Preparedness E-newsletter Archive - 2009

2009 News Icons

 

Making Preparedness a Priority

Published: December 2009
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

Background

The Trust for America’s Health (TFAH) 2009 Report, “Protecting the Public’s Health from Disease, Disasters, and Bioterrorism” was released earlier this week. TFAH is a non-profit, non-partisan organization dedicated to “saving lives and making disease prevention a national priority.” This report is the 7th in a series of annual reports reviewing the nation’s preparedness and response capacity. The report serves to highlight the importance of preparedness, identify gaps and challenges, and make recommendations for improvement. In this report, TFAH used a 10-point scale to assess preparedness state-by-state, looking at:

  • Mass Distribution (state antiviral purchases);
  • Hospital Preparedness (hospital bed availability reporting);
  • Public Health Laboratories (transportation and delivery of samples);
  • Public Health Laboratories (surge workforce);
  • Biosurveillance (NEDSS system compatibility);
  • Food Safety (detection and diagnosis);
  • Medical Reserve Corps Readiness (based on national MRC criteria);
  • Community Resiliency (laws requiring all-hazard planning for childcare sites);
  • Legal Preparedness (emergency liability protection); and
  • Public Health Funding (changes in funding from FY 2007–08 to FY 2008–09).

Scores

The low score was three (Montana). The highest score was nine (8 states). Pennsylvania scored an eight (along with 10 other states and DC), 11 states scored a seven, 13 states scored a six, and 6 states scored a five. Pennsylvania lost points for inadequate PH Lab Surge capacity and decreased public health funding. It is worth noting that Pennsylvania had among the lowest decreases of states that reduced money; it is also worth noting that despite economic hard times, 23 states and DC found a way to increase funding.

Recommendations

The report made recommendations for improving preparedness in 4 areas, including:

  • Ensure stable and sufficient funding;
  • Conduct an H1N1 after-action report and update preparedness plans with lessons learned;
  • Increase accountability and transparency; and
  • Improve community preparedness.

These recommendations all make sense. There is a general perception that we “dodged the bullet” with this pandemic, or as the Chicago Daily Herald put it, “The H1N1 pandemic should have come with an announcement: this is a test of the public health emergency system.” Despite rapid worldwide spread of a novel virus, insufficient viral medication, a stressed-to-the-limit medical care system, confusion about priority groups, and vaccine which arrived just AFTER the pandemic’s major wave, we did not suffer a 1918/19-like disaster. For this, we have mostly the virus itself to “thank,” because of its relatively low ability to cause fatal illness and because, through something of a fluke, the most vulnerable portion of the population—seniors—also turned out to be the most protected. We cannot expect that in the next pandemic or threat we will get the same breaks.

However, further data and analysis may complicate this sanguine perspective. CDC’s director Thomas Frieden noted that “the number of children and young adults killed by mid-November was five times more than in the average flu season,” and that so far 47 million Americans were infected, more than 200,000 hospitalized, and nearly 10,000 killed. Not to mention the many, many adults who lost time at work due to their personal illness or because they were caring for others, or the lost school time experienced by millions of students.

Conclusions

The report notes that “The U.S. public health system is responsible for protecting the American people from a range of potential health threats. An all-hazards public health system is one that is able to respond to and protect citizens from the full spectrum of possible public health emergencies, including bioterrorism and naturally occurring health threats. An all-hazards system recognizes that preparing for one threat can have benefits that will help prepare public health departments for all potential threats.”

I would add that a public health system which is truly “all-hazards” prepared will also be one that is able to successfully manage the day-to-day challenges of public health, whether smoking cessation, cavity prevention, low birth weight infants, obesity, cancer, or cardiovascular disease. The reason is that successful preparedness absolutely requires 1) comprehensive surveillance systems, 2) effective collaboration across the entire public health system, 3) clear communication with a wide variety of audiences, 4) inclusion of all high-risk groups in the planning process, and 5) recognition of the central role of public health leadership. All of these attributes will enhance both preparedness/response activities and “regular” public health. THIS is why public health preparedness is so important.

 

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Yes Pennsylvania, there is a pandemic

Published: October 2009
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

 

For those who were wondering if there was going to be a pandemic this fall, the answer is unequivocally “YES!” Local, state, national, and international data all paint the same picture—the novel 2009 H1N1 virus (“swine flu”) is highly contagious and pretty much impossible to stop. In Pennsylvania, the surge is here, and we are clearly in the thick of the pandemic. So far, we are very fortunate that the virus is generally very mild; but at these numbers the cases are straining health care systems, school systems, and parents’ ability to get to work.

This first graph (Figure 1) shows the number of laboratory confirmed cases per week during the past five “regular” flu seasons, the spring wave of the novel 2009 H1N1 (small purple wave) and the current wave (big purple spike that goes nearly straight up). It is important to recognize that although “7000” seems like a lot of cases in a week, this is only the number of laboratory confirmed cases—and it is for LAST week at best, since these data were released on Tuesday of this week. It doesn’t include the larger majority of cases that didn’t get tested. Such as my family—my 11 year-old had classic symptoms two weeks ago, with moderate fever (102 ish), headache, sore throat, dry cough, and extreme fatigue. He was sick for five days. My oldest son had milder symptoms that lasted three days. My daughter initially seemed to escape, but then missed an entire week of 1st grade last week with flu-like symptoms. None of them were tested, nor did they need to be. But it is clear that they very likely have participated in the pandemic. This means that the “7000” confirmed cases last week are just the tip of the iceberg, and that the number of actual new cases for that time period is greater by a factor of 50–100; in other words, between 350,000 and 700,000! This figure is supported by CDC’s recent release that estimated that the “true” number of U.S. cases in the spring wave was 1.8–5.7 million, contrasted with only 43,677 laboratory-confirmed cases. Seven hundred thousand cases in PA means that more than 5% of the population was infected in one week.

The state and local health departments are utilizing multiple surveillance methods in addition to laboratory-confirmed cases to estimate who is being affected and where they live. State data shows increases throughout the state as indicated in this graph (Figure 2). Although the Southeastern region of the state (Philadelphia and nearby counties) was hit hardest in the spring, all regions in the state have been heavily affected so far, and all regions except North Central showed more than 80% increases last week. Information on “influenza-like illness” (ILI) from sentinel sites shows that up to 15% of college students were affected in one week, although this is likely peaking, and that pediatric practices were estimating that 9% of all visits were related to patients with ILI symptoms (normal in non-flu seasons is around 2% or less).

This graph (Figure 3) shows the age breakdown of cases so far. Again, it is important to remember that this data is based on laboratory confirmed cases, which doesn’t necessarily include all ages equally, and is likely biased towards the sicker patients since they are more likely to be tested. As can also be seen, the age group distribution for the pandemic is quite distinct from the previous “regular” flu season. Key points and trends are that similar to the spring, pre-teens and teens are most likely to be infected, followed by K-5 grade children and then younger to middle-aged adults. There is some evidence that the pandemic may be peaking in the younger age groups, while at the same time increasing in older adults and seniors. This may cause more strain on the health care system, as older adults with more complex medical problems are more likely to become seriously ill and/or die. More than 400 people have been reported hospitalized due to the pandemic in this wave, and two of the deaths reported last week were in persons aged 80 or older.

