Spread the Word-Not the flu November 2nd 2009 OMSI Science Pub Gary Oxman, MD, MPH Paul Lewis, MD Tri-county Health Officer Group Clackamas, Multnomah, Washington Counties

Desired Outcomes for Session Participants will… Be introduced to a framework for thinking about emergencies Understand the basic science behind Influenza Understand the current pandemic influenza situation Become familiar with the Public Health response to H1N1 Have questions answered or acknowledged

Be introduced to a framework for thinking about emergencies

Understand the basic science behind Influenza

Understand the current pandemic influenza situation

Become familiar with the Public Health response to H1N1

Have questions answered or acknowledged

H1N1 Preparedness & Response A Framework for Action Read this book!* * Available in Paperback

The Unthinkable - B asics Through evolution, people are built to cope with disasters Individual capacity We all can cope, but some cope better than others All of us can improve our coping capacity Group capacity People naturally support each other to cope with disaster

Through evolution, people are built to cope with disasters

Individual capacity

We all can cope, but some cope better than others

All of us can improve our coping capacity

Group capacity

People naturally support each other to cope with disaster

The Unthinkable - Basics Three stages of human response to disaster Denial – not understanding the new realities Deliberation – considering possible actions Decisive moment – taking action Dysfunctional responses do occur Inaction/paralysis – very common Poor choices of action Panic – rare

Three stages of human response to disaster

Denial – not understanding the new realities

Deliberation – considering possible actions

Decisive moment – taking action

Dysfunctional responses do occur

Inaction/paralysis – very common

Poor choices of action

Panic – rare

The Unthinkable Take away points People are built to cope with disaster Understand that the response is in ordinary people’s hands – your hands Be prepared; rehearse Understand the situation Have a focused, realistic plan When disaster happens, act on your plan! Listen to authorities, but don’t wait.

People are built to cope with disaster

Understand that the response is in ordinary people’s hands – your hands

Be prepared; rehearse

Understand the situation

Have a focused, realistic plan

When disaster happens, act on your plan! Listen to authorities, but don’t wait.

Influenza Basics

Influenza

Influenza Symptoms It's NOT the common cold Fever, body aches, cough, sore throat Notably ill for 3-5 days Diagnosis – by health care provider (lab tests usually not necessary) Great majority recover without treatment

It's NOT the common cold

Fever, body aches, cough, sore throat

Notably ill for 3-5 days

Diagnosis – by health care provider (lab tests usually not necessary)

Great majority recover without treatment

Influenza Types & Definitions Seasonal Influenza Occurs every year Affects ~10-15% of population yearly Kills ~36,000 people in the US every year – mostly elderly There is a vaccine every year Pandemic Influenza A world-wide outbreak of influenza Occurs a few times per century Caused by a new influenza virus strain Illness can be mild to severe Can affect ~20-35% of the population

Seasonal Influenza

Occurs every year

Affects ~10-15% of population yearly

Kills ~36,000 people in the US every year – mostly elderly

There is a vaccine every year

Pandemic Influenza

A world-wide outbreak of influenza

Occurs a few times per century

Caused by a new influenza virus strain

Illness can be mild to severe

Can affect ~20-35% of the population

Biology of Pandemics

Influenza Virus

Changes in the Flu Virus Drift: continuous small RNA mutations H and N evolve during and between seasons Vaccine requires frequent modification to be effective Over many years a specific H or N-type can become much different from its origin

Drift: continuous small RNA mutations

H and N evolve during and between seasons

Vaccine requires frequent modification to be effective

Over many years a specific H or N-type can become much different from its origin

Drift: continuous small RNA mutations Shift: major changes Non-human virus infects humans Combining of genes between human and animal strains Shift required to produce a Pandemic Earthquake fault, New Zeeland Health Emergency Management, NZ Changes in the Virus

Drift: continuous small RNA mutations

Shift: major changes

Non-human virus infects humans

Combining of genes between human and animal strains

Shift required to produce a Pandemic

Genesis of New Influenza A Virus Subtypes with Pandemic Potential Gerberding, J. L. et al. N Engl J Med 2004;350:1236-1247

NIH Web conf

Pandemic H1N1 Genetic History www.sciencexpress.org / 22 May 2009 / Page 4/ 10.1126/science.1176225

Current Situation

Likely Origin Winter 2009 Rapid, global, spread April-June 2009 WHO declared pandemic in June Overall severity mild Shift in severe disease away from elderly 48 states in US reporting widespread flu activity at this time-very early Current Flu Situation

