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September 21, 2009 H1N1 Influenza A: Preparing Suffolk County’s Schools and School Districts Humayun J. Chaudhry, DO, MS, SM, FACOI, FACP, FAODME Commissioner,

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Presentation on theme: "September 21, 2009 H1N1 Influenza A: Preparing Suffolk County’s Schools and School Districts Humayun J. Chaudhry, DO, MS, SM, FACOI, FACP, FAODME Commissioner,"— Presentation transcript:

1 September 21, 2009 H1N1 Influenza A: Preparing Suffolk County’s Schools and School Districts Humayun J. Chaudhry, DO, MS, SM, FACOI, FACP, FAODME Commissioner, Suffolk County Department of Health Services, NY and Clinical Associate Professor of Preventive Medicine, Stony Brook University School of Medicine, N.Y.

2 September 21, 2009 Outline Suffolk County Department of Health Services Suffolk County Department of Health Services Definitions and a History of Pandemics Definitions and a History of Pandemics H1N1 Influenza A Virus H1N1 Influenza A Virus Symptoms and Transmission Patterns Symptoms and Transmission Patterns Suffolk County, New York, World Statistics Suffolk County, New York, World Statistics Suffolk County Public Health Response Suffolk County Public Health Response CDC Guidance for School Officials (K-12) CDC Guidance for School Officials (K-12) Q&A Q&A

3 September 21, 2009

4 Suffolk County, Long Island, New York

5 September 21, 2009 Suffolk County Department of Health Services Senior Leadership

6 September 21, 2009 Endemic, Epidemic, and Pandemic Defined Endemic—A disease that already occurs at a high rate in a given population Endemic—A disease that already occurs at a high rate in a given population Epidemic—An outbreak of new cases of a disease in numbers that exceed what is expected Epidemic—An outbreak of new cases of a disease in numbers that exceed what is expected Pandemic—An epidemic that spreads worldwide Pandemic—An epidemic that spreads worldwide Malarious Area

7 September 21, 2009 Pandemics Throughout History Plague of Justinian— 541 A.D. Plague of Justinian— 541 A.D. The Black Death— A.D. The Black Death— A.D. Typhus or camp fever— 15 th and16 th centuries Typhus or camp fever— 15 th and16 th centuries Smallpox— 16 th to 18 th centuries Smallpox— 16 th to 18 th centuries “Spanish” Flu— 1918 “Spanish” Flu— 1918 The Roof Rat

8 September 21, 2009 How Influenza Viruses Change Antigenic Drift: Antigenic Drift: Small changes in viruses over time Small changes in viruses over time New strains appear New strains appear May not be recognized by antibodies May not be recognized by antibodies Antigenic Shift: Antigenic Shift: Abrupt, major change (reassortment) Abrupt, major change (reassortment) Results in novel strain or new subtype Results in novel strain or new subtype Can cause pandemic influenza Can cause pandemic influenza

9 September 21, 2009 Seasonal Influenza, 2009 Annual seasonal influenza epidemics Annual seasonal influenza epidemics >36,000 deaths in US from seasonal influenza (~ deaths in Suffolk County each year) >36,000 deaths in US from seasonal influenza (~ deaths in Suffolk County each year) >200,000 hospitalizations from flu each year >200,000 hospitalizations from flu each year Over 85% mortality in persons ≥ 65 yrs Over 85% mortality in persons ≥ 65 yrs Severe disease in infants, young children, and elderly individuals Severe disease in infants, young children, and elderly individuals Attack rate of 5-15% (Nursing home attack rate of 60%) Attack rate of 5-15% (Nursing home attack rate of 60%) Potential for pandemic Potential for pandemic

