1. Pandemic Flu and You
DJ Holcombe, MD, MSA, FACP
JJ Naponick, MD, MPH
Administrator/Medical Director
Department of Health & Hospitals
Office of Public Health
Region 6
Hello and welcome to this presentation dealing with a potential pandemic flu event and how this would affect you.
My name is Dawne Arnold and I am the Pandemic Flu Coordinator for the Louisiana Department of Health and Hospital’s Region VI Office of Public Health. The Office of Public Health is your state health department. Many of you know the Office of Public Health as the agency that delivers invaluable public health services through the parish health units. However, we are involved in many other important activities outside the four walls of the parish health units. One of these is pandemic flu planning.

2. Topics of Discussion Seasonal Influenza Avian Influenza
Pandemic Influenza
Impact & Planning
Public Health Role
Your Role
Resources
The topics that will be discussed during this presentation will include:
Influenza, or seasonal flu
Avian, or bird, flu
The majority of the presentation will deal with pandemic flu
We’ll discuss the impact of pandemic flu on society and planning efforts that communities and individuals should be undertaking
Public Health’s role in pandemic flu will be explored, as well as your role
Finally we’ll look at some resources that would provide more information about pandemic flu
One special note here – no part of this presentation should be interpreted as definitive medical care for any one individual. When ill, individuals should contact their personal physician or visit a health care provider to discuss their unique health care needs.

3. So you’ve got the flu?

4. What is influenza (flu)?
mild to severe respiratory illness of sudden onset caused by an influenza virus
highly infectious-spreads rapidly from person to person
some strains more severe than others
occurs every year killing 36,000 people in U.S. and 550 in Louisiana
Let’s start with influenza or regular flu.
This is a mild to severe respiratory illness of sudden onset resulting from infection by an influenza virus.
It is highly infectious and spread rapidly from person to person.
Some strains are more severe than others.
It occurs every year and kills 36,000 people annually in the U.S., with 550 of those being Louisiana residents.

5. Symptoms of Influenza sudden onset of symptoms
fever, headache, aching muscles, weakness
respiratory symptoms
cough, sore throat, difficulty breathing
incubation period = time from exposure to virus to development of symptoms
varies for influenza , but generally 1 to 4 days
With influenza, there is a sudden onset of symptoms such as fever, headache, aching muscles, severe weakness and respiratory symptoms such as cough, sore throat, difficulty breathing.
You may have heard of a term called the incubation period for a disease. An incubation period is defined as the time from exposure to an infectious disease to development of symptoms. For influenza this generally ranges from 1 to 4 days.

6. Seasonal Flu is just that, seasonal. Pandemic Flu is not.
The peak month of Seasonal Flu is February. Pandemic may or may not occur during the regular Seasonal Flu months.

7. How does influenza spread?
Breathing in droplets
produced when infected person talks/coughs/ sneezes
Touching an infected person or surface
contaminated with the virus and then touching your own or someone else’s face
Influenza is easily passed from person to person through breathing in droplets containing the virus, produced when infected person talks, coughs or sneezes.
It is also transmitted by touching an infected person or surface contaminated with the virus and then touching your own or someone else’s face.
This picture on the right gives you an idea of the large droplets produced by someone who has influenza when they sneeze and how these droplets can fall on other people or surfaces allowing transmission.

9. Influenza A Virus
Hemagglutinin (H)–16 subtypes (attachment, penetration)
Hemagglutinin (H)–16 subtypes (attachment, penetration)
Neuraminidase (NA)–9 subtypes (release)
8 viral genes (assembly, replication)
The influenza virus contains antigens, or protein spikes, on their surface.
The two principle antigens on the surface of the influenza virus are hemagglutinin and neuramidase shown here.
The human immune system produces antibodies which are proteins as well to attack these antigens.
M2 protein (penetration)

10. Antigenic Drift vs. Shift
Antigenic drift: major changes in the form of one or both of the two principle antigens on the viral surface
our immune system has greater difficulty recognizing them
Antigenic shift: radical changes in the form of the one or both of the two principle antigens on the viral surface
our immune system can’t recognize them at all
The two principle antigens of the influenza virus, hemagglutinin and neuramidase, mutate, or change form, the fastest of all the flu virus antigens.
Sometimes the changes are minor and our immune system can still recognize these antigens; other times the changes in these antigens are major and our immune system has more difficulty reading them.
This phenomenon is known as antigenic drift.
Antigenic drift can create epidemics.
Public health experts monitor this drift each year to adjust the flu vaccine to keep pace with changes in the influenza virus.
Pandemics generally only develop when there are radical changes in surface proteins of the influenza virus.
This is called antigenic shift.
In this case, the immune system can’t recognize the antigen at all, so the virus can spread throughout the population at an explosive rate.

