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DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION

DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM, APRIL 2005. 1918. 1957. 1968. Spanish Flu H1N1. Hong Kong Flu H3N2. Asian Flu H2N2. Influenza Pandemics Happen!. H1. H3.

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DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION

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  1. DR. JULIE LOUISE GERBERDINGDIRECTORCENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM, APRIL 2005

  2. 1918 1957 1968 Spanish Flu H1N1 Hong Kong Flu H3N2 Asian Flu H2N2 Influenza Pandemics Happen! H1 H3 H2 H1 1915 1925 1935 1945 1955 1965 1975 1985 1995 2005

  3. Mechanisms of Antigenic Shift Direct Avian – Human Infection Avian host Human virus Avian virus New Reassorted virus Swine

  4. 1000 800 600 Mortality Rate per 100,000 400 200 0 1900 1920 1940 1960 1980 Year Infectious Disease Mortality in the United States 1900 - 1996 Source: Armstrong ;1999 et al., JAMA

  5. Bacteriologic Findings among Patients with Influenzal Pneumonia 1918-1919 Sputum Blood S. pneumoniae 1230/1609 (76%) 78/1507 (4.9%) S. aureus 133/1485 (9%) 0/1535 Beta-hemolytic strep 254/2077 (12%) 32/1587 (2%) H. Influenzae 436/729 (60%) 1/1400 (.1%) Stevens KM: NEJM 1976; 1363-66

  6. Potential Causes of Influenza-related Shock and Death • Exacerbation of undiagnosed underlying conditions • Coincidental occurrence of an unrelated problem • Influenza pneumonia • Secondary bacterial pneumonia • Toxic shock syndrome / endotoxemia • Hypersensitivity response • Myopericarditis • Cytokine-induced shock syndrome

  7. 1918 1957 1968 Spanish Flu H1N1 Hong Kong Flu H3N2 Asian Flu H2N2 Avian Influenza is Emerging H9 Avian Flu 1998 1999 H5 1997 2003 2004 H7 1980 1996 2003 H1 H3 H2 H1 1915 1925 1935 1945 1955 1965 1975 1985 1995 2005

  8. Outbreaks of Highly Pathogenic Avian Viruses Before 2004

  9. Situation Report: Confirmed Human H5N1 CasesUpdated April 3, 2005

  10. Risk Factors for Human H5N1 Illness in 1997 • Case control study primary risk factor for H5N1 illness • Exposure to live poultry in poultry stall or market in the week prior to illness • Studies on poultry workers in Hong Kong markets • 20% chickens infected with H5N1 • Seroprevalence for H5 antibody = 10% • Seroprevalence in general population = 0% • Occupational risk factors for poultry workers: • Butchering • Exposure to sick birds

  11. 1997 H5N1 Field Studies • Most cases likely contracted influenza after exposure to infected poultry • Human-to-human transmission occurred but was uncommon • Groups with greatest risk of H5-antibody • Household contacts and poultry workers • Although poultry workers had highest antibody rate, none found ill with H5 • May have been protected based on prior exposures to avian H5

  12. Avian Influenza Poultry Outbreaks, Asia, 2003-04

  13. Situation Report: Avian Influenza 2005 • H5N1 enzootic of unprecedented size and complexity now established • Poultry outbreaks in 9 or more countries • Ongoing poultry outbreaks and human cases • Substantial economic and social impact • Continuing risk of emergence of a pandemic

  14. Situation Report: Avian Influenza 2005 • H5N1 seasonal pattern for avian flu in Asia • Expect increased activity in winter months • Ongoing human cases • Most in young and healthy • Extremely high apparent case-fatality • No sustained person-to-person transmission

  15. Situation Report: Avian Influenza 2005 • Human isolates (Vietnam, Cambodia & Thailand and 1 group of Vietnamese avian isolates • Resistant to adamantane drugs • Sensitive to oseltamivir • Probable human-to-human transmission in Thailand; family clusters in Vietnam • ? increasing • Antigenic heterogeneity among current H5N1 viruses (unlike 2003 Hong Kong H5N1 virus) • How variable are the 2005 H5N1 viruses? • How immunogenic? • Must compare human and avian isolates

  16. WHO Collaborating Centers for Influenza WHO Collaborating Centers - Atlanta, London, Melbourne, and Tokyo Countries containing at least 1 WHO influenza laboratory

  17. HHS Response: Partnership with WHO • Support Global Influenza Pandemic Preparedness • Enhance Collaboration with Animal Influenza Health Authorities • Enhance Global Influenza Surveillance • Training - Laboratory, epidemiology, and biosafety

  18. HHS / CDC Contributions to Preparedness and Response in Asia: HHS/CDC A $5.5 M initiative to build surveillance capacity • Surveillance networks with bilateral funding to 9 countries in Asia • WHO HQ and Western Pacific Regional Office • CDC’s IEIP in Thailand and NAMRU-2 in Jakarta • WHO’s Animal Influenza Network • Communications between public health and veterinary agencies • Shipment of isolates and specimens

  19. Mongolia China South Korea India Thailand Philippines Pakistan Indonesia Malaysia Enhancing Influenza Surveillance: HHS/CDC

  20. Global Biosurveillance: International Health Protection Network FY04 Quarantine Stations Field Epidemiology/ Laboratory Training Programs CDC Field Stations International Business Connectivity New CDC Sentinel Sites New Quarantine Stations New International LRN Sites New CDC Sentinel Sites International Health Protection Network FY06 FY04 Laboratory Response Network (LRN) National Clinical Lab Orders DoD/VA Dx & Rx Records Biowatch Data OTC Drug Sales Private Clinical Care Expanded Real-Time LRN Data Expanded Quarantine Stations New Data Streams FY06 Global Health Protection Network Bio Sense & Biointelligence Center D A T A E X C H A N G E

  21. Quarantine Authorization • Public Health Service Act (Title 42 U.S. Code 264(b), Section 316 of the Public Health Services Act amended -- "(c) Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic.” • Quarantine and isolation tools were last used during the SARS 2003 outbreak • Quarantine duration of one incubation period

  22. CDC’s Research Priorities • Ggenetic determinants of pathogenicity and transmissibility • Testing for antiviral resistance, receptor binding properties, etc. • Tracking antigenic changes in the circulating viruses to facilitate appropriate vaccine development • Epidemiology of the current H5N1 epizootic • Why did it spread so rapidly? • How many people have been infected? • What is the extent of asymptomatic infection? • What is the actual death rate?

  23. Collaboration Coordination Commitment Competency Communication Consistency Compassion Candor Clinical Laboratories Community Common Sense

  24. Complacency is the enemy of preparedness! www.cdc.gov

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