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Influenza Brian Svazas, MD, MPH, FACOEM Medical Director Fermi National Accelerator Laboratory.

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Presentation on theme: "Influenza Brian Svazas, MD, MPH, FACOEM Medical Director Fermi National Accelerator Laboratory."— Presentation transcript:

1 Influenza Brian Svazas, MD, MPH, FACOEM Medical Director Fermi National Accelerator Laboratory

2 Flu Theories Of Origin China was the point of origin for the pandemics of 1889, 1957, and 1968. three major pandemics of the last 100 years began there Appears To Occur Where Pigs and/Or Fowl Cohabitate With Man Jump Across Species Modified Via Person To Person Spread

3 Three Flavors Type A –Moderate to Severe Disease –All Age Groups –Humans and All Other Animals Type B –Mild –Humans Only –Children Primarily Type C –Rare in Humans –No Epidemics

4 Influenza A: A Shifty Character The H an N Antigens can Shift or Drift Shift results in a radically new antigen site that almost no one living has seen before –Occurs every 10-40 years –Usually occurs with genetic swap with animal based virus Drift is when the antigens alter slightly enough to warrant reclassification –About every 2-3 years one sees “ second wave ”

5 Influenza Loves Kids Children typically have far greater viral loads than adults Children typically have the poorest hygiene 1. Hall & Douglas, Pediatarics 1975;55:673 2. Evans & Kline PIDJ, 1995;14: 332 3. Klimov et al. JID 1995;172:1352

6 Kids and Flu Viral Shedding Normal infants: up to 14 days Nosocomial infection in infants : up to 21 days 1 HIV-infected child: up to 63 days 2 SCID patient: 5 months 3 –Rapid development of antiviral resistance to rimantadine noted in both HIV-infected child and SCID patient; note that rimantadine-resistant virus can be spread to other patients 1. Hall & Douglas, Pediatarics 1975;55:673 2. Evans & Kline PIDJ, 1995;14: 332 3. Klimov et al. JID 1995;172:1352

7 Spread Droplets in a sneeze travel as fast as 150 ft/sec and as far as 12 feet Discover Science Almanac August 2004, page 381

8 Virus ’ Visit Infects Nasal Mucosa Multiplies There For 48 Hr At The 48 Hr Mark We Know Something Is Wrong Peak Replication at 72 Hr As Virus Heads Deeper In Respiratory Tract

9 Signs: When to Suspect the Flu Chills, fever, headache, and muscular pain mark the onset of influenza. Common Complaints of headache, pains in back, arms, legs and bones, sore throat, tightness in chest and cough. Constipation common, Other GI Complaints Not As Likely The initial temperature ranged from 99 degrees to 106 degrees, the average being about 102 degrees. The bar will likely be lower for screening: Airports and other venues in case of Pandemic. (100F 38C)

10 Treatment Rest Stay ahead on fluids –Fever –Rhinitis Avoid Tobacco & Alcohol Medication to relieve symptoms –Be Aware of Aspirin and Children Antivirals Tamiflu and Relenza –Decrease Severity –Decrease Duration –Reduce Viral Shedding (Your less contagious and for less days)

11 Seasonal Influenza Vaccine Supply 2002-2003 Season Oversupply with 95 Million Doses Produced 2003-2004 Season Shortage with 87 Million Doses Produced 2004-2005 61 Million Doses (Chiron Shortage) 2005-2006 70 Million Doses est. (Chiron Retooled) 2006-2007 120 Million Doses

12 I ’ m <65 + Healthy What ’ s in it for me? 34-44% Reduction in Physician Visits 32-45% Reduction in Lost Workdays (Includes your weekends!!!) 25% Reduction in Antibiotic Use (Co-Infections) Less chance of getting mislabeled as a SARS case or Avian Flu case.

13 You Can Correctly Have Second Thoughts About Flu Immunization By Any Route If: Egg Allergy Thimerosol Allergy (Local Reaction) CDC contends only those with life threatening reactions should avoid the flu vaccine Prior Episode of GBS -Peak Age 20-50 -1 Additional Case Per Million

14 Flu Shot Safety In Pregnancy and Breastfeeding Case Series of 2000 Pregnant Women Immunized-No Birth Defects No Issues With Any Trimester Breast Feeding Does Not Interfere With Immunity No Adverse Effects For Child All this based on non-live vaccine!!!

15 LAIV=FluMist Live Attenuated Influenza Vaccine Replicates in Nose - Very Poorly in Lower Airways Hen Embryo Derived Trivalent (Three Viruses Targeted) Shedding For About 2 Days Probability Of Transmission 0.58-2.4% Suitable For Age 5-49

16 LAIV Helps Children 87% effective against culture confirmed influenza in children 5-7 years 27% reduction in febrile Otitis Media (OM) 28% Reduction in OM with concomitant Antibiotic Use Decreased Fever and OM in those that did develop Flu

17 LAIV Helps Adults Adults 18-49 20% less Febrile Episodes 24% Less Febrile Upper Respiratory Illness Episodes 27%Fewer Lost Work Days due to Febrile Upper Respiratory Illness 18-37% Fewer Days Of HealthCare Provider Visits Due To Febrile Illness 41-45% Fewer Days Of Antibiotic Use

18 LAIV Not For Everybody Specific Age Range Non-Pregnant Not For ASA Users (5-17 y.o.) Immune Disorders All The Other Issues in “ Second Thoughts ” slide

19 Vaccine Roll Out AugustSeptemberOctoberNovemberDecember+ Vaccine release from manufacturer. Vaccine release from manufacturer. High risk individuals that desire vaccine should get it to avoid missed opportunity Prime season for vaccination. Health Care Workers and High Risk Individuals General Population General Population. Still Beneficial. Flu struck Alaska as late as August one recent season.