11. What’s Next?

12. The Avian Menace, our false feathered friends.

13. Avian (Bird) Influenza
An infection occurring naturally among birds caused by avian influenza viruses (e.g. H5N1 virus)
Birds
wild birds worldwide carry the virus – usually no illness
domesticated birds - can become ill and die
Humans
can become infected with avian influenza -> severe illness and death
most cases from close contact with infected poultry
very rarely may have spread from one person to another
cases/deaths since 2003 = 359/226
2003: 4/4
2004: 46/32
2005: 98/43
2006: 115/79
2007: 86/59
2008: 10/9
Avian influenza is an infection occurring naturally among birds caused by avian influenza viruses (e.g. H5N1 virus).
Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them.
It can make some domesticated birds, including chickens, ducks, and turkeys, very sick and die.
The avian influenza virus has infected some people, causing severe illness and death..
Most cases of avian influenza infection in humans have resulted from direct or close contact with infected poultry .
In very rare cases, the virus may have spread from one person to another. The very few people who may have gotten bird flu from another person did not pass it on.
There have been sporadic human cases:
starting in 2003 running through October 12, 2007, there have been 331 cases with 202 deaths
most in young and healthy with case-fatality rate of 61%

14. This is a chart showing the number of cases in each month of the year, through August of 2007.

16. Influenza A Subtypes: The Omnipresent Zoonoses
This illustration depicts the transmissibility of influenza viruses between different the species and humans. Notice birds are the main transmitter of influenza viruses to humans.

17. Viral Mutations Unlocking the Key to Infection
The mutations of the particles on the outer surface are what enables the virus to “connect” to our human cells, thus, infecting us with influenza.

18. Will H5N1 become the next pandemic?
Avian Flu not yet Pandemic Flu
current outbreaks of H5N1 Avian Flu in poultry and birds are the largest ever documented
Impossible to predict next pandemic flu event
If not H5N1, then another
Plan now
Avian Flu has not yet arrived to the point of causing a Pandemic Flu, but current outbreaks for H5N1 Avian Flu in poultry and birds are the largest ever documented.
It is impossible to know if or when next pandemic will occur.
If it turns out that H5N1 does not cause the next pandemic flu, eventually another influenza virus will come to do so.
That’s why it is so vital to plan now for pandemic flu.

19. How do we protect ourselves from our feathered friends?

20. Poultry Surveillance Culling the infected flocks.

21. Stopping the Avian Flu: Surveillance

22. Avian Flu: Sampling Flocks

23. Understanding Pandemic Flu
Epidemic: serious outbreak in a single community, population or region
Pandemic: an epidemic spreading around the world affecting hundreds of thousands of people, across many countries
Pandemic flu: a pandemic that results from an influenza virus strain that humans have not been previously exposed to
You’ve probably heard the term epidemic before and I’ve been using the term pandemic during this presentation. What’s the difference?
While an epidemic is a serious outbreak of an infectious disease in a single community, population or region, a pandemic is an epidemic spreading around the world affecting hundreds of thousands of people, across many countries.
So a pandemic is an epidemic on a world-wide scale and pandemic flu, of course, is a pandemic that results from an influenza virus that is new to humans.
Let’s explore that in a little more detail.

24. Putting Pandemic Flu into Perspective
2001 terrorist attack with anthrax
killed five people
2002 outbreak of West Nile Virus
killed 284 people nationally in six months
2003 SARS outbreak
killed over 800 people world wide
froze Asian economies
frightened millions of people into wearing masks on the streets

25. History of Pandemic Influenza
Worldwide 700,000 deaths (34,000 in US)
Worldwide 1.5 million deaths (70,000 in US)
1918
Worldwide million deaths (500,000–650,000 in US)
Typical Influenza Season
36,000 deaths in US
Looking at some of the flu pandemics in the 20th century,
There was one that ran from 1968 to 1969.
At least 700,000 people died worldwide.
There were 34,000 deaths in US.
There was a flu pandemic that occurred from 1957 to 1958.
At least 1.5 million people died worldwide.
There were 70,000 deaths in US.
And the worst pandemic occurred from 1918 to 1919 spreading around the globe in 4-6 months.
At least million people died worldwide.
And there were 500,000 – 650,000 deaths in the US.
During the course of the epidemic, 47% of all deaths were from influenza
& its complications.
Two major issues: overcrowding & public information withheld
All of this is in comparison to a typical influenza season where we see 36,000 deaths in US.