10 September 21, 2009 Novel H1N1 Influenza A Virus

11 September 21, 2009 H1N1 Influenza A (Swine Flu), 2009 WHO Phase 6 Pandemic (declared June 11, 2009) WHO Phase 6 Pandemic (declared June 11, 2009) >1 million cases in the U.S. >1 million cases in the U.S. >40,617 confirmed cases in U.S. >40,617 confirmed cases in U.S. >263 confirmed deaths in U.S. >263 confirmed deaths in U.S. >180 confirmed cases in Suffolk County (6 deaths) >180 confirmed cases in Suffolk County (6 deaths) Imminent Public Threat declared by NYSDOH August 6, 2009 Imminent Public Threat declared by NYSDOH August 6, 2009 A brand new virus A brand new virus A “quadruple reassortment of 2 swine strains, 1 human strain, and 1 avian strain of influenza virus” A “quadruple reassortment of 2 swine strains, 1 human strain, and 1 avian strain of influenza virus” Mean age of cases in Suffolk County and in U.S.: 12 Mean age of cases in Suffolk County and in U.S.: 12 Severe infection occurs in individuals who are not at the extremes of age Severe infection occurs in individuals who are not at the extremes of age Attack rate of 22-30% initially Attack rate of 22-30% initially

12 September 21, 2009 Novel H1N1 Influenza A Symptoms (Fever, cough, and/or sore throat), malaise, and headache (Fever, cough, and/or sore throat), malaise, and headache Vomiting and diarrhea (unusual for seasonal influenza) Vomiting and diarrhea (unusual for seasonal influenza) Chills, myalgias, and arthralgias Chills, myalgias, and arthralgias Infants: fever, lethargy, +/- cough Infants: fever, lethargy, +/- cough Elderly individuals and immunocompromised hosts may also have atypical presentations Elderly individuals and immunocompromised hosts may also have atypical presentations

13 September 21, 2009 Risk Factors for Novel H1N1 Influenza A Virus Complications Chronic lung disease (especially asthma, COPD) Chronic lung disease (especially asthma, COPD) Immunocompromised states (including pregnancy, kidney disease, cancer) Immunocompromised states (including pregnancy, kidney disease, cancer) Heart disease (other than HTN) Heart disease (other than HTN) Diabetes Mellitus Diabetes Mellitus Obesity? Obesity? *Most Common Reasons for Hospitalization: Pneumonia and Dehydration *Most Common Reasons for Hospitalization: Pneumonia and Dehydration

14 September 21, 2009 Management of Novel H1N1 Influenza A Infection This virus is sensitive to Tamiflu and Relenza, two antiviral medications (only available by prescription) This virus is sensitive to Tamiflu and Relenza, two antiviral medications (only available by prescription) It is resistant to other antiviral medications It is resistant to other antiviral medications Treatment is recommended for Treatment is recommended for All hospitalized patients with confirmed, probable or suspected cases All hospitalized patients with confirmed, probable or suspected cases Patients who are at higher risk for seasonal influenza complications Patients who are at higher risk for seasonal influenza complications Tamiflu and Relenza are not like antibiotics and are most effective when used within hours of an influenza illness Tamiflu and Relenza are not like antibiotics and are most effective when used within hours of an influenza illness

15 September 21, 2009 Testing for H1N1 in Fall, 2009 Not a priority of the CDC, NYSDOH, or the Suffolk County Department of Health Services except Not a priority of the CDC, NYSDOH, or the Suffolk County Department of Health Services except Pediatric hospitalizations for “influenza-like illness” Pediatric hospitalizations for “influenza-like illness” Any deaths attributed to, or linked with, a diagnosis of pneumonia or other respiratory infection Any deaths attributed to, or linked with, a diagnosis of pneumonia or other respiratory infection As determined by a health care provider in consultation with the NYSDOH As determined by a health care provider in consultation with the NYSDOH

16 September 21, 2009 Transmission of H1N1 Primarily by respiratory droplets (sneezing and coughing) Primarily by respiratory droplets (sneezing and coughing) Incubation Period: 1-4 days Incubation Period: 1-4 days Viral shedding (contagiousness) Viral shedding (contagiousness) Begins 1 day before symptoms Begins 1 day before symptoms Peak shedding is during first 3 days of illness with fever Peak shedding is during first 3 days of illness with fever Lasts 7 days in adults or 10+ days in children Lasts 7 days in adults or 10+ days in children

