Emergency Preparedness for School to Manage Large Outbreak of InfluenzaCentre for Health Education and Health Promotion, CUHKDecember 2005

Current WHO phase of pandemic alertSource: WHO

Inter-pandemic phase

New virus in animals, no human casesLow risk of human cases1Higher risk of human cases2Pandemic alert

New virus causes human casesNo or very limited human-to-human transmission3Evidence of increased human-to-human transmission4Evidence of significant human-to-human transmission5PandemicEvidence of sustained human-to-human transmission6

Will pandemic of influenza occur? If one has a crystal ball to view the future, this question would be answered.

Vector

HOSTAGENTENVIRONMENTWe would make some prediction based on the epidemiological triangle recognizing the three main factors-agent, environment and host in the pathogenesis of disease. /

If we can control any two of the main factors, one would prevent the occurrence of a communicable diseases.

Novel influenza virus subtype emerge for an old subtype re-emerges to which there is no herb immunity; The new virus must be able to replicate in humans and cause serious illness; and The new virus must be able to transmit from human to human. For an influenza pandemic to occur, there should be three pre-requisites:

Three pandemics occurred in last century1918/19 (Spanish Flu) causing death of 20 to 40 million people worldwide 20 40 1957/58 (Asian Flu) 1968/69 (Hong Kong Flu) At present, there is no place with influenzapandemic yet.

What is avian influenza?Avian influenza, or bird flu, is a contagious disease of animals caused by viruses that normally infect only birds and, less commonly, pigs. Avian influenza viruses are highly species-specific, but have, on rare occasions, crossed the species barrier to infect humans.

What is avian influenza? In domestic poultry, infection with avian influenza viruses causes two main forms of disease, distinguished by low and high extremes of virulence. Low pathogenic form commonly causes only mild symptoms. The highly pathogenic form spreads very rapidly through poultry flocks, causes disease affecting multiple internal organs, and has a mortality that can approach 100%, often within 48 hours. 48 100

Influenza A viruses1 have 16 H subtypes and 9 N subtypes2. Only viruses of the H5 and H7 subtypes are known to cause the highly pathogenic form of the disease. However, not all subtypes will cause severe disease in poultry. 16 H 9 N , H5 H7 H5 and H7 viruses are introduced to poultry flocks in their low pathogenic form. When allowed to circulate in poultry populations, the viruses can mutate, usually within a few months, into the highly pathogenic form. H5 H71 Influenza viruses are grouped into 3 types, A, B, and C. A and B viruses are of concern for human health. Only A viruses can cause pandemics.2 H subtypes are epidemiologically most important, as they govern the ability of the virus to bind to and enter cells, and multiplication of the virus then occurs. N subtypes govern the release of newly formed virus from the cellsH H N

Common types of FluA/Beijing/262/95 (H1N1)A/Fujian/411/2002 (H3N2)A/Moscow/10/99 (H3N2)

Considerable circumstantial evidence suggests that migratory birds can introduce low pathogenic H5 and H7 viruses to poultry flocks, which then mutate to the highly pathogenic form. H5 H7 Recent events make it likely that some migratory birds are now directly spreading the H5N1 virus in its highly pathogenic form. Further spread to new areas is expected. H5N1 Do migratory birds spread highly pathogenic avian influenza viruses?

The current outbreaks of highly pathogenic avian influenza, which began in SE Asia in mid-2003, are the largest and most severe on record. Never before in the history of this disease have so many countries been simultaneously affected. 2003 Despite the death or destruction of an estimated 150 million birds, the virus is now considered endemic in many parts of Indonesia and Viet Nam and in some parts of Cambodia, China, Thailand, and possibly also the Lao Peoples Democratic Republic. Control of the disease in poultry is expected to take several years. 1 5 What is special about the current outbreaks in poultry?

The widespread persistence of H5N1 in poultry populations poses two main risks for human health. H5N1The first is the risk of direct infection when the virus passes from poultry to humans, resulting in very severe disease. Unlike normal seasonal influenza, where infection causes only mild respiratory symptoms in most people, H5N1 infection follows an unusually aggressive clinical course, with rapid deterioration and high fatality. H5N1 What are the implications for human health?

Primary viral pneumonia and multi-organ failure are common. In the present outbreak, more than half of those infected with the virus have died. Most cases have occurred in previously healthy children and young adults. A second risk, of even greater concern, is that the virus if given enough opportunities will change into a form that is highly infectious for humans and spreads easily from person to person. Such a change could mark the start of a global outbreak (a pandemic). What are the implications for human health?

