Pandemic Influenza

Seasonal Influenza Infection

in Humans
Influenza is usually a respiratory infection

Transmission
– Regular person-to-person transmission
– Primarily through contact with respiratory
droplets
– Transmission from objects (fomites)
possible
 Transmission of Influenza
• Limited studies, varying
interpretations
• Contact, droplet, and droplet nuclei
(airborne) transmission all likely
occur
– Relative contribution of each
unclear
• Droplet thought most important
– Coughing, sneezing, talking
– Most studies either
• Animals or human experiments
under artificial conditions
• Outbreak investigations
– Unclear of infection source
 Key Characteristics
Communicability

– Viral shedding can begin 1 day

before symptom onset
– Peak shedding first 3 days of
illness
– Correlates with temperature
– Subsides usually by 5-7th day
in adults
– can be 10+ days in children
– Infants, children and the
immunocompromised may
shed the virus longer
Incubation period
– Time from exposure to onset of symptoms
– 1 to 4 days (average = 2 days)

Seasonality
– In temperate zones, sharp peaks in winter
months
– In tropical zones, circulates year-round with
seasonal increases.
 Clinical Illness, Seasonal
Influenza
• Abrupt onset
• Fever and constitutional symptoms: body
aches, headaches, fatigue
• Cough, rhinitis, sore throat
• GI symptoms and myositis more common in
young children
• Sepsis-like syndrome in infants
• Complications: viral and bacterial pneumonia,
febrile seizures, cardiomyopathy,
encephalopathy/encephalitis, worsening
underlying chronic conditions
 Individuals at Increased Risk for
Hospitalizations and Death
• Elderly > 65 years

• Children less than two years

• Certain chronic diseases

– Heart or lung disease, including asthma
– Metabolic disease, including diabetes
– HIV/AIDs, other immunosuppression
– Conditions that can compromise respiratory function or the
handling of respiratory secretions

• Pregnant women
 Vaccination
• Influenza vaccine is the best prevention for
seasonal influenza.
• Inactivated viruses in the vaccine developed from
three circulating strains (generally 2 Type A and 1
Type B strain)
– Therefore, seasonal “flu shot” only works for 3 influenza
subtypes and will not work on pandemic strains.
• Live, intranasal spray vaccine for healthy non-
pregnant persons 5-49 years
• Inactivated, injectable vaccine for persons 6
months and older
 Non-Pharmaceutical Interventions

• Voluntary isolation of sick people

• Voluntary quarantine of healthy contacts
• School closures
• Social distancing
Avian Influenza
 Avian Influenza
• Type A influenza
• Endemic in birds
• H5, H7 subtypes can cause serious
disease or death in wild birds; often
cause death in poultry
• Virus in saliva and feces of wild
birds and poultry can be directly
transmitted to humans and other
animals
• Can contaminate clothing,
equipment, water, feed
 H5N1 Avian Influenza
• Currently spreading through Asia, Africa,
Europe, Middle East
• Can be highly lethal to domestic poultry and
other animal species
• Occasional human cases but no efficient human
to human transmission yet
• Virus of greatest concern for pandemic potential,
but other viruses in animals also of concern

*As of March 8, 2007

 Influenza Viruses
• Characterized by ability to change
Continually → yearly epidemics
Drastically → sporadic pandemics
 Influenza Viruses
• Illness caused by
infection with an
influenza virus

• Negative single-
stranded RNA virus

• 8 gene segments
code for 10 proteins
 Influenza Viruses
• Classified into types A, B, and C
• Only Types A and B cause
significant disease
• Types B and C limited to
humans
• Type A viruses
• More virulent
• Affect many species C Goldsmith, CDC
 Influenza A Viruses
• Influenza A viruses categorized by subtype
• Classified according to two surface proteins

• Hemagglutinin (H) – 16 known

– Site of attachment to host cells
– Antibody to HA is protective

• Neuraminidase (N) – 9 known

– Helps release virions from cells
– Antibody to NA can help modify disease severity

