H 1 N 1 Pandemic Influenza Planning Videoconference

H 1 N 1 Pandemic Influenza Planning Videoconference August 26, 2009

Pandemic Flu H 1 N 1 Terry L Dwelle MD MPHTM CPH FAAP 2

Pandemic Influenza – General Information Ø Pandemic is a worldwide epidemic Ø We can expect several pandemics in the 21 st century 3

H 1 N 1 (Swine Origin Influenza Virus) Ø 33, 902 cases in the US (estimate is that there have been 1 million cases in the US) Ø 3663 hospitalizations (10. 8%, 0. 36% of estimated cases in the US) Ø 170 deaths (0. 5% of identified cases and 4. 6% of those hospitalized, 0. 017% of estimated cases in the US) Ø Genetically this H 1 N 1 is linked to the 1918 -19 strain Ø Currently we are seeing almost totally H 1 N 1 circulating Ø Majority of the cases are in children and young adults Ø 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). Ø There have been over 50 outbreaks in camps Ø Southern hemisphere – currently seeing substantial disease from H 1 N 1 that is cocirculating with seasonal influenza. There has been some strain on the health systems in some situations. Ø About 30% of infected individuals are asymptomatic (study from Peru) 4

H 1 N 1 in Pregnancy Ø April 15 to May 18, 2009 – 34 confirmed or probable cases of H 1 N 1 in pregnant women reported to the CDC Ø 11/34 (32%) were admitted to hospital Ø General population hospitalization rate 7. 6% Ø 6 deaths – pneumonia and acute respiratory distress syndrome Ø Promptly treat pregnant women with H 1 N 1 infection with antivirals Lancet on line, July 29, 2009 5

Pandemic Influenza - Impact Ø A moderate pandemic may exceed the capacity of hospitals to provide inpatient care 6

Estimates of the Impact of an Influenza ND estimates in parentheses 1957 and 1968 1918 90 million - 30% (160, 000) Outpatient medical care 45 million - 50% (80, 000) Hospitalization 865, 000 (1600) – 1% 9, 900, 000 (19, 200) – 12% ICU care 128, 750 (256) – 0. 16% 1, 485, 000 (2880) – 1. 8% Mechanical ventilation 64, 875 (128) – 0. 08% Deaths 209, 000 (416) – 0. 26% 1, 903, 000 (3840) – 2. 4% Illness 745, 500 (1488) – 0. 93% 7

Pandemic Influenza - Epidemiology Ø Pandemics occur in waves Ø The order in which communities will be affected will likely be erratic Ø Some individuals will be asymptomatically infected Ø A person is most infectious just prior to symptom onset Ø Influenza is likely spread most efficiently by cough or sneeze droplets from an infected person to others within a 3 foot circumference 8

Secondary Effects on Individuals and Communities Ø Individuals and Families l l l Income / job security due to absenteeism Protecting children from exposure to influenza Continuity of education Fear, worry, stigma Access to essential goods and services (eg food, medication, etc. ) l Home-based healthcare Ø Communities l l Maintaining business continuity Sustaining critical infrastructures Availability of essential goods and services (supply chains) Supporting vulnerable populations 9

Pandemic Influenza - Response Ø We don’t look at pandemic flu as a separate disease to be dealt with in a different way from regular seasonal influenza Ø Influenza response toolbox l Social distancing and infection control measure l Vaccine l Antiviral medications Ø The most effective way to prevent mortality is by social distancing 10

Proxemics of Influenza Transmission Residences Offices Hospitals 11. 7 ft Elementary 7. 8 ft Schools 3. 9 ft 16. 2 ft 11

Goals of Influenza Planning Goals • Delay outbreak peak • Decompress peak burden on hospitals and infrastructure • Diminish overall cases and health impacts Cases Day 12

Isolation Ø From www. cdc. gov/h 1 n 1 flu/guidance_homecare. htm Ø Data from 2009 l Most fevers lasted 2 -4 days l 90% of household transmissions occurred within 5 days of onset of symptoms in the 1 st case l Requires 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. l 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. 13

Unstressed Hospital and Clinic Surge - North Dakota Hosp / ILI Clinic Caution 16. 5 Clinic Crisis 21 X Regional ILI rate 14

