Presentation on theme: "WHEN PIGS FLU JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM"— Presentation transcript:
1WHEN PIGS FLU JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPM Interim Chair Department Preventive Medicine at NSU COMBackground:USAF Senior Flight Surgeon, Preventive and Aerospace Medicine SpecialistFlorida HRS then DOH 20 years Directed Orange, Lake and Sumter County Health DepartmentsAs 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 aboveJOHN C. PELLOSIE, JR., DO, MPH, FAOCOPMINTERIM CHAIR DEPARTMENT PREVENTIVE MEDICINENSU COLLEGE OF OSTEOPATHIC MEDICINECenter for Bioterrorism and All-Hazards Preparedness
2Continued Evolution of the H1N1 Pandemic, and it’s virus: A Basis for an Osteopathic Medical School ResponseInfluenza Virus is very interesting to studyDue to its ability to change and modify itselfIts ability to adapt from infecting animal to humanAvian 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 2009From 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 PlanningWhen developing a response plan we must considerKnown and archived informationExpert consult offering their experience and educationLocal resources and capabilitiesDevelop event scenarios to test and modify plansWhen we deal with an organism such as the Influenza Virus which has the ability to dramatically change we cannot accurately predict the future
4Distribution of H1N1 FluThe 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).
5IntroductionThe 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.
6We face an influenza challenge: Novel: Not circulated before, all population susceptible (especially young adult, infrastructure)How severe; Increased morbidity and mortalityHow virulent or contagious and how spreadPeople and populations at increased riskEvolution: is it stable or undergoing rapid change in characteristics?Stability needed to create a vaccineProduce, test and distributeA limited production and distribution requires risk assessment and possible prioritization of recipients and PODsAntiviral medications and availabilityEffective or is virus resistantUse as treatment and/or prophylaxisHow 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 challengesIs 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 complicationsIs the virus now stable enough to determine antiviral susceptibility and possible vaccine developmentHow 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
7While putting together Disaster Response Plans we addressed Pandemic and Pandemic Response at community and Statelevel.Fortunately the concerns over this new Corona Type Virus did escalate into a PandemicYet 37 Countries were involved780 Deaths8000 illnesses attributed
8Until Vaccine is available Note: Vaccine is best form of preventionDelay onsetDecrease numbers of people becoming infectedDelay onset of infection untilVaccine availableDiscover if antiviralsEffective as treatment and/or prophylaxisTheir availabilityHOW 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?
9EASIEST 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 HygieneFrequent and Proper Hand washing, hand sanitizer if soap and water is not available or as an added optionThen keep potentially contaminated hands away from face especially mouth, eyes and noseA problem we seem to be faced with as well is re-establishing common courtesyCough and Sneeze etiquetteProper disposal of contaminated tissues and other like items
10ILI (coined at time of SARS) Influenza Like Illness (ILI); nonspecific:Annually:Adults average 1 to 3 ILIs per yearChildren can average 3 to 6 ILIs per yearSymptoms includeFever, fatigue, cough, sometimes GIMost ILI is not influenza but caused by other viruses, such as:Rhinoviruses and respiratory syncytial virus (RSV) adenoviruses, and parainfluenza virusesBacteria such as Legionella spp., Chlamydia pneumoniae, Mycoplasma pneumoniae, and Streptococcus pneumoniaeI became aware of the term Influenza Like Illness in late 1990s while developing plans for Flu PandemicsGained more prevalence during Bio Terrorism awareness as most communicables produced influenza like illnessesBut most ILI is NOT influenza likely they are due to other infections some are shown.
11JUST LIKE HURRICANES SEASONAL CHALLENGE WITH FLU Seasonal Influenza symptoms include:Fever >100FHeadacheFatigueCoughSore throatRunny noseMyalgias[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 PlanBusiness need Response Plans as well as a Continuance of Operations or COOP plan.During USAFWorked with many different type of Pilots from Single Seat Fighter to Multiplace Heavy as well as Test and HelicopterDid some Flight Testing as well as contributed to development of Helmet Mount Displays for Fighter aircraftThere 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 WorldHis model was labeled the “OODA Loop” Observe Orient Decide and ActThis was later refined and re-labeled SA or Situational AwarenessWe must continue to be aware of our surroundings our resources and potential threatsJust 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”
12USA SEASONAL FLU ANNUAL STATISTICS 5% - 20% of population get flu36,000 people die of flu-related causes250K TO 500K WORLDWIDE> 200,000 people hospitalized due to complications Peak Month of Past 26 flu seasonsNovember for 1 seasonDecember for 4 seasonsJanuary for 5 seasonsFebruary for 12 seasonsMarch for 4 seasonsSEASONAL FLU STATISTICS;UP TO 20% OF POPULATION GET THE FLU EACH YEAR36,000 DIE>200,000 HOSPITALIZEDPEAK MONTHS NOTED FOR PAST 26 FLU SEASONS
13Types of Influenza Viruses Types A, B and CA and B cause Seasonal FluType C cause mild respiratory illnessNot thought to cause epidemicsType A Influenza; divided into subtypes based on two proteins on the surface of the virusHemagglutinin (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) andInfluenza B strainsAs you likely know there are 3 Types of Influenza; A, B, and C.A and B causing Seasonal FluWe face current Pandemic with Novel Type A H1 N1 Swine Origin InfluenzaAvian Origin H5 N1
14Properties of Pandemic Influenza Novel: universal vulnerability to infectionWhile not all become infected during a pandemic, nearly all people are susceptibleLarge numbers of people fall ill about same timePandemics, socially and economically disruptiveMany young adults become illAdversely impacting Community InfrastructuresPotential to overburden all servicesHealth System SurgeActual ill with complications needing professional servicesActual Ill without complications requiring services“Worried Well”CommunicabilitySpeed of spread, both within countries and internationally.Severity of impact, increasing the number of people falling ill and needing care within a short timeRecall the worst case scenario model, monitor the evolution and challenges that arise.And of course pray for the best case…CONCERNING PROPERTIES OF PANDEMIC FLUNEW OR NOVEL VIRUS TO A NAÏVE POPULATIONSOCIAL AND ECONOMIC DISRUPTIONMANY FALLING ILL AT SAME TIMEAGE 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?
