Protecting Your Family and Workplace During Pandemic Atlanta Federal Safety Council November 7, 2006 L. Casey Chosewood, MD Director, Office of Health and Safety Centers for Disease Control and Prevention

Overview What is Pandemic? What is Avian Flu? Seasonal Flu vs Pandemic Lessons from Past Pandemics Pandemic Control Infection Control Basics Preview of CDC’s Internal Workforce Protection Plan Questions

What is Pandemic? What is Avian Flu?

Seasonal Flu vs Pandemic

Lessons from Past Pandemics

Pandemic Control

Infection Control Basics

Preview of CDC’s Internal Workforce Protection Plan

Questions

What is a Pandemic? A Pandemic is a global disease outbreak. Pandemic flu is a global outbreak of a new type of influenza (flu) People typically have no immunity against the new strain of flu. Disease can then spread easily from person-to-person and can cause serious illness. In a short time period, the disease can spread worldwide.

A Pandemic is a global disease outbreak.

Pandemic flu is a global outbreak of a new type of influenza (flu)

People typically have no immunity against the new strain of flu.

Disease can then spread easily from person-to-person and can cause serious illness.

In a short time period, the disease can spread worldwide.

What about Avian Flu? Avian Flu is an influenza infection affecting bird populations—may or may not cause human illness Animals are the best reservoir for developing viruses. Avian influenza types have been responsible for the last three human pandemics (1918, 1957, and 1968). A specific strain of avian influenza, H5N1, which presently exists in birds in over 16 countries has resulted in a large number of deaths in birds and Some fear that H5N1 will become the next pandemic flu strain

Avian Flu is an influenza infection affecting bird populations—may or may not cause human illness

Animals are the best reservoir for developing viruses.

Avian influenza types have been responsible for the last three human pandemics (1918, 1957, and 1968).

A specific strain of avian influenza, H5N1, which presently exists in birds in over 16 countries has resulted in a large number of deaths in birds and

Some fear that H5N1 will become the next pandemic flu strain

Human Infections with H5N1 Avian Flu As of October 31, 2006 WHO reports 10 countries have confirmed cases Indonesia (55 ), Viet Nam (42 ) and Thailand (17) have most cases 256 persons have been infected 152 have died Fatality rate: 59%

As of October 31, 2006

WHO reports 10 countries have confirmed cases

Indonesia (55 ), Viet Nam (42 ) and Thailand (17) have most cases

256 persons have been infected

152 have died

Fatality rate: 59%

Seasonal Flu is less severe than pandemic strains, partial immunity exists Seasonal vaccine often prevents circulating strains Globally: 250,000 to 500,000 deaths each year to flu In the United States each year, seasonal flu causes: 36,000 deaths >200,000 hospitalizations $37.5 billion in costs from influenza and pneumonia Seasonal Flu vs Pan Flu

Seasonal Flu is less severe than pandemic strains, partial immunity exists

Seasonal vaccine often prevents circulating strains

Globally: 250,000 to 500,000 deaths each year to flu

In the United States each year, seasonal flu causes:

36,000 deaths

>200,000 hospitalizations

$37.5 billion in costs from influenza and pneumonia

What is the onset time for pan flu? The typical incubation period for pan flu is 2 to 3 days. A person may be shedding virus for up to 12 to 24 hours before s/he feels ill. However, at this stage, they typically do not have the symptoms of coughing or sneezing, so transmission will not yet be significantly elevated. The period of lost availability for those that are ill is 2 to 4 weeks.

The typical incubation period for pan flu is 2 to 3 days.

A person may be shedding virus for up to 12 to 24 hours before s/he feels ill.

However, at this stage, they typically do not have the symptoms of coughing or sneezing, so transmission will not yet be significantly elevated.

The period of lost availability for those that are ill is 2 to 4 weeks.

How long will the pan flu epidemic last? Pandemic flu may occur in waves in different communities. Each wave may last between 6 to 8 weeks; The duration of the pandemic may last between 12 and 18 months overall. It is estimated that absenteeism from pandemic flu will range from between 40 to 60%.

Pandemic flu may occur in waves in different communities.

Each wave may last between 6 to 8 weeks;

The duration of the pandemic may last between 12 and 18 months overall.

It is estimated that absenteeism from pandemic flu will range from between 40 to 60%.

