Influenza Its Outbreaks,

Epidemics and Pandemics

Scott Lindquist MD MPH
Director of The Kitsap County
Health District
Influenza Virus
Source: CDC/Dr. Erskine Palmer
 Symptom Influenza Common Cold
Fever Often high; sudden onset 38°C Rare
– 40°C and lasts 3-4 days
Headache Frequently Rare
Aches and pains Usual; often quite severe Slight
Weakness Moderate to extreme; may last Rare/Mild
up to one month
Bedridden Frequently; may last up to 5-10 Rare
days
Runny, stuffy nose Sometimes Common
Sneezing Sometimes Usual
Chest discomfort Usual and can be severe Sometimes, but mild to
moderate
Complications Respiratory failure; complicate Congestion, sinus or ear
a chronic condition infection
Prevention Influenza vaccine; frequent Frequent handwashing,
handwashing; cover your cough cover your cough
 Understanding Terminology

• Epidemic: serious outbreak in a single

community, population or region

• Pandemic: epidemic spreading around the

world affecting hundreds of thousands of
people, across many countries
 Influenza

• Family orthomyxoviridae
Source: Aventis Pasteur

• Enveloped viruses – 80-120 nm, negative stranded RNA with

8 different segments. Allows for genetic reassortment when
>1 virus infects a single cell

• Types A, B, and C: Significant differences in structure,

genetics, organization, host range, epidemiologic and clinical
characteristics

• Covered with surface projections or spikes -- Hemagglutinin

and neuraminidase—used to subtype influenza A virus types.
 Influenza Types Hosts

Type A Humans, birds, pigs

and horses
Type B Humans only
Type C Humans only
 Influenza

• Named by type / place isolated / culture # / yr

isolation
– A/Fujian/411/2002 (H3N2)
– B/Shanghai/361/2002-like
Source—Aventis Pasteur
 INFLUENZA – Epidemiology
• Incubation period 1-4 days

• Virus first detected just before onset of illness.

Virus usually not detected after 5 - 10 days.

• More prolonged shedding in children,

immunosuppressed hosts

• Transmission: via respiratory droplets

– person to person,
– direct contact,
 INFLUENZA – Epidemiology

• Attack rates 10-20% general population,

selected populations 40-50%

• Typical Season: 200,000 hospitalizations and

36,000 deaths

• INFLUENZA IS THE SINGLE MOST COMMON

VACCINE PREVENTABLE DISEASE
 Influenza, United States
• Estimated 36,000 deaths annually
• Estimated 200,000 hospitalizations
• Influenza vaccine recommended for ~185
million Americans annually
• Coverage abysmal
– Adults > 65 years: 65.6%
– Children 6-23 months: 7.4%
Week ending October 18, 2003 Week ending November 29, 2003

Week ending December 20, 2003 Week ending January 31, 2004

No Report No Activity Sporadic Local Regional Widespread

 How Does Influenza Change?
• Particular characteristic that enables
influenza A viruses to cause annual
epidemics, even pandemics
• Type A viruses undergo frequent changes in
their surface antigens or proteins
• Minor changes - antigenic drift
• Major changes - antigenic shift
 Antigenic Drift
• Occurs among influenza A viruses resulting
in emergence of new variants of prevailing
strains every year
• New variants result in seasonal flu each
winter
• Some years are worse than others – partly
related to degree of ‘drift’
 Antigenic Shift
Occurs in two ways:
• Sudden ‘adaptive’ change during replication
of a normal virus OR
• From an exchange of genes between human
strain of an influenza A virus and an animal
strain
 Influenza Diagnosis
• Most often a clinical diagnosis
• Laboratory tests
– molecular detection of virus in clinical
specimens
– culture of virus
– serology
• Rapid ‘near patient’ tests – detect the presence of
flu within 30 minutes – cannot determine the
specific virus
Treatment
Antiviral Drugs
 How Do Antiviral Drugs
Work?
• Prevent the flu virus from reproducing
• Treatment can shorten the illness by a day
and reduce hospitalisations by an estimated
50% (based on seasonal flu)
• To be effective, must be taken within 48
hours of the onset of flu symptoms
 Influenza Antivirals
Antiviral Trade Name Flu Use Age
Agent Type Restrictions
Amantadine Symmetrel A Prophylaxis > 1 year
Treatment
Rimantadine Flumadine A Prophylaxis Adults only for
Treatment Trx; > 1 year for
prophylaxis
Zanamivir Relenza A&B Treatment only > 7 years

Oseltamivir Tamiflu A&B Prophylaxis > 1 year for trx; >

Treatment 13 years for
prophylaxis
Prevention
 Influenza Vaccine
• Vaccine takes 6-8 months to produce
following the emergence of a new virus
• Supplies will be limited, if available at all
– Establish priority groups for use of limited
vaccine
– 2nd dose after 30 days will likely be required
– Need to monitor vaccine safety and efficacy
 Priority Groups For Influenza
Vaccination

