Pandemic Influenza and Avian Influenza

1. Pandemic Influenzaand Avian Influenza Dr Helen Howie 14 February 2006

2. Outline • Influenza Pandemics • Why now - Avian Influenza • Possible impact in Grampian • How we are preparing

3. Please do not confuse . . . • Seasonal influenza • Avian influenza in birds • Avian influenza in humans • Risk to travellers in affected countries • Risk in UK from birds - low • Pandemic influenza

4. Influenza pandemic • World wide epidemic • New strain of influenza A - antigenic shift • Highly susceptible population • Easily spread from human to human • Two criteria fulfilled • WHO closest since 1968 - evolving • However window of opportunity to plan

5. Influenza pandemic • Unpredictable • Any time of year • Likely to start in SE Asia • Be here within 1 month • Spread throughout UK 2 - 3 weeks • Activity last 3 - 4 months • Intense pressure 6 - 8 weeks - peak wk 6 • Second wave 6 - 9 months later ? worse

6. Pandemic influenza • Very infectious disease • Incubation period 1-3 days • Infectious before onset (10%) • Spreads rapidly in enclosed spaces • Airborne droplets and contaminated surfaces • Usually self limiting disease 2-7 days • Fever, headache, muscle pain, sore throat etc • Viral pneumonitis, bacterial pneumonia, cardiovascular disease • High morbidity and mortality

7. History • 31 pandemics described since 1580 • Millions of deaths, social disruption and profound economic losses • 1918-19 - swine - H1N1 - severe • 40-50 million deaths over 2 years • 1957-58 - Asian flu - H2N2 - severe • 1968-69 - Hong Kong Flu - H3N2 - moderate

8. Why increased risk now? Highly pathogenic avian influenza (H5N1)

9. Avian influenza in birds • Influenza A • First described in 1878 in Italy • All birds susceptible but wide spectrum disease • Highly pathogenic avian influenza (HPAI) • Sudden onset, severe illness, rapid death • Almost 100% mortality • All previous HPAI - H5 or H7 • 21 outbreaks before 2003

10. Avian influenza • Viruses from different species can merge • To spread need human genes • Humans living in close proximity to birds and pigs - ideal • Migratory birds - natural reservoir and can carry virus long distances • Illegal imports

11. H5N1 - a cause for concern • Mutates rapidly • Can acquire genes from other species • Can cause severe human disease • Birds can excrete for up to 10 days • As more humans infected increased chance of new subtype emerging • Has been found in pigs and other animals

12. H5N1 - cause for concern • In poultry since April 2003 • Very widespread in many countries • 165 human cases - 88 deaths • Cambodia, China, Indonesia ,Iraq,Thailand, Turkey and Vietnam • Still no evidence of human to human spread • Clusters spreading in time and space • Case fatality rate may decrease

13. Cambodia Croatia (Zdenci) China (including Tibet and Hong Kong) Indonesia Iraq (North East) Japan Kazakhstan Laos Mongolia Nigeria (Kaduna state) Romania Russia (Novosibrisk) Thailand Turkey Ukraine Vietnam 16 countries affected - 9 Feb 2006

14. Current travel advice is • Avoid contact with live poultry and wild birds • Avoid visiting live animal markets and poultry farms • Avoid contact with surfaces contaminated with animal faeces • Don’t handle dead birds • Do not eat or handle undercooked or raw poultry, egg or duck dishes • Exercise good personal hygiene with frequent hand washing • Do not attempt to bring any live poultry products back to the UK ECDC 15th October 2005

15. Control of HPAI • Cull poultry • Protective equipment for workers • Immunise workers with current vaccine • Anti-viral prophylaxis • Health surveillance • May happen in UK - IMT • Developing plan with vets

16. Pandemic Influenza Planning

17. WHO state of alert now

18. WHO Phases - Action Pre-pandemic • Reduce opportunities for human infections • Strengthen early warning system Emergence of pandemic virus • Contain or delay spread from source Pandemic declared • Reduce morbidity, mortality, social disruption • Conduct research to guide response

19. Aims of pandemic planning • Save lives • Reduce health impact • Minimise disruption to business • Reduce societal disruption • Provide authoritative advice Needs strong leadership, command and control, good co-ordination, clear lines of accountability and communication

20. Prevention • Vaccine - most effective option • Antivirals - treatment only • Infection control Hit hard to ‘buy time’ in the early stages • Isolation of cases • Limit mass gatherings • Limit non essential travel

21. Morbidity and mortality • Cumulative attack rate 25% -12 weeks • Up to 90% in residential settings • Children and adults affected • Impact determined by age group affected • Case fatality rate 0.37% (> 99% recover) • Minimum excess deaths in UK 50,000 • Third of deaths in <65 (5% normal)

22. Impact • Increase demand for NHS services • Increase demand for social care services • Increased deaths • Workforce depleted - • 25 % or more 7-8 days over 3 months • Absenteeism - 7% at peak (ill) 15% off • ?higher in NHS and Social Services - exposure • Maintaining essential services • Social disruption and economic loss • Public, political and media concern

23. Impact in Grampian • People ill - 125,000 (50,000 - 250,000) • Excess GP visits - 12,500 (5,000 - 25,000) • But this assumes only 10% see GP • Excess A/E attendances - 6250 (2500 - 12,500) • Minimum excess admissions 700 (250 - 1500) • Increased demand for ITU and HDU beds • Minimum excess deaths 450 (200 - 900) Based on 25% attack rate and 0.37% case fatality rate. CFR may be higher ?2.5%, AR 50%. Assumes no anti-virals.

24. Grampian response • Command and control • Based on integrated emergency management • Must be fit for purpose • Multi-agency • Strategic- civil emergency response and consequence management • Tactical- Pandemic IMT - manage outbreak • Operational Teams

25. Civil emergency response • Maintenance of essential services • emergency services • transport and utilities • food distribution • pharmaceuticals • communications • Management of mass causalities • Maintenance of public order • Recovery

26. Strategic Co-ordinating Group • Chief Executive, NHS Grampian • Chief Constable, Grampian Police • Director of Public Health • Chief Executive of Aberdeen City Council • Chief Executive of Aberdeenshire Council • Chief Executive of Moray Council • Director of Corporate Communication • General Manager of the Scottish Ambulance • Fire Master • Military Liaison Officer • Representative of the utilities

27. Core team CPHM ( chair) Sector GMs Pharmacy Infection Control/Micro NHS 24 and GMED Local authority EPO Police and SAS Liaison Corporate Communications Administrative support Support as required Senior clinicians - acute and primary care Occupational Health Social Work Education Environmental Health ND/Chair of ICG CPHM HEPO HPNS Pandemic IMT

28. Pandemic IMT tasks • Implement local plans • On advice from SEHD and HPS • Co-ordinate management of outbreak • Surveillance, investigation and control • Co-ordinate services (NHS and social services) • Anti-virals and vaccination • Brief strategic and operational teams, professionals, public and local media

29. Actions needed • Planning Group reconvened • Revise Grampian plan - living document • Effective command and control • Effective communication strategy • Business continuity for the NHS - all sectors • Must address infection control • Interagency working especially Social Services • Multi agency plan

30. Further information • SEHD www.show.scot.nhs.uk/sehd/pandemicflu • Health Protection Scotland - www.show.scot.nhs.uk/scieh • Health Protection Agency - www.hpa.org.uk • European Centre for Disease Prevention and Control - www.ecdc.eu.int • WHO - www.who.int