What about Vaccine?

Although the state received initial doses of vaccine several weeks ago, additional shipments have been limited. The state website notes that: “Pennsylvania continues to place orders with the federal government for the novel H1N1 flu vaccine for more than 4,000 pre-registered and certified providers in the state. However, due to the nationwide delay in the production of the vaccine, it is arriving in the state in very limited quantities. There are currently no public vaccination sites.”

The Pennsylvania Department of Health is recommending the limited vaccine doses for the following groups that are most vulnerable to being affected by H1N1:

  • Pregnant women
  • Persons six months to 24 years old
  • Health care providers and EMS personnel
  • Parents, household members, or caregivers of children under 6 months
  • Those under 65 with certain underlying medical conditions

If you or a loved one is in one of the five priority groups, please contact your health care provider or school district to find out if the H1N1 vaccine is available near you. If you are unable to find the vaccine in your area, please call the Pennsylvania Department of Health at 1-877-PA-HEALTH (1-877-724-3258).

 

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Virus vs. Vaccine: The Race is on

Published: October 2009
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

 

The first doses of H1N1 vaccine are now being shipped and are expected in states by next Tuesday. Unfortunately, the virus has a head start, and is active throughout the country (and world). In this edition of the e-newsletter we highlight key things for you to know. Major updates are: vaccine from major manufacturers has been approved for use; only one dose is required for people age 10 and older; clinical trials are ongoing and reassuring (so far); the virus has not shown evidence of significant mutation or worse pathology than previously encountered; and antiviral resistance is rare (though not absent).

Best ways to stay up-to-date:

Information In Pennsylvania
PA H1N1 information site
PA Epidemiology
Center for Public Health Preparedness

Information in the US and World
CIDRAP
Center for Biosecurity

CDC
US Epidemiology
Weekly Update, News, and recommendations
Clinical Information/Conference Calls

World Health Organization
WHO information site

Vaccine
How is vaccine getting to a site near you?
PA FAQ
How will you know about availability?
Check with your provider, read the news, or visit the PA DOH H1N1 website
Vaccine trial update

 

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Novel H1N1 Situation Update

Published: July 2009
Written by: Emily Rosenberger, Medical Scientist Training Program

 

Breaking News

CDC flu cases graph.gif

Source: CDC, 18 July 2009

The Advisory Committee on Immunization Practices (ACIP) recommended on July 29 the following priority groups for H1N1 vaccine.

The first 40+ million doses should go to

  • pregnant women,
  • household contacts of babies under 6 months of age,
  • health care workers and EMS personnel who have direct contact with patients or infectious substances,
  • children age 6 months–4 years, and
  • children age 5–18 with underlying medical conditions that place them at elevated risk for complication from influenza infection.

Next priority groups (as vaccine becomes available) are

  • children and young adults age 4–24,
  • other health care and EMS workers, and
  • adults age 25–64 with underlying medical conditions that place them at elevated risk for complication from influenza infection.

Next priority groups (if sufficient vaccine is available) are

  • healthy people age 25–64, and
  • people 65 and older.

The vaccine will be available in both injectable and nasal spray forms. Substantial amounts of vaccine are expected by October, if not sooner.

Confirmed Cases Chart



Deaths Chart




burke article genetic history image.gif

The diagram shows the full genetic history of the
novel H1N1 virus. Each chart represents the genetic
composition of a particular influenza virus lineage
over time. In each chart, gene segments are shown
along the left side, and dates from 1918 to 2009
are shown along the top. Color coding shows the
avian origins and history of each gene segment in
each virus lineage. Adapted from Zimmer S & Burke
D. Historical perspective – emergence of influenza
A (H1N1) viruses. New England Journal of Medicine
2009;361:279-85.

Background

As reports of cases and deaths attributable to the novel swine-origin influenza A H1N1 virus continue to make summer news, the ramifications of this new virus still remain unresolved. Headlines have portrayed the oscillating nature of the pandemic, touting conflicting numbers of confirmed cases and deaths. Mexico reduced its official case counts several weeks into the outbreak due to shifts in surveillance systems. The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) kept their surveillance systems active until July but then stopped requiring countries to report confirmed cases in order to shift their focus to outbreak control and management.

As of 29 July 2009, the number of confirmed cases worldwide had reached 220,822 with 1,349 deaths and 8,884 suspected cases, according to FluTracker, which tracks official sources, news reports, and user contributions. The northern hemisphere, now in its flu off-season, is observing much higher than normal levels of influenza-like illness. CDC reported 43,771 confirmed cases of novel H1N1 and 302 deaths attributable to novel H1N1 in the United States as of 24 July 2009; strikingly, 99 percent of influenza A viruses being subtyped and reported to CDC are novel H1N1 (1). The southern hemisphere, now in its flu season, is also observing a higher than usual incidence of flu cases, with high confirmed case counts of novel H1N1 in Australia, New Zealand, Argentina, and Chile. Although conclusive subtyping data are not yet available from many of these countries, rough estimates place the proportion of novel H1N1 cases (as opposed to seasonal flu) in the southern hemisphere upwards of 90 percent.

Genetic origins

The novel H1N1 is thought to have emerged in swine after a reassortment between a triple-reassortant swine influenza A H1N1 virus that was first noted in 1998 and a Eurasian swine influenza A H1N1 virus that emerged around 1979 and has not until now been seen outside of Eurasia. Six of the novel H1N1’s eight gene segments derive from the triple-reassortant. Half of these genes, hemagglutinin (HA), nucleoprotein, and nonstructural protein, are also expressed in currently circulating seasonal influenza A H1N1 viruses; the other half, the polymerase and transciptase genes, PB1, PB2, and PA, are also expressed in currently circulating seasonal influenza A H3N2 viruses. The remaining two genes, neuraminidase (NA) and matrix protein, derive from the Eurasian H1N1 and are thus new to human influenza viruses (2,3).

The likelihood that humans have immunity against the novel H1N1 virus based on past exposure to antigenically related viruses—particularly the HA gene, which codes for proteins that facilitate virus attachment to host cells, and the NA gene, which codes for proteins that facilitate virus release from host cells—seems to increase with increasing age. This is one of the reasons suggested by the epidemiologic observation that very few cases of the novel H1N1 have occurred in the population usually mostly at risk from flu, those 65 and older.

Despite the genetic similarity between circulating H1N1 strains and the novel H1N1 HA gene, amino acid changes in the novel H1N1 have occurred at key antigenic sites, thereby reducing the possibility that past exposure to H1N1 viruses confers immunity (4). A CDC study showed that cross-protection against the novel H1N1 from vaccination with the 2005–09 seasonal influenza vaccines is unlikely because the amount of genetic divergence between the novel H1N1 strain and the H1N1 strains used in the seasonal flu vaccines is too great. As a point of reference, the amino acid sequence of the HA portion of the H1N1 strains used in the 2005-09 seasonal flu vaccines differed from each other only by 2–3 percent, whereas the amino acid sequence in the HA portion of the novel H1N1 differs from that of the 2005–09 vaccine H1N1 strains by 27–28 percent (5).

