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Avian Influenza

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					     Pandemic Influenza


Brant Goode, RN, BSN, MPH
NC Division of Public Health
          Objectives

Review influenza fundamentals
Assess current pandemic threat
Describe pandemic planning in North
Carolina
       Flu Fundamentals:
         Viral Infection

Fragments of
genetic material
Protein shells
Attach to host cells
Use host cells to
reproduce

                       CDC Public Health Image Library
 Seasonal Flu: Signs and
      Symptoms
Fever
Headache
Muscle aches
Extreme fatigue
Dry cough
Sore throat
Runny or stuffy nose   happycarpenter.blogs.com
        Flu Fundamentals:
        Respiratory Spread
Transmission: Respiratory droplets
  Each infected person infects 2-3 others

Incubation period: 1 to 5 days from
exposure to onset of symptoms
Communicability:
   1-2 days before symptom onset
   4-5 days after onset
Timing: Peak usually occurs December
through March in North America
        Seasonal Influenza
    Impacts in the United States
                                                               Deaths
                                                               ~36,000
     Hospitalizations
        ~200,000


                                    Physician visits
                                      ~ 25 million


                              Infections and illnesses
                                   50 - 60 million



Thompson WW et al. JAMA. 2003;289:179-86. Couch RB. Ann Intern Med. 2000;133:992-8.
Patriarca PA. JAMA. 1999;282:75-7. ACIP. MMWR. 2004;53(RR06):1-40.
     Prevention of Seasonal
           Influenza
Annual vaccination
   Injection
        Inactivated
   Nasal mist
        Live attenuated
Wash hands
Stay away from persons
with illness
Cough etiquette: “Cover
your cough”
                       southbirminghampct.nhs.uk
    Seasonal Influenza:
        Treatment
Over-the-counter comfort measures
Antiviral medications
 Do not cure
 Can decrease severity or shorten illness
  by 1-2 days
 Must be given shortly after onset

Antibiotics don’t work
        Avian Influenza (AI)
            “Bird Flu”
Migratory waterfowl
are the natural
reservoir
   Carry virus in intestines
   Virus shed in feces and
    respiratory secretions
   Usually do not get sick
   Many more flu types
Source of potential
pandemic strains
    Avian Influenza in Humans
AI viruses typically don’t infect humans
 Conjunctivitis
 Influenza-like illness

 Pneumonia

 Death



Human AI infections don’t mean a
pandemic is imminent
        Pandemic Influenza
Worldwide epidemics
 Potential excess death and
  illness
 Multiple waves possible
     Six   to eight weeks long
Pandemic “Prerequisites”
New flu virus emerges
New flu virus causes disease in humans
Novel virus can be efficiently transmitted
person to person




            Dr. Asamoa-Baah, Assistant Director General,
            WHO Communicable Diseases
Pandemics of the 20th Century
Year              Subtype   US Mortality
1918-19
                    H1N1        550,000
―Spanish flu‖
1957-58
                    H2N2         69,800
―Asian flu‖
1968-69
                    H3N2         33,800
―Hong Kong flu‖
           “Pandemic Watch”
           Global Perspective
Good news
   No sustained person-to-person transmission
    of a novel virus…


Bad news
   H5N1 Avian flu virus bird pandemic continues
        Asia, Europe and Africa
   Eradication in birds not likely
   Mutation potential persists
   Clusters of human infection
Pandemic Influenza
Planning in North Carolina
Pandemic Influenza Planning
          Goals
    Reduce illnesses
    Reduce deaths
    Reduce social disruption
                North Carolina Impact
                                       Moderate                                 Severe
                             Seasonal Pandemic*                              Pandemic*
Doctor visits                    750,000             1.6 million              1.6 million

Hospital visits                      6,000                  35,000                 290,000

Deaths                               1,100                    7,950                  65,300

* Based on CDC software FluAid 2.0: Assumes a 35% attack rate, NC population of 8.5 million people.
Community Containment
          Isolation and quarantine of
          individuals
             Feasible?
             Practical?

