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Pandemic Influenza Prevention

Pandemic Influenza Prevention. Eisha Akbar, M.D. 5 /4/14 PUBH 6165 Dr. Raymond Thron. What is Influenza?. Influenza is an RNA virus that has three types: Influenza A, Influenza B, and Influenza C.

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Pandemic Influenza Prevention

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  1. Pandemic Influenza Prevention Eisha Akbar, M.D. 5/4/14 PUBH 6165 Dr. Raymond Thron

  2. What is Influenza? • Influenza is an RNA virus that has three types: Influenza A, Influenza B, and Influenza C. • Influenza A and B are the primary types that infects humans and have two types of antigens: hemagglutinin (H) and neuraminidase (N). 2 • There are sixteen distinct H subtypes and nine distinct N subtypes for influenza A- as a recombinant RNA virus, influenza viruses upon contact with other, different influenza viruses can reshuffle their genes and thus become more virulent and resistant to medication. 6. Fauci et al, 2008 5. CDC, 2014

  3. http://www.niaid.nih.gov/topics/flu/research/basic/pages/antigenicdriftillustration.aspxhttp://www.niaid.nih.gov/topics/flu/research/basic/pages/antigenicdriftillustration.aspx

  4. http://www.niaid.nih.gov/topics/Flu/Research/basic/Pages/AntigenicShiftIllustration.aspxhttp://www.niaid.nih.gov/topics/Flu/Research/basic/Pages/AntigenicShiftIllustration.aspx

  5. What does influenza do? • Influenza is a respiratory virus that spreads through respiratory droplets in the air from coughing, sneezing, or talking by infected persons. • The viruses attach to cells in the respiratory tract and rapidly multiply and spread throughout the respiratory tract. • Symptoms include fever, myalgias, headaches, sore throat, runny nose, and fatigue. • The flu is generally more severe in the very young and the very old with 90% of influenza deaths in persons who are 65 or older. • Those who are weakened by the flu can have a bacterial superinfection like pneumonia which can result in death. 6. Fauci et al, 2008

  6. Risk Factors • Children younger than five (especially those younger than 2) • People aged 65 or older • Pregnant women • Native Americans and Alaskan Natives • Persons with asthma, neurological/neurodevelopmental disorders, chronic lung disease, heart failure, metabolic disorders, immunosuppression, morbid obesity, kidney disorders, and more 6. Fauci et al, 2008

  7. Prevention and Treatment • Influenza vaccine is available during the flu season from October-March. • There are trivalent shots, quadrivalent shots, trivalent shots without egg, and quadrivalent nasal spray • Recommended for children age 6 months to 59 months • Recommended for those 50 and older • Nursing home residents and healthcare personnel have increased exposure and therefore require vaccination • Antiviral drugs • Primary drugs being oseltamivir and zanamivir; active against both type A and type B. Amantadine is no longer effective (Fauci et al, 2008) • Oseltamivir can be used on patients of any age while zanamivir is approved for those aged 7 years and older. • Antiviral drugs are used in severe cases, otherwise treatment is usually supportive. 5. CDC, 2014 6. Fauci et al, 2008

  8. History of pandemic influenza • The most infamous influenza pandemic was the Spanish flu which occurred between 1917 and 1918, killing around 40 million people, especially the young and healthy (WHO, 2003) • Risk factors during that time included being between 25-29, military service, chest circumference being 90-100+ cm (Summers et al, 2014) • Two other pandemics, Asian influenza in 1957 (H2N2) and Hong Kong influenza (H3N2) in 1968 were not as severe as Spanish flu but was found to have increased mortality in young people. (WHO, 2003, Fauci et al, 2008) • It is difficult to estimate how many people die of influenza each year, but the 2012-2013 season showed 42 admissions for every 100,000 years, which increased from 7.7-23.4 per 100,000 in the previous three seasons (Bresee et al, 2013)

