H1N1 Pandemic H1N1 Pandemic Influenza Planning Influenza Planning VideoconferenceVideoconference

August 18, 2009August 18, 2009

Purpose of the Purpose of the MeetingMeeting

H1N1 Virus OverviewH1N1 Virus Overview

Terry L Dwelle MD MPHTM Terry L Dwelle MD MPHTM CPH FAAPCPH FAAP

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

5

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

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

3663 hospitalizations (10.8%, 0.36% of estimated cases in the 3663 hospitalizations (10.8%, 0.36% of estimated cases in the US)US)

170 deaths (0.5% of identified cases and 4.6% of those 170 deaths (0.5% of identified cases and 4.6% of those hospitalized, 0.017% of estimated cases in the US)hospitalized, 0.017% of estimated cases in the US)

Genetically this H1N1 is linked to the 1918-19 strainGenetically this H1N1 is linked to the 1918-19 strain Currently we are seeing almost totally H1N1 circulatingCurrently we are seeing almost totally H1N1 circulating Majority of the cases are in children and young adultsMajority of the cases are in children and young adults Majority of hospitalized patients have underlying conditions Majority of hospitalized patients have underlying conditions

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

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

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

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

Pandemic Influenza - Pandemic Influenza - EpidemiologyEpidemiology

Pandemics occur in waves Pandemics occur in waves The order in which communities will be The order in which communities will be

affected will likely be erraticaffected will likely be erratic Some individuals will be asymptomatically Some individuals will be asymptomatically

infectedinfected A person is most infectious just prior to A person is most infectious just prior to

symptom onsetsymptom onset Influenza is likely spread most efficiently by Influenza is likely spread most efficiently by

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

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

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

Influenza response toolboxInfluenza response toolboxSocial distancing and infection control measureSocial distancing and infection control measureVaccineVaccineAntiviral medicationsAntiviral medications

The most effective way to prevent mortality The most effective way to prevent mortality is by social distancingis by social distancing

Proxemics of Influenza Proxemics of Influenza TransmissionTransmission

Elementary Schools

Hospitals

Offices

Residences

3.9 ft

7.8 ft11.7 ft

16.2 ft

Goals of Influenza PlanningGoals of Influenza Planning

Cases

Day

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

IsolationIsolation From From

www.cdc.gov/h1n1flu/guidance_homecare.htm

Data from 2009Data from 2009Most fevers lasted 2-4 daysMost fevers lasted 2-4 days90% of household transmissions occurred within 5 90% of household transmissions occurred within 5

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

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

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

Unstressed Hospital and Clinic SurgeUnstressed Hospital and Clinic SurgeNorth DakotaNorth Dakota

Hosp

/ ILI

Regional ILI rate

Clinic Caution 16.5

Clinic Crisis 21

X

Vaccination StrategyVaccination Strategy

Molly Sander, MPHMolly Sander, MPH

Immunization Program Immunization Program ManagerManager

VaccineVaccineNovel H1N1 vaccine will be available this

fall ~ mid-October.Separate vaccine from the seasonal trivalent

influenza vaccine.Vaccine purchased by the federal

government.Providers and local public health units

may charge an administration fee.The maximum fee will be set by the federal

government.

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 disordersImmunosuppresionMetabolic 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 RecommendationsEveryone will need two doses of

novel H1N1 vaccine.Doses separated by 3 to 4 weeks.

Both injectable and intranasal novel H1N1 vaccines will be available.

Seasonal influenza vaccine may be administered at the same time.

NDIISNDIISThe North Dakota Immunization

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

administered.Healthcare providers, local public

health units, schools, and childcares may have access to the NDIIS.

Strategies for VaccinationStrategies for VaccinationMass Immunization ClinicsSchool Located ClinicsVaccination similar to seasonal

influenza vaccination with a mixture of private and public clinics.

Schools ClinicsSchools ClinicsCDC is encouraging school

immunization clinics.Easy way to capture children and increase

uptake of vaccine.A draft advanced consent form is

available.It is a local public health unit decision

whether or not to conduct school-based vaccination clinics.Contact your local public health unit if you

are interested.

Contact InformationContact Information

Molly Sander, MPH, Program Manager 328-4556

Abbi Pierce, MPH, Surveillance Coordinator 328-3324

Keith LoMurray, 328.2404IIS Sentinel Site Coordinator

Tatia Hardy, VFC Coordinator 328-2035

Kim Weis, MPH, AFIX Coordinator 328-2385

Social Distancing and Social Distancing and Infection ControlInfection Control

Kirby Kruger, State Kirby Kruger, State Epidemiologist, Division Epidemiologist, Division

DirectorDirector

of Disease Controlof Disease Control

OutlineOutline

DiseaseDiseaseNovel H1N1Novel H1N1MitigationMitigationSurveillance in NDSurveillance in ND