17 September 21, 2009 Flu Pandemics: A Comparison YEAR World Population 1.8 Billion6.8 Billion Primary Mode of Ships, Jet Aircraft, TransportationRailroad Automobile Time for Virus to 4 months4 days Circle the Globe Estimated Dead 20+ Million ? Worldwide

18 September 21, 2009 Influenza Viral Morphology Influenza Type A, B, C - based on antigenic properties of nucleoproteins (NP) and matrix (M) proteins Influenza Type A, B, C - based on antigenic properties of nucleoproteins (NP) and matrix (M) proteins Hemagglutinin – protein that helps the virus attach to a healthy cell (15 types) Hemagglutinin – protein that helps the virus attach to a healthy cell (15 types) Neuraminidase – protein that helps release viruses into the body (9 types) Neuraminidase – protein that helps release viruses into the body (9 types)

19 September 21, 2009 Source: MMWR, September 26, 2008 How Are We Doing With Seasonal Influenza Vaccination Rates in the U.S.? Healthy People 2010 influenza vaccination targets are Healthy People 2010 influenza vaccination targets are 90% among persons aged ≥65 years 90% among persons aged ≥65 years 60% among persons aged years 60% among persons aged years CDC Data from the Influenza Season indicate vaccination rates of CDC Data from the Influenza Season indicate vaccination rates of 72.1% among persons aged ≥65 years 72.1% among persons aged ≥65 years 35.1% among persons aged % among persons aged % among persons aged % among persons aged 50-64

20 September 21, 2009 H1N1 in the Fall, 2009 Washington has had the nation’s highest rate of H1N1 during the peak period in the state (2,500 suspected cases) Washington has had the nation’s highest rate of H1N1 during the peak period in the state (2,500 suspected cases) cases of the flu for every 10,000 students cases of the flu for every 10,000 students New York State has had New York State has had 6.5 cases of the flu for every 10,000 students 6.5 cases of the flu for every 10,000 students

21 September 21, 2009 Cornell University “ILI” Outbreak A student at Cornell University dispensing soap to students on Sept. 18 Cornell University in Ithaca, New York, on Sept. 18 reported more than 700 cases of “ILI” since classes began A 20 year-old student at Cornell with an underlying medical condition died of complications from the H1N1 virus two weeks ago 3 adjoining college campuses have had a total of 100 cases

22 September 21, 2009 Legal Authority Pursuant to the New York Public Health Law, the Suffolk County Commissioner of Health Services has the legal authority to order the isolation and/or quarantine of any person or thing “infected with or exposed to” a communicable disease. New York Public Health Law § 2100 (1); 10 N.Y.C.R.R. §§ 2.1, 2.25 & N.Y.C.R.R. §§ 2.1, 2.25 & 2.29.

23 September 21, 2009

24 Personal Hygiene is Best Tool Handwashing with soap and water is critical Handwashing with soap and water is critical Virus can spread by contamination of hands that is then followed by hand contact with mucous membranes Virus can spread by contamination of hands that is then followed by hand contact with mucous membranes Alternatives to soap and water exist Alternatives to soap and water exist Alcohol-based hand gels Alcohol-based hand gels

25 September 21, 2009 Masks May Also Play a Role Use of masks may decrease the spread of virus between people Use of masks may decrease the spread of virus between people Widespread use during SARS outbreak Widespread use during SARS outbreak May prevent children from putting hands/objects into their mouths May prevent children from putting hands/objects into their mouths

26 September 21, 2009 This Might Help… Chicken Soup Chicken Soup Orange Juice Orange Juice Vitamin C Vitamin C Multivitamins Multivitamins

27 September 21, 2009 Kobe, Japan May 19, 2009

28 September 21, 2009 Daily Swine Flu Exam: China, May, 2009

29 September 21, 2009 School Closure, Deer Park School District, Suffolk County, N.Y., May, 2009

30 September 21, 2009 Purpose Purpose Provide guidance on suggested means for reducing exposure of students and staff to H1N1 and seasonal influenza during the school year Provide guidance on suggested means for reducing exposure of students and staff to H1N1 and seasonal influenza during the school year Goals Goals Decrease spread of flu among students and staff Decrease spread of flu among students and staff Minimize disruption of day-to-day social, educational, and economic activities Minimize disruption of day-to-day social, educational, and economic activities CDC Guidance for K-12 School Response

