1. Frank Agodi PhD student Walden University PUBH: 8165-2 Instructor: Dr. Raymond Thron Spring, 2011

2. AGENDA Introduction What is Pandemic Influenza? Review Influenza Basics History of influenza Epidemiology of Influenza Routes of transmission How does Seasonal Flu defer from Pandemic Flu? Data statistics of Influenza Prevention of Influenza Conclusion Questions Feedback References Supplemental Reading

3. INTRODUCTION For the past 400 years, epidemics resembling influenza have been recorded in many countries. Epidemics from as early as the 16th Century in England and the 18th Century in the USA are recognizable as influenza, even in the absences of precise knowledge of their causative In 1997 and again since 2003, there has been concern about the Influenza A(H5N1) virus which continues to circulate causing outbreaks in birds and occasional human infections http://www.unicef.org/avianflu/index.html

4. Pandemic = worldwide epidemic New influenza virus  No immunity Spreads from person-to-person Presumed to be like seasonal flu: respiratory droplets Can cause severe disease Incubation Period Presumed like seasonal flu: 1 to 5 days Contagious Period Presumed to be similar to seasonal flu Timing Waves that last weeks and could begin anytime WHAT IS PANDEMIC INFLUENZA?

5. FLU BASICS VIRAL INFECTION Fever Headache Muscle aches Extreme fatigue Dry cough Sore throat Runny or stuffy nose CDC Public Health Image Library

6. FLU BASICS VIRAL INFECTION - Flu Complications CDC Public Health Image Library Bronchitis Pneumonia Dehydration Worsening of chronic illness Sinus or ear problems in children Death ~65/100,000 infections 80-90% >65 y/o

7. HISTORY OF INFLUENZA 1976 to 2006 deaths range 3,000-49,000 First flu pandemic in 40 years, 2009-2010  United States mortality 12,000  January 2-8, 2011, WHO, (2011) reported worldwide 4,331 specimen, 706 positive influenza A  Four deaths, (two influenza A; two influenza B) CDC. 2011. Flu view: A weekly influenza surveillance report prepared by the influenza division. Retrieved from http://www.cdc.gov/flu/keyfacts.htm#whatis

8. HISTORY OF INFLUENZA Pandemics of the 20 th CenturyYear US Mortality 1918-19 “Spanish flu” 550,000 1957-58 “Asian” 69,800 1968-69 “Hong Kong” 33,800 1977-78 “Russian” 8,300

10. EPIDEMIOLOGY OF INFLUENZA - Influenza pandemic occurs when major mutation happens It happens in two ways: Genetic re-assortment Repeated transmission

11. Does Age Matter? Age at death, per 100,000 persons in each age group, United States, 1911–1918 -JK Taubenberger and DM Morens.1918 Influenza: the Mother of All Pandemics. EID, Jan. 2006 EPIDEMIOLOGY OF INFLUENZA -

12. ROUTES OF TRANSMISSION Novel virus Human-to-human transmission “R 0 ” = number of people an infected person infects Severity of illness Case fatality ratio (CFR) More distance between persons  spread of germs less likely Transmission “Respiratory droplets An infected person infects ~1.5—3 others

13. HOW DOES SEASONAL FLU DIFFER FROM PANDEMIC FLU? Seasonal Flu outbreaks follow predictable seasonal patterns; occurs annually, usually in winter, in the temperate climates. Usually some immunity are built up from previous exposure Healthy adults usually not at risk for serious complications; the very young, the elderly and those with certain underlying health conditions at increased risk for serious complications. http://www.cdc.gov/flu/ We can get more info about seasonal flu in CDC site above.

14. HOW DOES SEASONAL FLU DIFFER FROM PANDEMIC FLU? Pandemic Flu occurs rarely (three times in 20 th century – last in 1968). No previous exposure Little or no pre-existing immunity Healthy people may be at increased risk for serious complications. http://www.cdc.gov/flu/ Info about how seasonal flu differ from pandemic flu can be read from the CDC site above.