Main route of human infection- direct contact with infected poultry, or surfaces and objects contaminated by their faeces. Most human cases have occurred in rural or periurban areas where many households keep small poultry flocks, roaming freely, sometimes entering homes or sharing outdoor areas where children play. How do people become infected?

As infected birds shed large quantities of virus in their faeces, opportunities for exposure to infected droppings or to environments contaminated by the virus are abundant under such conditions. Exposure is considered most likely during slaughter, defeathering, butchering, and preparation of poultry for cooking. How do people become infected?

Yes, though certain precautions should be followed in countries currently experiencing outbreaks. In areas free of the disease, poultry and poultry products can be prepared and consumed as with no fear of acquiring infection.Is it safe to eat poultry and poultry products?

In areas experiencing outbreaks, poultry and poultry products can also be safely consumed provided these items are properly cooked and properly handled during food preparation. The H5N1 virus is sensitive to heat. Normal temperatures for cooking (70oC in all parts of the food) will kill the virus.H5N170 Is it safe to eat poultry and poultry products?

Consumers need to be sure that all parts of the poultry are fully cooked (no pink parts) and that eggs, too, are properly cooked (no runny yolks).Is it safe to eat poultry and poultry products?

One should be aware of the risk of cross-contamination. Juices from raw poultry and poultry products should never be allowed, during food preparation, to touch or mix with items eaten raw. Is it safe to eat poultry and poultry products?

When handling raw poultry or raw poultry products, persons involved should wash their hands thoroughly and clean and disinfect surfaces in contact with the poultry products. Soap and hot water are sufficient for this purpose.Is it safe to eat poultry and poultry products?

Avian influenza is not transmitted through cooked food. To date, no evidence indicates that anyone has become infected following the consumption of properly cooked poultry or poultry products, even when these foods were contaminated with the H5N1 virus. H5N1Is it safe to eat poultry and poultry products?

NO. Though more than 100 human cases have occurred in the current outbreak, this is a small number compared with the huge number of birds affected and the numerous associated opportunities for human exposure, especially in areas where backyard flocks are common.Does the virus spread easily from birds to humans?100

It is not presently understood why some people, and not others, become infected following similar exposures. How do people become infected?Does the virus spread easily from birds to humans?

The risk is serious. With the H5N1 virus now firmly entrenched in large parts of Asia, the risk that more human cases will occur will persist. H5N1Each additional human case gives the virus an opportunity to improve its transmissibility in humans, and thus develop into a pandemic strain. How serious is the current pandemic risk?

The recent spread of the virus to poultry and wild birds in new areas further broadens opportunities for human cases to occur. While neither the timing nor the severity of the next pandemic can be predicted, the probability that a pandemic, will occur has increased. How serious is the current pandemic risk?

When clusters of patients with clinical symptoms of influenza, closely related in time and place, are detected, this suggests human-to-human transmission is taking place.For similar reasons, the detection of cases in health workers caring for H5N1 patients would suggest human-to-human transmission. H5N1What are the most important warning signals that a pandemic is about to start?

Detection of such events should be followed by immediate field investigation of every possible case to confirm the diagnosis, identify the source, and determine whether human-to-human transmission is occurring. What are the most important warning signals that a pandemic is about to start?

Vaccines are produced each year for seasonal influenza but will not protect against pandemic influenza. Because the vaccine needs to closely match the pandemic virus, large-scale commercial production will not start until the new virus has emerged and a pandemic has been declared. What is the status of vaccine development and production?

Two drugs (in the neuraminidase inhibitors class), oseltamivir (commercially known as Tamiflu) and zanamivir (commercially known as Relenza) can reduce the severity and duration of illness caused by seasonal influenza./Relenza The efficacy of the neuraminidase inhibitors depends on their administration within 48 hours after symptom onset.48What drugs are available for treatment?

For cases of human infection with H5N1, the drugs may improve prospects of survival, if administered early, but clinical data are limited. H5N1The H5N1 virus is expected to be susceptible to the neuraminidase inhibitors. H5N1What drugs are available for treatment?

An older class of antiviral drugs, the M2 inhibitors amantadine and rimantadine, could potentially be used against pandemic influenza, but resistance to these drugs can develop rapidly. M2rimantadine What drugs are available for treatment?

Although Avian Flu has similar symptoms as seasonable influenza, Avian Flu is unlikely if one has not contacted infected poultry and/or birds.

If any students or staff has been to high risk area and/or in contact with poultry or birds, and develop flu like illness, they must consult doctors immediately. They must give an accurate account of history of traveling and history of contact.

