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1 WHEN PIGS FLU JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM INTERIM CHAIR DEPARTMENT PREVENTIVE MEDICINE NSU COLLEGE OF OSTEOPATHIC MEDICINE Center for Bioterrorism.

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Presentation on theme: "1 WHEN PIGS FLU JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM INTERIM CHAIR DEPARTMENT PREVENTIVE MEDICINE NSU COLLEGE OF OSTEOPATHIC MEDICINE Center for Bioterrorism."— Presentation transcript:

1 1 WHEN PIGS FLU 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 2 Continued Evolution of the H1N1 Pandemic, and its virus: A Basis for an Osteopathic Medical School Response

3 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

4 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 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. 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 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 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 Effective or is virus resistant Use as treatment and/or prophylaxis Use as treatment and/or prophylaxis How will it impact Health Systems (Surge) and Businesses (COOP)?

7 7

8 8 Until Vaccine is available Note: Vaccine is best form of prevention Delay onset Decrease numbers of people becoming infected Decrease numbers of people becoming infected Delay onset of infection until Delay onset of infection until Vaccine available Discover if antivirals Effective as treatment and/or prophylaxis Effective as treatment and/or prophylaxis Their availability Their availability HOW DO WE DELAY ONSET UNTILL WE GET VACCINE???

9 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).

10 10 ILI (coined at time of SARS) Influenza Like Illness (ILI); nonspecific: Annually: Annually: Adults average 1 to 3 ILIs per year Children can average 3 to 6 ILIs per year Symptoms include Symptoms include Fever, fatigue, cough, sometimes GI Most ILI is not influenza but caused by other viruses, such as: 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

11 11 JUST LIKE HURRICANES SEASONAL CHALLENGE WITH FLU Seasonal Influenza symptoms include: Fever >100F HeadacheFatigueCough 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.

12 12 USA SEASONAL FLU ANNUAL STATISTICS 5% - 20% of population get flu 36,000 people die of flu-related causes 250K TO 500K WORLDWIDE 250K TO 500K WORLDWIDE > 200,000 people hospitalized due to complications > 200,000 people hospitalized due to complications Peak Month of Past 26 flu seasons November for 1 season November for 1 season December for 4 seasons December for 4 seasons January for 5 seasons January for 5 seasons February for 12 seasons February for 12 seasons March for 4 seasons March for 4 seasons

13 13 Types of Influenza Viruses Types A, B and C A and B cause Seasonal Flu A and B cause Seasonal Flu Type C cause mild respiratory illness 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). Hemagglutinin (H) and the Neuraminidase (N). Influenza A further broken down into different strains. 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 A (H1N1), A (H3N2) and Influenza B strains Influenza B strains

14 14 Properties of Pandemic Influenza Novel: universal vulnerability to infection While not all become infected during a pandemic, nearly all people are susceptible 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 Pandemics, socially and economically disruptive Many young adults become ill Adversely impacting Community Infrastructures Adversely impacting Community Infrastructures Potential to overburden all services Health System Surge 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. 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 Severity of impact, increasing the number of people falling ill and needing care within a short time

15 15 Type A, H1N1, Swine Flu 11 June 2009; Pandemic declared; WHO Pandemic Worldwide Alert raised to Phase-6 Pandemic Worldwide Alert raised to Phase-6 Novel influenza originated from Swine Spread similar to Seasonal Flu Infected respiratory droplet 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 19 June all 50 states in US, DC, Puerto Rico, US Virgin Islands reported cases

16 16 Influenza Pandemic WHO declared Influenza Pandemic 11 June 2009 Novel, Type A, H1N1 Swine Flu Gone through the 1 st Wave Expect 2nd wave How bad will the 2 nd wave be (continued monitoring) How bad will the 2 nd wave be (continued monitoring) What are we doing What are we doing When planning response activities and resources; Plan for the worst and hope for the best.

17 17 Influenza Pandemics 20 th Century A(H1N1)A(H2N2)A(H3N2) 1918: Spanish Flu1957: Asian Flu1968: Hong Kong Flu ~50,000,000 deaths 675,000 US deaths ~1-4 m deaths 70,000 US deaths ~1,000,000+ deaths 34,000 US deaths Credit: US National Museum of Health and Medicine

18 18 Will past dictate what will occur? Model response plans; reference to past experiences and the documentation of events Technology; then to now Advantages: Advantages: More advanced technology, diagnostics, pharmaceutics, vaccines… Some Challenges: Some Challenges: Higher population densities common courtesy waning World wide travel More reliance (less individualism) More immune compromise Older population, naturally occurring Older population, naturally occurring Induced compromise Induced compromise Ca treatment Transplants HIV HIV Medically fragile and complex