15. SEASONAL FLU Occurs annually and is caused by influenza virus Strikes in the fall and winter Usually less severe than pandemic flu because many people may have developed some immunity Vaccines developed based on known flu strains and available annually

16. PANDEMIC FLU Usually, there is no pre-existing immunity or previous exposure. Flu shots will not be available at first they have to made. It may take 4 to 6 months or longer to prepare a flu shot for this virus

17. PANDEMIC FLU - Avian Influenza H5N1: Key Facts Transmission to humans: Rare Extensive contact with infected birds Contagiousness Very rarely spread between humans Spread among birds: increasing Birds and poultry in Southeast Asia, Asia, Indonesia, Europe, Africa, Middle East… Severity Of 281 people infected with H5N1 Avian Flu, 169 (60%) have died

20. DATA STATISTICS OF INFLUENZA The WHO has reported cases of influenza A (H1N1) Asia, Africa, Pacific and Europe Indonesia and Vietnam have the highest In Egypt they reported 121 confirmed cases 40 have been fatal WHO. 2011. Global Alert and Response.CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April 2009 – March 13, 2010. Retreivedromhttp://www.who.int/csr/don/2011_01_20/en/index.htmlhttp://www.who.int/csr/don/2011_01_20/en/index.html CDC shows the statistics for hospitalization and deaths due to H1N1

21. Pandemic Flu Vaccine and Drugs Vaccine Delayed production May require two doses Drugs Supplies: limited Distribution: unfamiliar Prioritization  rationing  fear…

22. How To Slow a Pandemic: Latest CDC Guidance 1. Ill persons should be treated and stay away from others 2. Exposed persons should stay away from others and receive prophylaxis 3. More ‘social distance’ between children in schools and childcare 4. More social distance between adults at work and play

23. Prevention and Planning It Begins At Home The more you prepare yourself and your family, the more likely you can fulfill roles in an emergency

24. PREVENTION OF INFLUENZA Stay home if you are sick until 24 hours after fever (100 F or 37.8 C)is gone [http://pandemicflu.gov/indivi dualfamily/prevention/index. html] Limit contact with others Cover your nose and mouth when you sneeze or cough (use tissue or bend of your arm) Throw away used tissue Use alcohol hand sanitizer Avoid touching your eyes, nose or mouth Centers for Disease Prevention and Control. (2010). CDC says “take 3” actions to fight the flu. Retrieved from http://www.cdc.gov/flu/protect/jpreventing.htmhttp://www.cdc.gov/flu/protect/jpreventing.htm U. S. Department of Health and Human Service. Flu.gov. (2011). Prevention and treatment. Retrieved from http://pandemicflu.gov/individualfamily/prevention/index.htmlhttp://pandemicflu.gov/individualfamily/prevention/index.html Note! Preventive steps are provided in the links above.

25. PREVENTION OF INFLUENZA Annual vaccination  Injection  Inactivated  Nasal mist  Live attenuated Prophylactic medicines Avoid ill persons Respiratory hygiene & etiquette: “Cover your cough” southbirminghampct.nhs.uk

26. PREVENTION OF INFLUENZA Step 1 Flu Vaccine 1 st (most important) Protects against the three viruses Influenza A - H3N2 Influenza B 2009 - H1N1 High risk populations As early as 6 months of age Children younger than 6 months can not receive the vaccine Person caring (vaccinated) Centers for Control Disease and Prevention. (2010). CDC says “take 3” actions to fight the flu Retrieved from http://www.cdc.gov/flu/protect/preventing.htmhttp://www.cdc.gov/flu/protect/preventing.htm Note! Info on steps to prevent spread of influenza could be read on the above link.