To prepare well to safeguard health of the community, the Government aims:Reduce risk of human infections Early detection of influenza pandemic, andEnhance emergency preparedness and response for influenza pandemic

Basic measures for keeping school premises hygienic and healthy to prevent pandemic influenza

For parents/students/staff: //Parents should check the temperature of their children daily before school with proper recording duly signed by parent Stay at home and consult doctor with fever or feeling unwell. School staff and students should wear face masks when they have respiratory tract inflection symptoms

Students should wash hands before meals and after sneezing, coughing or cleaning the nose. They should not share towels or utensils. Consult doctor promptly in case of fever and/or respiratory symptoms. School bus drivers and the assistants should not drive/get on the bus if they have fever. They should wear mask if they have respiratory tract infection.

Schools should: Clean and disinfect school premises and facilities at least daily with diluted household bleach with disinfectant mats at school entrance. Provide adequate facilities and cleaning material for hand-washing. Maintain good indoor ventilation and wash dust filters of air conditioners frequently.

Flexible break time and lunch time to avoid over crowding Notify the Department of Health and EMB of unusual symptoms of infection are noted or large number of students on sick leave. Encourage students/staff to increase body immunity by eating a balanced diet, taking regular exercise, adequate rest

Strongly advise students and staff not to attend schools when they have fever. Advice them to consult doctors. Provide adequate and proper face masks, gloves and other appropriate protective equipment. Develop contingency plan.

All organisation should have its own practical contingency plan.

Points for consideration in planning:- Identify personnel for designated jobs, i.e., infection control, liaison persons etc. Split into smaller working groups using different access points and reduce number of meetings with greater use of telephone conference.

Stock pile personal protective equipment (PPE) such as masks, disinfectants. To provide training and briefing for staff on general measures and also specific measures such as use of PPE. Test and review contingency. Designate deputies of management if become ill. Specify responsibilities of key individual team. Establish inflection control procedures.

SARS prevention also applicable. Take reference from EMB handbook www.emb.gov.hk www.emb.gov.hk Spandemic preparedness can be accessed at the Centre for Health Protection website via the Influenza Page.English versionhttp://www.chp.gov.hk/view_content.asp?lang=en&info_id=590Chinese versionhttp://www.chp.gov.hk/view_content.asp?lang=tc&info_id=590School against SARS http://www.hkedcity.net/project/cuhk_sars/index_e.phtml Hygiene Charter http://www.hygienecharter.org.hk/eng/index.php

Hygiene Charterhttp://www.hygienecharter.org.hk/eng/index.php

Hygiene Charter As a continuing effort in the fight against SARS, Operation UNITE (community initiated movement comprising community leaders from all sectors to help the community in fighting against SARS) has conceived a Hygiene Charter with the academic and professional advice by the Chinese University of Hong Kong, which aims at encouraging individuals, as well as business and industry sectors, to pledge their commitment to improve hygiene practices for the good of all. -

Schools Against SARS campaign

Schools Against SARS Campaign http://www.hkedcity.net/project/cuhk_sars/index_e.phtml

One School One Doctor: Healthy School Life II - Learning Together with your Doctors(Chinese Version Only)http://www.cuhk.edu.hk/med/hep/crisis_management/SARS/movie/movie.html

Facilities of Medical Rooms at school

Contingency Plan for managing suspected / confirmed cases of Flu or Avian Flu in Schools / :http://www.cuhk.edu.hk/med/hep/crisis_management/avianflu/chi_141005.pdf

English Version:http://www.cuhk.edu.hk/med/hep/crisis_management/avianflu/eng_101105.pdf

Student/staffSuspected to be infectedDiscover Dead poultry/birdInform AFCDHotline 1823Isolate, inform parents/relatives, consult doctor for advice Confirmed Avian FluDiagnosed Flu / common cold Number of infected persons. increases No new incident reported Activate Contingency group 5. School-based surveillance 4. Environment 2. Act according to Notify DH and act accordingly advice from DH & EMB3. school-parentcommunication 7. Reinforce hygiene education & Flu/ Avian Flu alertness 6. Student / Staff support Review hygienicstatus Cleaning &DisinfectionSpecial classroomarrangements Regular cleaning ofVentilation systems Routine precaution 1.School Environment 2. Hygiene education 3. School policy Parents Students Staffs Actions by AFCD1. Notify EMB & DH Follow DoctorsadviceEMB: Education and Manpower BureauDH: Department of HealthAFCD: Agricultural, Fisheries and Conservation DepartmentAction by school

No one can be responsible for your own health except you. Crisis can be turned into opportunities with better management