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Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

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Page 1: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Texas Pandemic Influenza Preparedness

Texas Pandemic Influenza Preparedness

Cynthia Morgan, PhD, RN

Pandemic Influenza Program Coordinator, Acting

Anita Wheeler, BSN, RN

School Nurse Consultant

Page 2: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

AgendaAgenda

• Everything you wanted to know about pandemic influenza but couldn’t find anyone to ask

• What you can do to prepare your family

• What you can do to prepare your school

• What you can do to prepare your students & their families

Page 3: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Everything you wanted to know. . . Everything you wanted to know. . .

• Definitions• Examine reasons

pandemics occur• Look at the progress of

Avian H5N1 Influenza• Discuss why we are

concerned• Review current

prevention efforts• Consider the state of

the science

Page 4: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Avian vs Pandemic InfluenzaAvian vs Pandemic Influenza

Page 5: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Epidemiology of Avian flu in humansEpidemiology of Avian flu in humans

• Avian (Bird) Flu is a disease of birds

• All Avian Flu viruses are endemic in waterfowl & do not harm them

• Wild birds mix with domestic chickens in back yard farms

• Domestic chicken flocks mix in live poultry markets

• People mix with sick or dead chickens

• People catch Avian Flu

Page 6: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Seasonal vs Pandemic FluSeasonal vs Pandemic Flu

Seasonal• Annually• Known virus• Vaccine available

(usually)• High mortality

young & old esp. w/ health problems

Pandemic• Irregular intervals• Novel virus• No or mismatched

vaccine• High mortality in

20-50 year olds; mortality in young similar to seasonal flu

Page 7: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Pandemics of the 20th CenturyPandemics of the 20th Century

Year Name Strain Deaths

1918 Spanish H1N1 >50 million

(US 675,000)

1957 Asian H2N2 1 – 2 million

1968 Hong Kong H3N2 700,000

Page 8: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Natural hosts of influenza virusesHaemagglutinin subtype Neuraminidase subtype

H 1 H 2H 3H 4H 5H 6H 7H 8H 9

H 10H 11H 12H 13H 14H 15H 16

N 1N 2N 3N 4N 5N 6N 7N 8N 9

Page 9: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Composition of Seasonal VaccinesComposition of Seasonal Vaccines

• 2004 – 2005• A / New Caledonia / 99 / H1N1• A / Fugian / 02 / H3N2

• 2005 – 2006• A / New Caledonia / 99 / H1N1• A / California / 03 / H3N2

• 2006 – 2007 (recommended)• A / New Caledonia / 99 / H1N1• A / Wisconsin / 05 / H3N2

Page 10: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Pandemics of the 20th CenturyPandemics of the 20th Century

Year Name Strain Deaths

1918 Spanish H1N1 >50 million

(US 675,000)

1957 Asian H2N2 1 – 2 million

1968 Hong Kong H3N2 700,000

Page 11: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Antigenic changeAntigenic change

• Antigenic ‘drift’ occurs in HA and NA

• Associated with seasonal epidemics

• Continual development of new strains secondary to genetic mutations

• Antigenic ‘shift’ occurs in HA and NA

• Associated with pandemics

• Appearance of novel influenza A viruses bearing new HA or both HA & NA

Page 12: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

HumanHuman virusvirus

ReassortedReassortedvirusvirus

Non-humanNon-humanvirusvirus

Mechanisms of Antigenic Shift

Direct Infection

Indirect Infection

Reassortment in humans

Page 13: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 14: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 15: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 16: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 17: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 18: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

0

10

20

30

40

50

60

Countries with H5N1 Influenza in animals & humans

Countries with H5N1 Influenza in animals & humans

Countries with H5N1 influenza in animals

2003 2004 2005 2006Through June 15, 2006

2 1

11

2

18

5

51

10

Countries with H5N1 influenza in humans

Page 19: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Bird and Human Cases H5N1Bird and Human Cases H5N1

Bird Cases Human CasesJune 13, 2006

Page 20: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 21: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

The H5N1 Flu Threat to HumansThe H5N1 Flu Threat to Humans

1. A new virus to which humans have no immunity - Yes

2. The virus causes significant human illness or death - Yes

3. The virus spreads easily from person-to-person – NO

The Avian Flu (H5N1) virus has 2 out of 3 of these today…

Page 22: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Why the Concern with H5N1?Why the Concern with H5N1?

