AH1N1 Swine Flu

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A/H1N1(Swine Flu)
What To Expect
Photo credits CDC Laboratory
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Todays Meeting

• Status of the pandemic Characteristics of H1N1
• Status of vaccine development production
• Antiviral use
• CDC School Guidance and Recommendations
• Priorities if it gets worse than expected
• Actions Public Health is taking
• Surveillance
• Additional Resources
• Answers to your questions

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Why are we concerned about this H1N1 Flu Virus?

• This virus contains genetic sequences of the
  deadly 1918 flu it is a 4th generation
  descendent.
• The 1918 killer flu has never gone away (it did
  disappear from 1957 to 1975).
• Its back having undergone complex genetic
  re-assortment with other swine and avian viruses
  - it has recently acquired the ability to easily
  infect and be passed between humans.
• And we have very little immunity to it.

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And there is more

• This virus was much more virulent in Mexico than
  in the US or Canada we dont yet know why.
• The age distribution of those infected is
  strikingly similar to its 1918 predecessor most
  are children and young adults very different
  from the seasonal flu
• In Mexico it demonstrated the ability to cause
  major lung damage w/resulting pneumonia among the
  young and healthy .

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Status of the Pandemic

• International Situation
• Circulating worldwide (170 countries)
• Epidemiologically similar across countries
• WHO reports 177,457 lab-confirmed cases
  including 1,462 deaths (case fatality 0.8)
• Gross underestimation of total cases
• A(H1N1) is dominant flu virus in U.S., England,
  S. Africa, New Zealand, Australia, Chile,
  Argentina and Brazil.
• Remains relatively mild

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International Situation
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Status of the Pandemic

• United States Situation
• All states reporting at least sporadic activity
• Epidemiologically similar to international cases
• 7,511 total hospitalizations 477 total deaths
• Estimated 1 million US cases April-June
• Outbreaks in gt50 summer camps
• A(H1N1) is 98 of US flu viruses sub-typed
• Flu activity decreased the first week of Aug.
• A (H1N1) will co-circulate with seasonal flu this
  fall/winter

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United States Situation
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United States Situation
INFLUENZA ISOLATES FROM THE HHS REGION VI (AR,
LA, NM, OK, TX) Reported By WHO/NREVSS
Collaborating Laboratories2008-2009 Season
INFLUENZA ISOLATES FROM THE HHS REGION VI (AR,
LA, NM, OK, TX) Reported By WHO/NREVSS
Collaborating Laboratories2008-2009 Season
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United States Situation
INFLUENZA ISOLATES FROM THE HHS REGION VI (AR,
LA, NM, OK, TX) Reported By WHO/NREVSS
Collaborating Laboratories2008-2009 Season
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United States Situation
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United States Situation
Percentage of Visits for Influenza-like Illness
(ILI) Reported by the U.S. Outpatient
Influenza-like Illness Surveillance Network
(ILINet), National Summary 2008-2009 and Previous
Two Seasons
INFLUENZA ISOLATES FROM THE HHS REGION VI (AR,
LA, NM, OK, TX) Reported By WHO/NREVSS
Collaborating Laboratories2008-2009 Season
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Signs and symptoms

• Symptoms of novel H1N1 flu are similar to those
  of seasonal flu.
• Fever
• Cough
• Sore throat
• Runny or stuffy nose
• Body aches
• Headache
• Chills
• Fatigue
• In addition, vomiting (25) and diarrhea (25)
  have been reported. (Higher rate than for
  seasonal flu.)
• NOT the nausea/vomiting/diarrhea that people call
  stomach flu.

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How soon does one become sick?

• Answer Very quickly due to short incubation!
• 1-4 days after you catch the virus, you feel sick
• Infected people shed virus make others sick
• Shedding can begin 1 day BEFORE you feel sick
• Peak shedding first 3 days of illness
• Subsides by 5-7 days
• Can be 10 days in children

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Who is at risk for severe infection?

• Children younger than 5 years old especially
  children younger than 2 years old.
• Pregnant women
• Adults 65 years of age and older.
• Persons with the following conditions
• Chronic pulmonary, including asthma
  cardiovascular, renal, hepatic, hematological,
  neurologic, neuromuscular, or metabolic disorders
  such as diabetes
• Person experiencing immunosuppression, including
  that caused by medications or by HIV
• Persons younger than 19 years of age who are
  receiving long-term aspirin therapy
• Residents of nursing homes and other chronic-care
  facilities.