  9. Avian Flu • Avian flu is an influenza A type virus that is found in birds all over the world, having been isolated from 100 different bird species (CDC) • H7N9 was reported in China in March of 2013, found in infected poultry with human crossover, although there was no human to human transmission • 44 deaths resulted of H7N9 during spring of 2013 • Increased frequency of H7N9 began in October 2013 • Highly pathogenic H5N1 (HPAI H5N1) usually kills what fowl or poultry it infects and has human crossover from animals and has resulted in death. • Because H5N1 is seriously pathogenic, there are restrictions on the importation of poultry from countries where outbreaks are common • There are currently stockpiles of vaccines against HPAI H5N1 should the virus easily begin to transfer from human to human and cause an outbreak 5. CDC, 2014

  10. Swine Flu • Swine flu is a type A influenza virus found primarily in pigs with the main viruses being H1N1, H3N2, and H1N2. Infection in humans is known as “variant influenza viruses”. • Those infected with variant influenza are usually those who work closely with pigs. • H1N1 in 2009 was found in humans in April of 2009 was declared a “public health emergency” by the WHO later that month. (Young et al, 2013) • Due to air travel, at least five cases were found on commercial air flights to the UK. 5. CDC, 2014

  11. H1N1 Pandemic of 2009 • First reported to who as “influenza-like illness” in the US and Mexico on 24th April, 2009 • By 30th April, 11 countries had reported incidence of H1N1 cases, totaling 257 cases • By June 3rd, 19,273 cases were reported in 66 countries with 117 deaths, 97 of them being in Mexico • On July 31st, 2009, 168 countries and territories had reported at least one case of H1N1 with 162,380 cases and 1154 deaths. • On July 30th, 2010, 214 countries and territories had reported over 18,000 cumulative deaths from H1N1 • H1N1 cases were decreasing by summer of 2010 but were still very active in New Zealand and India • By 10th September 2010, WHO relegated H1N1 as post-pandemic 15. WHO, 2010

  12. Ongoing Surveillance • WHO Global Influenza Surveillance and Response System • Monitors virus changes, provides recommendations for lab procedures, vaccines, risk assessment • If needed, gives out a global alert • Monitors for antiviral susceptibility and resistance • Has National Influenza Centres (NIC) to collect reports and analyses of viruses in nations around the world • Epidemiology and Prevention Branch of Influenza Division of the CDC in the United States • Finds and tracks influenza activity, determines virus type, discovers virus changes, and measures the impact of hospitalizations and deaths. • Virological surveillance in tandem with WHO 12. WHO, 2014 4. CDC, 2014

  13. Are we prepared? • While H1N1 resulted in deaths and caused the WHO to announce it as a worldwide public health issue, H1N1 did not have strong virulence. • Vaccine availability against H1N1 was low after it was announced as a pandemic and was only available in ample supply after October. • Antiviral drug production is not currently up to where there would be enough in the case of a pandemic and some virus strains may be resistant. • Areas of low resource are at higher risk as supply lines may halt to prevent spread, leaving insufficient amounts of food, medicine, and health care workers • Non-pharmaceutical interventions such as hand washing and isolation may be of some assistance (Starbuck et al, 2013)

  14. So what is being done?

  15. Actions of the WHO • Global Action Plan for Influenza Vaccines • Objective 1 is to increase vaccination use and policy in countries, objective 2 is to increase pandemic vaccine production and to vaccination 70% of the world’s population, and objective 3 is to develop better vaccines and improve the speed at which they are developed. • From institution in 2006 to 2013, GAP shows global vaccine production capacity increase to 1.5 billion, increased manufacturing bases in low and middle income countries, increased number of countries that vaccinate at risk groups from 46 to 72, and at least 380 clinical trials of pandemic vaccines. • FluNet • “Global tool for influenza virological surveillance” • Collects data from NICs and regional WHO databases • 10,986 specimens positive for influenza, 67.4% being influenza A and 32.6% being influenza B. 10. WHO, 2014 12. WHO, 2014