• 1918 (H1N1) flu and H5N1 avian flu are the only “kissing cousins” among the 169 known avian flu viruses.

Page 23: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

1918 Influenza Pandemic1918 Influenza Pandemic

• 20-40 million persons died worldwide, possibly more

• Death rate 25 times higher than previous epidemics

• 500-650,000 deaths in the U.S.: Ten times as many Americans died of flu than died in WW I

• The epidemic preferentially affected and killed younger, healthy persons

• The epidemic was so severe that the average life span in the U.S. was depressed by 10 years

Page 24: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

MOST FATAL EVENTMOST FATAL EVENTIN THE LAST 300 YRSIN THE LAST 300 YRSMOST FATAL EVENTMOST FATAL EVENTIN THE LAST 300 YRSIN THE LAST 300 YRS

35

40

45

50

55

60

65

70

1900 1906 1912 1918 1924 1930 1936 1942 1948 1954 1960

Date

Age

U.S. LIFE EXPECTANCY AT BIRTH

Page 25: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

1918 H5N1 Incident rate (0-75)1918 H5N1 Incident rate (0-75)

15 55

Page 26: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Case fatality rate comparison (0-75)Case fatality rate comparison (0-75)

15

55

Page 27: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Case fatality rate comparisonCase fatality rate comparison

Page 28: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Cytokine StormCytokine Storm

• Has been suggested as an explanation for the devastating nature of the 1918 flu

• Is an over reactive immune response that causes multiple organ system failure

• Evidence indicates H5N1 deaths are caused by this

Page 29: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Worst Case ScenarioWorst Case Scenario

Patient

Severe (1918-like)

National Texas

Number sick 150M 11.5M

Outpatient 75M (50%) 5.75M

Hospitalized 16.5M (11%) 1,265,000

ICU Care 2.5M (15%) 199,750

Ventilator 1.25M (50%) 94,780

Death 3.225M (2.15%) 247,250

Absenteeism 50% of workforce over 1 year

Page 30: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Pandemic wave mortalityPandemic wave mortality

Page 31: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 32: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Animal interventionAnimal intervention

Page 33: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Society during a pandemicSociety during a pandemic

• Healthcare system• Work• School• Travel• Supplies• Services

Page 34: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Prevention & Containment – NonpharmaceuticalPrevention & Containment – Nonpharmaceutical

• Public Health population focused measures

• Personal protective measures

• Business contingency planning

• Care of sick at home

Page 35: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant
Page 36: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Potential Community Measures to Decrease Transmission

Potential Community Measures to Decrease Transmission

• Travel advisories/limit travel to affected areas• Screening travelers from affected areas* • Limit large public gatherings; close schools• Encourage telecommuting• Limit availability of public transportation• Hand hygiene, respiratory hygiene/cough

etiquette• Quarantine of exposed persons*• Education to allow early identification and

isolation of cases*

* Note: Some measures may be most useful early in outbreak and with strains that are not efficiently transmitted

Page 37: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Evidence for use of masksEvidence for use of masks

• Limited evidence available on benefits of masks in preventing healthcare or community influenza transmission

• Use prudent at least in healthcare settings

• SARS studies have shown clear benefit mask use in healthcare setting

Page 38: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Influenza Antiviral Drug QuestionsInfluenza Antiviral Drug Questions

• How much supply will there be?• Will feds or state have control over

distribution decisions?

• How should it be used?

• Who should get it? • How can it be delivered? • Where does the $$ come from?

Page 39: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

12/07?? 50 million courses

Page 40: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Influenza Antiviral Drug QuestionsInfluenza Antiviral Drug Questions

• How much supply will there be?• Will feds or state have control over

distribution decisions?• Where do the $$ come from?

• How should it be used?

• Who should get it? • How can it be delivered?

Page 41: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Influenza Vaccine QuestionsInfluenza Vaccine Questions

• When will it be available?• How much will there be?• How effective will it be?• Who will own it?• How should it be delivered? • Who should get it?• Who will pay for it?

