Pandemic Influenza

Larimer County Community LeadersAwareness Meeting

Dec. 6, 2005

Larimer County in 1918Larimer County in 1918

County population about 27,000County population about 27,000

Fort Collins population 8,700Fort Collins population 8,700

Loveland population about 5,000Loveland population about 5,000

Social Environment in 1918Social Environment in 1918

Most residents involved in agriculture, Most residents involved in agriculture, directly or indirectlydirectly or indirectly

World War I was the major news storyWorld War I was the major news story There was rationing of coal, fuel, food There was rationing of coal, fuel, food

and other items needed for war effortand other items needed for war effort Red Cross was very active in Red Cross was very active in

community, supporting war effortcommunity, supporting war effort

Outbreak begins in military Outbreak begins in military training campstraining camps

Deaths occurring in Deaths occurring in training camps in training camps in East were reported East were reported in local newspapersin local newspapers

Numerous Larimer Numerous Larimer County enlistees/ County enlistees/ draftees were draftees were among the fatalities among the fatalities (4 from Camp Dix, (4 from Camp Dix, NJ in 1 wk.)NJ in 1 wk.)

Spreading to CiviliansSpreading to Civilians

Larimer County Larimer County residents were aware residents were aware of growing, alarming of growing, alarming deaths among deaths among civilians in Eastern civilians in Eastern citiescities

First cases in CO in First cases in CO in Boulder; army Boulder; army trainees on College trainees on College campus. (First cases campus. (First cases in FC at Ag College)in FC at Ag College)

Flu shut down schools and Flu shut down schools and businessesbusinesses

Loveland schools Loveland schools closed on Oct. 8closed on Oct. 8

Fort Collins Fort Collins closed schools closed schools on Oct. 10on Oct. 10

They would not They would not reopen untilreopen until Dec. 30 Dec. 30

Loveland, Oct 1918 - Feb 1919Flu/Pneumonia Deaths by week

1

3

4

8

17

5

3 3

2

3

5 5

2

1

2 2

0

1

0

2

4

6

8

10

12

14

16

18

Oct 6

-12

Oct 1

3-19

Oct 2

0-26

Oct 2

7-Nov

2

Nov 3

-Nov

9

Nov 1

0-Nov

16

Nov 1

7-Nov

23

Nov 2

4-Nov

30

Dec 1

-Dec

7

Dec87

-Dec

14

Dec 1

5-Dec

21

Dec 2

2-Dec

29

Dec 3

0-Ja

n 4

Jan

5-Ja

n 11

Jan

12-J

an 1

8

Jan1

9-Ja

n25

Jan

26-F

eb 1

Feb 2

-Feb

8

Week

Dea

ths

1918 Flu killed young adults1918 Flu killed young adults

Highest Highest number of number of deaths were in deaths were in the in late the in late teens through teens through the mid 30’sthe mid 30’s

Pneumonia & Influenza Deaths by Age, Loveland 1917 & 1918 (Sept-Dec)

0 0 0

1 1 1 1

0 0

5 5

16

17

6

7

2

1

00

2

4

6

8

10

12

14

16

18

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 over 75

Age in years

De

ath

s

1917 (Sept-Dec) 1918 (Sept-Dec)

By the end of the outbreakBy the end of the outbreak

Overall, there were 67 deaths in Overall, there were 67 deaths in Loveland, a town of 5,000 in a 15 Loveland, a town of 5,000 in a 15 week period.week period.

This represented an overall death This represented an overall death rate of 1.3% of the population.rate of 1.3% of the population.

Why are we Why are we concerned today?concerned today?

“We at WHO believe that the

world is now in the gravest possible

danger of a pandemic"

Shigeru Omi, World Health Organization , 2005

Pandemic influenza is the“the most

important threat that we are facing

right now. “

Julie Gerberding, CDC director, 2005Julie Gerberding, CDC director, 2005

“It will be absolutely essential that local communities are well prepared, have a plan, and have sorted out who will be responsible for what.”

Michael Leavitt, U.S. HHS director

“Localities should be prepared to rely on their own resources to respond.”