Recent Influenza Pandemics H1 H1 H3 H2 H7 * H5 * H9 * 1918 Spanish Influenza H1N1 500k US deaths 1957 Asian Influenza H2N2 70k US deaths 1968 Hong Kong Influenza H3N2 34k US deaths 1980 1997 1915 * Avian Flu 2003 2004 1977 1996 2002 1925 1935 1945 1955 1965 1975 1985 1995 2005 2003-2006 1998 1999 2003

HHS Pandemic Influenza Focus Slow the spread to reduce incidence of illness and death Use social distancing, targeted antiviral treatment, isolation and quarantine to buy time to increase: Antiviral supply Vaccine availability Weeks Impact Prepared Unprepared

Slow the spread to reduce incidence of illness and death

Use social distancing, targeted antiviral treatment, isolation and quarantine to buy time to increase:

Antiviral supply

Vaccine availability

Elements of Pandemic Control Infection control and prevention: Reduce transmission from contact between infected and non-infected Patient management and isolation: Reduce contact between infected and non-infected Contact management (e.g., quarantine): Reduce contact between possibly-infected and non-infected Community restrictions (e.g., school closures): Reduce contact between groups that might contain infected individuals

Infection control and prevention:

Reduce transmission from contact between infected and non-infected

Patient management and isolation:

Reduce contact between infected and non-infected

Contact management (e.g., quarantine):

Reduce contact between possibly-infected and non-infected

Community restrictions (e.g., school closures):

Reduce contact between groups that might contain infected individuals

History of Infection Control Precautions in the United States 1877 Separate facilities 1910 Antisepsis and disinfection 1950- 60 Closure of Infectious disease and TB hospitals 1970 CDC presented “Isolation Techniques for use in Hospitals” 1980-90s Universal/Standard Precautions

1877 Separate facilities

1910 Antisepsis and disinfection

1950- 60 Closure of Infectious disease and TB hospitals

1970 CDC presented “Isolation Techniques for use in Hospitals”

1980-90s Universal/Standard Precautions

Disease Transmission Leave original host Survive in transit Be delivered to a susceptible host Reach a susceptible part of the host Escape host defenses Multiply and cause tissue damage Pathogens:

Standard Precautions Constant use of gloves and handwashing (plus face-shields, masks or gowns if splashes are anticipated) for any contact with blood, moist body substances (except sweat), mucous membranes or non-intact skin. Gloves are removed and discarded immediately after completion of a task. Hands are washed every time gloves are removed.

Constant use of gloves and handwashing (plus face-shields, masks or gowns if splashes are anticipated) for any contact with blood, moist body substances (except sweat), mucous membranes or non-intact skin.

Gloves are removed and discarded immediately after completion of a task.

Hands are washed every time gloves are removed.

Transmission-based Precautions Used in addition to Standard Precautions Contact : Gloves, gown Droplet : Adds splash protection, eye protection and/or face shield Airborne : Adds respiratory protection and, ideally, other engineering controls

Contact : Gloves, gown

Droplet : Adds splash protection, eye protection and/or face shield

Airborne : Adds respiratory protection and, ideally, other engineering controls

Yes or No? Can influenza spread via contact route? Can influenza spread via the droplet route Can influenza spread via the airborne route?

Can influenza spread via contact route?

Can influenza spread via the droplet route

Can influenza spread via the airborne route?

Quick Review: How is pan flu likely to be transmitted? Influenza usually spreads from person to person through close contact via respiratory droplets from coughing, sneezing, or talking Influenza can also be spread by touching something that contaminated with the virus. This can include items such as: Tabletops Doorknobs Computer keyboards and Telephone handsets Cloth, tissues, paper or currency infected with the virus Another person’s hands or mouth

Influenza usually spreads from person to person through close contact via respiratory droplets from coughing, sneezing, or talking

Influenza can also be spread by touching something that contaminated with the virus.

This can include items such as:

Tabletops

Doorknobs

Computer keyboards and Telephone handsets

Cloth, tissues, paper or currency infected with the virus

Another person’s hands or mouth

Evidence for Benefits of Physical Separation Proximity of less than 3 feet has been associated with increased risk for transmission of infections via respiratory droplets. New Engl J Med 1982;307:1255-7 Am J Med 1948;4:690 *P=0.0001 for the difference 7% (5/71)* >102 cm 27% (20/73)* <102 cm Percentage of carriers or cases Distance between chairs

Proximity of less than 3 feet has been associated with increased risk for transmission of infections via respiratory droplets. New Engl J Med 1982;307:1255-7 Am J Med 1948;4:690

Potential for Contact Transmission Influenza virus can survive on surfaces at room temperature and moderate humidity: Steel and plastic: 24-48 hours Cloth and tissues: 8-12 hours Virus could be transferred from steel to hands 24 hours after inoculation, but from tissue to hands for only 15 minutes. J Infect Dis 1982;146:47-51

Influenza virus can survive on surfaces at room temperature and moderate humidity:

Steel and plastic: 24-48 hours

Cloth and tissues: 8-12 hours

Virus could be transferred from steel to hands 24 hours after inoculation, but from tissue to hands for only 15 minutes.

