Background to influenza Epidemic

Background to influenza Epidemic
From a presentation given by Dr Karen Poutasi on Influenza Planning
(Compiled for Dr Poutasi by Dr Andie Forde)

What is influenza? Influenza is an acute debilitating viral disease that affects the respiratory tree. Every word in that definition is important. It is acute, comes on suddenly, debilitating, it will knock you for six, and affects the respiratory tree. The respiratory tree includes the tissues that run through the nose, the back of the throat, the sinuses, the bronchi and the lungs. It is a virus that spreads from person to person in droplets and by hand to mouth transmission. So this rather complex picture encompasses everything you need to know about the influenza virus. The outer coat composed of haemaglutinin, and neuraminidase, are what enable our bodies both to recognise and to mount an immune response to the virus. This also enables us to classify influenza A viruses. There are 16 ‘H’s and 9 ‘N’s so you can immediately see the amount of combinations that arise. The Genome is composed of 8 pieces of RNA. These are not transmitted together but can be transmitted separately and therefore gives rise to the tremendous differences that can emerge and unpredictable nature of this virus. This of course, leaves aside the point mutations that can also occur within this virus.

So seasonal influenza or classical influenza comes on abruptly with the development of symptoms, and secondary complications of pneumonia, sinusitis, meningitis, and otitismedia arise. Influenza A viruses, because of their genetic instability, are exceedingly well adapted to elude body defences. With subtle changes that occur to the outer protein coat, the manufacture of a new vaccine each year to seasonal influenza is required. If a major change occurs to these proteins, if there are new ‘H’s and new ‘N’s’, this process is called antigenic shift. The population will have no immunity to this virus and pandemic may result.

Moving on to the ubiquitous nature of viruses. The range of species affected by influenza include Avian, mammals, and also some reptiles. Clearly from this, we can see the potential for a new virus to arise.

What will make pandemic influenza different to seasonal influenza? First, it may come at any time of the year, it may come, as seasonal influenza does, during the cold wintery months. It may come in spring or summer. It is likely that it will come in waves and it may impact on any age group not just the very young and the very elderly. The attack rate may be very high, we do not know what the mortality rate will be – it is possible that it may also be high. What we do know is that it will come, one day, possibly sooner rather than later.

How do we know this? Pandemic Influenza has been recognised since the 12th Century. On average, there have been three pandemics in each century. In the 20th Century Pandemic Influenza occurred in 1918 (the Spanish flu) and we know that the estimated death range runs between 50 – 100 million people. We have no more precise figure than that, because of course the case attack rate and the fatalities were not recorded in large parts of the globe – for example China, the Indian Subcontinent or Africa. This virus was an ‘H’ 1 ‘N’ 1 virus. In 1957, the globe experienced the pandemic of asian flu. This came as one large wave with an attack rate of approximately 70%. The mortality rate was very much reduced and the estimates are around 1 – 4 million dead around the globe, but within new Zealand during this pandemic, we know that at one time 40% of all Christchurch hospital nurses were bed ridden. The third pandemic of the last century occurred in 1968, the Hong Kong flu. Again, a small mortality rate but a lot of sickness. Where do these viruses come from?

In 1918, 1957, and 1968 the evolution was from wild waterfowl. The 1918 virus has had its genome reconstructed. The virus is an Avian virus that adapted to humans. The 1957 and 1968 viruses contained both avian genome and human genome. In 1977 the ‘H1’ ‘N1’ virus re-emerged. Nobody knows why or understands its re-emergence.

However, we also know that there have been a number of pandemic threats and there are lessons to be learned from the threats that did not create Pandemic Influenza. For example, the 1976 swine influenza in the United States. At this time, the Government of the United States applied force majeure to all vaccine manufacturing capacity within its borders. Influenza vaccine could not be exported, and so as it could not move north into Canada, as a consequence the Canadian Government developed its own influenza vaccine capacity.

The first appearance of ‘H5’ ‘N1’ was in Hong Kong in 1997. During this outbreak in poultry, 18 humans were infected, 6 died. This was recognised as being a significant threat and the Hong Kong authorities took what would initially be draconian steps. All poultry within the risk area were culled over a three-day period. This measure is widely believed to have averted the pandemic threat, and indeed, the virus was not seen again for six years. It re-emerged in 2003 at the same time as SARS.

However, there are other avian influenza viruses that have also caused human infection and human death. Of particular interest is the ‘H7’ ‘N7’ outbreak in the Netherlands in 2003. One vet died during this outbreak, and there was documented human to human transmission.