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

On average:On average:36,000 people die from the flu36,000 people die from the fluMore than 200,000 people are More than 200,000 people are

hospitalized from flu complicationshospitalized from flu complicationsThere are There are ≈≈ 25 million physician visits 25 million physician visitsAnd And ≈≈15 to 60 million infections 15 to 60 million infections

(5% to 20% of the population) (5% to 20% of the population)

Influenza in North DakotaInfluenza in North Dakota

Each season:Each season:Approximately 400 people die Approximately 400 people die

from Pneumonia and Influenzafrom Pneumonia and InfluenzaOn average 2,300 influenza cases are On average 2,300 influenza cases are

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

infectionsinfections• 2008-2009 season there were more than 2008-2009 season there were more than

1,600 cases reported to the health 1,600 cases reported to the health departmentdepartment

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

SchoolsSchoolsChildcare settingsChildcare settings Healthcare settingsHealthcare settings BusinessesBusinesses

General PublicGeneral PublicHome careHome 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 Exclusion Period - time ill people should be away from othersshould be away from others

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

In general - for the general publicIn general - for the general publicDoes Does NOTNOT apply to health care settings apply to health care settings

StaffStaffVisitorsVisitors

Antivirals not considered with exclusionAntivirals not considered with exclusion

SchoolsSchools

Under conditions seen this Under conditions seen this spring spring (current conditions) the goal (current conditions) the goal will be to keep schools open and will be to keep schools open and reduce disease transmission as much reduce disease transmission as much as possibleas possible

Under conditions of increased Under conditions of increased severity severity compared to spring of 2009compared to spring of 2009

Vaccination and SchoolsVaccination and Schools

Schools should promote vaccination Schools should promote vaccination for all studentsfor all studentsTwo influenza vaccines this yearTwo influenza vaccines this yearAll children ages 6 months to 18 years of All children ages 6 months to 18 years of

age are recommended to receive both age are recommended to receive both influenza vaccinesinfluenza vaccines

Vaccinating a high percentage of students Vaccinating a high percentage of students could provide “herd immunity” in schoolscould provide “herd immunity” in schools

Local Public HealthLocal Public Health

Schools Schools Current ConditionsCurrent Conditions

Ill staff and students are to stay homeIll staff and students are to stay home Ill staff and students to be separated from Ill staff and students to be separated from

others while waiting to go homeothers while waiting to go home Hand hygiene and respiratory etiquetteHand hygiene and respiratory etiquette Routine regular cleaningRoutine regular cleaning Early treatment of high risk individualsEarly treatment of high risk individuals Consideration of selective school dismissalConsideration of selective school dismissal

Schools Schools More Severe ConditionsMore Severe Conditions

Active ScreeningActive Screening High risk students and staff stay homeHigh risk students and staff stay home Quarantine if household members are sickQuarantine if household members are sick Increase distance between people at schoolIncrease distance between people at school Extend isolation periods - use 7 day period or 24 Extend isolation periods - use 7 day period or 24

hours after fever, whichever is longerhours after fever, whichever is longer School dismissalSchool dismissal

ReactiveReactivePreemptivePreemptive

Guidance for Guidance for Influenza Conditions Influenza Conditions Similar to this Last Similar to this Last

SpringSpring

Excluding Students and Excluding Students and StaffStaff

Students and staff should stay home Students and staff should stay home if they have an influenza – like illnessif they have an influenza – like illnessFever of 100° F or greater with a cough and/or Fever of 100° F or greater with a cough and/or

sore throatsore throatCan return to school 24 hours after fever has Can return to school 24 hours after fever has

subsided without the use of fever reducing subsided without the use of fever reducing medicationmedication

Consider absenteeism policies that are not Consider absenteeism policies that are not punitive for students and staff staying home punitive for students and staff staying home while illwhile ill

Separate Ill Staff and Separate Ill Staff and StudentsStudents

Ill staff and students should be placed Ill staff and students should be placed in a separate room or away from in a separate room or away from others while waiting to go home.others while waiting to go home.

Assign a staff member to watch or Assign a staff member to watch or care for the student care for the student Staff member should not be at increased Staff member should not be at increased

risk for complicationsrisk for complicationsAppropriate infection control measures Appropriate infection control measures

usedused

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 Hand Hygiene and Respiratory EtiquetteRespiratory Etiquette

Students and staff should wash hands oftenStudents and staff should wash hands oftenWhen arriving at school / when leaving schoolWhen arriving at school / when leaving schoolAfter bathroom breaksAfter bathroom breaksBefore eatingBefore eatingAfter coughing or sneezing into a tissueAfter coughing or sneezing into a tissue

Schools should provide time and supplies for Schools should provide time and supplies for hand washinghand washing

Hand sanitizers can be usedHand sanitizers can be usedConsider supplying for each classroomConsider 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

