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H5N1, H1N1, and Pandemic
Influenza
An Update
Eden V. Wells, MD, MPH
Michigan Department of
Community Health
Outline
 Novel Strain H5N1- Brief Update
 Novel Strain H1N1-Update
 Pandemic Influenza Planning-Michigan
 Pan Flu Planning for You
Avian Influenza A (H5N1)
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


Discovered in Hong Kong, 1997
Now multiple epizootics worldwide
Still has not entered the Western Hemisphere
Still has not met “WHO” criteria for pandemic
– New strain
– Causes severe illness in humans
– Sustained transmission from person to person
Humans at Risk-H5N1
 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
Human Vaccine for Avian H5N1
 Human H5N1 vaccine approved by FDA
 US has advance-ordered 20,000,000 doses
 Current US Strategic National 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
Current U.S. Status, H5N1
 No current evidence in U.S. of highly
pathogenic H5N1 in:
– Wild birds
– Domestic poultry
– Humans
2009 Novel Influenza A
(H1N1)
The 21st Century’s first influenza
pandemic
2009 Novel Influenza A (H1N1)
 April 2009, Mexico and SE California
 Rapid spread through Mexico and US
 May 2009, Spread throughout World
 WHO Pandemic Phase 6 June 2009
Transmission
 Transmitted human-to-human
 Transmitted similar as seasonal influenza
– Exposure to nearby coughing or sneezing
– Contact with contaminated surfaces
 Incubation: unknown and could range from
1-7 days, and more likely 1-4 days
 Infectious period: unknown– one day before to 7 days following illness onset
– Children, especially younger children, maybe
infectious up to 10 days.
World Health H1N1,
as of August 2009
US Epidemiology H1N1
August 2009
Mortality by Age, US,
as of August 1, 2009
US Epidemiology,
as of August 2009
 “More than one million people became
ill with novel H1N1 flu between April and
June 2009.”- cdc.gov
US Epidemiology,
as of August 2009
 Secondary attack rate (SAR) of H1N1 for household
contacts
– For acute-respiratory-illness (ARI two or more of the
following symptoms: fever, cough, sore throat, and
runny nose)-18 % to 19%
– 8% to 12% for influenza-like-illness (ILI- fever and
cough or sore throat)
– Slightly lower than seasonal influenza SAR
– US Case fatality rate: ? <0.1%
 Greater disease burden on people younger than 25
years of age than older people.
MI Epidemiology,
as of July 2009
 As of July 9, 2009: confirmed cases
Variables
Total pH1N1 (%)
(n=489)
Hospitalized pH1N1
(n=110)
Nonhospitalized
pH1N1 (n=325)
227 (46.4)
260 (53.2)
2 (0.4)
59 (53.6)
51 (46.4)
0
1
43 (44.0)
180 (55.4)
2 (0.6)
Average
age (yrs)
18.0
25.4
15.8
Median age
(yrs)
14.0
18.0
13.0
58 (11.9)
326 (66.7)
77 (15.7)
23 (4.7)
5 (1.0)
0.2─87
9 (8.2)
55 (50.0)
28 (25.5)
14 (12.7)
4 (3.6)
0.3─87
45 (13.8)
230 (70.8)
40 (12.3)
9 (2.8)
1 (0.3)
0.2─79
Gender
Females
Males
Unknown
Age group
0-4 yrs
5-24 yrs
25-49 yrs
50-64 yrs
65+ yrs
Age range
(yrs)
Antiviral Resistance
(as of August 2009)
Antiviral resistance pandemic (H1N1) virus
 Six oseltamivir resistant pandemic (H1N1) 2009
influenza viruses
–
–
–
–
Denmark
Hong Kong SAR
Japan
Canada
 Three were from patients in Japan.
 All six patients had received oseltamivir with the
exception of one and have recovered well.
 All resistant viruses had the characteristic mutation at
position 274/275 associated with resistance.