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Whats Going to Happen this Fall?
During the 1957-58 Asian Flu outbreak,
respiratory illnesses spiked just after school
started
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United States Situation
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H1N1 Targets the Young
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H1N1 Targets the Young
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Hand Hygiene - Cough Etiquette

• Frequently emphasize the basics
• Primary spread is by droplets from coughs and
  sneezes emphasize covering mouth with tissue
  and immediately dispose or cough into sleeve
• Also spread from surfaces (2-8 hrs.)
• emphasize and encourage frequent hand washing
• no sharing of items
• Hands away from eyes, nose mouth
• Routine and normal cleaning and cleaners is
  sufficient

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Sick Staff and Students

• Require sick staff students to stay home
• Watch for sick staff students upon arrival and
  during the day
• Isolate in a separate well-ventilated room
  distance if needed
• If tolerated, mask the patient
• Limit attending staff and provide protective
  equipment (mask) for them
• Send them home with information

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Emergency warning signs in children

• If a child gets sick and experiences any of
  these warning signs, seek emergency medical care.
• 
  
• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Irritable, the child does not want to be held
• Flu-like symptoms improve but then return
• with fever and worse cough

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Household cleaning, laundry, and waste disposal

• Throw away tissues and other disposable items
  used by sick person in the trash (wash hands)
• Keep surfaces clean by wiping down with a
  household disinfectant according to label
• Eating utensils and dishes of sick person
• Do not need to be cleaned separately wash
  thoroughly in dishwasher or with soap and water
• Linens and towels
• Household laundry soap and tumble dry on hot
• Avoid hugging laundry prior to washing to
  prevent contaminating yourself
• Clean hands with soap and water or alcohol-based
  hand rub right after handling dirty laundry

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Exclusion Period

• CDC recommends those with flu-like illness be
  excluded from school until at least 24 hrs. after
  fever (100 F) is gone (without using
  fever-reducing meds)
• H1N1 fever generally lasts 2-4 days (exclusion
  usually 3-5 days) may be longer
• Emphasize stay home unless for medical care
• Avoid contact with others
• Advise good hand and respiratory infection
  control etiquette
• Those on antivirals may shed resistant viruses

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Antiviral Recommendations

• Novel A (H1N1) virus is susceptible to both
  neuraminidase inhibitor antiviral medications
  zanamivir (Relenza) and oseltamivir (Tamiflu).
• It is resistant to the adamantane antiviral
  medications, amantadine and rimantadine.
• Antiviral treatment recommended for all
• confirmed, probable or suspected A(H1N1) cases
  who are hospitalized or
• are at higher risk for influenza complications.
• 84 M courses in federal state stockpiles with
  100 M expected this fall.

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Initial Vaccination Priority Groups

• All people 6 months through 24 years of age
• People who live with or care for children younger
  than 6 months of age
• Pregnant women
• Healthcare and emergency services personnel
• People aged 25 through 64 years who have health
  conditions associated with higher risk of medical
  complications from influenza

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Vaccine Supply-Driven Priorities

• Pregnant women
• People who live with or care for children younger
  than 6 months of age
• Healthcare and emergency services personnel with
  direct patient contact
• Children 6 months through 4 years of age
• Children aged 5 through 18 years who have health
  conditions associated with higher risk of medical
  complications from influenza

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Vaccine Production Delivery

• Novel H1N1 Vaccine production by 5 companies
• 4 inactivated virus vaccine and 1 live,
  attenuated
• Currently in clinical trials
• Two shots may be recommended 2-4 wks apart
• Delivery to PH directly to up to 90,000
  providers
• Estimated delivery beginning mid-September
• Approximately 45 million doses by mid-October
• Additional shipments at 20 million doses/week

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Est. Vaccine Delivery Schedule

• 88,500
• 39,300
• 324,300

Mid October Per week thru November? Total Doses
by end of November?
Based upon Tulsa County proportion of US
population
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Tulsa County Target Groups Est.

• 4,500
• 12,509
• 16,875
• 203,830
• 69,883
• 307,100

Pregnant women HH Care Contacts Children lt 6
mos. Healthcare Emergency Services Children
adults 6 mos. 24 years Non- elderly with high
risk conditions Target Group Totals
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If Virulence Increases

• Consider allowing high risk student to stay home
• Increase exclusion period to 7-day minimum
• Plan for alternative means of educating
• Develop critical staffing contingency plans
• Active parental and staff screening, e.g., fever
• Exclude siblings of ill family members 5 days
• Distance and reduce mixing (rotate teachers)
• School dismissals
• Cancellation of school-related gatherings

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Panel Discussion

• Mass Vaccination Plan
• School-based vaccinations
• Points of Dispensing
• Push Partners
• Surveillance
• Guidance Review
• Lessons Learned Spring 2009
• School Dismissal

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Available Resources and Guidance

• Websites
• CDC
• State Department of Health
• Tulsa Health Department
• Dont Bug Me Materials
• Direct Email Communications
• Surveillance postings

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QUESTIONS?