          Community-wide “quarantine”?

          Encourage social distancing
             Cancel public gatherings
             Close schools, other settings
              where people congregate
                                                                                                   Deaths Rates / 100,000 Population
                                                                                                            (Annual Basis)
                                                                                   9/
                                                                                     14
                                                                                          /1




                                                                                                       2000
                                                                                                              4000
                                                                                                                     6000
                                                                                                                            8000
                                                                                                                                   10000
                                                                                                                                           12000
                                                                                                                                                    14000
                                                                                                                                                             16000




                                                                                                   0
                                                                                   9/ 91
                                                                                      21 8
                                                                                          /1
                                                                                   9/ 91
                                                                                      28 8
                                                                                          /1
                                                                                   10 918
                                                                                       /5
                                                                                  10 /19
                                                                                     /1 18
                                                                                        2
                                                                                  10 /191
                                                                                     /1
                                                                                        9/ 8
                                                                                  10 19
                                                                                     /2 18
                                                                                        6/
                                                                                           1
                                                                                   11 91
                                                                                       /2 8
                                                                                          /1
                                                                                   11 91
                                                                                       /9 8
                                                                                          /
                                                                                  11 191
                                                                                     /1        8
                                                                                        6/


                                                                           Date
                                                                                  11 19
                                                                                     /2 18
                                                                                        3
                                                                                  11 /191
                                                                                     /3
                                                                                        0/ 8
                                                                                           1
                                                                                   12 91
                                                                                       /7 8
                                                                                          /
Weekly mortality data provided by Marc Lipsitch (personal communication)          12 191
                                                                                     /1        8
                                                                                        4/
                                                                                  12       19
                                                                                     /2 18
                                                                                        1
                                                                                                                                                                     1918 Death Rates: Philadelphia v St. Louis




                                                                                  12 /19
                                                                                     /2 18
                                                                                        8/
                                                                                                                                                   St. Louis




                                                                                           19
                                                                                              18
                                                                                                                                                   Philadelphia
                                                       St. Louis
                                                                St. Louis          Estimated attack rate
                                                                                   before interventions:
                                  14000
Death Rate / 100,000 Population




                                  12000
                                              First death recorded                         2.2%
                                  10000         Mayor closes ―theaters, moving picture
       (Annual Basis)




                                   8000         shows, schools, pool and billiard halls,
                                                Sunday schools, cabarets, lodges, societies,
                                   6000
                                                public funerals, open air meetings, dance
                                   4000         halls and conventions until further notice‖
                                   2000
                                                                                Closing order withdrawn
                                         0
                                             21 8

                                             28 8

                                                      8

                                                      8




                                                      8

                                                      8




                                                      8
                                                     18

                                                     18

                                                     18




                                                     18

                                                     18

                                                     18




                                                     18

                                                     18

                                                     18
                                       91

                                                   91

                                                   91

                                                   91




                                                   91

                                                   91




                                                   91
                                                  19

                                                  19

                                                  19




                                                  19

                                                  19

                                                  19




                                                  19

                                                  19

                                                  19
                                    /1

                                                /1

                                                /1

                                                /1




                                                /1

                                                /1




                                                /1
                                               2/

                                               9/

                                               6/




                                               6/

                                               3/

                                               0/




                                               4/

                                               1/

                                               8/
                                  14




                                              /5




                                              /2

                                              /9




                                              /7
                                            /1

                                            /1

                                            /2




                                            /1

                                            /2

                                            /3




                                            /1

                                            /2

                                            /2
                                          10




                                          11

                                          11




                                          12
                                  9/

                                         9/

                                          9/



                                         10

                                         10

                                         10




                                         11

                                         11

                                         11




                                         12

                                         12

                                         12
                                                                         Date


                                   Source: Lipsitch M, Hatchett R, Mecher C
                                                     Pittsburgh
                                                               Pittsburgh           Estimated attack rate
                                                                                    before interventions:
                                  14000
Death Rate / 100,000 Population