Selective School DismissalSelective School Dismissal

Aimed at schools who serve a Aimed at schools who serve a population of which the majority of population of which the majority of students and staff are at increased students and staff are at increased risk for severe disease or risk for severe disease or complicationscomplications

These types of schools may consider These types of schools may consider closing to prevent severe outcomes closing to prevent severe outcomes among students and staffamong students and staff

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

Childcare SettingsChildcare Settings

Guidance still under revisionGuidance still under revisionSimilar to schoolsSimilar to schoolsFor settings with very young children For settings with very young children

(< 5 years) (< 5 years) Consideration the longer exclusion Consideration the longer exclusion

period period

BusinessesBusinesses Review or develop business continuity plansReview or develop business continuity plans Provide education for employeesProvide education for employees Promote vaccinationPromote vaccination Review leave policies with employeesReview leave policies with employees

Non-punitiveNon-punitive

Encourage sick employees to stay homeEncourage sick employees to stay home Promote hand hygiene and respiratory etiquettePromote hand hygiene and respiratory etiquette Increase distances between employees and Increase distances between employees and

employees and the publicemployees and the public Implement telecommuting and staggered shifts if Implement telecommuting and staggered shifts if

possiblepossible

General PublicGeneral Public

Hand hygiene and respiratory etiquetteHand hygiene and respiratory etiquette Avoiding large public gatheringsAvoiding large public gatherings Stay home while ill with a feverStay home while ill with a fever Seek medical care or treatment if indicatedSeek medical care or treatment if indicated

High risk groupHigh risk groupSigns of more severe illnessSigns of more severe illness

Prepare to be at home for 7-10 daysPrepare to be at home for 7-10 days How to care for ill family membersHow to care for ill family members Infection control in the homeInfection control in the home

HomecareHomecare

Infection controlInfection control Drink plenty of clear fluidsDrink plenty of clear fluids OTC medications (no aspirin)OTC medications (no aspirin) Monitor fever and other symptomsMonitor fever and other symptoms When to seek medical careWhen to seek medical care

Difficulty breathing or chest painDifficulty breathing or chest painPurple or blue color in lipsPurple or blue color in lipsSevere vomiting Severe vomiting Signs of dehydration (dizzy, low urine output, no tears, Signs of dehydration (dizzy, low urine output, no tears,

loss of elasticity in skin)loss of elasticity in skin) Less responsive than usual or confusionLess responsive than usual or confusion

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

Name of school or school district: Zip code of school or school district: (5 digit format) Date school or school district dismissed: (yyyy-mm-dd) Date school or school district is projected to re-open (if known): (yyyy-mm-dd)

Optional Information: Name of person submitting this form: Organization/Agency: Email address: Telephone number:

School Closure ReportingSchool Closure Reporting

http://www.cdc.gov/h1n1flu/schools/dismissal_form/dismissal_form.htm

http://www.cdc.gov/h1n1flu/schools/toolkit

CDC Guidance for State and Local Public Health Officials and School Administrators for School (K-12) Responses to Influenza during the 2009-2010 School Year

http://www.cdc.gov/h1n1flu/schools/schoolguidance.htm

Technical Report for State and Local Public Health Officials and School Administrators on CDC Guidance for School (K-12) Responses to Influenza during the 2009-2010 School Year

http://www.cdc.gov/h1n1flu/schools/technicalreport.htm

Surveillance and Surveillance and ReportingReporting

Kirby Kruger, State Kirby Kruger, State Epidemiologist, Division Epidemiologist, Division

DirectorDirector

of Disease Controlof Disease Control

Laboratory SurveillanceLaboratory SurveillanceSentinel PhysiciansSentinel PhysiciansSyndromic SurveillanceSyndromic SurveillanceFollow-up of random sample of Follow-up of random sample of

children under the age of 18children under the age of 18School absenteeism reportsSchool absenteeism reportsOutbreak SupportOutbreak Support

SurveillanceSurveillance

HospitalizationsHospitalizationsWork with Infection Control NursesWork with Infection Control NursesParticipate in the Emerging Infections Participate in the Emerging Infections

ProgramProgramUse of RedBat to gather Hospitalization dataUse of RedBat to gather Hospitalization dataUse of HC StandardUse of HC Standard

School absenteeism ratesSchool absenteeism ratesIncrease the number of schools that reportIncrease the number of schools that reportMonitor school closuresMonitor school closures

SurveillanceSurveillance

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

Schools can help bySchools can help byStaying aware of community situationStaying aware of community situationReporting clusters of illness to state or local Reporting clusters of illness to state or local

health officialshealth officialsParticipate in routine absenteeism reportingParticipate in routine absenteeism reportingReporting increased absenteeism at schoolsReporting increased absenteeism at schoolsWorking with local and state health officials Working with local and state health officials

and the local community on appropriate and the local community on appropriate disease interventions disease interventions

ResourcesResources

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

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

Questions and Questions and AnswersAnswers