Populations at risk

The novel H1N1 virus continues to infect mainly teenagers and young adults. According to CDC, those at risk for severe complications include children under age 5 and adults over age 65; individuals with chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular or metabolic disorders; and individuals who are immunosuppressed (6). Pregnant women seem to be at a particularly increased risk for severe complications and death from novel H1N1. In the United States, pregnant women were four times more likely than the general population to be hospitalized for illness related to novel H1N1, and 6 percent of novel H1N1 deaths have thus far occurred in pregnant women, which is a marked contrast to their population prevalence of 1 percent (7).

Given that children are highly susceptible to novel H1N1, coupled with the highly social nature of schools and camps that seems conducive to influenza spread, school and camp closures have become one of the most widely discussed community mitigation measures of this pandemic. The efficacy of this intervention is a major source of debate, particularly when considering its broad impact on the workforce and students who receive free and reduced meals at school. Moreover, little is known about social patterns that dictate whether students experience less social contact while home from school rather than at school. After initially recommending school closure for 14 days following the confirmation of a novel H1N1 case, CDC now recommends that school closure decisions be made “at the discretion of local authorities based on local considerations, including public concern and the impact of school or child care program absenteeism and staffing shortages (8).” Many camps in the United States, especially those for children with chronic conditions or immunosuppression, are observing novel H1N1 outbreaks and sending campers home and even canceling sessions altogether. In the southern hemisphere, several of the hardest hit countries, including Argentina and El Salvador, are extending school vacations for up to two weeks. Developing control and prevention plans for novel H1N1 is one of the most pressing—and controversial—issues facing school systems as the start of the school year approaches.

Vaccine progress

Although development of a novel H1N1 vaccine began almost immediately after the pandemic nature of the virus was realized, WHO’s pandemic declaration on 11 June 2009 instigated the official rush to create the vaccine and, importantly, provided the political clout for governments to allocate funds for vaccines and medication stockpiles. Nearly half a dozen firms are now creating, testing and producing a novel H1N1 vaccine using both egg- and cell-based technologies. Novartis, GlaxoSmithKline, and SanofiPasteur have all begun clinical trials of a novel H1N1 vaccine and claim that their first doses will be available between September and November (9,10,11). The necessary dosage and number of administrations required for any of these new vaccines are still unknown; if multiple administrations per person are required, widespread distribution may be extremely challenging. As was the case for 2005–09 seasonal flu vaccines, it is unlikely that the recently FDA-approved seasonal flu vaccine, which contains strains of H1N1 and H3N2, will provide any cross-protection against the novel H1N1.

Lessons from past pandemics

Like the current pandemic, all three of the major twentieth century influenza pandemics were caused by reassortments between previously circulating human viruses and at least one virus of animal (either avian or swine) origin. Two features of these pandemics—their emergence in the Northern Hemisphere outside of the normal flu season and their multiple waves—are similar to what we have seen so far in the novel H1N1 pandemic. The extremely devastating 1918 H1N1 pandemic, commonly known as the “Spanish Flu,” emerged in May–June 1918 and peaked during a second wave in mid-November 1918; the mortality rate of the second wave, which reached as high as 2.5 percent (magnitudes higher than seasonal flu’s mortality rate of 0.1 percent), was nearly five times as high as the first wave and just under twice as high as the third wave, which peaked in March 1919 (12). Similarly, the second wave of the 1957 H2N2 pandemic, known as “Asian Flu,” peaked during February–March 1958, about seven months after the first wave, and was responsible for nearly half of the pandemic’s overall mortality (13). The 1968 H3N2 pandemic, which introduced the currently circulating strain of seasonal influenza, peaked in January 1969 in the United States and then saw a doubly devastating second wave one year later in Canada, Japan, and England (14).

What lies ahead?

Speculation about the course of the novel H1N1 pandemic abounds. If the current pandemic follows the pattern of multiple waves seen in the twentieth century pandemics, the upcoming 2009 flu season may bring a drastic increase in novel H1N1 morbidity and mortality. Further reassortment of the novel H1N1 with co-circulating seasonal H3N2 or H1N1 strains, which may create new viruses that are better adapted for transmissibility, pathogenicity, and antiviral resistance in humans, may also bring about a more severe second wave. Given the co-circulation of novel H1N1 and seasonal H3N2 during the southern hemisphere’s ongoing flu season, as well as recent reports of the five oseltamivir (Tamiflu)-resistant novel H1N1 cases, this is a very real possibility. Over the coming months, it will be important to develop a more complete epidemiologic picture of the novel H1N1 pandemic as it has unfolded since April so that health care systems, school systems, governments, workplaces, and individuals are all aware of what to expect from the pandemic and, if necessary, how to prevent and contain it.

References

(1) CDC. 2008-2009 influenza season week 28 ending July 18, 2009. Flu View 18 July 2009. Available http://www.cdc.gov/flu/weekly/.
(2) Morens D et al. The persistent legacy of the 1918 influenza virus. New England Journal of Medicine 2009;361(3):225-9.
(3) Zimmer S & Burke D. Historical perspective – emergence of influenza A (H1N1) viruses. New England Journal of Medicine 2009;361:279-85.
(4) Garten et al. Antigenic and genetic characteristics of swine-origin 2009 A(H1N1) influenza viruses circulating in humans. Science 2009;325:197-201.
(5) CDC.Serum cross-reactive antibody response to a novel influenza A (H1N1) virus after vaccination with seasonal influenza vaccine. MMWR 22 May 2009;58(19):521-4.
(6) CDC. Interim guidance for clinicians on identifying and caring for patients with swine-origin influenza A (H1N1) virus infection. 4 May 2009. Available http://www.cdc.gov/h1n1flu/identifyingpatients.htm.
(7) Jamieson D et al. H1N1 2009 influenza virus infection during pregnancy in the USA. The Lancet 29 July 2009 early online publication. Available http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961304-0/abstract.
(8) CDC. Update on school (K – 12) and child care programs: interim CDC guidance in response to human infections with the novel influenza A (H1N1) virus. 22 May 2009. Available http://www.cdc.gov/h1n1flu/K12_dismissal.htm.
(9) Novartis. Novartis successfully demonstrates capabilities of cell-based technology for production of A(H1N1) vaccine. 12 June 2009. Available http://www.novartis.com/newsroom/media-releases/en/2009/1322241.shtml.
(10) GlaxoSmithKline. Pandemic (H1N1) 2009 influenza update. 22 July 2009. Available http://www.gsk.com/media/pressreleases/2009/2009_pressrelease_10077.htm.
(11) Torsoli A. Sanofi to start flu tests in weeks, have vaccine in November. 22 July 2009. Available http://www.bloomberg.com/apps/news?pid=20601090&sid=aRMVoTrA1Ktw.
(12) Neumann G et al. Emergence and pandemic potential of swine-origin H1N1 influenza virus. Nature 2009;459(7249):931-9.
(13) Cohen J. Past pandemics provide mixed clues to H1N1’s next moves. Science 2009;324:996-7.
(14) Barry J. White paper on novel H1N1, prepared for the MIT Center for Engineering Systems Fundamentals. July 2009. Available http://esd.mit.edu/WPS/2009/esd-wp-2009-07.pdf.

