H1N1 Pandemic H1N1 Pandemic Influenza Planning Influenza Planning VideoconferenceVideoconference

August 28, 2009August 28, 2009

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Pandemic FluPandemic FluH1N1H1N1

Terry L Dwelle MD MPHTM CPH FAAP

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Pandemic Influenza – General Pandemic Influenza – General InformationInformation

Pandemic is a worldwide epidemicPandemic is a worldwide epidemicWe can expect several pandemics in We can expect several pandemics in

the 21the 21stst century century

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H1N1 (Swine Origin H1N1 (Swine Origin Influenza Virus)Influenza Virus)

33,902 cases in the US (estimate is that there have been 1 million cases in the US)

3663 hospitalizations (10.8%, 0.36% of estimated cases in the US) 170 deaths (0.5% of identified cases and 4.6% of those hospitalized,

0.017% of estimated cases in the US) Genetically this H1N1 is linked to the 1918-19 strain Currently we are seeing almost totally H1N1 circulating Majority of the cases are in children and young adults Majority of hospitalized patients have underlying conditions (asthma

being the most common, others include chronic lung disease, DM, morbid obesity, neurocognitive problems in children and pregnancy).

There have been over 50 outbreaks in camps Southern hemisphere – currently seeing substantial disease from

H1N1 that is cocirculating with seasonal influenza. There has been some strain on the health systems in some situations.

About 30% of infected individuals are asymptomatic (study from Peru)

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H1N1 in PregnancyH1N1 in PregnancyApril 15 to May 18, 2009 – 34 confirmed or

probable cases of H1N1 in pregnant women reported to the CDC

11/34 (32%) were admitted to hospitalGeneral population hospitalization rate

7.6%6 deaths – pneumonia and acute

respiratory distress syndromePromptly treat pregnant women with

H1N1 infection with antiviralsLancet on line, July 29, 2009

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Pandemic Influenza - Pandemic Influenza - EpidemiologyEpidemiology

Pandemics occur in waves The order in which communities will be

affected will likely be erraticSome individuals will be asymptomatically

infectedA person is most infectious just prior to

symptom onset Influenza is likely spread most efficiently by

cough or sneeze droplets from an infected person to others within a 3 foot circumference

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Secondary Effects on Secondary Effects on Individuals and CommunitiesIndividuals and Communities

Individuals and Families Income / job security due to absenteeismProtecting children from exposure to influenzaContinuity of educationFear, worry, stigmaAccess to essential goods and services (eg food,

medication, etc.)Home-based healthcare

CommunitiesMaintaining business continuitySustaining critical infrastructuresAvailability of essential goods and services (supply chains)Supporting vulnerable populations

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Pandemic Influenza - Pandemic Influenza - ResponseResponseWe don’t look at pandemic flu as a

separate disease to be dealt with in a different way from regular seasonal influenza

Influenza response toolboxSocial distancing and infection control measureVaccineAntiviral medications

The most effective way to prevent mortality is by social distancing

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Proxemics of Influenza Proxemics of Influenza TransmissionTransmission

Elementary Schools

Hospitals

Offices

Residences

3.9 ft

7.8 ft11.7 ft

16.2 ft

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Goals of Influenza PlanningGoals of Influenza Planning

-20

0

20

40

60

80

100

5 10 15 20 25 30 35 40 45 50 55 60

No Intervention

With Intervention

Cases

Day

Goals•Delay outbreak peak•Decompress peak burden on hospitals and infrastructure•Diminish overall cases and health impacts

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IsolationIsolation From

www.cdc.gov/h1n1flu/guidance_homecare.htm

Data from 2009Most fevers lasted 2-4 days90% of household transmissions occurred within 5

days of onset of symptoms in the 1st caseRequires 3-5 days of isolation (different from the 7

days previously used for influenza). The rule here is isolation for 24 hours after resolution of the fever without the use of fever-reducing medications.

Consider closing a school or business for a minimum of 5 days which should move the infected into the area of much lower nasal shedding and contagion.

