Pandemic Flu Presentation

Course Goal

Is to provide Worthington’s business leaders with education on the subject of pandemic influenza and its effect on our community, enabling him or her to effectively plan and prepare for an outbreak of pandemic influenza

Pandemic Influenza Planning and PreparednessPandemic Influenza—The Threat

Presented by:

Chris Craig FF/NREMT-P

City of Worthington Division of Fire

Objectives

Describe the historical aspects associated with the last great pandemic—Spanish Flu

Identify the factors associated with the cause of pandemics

Identify the distinctions among various pandemics

Identify the current peril associated with pandemic influenza

Understanding Pandemics

Pandemic Disease—Old Nemesis Rather than New Threat Pandemic disease is not a new threat

National Strategy for Pandemic Influenza (NSPI)—November 2005

Department of Health and Human Services (HHS) Pandemic Influenza Plan—November 2005

NSPI Implementation Plan released by the Homeland Security Council—May 2006

NSPIwww.ntis.gov

Endemic, Epidemic, and Pandemic DefinedEndemic—A disease that occurs at a high rate in a given population

Epidemic—An outbreak of new cases of a disease in numbers that exceed what is expected

Pandemic—An epidemic that spreads worldwide

Malarious Areawww.cbsnews.com

Pandemics Throughout History

Plague of Justinian—541 A.D.

The Black Death—1347-1350

Typhus or camp fever—15th and16th centuries

Smallpox—16th to 18th centuries

The Roof Ratwww.algonet.se

Influenza and Its Cause

Influenza and Its Cause

The flu is a viral respiratory disease that occurs throughout the world every winter

Responsible for 35,000 deaths each year in the United States

Most fatalities from seasonal flu are children and the elderly and those with debilitating medical conditions

Assisted Livingwww.contact-the-elderly.org

Influenza and Its Cause (continued)

Influenza pandemics—frequency

• Occur about every 30 years, or about three times each century

• New strain of flu not recognized by the immune systems of the population

• Rapidly spread worldwide

www.globalchicago.org

Influenza and Its Cause (continued)

Influenza pandemics—statistics

• May have higher mortality rates and higher rates of infection

• One in three pandemics may be particularly lethal

• Pandemics often occur in two or three distinct waves

• Second wave—usually the most deadly

• Third wave—the least deadly

Infant in Incubatorwww.sedares.com

Influenza and Its Cause (continued)Flu pandemics of the 20th Century

1918—Spanish Flu

• The Great Pandemic

• Killed 675,000 Americans and up to 100 million people world wide

1957—Asian Flu

• Killed 70,000 in the United States

1968—Hong Kong Flu

• Killed 35,000 in the United States

Cautious Ballerinas—SARSwww.cache.boston.com/bonzai-fba

The Spanish Flu Pandemic of 1918

The Spanish Flu Pandemic of 1918

Killed more people than any other disease in history

Caused more deaths than WWI, WWII, the Korean War, and the Vietnam War combined

Unusually high attack rates among young and otherwise healthy adults (soldiers)

Doughboys - 1918Info.detnews.com

The Spanish Flu Pandemic of 1918 (continued)Arose in February 1918 and spread rapidly throughout the spring

First wave disappeared in the early summer

Second wave appeared in August 1918

Masked Citizens - 1918Info.detnews.com

The Spanish Flu Pandemic of 1918 (continued)The first wave

• Unusually high mortality rate was not clearly recognized

• Influenza was not a reportable disease early in 1918

• Communication was not optimal to enable tracking of the disease

• Wartime conditions made

information sharing difficult

Tent Hospitals—1918Info.detnews.com

The Second Wave

Mutation:

• Flu viruses mutate very readily and frequently

• New variation of the virus may not be recognized by a population’s immunity

• New variation may be more deadly or less deadly than the previous variation

• New variation may be more or less contagious

Influenza Virus Particleswww.virology.net

The Second Wave (continued)

Reappeared in late August 1918

Appeared almost simultaneously in multiple cities around the globe

Had mutated to an exceptionally lethal variation

Military Loss—1918Info.detnews.com

America’s Forgotten Pandemic, page 65











Over 90% of the deaths occurred during the second wave

Had significant effect on the war effort in combatant countries

Not a single United States troop transport ship was sunk during the entire war, but thousands died from the flu en route to Europe

Loading Ambulance—1918Info.detnews.com


Second wave would strike 30% to 50% of the world population:

