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

DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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Page 1: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

DR. JULIE LOUISE GERBERDINGDIRECTOR

CENTERS FOR DISEASE CONTROL AND PREVENTION

CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREATPRESENTATION TO IOM, APRIL 2005

Page 2: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Influenza Pandemics Happen!

H1

H1

H3H2

1918SpanishFlu H1N1

1957Asian

Flu H2N2

1968Hong KongFlu H3N2

1915 1925 1935 1945 1955 1965 1975 1985 1995 2005

Page 3: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

HumanHuman virusvirus

NewNewReassortedReassorted

virusvirus

Avian Avian virusvirus

Avian host

Swine

Mechanisms of Antigenic ShiftDirect Avian – Human Infection

Page 4: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

0

200

400

600

800

1000

1900 1920 1940 1960 1980

Year

Mo

rta

lity

Ra

te p

er

100

,000

Source: Armstrong et al., JAMA;1999

Infectious Disease Mortality in the United States 1900 - 1996

Page 5: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Page 6: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Page 7: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Avian Influenza is Emerging

H1

H1

H3H2

H7H5

H9

1918SpanishFlu H1N1

1957Asian

Flu H2N2

1968Hong KongFlu H3N2

1980 1996 2003

1997 2003 2004

1998 1999 Avian Flu

1915 1925 1935 1945 1955 1965 1975 1985 1995 2005

Page 8: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Outbreaks of Highly Pathogenic Avian Viruses Before 2004

Avian subtype Country Year

H5N3 U.S. 1983

H7N7 Australia 1985

H5N2 Mexico 1995/95

H7N3 Pakistan 1995

H5N1 Hong Kong 1997

H5N2 Italy 1997

H7N1 Italy 1999

H5N1 Hong Kong 2001-2003

H7N7 Netherlands 2003

Page 9: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Situation Report: Confirmed Human H5N1 CasesUpdated April 3, 2005

Country H5N1 cases

Deaths Case fatality

Thailand 17 12 71%

Vietnam 55 35 64%

Cambodia 2 2 100%

Total 74 49 66%

Page 10: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Page 11: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Page 12: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Avian Influenza Poultry Outbreaks, Asia, 2003-04

Page 13: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Situation Report: Avian Influenza 2005

Page 14: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Situation Report: Avian Influenza 2005H5N1 seasonal pattern for avian flu in Asia

– Expect increased activity in winter monthsOngoing human cases

– Most in young and healthy– Extremely high apparent case-fatality – No sustained person-to-person transmission

Page 15: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Situation Report: Avian Influenza 2005

Page 16: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Countries containing at least 1 WHO influenza laboratoryWHO Collaborating Centers - Atlanta, London, Melbourne, and Tokyo

WHO Collaborating Centers for Influenza

Page 17: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Page 18: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Page 19: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Enhancing Influenza Surveillance: HHS/CDC

Pakistan

Malaysia

ThailandIndia

China

Mongolia

South Korea

Philippines

Indonesia

Page 20: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Global Biosurveillance: International Health Protection Network

Global Health ProtectionNetwork

Bio Sense &Biointelligence

Center

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

DATA

EXCHANGE

Page 21: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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

Page 22: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

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?

Page 23: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Commitment

CollaborationCoordination

Compassion

Communication Competency

Candor Clinical Laboratories

Consistency

Community Common Sense

Page 24: DR. JULIE LOUISE GERBERDING DIRECTOR CENTERS FOR DISEASE CONTROL AND PREVENTION CURRENT STATUS OF AVIAN INFLUENZA AND PANDEMIC THREAT PRESENTATION TO IOM,

Complacency is the enemy of preparedness!

www.cdc.gov