                                  12000
                                              Theaters, saloons closed*                         3.7%*
                                  10000
                                                   Sports suspended
       (Annual Basis)




                                                        Churches closed
                                   8000
                                                            Schools, libraries closed
                                   6000

                                   4000

                                   2000

                                         0
                                             21 8

                                             28 8

                                                      8

                                                      8




                                                      8

                                                      8




                                                      8
                                                     18

                                                     18

                                                     18




                                                     18

                                                     18

                                                     18




                                                     18

                                                     18

                                                     18
                                       91

                                                   91

                                                   91

                                                   91




                                                   91

                                                   91




                                                   91
                                                  19

                                                  19

                                                  19




                                                  19

                                                  19

                                                  19




                                                  19

                                                  19

                                                  19
                                    /1

                                                /1

                                                /1

                                                /1




                                                /1

                                                /1




                                                /1
                                               2/

                                               9/

                                               6/




                                               6/

                                               3/

                                               0/




                                               4/

                                               1/

                                               8/
                                  14




                                              /5




                                              /2

                                              /9




                                              /7
                                            /1

                                            /1

                                            /2




                                            /1

                                            /2

                                            /3




                                            /1

                                            /2

                                            /2
                                          10




                                          11

                                          11




                                          12
                                  9/

                                         9/

                                          9/



                                         10

                                         10

                                         10




                                         11

                                         11

                                         11




                                         12

                                         12

                                         12
                                                                          Date


                                                     Source: Lipsitch M, Hatchett R, Mecher C
The “Snow Day” Approach
      -For 6-8 Weeks?
Pandemic Influenza Planning
       Challenges
Widespread event
Long duration
Health services overwhelmed
Shortages likely
  Medications
  Equipment
  Hospital beds
  Personnel: ~30% for ~2 weeks
              Partners
Hospitals
Emergency
management agencies
Local and regional
public health
Businesses—           No one will survive
including             a severe pandemic
restaurants and       unaffected
lodging
Schools and
universities
Faith-based
Other government
  Online Resources

     www.who.org
     www.cdc.gov

 www.pandemicflu.gov
www.ncpublichealth.com
    Prevention and Planning

         It Begins At Home
The more you prepare yourself, your family, your
employees and their families, and your
business, the more likely you can all fulfill roles
in an emergency

Don’t allow workers to put others at risk if ill—
they should stay home and take care of
themselves there!!
Questions
   Feedback
       Thanks
       FOOD SAFETY &
       AVIAN INFLUENZA


Steven C. Wells, DVM
Director of Meat & Poultry Inspection Division
North Carolina Department of Agriculture & Consumer Services
       GOALS - Answer
         following:

1. What is the real threat of AI to poultry?


2. How concerned should I be?


3. Is consumption of poultry products
   safe?
OVER REACTION?
          KEY POINTS
 No documented cases of Avian
 Influenza from eating poultry products
 Extensive monitoring and prevention
 program exists in commercial poultry
 industry designed for:
1.   Early detection
2.   Rapid response
3.   Swift recovery
Summary of Prevention
and Control Measures
COMPREHENSIVE AI
     PLAN
Includes programs for:
  - prevention
  - surveillance
  - response
  - food safety
           PREVENTION
Accomplished by:
   Active Surveillance – sampling of commercial
    flocks, waterfowl, etc.
   Passive Surveillance – live bird markets, etc.
   On-farm testing prior to slaughter
   Evaluation of birds before slaughter
   Evaluation after slaughter
   Trained inspection personnel
Key Prevention Method!
       SURVEILLANCE
On-Farm Testing
   10 birds from each flock are blood tested
    prior to slaughter
Test results reported same day by
NCDA&CS Lab
All birds evaluated prior to and during
slaughter
            SLAUGHTER
           PRECAUTIONS
1.   Abnormalities (bruises, swellings, etc.)
     detected during any slaughter step require
     examination by trained veterinarian
2.   Symptomatic birds or carcasses with AI-like
     wounds/injuries are rejected
3.   Birds with symptoms/lesions of AI are
     traced back to flocks of origin
4.   All infected flocks that test positive for AI
     are quarantined and destroyed
     RESPONSE EFFORT
 NC HPAI Control PLAN=COLLABORATIVE
 EFFORT INVOLVING:
1.  State & Local Government Agencies
   NCDA& CS; NC Dept of Public Health; NC DENR; Local
    Health Departments
2.  Federal Government Agencies
   USDA/Animal Plant Health Inspection Agency/Vet
    Services; USDA, Food Safety Inspection Service
3.  Universities
   College of Vet. Medicine; Food Science Dept.; UNC School
    of Public Health
4. Industry - NC Poultry Industry & Restaurant and Hotel
    Industry
   RESPONSE GOALS
Protect public health

Cause as little disruption to business
and industry as possible

Maintain supply of poultry products
RESPONSE DOCTRINE
 Four key parts of response to AI
 outbreak
1.   Quarantine
2.   Depopulation
3.   Disposal
4.   Surveillance of quarantine zones
           FOOD SAFETY

Basic Food Safety steps
   Clean food prep areas
   Separate handling (by time and/or space)
   Cook properly
   Chill rapidly to below 40 deg F
Cook poultry to internal temperature of 165
deg Fahrenheit
  – kills both bacteria and viruses
Information applies to restaurant and home kitchens
ODDS OF HPAI ENTERING
    FOOD SUPPLY
Odds are extremely low
Excellent surveillance and detection
Inspection personnel trained to recognize
signs of disease & take appropriate action
Disease progresses rapidly in birds
All involved agencies continue to develop and
refine response plans to AI outbreak
          SUMMARY
Poultry products pose minimal risk to
humans
No human illness reported from eating
poultry products
Prevention methods are simple
Efforts continue to improve prevention
and response plans
Avian Influenza:
Focus for Food Service
Establishments
Cris Harrelson, RS, MPH
Regional Environmental Health Specialist

Larry Michael, RS, MPH
Food Defense Coordinator
          Overview
Approved Sources
Proper Storage
Safe Food Handling Practices
Proper Cooking
Safe Service
    The Flow of Food
Food products of concern
 Raw Poultry
 Raw Eggs

Follow the flow—receiving to serving
Develop procedures to control potential
hazards that may occur at each step
  Flow of Food (cont.)

Receive      Store           Prepare


      Cook           Serve
           Receive
Make sure all food products are
received from an approved source
    What is an approved
          source?
   Inspected by NCDA
    & Consumer
    Services, Meat and
    Poultry Inspection
    Service
   USDA
        USDA Poultry
         Inspection Legend
        USDA Red Meat
         Inspection Legend
                Exemptions
   The following are
    exempt from
    inspection:
        Farmers who sell up
         to 1,000 chickens or
         250 turkeys per year
        Farmers who sell up
         to 30 dozen eggs per
         week
    Exemptions (cont.)
Exempt Farmers:
 Must label products with their name and
  address
 Must keep records

 Inspect facilities for cleanliness,
  adulteration, and signs of sickness
       Best Practices
Save all invoices for three months for
trace back purposes.
   Why?
Ask your supplier what safeguards they
have in place to protect poultry from
contamination
       Asian Sources
Restrictions on live
birds, poultry and
poultry products
from Asian countries
Processed poultry is
not imported from
Asia.
      Employee Health
Exclude or restrict sick employees from
the food service establishment
Exclusion:
 Vomiting or diarrhea
 Diagnosed with norovirus