• 10% of those developed a massive pneumonia

• 60% of those died

Death sometimes occurred in 24 hours or less

Funeral—1918Info.detnews.com

Impact on Life in America

Impact on Life in America

www.pbs.org

Death Rates in the U.S. by Month (per 1,000 population)

0

10

20

30

40

50

60

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

Dea

th R

ate

(per

1,0

00 p

op

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1911 - 1917 1918

Impact on Life in America (continued)

www.andypryke.com

Impact on Life in America (continued)Deaths from pneumonia and influenza in U.S. in 1892 and 1918 pandemics (Massachusetts numbers)

Seattle Daily Times Archivesseattletimes.nwsource.com


Camp Funston, Kansas Emergency HospitalCourtesy of National Museum of Health and Medicine

Iowa State Gymnasium Tent Hospital


Wartime Poster 1918Courtesy of National Museum of Health and Medicine

Factors Causing Pandemics

Factors Causing Pandemics

Zoonotic diseases—Caused by an infectious agent that can be transmitted between, or shared by, animals and humans

Avian influenza is a zoonotic disease

Zoonotic organism may mutate to allow direct human-to-human transmission

Zoonotic Cyclewww.njcphp.org

Factors Causing Pandemics (continued)Human immune system may not be prepared to fight off a new zoonotic organism

Viruses rapidly and frequently mutate to new forms that may not be recognized by the human immune system

Bird Flu Collagewww.cnn.com

Factors Causing Pandemics (continued)Rate of transmission

Severity of the illness—Some diseases kill so rapidly that there is minimal opportunity for the spread of the disease (Ebola)

Overall health of a population

Ease of travel Birds to Live Marketwww.swissinfo.org

Factors Causing Pandemics—Conditions Favoring a Pandemic

A new Influenza A virus arising from a major genetic change (i.e., an antigenic shift)

A susceptible population with little or no immunity

A virus that is transmitted efficiently from person to person

A virulent virus with the capacity to cause serious illness and death

Lesser Pandemics of the Twentieth Century

Lesser Pandemics of the Twentieth Century

Asian Flu—1957—H2N2 Hong Kong Flu—1968—H3N2

Gargling Broth - 1957nmhm.washingtondc.museum

Vaccine Production - 1968www.npr.org

Swine Flu—1976

Initial cases suggested possible re-emergence of the 1918 virus

Nationwide immunization program initiated

1976 Swine Flu Vaccine Programhttp://assets.families.com

Swine Flu—1976 (continued)

40 million Americans were vaccinated before the program was discontinued because of deaths and illness attributed to the vaccine

No other reported deaths from the Swine Flu itself

President Ford—1976www.semp.us

Spanish Flu Differences

1957 (Asian Flu H2N2) and

1968 (Hong Kong Flu H3N2) attacked mostly the very young, the old, and the debilitated

1918 (Spanish Flu) attacked all age groups but killed a disproportionately large percentage of young adults

Doughboys—1918Info.detnews.com

Spanish Flu Differences (continued)

Asian and Hong Kong Flu viruses arose through reassortment (mixing) of the genetic material between avian and human viruses

Spanish Flu virus seems to have been a pure avian virus that developed the unique capability to infect humans and to spread easily by human-to-human contact

Reassortmentwww.bird-flu-masks.co.uk

Spanish Flu Differences—Causes of DeathIn a typical flu season, and during the lesser pandemics, most deaths are due to secondary bacterial pneumonias

In the 1918 pandemic, many deaths were due to an exceptionally lethal primary viral pneumonia

Pneumoniawww.mevis.de

The Current Situation

Antibiotic development

Critical care advances

Surveillance

Detection

Diagnosis

Advanced Critical Caremed.stanford.edu

The Current Peril—Status of Infectious Diseases in the Late 20th Century

The Current Peril—Trends in Emerging DiseasesLegionnaires' Disease—1976

HIV/AIDS—1978

Antibiotic-resistant TB

Nipah Virus—1997

SARS—2003 www.peterkuper.com

Influenza Mortality

Treatment of the rapidly progressive severe viral pneumonia is still suboptimal

Mortality rates from influenza seem to be rising

The treatment capabilities for influenza is not all that different from 1918

Bacterial Pneumoniawww.microscopy.com

http://www.microscopyu.com/galleries/pathology/viralpneumonia.html

Influenza Mortality (continued)

