The Pandemic H1N1 Flu

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The Pandemic (H1N1) Flu

• Dr Pat Lee
• I.B.E.C.
• 06/10/09

M.W.O.H.S.
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3 Flu Pandemics in the 20th Century

• 1918 Spanish Flu- A H1N1 (20-40 million
  deaths)
• 1957 Asian Flu - A H2N2 (1-4 million deaths)
• 1968 Hong Kong Flu - A H3N2 (1-4 million
  deaths)
• the 1918 Spanish Flu killed more people than
  WW1 (20-40 million deaths worldwide).

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In the 3 Pandemics in last century

• Up to a ¼ of the UK population developed illness
  in each pandemic i.e. a clinical attack rate of
  25 -
• (In Ireland 25 would equate at present to
  approx. 1 million people).

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Lessons from Previous Pandemics

• They are unpredictable in their occurrence.
• They vary in mortality, severity and pattern.
• There is a rapid surge in no. of cases over a
  brief period of time.
• They tend to occur in waves subsequent waves
  may be more or less severe.

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This Pandemic has spread faster than any previous
Pandemic - only 6 weeks elapsed between the
initial cases in Mexico and the declaration of a
global pandemic
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Contingency Plans

• In UK -
• Base Scenario -
• Clinical attack rate of 25 of the population
  with a fatality rate of 0.37
• Reasonable worst case Scenario -
• Clinical attack rate of 50 of the population
  with a fatality rate of 2.5.

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On 9th 0f July 09 HSE in Ireland changed its
Policy from -

• Containment
• to
• Mitigation

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Mitigation

• National surveillance of cases, deaths and
  outbreaks.
• Limited collection of clinical samples.
• Focus on patient management
• Non-pharmaceutical measures.
• Protection/support of the healthcare system.

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At present (6th Oct.) Pandemic H1N1 is the main
influenza virus circulating in Ireland.

• As we progress further into the Autumn it is
  likely that there will be co-circulating seasonal
  strains of influenza.

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Expect in Next 3-6 Months

• The lull prior to the normal flu season will be
  abating as the flu season takes over.
• Large nos. with flu over 12-16 weeks.
• Severity probably is now (4 deaths,10 ICU).
• Flu in the economically active.
• Social impact.
• Health impact.

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The present H1N1 Flu Pandemic virus is likely to
become the dominant Flu virus for the next 3 - 4
years
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Influenza Activity Week 39 (Sept. 2127).
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Ireland - Summary 1st Oct. 09
183 cases of confirmed pandemic (H1N1) 2009
have been hospitalised to date. Of the 183
hospitalised cases, 77 (42.1) have an underlying
condition putting them at increased risk
of complications. Currently, 28 cases of
confirmed pandemic (H1N1) 2009 remain
hospitalised. Fifteen cases of confirmed
pandemic (H1N1) 2009 have been admitted to ICU to
date. Ten cases of confirmed pandemic (H1N1)
2009 currently remain in ICU. Four patients
with confirmed pandemic (H1N1) 2009 have died.
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Is it Influenza or a Cold?
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The influenza Virus has 3 Genera

• A This is responsible for illness on the
  Pandemic scale.
• B
• C

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What is Influenza?
Neuraminidase
N
Haemagglutinin
H
RNA
M2 protein(only on type A)
Structure of the influenza A virus
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H and N

• H - Haemaglutinin(HA) This anchors the virus to
  any cell it seeks to enter and HA is the antigen
  used to prepare anti influenza vaccines.
• N - Neuramidase(NA) An enzyme that helps the
  virus digest its way through mucous secretions as
  it approaches the host cell and also helps in the
  release of newly synthesised virus. Antiviral
  drugs Tamiflu and Relenza work by inhibiting NA.

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Every Influenza A Virus

• Has a gene coding for -
• - 1 of 16 possible HA proteins
• - 1 of 9 possible NA proteins
• Giving a possible 144 total combinational
  possibilities.
• However only 3 combinations have been found in
  humans (H1N1, H2N2, H3N2)

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Influenza is Associated With Serious Complications
COMPLICATIONS
VIRALREPLICATION
Cardiac
Upper respiratory tract
Sinusitis Otitis media
Bronchitis Pneumonia Exacerbations AsthmaCOPD
AND
Lower respiratory tract
Nicholson. In Textbook of Influenza (1999), pp.
21964 Kaiser et al. Arch Intern Med
2003163166772
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How does novel H1N1 Influenza spread?