Potential for Contact Transmission Influenza viruses are enveloped Environmental cleaning may lower contact transmission risk Effectively inactivated by: Detergents Alcohol-based products (hand gels) Bleach solutions Household disinfectants

Influenza viruses are enveloped

Environmental cleaning may lower contact transmission risk

Effectively inactivated by:

Detergents

Alcohol-based products (hand gels)

Bleach solutions

Household disinfectants

Evidence for Benefits of Hand Hygiene Hand hygiene reduces the respiratory infections in healthcare and community settings. Among Navy Recruits Am J Prev Med 2001;21:79-83 Hand washing program implemented at a Navy training center. 45% reduction in outpatient visits for respiratory illness. Frequent hand washers had fewer respiratory illnesses.

Hand hygiene reduces the respiratory infections in healthcare and community settings.

Among Navy Recruits

Am J Prev Med 2001;21:79-83

Hand washing program implemented at a Navy training center.

45% reduction in outpatient visits for respiratory illness.

Frequent hand washers had fewer respiratory illnesses.

Among Students in Residence Halls AJIC 2003;31:364-70 College dorms were randomized to having alcohol hand rubs in various locations vs. not. Hand rub groups had: 14.8%-39.9% reduction in respiratory illnesses 43% fewer sick days

College dorms were randomized to having alcohol hand rubs in various locations vs. not.

Hand rub groups had:

14.8%-39.9% reduction in respiratory illnesses

43% fewer sick days

Stratifying Risk: How Likely Will I Be Infected? In Healthcare settings: ++++ Aerosol generating procedures performed on influenza patients ++++ Resuscitation of a patient with influenza (i.e., emergency intubation, CPR, etc.) ++/+++ Direct patient care for a symptomatic (ill) patient suspected to have influenza ++ Direct routine patient care for all other patients ++ Home care for a family member ill with influenza ++ Non-patient-care activities in a healthcare setting

In Healthcare settings:

++++ Aerosol generating procedures performed on influenza patients

++++ Resuscitation of a patient with influenza

(i.e., emergency intubation, CPR, etc.)

++/+++ Direct patient care for a symptomatic (ill) patient suspected to have influenza

++ Direct routine patient care for all other patients

++ Home care for a family member ill with influenza

++ Non-patient-care activities in a healthcare setting

In the Community: + Home care for a family member who is ill but not known to have influenza + Prolonged exposure within 3-6 feet to large numbers of individuals +/- Brief exposure within 3-6 feet to large numbers of individuals +/- Exposure within 3-6 feet to one or two individuals ~0 Being in a room alone Stratifying Risk (continued)

In the Community:

+ Home care for a family member who is ill but not known to have influenza

+ Prolonged exposure within 3-6 feet to large numbers of individuals

+/- Brief exposure within 3-6 feet to large numbers of individuals

+/- Exposure within 3-6 feet to one or two individuals

~0 Being in a room alone

Protecting the Workplace Prevent transmission within the workplace Optimize hand hygiene Facilitate respiratory etiquette Maintain good environmental hygiene Exclude sources of infection Consider a screening of and exclusion of individuals with fever or respiratory symptoms Exclude individuals with ill household members

Prevent transmission within the workplace

Optimize hand hygiene

Facilitate respiratory etiquette

Maintain good environmental hygiene

Exclude sources of infection

Consider a screening of and exclusion of individuals with fever or respiratory symptoms

Exclude individuals with ill household members

What’s Included in the CDC Workforce Protection Plan ? Personal and Family Readiness Keeping the Workplace Safe Assuring the Safety of CDC Deployments Managing Illness within the Workplace Guidance for Supervisors and Managers Mental Health and Resiliency During Pandemic

Personal and Family Readiness

Keeping the Workplace Safe

Assuring the Safety of CDC Deployments

Managing Illness within the Workplace

Guidance for Supervisors and Managers

Mental Health and Resiliency During Pandemic

Personal and Family Readiness General Preparedness = Pandemic Preparedness Family Emergency Plan Important Pandemic Awareness Initiative: Seasonal and Pandemic Flu Pamphlets “Flu Kit” Provided with Seasonal Vaccine Hand gel, tissues, waste bag “ Influenza Preparedness”: CDC Employee Guide

