Avian and Pandemic

Influenza

Where are we now?

(May 2008)

Eden V. Wells, MD, MPH

Michigan Department of
Community Health
 Outline

 Avian Update

 Pan Flu Planning Update

 State Operational Response Planning

 Avian Influenza
The “Bird Flu”

Images from: http://www.usda.gov/oc/photo

 Species Affected

Genetic Reservoirs H3, H7

H1, H2, H3
H5N1 Intermixing
H3

Commercial,
LBMs H1-12 H1-2, 4-7, H10
Others H14-15 H9-13, 15-16
Other Aquatic
Birds? H1, H3, H4, H7,
H13
H1, H3
 Avian Influenza A (H5N1)
 Discovered in Hong Kong, 1997
 Now multiple epizootics worldwide
 Still has not entered the Western
Hemisphere
 Still has not met WHO Pandemic criteria
– New strain
– Causes severe illness in humans
– Sustained transmission from person to person
Countries with H5N1 in Poultry
(OIE)

January 1, 2008- May 14, 2008

Pandemicflu.gov
 Areas with high overlapping
concentrations of Humans and Poultry
(UN World Food Program, 5/24/06)
 Humans at Risk
 Transmission from birds to humans does not occur
easily
– Contact with feces or secretions from infected birds
– Risk with butchering, preparing, defeathering of infected birds
– NOT transmitted through cooked food
 All age groups affected
– Higher rate < 40 years
– M:F=-0.9
 Case fatality remains ~ 63%
 Median duration of illness
– hospitalization 4 days
– death 9 days
 Clinical features
– Asymptomatic infection not common
 Clinical features specific to
H5N1 (WHO, 2/06)
 Unusually aggressive course
– Rapid progression (avg. of 5 days) with a high fatality rate

 Early symptoms
– High fever (usually > 38º C)
– Influenza-like symptoms
– Diarrhea (often watery) and/or vomiting
– Abdominal or chest pain
– Hemorrhage from the gums
– May have no respiratory symptoms or develop acute encephalitis
 3-13 days: Severe lower respiratory disease
– Dyspnea
– Inspiratory crackles; hoarse voice
– Variable sputum/respiratory secretions (sometimes hemorrhagic)
 Always see a 1º viral pneumonia that is unresponsive to antibiotics
 Commonly see multiorgan dysfunction
 Implications for Human Health
 Asian Strain H5N1 in humans more aggressive than
seasonal flu strains
– Severe clinical course
– Rapid deterioration
– High fatality
– Low transmissibility human-to-human
 Incubation may be longer than seasonal influenza
– Seasonal influenza: 2-3 days
– H5N1: possibly up to 10 days
 More studies needed
 When to test for H5N1
(CDC Recommendations, 6/7/06)

The patient must meet all of the following criteria:

 Has an illness that requires hospitalization or is fatal
AND
 has or had a documented temperature of ≥38°C (≥100.4° F)
AND
 has radiographically confirmed pneumonia, acute respiratory
distress syndrome (ARDS), or other severe respiratory illness
for which an alternate diagnosis has not been established
AND
 has at least one potential exposure within 10 days of
symptom onset (next slide)
When to test for H5N1 – Potential Exposures
(CDC Recommendations, 6/7/06)

1. History of travel to a country with influenza H5N1 documented in poultry,

wild birds, and/or humans, AND
had at least one of the following potential exposures during travel:
• direct contact with (e.g., touching) sick or dead domestic poultry.
• direct contact with surfaces contaminated with poultry feces.
• consumption of raw or incompletely cooked poultry or poultry products.
• direct contact with sick or dead wild birds suspected or confirmed to have
influenza H5N1.
• close contact (within 1 meter) of a person who was hospitalized or died due to a
severe unexplained respiratory illness.

2. Close contact (within 1 meter) of an ill patient who was confirmed or

suspected to have H5N1.
3. Worked with live influenza H5N1 virus in a laboratory.
 H5N1 Specimen Collection Protocols
(MDCH, 8/5/06 and CDC, 6/7/06)

•Get BOE approval for testing at (517) 335-8165.