• This virus is thought to spread the same way
  seasonal flu spreads
• Primarily through respiratory droplets
• Coughing
• Sneezing
• Touching respiratory droplets on yourself,
  another person, or an object, then touching mucus
  membranes (e.g., mouth, nose, eyes) without
  washing hands.

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At risk groups

• Age lt5yo gt65yo (but in Ireland, children
  young adults A/C for the most affected groups,
  80 were lt30yo)
• Pregnant women, especially 2nd 3rd term.
• Severely obese (BMI gt40)
• Immunocompromised
• Medical conditions
• - chronic lung / heart / liver / kidney
  diseases, diabetes.

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Sickness Absence- Not equally distributed4
Reasons -

• Employees with Swine Flu.
• Carers.
• Employees with non-flu medical conditions.
• Opportunists.

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Employees with Swine Flu

• Should be sent home if they are at work.
• Need to be out of work for 7 days from onset of
  symptoms.
• Close contacts can stay at work but monitor
  carefully.

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Carers

• Difficult to assess.
• Limited carer options.
• School closures.
• Force Majeure.

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Opportunists

• Particularly if self certification is accepted.
• GPs will not be routinely seeing cases.
• Diagnosis will often be made over the phone.
• Medical danger is person who subsequently
  develops the flu.

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Sickness Absence

• All employees should inform their
  supervisor/line manager as soon as possible on
  the first day of absence from work.
• The line manager should immediately inform the
  HR dept. particularly if the illness is Swine
  flu/Virus related.

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Businesss should appoint -A Pandemic
Co-ordinator and Deputy/- A Pandemic Working
Group to -

• Manage.
• Monitor and Revise where necessary.
• Communicate.
• The organisations Influenza Pandemic Plan.

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www.entemps.ie
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Business Planning Checklist

• Planning activities.
• Business issues.
• Measures to underpin continuity.
• Response to workplace issues in a pandemic.

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General Pandemic Measures

• Have a written Pandemic plan.
• Increase the awareness of Influenza
  posters/leaflets etc.
• Monitor levels of staff absence due to ILI.
• Check on reports of staff illness at start of
  day.
• Have contingency plans for dealing with above
  average levels of staff sick leave.

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Contd.

• Adequate supplies of cleaning materials and an
  agreed schedule for cleaning.
• Ensure that washing facilities are working
  properly and adequate supplies of soaps, plastic
  waste bags etc.
• Review communications arrangements.
• Ensure that staff know how to manage medical
  attention for guests.

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Preventative andTreatment Measures
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Infection Control

• Respiratory Etiquette.
• Hand hygiene.
• Environmental cleaning.
• PPE.
• Patient placement segregation.
• -- isolation.

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Hand Hygiene

• The single most important practice to reduce
  transmission of infectious agents.
• Includes hand washing with soap / water(15-20
  sec)
• Thorough drying using disposal paper towels /-
  the use of alcohol-based products.
• Dispose paper towel into waste bins with foot
  operated lid whenever possible.
• Hands should be free of dirt organic material
  when decontaminating hands using alcohol rub.
• Wash hands when get into work and on returning
  home.
  
  
  

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Role of Antivirals

• Tamiflu
• - Oral
• - Most used
• - Work best if started within 2 days of
  onset of symptoms
• - Some sporadic resistance.
• Relenza
• - Inhaled.

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Tamiflu

• Treatment -
• - 2 tablets per day for 5 days
• - Available free with prescription
• - Severe cases or high risk people only.
• Prophylaxis -
• - 1 tablet per day
• - 6 weeks only
• - High risk cases
• - Business Travellers ?
• - Business Continuity ?
• - Not currently available.

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2 Types of Vaccine

• Seasonal Flu vaccine
• Pandemic H1N1 Flu vaccine

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Vaccination - Goals

• To prevent and reduce death and illness.
• To minimize hospital admissions.
• To reduce virus transmission.
• To maintain essential services.

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Why Vaccinate ?

• 3,600 excess deaths each year in Ireland (mainly
  due to Flu).
• High volume and high morbidity.
• The virus might mutate.
• To reduce the Social impact.
• To reduce the Economic impact.

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Seasonal Flu Vaccine

• Has been available since September
• Does NOT protect from Swine Flu
• BUT will prevent Seasonal flu
• Thereby prevents the possibility of dual
  infection
• Will avoid confusion on cause of symptoms

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Contd.

• We DO recommend the vaccine

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Pandemic H1N1 Vaccine

• 2 Doses.
• 3 - 4 weeks apart.
• HSE have contracted/ordered enough for the Total
  population of Ireland.