To pick up the ‘H5’ ‘N1’ story. The virus now is endemic throughout South East Asia, North & Central Asia, Africa and has moved into Europe. There are areas of geographic and epidemiological silence. However, as we all know, absence of evidence is not evidence of absence.

How is it possible that a pandemic influenza strain may develop? Clearly, as is happening at present, the virus can move into domestic birds, and secretions and excretions of domestic birds contain virus that can infect a human being. Within that human being the virus can mutate and develop the ability to spread easily human to human. Alternatively, there may be a mixing vessel traditionally mixing vessels have been considered to be pigs. The pig can be infected simultaneously with both an avian and a human influenza virus. The virus could recombine and the progeny may be able to move human to human. Of course a human being can also act as the mixing vessel.

We know that there has been human to human transmission of ‘H5’ ‘N1’. This has not been sustained and in effect has occurred after prolonged close contact of an uninfected and infected person.

What is the risk to New Zealand?

It is extremely unlikely that migratory birds will carry this virus to New Zealand. It is possible that smuggled birds or poultry products could bring the virus into New Zealand.

However, the real risk arises from human travel. To circumnavigate the globe used to take months. Vasco de Gama took three years. The modern traveller and their ancillary passengers will take 36 hours. What are the potential impacts upon New Zealand?

There may be very high morbidity and mortality. We have no living memory of anything remotely similar that would require a whole community commitment to a response. The impacts upon society, the economy and people are likely to be immense. The health services will be under extreme pressure and we know the pressures that a bad seasonal influenza epidemic have upon the sector. There is no surge capacity, as we do not have the fever hospitals waiting with their empty beds and their nurses to respond to such a situation that were available decades ago. The health services will have to be reconfigured. The role will become one of co-ordination, support and leadership. Doctors and Nurses may not be able to deliver individual patient care and attention. The whole of Government will be involved.

Business and government activity will be affected, in some cases severely.

In 1918, the Public Health Department had a depot for the treatment of influenza. People lined up for inhalation treatments. The modern thinking or the old thinking is that we will again have community based assessment centres to diagnose, treat and manage influenza.

The whole of the community responds. The boy scouts delivered food to those who are too ill to prepare it for themselves.

So what is the structure of Pandemic Planning?

The whole of the health sector is involved. There is a Technical Advisory Committee and a group that encompasses the health sector. Both these feed into the Ministry’s Pandemic Emergency Group.

The whole of Government response sits under a standing cabinet committee – Domestic & External Security (DES). The Department of Prime Minister and Cabinet provides a strategic oversight for the interagency pandemic group. And this approach is taken because of the potential impacts. It may well be New Zealand’s most serious crisis. The use of the interagency group, and the DES process engages all of society. Work groups are set up and there are lead agencies in each work group. The work group that is addressing the broad economic aspects is led by Treasury. Similarly, as we have seen in Hurricane Katrina, the maintenance of law and order is vital. The police lead this work group. Some of the issues that are being considered in the interagency Pandemic group include:

• Border Management
• The possibility of closing educational institutions.
• Restrictions on public gatherings.
• Possibly there may be restrictions on internal travel for example we know that the Coromandel closed itself to travellers from Auckland in 1918. With good effect.
• The impact on infrastructure has to be considered.
• And most importantly educating, informing and empowering people to look after themselves and each other at home.

Within the Ministry of Health itself these are some of the projects.

• The purchase of anti-virals.
• The role of anti-virals and the prioritisation of their use.
• Vaccination of the population will give close to 100% protection, once vaccine becomes available.
• Community based assessment centres.
• The role of personal protective equipment.
• The importance of surveillance and monitoring obtaining that evidence which we know will be vital to inform the decisions that must be made once we have a virus.

The New Zealand Influenza Pandemic Action Plan has 3 broad strategic phases.

1. • To plan for it which is the current phase.
• To keep it out, and clearly there is a case for intensive border management and border controls.
• Every day that the entry of the virus is delayed brings us one day closer to total protection of the population by vaccination.

We acknowledge and the World Health Organisation (WHO) acknowledges that border controls are not a long-term strategy. They will delay the entry of the virus but will not exclude it for the six months or so that we may have to wait to obtain supplies of vaccine.

2. If clusters break out within New Zealand, then the Health Sector will initiate a stamping out process to control and eliminate infection within that cluster. The overall strategic response is scalable both up and down.

3. If Pandemic Influenza becomes wide spread within New Zealand then clearly we move into the ‘manage it’ phase and ultimately the ‘recovery phase’. The overall objective throughout all these phases being to exclude, block, suppress, delay and obstruct spread of pandemic influenza until the population can be protected by vaccination.