27. PANDEMIC INFLUENZA PREVENTION (Countermeasures) Counter- measures SeasonalAvianPandemic Vaccine++-+/- Anti-virals++++/- Non- Pharmaceutical Interventions (NPIs) +++/-++

28. Overall Goals Reduce deaths Reduce illnesses Reduce social disruption

29. Current Pandemic Planning Assumptions We’ll have some notice Don’t expect federal or state “response” Duration of event: weeks to months Absenteeism Plan for 30-40% for at least 2 weeks Vaccine Late, limited Anti-virals Insufficient stockpile for preventive treatment Sufficient for some treatment

30. Federal and State Public Health Roles Leadership—in collaboration with emergency management Information—regular updates, interim guidance Coordination—with multiple agencies and jurisdictions, e.g. counties, state agencies Evaluation—measure interventions’ effects

31. Public Health’s Legal Authorities CDC  State Public Health  County or City Health Departments Federal—guidance only www.pandemicflu.gov www.cdc.gov State—guidance and legal authority http://www.cdph.ca.gov/Pages/DEFAULT.aspx County/Local Health Departments—where guidance and legal authority meet real people http://www.acphd.org/

32. Federal Guidance DHS/HHS/CDC— leadership All Federal Cabinet Level Agencies Justice Defense Commerce Treasury

33. Pandemic Severity CDC’s Pandemic Severity Index Category 1 –mild Category 3 –moderate Category 5 –catastrophic Interventions α Severity Index Category 1 Ill persons stay home Schools generally not closed Category 5 Almost everyone stays home!

35. CONCLUSION The pandemic wave passes through Public Health impacts Illnesses and deaths Other impacts are losses to business sector Plans refined Vaccine or anti-flu drugs become available

36. REFERENCES Georgia State University. 2010. Office of Emergence Management. H1N1 General Info. Retrieved from http://www.gsu.edu/oem/37808.html http://www.gsu.edu/oem/37808.html Centers for Disease Prevention and Control. (2010). CDC says “take 3” actions to fight the flu. Retrieved from http://www.cdc.gov/flu/protect/jpreventing.htm http://www.cdc.gov/flu/protect/jpreventing.htm

37. REFERENCES Centers for Disease Prevention and Control. (2010). Cold versus flu. Retrieved from http://www.cdc.gov/flu/about/qa/couldflu.htm http://www.cdc.gov/flu/about/qa/couldflu.htm Louie, J. K., Acosta, M., Jamieson, D. J. & Honein, M. A. (2010). Severe 2009 H1N1 influenza in pregnant and postpartum women in California. New England Journal of Medicine. 362, 27-35.

38. REFERENCES Payaprom, Y., Bennett, P., Burnard, P., Alabaster, E. & Tantipong. (2009). Understandings of influenza and influenza vaccination among high risk urban Dwelling Thai adults: a qualitative study. Journal of Public Health. 32 (1). 26

39. REFERENCES U. S. Department of Health and Human Service. Flu.gov. (2011). Prevention and treatment. Retrieved from http://pandemicflu.gov/individualfamily/prevention/inde x.html;http://pandemicflu.gov/individualfamily/preventio n/index.html http://pandemicflu.gov/individualfamily/prevention/inde x.html;http://pandemicflu.gov/individualfamily/preventio n/index.html U. S. Department of Health and Human Service. Flu.gov. (2011). Prevention and treatment. Retrieved from http://pandemicflu.gov/individualfamily/prevention/inde x.html;http://www.flu.gov/individualfamily/prevention/m edicine/index.html http://pandemicflu.gov/individualfamily/prevention/inde x.html;http://www.flu.gov/individualfamily/prevention/m edicine/index.html

40. REFERENCES World Health Organization. 2011. Global Alert and Responses. CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April 2009 – March 13, 2010. Retrieved from http://www.who.int/csr/don/2011_01_20/en/i ndex.html http://www.who.int/csr/don/2011_01_20/en/i ndex.html

41. SUPPLIMENTAL INFORMATION http://www.cdc.gov/flu/about/qa/couldflu.htm http://www.cdc.gov/flu/protect/jpreventing.htm http://www.flu.gov/individualfamily/prevention/medicine /index.html http://www.flu.gov/individualfamily/prevention/medicine /index.html http://www.gsu.edu/oem/37808.html http://pandemicflu.gov/individualfamily/prevention/inde x.html http://pandemicflu.gov/individualfamily/prevention/inde x.html http://www.who.int/csr/don/2011_01_20/en/index.html

42. QUESTIONS Questions Feedback Thanks