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Avian and Pandemic Influenza

Kathy Harriman
Minnesota Department of Health
Infectious Disease Prevention and
Control Division
Acute Disease Epidemiology Section

What is influenza?
An acute respiratory illness resulting
from infection with an influenza virus
Highly infectious and can spread
rapidly from person to person
Some strains cause more severe
illness than others

Types of influenza viruses


Influenza viruses are divided into three
main types: influenza A, B, and C
A viruses infect birds and other
animals, as well as humans
A viruses source of seasonal
influenza epidemics and all pandemics
B and C viruses infect humans only
and do not cause pandemics

Where does influenza A virus


come from?
Human influenza A viruses start as avian (bird) influenza viruses
Migratory
water birds

Domestic birds

Humans
and other
animals

Influenza symptoms
Sudden onset
Fever, headache, muscle aches,
severe weakness
Respiratory symptoms, e.g., cough,
sore throat, difficulty breathing

How influenza spreads


Spreads easily from person to person
through coughing and sneezing
Transmitted by:
inhaling respiratory aerosols containing the virus,
produced when infected person talks, coughs, or
sneezes
touching an infected person or an item
contaminated with the virus and then touching
your eyes, nose, or mouth

Courtesy of CDC

Seasonal influenza:
minor changes - antigenic drift
Occurs among influenza A viruses
resulting in emergence of new variants
of prevailing strains every year
New variants result in seasonal
influenza each winter
Some years are worse than others
partly related to degree of drift

What is an influenza pandemic?


Influenza pandemics are worldwide
epidemics of a newly emerged
strain of influenza
Few, if any, people have any
immunity to the new virus
This allows the new virus to spread
widely, easily, and to cause more
serious illness

What causes a pandemic?


Pandemics occur when a new
avian influenza strain acquires
the ability infect people and to
spread easily person to person
This can occur in two ways:
Reassortment (an exchange of
seasonal and avian influenza
genes in a person or pig infected
with both strains)
Mutation (an avian strain becomes
more transmissible through
adaptive mutation of the virus
during human avian influenza
infection)

Pandemic influenza:
major changes - antigenic shift
Major changes occur in the surface antigens
of influenza A viruses by mutation or
reassortment
Changes are more significant than those
associated with antigenic drift
Changes lead to the emergence of potentially
pandemic strains by creating a virus that is
markedly different from recently circulating
strains so that almost all people have no preexisting immunity

Seasonal vs. pandemic influenza


Pandemic influenza is not just a bad flu, it is a wholly new
threat to humans
A severe pandemic would cause social disruption unlike
anything most persons now alive have ever experienced
Compared to seasonal influenzas, pandemic influenzas
infect more people, cause more severe illness, and cause
more deaths
Seasonal influenza viruses most often cause severe
disease in the very young, the very old, and those with
chronic illnesses, but pandemic influenza strains can infect
and kill young, healthy people
The highest mortality rate in the 1918-19 pandemic was in
people aged 20-40 years

History of influenza
412 BC - first
mentioned by
Hippocrates
1580 - first pandemic
described
1580-1900 - 28
pandemics

Pandemic influenza in the 20th Century

1918 Spanish Flu 1957 Asian Flu 1968 Hong Kong Flu
20-40 million deaths

1 million deaths

1 million deaths

H2N2

H3N2

H1N1

1920

1940

1960

1980

2000

1918 Pandemic

Highest mortality in people 20-40 years of age


- 675,000 Americans died of influenza
- 43,000 U.S. soldiers died of influenza

Lessons from past pandemics


Occur unpredictably, not always in winter
Great variations in mortality, severity of illness,
and pattern of illness or age most severely
affected
Rapid surge in number of cases over brief period
of time, often measured in weeks
Tend to occur in waves of 6 - 8 weeks,
subsequent waves may be more or less severe

Key lesson unpredictability

Why is there concern about an


influenza pandemic now?
A highly pathogenic avian influenza strain (A/H5N1)
emerged in Hong Kong in 1997, reemerged in birds
and humans in 2003, and is now circulating widely in
birds in many countries
Since 2003, this strain has spread from birds to
humans and as of August 23, 2006 has infected 241
people (141 deaths) in 10 countries
This strain has also been documented (rarely, so far)
to spread from person to person
Reassortment or mutation could allow this strain to
become easily transmissible between humans there
is no way to know if or when this will happen

Would the next pandemic be severe?


We just dont know
However, past pandemics
provide clues as to how
humans may be affected by a
new influenza virus and how
societies would react to a
pandemic
Information from past
pandemics is used in
economic and disease models
to predict the impact of future
pandemics

What could happen during an


influenza pandemic?
In the United States, up to 1.9 million
people could die, up to 9.9 million could
be hospitalized, and up to 90 million
could become ill
Intense pressure on healthcare
Disruption to many aspects of daily life

Emergency hospital, Camp Funston, Kansas 1918


Courtesy of National Museum of Health and Medicine

Pandemic waves
Past experience teaches us that following
the emergence of a new pandemic virus:
More than one wave of influenza is likely
Waves typically last 6-8 weeks
Gaps between the waves may be weeks or
months
A subsequent wave can be worse than the first

What can be done to slow


the spread of a pandemic?
Vaccine:
not expected to be available until later in a pandemic
Antivirals:
likely to be insufficient quantities, effectiveness
unclear
Disease containment measures:
may be the only measures available in the early
stages of a pandemic
may be helpful in slowing the spread of a pandemic,
allowing more time for vaccine production

Vaccine
Because the virus will be
new, there will be no
vaccine ready to protect
against pandemic influenza
at the start of a pandemic
Specific vaccine cannot be
made until the virus strain
has been identified and will
take at least 4-6 months to
produce

Antiviral drugs
Likely to be the only major
medical countermeasure
available early in a pandemic
Uncertainty about effectiveness
for treatment or prevention
U.S. goal is to stockpile enough
antiviral drugs to treat 25% of
the U.S. population

Reproduced with permission from Roche Products Ltd. Tamiflu

Disease containment measures


Isolation: restriction of movement/separation of ill
infected persons with a contagious disease
Quarantine: restriction of movement/separation of well
persons presumed exposed to a contagious disease
Self-shielding: self-imposed exclusion from infected
persons or those who may be infected
Social distancing: reducing interactions between
people to reduce the risk of disease transmission
Snow days: days on which offices, schools,
transportation systems are closed or cancelled, as if
there were a major snowstorm

Other methods to reduce transmission


Hand hygiene (cleaning hands with soap and
water or an alcohol-based hand rub)
Respiratory hygiene, e.g., Cover your cough
Cleaning and disinfection of contaminated
objects, surfaces
Physical barriers (e.g., glass or plastic
windows to protect front desk workers)
Use of personal protective equipment (PPE) in
some settings (e.g., healthcare) such as
gowns, gloves, eye, and respiratory protection

Employees of Stewart & Holmes Wholesale Drug Co. Seattle, 1918


Courtesy of Grace Loudon Mc Adam

Summary
The currently circulating avian influenza
strain may or may not cause a pandemic
Global surveillance is essential;
international cooperation is critical
Planning for a possible pandemic is
occurring nationally and internationally
National, state, local, and individual
preparedness are all important

Additional avian and pandemic


influenza information
MDH
http://www.mdhflu.com

CDC
http://www.cdc.gov/flu/avian/ index.htm

HHS
http://www.pandemicflu.gov/
http://www.hhs.gov/pandemicflu/ plan/

WHO
http://www.who.int/csr/disease/ avian_influenza/en/index.html

Questions?

Please call the


Minnesota Department
of Health at:
651-201-5414 or
1-877-676-5414

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