H
 Nomenclature
Virus type Strain number Virus subtype

A / Sydney / 05 / 97 (H3N2)
Place virus Year isolated
isolated
 H5N1 in Other Animals
H5N1 can infect other
animals:
– Pigs (China, Vietnam)
– Dogs
– Domestic cats; has
infected civet cats
– Tigers, leopards
(Thailand, China)
– Tiger-to-tiger
transmission (Thailand)
 Avian Influenza
• Low pathogenic AI (LPAI)
– Most common influenza infection in birds
– Causes mild clinical and unapparent infections
– May be any subtype (H1 to H15)
• Highly pathogenic AI (HPAI)
– Some H5 or H7 subtypes
– Causes severe illness in poultry and often death
– LPAI H5 or H7 subtypes can mutate
into HPAI H5 or H7 subtypes
 Avian influenza
Migratory Domestic birds
water birds

All known Influenza A Wild birds =

subtypes Reservoir for Influenza A strains
Circulate in wild birds &
& source for viruses infecting other
Infect domestic birds. species.
United Kingdom Department of Health
 H5N1 Epizootic – 2003-2006
• Since December 2003,
– >50 countries have
reported H5N1 among
domestic poultry and wild
birds
– Current outbreaks in a
many countries
– Expanded from Asia to the
Middle East, Europe, and
Africa
• Largest epizootic of avian
influenza ever described
• Over 200 million birds died
or destroyed
 H5N1 Clinical Features
• Case fatality ratio: 60%
• Median age: 20 years (range 3 mos-75
yrs)*
• Previously healthy children, young adults
• Incubation: 2-8 days
• Fever, cough, shortness of breath,
diarrhea
• Pneumonia, severe respiratory disease
• Leukopenia, multisystem organ failure
Beigel JH, et al. NEJM 2005;353:1374-85 *WHO WER;26:249-260
 Clinical illness with H5N1
compared with typical human
influenza illness
• More severe illness in younger persons
• Primary viral pneumonia appears to be
more common and with rapid onset
• Incubation period may be longer
• Duration of infectious period likely longer,
particularly among adults
 Avian Influenza in Humans
Year Subtype Location Cases Deaths
1996 H7N7 United Kingdom 1 0
1997 H5N1 Hong Kong 18 6
1998 H9N2 China 6 0
1999 H9N2 Hong Kong 2 0
2002 H7N2 United States 1 0
2003 H7N2 United States 1 0
2003 H9N2 Hong Kong 1 0
2003 H5N1 Hong Kong 2 1
2003 H7N7 The Netherlands 89 1
2004 H7N3 Canada 2 0
2003-07 H5N1 Worldwide 281* 169
* As of March 21, 2007
 H5N1 Possible Travel Routes
• Legal poultry business

• Illegal bird trade

• Untreated fertilizer

• Migrating birds

• Humans (contaminated
objects)
 Re-assortment and
Direct Transmission

IRE CT
D

Non-human Human
virus virus

Reassortant
virus
 What is Pandemic Influenza?
• Pandemic: epidemic spreading
around the world affecting hundreds
of thousands of people, across
many countries

• Flu pandemics: global influenza

epidemics of newly emerged strain
of influenza that
– passes easily from person to person
– causes severe disease

• Essentially no pre-existing immunity;

every body at risk
Influenza Pandemic Viruses
Requirements:
– A new influenza A subtype can infect humans
AND
– Causes serious illness
AND
– Spreads easily from human-to-human

The first two prerequisites have been met,

but not the last

– Each new human infection is an opportunity for the

virus to change
 Pandemic Influenza
•Timing unpredictable
• High illness rates across age groups
• Increased mortality
–Higher proportion deaths in younger
persons
 Estimated Mortality from
Influenza Pandemics
•1918-19 (H1N1)
•>500,000 deaths US
•20 -100 million worldwide

•1957-58 (H2N2)
•70,000 deaths US

•1968-69 (H3N2)
•34,000 deaths US
 Concerns about Pandemic
Influenza
• Rapid global spread (morbidity and mortality)

