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Annex F - Pandemic Influenza Response Plan According to the World Health Organization (WHO), “An influenza pandemic occurs when a new influenza virus appears against which the human population has no immunity, resulting in several simultaneous epidemics worldwide with enormous numbers of deaths and illness. With the increase in global transport and communications, as well as urbanization and overcrowded conditions, epidemics due to the new influenza virus are likely to quickly take hold around the world.” Influenza is a highly contagious respiratory virus that is responsible for annual epidemics in the United States and other countries. Each year an average of 200,000 people are hospitalized and 36,000 die in the U.S. from influenza infection or a secondary complication. During an influenza pandemic the level of morbidity and mortality from influenza will likely increase dramatically worldwide. During the last century, three influenza pandemics caused increased mortality, morbidity and societal burden throughout the world above the levels seen with usual yearly epidemics. The "Spanish" influenza pandemic of 1918 killed over 500,000 people in the United States and had a worldwide mortality of 20 to 40 million. The virus that year was notorious for its predilection for severely affecting healthy young adults. Since 1918, two global outbreaks of influenza A occurred. In 1957, Asian influenza caused approximately 80,000 deaths in the United States. During the Hong Kong pandemic in 1968-69, mortality in the United States was estimated at 30,000 deaths, with 51 million Americans affected by influenza. Influenza viruses are grouped into three types designated as A, B and C. Viruses of the C type are common but usually cause no symptoms or only very mild respiratory illness. They are not considered to be a public health concern. Type B viruses cause sporadic outbreaks of more severe respiratory disease, particularly among young children in school settings. Type A viruses typically cause the majority of morbidity and mortality each year during the influenza season. Both B and C viruses normally only infect humans. C viruses are stable, but A and B viruses are prone to mutation. Every year influenza viruses change because they have the ability to mutate genetically. Both influenza A and B viruses can undergo the minor genetic variations known as antigenic drift. Antigenic drift is a gradual change caused by minor point mutations in the viral genes that results in small changes to the surface proteins of the influenza virus. Antigenic drift occurs continuously, and is the reason that the make-up of the influenza vaccine is changed almost every year. Influenza A virus is unique in that it can infect a variety of animals, with wild birds being the natural reservoir. It can undergo the major genetic reassortment known as antigenic shift. This sudden change happens infrequently and often occurs as a result of a recombination of human influenza A with an animal influenza A virus. This recombination results in a new subtype of influenza A to which the human population has little or no immunity. An antigenic shift is often the impetus for an influenza pandemic. The impact of an influenza pandemic on the local healthcare system could be devastating. It is likely that 15-35% of Iowa's population will be affected. There is a potential for high levels of morbidity and mortality, as well as the significant disruption to society, making planning for the next influenza pandemic imperative. I. PURPOSE The purpose of this plan annex is to ensure an immediate and effective local response in the event of an influenza pandemic to limit the morbidity and mortality of Iowans and to keep economic loss and social disruption to a minimum. All components of the bio-emergency plan remain applicable and relevant to this pandemic influenza annex, including but not limited to; maintenance, exercise, activation, authority and NIMS Compliance. II.ASSUMPTIONS AND PLANNING FACTORS There may be very little warning. Most experts believe that we will have between one and six months between the time that a novel influenza strain is identified outside of the U.S. and the time that outbreaks begin to occur in the U.S. Outbreaks may occur simultaneously throughout much of the U.S., preventing shifts in human and material resources that normally occur with other natural localized or regional disasters. The effect of influenza on individual communities will be relatively prolonged -- weeks to months. The impact of a pandemic could have a devastating effect on the health and well being of the American public. Effective preventive and therapeutic measures -- including vaccines and antiviral agents -- will likely be in short supply, as well as antibiotics to treat secondary infections. Health-care workers and other first responders will likely be at even higher risk of exposure and illness than the general population, creating the potential to further impede care of victims. Widespread illness in the community will increase the likelihood of sudden and potentially significant shortages of personnel in other sectors that provide critical community services, including military personnel, police, firefighters, utility workers, and transportation workers. Local Emergency Planning Committees are currently in place or being established. These committees are or will begin to address the Pandemic Influenza planning process. III. PLAN ORGANIZATION This plan annex recognizes the World Heath Organization's Pandemic Periods and six phases of Pandemic Influenza and relates planning factors related to surveillance by each phase. Inter-pandemic period - Phase 1: No new influenza virus subtypes in humans; subtype that has caused human infection may be present in animals. Phase 2: As above, but circulating animal subtype poses substantial risk of human disease. Pandemic alert period - Phase 3: Human infection with new subtype, no human to human spread, or rare spread to close contact. Phase 4: Small clusters with limited human to human transmission, highly localized