  16. 13. World Health Organization (WHO). (2014). Percentage of respiratory specimens that tested positive for influenza, by influenza transmission zone (image). Retrieved from http://www.who.int/influenza/surveillance_monitoring/updates/2014_04_07_influenza_update_208_week_12.jpg?ua=1

  17. Actions of the CDC • FluView • Provides weekly surveillance reports on influenza activity • Obtains data from hospitals, laboratories, and public health services and is prepared to alert country and WHO in case of epidemic • Has found 8,995 laboratory confirmed cases of hospitalizations due to influenza • H3N2, H1N1, and influenza B viruses have all been reported in the 2013-2014 season • Highest percentage of cases were in week 52 of 2013 and has steadily decreased since • National Influenza Vaccination Week • Took place December 8-14th, 2013. • Works to shine a spotlight on influenza and the importance of vaccination through social media, vaccination clinics, newspaper and magazine articles, and news programs 3. CDC, 2013 4. CDC, 2014

  18. 4. Centers for Disease Control and Prevention (CDC). (2014). FluView: A Weekly Influenza Surveillance Report Prepared by the Influenza Division. http://www.cdc.gov/flu/weekly/index.htm#OISmap

  19. 4. Centers for Disease Control and Prevention (CDC). (2014). FluView: A Weekly Influenza Surveillance Report Prepared by the Influenza Division. http://www.cdc.gov/flu/weekly/index.htm#OISmap

  20. Prevention Methods • Influenza vaccine • For both those at risk and the healthy- herd immunity protects us all. • Hand washing, with increased frequency in those exposed to the sick • Covering nose and mouth when sneezing and coughing • Staying home when sick to prevent further spread • Disinfecting surfaces • Stop smoking • Canceling mass gatherings or closing schools when there is a large amount of illness. 2. CDC, 2012

  21. Cost Effectiveness of Prevention • School closure + antiviral drugs + vaccine prophylaxis are the most cost effective strategies. • Prophylaxis is key as vaccination can reduce severity of symptoms and time of disease. • Severe pandemic: ~$9 per life year saved • Reduced social contact (closed schools, no mass gatherings, closed crowded workplaces) and antiviral drugs cut down on cost • Costs are usually a result of hospitalizations and deaths • Low severity pandemic: ~$58 per life year saved • Costs result of productivity losses due to people staying at home due to illness. 7. Milne et al, 2013

  22. What have we learned? • Influenza is constant presence in the world of illness with the season usually lasting from October to March. • There have been severe historical pandemics that have resulted in huge losses of life. • We have vaccines and antiviral drugs available to prevent and treat influenza. • There are many daily activities we can perform to prevent ourselves from catching the flu. • Staying at home when ill is best to prevent further spread of disease.

