Twin Cities Metro Advanced Practice Center May 2007

1. Solid Waste Issues Related to Avian Influenza H5N1 Twin Cities Metro Advanced Practice Center May 2007

2. Outline • Overview of Environmental Health • Overview of Advanced Practice Center work • Environmental Health Preparedness • Waste and Disease • Influenza and Solid Waste Issues

3. Environmental Health The science and art of: • identifying agents of disease or injury, • designing and implementing programs to prevent transmission of the agent in the environment, and • protecting people from exposure to the agent. Minnesota Department of Health

4. Environmental Protection The science and art of: • identifying threats to environmental quality, • designing and implementing programs to prevent degradation of the environment, and • preventing environmental contamination or degradation. Minnesota Department of Health

5. Preparedness Issues Protecting health and the environment is critical during emergencies. Professionals who work in environmental health and environmental protection use many of the same tools during normal activities and during emergency response.

6. Food safety Lodging safety Recreational water quality Public pool safety Lead hazard control Water quality Wastewater management Outdoor air quality Indoor air quality Sustainable building & design Public health nuisance control Solid waste management Hazardous waste management Housing regulation And more Environmental Health: Actions to Protect Public Health Every Day and During Emergencies

7. This work is a product of the Twin Cities Metro Advanced Practice Center for Public Health Preparedness APC Purpose: To create models for implementing information technology and training in support of bioterrorism preparedness and emergency response.

8. Collaborative approach for Environmental Health preparedness in an urban area 10 goal areas over three years Focus on: Products Building EH capacity Sustainable tools Twin Cities Metro APC

9. Twin Cities Metro APC • Training Tools • Emergency Handbook for Food Managers • EH Preparedness Plans • Resource Tool Kit for EH Preparedness • Emergency contact system • Electronic data systems

10. Thanks For Some Materials Goes To: Buddy Ferguson Risk Communication Specialist Minnesota Department of Health

11. Seasonal Influenza • Caused by a virus • Easily transmitted by • talking, coughing, sneezing • touching infected person or contaminated surface – then touching eyes, nose, mouth

12. Seasonal Influenza • Symptoms include: • sudden onset • fever, headache, muscle aches, severe weakness • respiratory symptoms (cough, sore throat, difficulty breathing) • There is no such thing as “stomach flu”

13. Seasonal Influenza • Seasonal influenza is a big deal • Flu and its complications are • the 7th leading cause of death nationally • the 8th leading cause of death in Minnesota (700-800 deaths a year)

14. Seasonal Influenza • People usually don’t get excited about it. • Exceptions: • February 2007 – Child deaths • October 2004 (Chiron vaccine recall) • December 2003 (“kid-killer” flu)

15. Changes in Influenza Virus • Drift – gradual change • addressed through annual reformulation of vaccine • based on WHO/CDC surveillance • Shift – major, abrupt change (possibility of a global epidemic – also known as a pandemic)

16. Three Kinds of Flu • Influenza C – not a big problem • Influenza B – relatively stable but still subject to drift • Influenza A • unstable • subject to both drift and shift

17. An Aside About “H” and “N” • Hemagglutinin (H) and neuraminidase (N) are types of proteins • H and N are found on the outer surface of the flu virus • H and N come in different “flavors” • Recent human flu epidemics have been cased by H1N1 and H3N2 viruses

18. Animals Can Get The Flu • Different strains of influenza A can affect birds, pigs or humans • Avian flu can be high-path or low-path • Different strains can combine, jump from species to species or mutate • That’s how you get new strains

19. What We Have Now “High path” (highly pathogenic) H5N1 avian influenza

20. Why Is It a Public Health Concern? • Some human cases (300+ since 2003) • Not easily spread human-to-human • Very virulent (50%+ death rate – 200+ deaths since 2003) • Attacks young adults (like 1918 virus) • Could adapt to humans • But could change in process of adapting

21. Are We Going to Have a Pandemic? Some kind of pandemic Not if…..but when 1918 (or worse) pandemic Not when…..but if

22. Are We Going to Have a Pandemic? H5N1 could: • become human virus & remain highly virulent • become human virus & change radically • go away & never cause a pandemic

23. Multiple waves of illness, lasting 6-8 weeks 2nd and subsequent waves could be milder – or worse Waves could be several weeks – or several months – apart 30% of population ill 32,000 deaths in Minnesota 172,000 hospitalized in Minnesota Widespread social disruption How Bad Could It Be?

24. Recap We have an event that: • may – or may not – happen in the short run • is almost certain to happen in the long run • may – or may not – be really, really bad when it does happen

25. Protecting Public Health • Surveillance: look for disease/condition • Identifythe source • Actto disrupt transmission of disease/condition This works for biological, chemical, and physical causes of illness and injury

26. Model of Disease Transmission

27. Chain of Disease Transmission “R.E.T.E.R.” Reservoir Exit Route Mode of Transmission Entry Route Receptive Host

28. Agent Reservoir Mode of Exit Mode of Transmission Mode of Entry Host Human Contaminated ground beef Beef gut Eating a rare burger Cattle feces E. Coli 0157 Quiz Time: Foodborne Illness

29. Agent Reservoir Mode of Exit Mode of Transmission Mode of Entry Host Human that likes fish Burning coal in power plants Mercury Coal Mercury accumulating in the food chain Human eating fish Quiz Time – Chemical

30. Environmental Health Role • Among other jobs, EH will need to assure that solid waste continues to be managed in a manner to protect public health. • Key questions: • What wastes are associated with H5N1 flu in animals? • What wastes are associated with H5N1 flu in humans • Is any special management of wastes required?