26. The Spanish Flu of 1918

27. Mortality in 1918

28. Public Health Measures in 1918

29. Personal Protective Equipment (1918)

30. Law Enforcement in the 1918 Flu

31. Lessons from Past Pandemics
Occurs unpredictably, not always in winter
Variations in mortality, severity of illness and pattern of illness
Rapid surge in number of cases over brief period of time, often measured in weeks
Tend to occur in waves - subsequent waves may be more or less severe
Lessons that have been learned from past pandemic flu events include the following:
These events occur unpredictably and not always in winter.
There have been great variations in mortality, or death, severity of illness and pattern of illness, or ages most severely affected.
There is a rapid surge in number of cases over brief period of time, often measured in weeks.
Again these pandemics tend to occur in waves; and subsequent waves may be more or less severe.

32. Pandemic Flu: Current Status and Requirements
Currently no pandemic influenza in the world
For pandemic influenza to occur, three conditions must be met:
a new influenza A virus appears or “emerges” in the human population
it causes serious illness in people
it spreads easily from person to person worldwide
There is currently no pandemic influenza in the world.
For pandemic influenza to occur, three conditions must be met:
a new influenza A virus appears or “emerges” in the human population
it causes serious illness in people
it spreads easily from person to person worldwide

33. Current Status Interpandemic Pandemic alert Pandemic Phase 1 Phase 2
Larger clusters, localized
Limited spread among humans
Phase 5
Phase 6
No new virus in humans
Animal viruses low risk to humans
No new virus in humans
Animal viruses low risk to humans
New virus in humans
Little/no spread among humans
Small clusters, localized
Limited spread among humans
Increased and sustained spread in general human population
The current status of the H5N1 bird flu situation places us in what’s called Phase 3 of the World Health Organization pandemic flu classification.
As you can see, this means we are in the lowest stage of a pandemic alert.
Current status of H5N1
Current H5N1 status
WHO Global Influenza Preparedness Plan, Available at:

34. Pandemic Flu (Category and Projected Death Rates)

35. Pandemic Influenza Impacts
Estimated Impact in Louisiana
3 Million infected
Between 600, million clinically ill
Between 300K-700K requiring outpatient care
Between 10,000 – 22,500 hospitalized
Between 3,000 – 6,000 deaths
Impact on Infrastructure
Significant disruption of transportation, commerce, utilities, public safety and communications
Limited to no assistance from State and Federal governments due to nation-wide impact
This slide gives one an idea of the potential impact of pandemic flu in Louisiana – it is predicted that:
3 million people would be infected with this pandemic flu, some with and some without symptoms
Between 600, million would show symptoms of the flu
Between ,000 people would require outpatient care to see a health care provider
There would be between 10,000 – 22,500 individuals hospitalized
And there may be between 3,000 to 6,000 deaths
Our regional infrastructure would be disrupted. We’ll see disruptions to transportation, commerce, utilities, public safety services, and communications.
This pandemic outbreak will be nation-wide. Unlike other types of emergencies, we won’t be able to rely on State or Federal assistance. We’ll be on our own.

36. Impact on Health Care Illness rates will soar
Many people will require some medical care
Health care facilities will be overwhelmed
Symptoms may be severe
Complications:
may be more frequent
healthy people may be at increased risk
Illness rates will soar – many people will require some form of medical care.
Health care facilities will be overwhelmed.
Symptoms may be severe.
Complications may be more frequent.
Healthy people may be at increased risk for complications.

37. Impact on Business Impact on Business Owners Issues to Address
Up to 40% employee absenteeism
Possible increase/decrease in demand for products or services
Disruption of communication & supply chains
Fewer employees and customers
Issues to Address
Modification of:
customer/employee interaction
sick leave & work location
Communication/education
Collaboration
Infection Control
Businesses could expect up to a 40% employee absenteeism rate.
There might be possible increases or decreases in demand for certain products or services.
Again there would be disruption of communication & supply chains. American business’ adoption of just-in-time delivery of inventory means that if a single supplier had so many workers out sick, it couldn’t ship a key item possibly shutting down an entire economy.
There may very well be fewer employees and customers.
Business may have to modify their interactions with customers and make changes in such policies as sick leave or location of the work site.
It would be vital to maintain communication with employees/customers and provide accurate education to them in order to avoid unnecessary fears.
There would probably be greater collaboration with external organizations and greater emphasis on helping the entire community.
Employees would have to be educated on infection control with an expectation that such practices would be adhered to.

