Pandemic Flu Planning for Schools

Pandemic Flu Planning Pandemic Flu Planning for Schoolsfor Schools

Eden Wells, MD, MPHEden Wells, MD, MPHMichigan Department of Community HealthMichigan Department of Community Health

Influenza Strains• Type A

– Infects animals and humans– Moderate to severe illness– Potential epidemics/pandemics

• Type B– Infects humans only– Milder epidemics– Larger proportion of children affected

• Type C– No epidemics– Rare in humans

Source: CDC

A’s and B’s, H’s and N’s

• Classified by its RNA core– Type A or Type B influenza

• Further classified by surface protein– Neuraminidase (N) – 9 subtypes known– Hemagluttin (H) – 16 subtypes known

• Only Influenza A has pandemic potential

Influenza Virus Structure

A/Moscow/21/99 (H3N2)

NeuraminidaseHemagglutinin

Type of nuclearmaterial

Virustype

Geographicorigin

Strainnumber

Year of isolation

Virus subtype

Influenza Overview• Orthomyxoviridae, enveloped RNA virus• Strains

– Type A– Type B– Type C

• Further classified by surface protein– Neuraminidase (N) – 9 subtypes known– Hemagglutinin (H) – 16 subtypes known

Source: CDC

Influenza A: Antigenic Drift and Shift• Hemagglutinin (HA) and neuraminadase (NA)

structures can change

• Drift: minor point mutations– associated with seasonal changes/epidemics– subtype remains the same

• Shift: major genetic changes (reassortments)– making a new subtype – can cause pandemic

Seasonal Influenza

• October to April• People should get flu vaccine• Children and elderly most prone• ~36,000 deaths annually in U.S.

Seasonal Effects

Seasonal Influenza Surveillance

Differentiating Influenza

Seasonal– Caused by influenza A or B strains circulating in humans – ~36,000 human deaths annually in USA

Avian– Caused by Influenza A– Shorebirds and water fowl are the reservoir and rarely

see outbreaks, except in current H5N1 strain– Domestic poultry (chickens and turkeys), causes

morbidity and mortality with outbreaks annually worldwide

Pandemic– When new virus strain occurs– Humans lack immunity– Simultaneous epidemics worldwide– Disease easily transmitted between people– Significant number of illness and deaths

Avian InfluenzaThe “Bird Flu”

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

Avian Influenza• Infection can be in two forms

– “low pathogenic” (LPAI) - causes mild illness and may go undetected

– “highly pathogenic” (HPAI) - affects multiple organs, spreads rapidly among birds, causes high mortality very quickly

Avian Influenza A (H5N1)

• Discovered in1997 Hong Kong• Now multiple epizootics worldwide• Has not entered the Western Hemisphere• Has not met WHO Pandemic criteria

– New strain– Causes severe illness in humans– Sustained transmission from person to person

Poultry Outbreakshttp://www.oie.int/eng/en_index.htm (5/17/06)

• Egypt• France• Georgia• Germany• Greece• Hong Kong • Hungary• Kazakhstan • India• Indonesia• Iraq• Iran• Israel• Italy• Thailand• Turkey• Ukraine

• Jordan• Malaysia• Myanmar• Niger• Nigeria• Palestinian• Pakistan• Poland• Romania• Russia• Serbia &

Montenegro• Slovakia• Slovenia• Sudan• Vietnam

• Afghanistan • Albania• Austria• Azerbaijan• Bosnia & Herzegovina• Bulgaria• Burkina Faso • Cambodia• Cameroon• China • Côte d'Ivoire • Croatia• Czech Republic • Denmark• Sweden• Switzerland• United Kingdom

The Role of Animals in Influenza A Infection

Shore Birds and Wild Waterfowl

Domestic BirdsMammals

Humans

Domestic Poultry Surveillance

• Michigan veterinarians are responsible for overall livestock and poultry reportable disease programs

• They conduct investigations into reports of diseases such as:

– Avian influenza– Rabies– Eastern equine encephalitis– Equine infectious anemia– Tuberculosis– Psittacosis

www.michigan.gov/MDA

• Wildlife biologist monitor diseases of wild birds at the population level

• Sick or Dead Wildlife website reporting

• Bird Banding

• Hunter Surveillance

Wild Bird Surveillance

http://www.michigan.gov/dnr

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

(WHO, August 7, 2006)

33%412Turkey67%1624Thailand

63%58Azerbaijan

45%4293Vietnam

100%66Cambodia

0%01Djibouti

78%4254Indonesia100%22Iraq

58%135233Total

43%614Egypt

63%1219China

Case Fatality

DeathsH5N1 Cases

Country

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

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

Current U.S. Status

• No current evidence in U.S. of highly pathogenic H5N1 in:– Wild birds– Domestic poultry– Humans