• Shortages and delays – vaccines and antiviral

medications

• Increases burden on hospitals and outpatient

care systems

• Disrupts national and community infrastructures

 Inter-species Transmission
and Pandemics
• Many reports of transmission animal
influenza viruses to humans that do not
result in pandemic
– E.g. Swine Flu 1976
• 230 infected, 13 hospitalized, 1 death
• No sustained transmission beyond Ft. Dix, NJ
• But, because pandemics may be so
devastating, vigilance and planning critical
 WHO Stages of a Pandemic
• Inter-pandemic period

• Pandemic alert period

• Pandemic period

• Post pandemic period

WHO Phases of a Pandemic
Inter-pandemic Period

Phase 1: No new Influenza virus subtypes in

humans

Phase 2: No new virus subtypes in humans;

animal subtype poses a risk of human
disease
WHO Phases of a Pandemic
Pandemic Alert Period

Phase 3: Human infection with novel virus;

no instances of human-to-human spread

Phase 4: Small, localized clusters of human-

to-human spread

Phase 5: Larger clusters, still localized; virus

adapting to humans
WHO Phases of a Pandemic
Pandemic Period

Phase 6: Increased and sustained

transmission in the general population.

Post Pandemic Period

Recovery phase
The Challenges of H5N1 Given
Local Practices
Possible Scenarios in the Philippines
• No avian influenza in birds, thus no bird-
to-human transmission
• Avian influenza in birds, bird-to-human
transmission
• Avian influenza in birds, bird-to-human
transmission, human-to-human
transmission
• No avian influenza in birds, human
cases from other countries due to novel
virus
• Non-pharmaceutical interventions (NPIs)
– Measures other than vaccines and antivirals that
may reduce the risk of transmission of a influenza
to individuals and communities
– NPIs can be implemented at borders, or at the
level of the community and the individual
Goal Potential NPI
Limit spread across Travel screening and
borders entry/exit restrictions
Reduce spread within Social distancing;
national/local quarantine of exposed;
populations isolation
Reduce an individual Personal protective
person's risk measures (e.g., masks)
Communicate risk to the Public health
public communication
campaign
 Why are NPIs being
considered?
• During the first few months after a pandemic
begins:
– Vaccine made from a pandemic strain will probably
not to be available
– Antivirals may be insufficient in quantity, ineffective
and/or difficult to distribute in a timely way
• In many countries of the world, it may be some
time before either vaccine or antivirals are
available in sufficient quantity
 NPI timing and triggers
• Timing matters
– the effectiveness of NPIs will be
dependent on when they are
implemented
• Appearance and efficient person-to-
person transmission of pandemic virus
will trigger implementation
 Examples of possible
consequences of school dismissal
• Families
– Children
• Missed school/disruption of education
• School-meal dependent children lose meals, nutrition
• Happy not to have to go to schools
• More time with friends
– Parents
• Missed work/lost income
• Childcare
• Intangible costs (e.g., stress)
 Examples of possible
consequences of school dismissal
• Communities
– Lost productivity due to work absenteeism
– Industries that support school functioning
lose business (e.g., school meal industry)
– Additional transmission caused by children
re-congregating
 Other Prevention Strategies
• Community
• International ports of entry
• Individuals
 CDC Quarantine Stations
Ports of Entry NPIs
Travel screening and restrictions
• Goal: prevention of importation
• Trigger: human to human transmission and
clusters overseas caused by a of novel
influenza strain
• Possible control measures
– Close ports of entry (POEs)
– Funneling of flights
– Isolation and quarantine at POEs
– Exit screening
 CDC Quarantine Stations
Ports of entry NPIs

• Possible screening measures*

– Traveler questionnaire and/or interview
– Visual inspection
– Fever screening (temperature check)
– Specimen collection and testing (secondary)