Planning for an Impending
Pandemic
The Role of Public Health
th
20
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
America’s deaths from influenza were
greater than the number of U.S.
servicemen
killed
in
any
war
Thousands
900
800
700
600
500
400
300
200
100
0
Civil
War
Pestronk, Robert
WWI
1918-19
Influenza
WWII
Korean
War
Vietnam
War
Categories of Pandemic
Strength
Estimated Impact
of a Future Pandemic in Michigan
Gross Attack Rate 35%
Moderate
(1957 / 68-like)
Severe
(1918-like)
Health Outcome
Minimum
Maximum
Minimum
Maximum
Illness
3.4 million
3.4 million
3.4 million
3.4 million
Outpatient
medical care
1.4 million
2.6 million
1.3 million
2.2 million
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)
Public Health Leads
 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
 Vaccine
 Antivirals
– Treatment
– Prophylaxis
 Infection Control
 Social Distancing
Legal authority to
Implement Public
Health Measure
resides equally in
all 45 MI Local HD
Health Officers
MI PUBLIC HEALTH CODE
Similar but
multi-jurisdictional
authority resides with
State Health Officer
Menu of Public Health Actions, circa 1918
1.Making influenza a reportable
disease
2. Isolating sick individuals
3. Quarantine of households with
sick individuals
4. School closure
5. Protective sequestration of
children or adults
6. Cancellation of worship services
7. Closure of public gathering places
[e.g., saloons, theatres, etc.]
8. Staggered business hours to
decrease congestion on trams, etc.
Hatchett, et al, PNAS,
May 1, 2007
9. Mandatory or recommended use of
masks in public
10. Closing or discouraging the use of
public transit systems
11. Restrictions on funerals, parties,
and weddings
12. Restrictions on door-to-door sales
13. Community-wide curfew measures
and business closures
14. Social distancing strategies for
those encountering others
15. Public health risk communication
measures
16. Declaration of public health
emergency.
1918 Flint Journal
Headlines
Slide courtesy of Robert Pestronk
Michigan Pandemic
Planning
Coordination of state and local
responses
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
Networks
8
 Coordinate health care,
state and local public
health, and emergency
management partners
 100% Federally funded
– CDC Cooperative
Agreement
– HRSA Cooperative
Agreement
7
6
5
3
1
2n
2s
Preparedness Planning
 “All Hazards”Pandemic Flu an
excellent example
 Basis of all plans is a
strong Continuity of
Operations Plan
Preparedness-Local
“All Emergencies are Local”
 All 45 local health
departments:
– Health Officer with legal
authorities
– Medical Director
– Emergency Preparedness
Coordinator
– Immunization Staff
– Communicable Disease Staff
– Coordination of plans
– Partnerships
•
•
•
•
•
•
Emergency Management
Businesses
Community/organizations
Schools
Healthcare
…
Avian Influenza Hotline
1-888-354-5500 ext 7878 or
734-240-7878
West Nile Virus Hotline
1-888-354-5500 ext 7850 or
734-240-7850
The Role for the Community
Responder
Pandemic Influenza
How it will happen
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Public health surveillance
Disease detection
Warnings, declarations, and orders
Staged countermeasures initiated
Requests from local health departments initiated
Local hospitals overwhelmed
Rapid, repeated cycles of illness and death
Loss of response staff
Burn-out of disease and staff
Clean up
Things to do now at work
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Assure staff are vaccinated for flu each year
Assure other vaccinations are up-to-date
Plan for loss of staff and use of volunteers
Get to know your local health department and tribal
leaders
Review inter/intra-agency planning documents and
checklists
Participate in exercises: train, emphasize
leadership shift
Practice staying home when sick
Practice healthy hygiene
Robert Pestronk, Genesee Cty)
Emotional Impacts
 Reacting to inconsistent information
 Fear of exposure/infection
 Massive loss and grief
 Exposure to traumatic images
 An inability to see loved ones
 Not being able to say “good-bye” to those who may
die in the hospital or while separated from family.
