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WHEN PIGS FLU JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM

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Presentation on theme: "WHEN PIGS FLU JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM"— Presentation transcript:

1 WHEN PIGS FLU JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM
Interim Chair Department Preventive Medicine at NSU COM Background: USAF Senior Flight Surgeon, Preventive and Aerospace Medicine Specialist Florida HRS then DOH 20 years Directed Orange, Lake and Sumter County Health Departments As result of Terrorist threats became First Responder to “white Powder” suspect Bio/Chem and HazMat events and Rash Response team relative to the States Operation Vaccinate Florida Campaign (Smallpox) worked very closely with LCSO, local LE and Fire Rescue. Associate Medical Director for Lake / Sumter EMS relative to the above JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM INTERIM CHAIR DEPARTMENT PREVENTIVE MEDICINE NSU COLLEGE OF OSTEOPATHIC MEDICINE Center for Bioterrorism and All-Hazards Preparedness

2 Continued Evolution of the H1N1 Pandemic, and it’s virus: A Basis for an Osteopathic Medical School Response Influenza Virus is very interesting to study Due to its ability to change and modify itself Its ability to adapt from infecting animal to human Avian Origin H5 N1 and now Swine origin H1N1

3 “WE WISH WE COULD PREDICT EXACTLY WHAT IS GOING TO HAPPEN, BUT UNFORTUNATELY WE CANNOT.”
Dr. Anne Schuchat, Director; National Center for Immunization and Respiratory Diseases; CDC; 8 Sept 2009 From an early age I’ve been involved in aviation; Prevention plays a very important role in aviation as well in other fields such as Fire Rescue, EMS, MCI Response and Disaster Response Planning When developing a response plan we must consider Known and archived information Expert consult offering their experience and education Local resources and capabilities Develop event scenarios to test and modify plans When we deal with an organism such as the Influenza Virus which has the ability to dramatically change we cannot accurately predict the future

4 Distribution of H1N1 Flu The H1N1 virus has caused infections in humans in 140 countries. Nowhere is it more prevalent than in the U.S. The U.S. has more than 37,000 of the world's 95,000 confirmed cases, 1,380 hospitalizations, and more than 196 confirmed deaths (September 10, 2009, CDC).

5 Introduction The number of confirmed cases represents only a fraction of those infected. Most people have only a mild illness and don't require a doctor's care. WHO estimates as many as a million people in the U. S. may be infected, but not all will fall ill.

6 We face an influenza challenge:
Novel: Not circulated before, all population susceptible (especially young adult, infrastructure) How severe; Increased morbidity and mortality How virulent or contagious and how spread People and populations at increased risk Evolution: is it stable or undergoing rapid change in characteristics? Stability needed to create a vaccine Produce, test and distribute A limited production and distribution requires risk assessment and possible prioritization of recipients and PODs Antiviral medications and availability Effective or is virus resistant Use as treatment and/or prophylaxis How will it impact Health Systems (Surge) and Businesses (COOP)? When confronted with a new or Novel Influenza which has potential of causing Pandemic or global spread we face a number of challenges Is it a Novel virus not circulated before with many in our population susceptible to infection (esp young adults) How severe will the infection be on the individual and the community at large (infrastructure) What populations will be at increased risk due to infection and potential complications Is the virus now stable enough to determine antiviral susceptibility and possible vaccine development How will expected absenteeism effect infrastructure, will it overwhelm the Health System (Surge) How must we modify our response plans and Continuance of Operations Plans; Personal, Family, Business

7 While putting together Disaster Response Plans we addressed Pandemic and Pandemic Response at community and State level. Fortunately the concerns over this new Corona Type Virus did escalate into a Pandemic Yet 37 Countries were involved 780 Deaths 8000 illnesses attributed

8 Until Vaccine is available
Note: Vaccine is best form of prevention Delay onset Decrease numbers of people becoming infected Delay onset of infection until Vaccine available Discover if antivirals Effective as treatment and/or prophylaxis Their availability HOW DO WE DELAY ONSET UNTILL WE GET VACCINE??? Vaccination, as you know, is the best form of prevention. Our technology permits vaccination to prevent a communicable disease.. But to discover whether an effective vaccine can be created, found safe and be distributed takes precious time - Months. We must also ask relative to Flu whether antivirals will be effective treatment and/or prophylaxis to the Novel strain. So then how do we delay onset of infection until that time?

