family • Local people resist chicken culling & demand departure of WHO team Viet Nam: No human cases, 2006

  25. H5N1 in 1997 & Since 2003: Three Requirements for a Flu Pandemic: • Novel flu virus for humans Yes • Ability to replicate in humans Yes& cause illness • Ability to pass easilyNot Yetfrom person to person (signaled by growing clusters / outbreaks of human cases)

  26. (WHO phases apply to the whole world. Phases 4 & 5 may be skipped altogether - they assume gradual evolution of the virus & an R0 < 1.0.) * Key to Phases 3 - 6: The size & growth of clusters of human cases (See notes below)

  27. Current (~1950’s!) flu vaccine technology requires slow production in eggs * * Recent progress in growth of virus in cell cultures instead of in eggs

  28. (In millions of courses for the US market) (for USA) • Global flu vaccine production capacity can meet only a small fraction of global need. • The US goal is to be able to immunize the entire US population within 6 months of pandemic onset by 2011

  29. Medical masks (surgical / procedure) help protect against droplets • N95 masks (should be fit-tested) • Neither protect eyes or prevent contact transmission • Neither tested for influenza • Must discard after dirty or moist • Will likely be in short supply • Woven cloth masks: Little data 1918 (& 21st Century?)

  30. Analysis of 1918 data: early & sustained use of multiple partially effective non-pharmaceutical interventions (NPIs), can: • Delay the outbreak peak; • Reduce peak burden on hospitals & infrastructure; & • Modestly reduce total # of cases & deaths. NPIs 16 days after 1st case NPIs 2 days after 1st case (US CDC, Feb., 2007: http://www.pandemicflu.gov/plan/community/mitigation.html) (* see photos in Barry, The Great Influenza) Excess pneumonia & flu mortality over 1913–1917 baseline in Philadelphia & St. Louis, Sep. 8–Dec. 28, 1918

  31. Community Strategies by Pandemic Flu Severity (1) From U.S. CDC (& 15 Other Federal Agencies!) Feb. 1, 2007

  32. Community Strategies by Pandemic Flu Severity (2) (http://www.pandemicflu.gov/plan/community/mitigation.html)

  33. Pandemic (Isolating the ill is also very important) (See Danbury News, Oct. 1918, for details) (Advice based on current understanding of transmission, with little evidence of efficacy) Currently feasible “protection” for the general public! 2007 state-of-the-art public health! (~ 1918 tech., 89 years later!)

  34. (www.BirdFluManual.com) A Critical Gap in WHO & HHS Guidance • During the pandemic, most ill people will be cared for at home. • Woodson’s 17-page guide fills a critical gap for the US setting: • “Preventing or treating dehydration in people with flu will save more lives than any other intervention during the influenza pandemic.” • Guidelines for families & community health workers are needed for resource-poor settings. (August 29, 2006)

  35. Pandemic influenza preparedness and mitigation in refugee and displaced populationsWHO training modules for humanitarian agencieswww.who.int/diseasecontrol_emergencies/training/influenza/en/ Module 5: Case Management Objectives: • How to manage patients at home • How to manage patients in facilities • What to stockpile • How to prioritize resources like antibiotics and antivirals

  36. A Sobering Call to Action “All concerned should keep in mind that no health emergency on the scale of a severe influenza pandemic has confronted the international community for several decades ...... the present threat to international public health is sufficiently serious to call for emergency actions calculated to provide the greatest level of protection and preparedness as quickly as possible." WHO Strategic Action Plan for Pandemic Influenza 2006–2007, page 4

  37. “Any community that fails to prepare with the expectation that the federal government will at the last moment be able to come to the rescue will be tragically wrong, not because the federal government lacks will, not because we lack wallet, but because there is no way in which 5,000 different communities can be responded to simultaneously, which is a unique characteristic of a human pandemic.” (3/20/06) ---Mike Leavitt, US Secretary of Health and Human Services

  38. Pandemic Planning Assumptions and Uncertainties • Another pandemic will occur • but we don’t know when • Approximately 20-40% of everyone on earth will become ill • but we can’t predict the severity • CFR in seasonal flu: <0.1% • CFR in 1918 pandemic: ~2.2% • CFR with current H5N1: ~59%

  39. Save the Children’s Pandemic Flu Preparedness Goals 1. Protect the health of SC staff and their families worldwide

  40. Save the Children’s Pandemic Flu Preparedness Goals 2. Continue key agency functions • Payroll • Communications Technology • Essential staff roles backfilled • Human Resources

  41. Save the Children’s Pandemic Flu Preparedness Goals 3. Protect the health and well-being of children and families

  42. Preparedness Efforts • Oct 05 Influenza Working Group formed, 2 VPs assigned as co-leaders • Jan 06 Boston Summit, Pandemic Simulation exercise • Feb 2 HQ staff re-assigned to 50% LOE each • March Track I, Track II preparedness roll-out • Regular updates with SC President • Staff preparedness sessions begin • April/May Influenza Point Person (IPP) regional trainings

  43. Preparedness Efforts June Country Office Influenza plans submitted, reviewed July Business Continuity Planning August Agency-wide BCP finalized Dec 90K distributed to country offices for preparedness Jan 07 external website live and regularly updated Ongoing: staff preparedness sessions in headquarters and country offices

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