•Preferred specimens
•Oropharyngeal (OP) swabs
•Bronchoalveolar lavage (BAL)
*A high-risk aerosol-generating procedure; use proper infection control precautions
•Tracheal aspirate
•Nasal or nasopharyngeal (NP) swabs are acceptable but less preferred
•Postmortem: Paraffin-embedded or formalin-fixed respiratory tissues

•Timing of specimen collection

•First 3 days of illness onset is ideal
•Collect serial samples over several days from several sites
•Swabs should have a Dacron tip (not calcium or cotton) and an aluminum or plastic shaft (not wooden).
•Specimens should be placed at 4°C immediately after collection.
 Human-to Human
Transmission-
Still Unsustained
Examples:  Clusters of human H5N1 cases
range from 2-8 cases
 Identified in most countries that
 Pakistan- Oct/Nov 2008 have reported H5N1 cases
– 4 cases: 2 recovered- 2  Most of the cluster cases
fatal occurred in blood-related family
members in same household
 If such clusters are related to
 Indonesia-2006 genetic or other factors currently
– 3 clusters 2005 (NEJM unknown.
Volume 355:2186-2194  Limited human-to-human
Nov 2006 Number 21) transmission of H5N1 virus
cannot be excluded in some
clusters
 Viet Nam-2005  “diagnosis of exclusion”

cdc,gov
 Antivirals for H5N1
Adamantanes:
 Resistant: Clades 1, 2 (80%)
 Sensitive: Clades 2.2, 2.3
Neuraminadases*:
 “…all viruses demonstrated
similar sensitivity to zanamivir, but
compared with the 2004 clade 1
viruses, the Cambodian 2005
viruses were 6-fold less sensitive
and the Indonesian clade 2
viruses were up to 30-fold less
sensitive to oseltamivir.

Jennifer L. McKimm-Breschkin,* Paul W. Selleck,† Tri Bhakti Usman,‡ and Michael A.

Johnson†
EID Volume 13, Number 9–September 2007
Reduced Sensitivity of Influenza A (H5N1) to Oseltamivir
Human Vaccine for Avian H5N1
 Human H5N1 vaccine approved by FDA
 US has advance-ordered 20,000,000 doses
 Current US stockpile (SNS)
– Clades 1, 2.1, 2.2, 2.3
– currently (April 29, 2008) contains enough H5N1 vaccine for 12
million to 13 million people
– assuming two 90-microgram (mcg) doses per person
– Potential adjuvants (AL-OH, oil/water,etc)

 May not match strain that causes pandemic

 Seasonal influenza vaccine does not protect
against H5N1 strain
 H5N1 viruses
Vaccines being made from Clade 1 and 2 viruses
•Clinical trials
•Stockpiles

Clade 1:
• Human- Cambodia, China, Hong Kong, Viet Nam, Thailand
• Avian-Cambodia, Viet Nam

Clade 2.1:
• Avian and human- Indonesia
Clade 2.2:
• Avian- outbreaks in over 60 countries

Antigenic and genetic characteristics of H5N1

viruses and candidate H5N1 vaccine viruses developed
for potential use as human vaccines
WHO, February 2008
Antigenic and genetic characteristics of H5N1
viruses and candidate H5N1 vaccine viruses developed
for potential use as human vaccines
WHO, February 2008
 Current U.S. Status
 No current evidence in U.S. of highly
pathogenic H5N1 in:

– Wild birds

– Domestic poultry

– Humans
 What is the H5N1 Pandemic
Risk?
 Three conditions must be met for a pandemic
to start:
– Emergence of a new influenza subtype

– The strain infects humans causing

serious illness

– Spreads easily between humans

 A pandemic will impact ALL sectors of

Michigan society
Planning for an Impending
Pandemic

The Role of Public Health

 20th Century Influenza
Pandemics
 1918 – 1919, “Spanish Flu” (H1N1)
– Influenza A H1N1 viruses still circulate today
– US mortality: approx. 500,000+
 1957-58, “Asian Flu” (H2N2)
– Identified in China (February 1957) with spread to
US by June
– US mortality: 69,800
 1968-69, “Hong Kong Flu” (H3N2)
– Influenza A H3N2 viruses still circulate today
– First detected in Hong Kong (early 1968) and
spread to US later that year
– US mortality: 33,800
WHO Phases and Federal Stages
 Stage 0: New Domestic Animal
Outbreak in At-Risk Country
 Stage 1: Suspected Human
Outbreak Overseas
 Stage 2: Confirmed Human
Outbreak Overseas
 Stage 3: Widespread Human
Outbreaks in Multiple Locations
Overseas
 Stage 4: First Human Case in
North America
 Stage 5: Spread throughout
United States
 Stage 6: Recovery and
Preparation for Subsequent
Waves
Categories of Pandemic
Strength
 Estimated Impact
of a Future Pandemic in
Michigan
Gross Attack Rate 35%

Health Outcome Moderate Severe

(1957 / 68-like) (1918-like)

Minimum Maximum Minimum Maximum

Illness 3.4 million 3.4 million 3.4 million 3.4 million

Outpatient 1.4 million 2.6 million 1.3 million 2.2 million

medical care
Hospitalization 14,000 51,000 120,000 420,000

Death 5,000 15,000 43,000 126,000

(*Michigan figures developed with Flu-Aid 2.0

software, CDC)
 Leads for Public Health
 International: World Health Organization