9 EASIEST WAY TO PREVENT MOST COMMUNICABLES?
FREQUENT AND PROPER HAND WASHING! Keep potentially contaminated hands away from face (self-inoculate via eyes, nose, mouth). Basis of Preventive Medicine and Public Health is Personal Hygiene Frequent and Proper Hand washing, hand sanitizer if soap and water is not available or as an added option Then keep potentially contaminated hands away from face especially mouth, eyes and nose A problem we seem to be faced with as well is re-establishing common courtesy Cough and Sneeze etiquette Proper disposal of contaminated tissues and other like items

10 ILI (coined at time of SARS)
Influenza Like Illness (ILI); nonspecific: Annually: Adults average 1 to 3 ILIs per year Children can average 3 to 6 ILIs per year Symptoms include Fever, fatigue, cough, sometimes GI Most ILI is not influenza but caused by other viruses, such as: Rhinoviruses and respiratory syncytial virus (RSV) adenoviruses, and parainfluenza viruses Bacteria such as Legionella spp., Chlamydia pneumoniae, Mycoplasma pneumoniae, and Streptococcus pneumoniae I became aware of the term Influenza Like Illness in late 1990s while developing plans for Flu Pandemics Gained more prevalence during Bio Terrorism awareness as most communicables produced influenza like illnesses But most ILI is NOT influenza likely they are due to other infections some are shown.

11 JUST LIKE HURRICANES SEASONAL CHALLENGE WITH FLU
Seasonal Influenza symptoms include: Fever >100F Headache Fatigue Cough Sore throat Runny nose Myalgias [Stomach symptoms (nausea, vomiting, and diarrhea) can occur but are more common in children than adults] Complications of flu can include: bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. We are in the Peak of our Hurricane Season I hope and encourage each of you to have a Personal and Family Disaster Response Plan Business need Response Plans as well as a Continuance of Operations or COOP plan. During USAF Worked with many different type of Pilots from Single Seat Fighter to Multiplace Heavy as well as Test and Helicopter Did some Flight Testing as well as contributed to development of Helmet Mount Displays for Fighter aircraft There was a term and model developed by a USAF at Eglin which became a prominent model for Air to Air combat as well as for the Business World His model was labeled the “OODA Loop” Observe Orient Decide and Act This was later refined and re-labeled SA or Situational Awareness We must continue to be aware of our surroundings our resources and potential threats Just as we plan for Hurricane Season we have a seasonal Challenge with the FLU or “Seasonal Flu” We protect ourselves against this challenge by use of “Seasonal Flu Vaccine”

12 USA SEASONAL FLU ANNUAL STATISTICS
5% - 20% of population get flu 36,000 people die of flu-related causes 250K TO 500K WORLDWIDE > 200,000 people hospitalized due to complications   Peak Month of Past 26 flu seasons November for 1 season December for 4 seasons January for 5 seasons February for 12 seasons March for 4 seasons SEASONAL FLU STATISTICS; UP TO 20% OF POPULATION GET THE FLU EACH YEAR 36,000 DIE >200,000 HOSPITALIZED PEAK MONTHS NOTED FOR PAST 26 FLU SEASONS

13 Types of Influenza Viruses
Types A, B and C A and B cause Seasonal Flu Type C cause mild respiratory illness Not thought to cause epidemics Type A Influenza; divided into subtypes based on two proteins on the surface of the virus Hemagglutinin (H) and the Neuraminidase (N). Influenza A further broken down into different strains. Current subtypes of influenza A viruses found in people are A (H1N1) and A (H3N2). Note: Seasonal flu vaccine contains: Influenza A (H1N1), A (H3N2) and Influenza B strains As you likely know there are 3 Types of Influenza; A, B, and C. A and B causing Seasonal Flu We face current Pandemic with Novel Type A H1 N1 Swine Origin Influenza Avian Origin H5 N1