Growing numbers of cancer survivors on drugs with immunosuppressant properties

40 million persons living with HIV/AIDS

Millions on various steroids that suppress the immune system Cancer Survivors

www.greenville.k12.sc.us

Flu Morbidity and Mortality

An average year—36,000 deaths in US

Mostly affects people over 65 years old

Epidemics occur in winter months

Peaks in hospitalization and death related to influenza occur week five to week 10 Seasonal Nature of Flu

www.patienteducationcenter.org

World Population Growth

World Population Growth

1918 world population 1.8 billion—104 million in the United States

2006 world population exceeds 6 billion—290 million in United States

World Population Growthwww.uwsp.edu

World Population Growth (continued)Reported deaths from the 1918 flu range from 20 million to 100 million worldwide—675,000 known deaths in the United States

A pandemic of similar lethality, based on population growth alone, could yield fatalities ranging from 67 million to 333 million—1.6 million in the United States

Avian influenza (H5N1) case fatality rate has been 53% consistently

agora.ex.nii.ac.jp

http://agora.ex.nii.ac.jp/digital-typhoon/latest/globe/2048x2048/ir.jpg

World Population Growth—Travel PatternsTravel was relatively primitive in 1918

Rapid worldwide travel, particularly by air, may allow more rapid spread of a pandemic

Travel in 1918info.detnews.com

Travel Todaywww.century-of-flight.freeola.com

Possibility Versus Probability

World Health Organization (WHO) assures us that there will be another pandemic

Unknown when it will occur

Unknown what the organism will be

Unknown how severe the next pandemic will be

Difficulty preparing for these unknowns

Comparison to bioterrorism threat and planning

WHO Logowww.who.int.org

Medical Response Capability

United States hospital capacities decreasing

United States Intensive Care Unit (ICU) beds decreasing

Insufficient numbers of mechanical ventilators

Staffing shortages

Minimal surge capacity

Public reliance on EMS( 911) and Emergency rooms for Primary Medical Care

Hospital Wardwww.i-freed.org

Key Points About Pandemics

Pandemic Influenza is a significant threat

Nature and extent of next pandemic is unpredictable

History of previous pandemics, particularly the 1918 Spanish Flu, can provide useful information for today’s planners

Many factors affect the nature and extent of a pandemic

Each pandemic somewhat distinct

Influenza Viruswww.bird-flu-masks.com

Influenza

Influenza

What is influenza?

What causes it?

What are Types A, B, and C?

How much does it affect us normally?

Bird flu is not pandemic influenza


Influenza (continued)

Essential Terminology

• Common (seasonal) flu

• Avian (bird) flu

• Pandemic flu

Virionswww.ncbi.nih.gov

Types of Influenza Virus

Orthomyxoviruses

Three main types

• Type A—Multiple species

• Type B—Humans

• Type C—Humans and swine


Types of Influenza Virus—Influenza Virus AMultihost pathogen

• Humans

• Avian Influenza

Most virulent group

Classification by surface antigensinto subtypes

• Hemagglutinin (H or HA)

• Neuraminidase (N or NA)

Cross Section of Influenza Viruswww.cs.indiana.edu

Types of Influenza Virus—Influenza Virus BMostly humans

Common

Less severe than A

Epidemics occur less often than A

Human seasonal vaccine

• Two strains of type A

• One strain of type B

Influenza B Viruswww.city.sapporo.jp

H5N1What do the numbers and letters mean ?

Influenza Virus A

Surface antigens and subtypes

• 15 HA and nine NA

– All in aquatic birds

• Hemagglutinin (HA)

– Sites for attachment to infect host cells

• Neuraminidase (NA)

– Remove neuraminic acid from mucin and release from cell

Influenza A Viruswww.virology.net

Genetic Variability

Mixing ScenarioSource: CDC Influenza Branch

How is it spread?

The Flu Virus as a Contagion

One of the most infectious pathogens

Transmission: Droplets, aerosol, and contact

Survive off the host for 48 hours!

Peak transmission in United States

Many strains circulating

Sneeze Profilewww.people.virginia.edu

The Flu Virus as a Contagion (continued)

IncubationIncubation Symptomatic (Sick)Symptomatic (Sick) RecoveringRecovering

Work, etc. Work/Home/Hospital Back to work, etcDay 0 Day 11Day 4 Day 15

DANGER OF INFECTION

Day 2

Infectious (Shedding Virus)Infectious (Shedding Virus)