*Effectiveness unknown; dependent on clinical syndrome

and other factors (e.g. time of flight)
 Infection Control Measures
• All interventions should be used in
combination with infection control measures
including:
– Hand hygiene
– Cough etiquette
– Environmental cleaning
– Personal protective equipment such as face
masks
Maintaining essential services
In an explosive spread, efforts and resources
will be shifted to maintenance
of essential services
Persons providing
– Emergency and disaster response
– Maintenance of peace and order
– Transportation, including air traffic controllers
– Utilities – water, electricity

• Arrange ahead places of duties and schedule to

cover the required duties during the pandemic
• Back up
Coping with increased demand for health
services and goods
Primary care
• manpower augmentation
• antipyretics, analgesics, liniments and
antibiotics for home care
• triaging of cases in out-patient clinics
Secondary and tertiary care
• Shortage of beds, equipment and supplies
• Only serious and urgent cases will be
admitted
• Back-up / buddy system
• Supplies of relevant drugs (e.g.
antibiotics) and equipment (e.g. Ventilator)
What is the DOH doing?
 What has been accomplished
• Establishment of unified private sector network, primarily the civil
society organization and the business sector
• Capability building of key people from the central and regional
offices of DA, DOH and DENR and of Agricultural and Health
Officers in 20 critical sites covering 103 municipalities
• Consultative Forum for DOH Regional Coordinators on SARS, AI &
Other Emerging Infectious Diseases
– Provided the trained trainors with updates from DOH and DA
– Obtained feedback from the participants on their field experiences
– Gathered baseline information from the core trainors on the impact of
TOT & the previous regional training series for processing through
SWOT analysis
– Presentation of the revised course outline
– Finalization of the regional action plan
 What has been accomplished
• Training of DOH-retained and selected local
hospitals
• Regional Training Series
– Fighting a Pandemic: Training of LGUs on
Preparedness for SARS, Avian Influenza and Other
Emerging Infectious Diseases
• Aimed to build the capacity of PHOs / MHOs / CHOs in AI /
SARS / EID preparedness and response
• Development and dissemination of information
on avian influenza
 What has been accomplished
• Ban importation of poultry and its products from
AI-affected countries
• Assist Local Government Units (LGUs) in
drafting their Preparedness and Response Plans
• Conduct AIPP lectures and AI updates to
requesting parties & concerned groups
• Assessment of prior surveillance work and
institutionalization of surveillance activities
 What has been accomplished
• Orientation of Barangay Health
Emergency Response Teams on Avian
Influenza
– Aimed at orienting the BHERTS on Avian
Influenza
• Provision of PPEs to CHDs & DOH
retained hospitals designated as AI
referral hospital
 Moving Forward
• Conduct of simulation exercises as teaching, planning
and assessment tools
• Expansion of the information campaign to the local
communities through a collaborative effort of the public
and the private sector
• Continuing efforts for strengthening of surveillance of
birds and humans
• Capacity building of DOH-retained and local hospitals for
response to serious infectious disease disasters
• Strengthened participation of other government agencies
and the private sector for avian and pandemic influenza
preparedness
 Moving Forward
• Continuing efforts to prepare the public health
and hospital systems for avian and pandemic
influenza that could further lay the foundation to
strengthen preparedness to any severe
emerging infectious disease
• Training of more Municipal Agricultural and
Health Officers for Avian and Pandemic
Influenza from 1200 municipalities
• Training of Barangay Health Emergency
Response and Rapid Action Teams
– Pilot testing of the Early Warning System
 Moving Forward
• Conduct of real time simulation exercises to test
the AIPP
• Expanding areas for disease surveillance
• Intensification of IEC campaign in the twenty
(20) critical areas for AI, international borders
and coastlines
 Moving Forward
• Review of the AIPP for further improvement of
disease control and eradication protocols
• Training of more military men and volunteers for
immediate response in the event of an outbreak
• Establishment of AI laboratories in Luzon,
Visayas and Mindanao to complement activities
of the National Influenza Center (RITM)
Critical in averting a potential
pandemic:

Early Recognition
and Containment