 United States: Centers for Disease Control

and Prevention, DHHS

 Michigan: Michigan Department of

Community Health

 County: Local Health Department/Jurisdiction

 Public Health Containment
Tools-Pandemic Flu
Legal authority to
 Vaccine Implement Public
Health Measure
 Antivirals resides equally in
– Treatment all 45 MI Local HD
Health Officers
– Prophylaxis
MI PUBLIC HEALTH CODE
 Infection Control Similar but
multi-jurisdictional
 Social Distancing
authority resides with
State Health Officer
 Public Health:Non-
Pharmaceutical Interventions

 Social distancing
 Respiratory/Cough
etiquette
 Infection Control
– Droplet /Airborne Precautions
 Isolation
 Quarantine
 Public Health Measures
 Isolation
– Ill persons with contagious diseases
– Usually in hospital, but can be in home or in a
dedicated area

 Quarantine
– Restriction of movement select exposed, not ill,
person(s)
– Home, institutional, or other forms (“work quarantine”)
– Voluntary vs. compulsory
 Public Health Measures
 Social Distancing interventions to prevent
contact:
– School closures
– Cancellation of public gatherings
– Worksite closures (computing,etc)

 Infection Control interventions to prevent

transmission:
– Masks
– Hand hygiene
 Goals of Community Measures

1 Delay onset of outbreak

Reduce the peak burden

2
Number of Daily Cases

Pandemic on hospitals/infrastructure
Outbreak: Decrease a) number of
3
No
No Community
Community cases of death and
Measures Used illness and b) overall
health impact

Pandemic
Outbreak:
With Measures
Taken

Days Since First Case

Draft- MI Public Health Interventions
State-Level Preparedness

Michigan’s Draft Pandemic

Influenza
State Operational Plan
 Emergency Management &
Homeland Security Division

 Responsible to coordinate state and federal resources to assist local

government in response and relief activities in the event of an emergency or
disaster.
 Responsible for the coordination of homeland security initiatives and several
federal grants, as directed by the U.S. Department of Homeland Security.
Pre-positioning MedPack for
Special Events

Bill Fales, Region 6

L. Scott, MDCH
 All-Hazard Preparedness
 Since 9/11, enhanced infrastructure for emergency response
 Requirement for coordinated hospital and first responder actions
 Public health’s enhanced role in emergency management
 A need to integrate community response
 Continuity of business planning
 Continuity of operations planning
 Keweenaw
44 %

 Regional Bio-Defense 8
Networks

 Coordinate health care,

public health and 7
emergency
management partners
6
 100% Federally funded 3
– CDC Cooperative
Agreement 2n
1
– HRSA Cooperative 5 2s
Agreement
 Regional Medical Bio-Defense
Networks Keweenaw
44 %

Region 1: Region 5:
Dan Young Bob Dievendorf
Region 1 BT. Coordinator Region 5 BT. Coordinator
4990 Northwind Ste. 240 1000 Oakland Dr.
East Lansing, MI 48823 Kalamazoo, MI 49008

8
Office: 517-324-4404 Office: 269-337-6549
Fax: 517-324-4406 Fax: 269-337-6475
D1RMRC@sbcglobal.net dievendorf@kcms.msu.edu
 
 Region 2N: Region 6:
Gary Canfield Tim Bulson
Region 2N BT. Coordinator Region 6 BT. Coordinator
2032 E. Square Lake Road, Ste. 200 678 Front NW Ste. 235
Troy, MI 48085 Grand Rapids, MI 49504
Office: 248-828-0180 Office: 616-451-8438
Fax: 248-828-0185 Fax: 616-451-8462
gcanfig@aol.com tbulson@kcems.org

7
 
 Region 2S: Region 7:
Amy Beauregard Tres Brooke
Region 2S BT. Coordinator Region 7 BT. Coordinator
Wayne Co. Health Adm. C/O Northwest Regional MCA
33030 VanBorn Road 1105 Sixth Street
Wayne, MI 48184 Traverse City, MI 49684
Office: 734-727-8001 Office: 231-935-7846
Office (24 hours): 734-727-7280 Fax: 231-935-7845
Fax: 734-727-7110 lbrooke@mhc.net
Abeauregard@waynecountyemd.com  