• Children 6-23 months of age

• Adults >65 years
• Persons 2-64 years of age with underlying
chronic medical conditions
• Women who will be pregnant during
influenza season

MMWR 2004;53(39);923-4
Bird Influenza
 Influenza
From Birds to Humans
Migratory Domestic birds
water birds

• Hong Kong
1997, H5N1
• HK, China
1999, H9N2
• Netherlands
2003, H7N7
• Hong Kong
2003, H5N1
•Viet Nam and
Thailand, 2004
H5N1
 Situation Update (10 Oct 2005)

• THAILAND
– 17 confirmed cases of avian flu (12 deaths)

• VIETNAM
– 91 confirmed cases (41 deaths)

• CAMBODIA
– 4 confirmed cases (4 deaths)

• INDONESIA
– 5 confirmed cases (3 deaths)
Bird Influenza and
Human Influenza
Migratory
water birds
 Animal Influenza
and Human Influenza
Migratory
water birds
Influenza Pandemic
 Circulating Influenza strains and
pandemics in 20th Century

1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”
20-40 million deaths 1 million deaths 1 million deaths
H3N2
H2N2
H1N1 H1N1

1920 1940 1960 1980 2000

Source: America’s Forgotten Pandemic, 1918-1919
 How Should We Respond to
Epidemics?
• Surveillance
• Personal Health Interventions
• Population Based Interventions
Influenza Surveillance Systems
 INFLUENZA – Surveillance
Systems First Method
• 122 US Cities Pneumonia and Influenza
Mortality Surveillance (CDC)
Pneumonia and Influenza Mortality
for 122 U.S. Cities
Week Ending 11/06/2004
12

Background and Threshold for Epidemic Diagnosis

10
% of All Deaths Due to P&I

Epidemic Threshold

Seasonal Baseline

2001 2002 2003 2004

4
10 20 30 40 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40

Weeks
 INFLUENZA – Surveillance
Systems Second Method
Sentinel Providers

• Office visits for “Influenza like Illness”

(Health Departments and CDC)

– Sentinel Provider Offices: % visits for

“influenza like illnesses” -- fever + sore
throat or cough without another identified
cause;
 INFLUENZA – Surveillance
Systems Third Method
Laboratory Surveillance--WHO

WHO/NREVSS Collaborating Laboratories

National Summary, 2004-05
30 A(H3N2) 30

A(H1N1) and A(H1N2)

A(Unsubtyped)
25 25
B
Percent Positive

Number of Isolates

Percent Positive
20 20

15 15

10 10

5 5

0 0
40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20

Week
Personal Health Interventions

– Basic measures to reduce the spread of infection

• Hand washing: washing hands frequently with soap and water reduces
the spread of the virus from the hands to the face, or to others
• Respiratory hygiene: covering the mouth and nose when coughing or
sneezing; using a tissue when possible; disposing of dirty tissue
promptly are carefully – bag and bin
• Avoiding non essential travel: non attendance at large gatherings
such as concerts, theatres, cinemas, sports arenas etc
 Personal Health Interventions
• Have a Medical Home
• Mask
• Increase Social Distancing
• Antivirals
• Vaccines
Increase Social Distancing

• Avoid face to face meetings

• Use alternate methods of communication
• Attend only essential meetings
• Avoid public transit
• Flex work hours
• Pack a lunch, do not eat together
• If you must meet people, stay 1 meter away
• Wash your hands
 Population Based Interventions

• Travel restrictions
• Restrictions of mass public gatherings
• Schools closure
• Voluntary home isolation of cases
• Voluntary quarantine of contacts of known
cases
• Screening of people entering ports
What is Kitsap County Doing?
• County Emergency Response Plan
– Public Health Response Plan
– Influenza Response Plan
• Duty Officer
– 24 hour pager for Public Health Officer
covering 7 days/week and holidays.
What is Kitsap County Doing?
• Surveillance
– 3 Epidemiologists to track/monitor disease
trends.
– Peninsula Disease Tracking System
– Sentinel Providers
– Absenteeism monitoring
– Public Health Laboratory Capability
What is Kitsap County Doing?
• Communications
– PIO
– Prepared Disease Specific Fact Sheet
– Phone (cell, landline, satellite)
– HAM Radio
– Blast Fax capability
• Supplies
– National Stockpile(12 hour capability)
– Stockpiled Masks
What is Kitsap County Doing?
• Respiratory Etiquette Guidelines/Packages
– Created 2 years ago
• Citizens Reserve Corp
– Civilian mobilization to pass vaccines, supplies
– Neighborhood Distribution Centers
• Partnerships
What is Kitsap County Doing?
• Formal Isolation and Quarantine Procedures
– Legal authority and process to invoke isolation
and/or quarantine.
– Isolation and Quarantine Conference last year.
• Continue to drill and exercise influenza
planning
– County wide exercise past summer
 The Goal

• Keep Kitsap County Educated about

Influenza

• All Hazards Preparedness