Throughout all phases critical services and functions must be maintained. For example within the Health Sector there will still be motor vehicle accidents, women will still have babies, and there will still be heart attacks and acutely ill people requiring surgery.

We know that New Zealand has some advantages. As an island nation distance and isolation become one of those. We have few entry points. Most of those are under very good control and those that are not are often isolated from other parts of New Zealand. This geography enables considerations of restrictions on travel, and internal isolation – the raising of a cordon sanitaire around regions that can be protected.

We have good surveillance mechanisms within New Zealand and most importantly we have the full engagement of the whole of Government and we hope that Pandemic Influenza will have several stages to pass through before arriving in New Zealand.

To conclude with some key take home messages, based on the definition of influenza. It is an acute debilitating viral disease spread by large and small droplets or hand to mouth transmission.
There are some simple measures that can be taken every day to protect not just against pandemic influenza but other infectious diseases as well.

Wash and dry the hands before preparing food, after going to the toilet, after wiping children’s noses or your own, cover the mouth when coughing and sneezing, and most importantly if you are sick stay home from work. We must initiate this behavioural change, because influenza is transmitted in large and small droplets - knowing this we can break the chain of transmission from person to person.

Part 2

Epidemic Preparedness Act 2006

Introduction

With a threat of pandemic influenza coming at any unknown time, Cabinet wished to ensure that if and when a pandemic eventuated, New Zealand had appropriate powers to manage the effects. This management, by addressing legislative powers, arose out of the development of the New Zealand Influenza Pandemic Action Plan.

The role to address those gaps fell to Health Legal of the Ministry, to identify and seek to fill in, any gaps in the legislative framework for managing in a potentially very difficult pandemic situation. We had the invaluable assistance of Dr Mark Jacobs, Director of Public Health, and his colleague, Dr Andrea Forde.

Work began to identify current legislative powers, to identify what was needed to manage in a pandemic, and to identify the gaps. This was unplanned work for that financial year. We were fortunate to be able to obtain a secondee from Buddle Findlay to assist us in analysing the current legislative powers, matched to expectations under the Pandemic Plan.

From that work the gestation of the Epidemic Preparedness Bill began. During that gestation the issue of not only health management, but also management of impacts on society in general arose.

After the necessary Cabinet decisions, and helpful involvement from many departments, particularly DPMC, Justice, and Parliamentary Counsel, the Bill was developed and proceeded through Select Committee with the normal public submissions process. A key element of the ultimate success came from the advice from the Law Commission (provided by Sir Geoffrey Palmer), which helped address concerns that arose on a number of issues, and in particular over the balance to be struck between assertion of individual rights over population and community rights, and over the mechanisms for Parliamentary scrutiny.

The Law Commission recommended a number of positive changes to the Bill, and almost all were adopted. The Bill had implications for Parliament itself, and we received helpful and positive assistance from the Office of the Clerk.

The resulting Epidemic Preparedness Act 2006 received unanimous cross party support as a result. It is very unusual to obtain all party support in Parliament on controversial legislation. The Government and Administration Select Committee, led by Shane Adern, was very receptive to ensuring NZ had a solution to managing a pandemic situation. All members contributed to the discussion and debate, and all were very pragmatic in attempting to reach a workable outcome. Compromises were made to accommodate various concerns of political parties. The government itself was very pragmatic also, and so a workable outcome resulted that all parties could support.

What did the resulting legislation achieve?

Arising out of the Epidemic Preparedness Bill were:

• One substantive Act – the Epidemic Preparedness Act 2006
• 6 amendment Acts – to the Health Act, the Immigration Act, the Parole Act, the Sentencing Act, the Social Security Act, and the Summary Proceedings Act.

Epidemic Preparedness Act

This Act is mainly related to managing in society should a pandemic become a real threat or reality.

It allows the making of an epidemic notice by the Prime Minister with the agreement of the Minister of Health upon advice received from the Director General of Health (s.5).

For an epidemic notice to be issued requires the Prime Minister to be satisfied that the effects of an outbreak of the disease (a quarantinable disease within the meaning of the Health Act) are likely to disrupt or continue to disrupt essential government and business activity in New Zealand (or parts of NZ) significantly.

The pandemic outbreak could occur in New Zealand or overseas.

The notice lasts for 3 months maximum but can be renewed.

Once this epidemic notice is given, Parliament must meet within 7 days of the notice being issued.

Associated with the issue of the notice is the ability to invoke modification orders under an epidemic management notice (and invoke powers given in some of the Amendment Act).