6
3
 Region 3: Region 8:
Jim Brasseur Interim-Alyson Sundberg
Region 3 BT. Coordinator Region 8 BT. Coordinator
1600 N. Michigan Ave. 420 Magnetic Street
Saginaw, MI 48602 Marquette, MI 48955
Office: 989-583-7938 Office: 906-225-7745
Fax: 989-583-7930 Fax: 906-225-3038
jbrasseur@saginawcounty.com
 
asundberg@mgh.org
2n
1
5 2s
 Preparedness Planning
 “All Hazards”-Pandemic Flu an excellent example

 www.pandemicflu.gov
– Business Continuity of Operations
– Clinics and Medical Offices
– Family and individual preparedness
– Home health care
– Long-term facilities
– Schools
– Health insurers
 Basis of all plans is a strong Continuity of
Business Plan (CBP)
The Importance of Surveillance

 Continuous global surveillance of influenza is

key…
 Rapid detection of unusual influenza
outbreaks, isolation of possible pandemic
viruses and immediate alert to the WHO
system by national authorities is decisive for
mounting a timely and efficient response to
pandemics.

World Health Organization

 Pandemic Influenza
Coordinating Committee
(PICC)
 Concept presented in September 2006
 Purpose of the PICC
– Assure pandemic influenza plans are being
developed
– Assure plans are coordinated
– Assure plans involve all necessary areas
 Encompasses all state agencies
 Pandemic Influenza Coordinating Committee (PICC)
- Steering Group -
(A Representative from each State of Michigan Departments and Tribal)

Subcommittees

Transportation/ Human Health School/ Public Animal Health Legal / Public Safety
Border •MDCH Core Health • Governor’s Legal
•AIIWG
•MDOT •Mental Health Workgroup • Homeland
• DLEG •Medicaid Security Advisor
• MDCH •OSE PIO Meetings • MSP
• MSP •LHDs • DMVA
• MDA •HRSA Liaison: James • Attorney General
• Tribes •DOC McCurtis, MDCH • Civil Rights
• CDC •DHS • Michigan Sheriff’s
Quarantine •Tribes 3rdrd Party Payers Association
• MSU College of Law
Workgroup • Univ of Michigan
• DMVA
Long-Term Care Pandemic Safe • DIT
Workgroup Work Practice Two Workgroups:
• DMB
Workgroup •Legal Authority • MI Supreme Court
• MALPH
•Public Safety
•Executive Office
• Assoc of Chiefs of
Police
• Treasury
 PICC Report

• Presenting key recommendations:

– Legal / Legislative
– Community Preparedness
• School
• Business
• At-Risk Populations
– Human Health
– Protecting State employees
 Recommendations of the
Human Health Sub-committee
 Outreach to vulnerable populations
 Implementation of safe work practices
 Increase seasonal vaccination rates
 Involve third party payers / private
insurers
 OSHA Guidelines
 February 2007
 Understand risks
to staff, patients,
public
 Educate!
 DHHS
Guidelines
coming soon
about use of
masks for
general public
 State Operational Plan
 Planning Guidance to States
 Released March 13, 2008
 Purpose- strategic framework to help the
50 states, DC and the 5 US territories to
improve and maintain their operational
plans for responding to and sustaining
functionality during an influenza pandemic
 SOP Strategic Goals

 Goal A: Ensure continuity of ops for

state agencies/state government
 Goal B: Protect citizens
 Goal C: Sustain/support 17 Critical
infrastructure/key resource sectors
 Goal A-Continuity of Ops

 Continuing critical services and lifelines

that citizens rely on for survival (eg,
Medicaid, safe food and water, etc)

 Must prepare for and exercise and

improve comprehensive operational
plans
 Goal B- Protection of Citizens

 State Government is conducting

business as usual with functions such as
CD surveillance
 State is altering the way it conducts
business to delay the introduction, slow
the spread, or lessen the severity of pan
flu
 Goal C: CI/KR

 Sustain and support 17 critical

infrastructure and key resources
 Redevelop and implement statewide
CI/KR protection programs
 Reflect and align with full spectrum of
homeland security activities in National
Infrastructure Protection Plan (NIPP)
 State Operational Plans

 Due July 9, 2008

 To be reviewed by DHHS/DHS
 SOP’s will be graded
 Future funding tied to grades
 State’s grades reported to Congress,
with subsequent release to public
 Ongoing activity- support to All Hazards
 Summary
 Avian influenza epidemiology
knowledge evolving
 Pan flu risk persists regardless of H5N1
activity
 Pan flu planning is
– Extremely comprehensive
– Extensive coordination
– Enhanced collaboration
– New partnerships
– To become supporting plan to All Hazards
 References
 Mivolunteerregistry.org
 Local Health Department
 Michigan Department of Community Health
(www.michigan.gov/flu)
 WHO www.who.int
 CDC www.cdc.gov
 DHHS (www.pandemicflu.gov) (CHECKLISTS)