19 19 Specifically, who is monitoring? WHO; is monitoring, globally Nationally: CDC State: DOH We work collaboratively with DOH County Health Department DOH County Health Department DOH DOH We participate in DOH and DOE Advisory Committee on Pandemic DOH and DOE Advisory Committee on Pandemic Deans Advisory Committee for Medical Schools in State Deans Advisory Committee for Medical Schools in State

20 20 Monitoring Through: 1.ESSENCE; (ED) Electronic Surveillance System for the Early Notification of Community-based Epidemics 2.Sentinel Physicians; report to DOH clinical flu activity 3.State Bureau of Laboratories 4.DOH CHD Epidemiology reports of flu activities 5.State Pneumonia and Influenza Mortality Surveillance System 6.DOH Merlin, a computer based epidemiology system on novel influenza on special at risk population groups

21 21 State Regional Domestic Security Task Force (RDSTF) RDSTF Regions (Multi County) RDSTF Regions (Multi County) Developed from of RDTTF ; 9.11 and Bio/Chem Developed from of RDTTF ; 9.11 and Bio/Chem Evolved to include all natural and man-made challenges 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 All Regions show increases in Flu activity in last few weeks Some regions reporting higher levels than peak of normal Seasonal Flu Some regions reporting higher levels than peak of normal Seasonal Flu Exceeds initial surge of Worried Well Exceeds initial surge of Worried Well

22 22 Why Do We Monitor? (We know its 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 Once documented as occurring and prevalent in the population; then clinical diagnosis accepted Selected sampling / testing allows Tracking of infection Tracking of infection Determining if virus has changed or altered its characteristics Determining if virus has changed or altered its characteristics

23 23 COMMUNICABLES How and where people are infected Home Home Public Places Public Places Work (School) Play Social gatherings Travel How can we prevent infection Non-Medical means Non-Medical means Medical / Pharmaceuticals Medical / Pharmaceuticals

24 24 A Layered Approach Individual/Household/ Agency Hand hygiene Cough etiquette Infection control Living space control Isolation of ill Designated care provider Facemasks where indicated Community,Colleges/ Universities Isolation of ill Treatment of ill Protective sequestration of children Social distancing - Community - Workplace -Self Isolation Liberal leave policies International Containment-at- source Support efforts to reduce transmission Travel advisories Layered screening of travelers Health advisories Limited points of entry

25 25 DROPLET PRECAUTIONS Diseases spread by infected large particles / droplets during cough, sneeze, spittle, procedures: Influenza Influenza Hemophilus influenzae; meningitis, pneumonia (in infants), epiglottitis Hemophilus influenzae; meningitis, pneumonia (in infants), epiglottitis Neisseria meningitis; meningitis, pneumonia, bacteremia Neisseria meningitis; meningitis, pneumonia, bacteremia Mycoplasm pneumonia Mycoplasm pneumonia Group A streptococcal pneumonia, pharyngitis, scarlet fever Group A streptococcal pneumonia, pharyngitis, scarlet fever Adenovirus Adenovirus Rubella Rubella Parvovirus B19 Parvovirus B19

26 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 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 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…)

27 27 Non-Medical Prevention Personal hygiene and courtesy Cough and Sneeze Etiquette Cough and Sneeze Etiquette Away from others and cover Dispose of dirty tissues appropriately Wash hands thoroughly Social Distancing Social Distancing If ill stay away from others Self isolate till not communicable 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

28 28 Non-Medical Prevention Active screening: Check staff & students in morning when they get to school Consider not requiring a physicians 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

29 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) Seasonal Influenza (important to get it annually) Novel flu vaccine when available Novel flu vaccine when available

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

31 31 H1N1 Vaccine Priority Groups 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 32 Person with ILI Person should be: Moved away from others in wait area Distancing Moved away from others in wait area Distancing (Offered Sanitizer for hands) (Offered Sanitizer for hands) (Offered a mask if coughing and sneezing) (Offered a mask if coughing and sneezing) Dispose of potentially contaminated items properly Dispose of potentially contaminated items properly Tissues to be disposed of in the trash Providing services Limit interaction and other potential staff exposures Limit interaction and other potential staff exposures Dont 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 Distancing: maintain 6 foot separation as much as possible Mask use if coughing and sneezing present Mask use if coughing and sneezing present Wear gloves and wash hands after use Wear gloves and wash hands after use Clean equipment (stethoscope) Clean equipment (stethoscope) Sanitize potentially contaminated surfaces Sanitize potentially contaminated surfaces Wash hands frequently Wash hands frequently

33 33 QUESTIONS


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