EMS Response Roles Stephen P. Pickard MD 15

EMS Response Roles Ø Current EMS roles l Transport l Vaccination (paramedics) Ø Potential additional roles in a surge l Altered transport rules if surge occurs l Supplementation of acute care (ER, inpatient) l MCF director 16

Pan Flu Antivirals Terry L Dwelle MD MPTHM CPH FAAP 17

Intervention - Antivirals Ø Antivirals (Tamiflu and Relenza) will be used primarily for treatment not prophylaxis l ND will have approximately 160, 000 treatment courses available for a pandemic (25% of the population) Ø Distribution flow l Normal + Supplementation (from the state cache, some prepositioned with LPHU’s) l Points of Distribution Ø Resistance is a major concern 18

Antiviral Treatment – H 1 N 1 Ø Sensitive to anitvirals - zanamivir (Relenza) and oseltamivir (Tamilflu) Ø Uncomplicated febrile illness due to H 1 N 1 does not require treatment Ø Treatment is recommended for l All hospitalized patients with confirmed, probable or suspected H 1 N 1 l High risk patients for complications www. cdc. gov/h 1 n 1 flu/recommendations. htm 19

High risk groups for complications Ø < 5 yo (highest risk is < 2 yo) Ø Adults > 65 yo Ø Persons with the following conditions l l l l Asthma Other chronic pulmonary diseases Cardiovascular 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 < 19 yo receiving long-term aspirin therapy Residents of nursing homes and other chronic care facilities www. cdc. gov/h 1 n 1 flu/recommendations. htm

Treatment guidance Ø Start treatment as soon as possible after onset of symptoms l Best if started before 48 hours from Sx onset l Still may be some benefit in Rx after 48 hours Ø Duration – 5 days www. cdc. gov/h 1 n 1 flu/recommendations. htm 21

Prophylaxis Ø Close contact of cases (confirmed, probable or suspected) who are at highrisk for complications Ø Health care personnel, public health workers, or first responders who have unprotected close contact to a case (confirmed, probable or suspect) during the infectious period (24 hours before to 24 hours after becoming afebrile) www. cdc. gov/h 1 n 1 flu/recommendations. htm 22

Vaccination Strategy Molly Sander, MPH Immunization Program Manager

ND House Bill 1215 Ø Certified or licensed emergency medical technicians-intermediate and paramedics, who are employed by a hospital and who are working in a non-emergency setting, may provide patient care within a scope of practice established by the department and may administer influenza vaccinations. l EMS personnel may NOT administer vaccine to anyone under the age of 18.

Vaccine Ø Separate novel H 1 N 1 influenza vaccine from seasonal trivalent vaccine. Ø 45 million doses in mid-October l Followed be 20 million doses per week there after. Ø Five manufacturers: same age indications as seasonal vaccine. l Both injectable and intranasal vaccine will be available. Ø Assume 2 doses required for everyone, separated by 3 to 4 weeks.

ACIP Recommendations Ø Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated; Ø 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 Recommendations Ø Healthcare 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; l Include public health personnel

ACIP Recommendations Ø All people from 6 months through 24 years of age l Children from 6 months through 18 years of age because many cases of novel H 1 N 1 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 l Young adults 19 through 24 years of age because many cases of novel H 1 N 1 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 Recommendations Ø Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza. l Chronic pulmonary disease, including asthma l Cardiovascular disease l Renal, hepatic, neurological/neuromuscular, or hematologic disorders l Immunosuppression l Metabolic disorders, including diabetes mellitus

ACIP Recommendations Ø 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. Ø 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 Recommendations Ø If demand exceeds supply (not expected): l pregnant women, l people who live with or care for children younger than 6 months of age, l health care and emergency medical services personnel with direct patient contact, l children 6 months through 4 years of age, and l children 5 through 18 years of age who have chronic medical conditions.