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Unstressed Hospital and Clinic Unstressed Hospital and Clinic Surge - North DakotaSurge - North Dakota

8.36

4.18

2.792.09

1.67

0

1

2

3

4

5

6

7

8

9

10 20 30 40 50

100% CapHosp / ILI

Regional ILI rate

Clinic Caution 16.5

Clinic Crisis 21

X

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CDC’s recommendations for CDC’s recommendations for Institutions of Higher Education Institutions of Higher Education

Main goal is to decrease exposure to influenza while limiting disruption of day-to-day activities

Generally students, faculty and staff with ILI remain home until 24 hours after resolution of fever without fever reducing medications

Review and revise pandemic plans

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Pandemic Influenza PlansPandemic Influenza PlansUpdate contact information for students and familiesConfirm contingency plans for key vendors (eg food

service, hygiene supplies, security, PPE for staff, etc.)Encourage hand hygiene and respiratory etiquetteEncourage influenza vaccinationsPlan to separate the ill from well individualsRoutine / frequent cleaning of bathrooms and other

frequently used areas with high touch surfacesReview the operational threshold for suspending

classes or activities

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Pandemic Influenza PlansPandemic Influenza PlansReview and revise sick leave policies to

remove barriers for faculty and staff staying home while ill

Review and revise policies on missed classes, exams and late assignments that would prevent an ill student from prematurely returning to class

Do not require a doctor’s note for a student, faculty or staff to validate the illness and / or return to work

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Pandemic Influenza PlansPandemic Influenza PlansUtilize distance learning or web based

learning to facilitate social distancing when ill

Determine quantities of supplies and space needed to facilitate self-isolation (eg hygiene supplies, masks and other PPE)

Publicize the importance of self-isolation when ill, early evaluation by a health care provider when ill especially for those at high risk, hand hygiene and respiratory etiquette (www.cdc.gov/h1n1flu)

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For a Pandemic with For a Pandemic with Increased SeverityIncreased Severity

Permit high-risk students, faculty and staff to stay home

Increase social distance – goal is 6 feet between individuals

Extend the self isolation period to at least 7 days or when symptoms resolve whichever is longer

Consider suspending classes – for 5-7 calender daysHigh rates of absenteeismWhen deemed necessary to augment other

community strategies to control spread

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Pan Flu AntiviralsPan Flu Antivirals

Terry L Dwelle MD MPTHM Terry L Dwelle MD MPTHM CPH FAAPCPH FAAP

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Intervention - AntiviralsIntervention - Antivirals

Antivirals (Tamiflu and Relenza) will be used primarily for treatment not prophylaxisND will have approximately 160,000

treatment courses available for a pandemic (25% of the population)

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Antiviral Treatment – H1N1Antiviral Treatment – H1N1

Sensitive to anitvirals - zanamivir (Relenza) and oseltamivir (Tamilflu)

Uncomplicated febrile illness due to H1N1 does not require treatment

Treatment is recommended forAll hospitalized patients with confirmed,

probable or suspected H1N1High risk patients for complicationss

www.cdc.gov/h1n1flu/recommendations.htm

High risk groups for High risk groups for complicationscomplications

< 5yo (highest risk is < 2yo) Adults > 65yo Persons with the following conditions

AsthmaOther chronic pulmonary diseasesCardiovascular disease (except hypertension)Kidney, liver, blood disorders (including sickle cell disease),

neurologic, neuromuscular, metabolic (including diabetes mellitus)

Immunosuppression including that caused by medication or by HIV

Pregnant women< 19yo receiving long-term aspirin therapyResidents of nursing homes and other chronic care facilities

www.cdc.gov/h1n1flu/recommendations.htm

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ProphylaxisProphylaxis

Close contact of cases (confirmed, Close contact of cases (confirmed, probable or suspected) who are at probable or suspected) who are at high-risk for complicationshigh-risk for complications

Health care personnel, public health Health care personnel, public health workers, or first responders who have workers, or first responders who have unprotected close contact to a case unprotected close contact to a case (confirmed, probable or suspect) (confirmed, probable or suspect) during the infectious period (24 hours during the infectious period (24 hours before to 24 hours after becoming before to 24 hours after becoming afebrile)afebrile)

www.cdc.gov/h1n1flu/recommendations.htm

Vaccination StrategyVaccination Strategy

Molly Sander, MPHMolly Sander, MPH

Immunization Program Immunization Program ManagerManager

VaccineVaccineSeparate novel H1N1 influenza

vaccine from seasonal trivalent vaccine.

45 million doses in mid-OctoberFollowed by 20 million doses per week

there after.Five manufacturers: same age

indications as seasonal vaccine.Both injectable and intranasal vaccine

will be available.Assume 2 doses required for

everyone, separated by 3 to 4 weeks.