spread, suggesting virus is not well adapted to humans. Phase 5: Larger clusters, but human to human spread still localized, virus increasingly better adapted to humans, but not yet fully transmissible. Pandemic period - Phase 6: Increased and sustained transmission in general population. This plan annex recognizes the Iowa Pandemic Period Progressions. The progressions are part of Phase 6 of the Pandemic period described above. The plan is designed to outline the objectives regardless of the order in which progressions might appear. For example, the pandemic strain may appear in Iowa before any other state and the objectives in this plan would still apply. The progressions are the following:  Pandemic strain is circulating throughout the world but is not yet in the U.S. Pandemic strain is circulating in the U.S. but is not yet in Iowa. Pandemic strain is circulating in Iowa.Influenza Specific Surveillance by Phases: In the event of an influenza pandemic, routine local surveillance systems will be rapidly adapted or enhanced to respond to the challenges of a pandemic in order to support the surveillance activities conducted at the state level. Enhanced surveillance would be any additional component or improvement to the current surveillance system as directed by the IDPH. The IDPH's routine influenza surveillance is conducted from October to May each year; yet some influenza components of the surveillance is system are conducted year-round. In the event of influenza pandemic Greene County will assist the IDPH in surveillance efforts for each phase as listed below. Phases 1 and 2: Continue with current local routine influenza surveillance methods: Maintain communication with IDPH allowing for rapid communication should a strain which affects humans and animals be detected. Phase 3: Continue ongoing activities from previous phases as appropriate. Communicate with IDPH as they will monitor and revise recommendations from the CDC for any additional surveillance activities that should be undertaken. IDPH may consider expanding virologic and disease-based surveillance to year-round surveillance. Greene County will support IDPH by communicating with: Sentinel providers that monitor ILI year-round; Schools, child care and long-term care participants. Educating local physicians to screen for ILI in persons traveling from geographic areas in which pandemic strains have been isolated and/or in areas where there has been confirmed highly pathogenic avian influenza (HPAI) activity. Communicate with local veterinarians regarding animal influenza surveillance. Phase 4: Continue ongoing activities from previous phases as appropriate. Phase 5: Continue ongoing activities from previous phases as appropriate. Communicate with IDPH regarding monitoring and revising recommendations from the CDC for any additional surveillance activities. Communicate with IDPH regarding case definition, based on description of known cases from affected countries. Educate schools to report weekly absentee levels. Phase 6: Continue ongoing activities from previous phases. Communicate with IDPH for direction as they may consider initiating travel screening methods at incoming Iowa conveyance locations and in health care settings for ILI and international exposure. Strategies if current systems of ILI surveillance and lab testing are exceeding capacity: CADE may choose to switch to active surveillance and call providers on a weekly basis. Greene County will support this effort by communicating with local providers and healthcare facilities for this information. Greene County will utilize Iowa's Capacity Reporting System (estimated to be operational winter 2005) to monitor ILI within the county. Iowa's Capacity Reporting System will provide real-time information on the capacity of Iowa's hospitals and EMS transport services in the event of a disaster. The system can be modified so IDPH can request that hospitals relay information from their Infection Control Providers on the number of inpatients within their facility meeting a defined case definition of illness in the event of a pandemic. The system could also be used to identify how many persons are presenting to Iowa's emergency departments who meet the defined case definition for influenza-like illness. (Iowa's Capacity Reporting System could be activated at any phase and level). Greene County will closely monitor Iowa's Health Alert Network as it will likely be used in conjunction with the Iowa Capacity Reporting System to notify LPHA's, hospitals and EMS transport services. In collaboration with the IDPH develop a system to assess vaccine priority groups, coverage and determine number of persons who remain unprotected. Consider using antibody testing to determine who may be immune if the public situation becomes extreme and immunologically-protected volunteers are needed. IDPH will monitor and revise recommendations from the CDC and notify LPHAs for any additional surveillance activities that should be undertaken. Pre-vaccine preparedness: Your Pandemic Flu annex should include actions to be taken in the event that a vaccine is not available or in very limited supply once the novel virus has reached your population. LPHA will need to prepare procedures for monitoring vaccine effectiveness and vaccination rates with mechanisms of reporting to IDPH. Utilizing guidance from the IDPH for use of Anti-virals: Your Pandemic flu annex will include how your agency will receive and utilize all guidance from the IDPH regarding the use of anti-virals. Utilizing guidance from the IDPH for prioritization of vaccine once available: Your Pandemic flu annex should include how your agency will receive and utilize all guidance from the IDPH regarding the prioritization of vaccine once available. Include how the LPHA and healthcare providers will report vaccine adverse reactions to IDPH, who will then submit the information into the national reporting program VAERS. Developing and maintaining procedures for implementing this plan: The local agency must develop triggers, policies and staff procedures for each component of this plan for implementation, the