U.S. draft pandemic influenza plan, 2005

InfluenzaInfluenza

Outbreaks yearly, usually in winter Outbreaks yearly, usually in winter monthsmonths

Illness more severe for very young, Illness more severe for very young, elderly, or those with pre-existing health elderly, or those with pre-existing health conditionsconditions

Yearly, 5-20% of population get the fluYearly, 5-20% of population get the flu Annually causes >200,000 Annually causes >200,000

hospitalizations in UShospitalizations in US 36,000 deaths yearly in US36,000 deaths yearly in US

Influenza PreventionInfluenza Prevention

Yearly influenza shotYearly influenza shot Avoid those who are illAvoid those who are ill Wash your handsWash your hands Antivirals (in special circumstances)Antivirals (in special circumstances)

If you are ill--don’t come to work, cover If you are ill--don’t come to work, cover coughs and sneezes.coughs and sneezes.

Influenza Virus typesInfluenza Virus types

– Type AType A: Infects humans and other : Infects humans and other animalsanimals

More severe illnessMore severe illnessCauses regular epidemics; can cause Causes regular epidemics; can cause pandemicspandemics

– Type BType B: Infectious only to humans: Infectious only to humansCauses epidemics, but less severe Causes epidemics, but less severe illnessillness

InfluenzaInfluenza Influenza A is subtyped Influenza A is subtyped

by surface proteinsby surface proteins– Hemagglutinin (H)Hemagglutinin (H)

16 different types16 different types Helps virus enter cellsHelps virus enter cells

– Neuraminidase (N)Neuraminidase (N) 9 different types9 different types Helps virus leave cell Helps virus leave cell

to infect othersto infect others

InfluenzaInfluenza

All known subtypes of Influenza A found All known subtypes of Influenza A found in birds - 144 possible combinations ofin birds - 144 possible combinations of H’s and N’s H’s and N’s

H5 and H7 cause severe outbreaks in H5 and H7 cause severe outbreaks in birdsbirds

Human disease usually due to H1, H2, Human disease usually due to H1, H2, H3 and N1 and N2.H3 and N1 and N2.

InfluenzaInfluenza

The flu virus constantly changesThe flu virus constantly changes

When it does, vaccines will be less When it does, vaccines will be less efficient efficient

Immune system may be unable to Immune system may be unable to recognize new virusrecognize new virus– No immunity in population for new No immunity in population for new

virus—potential for pandemicvirus—potential for pandemic

Vaccine DevelopmentVaccine Development Inactivated trivalent vaccine (killed vaccine)Inactivated trivalent vaccine (killed vaccine) 2 A, 1 B2 A, 1 B Effectiveness of vaccine depends on “match” Effectiveness of vaccine depends on “match”

between circulating strains and those in vaccinebetween circulating strains and those in vaccine

(H3N2)(H1N1)

Influenza

Protection

A/California/7/2004-like

B/Shanghai/361/2002-like

2005–2006 Influenza Season

A/New Caledonia/20/99-like

Influenza—Vaccine Influenza—Vaccine ProductionProduction

Flu vaccines first produced in Flu vaccines first produced in 1940s1940s

2 manufacturers in US for flu 2 manufacturers in US for flu vaccinevaccine

80 million doses produced by late 80 million doses produced by late September September

6-9 months to produce vaccine6-9 months to produce vaccine

Influenza PandemicsInfluenza Pandemics What is a Pandemic?What is a Pandemic?

– Outbreak in wide geographic area (global)Outbreak in wide geographic area (global)– Effects large # of people with serious Effects large # of people with serious

illnessillness– Usually a new virus or one which Usually a new virus or one which

population has not had exposure in a long population has not had exposure in a long timetime

– May have rapid spreadMay have rapid spread– May occur in wavesMay occur in waves

Seasonal Flu vs Pandemic Seasonal Flu vs Pandemic FluFlu

SeasonalSeasonal Occurs every yearOccurs every year

Occurs during winter Occurs during winter (usually Dec-Mar)(usually Dec-Mar)

Most recover in 1-2 Most recover in 1-2 weeks without txweeks without tx

Very young, very Very young, very old, ill most at risk of old, ill most at risk of serious illness serious illness

PandemicPandemic Occurs infrequentlyOccurs infrequently

(3 per century)(3 per century) Occurs any time of Occurs any time of

yearyear Some may not Some may not

recover, even with recover, even with txtx

People of all ages People of all ages may be at riskmay be at risk

Pandemic InfluenzaPandemic Influenza

Past Pandemics:Past Pandemics:

– 1968 Hong Kong Flu (H3N2) 1968 Hong Kong Flu (H3N2) – 1957 Asian Flu (H2N2) 1957 Asian Flu (H2N2) – 1918 Spanish Flu (H1N1)1918 Spanish Flu (H1N1)

1918-1919 influenza 1918-1919 influenza pandemicpandemic

Worst of past centuryWorst of past centuryEstimated 20-40% of world Estimated 20-40% of world population illpopulation ill

40-50 million people died 40-50 million people died worldwideworldwide

600,000 or more deaths in US600,000 or more deaths in USHigh mortality in young adultsHigh mortality in young adults

Why did young people die?Why did young people die?