Flu Morbidity and Mortality (continued)Annual Peak of Influenza Cases

Avian Influenza

Avian Influenza

Sometimes referred to as bird flu

Caused by Type A influenza virus

LPAI and HPAI

HPAI can be devastating to poultry industry

Containment is difficult

Containing HPAI in Japanwww.biwa.ne.jp

Avian Influenza—Animal TransmissionInitial source of infection

• Other poultry, migratory waterfowl, pet birds

Spread by aerosol, shared drinking water, fomites

Virus in respiratory secretions and feces

Virus present in eggs but eggs unlikely to survive and hatch

Migratory Birdswww.csiro.org

Pandemic Influenza and H5N1Previously considered nonpathogenic for humans

1997—Hong Kong

• 18 humans infected, six died

• H5N1 virus linked to outbreak in live bird market and area farms

•2003—The Netherlands

• 83 confirmed cases in humans, one death H7N7 strain H5N1 Strain of Type A

www.bact.wisc.edu

Pandemic Influenza and H5N1—Human Transmission2004-2005—Southeast Asia

79 cases, 49 deaths

• Vietnam, Thailand, Cambodia

H5N1 strain

Within the vicinity of poultry outbreaks

No sustained human-to-human transmission

Bird Flu”in Asiawww.cbsnews.com

Avian Flu Human-to-Human TransmissionBird Flu—Current Situation

Death Rate over 50%

Spreading globally

Not in North America

Role of migratory birds—evident

Sustained human-to-human transmission not yet a factor

Cases H5N1www.who.org

BREAKOUT SESSION

• Business Impacts

• Seasonal Influenza/Prevention

Workforce AbsenteeismHow will my business:

• Maintain essential operations and services if 40 percent or more of all workers are out sick or choose to stay home to avoid exposure?

• Maintain essential operations when well workers choose or are forced to stay home?

• Maintain essential operations when community outbreaks last 6-8 weeks, with multiple waves strike in a calendar year?

• Bolster the depth of reserves for essential workers at all levels?

• Ensure family and child care support for essential workers?

• Provide delegations of authority and orders of succession for workers?

Geographic Dispersion and Rapid Spread

How will my business:

• Maintain essential operations and services when necessary resources are not available?

• Ensure sufficient essential resources are available at each work site?

• Ensure that their planning takes into account the people and businesses that depend them for supplies and services?

• Afford to cross-train nonessential personnel for essential functions?

• Afford to stockpile adequate levels of essential reserve materials?

Time Duration and “Waves”


• Ensure essential functions over a six to eight week pandemic wave?

• Ensure recovery from a first wave, while preparing for possible subsequent waves over the course of a calendar year?

• Define breaking points when a portion or all basic and essential functions begin to fail?

Mobility and Travel


• Ensure continuity despite significant delays in, and restrictions on moving personnel and materials?

• Withstand a lengthy quarantine for all traveling personnel?

• Ensure continuity of overseas operations if U.S. personnel abroad return to protect their families and/or seek better healthcare?

Supply Chain and Delivery Networks


• Ensure continuity when worker absenteeism and movement restrictions delay or stop their supply and delivery chains?

• Ensure adequate visibility of their entire essential supply and delivery chain in order to uncover potential impacts on second and third order manufacturers and supplies?

• Define the breaking points when movement restrictions affect a portion or all of the functions of a business?

• Ensure all essential business partners in the supply chain are equally well prepared for a pandemic?

Health Care Delivery and Public Health


• Ensure the healthcare and public health support for workers and their families?

• Know when their workers and their families have contracted a the virus?

• Know how to protect their employees and families when seemingly healthy individuals are spreading the disease?

• Protect workers from others who, while infected, do not feel ill or exhibit any symptoms?

National Economic Disruption


• Ensure economic viability at each phase of the pandemic?

• Prepare and respond when other businesses around us are failing?

Security Risks and Social Stability


• Ensure the security of its workers and families from home to work?

• Ensure the security of their workplace operations and supplies?

• Ensure security up and down our supply and delivery chains?

What can be done now for prevention?

Seasonal Influenza Prevention Measures

• Get yourself and you workers vaccinated against seasonal flu!

• Wash hands frequently with soap and water!

• Cover you mouth and nose when you cough or sneeze!

• Put used tissues in a waste basket

• Clean your hands after coughing or sneezing.

• Use soap and water or alcohol based hand cleaner.

• Stay home if you are sick

Summery

Seasonal flu kills 36,000 people every year!

Lost work time due to seasonal flu leads to millions in lost revenue.

A sick workforce is less productive than a well one.

Remember the flu is a virus, whether it is pandemic or seasonal the same prevention strategies work to limit the spread.

If we can reduce the spread of seasonal flu, we can limit the impact of a pandemic.

If we work together we can “flatten the curve”, reduce the spread/ severity of the flu, and possibly avoid an economic disaster.

Education

Pandemic Flu Presentation