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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