  23. THE END Any Questions?

  24. References 1. Bresee, J., Reed, C., Kim, I.K., Finelli, L., Fry, A., Chaves, S.S., Burns, E., Garuillo, P., Jernigan, D., Cox, N., Singleton, J., Zhai, Y., O’Halloran, A., Kahn, K., Lu, P-J., Santibanez, T. (2013). Estimated Influenza Illnesses and Hospitalizations Averted by Influenza Vaccination — United States, 2012–13 Influenza Season. Morbidity and Mortality Weekly Report. 62(49): 997-1000. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6249a2.htm 2. Centers for Disease Control and Prevention (CDC). (2012). Nonpharmaceutical Interventions (NPIs). Retrieved from http://www.cdc.gov/nonpharmaceutical-interventions/ 3. Centers for Disease Control and Prevention (CDC). (2013). National Influenza Vaccination Week. Retrieved from http://www.cdc.gov/flu/nivw/index.htm 4. Centers for Disease Control and Prevention (CDC). (2014). FluView: A Weekly Influenza Surveillance Report Prepared by the Influenza Division. http://www.cdc.gov/flu/weekly/index.htm#OISmap 5. Centers for Disease Control and Prevnetion (CDC). (2014). Seasonal Influenza (Flu). Retrieved from http://www.cdc.gov/flu/about/disease/index.htm 6. Fauci, A.S., Kasper, D.L., Longo, D.L., Brauwald, E., Hauser, S.L., Jameson, J.L., Loscalzo, J. (2008). Harrison’s Principles of Internal Medicine, 17th ed. New York City , NY: McGraw Hill. 7. Milne, G.J., Halder, N., Kelso, J.K. (2013). The Cost Effectiveness of Pandemic Influenza Interventions: A Pandemic Severity Based Analysis. PLoS One. 8(4):e61504. doi:10.1371/journal.pone.0061504. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?sid=0194aa2c-fd9e-46f2-935a-b6658547d7d3%40sessionmgr113&vid=8&hid=128 8. Starbuck, E.S., von Bernuth, R., Bolles, K., Koepsell, J. (2013). Are we prepared to help low-resource communities cope with a severe influenza pandemic? Influenza and Other Respiratory Viruses. 7(6): 909-913. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?sid=ca8d283b-4f86-483a-8372-753252af3da0%40sessionmgr112&vid=2&hid=128

  25. References 9. Summers, J.A., Stanley, J., Baker, M.G., Wilson, N. (2014). Risk factors for death from Pandemic influenza in 1918-1919: a case control study. Influenza and Other Respiratory Viruses. 8(3): 329-338. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?sid=2c015b38-7921-4bfa-a040-96a310c41847%40sessionmgr115&vid=2&hid=128 10. World Health Organization (WHO). (2014). FluNet Summary. Retrieved from http://www.who.int/influenza/gisrs_laboratory/updates/summaryreport/en/ 11. World Health Organization (WHO). (2014). Global Action Plan for Influenza Vaccines: Global Progress Report January 2006-September 2013). Geneva, Switzerland: WHO Press. http://apps.who.int/iris/bitstream/10665/112307/1/9789241507011_eng.pdf?ua=1 12. World Health Organization (WHO). (2014). Global Influenza Surveillance and Response System (GISRS). Retrieved from http://www.who.int/influenza/gisrs_laboratory/en/ 13. World Health Organization (WHO). (2014). Percentage of respiratory specimens that tested positive for influenza, by influenza transmission zone (image). Retrieved from http://www.who.int/influenza/surveillance_monitoring/updates/2014_04_07_influenza_update_208_week_12.jpg?ua=1 14. World Health Organization (WHO). (2003). Influenza. Retrieved from http://www.who.int/mediacentre/factsheets/2003/fs211/en/ 15. World Health Organization (WHO). (2010). Situation Updates- Pandemic (H1N1) 2009. Retrieved from http://www.who.int/csr/disease/swineflu/updates/en/ 16. Young, N, Pebody, R., Smith, G., Olowokure, B., Shankar, G., Hoschler, K., Galiano, M., Green, H., Wallensten, A., Hogan, A., Oliver, I. (2014). International flight related transmission of pandemic influenza A (H1N1)pdm09: an historical cohort study of the first identified cases in the United Kingdom. Influenza and Other Respiratory Viruses. 8(1): 66-73. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?sid=8b6da3de-998e-4934-8fe3-9f26925991a5%40sessionmgr114&vid=2&hid=128

  26. References 17. Antigenic Drift. (2011). National Institute of Allergy and Infectious Diseases. Retrieved from http://www.niaid.nih.gov/topics/flu/research/basic/pages/antigenicdriftillustration.aspx 18. Antigenic Shift. (2011). National Institute of Allergy and Infectious Diseases. Retrieved from http://www.niaid.nih.gov/topics/Flu/Research/basic/Pages/AntigenicShiftIllustration.aspx

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