15Type A, H1N1, “Swine Flu” 11 June 2009; Pandemic declared; WHO Pandemic Worldwide Alert raised to Phase-6Novel influenza originated from SwineSpread similar to “Seasonal Flu”Infected respiratory dropletCough sneezeContaminated surfaceFirst noted in Mexico then US in March / April19 June all 50 states in US, DC, Puerto Rico, US Virgin Islands reported casesChronology relative to the H1N1What has been learnedSaw some differences in case presentation from that reported in MexicoLess severityCommunicability without fever19 June all 50 states reporting cases
16Influenza Pandemic WHO declared Influenza Pandemic 11 June 2009 Novel, Type A, H1N1 “Swine Flu”Gone through the 1st “Wave”Expect 2nd waveHow bad will the 2nd wave be (continued monitoring)What are we doingWhen 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 onceMulti 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
17Influenza Pandemics 20th Century Credit: US National Museum of Health and MedicineSome past Pandemics1918 “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 deaths675,000 US deaths~1-4 m deaths70,000 US deaths~1,000,000+ deaths34,000 US deaths17
18Will past dictate what will occur? Model response plans; reference to past experiences and the documentation of eventsTechnology; then to nowAdvantages:More advanced technology, diagnostics, pharmaceutics, vaccines…Some Challenges:Higher population densities common courtesy waningWorld wide travelMore reliance (less individualism)More immune compromiseOlder population, naturally occurringInduced compromiseCa treatmentTransplantsHIVMedically fragile and complexWe 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)AdvantagesLaboratory and Diagnostic capabilities, new pharmaceuticals (antibiotics, antivirals, vaccines)ChallengesHigher population densitiesTravel continent to continent in mere hours (Think SST and soon Space Plane)Less Self-RelianceImmune CompromiseGreat population at risk of infection and complication due to naturally occurring compromiseInduced immune compromise (technical advancement) from Ca treatment and TransplantHIVMedically 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)
19Specifically, who is monitoring? WHO; is monitoring, globallyNationally: CDCState: DOHWe work collaboratively withDOH County Health DepartmentDOHWe participate inDOH and DOE Advisory Committee on PandemicDeans Advisory Committee for Medical Schools in StateThe World Health Organization or WHO monitors “Globally”Centers for Disease Control monitor on a National or Federal levelState Department of Health DOH monitors at a State and County levelWork collaboratively withCounty and with State DOHParticipate in DOH DOE Advisory Committee on Pandemic Planning
20Monitoring Through:ESSENCE; (ED) Electronic Surveillance System for the Early Notification of Community-based EpidemicsSentinel Physicians; report to DOH clinical flu activityState Bureau of LaboratoriesDOH CHD Epidemiology reports of flu activitiesState Pneumonia and Influenza Mortality Surveillance SystemDOH Merlin, a computer based epidemiology system on novel influenza on special at risk population groupsMonitoring Methods utilized by the StateESSENCE Syndromic Surveillance System in place at certain Hospital ED (if cases exceed predetermined number relative to a specific illness or syndrome alerts)Sentinel PhysiciansState Bureau of LaboratoriesCHD Epi ReportsPneumonia and Influenza Monthly Surveillance SystemDOU computer based epi systemALSO:Monitor Pharmaceutical OTC purchases
21State Regional Domestic Security Task Force (RDSTF) RDSTF Regions (Multi County)Developed from of RDTTF ; 9.11 and Bio/ChemEvolved to include all natural and man-made challengesESSENCE (ED Surveillance) for RDSTFAll Regions show increases in Flu activity in last few weeksSome regions reporting higher levels than peak of normal Seasonal FluExceeds 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 collaborativeRenamed to Regional Domestic Security Task Force (RDSTF) evolved into Disaster and Response Planning for Natural and Man made incidentsCurrently Regional ESSENCE reports:
22Why Do We Monitor? (We know it’s out there!) At a point, no need nor value in testing all ILI to document H1N1Once documented as occurring and prevalent in the population; then clinical diagnosis acceptedSelected sampling / testing allowsTracking of infectionDetermining if virus has changed or altered its characteristicsIf 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 acceptableSelected sampling and testing the virus allows awareness of evolution or change in the organism (more or less severe resistance, vaccine capabilities) and allows tracking.