38. Pandemic Flu Simulation

39. Making Vaccines

40. Will there be a vaccine?
Because the virus will be new, there will be no vaccine ready to protect against pandemic flu
A specific vaccine cannot be made until the virus has been identified
Seasonal flu vaccine or past flu immunization will not provide protection
Because the virus will be new, there will be no vaccine ready to protect against pandemic flu in the early stages of the pandemic.
Vaccine will probably not be available until the second wave of the pandemic.
A specific vaccine cannot be made until the virus has been identified.
The virus cannot be predicted in same way as seasonal flu.
Seasonal flu vaccine or past flu immunization will not provide protection against pandemic flu.

41. Medications During Pandemic Flu
Antiviral Medications
can prevent complications if taken within first 48 hours of illness
may not be effective against a pandemic flu virus
extremely limited supply now
would be prioritized
initial use probably only for treatment, not prophylaxis
Antiviral Medications
Amatadine (Symmetrel)
Rimantadine (Flumadine)
Zanamivir (Relenza)
Oseltamivir (Tamiflu)
You may have heard about antiviral agents, or medications, such as those listed on the right portion of this slide:
These medications are taken by mouth and can prevent complications if taken within first 48 hours of illness.
They may not be effective against a pandemic flu virus.
At this time, supplies are extremely limited.
As a result, such medications would be prioritized (based on national guidance).
Antiviral agents would probably initially be used only for treatment, not prophylaxis, or prevention, of the disease.

42. Influenza Containment Strategy: Community Response
Basic Activities
Surveillance and quarantine of early cases
Public information and education
Promote “respiratory hygiene” and hand washing
Enhanced Activities
Focused measures to increase social distance
Community-wide measures to increase social distance
Basic Community Containment Response Activities involve:
Surveillance, or counting, of cases and quarantine of early cases
Public information and education – I’ll speak more about that is a few seconds
Promotion of “respiratory hygiene” and hand washing
Enhanced Activities include:
Focused measures to increase social distancing.
Community-wide measures to increase social distancing.
Public information activities might include:
Education about personal protection, such as hand hygiene and
respiratory etiquette.
Avoidance of people sick with the flu if possible, staying home if sick, and caring for sick household members safely.
There would also be a need for education about antivirals medications, masks and vaccine as deemed appropriate.

43. Isolation and Quarantine
isolate ill individuals with certain contagious diseases
quarantine contacts (those exposed to such contagious diseases)
play a role in the early stages of the pandemic
legal measures possible
probably would rely on voluntary cooperation
once beyond initial cases
“stay home when you are sick”
You may also have heard the terms isolation and quarantine.
We isolate the ill or individuals with certain contagious diseases and quarantine contacts or those exposed to such contagious diseases.
The initial objective with such activities is to slow the spread of disease.
Isolation and Quarantine more than likely would play a role in the early stages of the pandemic.
Legal measures would be possible, but more than likely we would probably rely on voluntary cooperation.
Housing, health care, psychological, spiritual and food needs must be met for those in isolation or quarantine.
Once beyond initial cases, the strategy will quickly shift to “stay home when you are sick” as the only option.

44. Influenza Prevention Vaccination Stay at home when sick
Cover your cough
Wash hands regularly
Avoid touching eyes, nose and mouth
Avoid close contact with people who are sick
What should we do to prevent the transmission of influenza?
Our best protection against seasonal flu is vaccination.
However, it is important to stay home when you are sick with the flu, even though your role at work or your attendance in school may be vital.
Always remember to cover your cough, wash your hands regularly, and avoid touching your eyes, nose and mouth.
Also avoid close contact with people who are sick with the flu as much as possible.
As you will learn, these basic measures may be our most powerful weapons when combating pandemic flu.