Slide information extracted from UNC webinar January 2008
“Mental Health Aspects of Pandemic Flu Preparedness” Patricia Watson, Ph.D.
National Center for PTSD
Social Impacts
 Isolation/quarantine (home care)
 Social distancing (comfort)
 School dismissal (child care)
 Closing places of assembly (social support)
Slide information extracted from UNC webinar January 2008
“Mental Health Aspects of Pandemic Flu Preparedness” Patricia Watson, Ph.D.
National Center for PTSD
Supporting First Responders
 Illness and death among colleagues and family
members
 Fear of contagion and/or of transmitting disease
to others
 Shock, numbness, confusion, or disbelief;
extreme sadness, grief, anger, or guilt;
exhaustion; frustration
 Sense of ineffectiveness and powerlessness
 Difficulty maintaining self-care activities (e.g.,
getting sufficient rest)
 Prolonged separation from family
DHHS Pandemic Plan 2005
Support of First Responders
 Concern about children and other family
members
 Constant stress and pressure to keep performing
 Domestic pressures caused by school
dismissals, disruptions in day care, or family
illness
 Stress of working with sick or agitated persons
and their families and/or with communities under
quarantine restrictions
 Concern about receiving vaccines and/or antiviral
drugs before other persons
Tools for the First Responder
 Surveillance
 Community Mitigation
– Social Distancing
– Infection Control, based on Risk Assessment
 Vaccination
 Communication
Surveillance
 MDCH, local health departments, tribes
–
–
–
–
–
–
Emergency Departments
Schools
Pharmacies
Hospitals
sentinel laboratories and physicians
local health departments
 www.michigan.gov/flu
Community Mitigation
 Attempt to keep children in school
– Schools may consider temporary dismissal
– Virus severity, or uncontrolled transmission

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Do NOT go to work or school if sick!
Social distancing
Infection Control
Medical intervention, if necessary
– Antivirals for at-risk individuals
– Hospital surge responses
Vaccination
 H1N1 vaccination planning currently evolving
 Public and private sector delivery
 Target groups different from seasonal flu:
– Pregnant women
– Household contacts and caregivers for children younger
than 6 months of age
– Healthcare and emergency medical services personnel
– All people from 6 months through 24 years of age
– Persons aged 25 through 64 years who have health
conditions associated with higher risk of medical
complications from influenza.
Communications
 Streamlined, unified- federal, state, local
 Primary federal websites
– www.flu.gov
– http://www.cdc.gov/h1n1flu/
 Primary state website
– michigan.gov/flu
 Alternate routes:
– Twitter
– Facebook
 Regular media calls and updates
Health Alert System
 The Michigan Health Alert Network (MIHAN)
is a secure, Internet-based, emergency
notification system
 The MIHAN contains over 4,000 participants
–
–
–
–
–
local health departments
Hospitals
Clinics
Critical first responders across the state
Michigan's state governmental agencies.
Things to do now at home
 Get family members vaccinated each
year
 Practice healthy hygiene
 Plan how you will care for someone in
your household who becomes sick if
you are called to work.
Practice Healthy Hygiene
 Clean hands often
– Wash with soap and water or
– Clean with hand sanitizer
 Cover mouth and nose when you sneeze
or cough and clean hands afterwards
 Keep hands away from face
 Stay away from people who are sick
 Single use tissue
Robert Pestronk, Genesee Cty)
Summary
 Knowledge about novel
influenza evolving
 Pan flu risks persist– regardless of H5N1 activity,
– especially due to H1N1
activity
 Pan flu planning
–
–
–
–
–
Is extremely comprehensive
Is extensive coordination
Enhances collaboration
Means new partnerships
Assists in planning for other
events
– Is NECESSARY
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)
Acknowledgements
 Howard Markel, University of Michigan
Medical School
 Several slides courtesy of:
– Robert Pestronk
– Christi Carlton, MDCH