Distribution Ø H 1 N 1 vaccine purchased from manufacturers by the federal government. Ø Vaccine is allocated to states based on population. l North Dakota will receive 0. 208% Ø H 1 N 1 vaccine will be distributed through a third party distributor (Mc. Kesson) l Will also ship ancillary supplies. • Alcohol pads, syringes, needles, sharps containers

Enrollment Ø Providers are required to sign an enrollment form in order to receive H 1 N 1 vaccine. l CDC is creating a standardized form. It is currently unavailable. Ø Enrollment requirements unknown, but most likely include: l Proper storage and handling: 35 ° – 46° F l Following of ACIP recommendations l Reporting of doses administered?

Administration Fee Ø The federal government will set a maximum administration fee. l Most likely at the Medicare rate: $18. 45/dose in North Dakota. (Different than Medicaid fee cap for VFC: $13. 90) l Cannot charge for the cost of the vaccine, as it is free from the federal government. Ø Administration fee may be billed to patient, Medicaid, Medicare, private insurance, etc. Ø Local public health units cannot refuse to vaccinate based on inability to pay. l Private providers will probably be able to refuse vaccination if patient is unable to pay.

NDIIS ØThe North Dakota Immunization Information System (NDIIS) is a confidential, population-based, computerized information system that attempts to collect vaccination data about all North Dakotans. ØHealthcare providers, local public health units, schools, and childcares may have access to the NDIIS.

NDIIS Ø The NDIIS will be used to track doses administered. l Similar data entry to other vaccines, but includes high-risk groups for vaccination. Ø Doses administered must be reported to CDC by the state on a weekly basis. l Report each Tuesday for the previous week. Ø Contact the NDDo. H at 701. 328. 3386 or tollfree at 800. 472. 2180 if interested in obtaining access.

Strategies for Vaccination Ø Check with local public health unit to determine local strategies. l Mass Immunization Clinics l School Clinics: • Recommended by CDC • Good way to capture children l Vaccination similar to seasonal influenza vaccination. (private and public mix)

Seasonal Influenza Vaccination Ø May be started when vaccine is available. l Immunity lasts for at least one year according to CDC. Ø ACIP recommendations published and available at: http: //www. cdc. gov/mmwr/preview/mmwrhtml/rr 5808 a 1. htm? s_cid=rr 5808 a 1_e. l All children, 6 months – 18 years of age l All persons 50 years of age or older l Residents of long-term care facilities l Pregnant women (during any trimester) l Persons 6 months and older with a chronic illness l Healthcare personnel, including home care l Employees of long-term care facilities l Household contacts of high-risk persons

Vaccine Types Ø Trivalent Inactivated Vaccine (TIV): l Injectable l Adults need 0. 5 m. L dose IM l Available in syringes and multi-dose vials l Different brands have different age indications Ø Live Attenuated Intranasal Vaccine (LAIV): l Licensed for people ages 2 – 49 years l Half of the sprayer in each nostril

Contraindications and Precautions Ø TIV l Persons with a severe allergic reaction (anaphylaxis) to a vaccine component or following a prior dose of TIV should not receive TIV. • Includes anaphylactic allergy to eggs l Moderate or severe acute illness—vaccinate after symptoms have decreased

Contraindications and Precautions Ø LAIV l Persons who should NOT receive LAIV: • • Children <2 years of age 50 years of age or older Persons with chronic medical conditions Children or adolescents receiving long-term aspirin therapy Pregnant women Immunosuppressed persons Persons with a history of a severe allergy to egg or any other vaccine component • Persons with a history of Guillain-Barré syndrome l Defer vaccine for persons with moderate or severe acute illness until symptoms improve

Vaccine Information Statements Ø A VIS must be given with each dose. Ø 2009 -2010 seasonal VIS are available at www. cdc. gov/vaccine s/pubs/vis/default. htm. Ø H 1 N 1 VIS not yet available.

VAERS Ø Remember to report vaccine adverse events for both seasonal and H 1 N 1. Ø http: //vaers. hhs. gov/ Ø VAERS module will be available in NDIIS. l Same fields as VAERS form. l Pre-populated with demographic and vaccine information from NDIIS.