20 Avian Flu Contingencies Travel -Surveillance -Recalls -Travel Bans Anticipate Public Health Measures -Mass Transit -Schools -Roadways Employee Health -Emphasis on not increasing risk Prevention -Begins with Annual Vaccination -Scaled response with risk

21 Human Avian Flu Toll

22 H5N1: Most Aggressive of Many

23 Animal and Human Cases

24 Migratory Bird Flyways


26 Avian Flu An Influenza Type A virus Normally infects Domesticated Poultry, Shore Birds and Water Fowl, rarely humans and not usually spread human to human Different than the Circulating Human Influenza Possibly infects those with extensive contact with birds Since its not a viral type typically encountered by humans the potential for spread is greater (less immunity in humans)

27 Avian Flu Birds that are infected with avian influenza viruses can shed virus in saliva, nasal secretions, and feces. Contact with feces or respiratory secretions is important in the transmission of infection among poultry. Between flocks, infection usually spreads due to movement of infected birds and the actions of humans in moving feedstuff, personnel, equipment, and vehicles into and from premises that are contaminated with infected feces or respiratory secretions. The duration that these viruses can survive in the environment depends on temperature and humidity conditions, but they may survive up to weeks in cooler and moister conditions (droppings.) 48 hr infectivity on smooth surfaces.

28 Flu Pandemics: The Toll 1918-19 Spanish Flu 500K Dead in US 20-50M Worldwide 1957-58 Asian Flu 70K deaths US 1968-69 Hong Kong Flu 34K deaths US

29 Pandemics

30 Play Defense The Avian Flu Virus physically resembles the “ common ” Human Flu virus. –There are ways to block the virus’ attack –There are ways to avoid picking up the virus –A certain amount of Virus needs to get into you to cause illness

31 Hand Washing Agent Time Technique Frequency

32 What happens if you do not wash your hands frequently? You pick up germs from objects and surfaces and then you infect yourself when you: -Touch your eyes -Or your nose -Or your mouth

33 When should you wash your hands? You should wash your hands often. Probably more often than you do now because you can't see germs with the naked eye or smell them, so you do not really know where they are hiding. It is especially important to wash your hands –Before, during, and after you prepare food –Before and after you eat, and use the bathroom –After handling animals or animal waste –When your hands are dirty, and –More frequently when someone in your home is sick.

34 What is the correct way to wash your hands? First wet your hands and apply liquid or clean bar soap. Place the bar soap on a rack and allow it to drain. Next rub your hands vigorously together and scrub all surfaces. Continue for 10 - 15 seconds or about the length of a little tune. It is the soap combined with the scrubbing action that helps dislodge and remove germs. Rinse well and dry your hands.

35 Remember It is estimated that one out of three people do not wash their hands after using the restroom. So these tips are also important when you are out in public


37 Alcohol Based “ Waterless ” Hand Cleaner Useful if your hands are not visibly soiled Apply liberally and spread it as thoroughly and as long as possible. –Don’t wipe it off –Allow it to air dry Convenient, but can cause hand drying if overused.

38 Alcohol in Moderation? A CDC Study Points Out That The Most Effective Concentration of Alcohol in a “ Dry ” Hand Sanitizer is 62% or More. Reynolds SA, Levy F, Walker ES. Hand sanitizer alert [letter]. Emerg Infect Dis. 2006 Mar. Available from 0955.htm

39 Creativity in Shared Surface Handling When it comes to entering the restroom: Make like a surgeon turn your back to the door and press in backwards When using the faucet Turn on with a clean towel Turn off with a clean towel When leaving the restroom Use a towel to open the door (there will be a receptacle outside the restroom) Use an elbow to press the elevator call button

40 Gloves Nitrile gloves present a good barrier but you don ’ t want what ’ s outside to get on you. Taking off (doffing) PPE 1)Gloves Outside of gloves is contaminated! Grasp outside of glove at the wrist with opposite gloved hand; peel off Hold removed glove in gloved hand Slide fingers of ungloved hand under remaining glove at wrist Peel glove off over first glove Discard gloves in waste container

41 Masks The Flu virus is suspended on some very small droplets. –Generated by talking, laughing, sneezing or coughing. A surgeon ’ s mask helps keep out the larger droplets A N-95 mask will keep out the smaller particles Really no need for masks if 3 ft separation maintained

42 Goggles Eye protection advised with close contact as in healthcare setting.

43 Surface Cleaning As with hand washing time is an important factor. Match the cleaner with the surface. –Alcohol or baby wipes on vertical and odd shaped surfaces (phones, push plates, computer keys/mouse etc.) –Allow cleaner (Windex or Spectrasol) to pool on desk tops or tables –Increased contact time helps!