31 September 21, 2009 Stay home when sick Stay home when sick Separate ill students and staff Separate ill students and staff Teach hand hygiene and respiratory etiquette! Teach hand hygiene and respiratory etiquette! Early identification and treatment of high- risk students and staff Early identification and treatment of high- risk students and staff Routine cleaning Routine cleaning Consideration of selective school dismissal Consideration of selective school dismissal Recommended School Responses (If similar severity as in Spring 2009)

32 September 21, 2009 “Active” screening “Active” screening High-risk students and staff stay home High-risk students and staff stay home Students with ill household members stay home for 5 days Students with ill household members stay home for 5 days Increase distance between people at schools Increase distance between people at schools Extend the period for ill persons to stay home Extend the period for ill persons to stay home Selective, reactive, and pre-emptive school dismissals Selective, reactive, and pre-emptive school dismissals Recommended School Responses (If increased severity)

33 September 21, 2009 Ask about fever and other symptoms Ask about fever and other symptoms Send home people with symptoms of acute respiratory infection Send home people with symptoms of acute respiratory infection Be vigilant throughout the day Be vigilant throughout the day Send students and staff who appear ill for further screening by school-based health care worker Send students and staff who appear ill for further screening by school-based health care worker If possible, have ill person wear a mask until sent home If possible, have ill person wear a mask until sent home “Active” Screening for Illness

34 September 21, 2009 Explore innovative methods Explore innovative methods Rotate teachers rather than students Rotate teachers rather than students Cancel classes that bring students together from multiple classrooms Cancel classes that bring students together from multiple classrooms Outdoor classes Outdoor classes Move desks farther apart Move desks farther apart Move classes to larger spaces Move classes to larger spaces Discourage use of school buses and public transit Discourage use of school buses and public transit Postpone some class trips Postpone some class trips If severity increases: Increase Distance between People

35 September 21, 2009 Suffolk County’s H1N1 Plan for Fall 1) Two possible scenarios 1) Two possible scenarios Moderately severe illness Moderately severe illness Slightly more cases than in Spring, 2009 Slightly more cases than in Spring, 2009 Increased severity of illness Increased severity of illness No indication from CDC or WHO that this is happening, or will happen, but we will be prepared No indication from CDC or WHO that this is happening, or will happen, but we will be prepared 2) “Stay Home if You Are Ill” 2) “Stay Home if You Are Ill” Influenza-like Illness (ILI): Fever, Cough Influenza-like Illness (ILI): Fever, Cough Suffolk County’s definition of fever: >100ºF or feeling warm/hot plus chills/sweats Suffolk County’s definition of fever: >100ºF or feeling warm/hot plus chills/sweats

36 September 21, 2009 Suffolk County’s H1N1 Plan for Fall 3) H1N1 vaccination and seasonal influenza vaccination will be urged for target populations 3) H1N1 vaccination and seasonal influenza vaccination will be urged for target populations Hospitals, Private Physician Practices, Pharmacies Hospitals, Private Physician Practices, Pharmacies 10 SCDHS Health Centers and >50 Vaccination Clinic PODs (Points of Dispensing) throughout County 10 SCDHS Health Centers and >50 Vaccination Clinic PODs (Points of Dispensing) throughout County Schools, if they wish to have vaccination clinics Schools, if they wish to have vaccination clinics Mandatory in NYS for all physicians and staff at hospitals, Article 28 facilities, Home Health Care, Hospice (NYSDOH Emergency Regulation) Mandatory in NYS for all physicians and staff at hospitals, Article 28 facilities, Home Health Care, Hospice (NYSDOH Emergency Regulation) 4) Upon request, SCDHS will provide guidance and education to public and private school nurses and physicians about H1N1 vaccination procedures, techniques and precautions 4) Upon request, SCDHS will provide guidance and education to public and private school nurses and physicians about H1N1 vaccination procedures, techniques and precautions