14 Properties of Pandemic Influenza
Novel: universal vulnerability to infection While not all become infected during a pandemic, nearly all people are susceptible Large numbers of people fall ill about same time Pandemics, socially and economically disruptive Many young adults become ill Adversely impacting Community Infrastructures Potential to overburden all services Health System Surge Actual ill with complications needing professional services Actual Ill without complications requiring services “Worried Well” Communicability Speed of spread, both within countries and internationally. Severity of impact, increasing the number of people falling ill and needing care within a short time Recall the worst case scenario model, monitor the evolution and challenges that arise. And of course pray for the best case… CONCERNING PROPERTIES OF PANDEMIC FLU NEW OR NOVEL VIRUS TO A NAÏVE POPULATION SOCIAL AND ECONOMIC DISRUPTION MANY FALLING ILL AT SAME TIME AGE OF THOSE AFFECTED INCLUDE YOUNG THOSE IN WORKING AND SUPPORT GROUPS (DIFFER FROM SEASONAL) Many young adults become ill at same time. What will this due to infrastructure; Health System Surge?

15 Type A, H1N1, “Swine Flu” 11 June 2009; Pandemic declared; WHO
Pandemic Worldwide Alert raised to Phase-6 Novel influenza originated from Swine Spread similar to “Seasonal Flu” Infected respiratory droplet Cough sneeze Contaminated surface First noted in Mexico then US in March / April 19 June all 50 states in US, DC, Puerto Rico, US Virgin Islands reported cases Chronology relative to the H1N1 What has been learned Saw some differences in case presentation from that reported in Mexico Less severity Communicability without fever 19 June all 50 states reporting cases

16 Influenza Pandemic WHO declared Influenza Pandemic 11 June 2009
Novel, Type A, H1N1 “Swine Flu” Gone through the 1st “Wave” Expect 2nd wave How bad will the 2nd wave be (continued monitoring) What are we doing When planning response activities and resources; “Plan for the worst and hope for the best.” Some models of Past Pandemics suggest varied “Wave Models” Tidal all get sick at once Multi Wave with some suggestion that succeeding wave are more severe. We await the 2nd Wave knowing that the second wave of the 1918 Flu was very severe

17 Influenza Pandemics 20th Century
Credit: US National Museum of Health and Medicine Some past Pandemics 1918 “Spanish Flu” 1957 “Asian Flu” 1968 “Hong Kong Flu” 1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu” A(H1N1) A(H2N2) A(H3N2) ~50,000,000 deaths 675,000 US deaths ~1-4 m deaths 70,000 US deaths ~1,000,000+ deaths 34,000 US deaths 17

18 Will past dictate what will occur?
Model response plans; reference to past experiences and the documentation of events Technology; then to now Advantages: More advanced technology, diagnostics, pharmaceutics, vaccines… Some Challenges: Higher population densities common courtesy waning World wide travel More reliance (less individualism) More immune compromise Older population, naturally occurring Induced compromise Ca treatment Transplants HIV Medically fragile and complex We model Response plans by factoring in past events so what are some consideration we must address? Technology is more advanced yet sometimes less functional or operational (Washing hands to the tune of Happy Birthday to You) Advantages Laboratory and Diagnostic capabilities, new pharmaceuticals (antibiotics, antivirals, vaccines) Challenges Higher population densities Travel continent to continent in mere hours (Think SST and soon Space Plane) Less Self-Reliance Immune Compromise Great population at risk of infection and complication due to naturally occurring compromise Induced immune compromise (technical advancement) from Ca treatment and Transplant HIV Medically fragile and complex and greater legal considerations (from who can render care and what is considered proper treatment to development of treatment modalities) (Smallpox extending expiration date and dilutions to antiviral reducing acceptable age and extending expiration date)