Pandemic Phases (WHO)

Planning for an Impending Pandemic

Planning for an Impending Planning for an Impending PandemicPandemic

The Role of Public HealthThe 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

Estimated Impact of a Future Pandemic in Michigan

(*Michigan figures developed with Flu(*Michigan figures developed with Flu--Aid 2.0 software, CDC)Aid 2.0 software, CDC)

Characteristic Moderate(1957 / ‘68-like)

Severe (1918-like)

Illness 3.4 million 3.4 million

Outpatient 2.5 million 1.5 million

Hospitalization 51,000 420,000

Deaths 15,000 125,000

MDCH Pandemic Influenza Plan 2005

• Revision of 2002 plan• Released November 2005• Appendix to MDCH All-Hazards

Response Plan• Pandemic plan updated as needed• www.michigan.gov/influenza

Public Health Response:Risk Communication

• Intra-agency– Health Alert Network (MI-HAN)

• Inter-agency– AIIWG– MI-HAN

• Stakeholders– Website:

www.michigan.gov/flu– MI-HAN

Influenza Surveillance

• Michigan Disease Surveillance System

• Sentinel Surveillance• Syndromic

– Pharmacy– ER

• Laboratory • National • International

LHD’s/LHD’s/MDSSMDSS

NonNon--MDCH MDCH LabsLabs

WHO DataWHO Data

CDC DataCDC DataLHD’s/LHD’s/

Healthcare Healthcare providersproviders

PharmacyPharmacyOTCOTC

Sentinel Sentinel PhysiciansPhysicians

ER ER SyndromicSyndromic

HospitalsHospitals

MDCH MDCH LabsLabs

MiMi--FluFluFocusFocus

Measures To Combat Pandemic Flu

• Antiviral medications – Oseltamivir (Tamiflu®)or others

• Education to encourage self-diagnosis• Public health information (risk avoidance, advice

on universal hygiene behavior)• Face masks for persons with symptoms• Cancellation of school and social gatherings• Deferring travel to involved areas

Medical Containment (models)

• Targeted antivirals

• Widespread antivirals prophylaxis

• Vaccine stockpiles

• ?”Tiered Layered Containment”

Social Distancing-Possible Measures

• School closures

• Travel restrictions- (models don’t seem to impact overall attack rate)

• Case isolation/ home quarantine

Pandemic PlanningPandemic PlanningPandemic Planning

Michigan Schools and Public Health

Lead for School Response

• United States: Division of Adolescent School Health – CDC

• Michigan: Michigan Departments of Education and Community Health

• School Jurisdiction: Superintendent

• School: Superintendent, Building Principal

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

Michigan School Communications

• MDE Official Listserv to all superintendents

• Direct connections to professional organizations (MASA, MASB, MAISA, MEA, CSHCA)

• Webstreaming• Media• School Master Database

http://www.emc.cmich.edu/avian/

Infection Controlin Schools

Non-Pharmaceutical Interventions

• Social distancing

• Hand Hygiene

• Respiratory/Cough etiquette

School Administrators• Develop school pandemic plan• Know the local health department• Know the public health authority of

the Local Health Officer• Educate staff, students, and parents• Educate food service workers

Teachers

• Become involved in planning

• Teach students

• Keep updated in public health information

Toolkit for SchoolsFact sheetPresentationVideo on proper hand washingHealth and hygiene lesson plansPostersContact lists

http://www.scrubclub.org/home.php

Avian/Pandemic Influenza Fact Sheet

Public Health/School Pandemic Planning Collaboration-Summary

• A pandemic affects all sectors of society• Schools great sites for public health education• School closure may be a tool to mitigate

pandemic spread• Collaborative pandemic planning enhances all-

hazard responses to ANY emergency• Respiratory etiquette/hand hygiene education

useful any time

Have a Plan• Develop• Exercise• Update• Review• Exercise• Update….

CDC/EOC-PHIL

Health Advice:Good now, Good in a Pandemic

• Get your annual flu shot– It won’t protect you against a pandemic strain but you will

be stronger to fight a new strain if you are healthy

• Stay at home if you have a fever; don’t send kids to school with a fever

• Wash hands with soap or hand sanitizers when you sneeze or cough

• Get adequate sleep, eat healthy, stay hydrated

References

• Local Health Department• Michigan Department of Community

Health (www.michigan.gov/flu)• WHO www.who.int• CDC www.cdc.gov• DHHS (www.pandemicflu.gov)

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