 

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All-Hazards Preparedness Training for Local Federally Qualified Health Centers

Published: July 2009
Written by: Sherrianne Gleason, Project Coordinator, Public Health Adaptive Systems Studies

 

Nurse immunizing a patient

Access to affordable, quality healthcare has always been a problem for the uninsured and medically underserved, vulnerable populations in the United States. Recently, this has become an even greater concern in many communities due to the steady rise in the unemployment rate across the nation. One option for many people seeking routine medical care is the Federally Qualified Health Centers (FQHCs). These are community-based health centers with funding support from the Health Resources and Services Administration (HRSA) under the Public Health Service Act (1). The designation of FQHCs assigned to private non-profit or public health care organizations that serve predominately uninsured or medically underserved populations comes from the Bureau of Primary Health Care (BPHC) and the Center for Medicare and Medicaid Services. FQHCs are regulated by guidelines set forth by the BPHC which must be followed to maintain their funding (2, 3).

The need for these services has grown so much that the U.S. Department of Health & Human Services announced in March 2009 that they were releasing approximately $343 million to assist existing community health centers to serve more patients. These Increased Demand for Services grants, which will be distributed to over 1,000 FQHC grantees, are part of the American Recovery and Reinvestment Act. In addition, $155 million in Recovery Act grants will support 126 new community health centers, also increasing access to health care services (4).

FQHCs are an essential part of the health care system in the United States. In 2007, 1,067 grantees served over 16 million people, with over 6 million of them having no health insurance (5). With the responsibility of caring for so many people, FQHCs must prepare for emergencies which may affect normal operations. In the event of an emergency they may be called upon to deliver critical services or assist local communities. As such, all-hazards planning is a vital component for preventing discontinuity of care for patients in the event of an emergency. On August 22, 2007, BPHC released new guidelines which described Health Center Emergency Management Program Expectations (PIN 2007-15). This PIN provided guidance on emergency management planning, linkages and collaborations, communications and information sharing, and maintaining financial and operational stability (6).

A Network of Pennsylvania Federally Qualified Health Centers

Within Pennsylvania, there were 32 grantees representing 65+ clinics in 2007, receiving over $50 million in total federal grants. These health centers treated over 500,000 people (7). One of the grantees is Primary Care Health Services, Inc. (PCHS), a network of community-based health centers serving the City of Pittsburgh and its surrounding area, which falls under the specific categories of community health center, health care for the homeless, and public housing primary care (5). PCHS is a non-profit community-based corporation consisting of 13 health centers which offer a full array of medical services, including adult medicine, women’s health, dental, pediatric, podiatry, laboratory, pharmacy, social, and mental health services. In addition to the health centers, they have special initiatives including Health Care for the Homeless, Preparing for Childbirth, Supportive House Program, Senior Care Program, and a Family Support Program (8).

In order to comply with the new HRSA standards PCHS developed an All-Hazards Preparedness Plan. They consulted with the Center for Public Health Preparedness (UPCPHP) at the University of Pittsburgh Graduate School of Public Health, and then contracted with them to familiarize and train their personnel on the new plan. The training is important not only to meet their funding requirements, but to prepare personnel to respond in a way that protects employees, patients, and facilities. Having an all-hazards plan in place was the first step, the second step was training.

All-Hazards Preparedness Plan Training

Following the Homeland Security Exercise and Evaluation Program (HSEEP), which provides guidance in exercise design and development, conduct, evaluation, and improvement planning (9), UPCPHP successfully developed a multifaceted training program, which included a 30 minute online module and a three hour tabletop exercise. Since this was the first formal training PCHS personnel had on emergency preparedness, the module’s main objective was to orient PCHS administrative personnel, nursing assistants, nurses, and physicians about the fundamental concepts within their plan, including incident command, information on local health and emergency response agencies, and key aspects of personal preparedness. The module was and is available online for all current personnel, new personnel, or anyone interested in all-hazards preparedness planning to take for continuing medical credits or continuing education credits on the University of Pittsburgh’s eLearning environment Internet-based Studies in Education and Research website. Before the module became available online on January 30, 2009, it was shown to 36 nurses and physicians in-person during two separate monthly meetings. The module was also used as an introduction to the discussion-based tabletop exercise.

The tabletop exercise was a shelter-in-place scenario based on a train derailment and chemical release. This scenario was chosen because of the multitude of railroad tracks that run through Pittsburgh and the surrounding areas. Though train derailments are not a common occurrence, they do happen within Western PA, as on October 20, 2006, when a train derailment occurred near New Brighton, PA, approximately 30 miles north of Pittsburgh, causing the release of ethanol from the tanker cars. The associated fires resulted in the evacuation of approximately 150 residents (10). Previous to that incident, in 2005, 200 people were evacuated after a derailment sent tanker cars filled with anhydrous hydrogen fluoride, a caustic concentrated gas that turns into hydrofluoric acid when mixed with water, into the Allegheny River (11).

Over 45 PCHS employees took part in the tabletop exercise in March 2009. Since PCHS personnel are at the very beginning stages of their emergency preparedness training, information and issues surrounding the emergency operations center, incident command, communications capabilities, continuity of patient care, protection of clinic staff and patients, physical resources, and personal preparedness were all addressed during the exercise.

Beyond Local Training

Given the importance of training FQHCs around the nation, in February 2009, UPCPHP presented an interactive session at the National Association of City and County Health Officials 2009 Public Health Preparedness Summit on their work with the local FQHC (12). We were able to offer advice and provide resources to public health professionals from around the country who were interested in building partnerships with their local FQHCs. We also demonstrated how an academic institution was able to help a community organization with its operating and educational needs—a resource many were unaware of.

The online module and tabletop exercise were designed to be easily adapted for use with other community health centers, making them useful templates for other academic institutions wanting to work with community health centers and useful for community health centers that want to do their own all-hazards planning.

Summary

Community health centers are an indispensable resource of affordable health care for medically underserved and uninsured populations. Federal funding assists these centers in providing quality care to those who need it most. In order to ensure continuity of care in a disaster, FQHCs need to develop an All-Hazards Preparedness Plan and train their personnel on the policies and procedures within the plan. Academic institutions can be a good resource for community organizations. Partnerships between academic institutions and FQHCs benefit the public’s health by ensuring the continuity of care during a disaster or other unexpected emergency.