plan must state how this will be achieved. Identify the authorities to activate the plan Attachment 1 Fact Sheet on Pandemic Influenza for Medical and Public What is pandemic influenza? Annual outbreaks of influenza are due to minor changes in the surface proteins of the viruses that enable the viruses to evade the immunity humans have developed after previous infections with the viruses or in response to vaccinations. When a major change in either one or both of their surface proteins occurs spontaneously, no one will have partial or full immunity against infection because it is a completely new virus. If this new virus also has the capacity to spread from person-to-person, then a pandemic will occur. The surface proteins monitored for change are hemagglutinnin (H) and neuraminidase (N). The H surface protein is responsible for cell attachment and entry and is the major antigen of the virus against which antibodies are produced. There are 14 subtypes of H and 9 subtypes of N. Each time a new strain is discovered, the strain subtype of H and N are given determined resulting in the strain type. Previous influenza pandemics have been associated with changes in H structure. In order for a strain of influenza to be distinguished as pandemic, it must meet the following criteria: The virus must have the ability to infect humans and cause high mortality (death); Existence of a global human population that is immunologically naïve; and Efficient and sustained human-to-human spread.What is the role of livestock and other animals in spreading pandemic influenza? Animals are often the source of novel strains of influenza for several reasons. First, viruses must change so they have the ability to infect an animal. Second, animals may become infected with several strains of influenza which allows strains to share genes and further mutate. These mutations may either be drifts, which are slight mutations or shifts which are significant enough to allow a virus to infect large numbers of humans or another animal species. Why do the H5 strains of influenza have the potential to cause pandemic influenza? All known subtypes of influenza have the ability to infect birds. H5 and H7 subtypes can be further distinguished as either “low pathogenicity” or “high pathogenicity”. H5 viruses have nine potential subtypes and have been documented in humans, sometimes causing severe illness or death. Human infection with H7 is rare, but can occur in people who have close contact with infected birds. H5N1 and H7N7 strains are of particular interest at this time, and the H5N1 strain has caused the most recent cases resulting in severe illness or death. Will stockpiling of antivirals affect my ability to The federal government is purchasing a large amount of antiviral medication from the manufacturer. There have been no indications at this time that this will affect routine medical care. Will there be a vaccine for pandemic influenza? There is not a vaccine for avian influenza although there are now researchers working with national governments to develop a vaccine. Will antiviral medication (such as Tamiflu) be effective No one knows definitively whether anitivirals such as Tamiflu will be effective against pandemic influenza. It is likely that a pandemic strain will be unlike previous strains and therefore may be resistant to antivirals and existing vaccines. Do I need to vaccinate patients for pandemic influenza? There is no vaccine for pandemic influenza and we are not experiencing pandemic influenza anywhere in the world. What is the Iowa Dept. of Public Health doing to prepare for pandemic influenza? The Iowa Dept. of Public Health (IDPH) is developing a pandemic influenza response plan in the event that pandemic influenza occurs in Iowa. The state health department also watches for the different types of influenza in people who visit their doctor, attend school, child care or live in a long term care facility. For more information on influenza, pandemic influenza and avian influenza refer to our website at www.idph.state.ia.us/adper/flu.asp. What can I do to prepare my practice and my patients for The best way to protect your patients is to educate them on the basics of disease prevention: 1) when and how to wash hands or use alcohol gels, 2) to cover mouth and nose when coughing or sneezing, using disposable tissues, throwing them away after use and than washing hands or using an alcohol based hand gel. Encourage your patients to get the influenza vaccine every year to lower their chances of getting both causes of influenza at once and ensure that your patients in the recommended groups have received the pneumococcal vaccine to lower their chances of getting a bacterial pneumonia along with influenza. Should I screen patients for exposure to avian Ask about risk factors for acquiring disease. Have they traveled to an area of the world that is currently experiencing avian influenza, were they exposed to poultry or to persons who were ill with influenza like illness (ILI) after exposure to poultry? If yes are they currently ill? If ILI is present you should notify the health department and test for influenza. There is no recommendation or reason to test persons who do not have symptoms. Links Information about influenza pandemics (Centers for Disease Control) National Pandemic Influenza Preparedness and Response Plan (Health and Human Services) WHO Iowa Dept. of Public Health Updated 10/25/05 Center for Acute Disease Epidemiology Attachment 2 Fact Sheet on Pandemic Influenza for General Public What is “pandemic influenza”? Pandemic influenza refers to a very severe strain of influenza that has the ability to spread across the world. The word, “pandemic”, means that a disease has caused illness in a person on nearly every continent. Many other diseases throughout the history of the world have been pandemic. An example is HIV/AIDS. HIV/AIDS is currently pandemic since it has become widespread roughout the world. Influenza occurs at different times throughout the world. Influenza season strikes in the U.S. in the fall and winter months likely because people stay inside often and