19 Specifically, who is monitoring?
WHO; is monitoring, globally Nationally: CDC State: DOH We work collaboratively with DOH County Health Department DOH We participate in DOH and DOE Advisory Committee on Pandemic Deans Advisory Committee for Medical Schools in State The World Health Organization or WHO monitors “Globally” Centers for Disease Control monitor on a National or Federal level State Department of Health DOH monitors at a State and County level Work collaboratively with County and with State DOH Participate in DOH DOE Advisory Committee on Pandemic Planning

20 Monitoring Through: ESSENCE; (ED) Electronic Surveillance System for the Early Notification of Community-based Epidemics Sentinel Physicians; report to DOH clinical flu activity State Bureau of Laboratories DOH CHD Epidemiology reports of flu activities State Pneumonia and Influenza Mortality Surveillance System DOH Merlin, a computer based epidemiology system on novel influenza on special at risk population groups Monitoring Methods utilized by the State ESSENCE Syndromic Surveillance System in place at certain Hospital ED (if cases exceed predetermined number relative to a specific illness or syndrome alerts) Sentinel Physicians State Bureau of Laboratories CHD Epi Reports Pneumonia and Influenza Monthly Surveillance System DOU computer based epi system ALSO:Monitor Pharmaceutical OTC purchases

21 State Regional Domestic Security Task Force (RDSTF)
RDSTF Regions (Multi County) Developed from of RDTTF ; 9.11 and Bio/Chem Evolved to include all natural and man-made challenges ESSENCE (ED Surveillance) for RDSTF All Regions show increases in Flu activity in last few weeks Some regions reporting higher levels than peak of normal Seasonal Flu Exceeds initial surge of “Worried Well” During Terrorism concerns and resulting experience working in EMS LE and HazMat Mutual Aid agreements we had provided Mutual Aid through Agreements to communities (counties outside our own). This to address MCI (Mass Casualty Incidents) potentially overwhelming a community. From this grew the Regional Domestic Terrorism Task Force (RDTTF) a Multi-county regional collaborative Renamed to Regional Domestic Security Task Force (RDSTF) evolved into Disaster and Response Planning for Natural and Man made incidents Currently Regional ESSENCE reports:

22 Why Do We Monitor? (We know it’s out there!)
At a point, no need nor value in testing all ILI to document H1N1 Once documented as occurring and prevalent in the population; then clinical diagnosis accepted Selected sampling / testing allows Tracking of infection Determining if virus has changed or altered its characteristics If it is widespread and we know it is out there then why do we monitor? Once we track the flow of the infection and determine its prevalence then it is felt not necessary to lab confirm each case; tying up resources and growing costs; a clinical diagnosis is then considered acceptable Selected sampling and testing the virus allows awareness of evolution or change in the organism (more or less severe resistance, vaccine capabilities) and allows tracking.

23 COMMUNICABLES How and where people are infected
Home Public Places Work (School) Play Social gatherings Travel How can we prevent infection Non-Medical means Medical / Pharmaceuticals HOW? Exposure from direct contact (inoculation) or through inhalation No prior immunity through vaccine or history of illness with specific organism Touching face, mouth, and/or eyes with potentially contaminated hands WHERE? Home From ill family member or friend Poor hygiene / sanitation, not washing (after bathroom and changing diapers) before or after food prep, not sanitizing prep surfaces, improper cooking Public Places Close to ill person especially those not using common cough and sneeze etiquette Contaminated surfaces HOW TO PREVENT INFECTIONS Non-Medical or Pharmaceutical means Medical / Pharmaceutical

24 Individual/Household/ Agency
A Layered Approach Individual/Household/ Agency Hand hygiene Cough etiquette Infection control Living space control Isolation of ill Designated care provider Facemasks where indicated International Containment-at-source Support efforts to reduce transmission Travel advisories Layered screening of travelers Health advisories Limited points of entry Community,Colleges/ Universities Isolation of ill Treatment of ill Protective sequestration of children Social distancing - Community - Workplace -Self Isolation Liberal leave policies A combination of interventions are necessary A “LAYER APPROACH” In the absence of a well-matched vaccine.