Over-reaction by the immune system Over-reaction by the immune system called “cytokine storm” called “cytokine storm”

Those with the strongest immune Those with the strongest immune systems affectedsystems affected

Older people and youngest often die Older people and youngest often die of bacterial pneumonia complicating of bacterial pneumonia complicating flu -- treatable now with antibioticsflu -- treatable now with antibiotics

Even in 2005, no good treatment for Even in 2005, no good treatment for “cytokine storm.”“cytokine storm.”

There are There are severe pandemics severe pandemics

and mild pandemicsand mild pandemics

Infectious Disease Deaths Infectious Disease Deaths 1900’s1900’s

1918

1957 1968

Deaths per 100,000 per year

Pandemics can last Pandemics can last for months and come for months and come

in wavesin waves

Loveland, Oct 1918 - Feb 1919Flu/Pneumonia Deaths by week

1

3

4

8

17

5

3 3

2

3

5 5

2

1

2 2

0

1

0

2

4

6

8

10

12

14

16

18

Oct 6

-12

Oct 1

3-19

Oct 2

0-26

Oct 2

7-Nov

2

Nov 3

-Nov

9

Nov 1

0-Nov

16

Nov 1

7-Nov

23

Nov 2

4-Nov

30

Dec 1

-Dec

7

Dec87

-Dec

14

Dec 1

5-Dec

21

Dec 2

2-Dec

29

Dec 3

0-Ja

n 4

Jan

5-Ja

n 11

Jan

12-J

an 1

8

Jan1

9-Ja

n25

Jan

26-F

eb 1

Feb 2

-Feb

8

Week

Dea

ths

H5N1 Avian InfluenzaH5N1 Avian Influenza

Hong Kong 1997Hong Kong 1997– 18 human cases, 6 deaths18 human cases, 6 deaths– 1.4 million birds destroyed1.4 million birds destroyed

Dec. 2003: AsiaDec. 2003: Asia– Ongoing extensive outbreak in poultryOngoing extensive outbreak in poultry– Limited human to human transmissionLimited human to human transmission– 125 human cases, 64 fatal125 human cases, 64 fatal

July-Aug 2005 Kazakhstan, RussiaJuly-Aug 2005 Kazakhstan, Russia October 2005 Turkey, Romania, RussiaOctober 2005 Turkey, Romania, Russia

H5N1 SymptomsH5N1 Symptoms

Symptoms (human)Symptoms (human)– FeverFever– Shortness of breathShortness of breath– CoughCough– PneumoniaPneumonia– Acute Respiratory DistressAcute Respiratory Distress– Diarrhea, sometimes severeDiarrhea, sometimes severe– Life-threatening complications Life-threatening complications

Transmission of flu virusTransmission of flu virus

Incubation period of 1-4 days for regular Incubation period of 1-4 days for regular flu - not clear if H5N1 might be longerflu - not clear if H5N1 might be longer

Can be communicable to others 24 hours Can be communicable to others 24 hours before symptoms begin - and up to 5 before symptoms begin - and up to 5 days or more after onset (adults) or 10 or days or more after onset (adults) or 10 or more days (children)more days (children)

Usually spread through respiratory Usually spread through respiratory droplets or contaminated objects. May droplets or contaminated objects. May also be airborne, and perhaps thru feces.also be airborne, and perhaps thru feces.

Concern with Avian Concern with Avian InfluenzaInfluenza

Virus mutates rapidlyVirus mutates rapidly Can acquire genes from viruses Can acquire genes from viruses

infecting other speciesinfecting other species H5N1 has acquired some of genetic H5N1 has acquired some of genetic

changes in the 1918 virus associated changes in the 1918 virus associated with human-human transmissionwith human-human transmission

Causes severe disease in humansCauses severe disease in humans High fatality rateHigh fatality rate

Current H5N1 casesin Vietnam, Thailand, Cambodia, & Indonesia as of 11/1/05

Case-fatalitycases deaths rate

Dec 2003-Mar 2004 35 24 69%July 2004 - October 2004 9 8 89%Dec 2004 to date 78 30 38%Total 122 62 51%

Date of onset

Total

Are we more or less Are we more or less at risk today at risk today

compared to 1918?compared to 1918?