ACIP RecommendationsACIP RecommendationsPregnant women because they are at higher

risk of complications and can potentially provide protection to infants who cannot be vaccinated;

Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus;

ACIP RecommendationsACIP RecommendationsHealthcare and emergency

medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity; Include public health personnel

ACIP RecommendationsACIP RecommendationsAll people from 6 months through 24

years of age Children from 6 months through 18 years

of age because many cases of novel H1N1 influenza are in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and

Young adults 19 through 24 years of age because many cases of novel H1N1 influenza are in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,

ACIP RecommendationsACIP RecommendationsPersons aged 25 through 64 years who

have health conditions associated with higher risk of medical complications from influenza. Chronic pulmonary disease, including asthmaCardiovascular diseaseRenal, hepatic, neurological/neuromuscular, or

hematologic disordersImmunosuppressionMetabolic disorders, including diabetes mellitus

ACIP RecommendationsACIP Recommendations Once the demand for vaccine for the

prioritized groups has been met at the local level, programs and providers should also begin vaccinating everyone from the ages of 25 through 64 years.

Current studies indicate that the risk for infection among persons age 65 or older is less than the risk for younger age groups. However, once vaccine demand among younger age groups has been met, programs and providers should offer vaccination to people 65 or older. 

ACIP RecommendationsACIP Recommendations If demand exceeds supply (not expected):

pregnant women, people who live with or care for children

younger than 6 months of age, health care and emergency medical

services personnel with direct patient contact,

children 6 months through 4 years of age, and

children 5 through 18 years of age who have chronic medical conditions.

DistributionDistributionH1N1 vaccine purchased from

manufacturers by the federal government.

Vaccine is allocated to states based on population.North Dakota will receive 0.208%

H1N1 vaccine will be distributed through a third party distributor (McKesson)Will also ship ancillary supplies.

• Alcohol pads, syringes, needles, sharps containers

EnrollmentEnrollmentProviders are required to sign an

enrollment form in order to receive H1N1 vaccine.CDC is creating a standardized form. It is

currently unavailable.Enrollment requirements unknown,

but most likely include:Proper storage and handling: 35 ° – 46° FFollowing of ACIP recommendationsReporting of doses administered?

Administration FeeAdministration Fee The federal government will set a

maximum administration fee.Most likely at the Medicare rate:

$18.45/dose in North Dakota. (Different than Medicaid fee cap for VFC:$13.90)

Cannot charge for the cost of the vaccine, as it is free from the federal government.

Administration fee may be billed to patient, Medicaid, Medicare, private insurance, etc.

Local public health units cannot refuse to vaccinate based on inability to pay.Private providers will probably be able to

refuse vaccination if patient is unable to pay.

NDIISThe North Dakota Immunization

Information System (NDIIS) is a confidential, population-based, computerized information system that attempts to collect vaccination data about all North Dakotans.

Healthcare providers, pharmacists, local public health units, schools, and childcares may have access to the NDIIS.

NDIISNDIISThe NDIIS will be used to track doses

administered.Similar data entry to other vaccines, but

includes high-risk groups for vaccination.

Doses administered must be reported to CDC by the state on a weekly basis.Report each Tuesday for the previous week.

Contact the NDDoH at 701.328.3386 or toll-free at 800.472.2180 if interested in obtaining access.

Strategies for VaccinationStrategies for VaccinationCheck with local public health unit

to determine local strategies.Mass Immunization ClinicsSchool Clinics:

• Recommended by CDC• Good way to capture children

Vaccination similar to seasonal influenza vaccination. (private and public mix)

Vaccine Information Statements

A VIS must be given with each dose.

2009-2010 seasonal VIS are available at www.cdc.gov/vaccines/pubs/vis/default.htm.

H1N1 VIS not yet available.

VAERS Remember to report

vaccine adverse events for both seasonal and H1N1.

http://vaers.hhs.gov/

VAERS module will be available in NDIIS.Same fields as

VAERS form.Pre-populated with

demographic and vaccine information from NDIIS.