References:

  1. HRSA. Health Center Program: Section 330 of the Public Health Service Act. http://bphc.hrsa.gov/about/legislation/section330.htm
  2. HRSA. Health Center Program: What is a Health Center? http://bphc.hrsa.gov/about/
  3. Policy Information Notice 98-23 Health Center Program Expectations. August 17, 1998. ftp://ftp.hrsa.gov/bphc/docs/1998pins/PIN98-23.PDF
  4. Recover Act Program: Health Centers – Services ($500M). http://www.hhs.gov/recovery/reports/plans/healthcentersservices.pdf
  5. HRSA, BPHC. “Bureau of Primary Health Care Section 330 Grantees Uniform Data System: Calendar Year 2007 Data National Rollup Report.” 2008. ftp://ftp.hrsa.gov/bphc/pdf/uds/2007nationaluds.pdf
  6. Policy Information Notice 2007-15 Health Center Emergency Management Program Expectations. August 22, 2007. ftp://ftp.hrsa.gov/bphc/docs/2007pins/pin200715.pdf
  7. HRSA, BPHC. “Bureau of Primary Health Care Section 330 Grantees Uniform Data System: Calendar Year 2007 Data Pennsylvania Rollup Report.” 2008. ftp://ftp.hrsa.gov/bphc/pdf/uds/2007/07Rollup_StatePA_08Jul2008.pdf
  8. PCHS Brochure.
  9. HSEEP. “HSEEP 101 - Homeland Security Exercise and Evaluation Program: Terminology, Methodology, and Compliance Guidelines.” https://hseep.dhs.gov/support/HSEEP_101.pdf
  10. National Transportation Safety Board. Railroad Accident Report NTSB/RAR-08/02. “Derailment of Norfolk Southern Railway Company Train 68QB119 with Release of Hazardous Materials and Fire, New Brighton, Pennsylvania, October 20, 2006.” Adopted May 13, 2008. http://www.ntsb.gov/publictn/2008/RAR0802.pdf
  11. Bucsko M. “200 evacuated after derailment send tanker cars into Allegheny River.” Pittsburgh Post-Gazette. February 1, 2005. http://www.post-gazette.com/pg/05032/450926.stm
  12. Public Health Preparedness Summit 2009 Conference Program. Pg 44. http://www.phprep.org/2009/Agenda/upload/2009-PHPrep-Summit-Program-FINAL.pdf

 

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Disaster Preparedness and Response for School Nurses June 22–24, 2009

Published: June 2009
Written by: Leslie Fink, Preparedness Coordinator, Center for Public Health Preparedness; and Stefanie Junker, MPH, Project Coordinator, Center for Public Health Preparedness

 

School Nurses
Summer Trainings

3 Days - 3 Trainings
6/22 – 6/24 – Bradford, PA

The University of Pittsburgh Center for Public Health Preparedness (Center), considers school personnel to be first responders in public health emergencies since they are on site in the community and working with a distinct population. Along with our partners, the Pennsylvania Department of Health (PADOH), and the National Association of School Nurses (NASN), we provide key training to K-12 school nurses, administrators, guidance counselors, and crisis response teams in planning for and responding to emergencies in schools.

To date, 960 school personnel have received all-hazards disaster preparedness training through the Center. Our trainings provide important information that will save lives, help schools, and share “best practices” for implementation.

The three major themes that inform our activities include:

  • a dedication to in-depth instruction which provides life-long skills to the recipient
  • a desire to continually evaluate our programs for effectiveness and improve the content and manner in which they are taught
  • a commitment to broad and successful collaboration

In addition, we continue to work closely with local and national partners to continually update for maximum benefit to the participant.

In response to evaluation data provided by the Center, NASN created a new course focusing on triage, School Emergency Triage Training (SETT). Since its initial roll-out at the NASN Annual Conference in July 2008, the Center has been the only state site to present this innovative new program, training 110 school nurses so that they, in turn, could train their own school’s First-Aid teams in the practices and principles of triage. In addition to the program itself, the Center also facilitated a train-the-trainer workshop for seven school nurses from around the country to be trained as SETT presenters.

Response to the SETT course has been positive across the board and learners greatly appreciated the tabletop exercises and hands-on practice. After a training in Philadelphia, one participant emailed:

“I just wanted to let you know how much I enjoyed the conference earlier this week. I am so pleased that you all allowed me to participate. I learned a great deal and am looking forward to sharing the information with my school staff and the other Prince George's County Nurses. Thank you again for allowing me to participate in this truly valuable session!”

There’s still time to register for the innovative School Nurse Summer Trainings: Disaster Preparedness and Response to be held June 22–24, 2009 at the University of Pittsburgh at Bradford. This special three day conference for school nurses, crisis response team members, administrators, and rural responders will include “What All Rural Responders Must Know About Public Health Emergencies,” “Disaster Preparedness for School Nurses,” and “School Emergency Triage Training.” The conference will address the needs of those who have responsibilities to provide planning, response, or recovery in the event of a school or community disaster. Act 48 credits and continuing education are available. Sponsored by the School Preparedness Program; the University of Pittsburgh at Bradford, Office of Outreach Services; and the University of Pittsburgh at Bradford, Center for Rural Health Practice.

 

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Pennsylvania 2009 H1N1 Update

Published: May 2009
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

PA H1N1 Map

Pandemic severity index

Chart of cases

Charting H1N1

 

The latest information on Pennsylvania, the United States, and the world situation is included in the graphs on the right. Additional commentary and links are attached below. As the graphs illustrate, the novel 2009 H1N1 virus continues to spread both within the United States and worldwide.

Because of the dynamic nature of this pandemic, the comments and recommendations listed below should be evaluated by the reader and weighed against changing facts on the ground. The Center will continue to highlight the most important and timely information for public health and other response professionals throughout the state.

  1. Is this a pandemic?

    Obviously, yes. There are multiple outbreaks in multiple countries around the world. The only remaining question is whether this is a “minor” or a “major” pandemic.

  2. What is the difference between a minor and major pandemic?

    There is not an exact definition. CDC created a “pandemic severity index” several years ago based on case fatality ratio. Unfortunately, it is mostly useful retrospectively, AFTER we know what the death rate is, how many people were infected, and thus how many died. It also doesn’t apply well in situations like SARS which was Category 5 based on case fatality ratio (nearly 10 percent) but only a tiny number of cases worldwide (8096 confirmed and 774 fatalities) which put it well below Category 1.

    A “minor” pandemic may thus be one that has a very low case fatality rate even if widespread, or one that has alimited number of cases, or that causes minimal economic disruption, or that is easily controlled, or which causes minimal “panic”. And the opposite would hold true for a “major” pandemic.

  3. Why does the outbreak seem so much worse in Mexico?

    There may be a variety of factors at work, but current information suggests that the original reports of associated deaths was overestimated, which isn’t unusual in a major outbreak. The most likely alternative explanation is that Mexico has MANY more cases that are unreported, and that the overall death rate will drop dramatically once these are factored in. There is not currently evidence that the virus in Mexico was more virulent, or that health care was dramatically worse, or other alternative explanations.