Why at LESS risk in 2005Why at LESS risk in 2005

Antibiotics for bacterial Antibiotics for bacterial pneumonia complications of pneumonia complications of influenzainfluenza

Some antiviral medicinesSome antiviral medicines IV fluids, ventilatorsIV fluids, ventilatorsGreater ability to do surveillance, Greater ability to do surveillance,

confirm diagnosis of fluconfirm diagnosis of flu

Why at LESS risk in 2005 Why at LESS risk in 2005

Rapid means of Rapid means of communications - internet, TV, communications - internet, TV, radio, email radio, email

More effective personal More effective personal protective equipmentprotective equipment

Fewer people living in each Fewer people living in each household and more rooms.household and more rooms.

Why at MORE risk in 2005Why at MORE risk in 2005

A lot more international travelA lot more international travel 10 times more people in Larimer 10 times more people in Larimer

County, contact with far more County, contact with far more people dailypeople daily

Very little surge capacity in health Very little surge capacity in health care todaycare today

Greater reliance on health Greater reliance on health professionalsprofessionals

Why at MORE risk in 2005Why at MORE risk in 2005

More elderly and immune-More elderly and immune-compromised people in populationcompromised people in population

Much less self-sufficient than in Much less self-sufficient than in 1918’s (households and businesses)1918’s (households and businesses)

Today’s society not used to Today’s society not used to rationing, sacrifice, compared to rationing, sacrifice, compared to war-time 1918.war-time 1918.

Why at MORE risk in 2005Why at MORE risk in 2005

Far more manufactured goods Far more manufactured goods and raw materials come from and raw materials come from distant areas, especially Asiadistant areas, especially Asia

““Just-in-time” ordering of needed Just-in-time” ordering of needed supplies instead of warehousing supplies instead of warehousing critical items on sitecritical items on site

Overall, are we at more or Overall, are we at more or less risk?less risk?

Up to individuals, communities, Up to individuals, communities, states, and nations to decide as states, and nations to decide as they plan for a possible they plan for a possible pandemicpandemic

What might happen What might happen in a severe in a severe pandemic?pandemic?

If it happens soon…..If it happens soon…..

There will be little or no vaccine until There will be little or no vaccine until 6 - 9 months after the outbreak begins6 - 9 months after the outbreak begins

There will be very limited supplies of There will be very limited supplies of antiviral medicines for treatment (for antiviral medicines for treatment (for 1% of populations, perhaps less).1% of populations, perhaps less).

All communities hit a about the same All communities hit a about the same timetime

We need a plan for the short-term that We need a plan for the short-term that assumes no effective shots or Rxassumes no effective shots or Rx

What might occurWhat might occur

Health system could be Health system could be overwhelmedoverwhelmed

Essential services could be at risk Essential services could be at risk (fuel, power, water, food, etc.)(fuel, power, water, food, etc.)

““Just-in-time” supply lines could Just-in-time” supply lines could be disruptedbe disrupted

High mortality rates could occurHigh mortality rates could occur Social disruption could occurSocial disruption could occur

Considerations for Considerations for preparednesspreparedness

Can we maintain our Can we maintain our utilities?utilities?

Recent disasters have showed us the Recent disasters have showed us the need for water, power, telecommuni-need for water, power, telecommuni-cations, heat in an emergencycations, heat in an emergency

Could they operate with 50% of staff?Could they operate with 50% of staff? Do they stockpile materials and parts Do they stockpile materials and parts

to ensure operation for 90-120 days?to ensure operation for 90-120 days?

Who will provide health Who will provide health care?care?

Health workers will be disproportion-Health workers will be disproportion-ately exposed and may become illately exposed and may become ill

Some will not show up due to fearSome will not show up due to fear Some will not be able to leave sick Some will not be able to leave sick

family members, children out of schoolfamily members, children out of school Little or no surge capacity; nursing Little or no surge capacity; nursing

shortage; future of Medical Reserveshortage; future of Medical Reserve

Will transportation/trade Will transportation/trade problems impact food problems impact food

supply?supply? Typical household has food on hand Typical household has food on hand

to last 3 days.to last 3 days. Few families have emergency Few families have emergency

reserves for a prolonged periodreserves for a prolonged period Low-income least able to set Low-income least able to set

supplies aside for an emergencysupplies aside for an emergency Prices may rise quickly in Prices may rise quickly in

emergency.emergency.