37 September 21, 2009 Suffolk County’s H1N1 Plan for Fall 5) SCDHS will provide, upon request, educational and other curricular material about H1N1 and preventive hygiene to public and private schools 5) SCDHS will provide, upon request, educational and other curricular material about H1N1 and preventive hygiene to public and private schools 6) Regular schedule of meetings and communications between SCDHS and the SCSSA, Eastern Suffolk BOCES and Western Suffolk BOCES 6) Regular schedule of meetings and communications between SCDHS and the SCSSA, Eastern Suffolk BOCES and Western Suffolk BOCES

38 September 21, 2009 Suffolk County’s H1N1 Plan for Fall 7) Communication to the public 7) Communication to the public Posters on buses, PSAs (radio, TV, print media), press releases, weekly electronic updates, SCDHS website announcements, press conferences Posters on buses, PSAs (radio, TV, print media), press releases, weekly electronic updates, SCDHS website announcements, press conferences SCDHS H1N1 Telephone Hotline, starting September 9 SCDHS H1N1 Telephone Hotline, starting September 9 8) If increased severity of illness, selective or pre-emptive school closures may be considered as a last resort, especially if school operations disrupted 8) If increased severity of illness, selective or pre-emptive school closures may be considered as a last resort, especially if school operations disrupted

39 September 21, 2009 Suffolk County’s H1N1 Plan for Fall 9) If increased severity of disease, communications will be enhanced and more frequent 9) If increased severity of disease, communications will be enhanced and more frequent SCDHS H1N1 Hotline Hours Extended SCDHS H1N1 Hotline Hours Extended Enhanced surveillance of severity of disease Enhanced surveillance of severity of disease Daily electronic updates Daily electronic updates 10) First Responders (EMS, Police) may be asked to wear N-95 masks this Fall. All other health care personnel may be asked to wear N- 95 masks or disposable masks 10) First Responders (EMS, Police) may be asked to wear N-95 masks this Fall. All other health care personnel may be asked to wear N- 95 masks or disposable masks

40 September 21, 2009 Points of Distribution (POD)

41 September 21, 2009 Why do we think vaccines work? Viral Disease Year of Peak U.S. Prevalence Peak Number of Cases per Year in U.S. Number of Annual U.S. Cases in Modern Vaccine Era (2007) Hepatitis A , Hepatitis B , Measles , Mumps ,69130 Polio ,3160 Rubella ,74511 Congenital Rubella Smallpox ,1640

42 September 21, 2009 Preemptive dismissals Preemptive dismissals CDC will consider need to recommend based on global and national risk assessments CDC will consider need to recommend based on global and national risk assessments Goal: decrease spread of influenza virus and reduce demand on health care system Goal: decrease spread of influenza virus and reduce demand on health care system Use early and in conjunction with other strategies Use early and in conjunction with other strategies Time to vaccine-induced immunity may be considered Time to vaccine-induced immunity may be considered If dismissing, do so for 5 to 7 days and reassess If dismissing, do so for 5 to 7 days and reassess Allow staff to continue to use facilities Allow staff to continue to use facilities Plan for prolonged dismissals and secondary effects Plan for prolonged dismissals and secondary effects If severity increases: School Dismissals

43 September 21, 2009 Review Suffolk County Department of Health Services Suffolk County Department of Health Services Definitions and a History of Pandemics Definitions and a History of Pandemics Novel H1N1 Influenza A Virus Novel H1N1 Influenza A Virus Symptoms and Transmission Patterns Symptoms and Transmission Patterns Suffolk County, New York, World Statistics Suffolk County, New York, World Statistics Suffolk County Public Health Response Suffolk County Public Health Response CDC Guidance for School Officials (K-12) CDC Guidance for School Officials (K-12) Q&A Q&A

44 September 21, 2009 How Bad will the Novel H1N1 Influenza A Virus be in the Fall/Winter of 2009?

45 September 21, 2009

46 Thank You! v


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