25 DROPLET PRECAUTIONS Diseases spread by infected large particles / droplets during cough, sneeze, spittle, procedures: Influenza Hemophilus influenzae; meningitis, pneumonia (in infants), epiglottitis Neisseria meningitis; meningitis, pneumonia, bacteremia Mycoplasm pneumonia Group A streptococcal pneumonia, pharyngitis, scarlet fever Adenovirus Rubella Parvovirus B19 Seasonal Influenza and other illnesses, some noted here are spread by Contaminated Droplet from Cough, Sneeze, Spittle, …

26 Transmission of novel influenza A (H1N1)
Same as Seasonal Influenza virus and many URIs Person to person spread: Large-particle respiratory droplet transmission when an infected person coughs or sneezes near a susceptible person Proximity as droplets do not remain suspended in the air and fall generally only short distance; personal distancing the - “6 foot bubble” Contamination of surfaces is possible source of transmission Keep hands clean and away from face, food, smokes … Keep pens and other objects away from face / mouth Keep equipment clean (stethoscope…) Transmission of the Novel H1 N1 Flu is reported similar to the Seasonal Influenza

27 Non-Medical Prevention
Personal hygiene and courtesy “Cough and Sneeze Etiquette” Away from others and cover Dispose of dirty tissues appropriately Wash hands thoroughly Social Distancing If ill stay away from others Self isolate till not communicable Personal bubble (6 feet) Teach and Model for children and others Use of mask for close contact such as caring for ill family members Particular to the current Influenza Challenge “Cough and Sneeze Etiquette” Social Distancing 6 foot bubble Stay away from others if ill (home from work or school) esp for ILI Teach and more importantly MODEL for children and other adults Mask use difference between “Face or Surgical Mask” and Respirator Mask N-95 Which is best and which will work if utilized and worn correctly

28 Non-Medical Prevention
Active screening: Check staff & students in morning when they get to school Consider not requiring a physician’s note when out or when cleared for duty especially if “Surge” conditions occur. Students, staff and faculty with ill household members should stay home for five days from the day the first household member got sick. Strongly discourage “Swine Flu Parties” At present the local impact from H1 N1 “Swine Flu” is low and hopefully it will remain that way perhaps fade away But we await the 2nd wave predicted As the Challenge and event evolves and we await the Vaccine, most important is awareness if there is an escalation of challenge and growing concern over outbreak control and operations Actively Screen and move away ill from healthy population and if one meets the criteria of a ILI send them home Consider HR modification of normal policy and procedures to ease Sick Leave requirements Family Sick Leave Requiring Physician’s Note to leave and/or return Strongly discourage “Swine Flu Parties”

29 Medical / Pharmaceutical Prevention
Immunizations: keep them up-to-date Antiviral Medications use (availability and resistance) Vaccines against influenza Seasonal Influenza (important to get it annually) Novel flu vaccine when available As part of you Personal Protective Equipment or PPE please keep your Immunizations Up to Date.

30 FLU VACCINES Seasonal Flu Vaccine should be encouraged
Vaccine is currently available Does not protect against H1N1 flu Will protect against a possible complication to Novel flu infection Pandemic Novel Type A H1N1 Vaccine Anticipated in October 2009. Likely to be a single dose Production and Availability will dictate risk groups

31 H1N1 Vaccine Priority Groups
Pregnant Women Household contacts and care givers for infants <6 months of age Healthcare workers and Emergency Medical Services personnel Children and Young adults (6 months to 24 years) – not approved for <6 months People 25 to 64 years with underlying chronic medical conditions

32 Person with ILI Person should be: Providing services
Moved away from others in wait area “Distancing” (Offered Sanitizer for hands) (Offered a mask if coughing and sneezing) Dispose of potentially contaminated items properly Tissues to be disposed of in the trash Providing services Limit interaction and other potential staff exposures Don’t go in and out of room repeatedly and limit the number of different people who enter the room Distancing: maintain 6 foot separation as much as possible Mask use if coughing and sneezing present Wear gloves and wash hands after use Clean equipment (stethoscope) Sanitize potentially contaminated surfaces Wash hands frequently

33 QUESTIONS


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