  4. So how big is the “pyramid” of cases underneath the confirmed ones?

    This is the big question: what is the “multiplier” of unknown to known cases? Previously we estimated that in the Salmonella St. Paul outbreak in 2008 the ratio of undiagnosed cases to known cases was 39, meaning that for every single known case, there were at least 39 additional cases in the community. For influenza, the multiplier may be much higher. In our Pittsburgh Influenza Prevention Project (funded by CDC), we were impressed by the many times in which a child who subsequently had laboratory-confirmed influenza did not appear particularly ill. Some of the children we tested were running around in the yard, riding their bike, etc., and could easily have been in school potentially infecting others.

    In the 2007–08 influenza season in Pennsylvania, there were nearly 17,000 laboratory-confirmed cases. The very roughly estimated attack rate was 10–20 percent of the total state population, or 1.2–2.4 million people. This gives a multiplier in the range of 70–140 for that flu season. It is important to understand that this estimate will vary with the contagiousness of the disease, the resistance by the population (either due to vaccination or previous exposure to the same or a similar virus), the availability and accuracy of testing, the effectiveness of public behavior change that reduce the risk of exposure, and so on.

  5. Why is the “multiplier” effect important?

    It is important for two reasons. First, it is important to estimate AHEAD of the number of confirmed cases and understand that there are always many more uncounted than counted cases. Second, it illustrates why it is going to be so hard (probably impossible) to “stamp out” this pandemic in the same way that SARS was able to be eradicated (and is no longer circulating in human populations). Because if the multiplier is “only” 10, that means that the US currently has 10,000 cases, 90 percent of which are undiagnosed and undocumented.

  6. Why will the pandemic persist?

    It may not, but this is our best guess, and for several reasons. First, the disease is too contagious, and symptoms too mild in many cases, to be able to effectively identify enough cases for non-pharmaceutical or pharmaceutical interventions to be completely effective. Second, although summer is approaching in the northern hemisphere, and this usually damps influenza outbreaks (at least in temperate climates), the opposite is true for the southern hemisphere. Those countries are now facing both a “regular” flu season along with the new 2009 H1N1 virus piled on top, and the effects may be striking. Third, because of the novel nature of the virus, humans have either absolutely no or very little preexisting antibody protection against the virus. Translated: there are 6.7 billion people who are going to be prone to this infection. They will not all get sick at once, but spot outbreaks are likely to occur episodically worldwide for some time to come, and each of those outbreaks will carry the potential for seeding distant sites given the speed and frequency of international travel. Fourth, to the extent that an active public health system can identify early cases and apply effective public health measures to control local cases and outbreaks, everyone is better off. Unfortunately, much, if not most of the world lacks the resources to be highly effective in a situation like this, and thus it is likely that prolonged outbreaks will occur in various regions of the world. This will be exacerbated by the perception that this is “just the flu” and thus no special activity is required.

  7. Isn’t this “just” the flu?

    Current evidence suggests that the novel 2009 H1N1 virus is behaving similarly to seasonal flu. However, even in an average year, seasonal influenza causes hundreds of thousands of hospitalizations and 20–40 thousand deaths in the United States alone. And this is in the context of 60+ million doses of vaccine for high-risk populations and substantial partial immunity from previous infections with similar strains of virus. In the setting of a novel virus, where everyone is likely prone to infection, a lack of vigilance could quickly lead to a hundred thousand or more deaths. And the people most likely to die will be the most vulnerable—the very young, the very old, those with serious medical conditions, and women who are pregnant. This is not something that public health can allow if there is anything we can do about it—which there is.

  8. What can and should be done?

    CDC and state and local health departments have done an excellent job articulating the next steps. These include heightened surveillance and testing, active measures to isolate possible cases and quarantine close contacts, judicious usage of antiviral medication ONLY in appropriate settings, school interventions if necessary, and other public health activities. However, it is clear that the only true “solution” is an effective vaccine, and that this will take at least 4–6 months to manufacture, not counting time for distribution, inoculation, and the week and a half it takes for immunity to take root. In the interim, it is incumbent upon everyone to participate in collective activities to reduce their own risk and the risk to others of 2009 H1N1 infection. Some of the side benefits may be reduction in the incidence of other diseases transmitted by contact and droplet exposure, a collective appreciation of the importance of public health and all the work that has gone into pandemic planning over the last few years, and a better understanding of the world of “germs” in which we live.

    One or two last predictions: First, that the novel 2009 H1N1 will become resistant to Tamiflu within 1–3 months. This seems inevitable given the probable massive misuse of this and related medications that will accompany this pandemic. Second, that scientists, public health practitioners, and perhaps even politicians will appreciate with greater clarity the linkages between human health, animal health, and the ecological settings in which they exist. The Consortium for Conservation Medicine is an example of a collaborative institution that strives to understand these linkages, and to both understand and predict where “emerging infectious diseases” such as this virus originate. Given the increases in world population and necessary food supply, and the consequent reduction in distance between humans and domestic and wild animal populations, it is very likely that the risk for similar or worse outbreaks will only increase. In this setting, our best defense is a worldwide public health system that can handle all the normal day-to-day activities and also nimbly sound the alert and respond to threats in a timely and effective manner.

Thank you to Leslie Fink for editing and Jason Sanders for Research.

 

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National Public Health Week April 6-12, 2009

Published: March 2009
Sources: Robert Wood Johnson Foundation, Public Health, 2008; American Public Health Association, 2009
Edited by: Linda Duchak, EdM, CHES

 

Building the Foundation for a Healthy America

Building the Foundation for a Healthy America

What challenges face public health?

Even though America spends more than $2 trillion annually on health care—more than any other nation in the world—we do not have the healthiest people. Ninety-five percent of health spending goes toward medical care and biomedical research; five percent goes toward public health and disease prevention.

  • U.S. life expectancy has reached a record high of 78.1 years but still ranks 46th, behind Japan and most of Europe, as well as countries such as Guam, South Korea, and Jordan.
  • A baby born in the United States is more likely to die before its first birthday than a child born in almost any other developed country. Among developed nations, only Latvia has a higher death rate for newborns than the United States.
  • America is among the top 10 countries that have the most people with HIV/AIDS.
  • Disparities persist with ethnic minority populations having nearly eight times the death rate for key health conditions, such as diabetes, than that of non-minority populations.

Millions of Americans suffer from preventable illnesses and chronic diseases that rob them of health and quality of life. Public health epidemics such as obesity and tobacco use and exposure put millions of adults and children at risk for unprecedented levels of major diseases such as heart disease, cancer, and diabetes. The major disease problems of our time will not be solved within our clinical care system with more intensive treatment; the incidence of disease must be decreased.

Serious gaps exist in the nation’s ability to safeguard health, putting our families, communities, states, and nation at risk. Almost seven years after September 11th, and almost three years after Hurricane Katrina, major problems remain in our readiness to respond to large-scale health emergencies. The country is still insufficiently prepared to protect people from disease outbreaks, natural disasters, or acts of bioterrorism, leaving Americans unnecessarily vulnerable to these threats.