45. Infection Control - Our Basic Protection
Hand Hygiene
Wash hands regularly with soap & water
If no water available: 60%-95% alcohol-based sanitizer
Cover your cough strategy
Environmental cleaning
1:10 bleach solution
EPA registered disinfectant
Gloves & surgical masks
Again, our basic protection would be our infection control measures such as:
Hand Hygiene
Hands should be washed regularly with soap & water.
If no water is available, use a 60%-95% alcohol-based sanitizer
Cover your cough strategy would be emphasized.
Environmental cleaning could be accomplished with a 1:10 bleach solution or an EPA registered disinfectant
Bleach solution should be changed out every 24 hours
EPA solution should be changed out every 7 days
Use of gloves & surgical masks might be encouraged.

46. Hand washing

48. Alcohol-based Hand Sanitizers

49. Different Masks for Different Folks

50. Community Wide Measures
Reduce Social Contact by canceling large gatherings, mass transit, school
Decision based on location of flu activity:
Outbreak not local: large gatherings cancelled
Outbreak in local/neighboring county: small gatherings cancelled
School closings determined by
State Department of Health & Hospitals
Department of Education
Local School Boards.
We can reduce social contact by canceling large gatherings, mass transit, and school.
Such decisions would be based on location of flu activity:
If there were no local outbreaks, large gatherings might be cancelled.
If there were outbreaks in local or neighboring county, small gatherings might be cancelled.
School closings would be determined by State Department of Health & Hospitals, Department of Education and Local School Boards.

51. Workforce Support
Psychological and physical strain on personnel responding in emergency situation
Psychological stress for families
Plan for staff to have adequate
Sleep
Food
Access to psychological
and spiritual support
There would be great psychological and physical strain on personnel responding in such an emergency situation.
This would transfer over into psychological stress for families.
We need to plan for staff to have adequate sleep, food and access to psychological and spiritual support.

53. Guidance Personal/Family Planning
Personal protection:
Hand hygiene and respiratory etiquette
Surgical masks: proven effective for droplet precautions
Seasonal influenza vaccination
Stockpiling: One to three week essential water, food, supplies, medicines
Planning from the family and individual perspective should include measures for:
Again, personal protection involves:
Hand hygiene and respiratory etiquette
Surgical masks have been proven to be effective for droplet precautions – N95 masks, a more sophisticated mask, is necessary when coming in contact with an ill person during an aerosolization procedure. Changing masks frequently would be important as well.
Pneumococcal vaccination should be provided for those for whom it is recommended (healthy adults >65 yrs and others >2yrs if immunocompromised or chronically ill)
Stockpiling a one to three week supply of water, food, supplies, and medicines is recommended.
Remember 1 to 3 gallons of water per person per day

54. Community Goals in Pandemic Flu
Limit death and illness
Preserve continuity of essential government and business functions
Minimize social disruption
Minimize economic losses
Whether you’re from the business sector, government, or the health care system, you share the same overarching goals in a pandemic:
Limit death and illness
Preserve continuity of essential government and business functions
Minimize social disruption and
Minimize economic loss

55. Public Health Role in Pandemic
Facilitate planning
Disease tracking & control
Communication about public health issues
Coordinate mass antiviral medication and vaccination clinics
Issue isolation and quarantine orders
What would the Office of Public Health’s role be in pandemic flu?
We have been working hard to raise awareness of the potential of a pandemic flu event and facilitating local planning.
During a pandemic flu event:
- we would track the disease in the community
- be engaged in disease control
- provide communication about public health issues to the general public, media and our stakeholders
- coordinate Mass Antiviral and Vaccination Clinics
- issue Isolation and Quarantine Orders

56. Get Informed! Be Prepared!
State Draft Pandemic Flu Plan
Family Readiness Guide
Official Pandemic Flu Web Site
Centers for Disease Control and Prevention
Speaking of looking for helpful information, here are some helpful websites:
You can find the Louisiana State Draft Pandemic Flu plan at this web address
You can also find a helpful Family Readiness Guide for disasters at this web location
A large amount of information about pandemic flu can be obtained at the official national pandemic flue web site, as well as the Centers for Disease Control and Prevention pandemic flu web site,
With everything that I’ve said in this presentation, probably one of the most important statements appears at the bottom of this slide, “Even though local, state and federal agencies have plans to protect the public, you are responsible for your own safety, even in an emergency!” This is especially true during the time of a pandemic flu event when essential community functions may very well be severely disrupted.
Even though local, state and federal agencies have plans to protect the public, you are responsible for your own safety, even in an emergency!