Page 42: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Current methodCurrent method

• 1950’s technology• Depends on

eggs and chicks• Shortages often

due to problems here

• Requires 4-6 months for vaccine production

Page 43: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Pandemic wave mortalityPandemic wave mortality

Page 44: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

New methodNew method

• Cell cultures

• Less room

• More dependable

• Requires 4-6 weeks for vaccine production

Page 45: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Vaccine Consumption - 2000Vaccine Consumption - 2000

Source: WHO Global Influenza Program

Page 46: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Vaccine Production CapacityVaccine Production Capacity

Page 47: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Texas Plan Challenges InHealth Systems Response Texas Plan Challenges InHealth Systems Response

• Assuring essential workers are prophylaxed and/or vaccinated

• Surge Capacity• Emergency Systems for Advance

Registration of Volunteer Health Professionals Program (ESAR-VHP)

• Availability of PPE• Disaster Mental Health• Dead bodies

Page 48: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Texas Plan Challenges InCommunicationTexas Plan Challenges InCommunication

• Risk Communication• Pre-event message preparation for

the public• Educating decision makers• Communication technology• Interoperability

Page 49: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

How can you prepare?How can you prepare?

• Visit the DSHS website at: www.dshs/state/tx/us

• Follow the Pandemic Influenza link to the state’s plan.

• Appendix F “Personal Protective Strategies

Page 50: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

How can you prepare?How can you prepare?

• Get seasonal flu vaccine• Stay informed• Stockpile supplies, food, & some $$• Talk to MD and RPh about extra

routine meds• Don’t forget pets• Have a family plan• Know your business’ continuity plan

Page 51: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

WebsitesWebsites

• http://www.pandemicflu.gov• http://www.cidrap.umn.edu/cidrap/• http://www.cidrap.umn.edu/services/

email/change• http://www.cdc.gov/flu/pandemic/• http://www.psandman.com/indxpand.htm• http://www.dshs.state.tx.us

Page 52: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Planning Takes Partnerships

Planning Takes Partnerships

Page 53: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Considerations in School Planning

Considerations in School Planning

▶THE ROLES OF SCHOOLS IN THE COMMUNITY

▶ COMMUNICATING/COORDINATING WITH PUBLIC HEALTH/GOVERNMENT OFFICIALS

▶ UPDATING SCHOOL CRISIS PLANS

▶ LEARNING ABOUT PREVENTING INFECTIONS

▶ EDUCATING PARENTS, KIDS, STAFF

▶ INFORMING/COUNTERING DISINFORMATION

▶ MAINTAINING THE LEARNING ENVIRONMENT

Page 54: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Local Planning Is Critical

Local Planning Is Critical

Planning must be broad/interactive/cross-cutting/coordinated: city government, civil

agencies health departments, community centers, medical providers,

businesses, schools, private/voluntary/faith based organizations

Page 55: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Resources to Assist in Crisis Planning

Resources to Assist in Crisis Planning

Page 56: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Federal and State Resources Focus on

Local Planning

Federal and State Resources Focus on

Local Planning

Page 57: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Mitigation and Prevention Activities

Mitigation and Prevention Activities

►►Liaison with state/local health Liaison with state/local health officialsofficials

►Clear Roles/responsibilities of staff

►Roles of school nurses

►Assign key roles

►Review health needs of students

►Improve health activities

Page 58: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Pandemic Preparedness

Pandemic Preparedness

►Update crisis plans

►Educate staff, students & parents

►Account for Procedures

►Delegate Crisis Communication/Authority

Page 59: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Local School ConsiderationsLocal School

Considerations►Maintain operations & the learning environment

►Triage/isolate students and staff

►Use good health practices: handwashing, disinfect, etc.

►Address misinformation

►Plan for school closure

►Disseminate community information

► Utilize schools as clinics, hospitals, morgues, vaccination sites or vaccine storage sites

Page 60: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

School Houses were turned into temporary hospitals during the 1918 Influenza Pandemic

Page 61: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Pandemic Recovery Period

Pandemic Recovery Period

► Allocate time for recovery

► Involve kids & parents

► Counsel

► Debrief

► Plan anniversaries

► Facility remediation

Page 62: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

School Specific Websites

School Specific Websites

• www.itsasnap.org/snap/about.asp• www.scrubclub.org/home.php• www.cdc.gov/flu/protect/covercough.htm• www.cdc.gov/germstopper/• www.pandemicflu.gov/plan/schoolchecklist.html• www.state.gov/m/a/os/c17204.htm• www.tea.state.tx.us/pandemic_spellingsltr.html

Page 63: Texas Pandemic Influenza Preparedness Cynthia Morgan, PhD, RN Pandemic Influenza Program Coordinator, Acting Anita Wheeler, BSN, RN School Nurse Consultant

Questions?Questions?