Who will help us?Who will help us? Little or no state and federal assistanceLittle or no state and federal assistance Local government also limited in what it Local government also limited in what it

can do to assist citizenscan do to assist citizens Churches, neighbors, friends and Churches, neighbors, friends and

families would need to help each otherfamilies would need to help each other Vulnerable groups would need extra Vulnerable groups would need extra

assistanceassistance Advance planning and stockpiling of Advance planning and stockpiling of

necessities could help.necessities could help.

What public agencies What public agencies and businesses can and businesses can

dodoas employersas employers

Maintain Essential ServicesMaintain Essential Services

Halt non-essential activities and Halt non-essential activities and re-deploy staff to fill vacancies in re-deploy staff to fill vacancies in critical services.critical services.

Cross train: Make sure all critical Cross train: Make sure all critical functions can be done by several functions can be done by several different people.different people.

Maintain Essential ServicesMaintain Essential Services

Create written instructions/ Create written instructions/ procedures for critical processes procedures for critical processes that can be carried out by othersthat can be carried out by others

If possible, keep essential If possible, keep essential supplies/ parts stockpiled in supplies/ parts stockpiled in advance to maintain services.advance to maintain services.

Increase Social DistanceIncrease Social Distance

Determine how to provide services Determine how to provide services with less person-to-person contact with less person-to-person contact whenever possiblewhenever possible

Increase telecommuting if possibleIncrease telecommuting if possible Use phone, web, virtual conferences Use phone, web, virtual conferences

to replace face-to-face meetingsto replace face-to-face meetings Waive non-critical policies if they Waive non-critical policies if they

force in-person contactforce in-person contact

Decrease contact exposuresDecrease contact exposures

Increase cleaning/sanitizing of Increase cleaning/sanitizing of locks/ doorknobs, faucet and locks/ doorknobs, faucet and toilet handles, shared keyboards, toilet handles, shared keyboards, telephones, other equipment telephones, other equipment

Vacuuming/sweeping may stir up Vacuuming/sweeping may stir up infectious particlesinfectious particles

Decrease contact exposuresDecrease contact exposures

Use/provide tissues, hand Use/provide tissues, hand sanitizers, disposable gloves if sanitizers, disposable gloves if available (All could be scarce available (All could be scarce during a pandemic)during a pandemic)

Increasing humidity may reduce Increasing humidity may reduce virusvirus

Provide Personal Protective Provide Personal Protective Equipment Equipment

Need will vary with type businessNeed will vary with type business Will be difficult to obtain in a Will be difficult to obtain in a

pandemic - need to secure in pandemic - need to secure in advanceadvance

Masks (N95 or better) may reduce Masks (N95 or better) may reduce exposure, but are difficult to wear exposure, but are difficult to wear for prolonged time or if employee for prolonged time or if employee has health problems.has health problems.

Teach protective actionsTeach protective actions

Hand washing without Hand washing without recontaminationrecontamination

Covering cough, not using handsCovering cough, not using hands Avoid putting hands to face, Avoid putting hands to face,

mouth, nose, eyes.mouth, nose, eyes. Staying home if any signs of Staying home if any signs of

illnessillness

Prepare Communications Prepare Communications PlanPlan

How will key managers How will key managers communicate among themselvescommunicate among themselves

How will information be conveyed How will information be conveyed to customers?to customers?

How will information be conveyed How will information be conveyed to employees?to employees?

How will employees know who to How will employees know who to call in specific situations?call in specific situations?

Prepare for difficult HR Prepare for difficult HR issuesissues

If offices are closed, will staff be paid?If offices are closed, will staff be paid? If staff are needed, can they refuse to If staff are needed, can they refuse to

come to work?come to work? If required to report, what protective If required to report, what protective

equipment, if any, will be provided?equipment, if any, will be provided? Can employer force someone who may Can employer force someone who may

be ill NOT to work? (Employees without be ill NOT to work? (Employees without sick leave may try to work while ill.)sick leave may try to work while ill.)

Prepare for difficult HR Prepare for difficult HR issuesissues

If an employee is required to work If an employee is required to work with ill people and becomes ill, is itwith ill people and becomes ill, is ita worker’s comp situation?a worker’s comp situation?

How Ready Are We?How Ready Are We?

Used with permission of the Minneapolis Star-Tribune

"Every day a pandemic doesn't

happen is another day

we have to prepare.”

--Michael Osterholm