General Preparedness = Pandemic Preparedness

Family Emergency Plan Important

Pandemic Awareness Initiative:

Seasonal and Pandemic Flu Pamphlets

“Flu Kit” Provided with Seasonal Vaccine

Hand gel, tissues, waste bag

“ Influenza Preparedness”: CDC Employee Guide

Keeping the Workplace Safe Cough Etiquette Hand Hygiene Social Distancing Limiting Face to Face Meetings Telecommuting and Teleconferencing Lunch “To Go” Surface Cleaning and other Environmental Measures Potential for Workplace Entry Screening

Cough Etiquette

Hand Hygiene

Social Distancing

Limiting Face to Face Meetings

Telecommuting and Teleconferencing

Lunch “To Go”

Surface Cleaning and other Environmental Measures

Potential for Workplace Entry Screening

Managing Illness within the Workplace Have Workers Pay Attention to Your Own Body Promote this--Stay Home if You Are Feeling Ill! Supervisors, Managers and Team Leads Have a Role to Play Onsite Occupational Health Clinics Can Offer Assistance Know About and Use Appropriate Leave if Needed http://www.opm.gov/pandemic/index.asp

Have Workers Pay Attention to Your Own Body

Promote this--Stay Home if You Are Feeling Ill!

Supervisors, Managers and Team Leads Have a Role to Play

Onsite Occupational Health Clinics Can Offer Assistance

Know About and Use Appropriate Leave if Needed

http://www.opm.gov/pandemic/index.asp

Guidance for Supervisors and Managers Stay Engaged in Pandemic Planning Act Promptly if Illness Occurs Among Your Workforce Understand and Apply Leave Policies Consider Telecommute Options and Plan for Them in Advance Cross-train Workers and Plan for a “3 Deep” Strategy

Stay Engaged in Pandemic Planning

Act Promptly if Illness Occurs Among Your Workforce

Understand and Apply Leave Policies

Consider Telecommute Options and Plan for Them in Advance

Cross-train Workers and Plan for a “3 Deep” Strategy

Mental Health and Resiliency During Pandemic Stay Connected to Those Around You Optimize Your Current Level of Wellness Find Hobbies, Sports, Pastimes or Activities that Make You Happy and Give Purpose Remain Hopeful and Optimistic

Stay Connected to Those Around You

Optimize Your Current Level of Wellness

Find Hobbies, Sports, Pastimes or Activities that Make You Happy and Give Purpose

Remain Hopeful and Optimistic

Communicating with Your Workforce During the Pandemic Share information with staff on pandemic status through emails or periodic “town hall” conference calls Set-up a hotline which provides current status and any specific directions to staff with critical or essential job functions Provide communication/talking points to leaders and supervisors based on the specific stages of the pandemic

Share information with staff on pandemic status through emails or periodic “town hall” conference calls

Set-up a hotline which provides current status and any specific directions to staff with critical or essential job functions

Provide communication/talking points to leaders and supervisors based on the specific stages of the pandemic

For More Information: Accurate and Up-to-Date Resources www.pandemicflu.gov (Government-wide pan flu site) www.cdc.gov (CDC) www.dhs.gov (Department of Homeland Security) http://www.who.int/en/ (World Health Organization) http://www.redcross.org/ (Red Cross)

www.pandemicflu.gov (Government-wide pan flu site)

www.cdc.gov (CDC)

www.dhs.gov (Department of Homeland Security)

http://www.who.int/en/ (World Health Organization)

http://www.redcross.org/ (Red Cross)

Acknowledgements Thanks goes to the following persons who have contributed to this presentation and to the development of the CDC Pandemic Workforce Protection Plan Dr. Mike Bell, Division of Healthcare Quality Promotion, Coordinating Center for Infectious Diseases, CDC Dr. Eli Warnock, Medical Director of CDC’s Occupational Health Clinics Dr. Marie Socha, Senior Health Scientist and Consultant to the CDC Office of Health and Safety

Thanks goes to the following persons who have contributed to this presentation and to the development of the CDC Pandemic Workforce Protection Plan

Dr. Mike Bell, Division of Healthcare Quality Promotion, Coordinating Center for Infectious Diseases, CDC

Dr. Eli Warnock, Medical Director of CDC’s Occupational Health Clinics

Dr. Marie Socha, Senior Health Scientist and Consultant to the CDC Office of Health and Safety

QUESTIONS?