Contact Information Ø Molly Sander, MPH, Program Manager Ø Abbi Pierce, MPH, Surveillance Coordinator Ø Keith Lo. Murray, IIS Sentinel Site Coordinator Ø Tatia Hardy, VFC Coordinator Ø Kim Weis, MPH, AFIX Coordinator 328 -4556 328 -3324 328 -2404 328 -2035 328 -2385

Community Mitigation and Infection Control Kirby Kruger, Director Division of Disease Control

Community Mitigation Ø Schools Ø Childcare settings Ø Healthcare settings Ø Businesses Ø General Public Ø Home care

Community Mitigation ØIsolation or exclusion l Voluntary and passive l 24 hours after fever subsides and not using fever reducing medication ØHand hygiene ØRespiratory etiquette

Exclusion Period - time ill people should be away from others Ø Applies to settings in which the majority of the people are not at increased risk for complications Ø For the general public Ø Does NOT apply to health care settings l Staff l Visitors Ø Antivirals not considered with exclusion

Infection Control Healthcare Facilities Ø CDC still recommending airborne precautions (N 95) with all encounters with patients with ILI Ø HICPAC l Has endorsed standard precautions plus droplet precautions Ø WHO – same as HICPAC Ø NDDo. H Similar to HICPAC and WHO

Infection Control for EMS Ø Infectious Period for Novel H 1 N 1 l One day before to 7 days following onset or after symptoms subside – whichever is longer

PSAPs Ø PSAPs should determine if anyone at the incident has influenza-like illness l Febrile respiratory illness Ø This should be communicated with EMS

Potential for Febrile Respiratory Illness at the Scene Ø PSAP advises potential febrile respiratory illness l Assess scene safety l EMS should don appropriate PPE prior to entering the scene

PSAP Does not Advise Potential for Febril Respiratory Illness Ø Maintain a distance of 6 feet between yourself and others at the scene Ø Assess patients for fever and respiratory symptoms l If no symptoms – provide standard care l If symptoms use appropriate PPE

PPE Ø Use standard precautions plus droplet precautions for patients with respiratory illness l Wear a gown l Droplet precautions – use of a surgical or procedure mask l Use an N-95 or N-100 if performing respiratory procedures that may aerosolize respiratory secretions l Use eye and/or face protection if warranted l Follow good hand hygiene procedures

Aerosol Generating Activities Ø Endotracheal intubation Ø Nebulizer treatments Ø CPR Ø Resuscitation involving emergency intubation

Finally Ø Have the patient wear a surgical mask, if he or she can tolerate it Ø Routine cleaning with an EPA registered product Ø Notify receiving facility regarding the febrile respiratory illness

Infection Control in the Home Caring for an Ill Person at Home Ø Place ill person in a private room try to designate one bathroom for ill person Ø Have ill person wear a surgical mask Ø No visitors Ø One non-pregnant person should provide care Ø Caregiver should consider wearing mask Ø Caregiver should consider N 95 if assisting with respiratory treatment Ø Hand hygiene and respiratory etiquette for household Ø Use paper towels to dry hands

Surveillance, Testing and Reporting Kirby Kruger, State Epidemiologist, Division Director of Disease Control

What have we seen in ND?

Surveillance Ø Laboratory Surveillance Ø Sentinel Physicians Ø Syndromic Surveillance Ø Follow-up of random sample of children under the age of 18 Ø School absenteeism reports Ø Outbreak Support

Surveillance Ø Hospitalizations l Work with Infection Control Nurses l Participate in the Emerging Infections Program l Use of Red. Bat to gather Hospitalization data l Use of HC Standard Ø School absenteeism rates l Increase the number of schools that report l Monitor school closures

Surveillance Ø Outbreak Support l Increase the number of facilities that can report outbreaks and receive free testing

Testing Ø Limited testing in all areas of North Dakota where novel H 1 N 1 has not been demonstrated l Testing will be stopped once ongoing transmission is likely (2 -5 positive tests) l Current restriction on testing • Ward, Cass and Burleigh Counties Ø All areas can continue to test for novel H 1 N 1 in hospitalized patients in which H 1 N 1 infection has not been ruled out

Resources Ø NDDo. H flu web-page (updated every Wednesday) l http: //www. ndflu. com/ Ø CDC flu web-page l http: //www. cdc. gov/flu/

Questions and Answers