31. Waste Management & H5N1 • What are the risks* associated with wastes from birds that are infected with HPAI H5N1? Are those wastes safe to handle? • What are the risks* associated with wastes from humans infected with H5N1? Are those wastes safe to handle? * Risks: public health, occupational health, animal health, environmental protection

32. Waste Management and Disease Outbreaks Little guidance for local public health Little information available in the literature regarding risks to workers who come in contact with wastes associated with flu, any flu, including H5N1 Little information available regarding industry practices and risk

33. Purpose of This Work Create a decision-making model for the management of wastes associated with H5N1 that is based on widely agreed upon scientific principles and practices.

34. Why? • Our literature review showed little practical information available • Federal and state guidance is varied and vague, and refers to local decision making. • History of infectious waste management in Minnesota – a risk communication issue • Avoid panic, create understanding

35. Isn’t this just a rural, agriculture-related problem? Pecks and the City “Fowl play or good eggs? Minneapolis poultry owners assert their flocks' right to roost.” By Rachel Hutton Photo by Curtis Johnson

36. Typical Federal Statement “The decision making for disposal occurs at the state and local levels, with technical and resource support in place from federal agencies…” U.S. EPA – “Disposal of domestic birds infected by Avian Influenza – an overview of considerations and options. August 11, 2006. EPA530-R-06-009

37. Federal Direction on Animal Carcass Disposal “Primary resources are at the local level. State resources may be used. Need for Federal resources is limited.” Homeland Security Presidential Directive – 9 Federal Food and Agriculture Decontamination and Disposal Roles and Responsibilities November 2005.

38. Minnesota DNR “If you find a dead bird that must be moved, place it in a plastic bag and dispose of it in the garbage. Be sure to wash your hands thoroughly.” Minnesota Department of Natural Resources: Monitoring for Avian Influenza. www.dnr.state.mn.us

39. Minnesota’s Pandemic Flu Plan “The MDH Clinical Infection Control Team (C-ICT) is responsible for developing, disseminating, and revising infection control guidance for patients, healthcare workers, other caregivers, volunteers and the public…In addition, the C-ICT…will develop and disseminate key infection prevention and control messages for the public and partners. Infection control guidance will include, but is not limited to, recommendations for… • Appropriate types of infection control precautions…to be used • Personal Protective Equipment (PPE)… • Airborne infection isolation room requirements… • Cleaning and disinfection of equipment, linen, and the patient care environment; and • Waste disposal” Draft Version 2.5 April 2006 Technical Section D: Infection Control

40. Private Sector “Waste management companies need to decide soon what role they are going to play in the management of infected carcasses and associated materials, including the transportation and disposal issues as well as whether their employees are willing to handle these types of materials.” NSWMA, “Avian Influenza: The hunt and peck for answers.” October 2006

41. Non-Profit Sector • “Farm personnel involved in the culling of sick poultry, as well as transporting/or disposing carcasses should wear personal protective equipment…”

42. Decision-making Model: Process • Assess the risk via literature review and interviews • Identify types of wastes associated with flu in birds and humans • Assess risk for different elements of waste management • Peer review • Conclusions

43. Minnesota Department of Health Environmental Health Office of Emergency Preparedness Acute Disease Investigation and Control Local public health (Epidemiology and Environmental Health): Hennepin County Washington County City of Minneapolis Minnesota Pollution Control Agency Minnesota Department of Natural Resources Region’s Hospital Minnesota Board of Animal Health Minnesota Occupational Safety and Health University of Minnesota School of Public Health Mayo Clinic Collaborators

44. Assess Risk Associated with H5N1 • H5N1 found in wild and domestic waterfowl and shorebirds • Wild birds can infect domestic poultry • Human susceptibility is not known, but transmission from birds to humans appears to be inefficient • H5N1 virus survival appears similar to seasonal influenza viruses

45. Agent Reservoir Mode of Exit Mode of Transmission Mode of Entry Host Flu virus Humans that have flu Respiratory secretions Virus particles in aerosols, large droplets & on surfaces Inhalation or hand-to-mouth, nose or eyes Humans Seasonal Influenza in Humans

46. Agent Reservoir Mode of Exit Mode of Transmission Mode of Entry Host H5N1 Flu virus Wild and domestic birds Bird feces, blood and respiratory secretions Aerosols or virus particles on surfaces Inhalation or hand-to-mouth, eyes or nose; relative importance of each is unknown Humans H5N1 Infection in Humans Associated with Birds

47. Waste Types • H5N1 in Birds: Types of waste: wild and domestic bird carcasses, bird feces, bedding, cages, food and water dishes, cages, feathers, innards, egg crates, other equipment • H5N1 in Humans: tissues, bedding, masks, gloves, clothing, leftover food, bed pads, beverage bottles, cleaning materials

48. Waste Management • Storage • Collection • Transport and Transfer • Disposal

49. Decision Tree for the Assessment, Evaluation and Management of Wastes Associated with Highly Pathogenic Avian Influenza (HPAI) H5N1 Virus

50. Implications for Waste Management