23COMMUNICABLES How and where people are infected HomePublic PlacesWork (School)PlaySocial gatheringsTravelHow can we prevent infectionNon-Medical meansMedical / PharmaceuticalsHOW?Exposure from direct contact (inoculation) or through inhalationNo prior immunity through vaccine or history of illness with specific organismTouching face, mouth, and/or eyes with potentially contaminated handsWHERE?HomeFrom ill family member or friendPoor hygiene / sanitation, not washing (after bathroom and changing diapers) before or after food prep, not sanitizing prep surfaces, improper cookingPublic PlacesClose to ill person especially those not using common cough and sneeze etiquetteContaminated surfacesHOW TO PREVENT INFECTIONSNon-Medical or Pharmaceutical meansMedical / Pharmaceutical
24Individual/Household/ Agency A Layered ApproachIndividual/Household/ AgencyHand hygieneCough etiquetteInfection controlLiving space controlIsolation of illDesignated careproviderFacemasks whereindicatedInternationalContainment-at-sourceSupport efforts toreduce transmissionTravel advisoriesLayered screening of travelersHealth advisoriesLimited points of entryCommunity,Colleges/UniversitiesIsolation of illTreatment of illProtectivesequestration ofchildrenSocial distancing- Community- Workplace-Self IsolationLiberal leave policiesA combination of interventions are necessaryA “LAYER APPROACH” In the absence of a well-matched vaccine.
25DROPLET PRECAUTIONSDiseases spread by infected large particles / droplets during cough, sneeze, spittle, procedures:InfluenzaHemophilus influenzae; meningitis, pneumonia (in infants), epiglottitisNeisseria meningitis; meningitis, pneumonia, bacteremiaMycoplasm pneumoniaGroup A streptococcal pneumonia, pharyngitis, scarlet feverAdenovirusRubellaParvovirus B19Seasonal Influenza and other illnesses, some noted here are spread by Contaminated Droplet from Cough, Sneeze, Spittle, …
26Transmission of novel influenza A (H1N1) Same as Seasonal Influenza virus and many URIsPerson to person spread:Large-particle respiratory droplet transmission when an infected person coughs or sneezes near a susceptible personProximity 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 transmissionKeep hands clean and away from face, food, smokes …Keep pens and other objects away from face / mouthKeep equipment clean (stethoscope…)Transmission of the Novel H1 N1 Flu is reported similar to the Seasonal Influenza
27Non-Medical Prevention Personal hygiene and courtesy“Cough and Sneeze Etiquette”Away from others and coverDispose of dirty tissues appropriatelyWash hands thoroughlySocial DistancingIf ill stay away from othersSelf isolate till not communicablePersonal bubble (6 feet)Teach and Model for children and othersUse of mask for close contact such as caring for ill family membersParticular to the current Influenza Challenge“Cough and Sneeze Etiquette”Social Distancing6 foot bubbleStay away from others if ill (home from work or school) esp for ILITeach and more importantly MODEL for children and other adultsMask use difference between “Face or Surgical Mask” and Respirator Mask N-95Which is best and which will work if utilized and worn correctly
28Non-Medical Prevention Active screening: Check staff & students in morning when they get to schoolConsider 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 awayBut we await the 2nd wave predictedAs 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 operationsActively Screen and move away ill from healthy population and if one meets the criteria of a ILI send them homeConsider HR modification of normal policy and procedures to easeSick Leave requirementsFamily Sick LeaveRequiring Physician’s Note to leave and/or returnStrongly discourage “Swine Flu Parties”
29Medical / Pharmaceutical Prevention Immunizations: keep them up-to-dateAntiviral Medications use (availability and resistance)Vaccines against influenzaSeasonal Influenza (important to get it annually)Novel flu vaccine when availableAs part of you Personal Protective Equipment or PPE please keep your Immunizations Up to Date.
30FLU VACCINES Seasonal Flu Vaccine should be encouraged Vaccine is currently availableDoes not protect against H1N1 fluWill protect against a possible complication to Novel flu infectionPandemic Novel Type A H1N1 VaccineAnticipated in October 2009.Likely to be a single doseProduction and Availability will dictate risk groups
31H1N1 Vaccine Priority Groups Pregnant WomenHousehold contacts and care givers for infants <6 months of ageHealthcare workers and Emergency Medical Services personnelChildren and Young adults (6 months to 24 years) – not approved for <6 monthsPeople 25 to 64 years with underlying chronic medical conditions
32Person 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 properlyTissues to be disposed of in the trashProviding servicesLimit interaction and other potential staff exposuresDon’t go in and out of room repeatedly and limit the number of different people who enter the roomDistancing: maintain 6 foot separation as much as possibleMask use if coughing and sneezing presentWear gloves and wash hands after useClean equipment (stethoscope)Sanitize potentially contaminated surfacesWash hands frequently