are in close contact with others who may be ill. What is the difference between influenza (flu) and Influenza (flu) happens every year in nearly every country in the world. It spreads through a population for a few months and then will disappear or will move onto another country. Influenza usually occurs in the fall and winter months. Also, people who usually become ill with influenza are the elderly, the very young and people with chronic medical conditions. Pandemic influenza could strike at any time in the year. The strain will be one never seen before and there will not likely be a vaccine immediately available. It will spread quicker and easier from person to person compared to non-pandemic influenza. Pandemic influenza may cause illness in any person, and in the past has caused illness in more healthy, middle-aged people than those who usually become ill with influenza. It will probably circulate several times around the world, or in “waves”. Overall, pandemic influenza will cause more disease and death than seasonal influenza. How often do influenza pandemics occur? Pandemics of influenza have occurred three times about every 100 years. From 1900-2000, there were three influenza pandemics, all about 30 years apart. What is Avian or Bird Flu? Avian influenza is currently making many different types of birds in Asia sick. There are several different types of avian influenza and most types are found in birds. Avian influenza is often found in birds and is not easily spread from birds to people. The type found in birds in Asia right now has spread to a few people, but has not spread from person to person. There is concern about this type of avian influenza because it is a type of influenza that has caused serious illness in people in the past. The influenza virus changes all the time so there is also worry if this type of avian influenza ever changed so that it could spread person to person, many people would become ill. Can pandemic influenza infect animals? Influenza infects different types of animals, usually pigs, birds and sometimes horses, cats, dogs and other animals. Pandemic influenza will likely be able to infect animals and may even infect people because of their contact with infected animals. Most household pets in the U.S. do not carry or are able to catch strains of influenza that make people ill therefore you do not need to worry about your household pet infecting you or your family with influenza during normal influenza season. If pandemic influenza occurs, you may need to take action to protect your pet and your family. What is the Iowa Department of Public Health doing to Throughout every “flu season”, usually in the fall and winter months, Iowa Dept. of Public Health (IDPH) tracks the different types of influenza that occur in people who visit their doctor, attend school, child care or live in a long term care facility. IDPH is also developing a pandemic influenza response plan. For more information on influenza, pandemic influenza and avian influenza refer to our website at www.idph.state.ia.us/adper/flu.asp. Is there a vaccine for pandemic influenza? Currently, there is not a vaccine for pandemic influenza because we do not know what strain will cause pandemic influenza. Many national governments are working with researchers and scientists on a vaccine against the H5N1 strain of avian influenza, which has infected people and birds in Asia. Is Iowa stockpiling vaccine for the public? IDPH is not stockpiling vaccine or antiviral medication for pandemic influenza for three reasons. The federal government has started to stockpile antiviral medication. For a vaccine to provide protection, it must be specific against the new strain of influenza (the vaccine must “match” the strain causing human illness). 3o Even though the federal government has started to stockpile antiviral medication, there is no guarantee this medication will be effective or prevent illness due to a new strain of influenza. The best preparation and defense for a possible pandemic is the ability to detect and identify a new strain of influenza virus quickly, and then determine the best response measures to limit exposure and spread, and identify medication(s) to effectively treat the disease. Is there medicine for pandemic influenza? Depending on the type of influenza, there may be no medicine a limited amount of medicine to treat those who are ill. Once a pandemic strain is identified, then public health officials will have to determine if any current medications may be used or if new ones need to be developed. The federal government is stockpiling antiviral medication in the event that a pandemic of influenza happens. However, there is no guarantee that the medication they are stockpiling will work against the pandemic strain of influenza. Is Iowa or the U.S. government stockpiling medication Iowa is not stockpiling medication and does not the Iowa Dept. of Public Health recommend health care professional stockpile antiviral medication. The U.S. government is currently increasing the stockpile of an antiviral drug in the event that it may be effective against the kind of influenza virus causing the pandemic. How can I protect my family from pandemic influenza? The best way to protect yourself and others is to do the following: 1. Wash your hands frequently with warm water and soap and scrubbing for at least 15 seconds. 2. Cover your mouth and nose when coughing or sneezing and to use disposable tissues. 3. Use an alcohol-based hand sanitizer when hands are not visibly soiled. 4. Get the influenza vaccine every year to significantly lower your chances of getting pneumonia due to influenza. 5. People over the age of 65 and others with underlying illness should also receive the pneumococcal vaccine to lower their chances of getting a bacterial pneumonia and / or along with influenza. 6. If you are ill, stay home and call your doctor. Links 1. Information about influenza pandemics (Centers for Disease Control) 2. National Pandemic Influenza Preparedness and Response Plan (Health and Human Services) 3. WHO |
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