Contact InformationContact Information

Molly Sander, MPH, Program Manager 328-4556

Abbi Pierce, MPH, Surveillance Coordinator

328-3324 Keith LoMurray,

IIS Sentinel Site Coordinator 328-2404

Tatia Hardy, VFC Coordinator 328-2035

Kim Weis, MPH, AFIX Coordinator 328-2385

Social Distancing and Social Distancing and Infection ControlInfection Control

Tracy K. Miller, MPHSenior Epidemiologist

Division of Disease Control

OutlineOutline

DiseaseDiseaseNovel H1N1Novel H1N1MitigationMitigationSurveillance in NDSurveillance in ND

Each Year in the US…Each Year in the US…

On average:36,000 people die from the fluMore than 200,000 people are

hospitalized from flu complicationsThere are ≈ 25 million physician visitsAnd ≈15 to 60 million infections (5% to 20% of the population)

Influenza in North DakotaInfluenza in North Dakota

Each season:Approximately 400 people die from Pneumonia and InfluenzaOn average 2,300 influenza cases are

reported to the health department• Using CDC estimates ≈ 3,000 to 128,000

infections• 2008-2009 season there were more than

1,600 cases reported to the health department

07-08 and 08-09 Flu 07-08 and 08-09 Flu SeasonsSeasons

Influenza Mortality/MorbidityInfluenza Mortality/Morbidity

Influenza-related deaths among Influenza-related deaths among children is uncommonchildren is uncommonTypically over 90% of the P&I deaths in Typically over 90% of the P&I deaths in

ND are in those ND are in those ≥ 65 years of age≥ 65 years of ageChildren represent a substantial Children represent a substantial

portion of influenza morbidity in the portion of influenza morbidity in the state state Influenza “amplifiers” in communitiesInfluenza “amplifiers” in communities

Flu Cases by Age GroupFlu Cases by Age Group

What have we seen in ND?What have we seen in ND?

Community MitigationCommunity Mitigation

SchoolsChildcare settings Healthcare settings Businesses

General PublicHome care

Community MitigationCommunity Mitigation

Isolation or exclusionIsolation or exclusionVoluntary and passiveVoluntary and passiveInvoluntary and activeInvoluntary and active24 hours after fever subsides and not 24 hours after fever subsides and not

using fever reducing medicationusing fever reducing medicationHand hygieneHand hygieneRespiratory etiquetteRespiratory etiquette

Exclusion Period - time ill people should be away from others

Applies to settings in which the majority of the people are not at increased risk for complications

Typically applies to the general publicDoes NOT apply to health care settings

StaffVisitors

Antivirals not considered with exclusion

Institutions of Higher EducationInstitutions of Higher Education (IHE) will

refer to public and private, residential and nonresidential, degree-granting and non-degree-granting institutions providing post-secondary education in group settings regardless of the age of their students.

IHE’s should tailor this guidance to account for size, diversity, and mobility of their students and staff.

IHE’s – Current Conditions

RESIDENTIAL STUDENTS/STAFF Those in private rooms should remain in

their roomFlu “buddy system”

For those w/o private room IHE’s may consider temporary room re-

assignmentIll persons should wear a mask

NON-RESIDENTIAL STUDENTS/STAFF

ill staff and students should stay home24 hours after fever subsides w/o use of

medicationIf at school when ill – take private car or taxi

home

IHE’s – Current Conditions

ADDITIONAL CONSIDERATIONSHand hygiene and respiratory etiquetteRoutine regular cleaningEarly treatment of high risk individualsDiscourage campus visits by ill persons

Posters, flyers, emails, etc

Consideration of selective school dismissalVACCINATE! VACCINATE! VACCINATE!!

IHE’s – Current Conditions

Vaccination and IHEs

IHEs should promote vaccination for all students and staffTwo influenza vaccines this yearPeople under age 25 are recommended

to receive both influenza vaccinesVaccinating a high percentage of

students could provide “herd immunity”Local Public Health

IHE’s More Severe Conditions

High risk students and staff stay homeDistance learningAbsenteeism policies

Increase distance between students Desks six feet apart

Extend isolation periods - use 7 day period or 24 hours after fever, whichever is longer

School dismissalReactivePreemptive

Infection Control and PPEInfection Control and PPE

Separation of ill people from rest of schoolSeparation of ill people from rest of school Ill person wears a surgical maskIll person wears a surgical mask Staff member wear a surgical maskStaff member wear a surgical mask Masks should be used once and disposed Masks should be used once and disposed

of in the garbage receptacleof in the garbage receptacle Avoid touch the mask Avoid touch the mask Wash hand after removing masksWash hand after removing masks Clean frequently touch areas regularlyClean frequently touch areas regularly

