PandemicPandemicPandemic FluFluFlu PlanningPlanningPlanning forforfor SchoolsSchoolsSchools EdenEden Wells,Wells, MD,MD, MPHMPH Michigan Department of Community Health Influenza Strains

•Type A – Infects animals and humans –Moderate to severe illness – Potential epidemics/pandemics • Type B – Infects humans only Source: CDC – Milder epidemics – Larger proportion of children affected •Type C –No epidemics –Rare in humans 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

Type of nuclear material Neuraminidase Hemagglutinin A/Moscow/21/99 (H3N2)

Virus Geographic Strain Year of Virus type origin number isolation subtype Influenza Overview

• Orthomyxoviridae, enveloped RNA virus •Strains –Type A –Type B –Type C Source: CDC • Further classified by surface protein –Neuraminidase (N) – 9 subtypes known – Hemagglutinin (H) – 16 subtypes known 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 Influenza The “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 Outbreaks http://www.oie.int/eng/en_index.htm (5/17/06)

•Afghanistan •Egypt •Jordan •Albania • France •Malaysia •Austria •Georgia •Myanmar • Azerbaijan •Germany •Niger • Bosnia & Herzegovina •Greece • Nigeria •Bulgaria •Hong Kong •Palestinian •Burkina Faso •Hungary •Pakistan •Cambodia • Kazakhstan •Poland • Cameroon •India •Romania •China •Indonesia •Russia • Côte d'Ivoire • Iraq •Serbia & •Croatia • Iran Montenegro •Czech Republic •Israel •Slovakia •Denmark •Italy •Slovenia •Sweden •Thailand •Sudan •Switzerland •Turkey •Vietnam • United Kingdom •Ukraine The Role of Animals in Influenza A Infection

Mammals Domestic Birds

Shore Birds and Wild Waterfowl 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 Wild Bird Surveillance • Wildlife biologist monitor diseases of wild birds at the population level • Sick or Dead Wildlife website reporting • Bird Banding • Hunter 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 Country H5N1 Deaths Case Cases Fatality Azerbaijan 8 5 63% Cambodia 6 6 100% China 19 12 63% Djibouti 1 0 0% Egypt 14 6 43% Indonesia 54 42 78% Iraq 2 2 100% Thailand 24 16 67% Turkey 12 4 33% Vietnam 93 42 45% Total 233 135 58%

(WHO, August 7, 2006) 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) PlanningPlanningPlanning forforfor ananan ImpendingImpendingImpending PandemicPandemicPandemic

TheThe RoleRole ofof PublicPublic HealthHealth 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

Moderate Severe Characteristic (1957 / ‘68-like) (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

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

MDCH • Michigan Disease Labs LHD’s/ Surveillance System Hospitals MDSS • Sentinel Surveillance

•Syndromic Non-MDCH ER –Pharmacy Labs Syndromic –ER Mi-Flu Focus •Laboratory Sentinel WHO Data •National Physicians • International Pharmacy CDC Data LHD’s/ OTC Healthcare providers 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 PandemicPandemicPandemic PlanningPlanningPlanning

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 Control in 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 Schools Fact sheet Presentation Video on proper hand washing Health and hygiene lesson plans Posters Contact 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) (CHECKLISTS)