Modification orders can be made in advance (called prospective modification orders), ready for invocation if needed, or can be made during the epidemic (called immediate modification orders).

Modification orders allow requirements or restrictions in any Act to be modified (except the Bill of Rights Act 1988, the Constitution Act 1986, the Electoral Act 1993, the Judicature Amendment Act 1972, the NZ Bill of Rights Act 1990, and the Epidemic Preparedness Act itself).

Examples of proposed modification orders for the health and disability sectors are relaxation of requirements relating to crossing professional boundaries under the Health Practitioners Competence Assurance Act 2003, of requirements relating to the prescribing dispensing and provision of medicines to people who are ill (under the Medicines Act 1981), and of requirements under the Health and Disability Services (Safety) Act should hospitals be unable to comply with strict standards (for example in relation to staff who may be ill).

Examples of proposed modification orders in other Acts are the proposals in the Bill (that were taken out) for amendments to the Births Deaths & Marriages Act 1995, the Holidays Act 2003, the Income Tax Act 2004, the Resource Management Act 1991, the Student Loan Scheme Act 1992, and the Tax Administration Act 1994.

These involved matters like nurses signing death certificates instead of doctors, relaxing timing around paying taxes (particularly for businesses that may have to cease operations), being able to carry out necessary activities without first obtaining a resource consent, and relief from due dates to pay student loans. Essentially the modification orders are designed to help society continue to operate by recognising that strict compliance with many laws will not be possible if society is devastated by a pandemic event.

Modification orders are not to go further than reasonably necessary in the circumstances. There are also some matters in respect of which such orders cannot be made (eg, postponing the release of a person from custody, or review of a persons detention).

All modification orders will receive Parliamentary scrutiny with fast track consideration for immediate modification orders (6 sitting days for disallowance).

Modification orders, like an Epidemic notice, can be geographically area specific.

Modification of Court Rules

Provision is made to allow Judges to modify Court rules so they can appropriately meet requirements. This is anticipates that Court staff or the judiciary itself may be adversely affected by pandemic flu.

The judiciary is eminently capable of ensuring any modifications are balanced and fair, so no controls on that power were seen as necessary.

Reading people their rights

For the sake of completeness a provision was inserted to ensure that if rights are modified and people have to be advised of their rights, they are advised of the rights as modified.


Health Act Changes

1. Emergency powers

Amendments made to the emergency powers (sections 70/71/72). These powers are not restricted pandemics only, but can apply to any emergency within the scope of these provisions, one of which is the issuing of an epidemic notice.

The amendments are:
- to provide for medical testing in addition to medical examination, as well as testing of places, buildings, craft etc
- instead of only being able to close premises if concerns arise, provision was made for allowing them to remain open with infection control procedures in place (eg, supermarkets – covering fruit and veges, issuing masks and gloves etc, to help towards avoiding the potential for people in a desperate position helping themselves)
- forbidding people congregating together where there are no infection control procedures operating
- requisition powers have been extended (noting provision already exists in s.71 for compensation)
- Police can provide back up the exercise of emergency powers through the new s.71A (noting that health officers will be concentrating on disease control so cannot be expected to chase the non-compliant people).

2. Non-emergency provisions – new additions

Provision is also made for:
- Results from lab tests results to be notified to a medical officer of health when an epidemic is in force.
- A policy on medicine prioritisation to be put in place to manage appropriate distribution of medicines in short supply (and protection to people who comply with that policy)

3. Border provisions

New provisions for use at the Border have been inserted. Historically border control has related to traditional quarantinable diseases recognised by the WHO (yellow fever, plague, and cholera). Avian influenza has been added, and the ability to add more diseases by order in council has also been provided for – this allows any mutation of the flu virus to be catered for, or for example if an ebola kind of virus mutates into an easily transmissible disease.

Specific amendments made are:
- Clarification of applying quarantine (s.97)
- Requiring compliance with health measures at the border (s.97A) – to separate the well from the unwell to prevent risk of disease transmission, to provide necessary information so as to determine risk profiles for disease transmission.
- Detention of craft for inspection and lifting of detention.
- Examination and testing of arrivals who may show signs of the disease
- Allowing people to pass through the border but subject to quarantine, isolation, or surveillance at large (depending on the risk profile)
- Clarifying that emergency powers can apply at the border.

Amendments to other legislation

Amendments have been made to the Immigration Act, Parole Act, Sentencing Act, Social Security Act, and Summary Proceedings Act. These were made because they concern fundamental rights and freedoms, so were not considered appropriate for modification orders.

I do not propose to cover them here but if you are interested in them, they can be viewed in the relevant Amendment Acts.