Restriction:
   Diagnosed with norovirus but is
    asymptomatic
Employee Health (cont.)
Food workers may be exposed to AI-
infected birds in their home life
  Fighting cocks
  Chickens

 An effective employee hygiene policy
(e.g. handwashing procedures, eating,
drinking, smoking, etc.) is crucial
              Storage
Store at or below
45°F or frozen until
ready to cook
Keep raw meat and
poultry separate
from ready-to-eat
foods.
Recommended Storage for Foods
in Refrigeration (Top to Bottom)
 Ready-to-eat, cooked, pre-cooked
 Raw frozen vegetables
 Raw eggs
 Raw ready-to-cook seafood and beef
 Raw ready-to-cook pork
 Raw ready-to-cook hamburger
 Raw ready-to-cook poultry and stuffed meats
    Cover raw poultry to prevent cross-contamination
         Preparation
Utilize safe food handling practices
Protect from cross-contamination
 Utensils and equipment
 Clean, sanitized work surfaces

 Handwashing
Methods for Safe Thawing
In the refrigerator at 45°F or below
Under potable running water at 70°F or less
As part of the cooking process
In a microwave oven
   If immediately transferred to conventional cooking
    equipment, or
   When the entire uninterrupted cooking process
    takes place in the microwave
     Proper Cooking
Perhaps the most important step in the
flow
Proper cooking will kill H5N1
Proper cooking will kill all pathogens
 Proper Cooking                 (cont.)

Poultry and poultry stuffings must be
cooked to an internal temperature of
165°F for 15 seconds
Fresh raw eggs and egg products
(unless pasteurized):
 Should not be consumed or used in any
  dishes that will not be cooked
 Cook until both yolks and whites are solid
               Serve
Avoid recontamination of the food after
cooking
 Make sure food contact surfaces are clean
  and sanitized
 Train food workers and wait staff how to
  properly handle ready-to-eat food
          Conclusion
Address hazards within each step of the flow
of food
Obtain food products from approved sources
Observe proper storage practices
Utilize safe food handling practices and
proper thawing
Conduct adequate handwashing
Avoid cross-contamination
Cook to 165°F
Avoid cross contamination before serving
    Contact Information
Larry Michael
Food Defense Coordinator
(919) 715-0927
Larry.Michael@ncmail.net

Cris Harrelson
Regional EHS
(910) 863-4930
Cris.Harrelson@ncmail.net
      Risk Communication:
      How to Educate &
      Inform Customers &
      Employees

Claudia S. Rumfelt-Wright, MSW
Public Health Program Consultant
Dairy & Food Protection Branch
       What is Risk?


The probability of losing something or
 someone you value, i.e. your health
       What is Risk
      Communication
The targeted exchange of information about
the possible effects of events or actions on
human health.

Important elements here are the creation of
trust and credibility, the conveying of
information and knowledge, and two-way
communication.
      Risk Vs Crisis Risk
       Communication
Risk Communication              Crisis/Emergency Risk
                                  Communication
 Communicator: Expert who         Communicator: Expert who
 did not participate in the       is a post-event participant
 event and is neutral             invested in the outcome
 regarding the outcome            Time Pressure: Urgent and
 Time Pressure: Anticipated       unexpected
 communication with little or     Message Purpose: Explain,
 no time pressure                 persuade and empower
 Message Purpose:                 decisionmaking
 Empower decisionmaking
    Perception of Risk