How will a healthy nation be built?

Building a healthy nation will require a renewed emphasis on the very strategies that all public health professionals employ, regardless of discipline: prevention and intervention. As our nation’s leaders debate health policies, they need to understand why these strategies work and are necessary for the success of any policy they consider. A strong public health system and public policies focused on prevention of disease and injury are a critical part of the solution. Instead of planning health care reform, we must instead promote a broader definition that is more inclusive of the entire system, not just the treatment of illness. It will take health system reform, with an emphasis on an effective public health foundation, to build a healthy nation.

A comprehensive approach requires us to restore and increase funding for federal, state, and local public health programs such as those that track diseases, immunize children, and help people utilize preventive services. It requires us to ensure that all people living in America have access to comprehensive health care and that communities have the resources to implement programs to meet the needs of their residents. It also requires that the social determinants of health—the social and economic conditions under which people live that contribute to pervasive health inequities—be addressed.

What is National Public Health Week and why is it important?

Despite the dramatic progress achieved through a century of public health advancements — the elimination of polio, fluoridation of drinking water, and seatbelt laws—our nation’s health falls far short of its potential. Our progress has stalled and we have reached a point where we must examine our health system and the foundation upon which it stands. By recommitting ourselves to support our nation’s public health system, we can build on the successes of the past and establish the solid foundation needed for a healthy nation.

For over a decade, the American Public Health Association (APHA) has organized National Public Health Week to educate the public, policy-makers, and the public health community about critical public health challenges the nation is facing. Through National Public Health Week and beyond, APHA and its members, partners, and affiliated state public health associations come together to raise awareness and support for the public health system in order to build on the successes of the past and insert public health into policy discussions directed at America’s health system.

National Public Health Week 2009 launches the American Public Health Association’s new campaign, Building the Foundation for a Healthy America, which aims to establish the critical role public health must play as we focus our efforts on improving our nation’s health. The theme will guide efforts to ensure that core public health principles such as preventing disease and promoting health are the foundation upon which our nation’s current dialogue about health reform is built. At a time when our nation’s health is an important issue among policy-makers, we must establish the importance of a public health foundation in determining the policies and initiatives that will affect the future of America’s health. Simply put, successful health reform requires the support of a strong public health infrastructure.

 

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The National Association of City and County Health Officials Public Health Preparedness Summit 2009

Published: February 2009
Written by: Leslie Fink, Preparedness Center Coordinator, Center for Public Health Preparedness;


PHP Summit Daily News Cover

More than 1500 preparedness professionals from around the country – including from Bucks, Chester, Montgomery, Erie and Allegheny County Health Departments and the Pennsylvania Department of Health – gathered in San Diego last week for the 2009 Public Health Preparedness Summit (February 18 – 20, 2009). This was the Summit’s 4th year and the first time it took place on the West Coast. The Summit is the preeminent venue for dedicated preparedness professionals to gather, learn from each other, and improve their ability to plan, prepare for, respond to, and recover from public health emergencies and disasters. Next year’s Conference will be in Atlanta, GA. For details please visit the Public Health Preparedness Summit.

Faculty, staff, and students from the University of Pittsburgh Center for Public Health Preparedness attended and provided a diverse array of presentations. In addition, the new area of Preparedness and Emergency Response Research was highlighted, and Pitt’s brand-new “PHASYS” program (Public Health Adaptive Systems Studies) was highlighted at the opening plenary session.

Presentations

Maggie Potter


Margaret Potter, JD, MS, Associate Dean and
Director, Center for Public Health Practice
Gleason/UPCPHP

Sustainable Public Health Preparedness and Response Systems: The Role of Research, Margaret Potter, JD, MS

Margaret Potter, JD, MS, Associate Dean and Director, University of Pittsburgh Graduate School of Public Health Center for Public Health Practice, along with Captain Mildred Williams-Johnson of the U.S. Public Health Service, Ruth L. Berkelman of Emory University, Rollins School of Public Health, and Jennifer Horney of the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, presented an overview of the newly formed Preparedness and Emergency Response Research Centers (PERRC) which resulted from the “Pandemic and All-Hazards Preparedness Act” (PAHPA). Preparedness professionals from around the country were on hand to hear about the planned studies for creating and maintaining sustainable public health preparedness and response systems.

Dean Potter’s presentation focused on Public Health Adaptive System Studies (PHASYS), the University of Pittsburgh’s PERRC. PHASYS will generate criteria and metrics for measuring the effectiveness and efficiency of preparedness and emergency response systems. These metrics will encompass all aspects of response, including clinical, laboratory, legal, epidemiologic, communications, and management, and will be used to build models of response which will be refined using real world field observations to create practical applications for preparedness practitioners.

All-Hazards Preparedness in a Network of Medical Clinics  Serving the Urban Poor Sign


All-Hazards Preparedness in a Network of
Medical Clinics Serving the Urban Poor

Gleason/UPCPHP

All-Hazards Preparedness in a Network of Medical Clinics Serving the Urban Poor,
Sam Stebbins, MD, MPH and Sherrianne Gleason, PhD

The Center has recently developed on-line training and a creative workshop/exercise for medical clinical preparedness and response. This project was in response to a request from a network of 13 Federally Qualified Health Centers (FQHC) and four associated shelters in the Pittsburgh, PA area. Details were shared with a diverse audience of public health and preparedness personnel from both the state and local level. The session included a discussion on the Pittsburgh area FQHC’s regional all-hazards preparedness and response plan, a detailed online module for orientation and training of clinic employees, a Situation Manual for a tabletop exercise based on a shelter-in-place scenario, and plans for the after-action report. The presentation was well received and the diverse experiences of the audience led to dynamic and interactive discussions about the challenges of preparedness planning for FQHCs in particular and medical clinics in general. Resources are available by contacting the Center at 412-383–2400.

What All Rural Responders Must Know About PH Emergencies,
J. David Piposzar, MPH and Sherie Wallace

The ratio of public health workers to the general population in rural areas is typically low and training is therefore needed for nontraditional “disaster” responders so that they will be able to fulfill public health emergency functions in the event of a disaster. One hundred twenty-five public health professionals attended this session to learn about strategies to train rural professionals and volunteers and methods of integrating them into an existing emergency management framework. As a result of the training there were several inquiries regarding national collaboration, as well as requests for more information, including requests for a training model for those states with large rural populations.

The Role of Non-pharmaceutical Interventions and School Closure in Pandemic Influenza,
Sam Stebbins, MD, MPH and Charles J. Vukotich, Jr., MS

Pandemic influenza threatens to cause substantial disability, death, and societal disruption, and to overwhelm health care systems. Effective vaccines and anti-viral medications may not be available during the initial months of a pandemic and therefore non-pharmaceutical interventions (NPIs), such as infection control measures and behavioral changes, may be the primary means to decrease the spread of pandemic influenza. CDC’s Community Strategy for Pandemic Influenza Mitigation (2007) lists school closure as one of the most important strategies during a pandemic. This workshop included an exchange of ideas around school closure and alternatives, including concrete steps that can be taken toward policy changes to prepare schools for a pandemic. As part of the session, seventy-two people participated in The School Closure Game, an unrehearsed look at the impact of school closure on real people who, as preparedness professionals, would be part of the response to the pandemic. This real world simulation suggested that a minimum of 12-16% of people would have to miss work to care for children, and that this problem would quickly worsen the longer schools are closed. For details please visit the Pittsburgh Influenza Prevention Project.