Rapid, global, spread April-June 2009

WHO declared pandemic in June

Overall severity mild

Shift in severe disease away from elderly

48 states in US reporting widespread flu activity at this time-very early

Hospitalizations by Age Group, Oregon* *data as of 10/09/09

US Pandemic Severity Scale Anticipated range of H1N1 severity during 2009-2010

How bad is it ? Assumptions: 20 to 30% of the population will get influenza Death rate is same as seasonal flu (0.05% or 1 in 2,000) Metro area population is 2 million people 400,000- 600,000 Sick 1,400,000- 1,600,000 Well 200 - 300 Severely ill or dead

Assumptions:

20 to 30% of the population will get influenza

Death rate is same as seasonal flu (0.05% or 1 in 2,000)

Metro area population is 2 million people

Risk Factors Pregnancy Heart disease Kidney disease Immune system problems Diabetes Obesity Cancer Asthma & other lung diseases About 2/3 of severe H1N1 illness and hospitalization impacts people with risk factors:

Pregnancy

Heart disease

Kidney disease

Immune system problems

Diabetes

Obesity

Cancer

Asthma & other lung diseases

H1N1: Some Take-home Points Typical influenza virus with typical symptoms, complications – a “mild” influenza Can be treated with antiviral drugs Most cases recover uneventfully Compared with seasonal flu, shift to younger ages for hospitalization and death

Typical influenza virus with typical symptoms, complications – a “mild” influenza

Can be treated with antiviral drugs

Most cases recover uneventfully

Compared with seasonal flu, shift to younger ages for hospitalization and death

Public Health & Medical Response

Goals of Pandemic Response Minimizing death and disability as much as practical given available resources, and Maintaining an intact community – one that is poised to resume normal life physically, socially, economically, emotionally and spiritually following the pandemic

Minimizing death and disability as much as practical given available resources, and

Maintaining an intact community – one that is poised to resume normal life physically, socially, economically, emotionally and spiritually following the pandemic

Public Health Response Strategies Prevention through appropriate individual and institutional behaviors to protect self and others Vaccination Medical care to treat illness and prevent complications

Prevention through appropriate individual and institutional behaviors to protect self and others

Vaccination

Medical care to treat illness and prevent complications

Preventing Illness Through Appropriate Behavior The mantra Wash you hands Cover your cough Stay home when you’re sick Sounds simple, but…”The choices people make are driven by the choices they have” Choice requires Information for people (and their friends, family and coworkers) Supportive policies (e.g., sick time policies) Absence of disincentives (e.g., losing pay or job)

The mantra

Wash you hands

Cover your cough

Stay home when you’re sick

Sounds simple, but…”The choices people make are driven by the choices they have”

Choice requires

Information for people (and their friends, family and coworkers)

Supportive policies (e.g., sick time policies)

Absence of disincentives (e.g., losing pay or job)

ACIP H1N1 2009 Vaccine Recommendations (not in order of priority) Pregnant women Live with or care for infants < 6 mo old Healthcare/EMS workers with direct contact with patients or infectious material People 6 months – 24 years old People 25 - 64 years old with high-risk medical conditions http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm ~ 50% Of USA

Pregnant women

Live with or care for infants < 6 mo old

Healthcare/EMS workers with direct contact with patients or infectious material

People 6 months – 24 years old

People 25 - 64 years old with high-risk medical conditions

PH Strategy: Access to Medical Care Goals: Treat illness Prevent complications Two Approaches Providers continue to care for their established patients Anticipate surge in demand – visits calls Plan ahead – office protocols, methods for testing, prescribing antivirals Regional Access to Care initiative for those without a medical home

Goals:

Treat illness

Prevent complications

Two Approaches

Providers continue to care for their established patients

Anticipate surge in demand – visits calls

Plan ahead – office protocols, methods for testing, prescribing antivirals

Regional Access to Care initiative for those without a medical home

Temporary healthcare reform Access to care during a pandemic

Supporting PH Strategies Communication Information for the public Partner and Clinician outreach and communication – e.g., detailed clinical practice guidelines PH surveillance and investigation Tracking hospitalized cases, deaths – now reportable Tracking hospital/health care utilization Outbreak investigation – selected situations only

Communication

Information for the public

Partner and Clinician outreach and communication – e.g., detailed clinical practice guidelines

PH surveillance and investigation

Tracking hospitalized cases, deaths – now reportable

Tracking hospital/health care utilization

Outbreak investigation – selected situations only

Questions and Dialogue