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If the Facts Change, My Opinion Changes.

• Mark Twain

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Pandemic H1N1 Vaccine

• Rather than 2 vaccinations being required, 1
  vaccination is all that may be required.

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Ireland - HSE - Pandemic H1N1 Vaccines

• GlaxoSmithKline - Pandemrix.
• Novartis - Focetria.
• Baxter (no thiomersil) Awaiting regulatory
  approval from EU.
• - vaccines are not interchangeable

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Pandemic and Seasonal flu vaccine can be given
together but in different arms (time space
between the vaccines is not important).
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Pandemic (Swine Flu) H1N1 Vaccine

• Will become available in October.
• HSE Ireland have ordered 7.7 million doses
• They envisage delivering through 60 - 100 centres
• They want to ensure equality of delivery
• At present we do not know if they will release
  the vaccine to employers
• If yes we at M.W.O.H.S. have offered to provide
  workplace vaccination service.

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Pandemic H1N1 Vaccine will firstly be rolled out
to -

• Healthcare workers and staff.
• At Risk Groups Approx. 400,000.

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Issues

• Vaccine availability.
• Vaccine licensing.
• Impact of Pandemic.
• Vaccine uptake.
• Duration of campaign.

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Vaccination Uptake

• With flu you need to achieve vaccination rates of
  75.
• At Present -
• Over 65 60-65.
• General 30-35.
• HSE -- 20.

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HSE - Communication

• General messages.
• Messages for HCWs.
• Messages for special groups.
• Calling methods.
• Helpline/websites.
• Leaflets/Factsheets/Posters.
• Advance notice for clinic attendees.

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The Pandemic H1N1 vaccines approved today
undergo the same rigorous FDA manufacturing
oversight, product quality testing and lot
release procedures that apply to the Seasonal
Flu Vaccine.
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Potential side effects of the Pandemic H1N1
vaccines are expected to be similar to those of
Seasonal Flu vaccines
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The Pulpit Rock - Norway
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Business Traveller

• No specific restrictions apply at present.
• A common-sense approach to travel should be
  taken.
• Restrict travel to what is really necessary.

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Business Traveller- Issues -

• Travellers away from home
• Unfamiliar health systems
• Some special cases e.g. China
• Some airlines not allowing travel for anyone who
  is ill
• Thermal screening in some countries.

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Advice for Travellers

• Do not travel if ill
• Consider not travelling if at high risk
• - e.g. close contact
• Possible use of antivirals
• - either as Prophylaxis or as Treatment
  should you become ill while away.
• - These must be prescribed before taking.
• Avoid close contact with anybody who has a fever
  sore throat or cough
• Consult regularly travel advisory information at
  www.dohc.ie and www.who.org and the Dept. of
  Foreign Affairs websites.

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Workplace Contact

• Patient is infectious for up to 1 day prior to
  the onset of symptoms.
• 6 feet or 2 metres area.
• Potential for sneeze or cough to go further.
• Hand contact / touching.
• Flu virus can survive on environmental surfaces
  US CDC - 2-8 hours
• -- UK NHS - soft surfaces 8-12 hrs
• -- hard surfaces 24-72 hrs

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General Health and Safety Advice

• Anticipate the problem.
• Have a plan of action in place.
• Avoid unnecessary contact.
• Carry out a Risk Assessment.
• Strictly adhere to proper work practices.
• Adhere to Health and Safety guidance.

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Contd.

• Observe good work and personal hygiene measures.
• Observe appropriate cough etiquette.
• Comply with wearing PPE where appropriate.
• Participate in Health screening/vaccination
  programmes.
• Stay at home if sick with Flu-like symptoms and
  send home anybody with Flu-like symptoms.

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Websites

• www.mwoh.net
• www.dohc.ie
• www.hse.ie
• www.hpsc.ie
• www.who.org
• www.cdc.com
• www.ecdc.europa.eu
• HSE also have a 24 hr helpline 1800 94 11 00

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Optimistic Note

• We are now better prepared than during previous
  pandemics.
• We have developed antiviral treatment.
• We can produce Pandemic vaccines rapidly.
• Ireland is able to secure large amounts of these
  antiviral treatment and vaccines relative to our
  needs.
• Our population is now much healthier than during
  previous pandemics.

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I would not say that the future is necessarily
less predictable than the past. I think the past
was not predictable when it started.

• Donald Rumsfeld

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Socrates was a man.Socrates was a Greek.He went
around tellingpeople what they shoulddo.They
Killed him !
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Thank You All For Listening