44 Cough/Sneeze Etiquette Stop droplet spread at the source! –Cover your mouth and nose during a sneeze –Contain droplets in a tissue –Discard the tissue promptly –Wash your hands after the sneeze, cough or “allergic salute.”

45 The Medications Antivirals: TamiFlu and Relenza –Prevent Virus from exiting cells Vaccine –Trains your body to recognize and fight that one variety of flu (or one that looks similar). –Need a best approximation of the current model of virus.

46 Tamiflu Oral capsule >age 1 y Once a day for prevention Twice a day for treatment Reduce dose in kidney failure Level at same dose higher if taking Benemid (a drug for Gout) Adjusted dose for renal failure

47 Relenza Inhaled Not for asthmatics other chronic lung disease No track record for elderly and chronically ill and those with hepatic failure. Advice against use by those with renal failure > age 5 y Two puffs twice a day dosing for treatment Two puffs once a day for prevention Some lower airway spasm - deaths

48 Personal Preparation Keep a supply of prescription meds current Think Blizzard! -Food -Water -Batteries Anticipate -Child Care Issues -Transportation/Commute Changes Cleaning Supplies -Alcohol Wipes -Dry Hand Cleaner (Purell) -Surface Wipes/Cleaner (Chlorox,Spectrasol)

49 Thank You!

50 Other Things You May Want To Know Due to limited time I provide the following in note form ….

51 FAQ on Flu Vaccine I ’ m Sick Now Should I Get The Shot? –Efficacy Not Affected By Illness –If you Do Have A Fever Or Other Problems It May Be Hard To Sort Out If The Shot Or The Illness Caused The Problem I Had The Shot In The Early 80s It Made Me Feel Bad For 2-3 Days –Filtration Techniques Have Improved Over Time. In The Early 80s There Were A Significant Amount Of Impurities That Made It Through Which Could Explain Feeling Out Of Sorts For a Few Days. –Further Advances Post 1993 Have Greatly Reduced The Amount Of Reactions Seen.

52 FAQ Continued Last Year I Managed To Get The Flu Even Though I Had The Flu Shot –I Would Argue That Your Course Was Shortened And Of Less Severity Because Of The Vaccine –The Vaccine Makers Are Really In The Business Of Saving Lives What About That Avian Flu-Will The Vaccine Help? –The Avian Strains Of Flu Are Often Different Than The Ones The Vaccine Is Aimed Against –CDC Advises Those At Risk For Avian Flu To Get The Vaccine Anyhow As It Could Make It Clearer What Illness Is At Work

53 The 2006-07 Models Type A –Wisconsin 67/2005 (H3N2-Like) –New Caledonia 20/99 (H1N1-Like) Alternate –Substitute for Wisconsin: Hiroshima/52/2005 (H3N2-Like) Type B – Malaysia/2506/2004 Alternate – Substitute for Malaysia Ohio/1/2005

54 Master of Disguise The characteristic "spikes" of the influenza virus are haemagglutinin. They radiate all over the surface and are interspersed (in some types) by clusters of neuraminidase. These (HA and NA) molecules are thought to pass through the envelope and interact with the underlying matrix protein, M1. The HA and NA are the targets for each year’s Flu Vaccine. These sites are under constant change.

55 Reyes Syndrome Cause Unknown. Link To Viral Illness + Aspirin Children Under 16 Severe increase of pressure in the brain Abnormal accumulations of fat in the liver Typically Intractable Nausea and Vomiting Lethargy, Drowsiness's, Irritability, Disorientation. Seizures Coma Respiratory Arrest 60% Fatality Rate If Not Caught Early.

56 Gullain Barre Syndrome Literary Reference: The Character Faria in The Count Of Monte Cristo -Alexander Dumas Ascending Paralysis Affects Mylein Sheath (Insulator) around Nerves 1-4/100,000 In US Annually Onset Typically days to weeks after a viral illness Full recovery in 50-90% of people Many cases coincident with 1976-77 Flu Vaccine Campaign

57 Risk Strata “ Front of the Line ” Existing Conditions (Increased Risk) Caregivers Health Care Workers Good Idea General Population “ Back of the Line ”

58 Increased Risk > Age 65 Chronic-Care Facilities Resident Chronic Disorders Pulmonary Or CV Regular Medical Follow-up/Hospitalizations Required Age 6mo-18y On ASA (Reyes) Pregnant During Flu Season Children 6-23 mo.

59 Age>65 30% Effective in Preventing Flu Illness 30-70% Effective in Preventing Hospitalization 80% Effective in Preventing Death

60 Potential Carriers Medical System Nursing Home Employees Assisted Living Care Givers To Those At Risk Household Contacts Of High Risk Groups

61 A Good Idea Age 50-65 –Assumption that there is a greater likelihood of underlying conditions

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