Hand Hygiene and Respiratory Etiquette

Students and staff should wash hands oftenWhen arriving at class / when leaving for the

dayAfter bathroom breaksBefore eatingAfter coughing or sneezing into a tissue

Hand sanitizers can be usedConsider supplying for each classroom

Respiratory EtiquetteRespiratory Etiquette

Students and staff shouldStudents and staff shouldCough, sneeze or blow noses into Cough, sneeze or blow noses into

disposable tissuesdisposable tissuesThrow tissues away right after useThrow tissues away right after useWash hand/use a hand sanitizer after Wash hand/use a hand sanitizer after

coughing or sneezingcoughing or sneezingCough or sneeze into the inside of Cough or sneeze into the inside of

elbow if tissues are not availableelbow if tissues are not available

Environmental CleaningEnvironmental Cleaning

Regular cleaning of surfaces, Regular cleaning of surfaces, especially frequently touched especially frequently touched surfacessurfacesUse an EPA registered cleaning productUse an EPA registered cleaning productUse according to label instructionsUse according to label instructionsLook for products that can be used on Look for products that can be used on

keyboardskeyboards

Early Treatment of Staff and Early Treatment of Staff and Students at Increase Risk of Students at Increase Risk of

Severe DiseaseSevere DiseaseStudents and staff that have Students and staff that have

underlying health conditions who underlying health conditions who develop illness should seek medical develop illness should seek medical care promptlycare promptly48 hour window for antivirals48 hour window for antiviralsAntivirals can reduce the risk for severe Antivirals can reduce the risk for severe

diseasedisease• Immunosuppression, asthma, diabetes, HIV, Immunosuppression, asthma, diabetes, HIV,

cancer, heart and lung diseasecancer, heart and lung disease

SportsSports

Coaches should encourage their athletes to be Coaches should encourage their athletes to be vaccinated against the fluvaccinated against the flu

Athletes should not participate in practice or Athletes should not participate in practice or games while ill (same guidance as schools)games while ill (same guidance as schools)

Athletes should not share water bottles and Athletes should not share water bottles and other personal itemsother personal items

Coaches and trainers should follow basic Coaches and trainers should follow basic infection control practicesinfection control practices

Regular cleaning of frequently-touched Regular cleaning of frequently-touched surfacessurfaces

Infection Control in the Infection Control in the HomeHome

Place ill person in a private room try to designate one Place ill person in a private room try to designate one bathroom for ill personbathroom for ill person

Have ill person wear a surgical maskHave ill person wear a surgical mask No visitorsNo visitors One non-pregnant person should provide careOne non-pregnant person should provide care Caregiver should consider wearing maskCaregiver should consider wearing mask Caregiver should consider N95 if assisting with Caregiver should consider N95 if assisting with

respiratory treatmentrespiratory treatment Hand hygiene and respiratory etiquette for Hand hygiene and respiratory etiquette for

householdhousehold Use paper towels to dry handsUse paper towels to dry hands

Public EducationPublic Education

www.ndflu.comwww.ndflu.com

Surveillance and Surveillance and ReportingReporting

Tracy K. Miller, MPHSenior Epidemiologist

Division of Disease Control

Laboratory SurveillanceTotal number of all tests ranTotal number of positives reported

Sentinel PhysiciansCDC Sentinel Provider ProgramCSTE/CDC Influenza Pilot Project

Syndromic SurveillanceILI reported from select ER’s around the state

Follow-up all cases of influenza Mail out survey

Surveillance

HospitalizationsWork with Infection Control NursesParticipate in the Emerging Infections

ProgramUse of RedBat to gather Hospitalization dataUse of HC Standard

School absenteeism ratesIncrease the number of schools that reportMonitor school closures

Surveillance

Outbreak SupportOutbreak SupportIncrease the number of facilities that Increase the number of facilities that

can report outbreaks and receive free can report outbreaks and receive free testingtesting

SurveillanceSurveillance

SurveillanceSurveillance

IHE’s can help byStaying aware of community situationReporting clusters of illness to state or

local health officialsPossible participation in sentinel

provider programWorking with local and state health

officials and the local community on appropriate disease interventions

Resources

NDDoH flu web-page (updated every Wednesday)http://www.ndflu.com/

CDC flu web-pagehttp://www.cdc.gov/flu/