Twin Cities Metro Advanced Practice CenterMay 2007

Solid Waste Issues Related to Avian Influenza H5N1

Outline

• Overview of Environmental Health

• Overview of Advanced Practice Center work

• Environmental Health Preparedness

• Waste and Disease

• Influenza and Solid Waste Issues

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

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

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.

Environmental Health: Actions to Protect Public Health Every Day and During Emergencies

• 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

APC Purpose:

To create models for implementing information technology and training in support of bioterrorism

preparedness and emergency response.

This work is a product of the Twin Cities MetroAdvanced Practice Center for Public Health Preparedness

Twin Cities Metro APC

• 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• Training Tools

• Emergency Handbook for Food Managers

• EH Preparedness Plans

• Resource Tool Kit for EH Preparedness

• Emergency contact system

• Electronic data systems

•

Thanks For Some Materials Goes To:

Buddy Ferguson

Risk Communication Specialist

Minnesota Department of Health

Seasonal Influenza

• Caused by a virus

• Easily transmitted by– talking, coughing, sneezing– touching infected person or contaminated

surface – then touching eyes, nose, mouth

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”

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)

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)

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)

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

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

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

What We Have Now

“High path” (highly pathogenic) H5N1 avian influenza

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

Are We Going to Have a Pandemic?

Some kind of pandemic

Not if…..but when

1918 (or worse) pandemic

Not when…..but if

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

How Bad Could It Be?

• 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

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

Protecting Public Health

• Surveillance: look for disease/condition

• Identify the source• Act to disrupt

transmission of disease/condition

This works for biological, chemical, and physical causes of illness and injury

Model of Disease Transmission

Chain of Disease Transmission

Reservoir

Exit Route

Mode of Transmission

Entry Route

ReceptiveHost

“R.E.T.E.R.”

Quiz Time: Foodborne Illness

• 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 – Chemical

• 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

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?

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

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

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.

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

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

Isn’t this just a rural, agriculture-related problem?

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

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.

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

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 2006Technical Section D: Infection Control

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

Non-Profit Sector

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

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

Collaborators

• 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

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

Seasonal Influenza in Humans

• 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

H5N1 Infection in Humans Associated with Birds• Agent• Reservoir• Mode of Exit• Mode of Transmission

• Mode of Entry

• Host

H5N1 Flu virusWild and domestic birdsBird feces, blood and respiratory secretionsAerosols or virus particles on surfaces Inhalation or hand-to-mouth, eyes or nose; relative importance of each is unknownHumans

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

Waste Management

• Storage

• Collection

• Transport and Transfer

• Disposal

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

Implications for Waste Management

Conclusion

• Based on current science and epidemiology, wastes that have come in contact with H5N1 in either birds or humans do not pose a risk to the waste handler or public.

• Recommend the use of personal protective equipment that may already be part of normal daily operations.

Basic Prevention…Break the Chain of Transmission