Tina Assi stands next to her Presentation Poster.


Tina Assi stands next to her Student Public
Health Epidemic Response Effort poster.
Stebbins/UPCPHP

Student Public Health Epidemic Response Effort (SPHERE),
Tina Assi, MPH

SPHERE is a new student organization at the University of Pittsburgh Graduate School of Public Health that fosters the development of public health skills by training students in local outbreak investigations, emergency response, and community health events. Numerous public health students and practitioners stopped by this poster presentation to inquire into developing similar programs at their institutions, the various training requirements, and the sustainability of a program like SPHERE. The interest was encouraging and prompted discussion on forming a collaboration of student response teams from around the country.

In addition to five presentations, the Center was able to impact even more preparedness professionals as they stopped by our conference exhibit table to talk with our faculty and staff and sign up for the Preparedness e-newsletter. The Center’s involvement with the 2009 Public Health Preparedness Summit was a wonderful success and we look forward to being in Atlanta next year!

San Diego, CA

 

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Flu is smarter than we are

 

Germs are nasty

Published: January 2009
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness;

 

The “family” of influenza viruses – A and B, plus all the many subtypes and clades and subclades of A – is clearly gaining the upper hand. This is due in part to the nature of influenza viruses: their very high mutation rate which allows them to generate new variations partly or completely unrecognizable by our immune system; their ubiquity in human and animal populations; their tendency to often cause very few symptoms and thus “hide” as something that looks like the common cold; and their ability to move between species (especially humans, pigs, wild and domestic birds, and other animals). In combination with the tendency of human beings to approach all infections as candidates for antibiotic use – whether in people or in animals - the viruses are in the process of winning this round of the war. Or in the words of one of our first-graders, “Germs are nasty”.

Medication

CDC candles an egg

CDC microbiologist, Amanda Balish, “candles”
an embyonated chicken egg. By using this
procedure, Amanda was able to access the
viability of each egg used in the isolation
of influenza viruses. CDC/Laura R. Zambuto

In the hundred and seventeen years since Dmitri Iwanowski first recognized that mosaic tobacco disease was caused by a “soluble germ” – a virus - no viral illness has ever been controlled on a population level through treatment with medication. Even HIV/AIDS, with the advent first of AZT and then Highly Active Anti-Retroviral Therapy (HAART), cannot be stopped through medical treatment. The World Health Organization (WHO) estimates that the number of deaths from HIV/AIDS will increase from 3 million in 2000 to 6 million in 2030 – and this assumes effective treatment reaches 80% of the population in the hardest-hit countries.

The failure of prevention and the overuse of antibiotics are profoundly illustrated in the case of influenza. In only three years, between 2003 and 2006, influenza A resistance to the adamantane class of antivirals (Adamantine and Rimantadine) spread around the world. Why did this happen? One important reason is that only a single point mutation is required for flu to become resistant to this class of medications, and this can occur over a single course of treatment. However, this doesn’t tell the whole story. Data from around the world strongly suggest that the trend began in Southeast Asia – most likely China – and then spread rapidly regionally and then globally 1. This spread was very likely engendered by much wider usage of adamantanes in human and/or domestic animal populations.

"You introduce an antibiotic, you get resistance. That's just how the world works."

- Tom Chiller, CDC's "Get Smart on the Farm" Program

Next to fall was Tamiflu (oseltamivir). The mutation required is more complex and scientists initially thought that resistance wouldn’t develop or the mutation would be so complicated it would impair the virus in other ways (thus reducing its survival advantage). However, as Jeff Goldblum’s character recognized in Jurassic Park, “life finds a way”. In only one year, beginning in 2007-2008 and initially documented in European countries, the H1 strain of influenza A has become resistant to Tamiflu in every country. Click here for a detailed description. The speed is breathtaking. Why did this happen so quickly and suddenly? Again, the answer is likely the same as for the adamantanes – large increases in Tamiflu usage, in human or animal populations (or both), caused a “tipping point” where selection pressure overcame other genetic barriers and resistant virus became the dominant variant. This process almost certainly began in Southeast Asia, most likely in 2005–06 2.

Where we are now

Table 1 - From CDC Weekly Report 1/27/2009

Isolates

tested (n)

Resistant Viruses,
Number (%)

Isolates

tested (n)

Resistant Viruses,

Number (%)

Oseltamivir

Zanamivir

Adamantanes

Influenza A

(H1N1)

103

101 (98%)

0 (0)

103

1 (1%)

Influenza A

(H3N2)

23

0 (0)

0 (0)

23

23 (100%)

Influenza B

61

0 (0)

0 (0)

N/A*

N/A*

* The adamantanes (amantadine and rimantadine) are not effective against influenza B viruses.

The only “good” news is that the H3 variant of influenza A along with the main clades of H5N1 remain sensitive to Tamiflu. And that Relenza (zanamivir) remains unaffected by these trends – so far. However, Relenza is currently formulated as an inhaled medication, and because it can cause bronchospasm it is not recommended for people with chronic lung disease – often those most in need of treatment.

However, given influenza’s proven ability to drift, shift, translocate and otherwise exchange genetic information, I do not hold out much hope that these medications will long retain their usefulness.  The most likely scenario is that in the near future H3 will become resistant to Tamiflu. Even worse, I predict that this resistance will spread to H5N1, which will largely erase the effectiveness of the world-wide stockpiles of Tamiflu, leaving us much more vulnerable to a pandemic (at least one which has H5N1 as the precursor). Lastly, as Relenza gets utilized more, it is very likely that over the next several years we will see resistance to that develop as well.

 

1. Bright et al, 2005. “Incidence of adamantane resistance among influenza A (H3N2) viruses isolated worldwide from 1994 to 2005: A Cause for Concern. Lancet 366:1175-1181.

2. http://www.recombinomics.com/News/01130903/H274Y_Japan_Concern.html - text below is from this article:
“However, sequence analysis indicates that the H274Y outbreak had already started in 2006, as evidenced by H274Y in H1N1 in hosts not taking Tamiflu.  These hosts were initially found in China, in patients infected with clade 2C (Hong Kong), which was followed by patients in the US and UK infected with clade 1 (New Caledonia) in 2007.  Last season the initial cases were in Hawaii in patients infected with clade 2B (Brisbane), but the H274Y was subsequently acquired by another Brisbane sub-clade that spread H274Y at high frequencies in Norway, Russia, and France, and somewhat lower frequencies in other countries in Europe and North America.”

 

Special Thanks - Thanks to Maggie Whelan in the MSTP program for background research.

 

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