Voluntary vs. involuntary
Personally controlled vs controlled by others
Familiar vs exotic
Natural origin vs manmade
Reversible vs permanent
Know your Audience
Who is your audience?
Employees
 They want to know how to protect
  themselves and their families
 They want to know if they can trust you to
  help protect them
Who is your audience?
Customers
 Are you taking the proper precautions to
  protect them by cooking the chicken
  properly?
 Is there an increased risk being close to
  waiters or kitchen staff?
 How can they protect themselves and their
  families?
What do people know?
93% of those surveyed by Rutgers University
said they had heard of Avian Influenza
71% say they have talked to others about it
On average those surveyed were able to
answer 13 out of 22 objective questions
about Avian Influenza and food
 What People Believe
About 1 in 10 believe that it is easy to
see if a live bird is infected
About 1 in 4 (25%) think it is easy to see
if a raw chicken is infected
Only 4 in 10 believe that cooking kills
the H5N1 virus; nearly a third (31%)
don’t know if it does or not
 What People Believe
About 72% are worried to some extent
about their risk of infection
74% believe they are at risk of infection
Most believe that others are have a
higher risk of becoming infected
Higher perceived risk among lower
socioeconomic status, non-white,
female
       Poor Risk
     Communication
Mixed messages from different experts
and agencies
Information released too late
Myths & rumors unchallenged
Dishonesty
Lack of trust
             Successful Risk
             Communication
  Risk communication ―is more likely to succeed
  if it sets the goal of helping people
  understand the facts, in ways that are
  relevant to their own lives, feelings, and
  values so that they are empowered to put the
  risk in perspective and make more informed
  choices.‖

Source: Gray & Ropeik
         Keep in mind
―Adjustment Reaction‖— Human and Media
Headlines, images are intense and troubling
It is natural to fear chicken after news of
outbreak
Media emphasis and public fears will ease in
time
Poultry additional protection
Remember to Emphasize

Commercial poultry subject to tight controls
Thorough cooking destroys influenza virus
We live ―comfortably‖ with other food-borne
threats
Diligence affords additional protection
Components of Communication
  Three things you want them to know
      1. We are taking steps to protect our workers.
      2. The FDA and the USDA say that cooking
      chicken to 165º kills the virus. We are making
      sure that all chicken served in our establishment
      is thoroughly cooked.
      3. We know our suppliers and where their
      chickens come from and how they process it.
      4. There have been no documented cases of AI
      from eating poultry.
       5. The commercial poultry industry has an
      extensive monitoring & prevention program.
      6. Eating poultry and eggs pose a minimal threat
      to consumers.
Three Things They Want
       to Know

Is it safe to eat chicken, turkey and
eggs?
How great is the risk?
How can I protect my family?
Three most important things
the consumer is likely to get
 wrong unless emphasized
There are no documented cases of people becoming
ill with AI from eating poultry or eggs.
Avian influenza is passed from bird-to-bird, from bird-
to-person but not effectively from person-to-person.
Cooking poultry and eggs to 165ºF throughout will kill
the virus.
Planning for the Event
Risk Communication vs
      Crisis Risk
    Communication
The communication by individual
restaurants and the restaurant industry
is more likely to be risk communication.
The CDC, FDA, USDA, etc., will likely
address the risks of contracting avian
influenza. Thus they will be doing the
crisis risk communication.
    Steps toward a good
      communication
         campaign
Consider in advance –
 What types of communications to use
 What resources are available to you

 Your audiences (customer and employee)

 Actions you can take to increase your
  credibility
 Collaboration with NCRLA, NRA, State or
  local Public Health Department
                 Tips
Be honest & candid
Don’t over-reassure
Be sensitive to the culture and beliefs of
others
Acknowledge uncertainty
Don’t try to allay panic
Acknowledge people’s fears
Explain the process – tell them what you are
doing to reduce the risk for your customers
and your employees
             And Remember
   ―There is virtually no correlation
   between the ranking of hazards by
   experts and the ranking of those same
   hazards by the public.‖

Source: Vincent Covello
        Resources
www.cdc.gov/flu/avian/index.htm
www.usda.gov/wps/portal/usdahome
www.cfsan.fda.gov
www.fsis.usda.gov
www.restaurant.org
     Questions


              ?
   Claudia Rumfelt-Wright
claudia.rumfelt-wright@ncmail.net
    Telephone (919) 715-8497

				
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