1. H1N1 Pandemic Influenza Planning Videoconference August 24, 2009

2. Purpose of the Meeting

3. 3 Pandemic Flu H1N1 Terry L Dwelle MD MPHTM CPH FAAP

4. 4 Pandemic Influenza – General Information  Pandemic is a worldwide epidemic  We can expect several pandemics in the 21 st century

5. 5 H1N1 (Swine Origin Influenza Virus)  33,902 cases in the US (estimate is that there have been 1 million cases in the US)  3663 hospitalizations (10.8%, 0.36% of estimated cases in the US)  170 deaths (0.5% of identified cases and 4.6% of those hospitalized, 0.017% of estimated cases in the US)  Genetically this H1N1 is linked to the 1918-19 strain  Currently we are seeing almost totally H1N1 circulating  Majority of the cases are in children and young adults  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).  There have been over 50 outbreaks in camps  Southern hemisphere – currently seeing substantial disease from H1N1 that is cocirculating with seasonal influenza. There has been some strain on the health systems in some situations.  About 30% of infected individuals are asymptomatic (study from Peru)

6. 6 H1N1 in Pregnancy  April 15 to May 18, 2009 – 34 confirmed or probable cases of H1N1 in pregnant women reported to the CDC  11/34 (32%) were admitted to hospital  General population hospitalization rate 7.6%  6 deaths – pneumonia and acute respiratory distress syndrome  Promptly treat pregnant women with H1N1 infection with antivirals Lancet on line, July 29, 2009

7. 7 Pandemic Influenza - Impact  A moderate pandemic may exceed the capacity of hospitals to provide inpatient care

8. Estimates of the Impact of an Influenza 1957 and 1968 1918 Illness90 million - 30% (160,000) Outpatient medical care 45 million - 50% (80,000) Hospitalization865,000 (1600) – 1%9, 900,000 (19,200) – 12% ICU care128,750 (256) – 0.16%1,485,000 (2880) – 1.8% Mechanical ventilation64,875 (128) – 0.08%745,500 (1488) – 0.93% Deaths209,000 (416) – 0.26%1,903,000 (3840) – 2.4% ND estimates in parentheses

9. 9 Pandemic Influenza - Epidemiology   Pandemics occur in waves   The order in which communities will be affected will likely be erratic   Some individuals will be asymptomatically infected   A person is most infectious just prior to symptom onset   Influenza is likely spread most efficiently by cough or sneeze droplets from an infected person to others within a 3 foot circumference

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

11. 11 Interventions InterventionDecrease in Attack Rates Social distancing72% Social distancing + Antiviral treatment 72.6% Social distancing + Antiviral treatment + Broad prophylaxis 75.6%

12. Proxemics of Influenza Transmission Elementary Schools Hospitals Offices Residences 3.9 ft 7.8 ft11.7 ft 16.2 ft

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

14. 14 Isolation   From www.cdc.gov/h1n1flu/guidance_homecare.htm www.cdc.gov/h1n1flu/guidance_homecare.htm   Data from 2009 Most fevers lasted 2-4 days 90% of household transmissions occurred within 5 days of onset of symptoms in the 1 st case 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. 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.

15. 15 Unstressed Hospital and Clinic Surge - North Dakota Hosp / ILI Regional ILI rate Clinic Caution 16.5 Clinic Crisis 21 X

16. 16 Pan Flu Antivirals Terry L Dwelle MD MPTHM CPH FAAP

17. 17 Intervention - Antivirals  Antivirals (Tamiflu and Relenza) will be used primarily for treatment not prophylaxis ND will have approximately 160,000 treatment courses available for a pandemic (25% of the population) ND will have approximately 160,000 treatment courses available for a pandemic (25% of the population)  Distribution flow Normal Normal Normal + Supplementation (from the state cache, some prepositioned with LPHU’s) Normal + Supplementation (from the state cache, some prepositioned with LPHU’s) Points of Distribution Points of Distribution  Resistance is a major concern

18. 18 Antiviral Treatment – H1N1  Sensitive to zanamivir (Relenza) and oseltamivir Tamilflu but resistant to amantadine and rimantadine  Some circulating seasonal Influ A viruses may be resistant to oseltamivir – consider combination treatment with oseltamivir and amantidine or rimantidine  Uncomplicated febrile illness due to H1N1 does not require treatment  Treatment is recommended for All hospitalized patients with confirmed, probable or suspected H1N1 All hospitalized patients with confirmed, probable or suspected H1N1 High risk patients for complications High risk patients for complications

19. 19 High risk groups for complications  < 5yo (highest risk is < 2yo)  Adults > 65yo  Persons with the following conditions Asthma Asthma Other chronic pulmonary diseases Other chronic pulmonary diseases Cardiovascular disease (except hypertension) Cardiovascular disease (except hypertension) Renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, metabolic (including diabetes mellitus) Renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, metabolic (including diabetes mellitus) Immunosuppression including that caused by medication or by HIV Immunosuppression including that caused by medication or by HIV Pregnant women Pregnant women < 19yo receiving long-term aspirin therapy < 19yo receiving long-term aspirin therapy Residents of nursing homes and other chronic care facilities Residents of nursing homes and other chronic care facilities

20. 20 Treatment guidance  Start treatment as soon as possible after onset of symptoms Best if started before 48 hours from Sx onset Best if started before 48 hours from Sx onset Still may be some benefit in Rx after 48 hours Still may be some benefit in Rx after 48 hours  Duration – 5 days  Doses – H1N1 same as for seasonal flu

21. 21 Antiviral doses Medication / Group Rx for 5 days Chemoprophylaxis Oseltamivir (Tamiflu) Adults 75 mg bid 75 mg od Children < 15 kg 30 mg bid 30 mg od 16-23 kg 45 mg bid 45 mg od 24-40 kg 60 mg bid 60 mg od > 40 kg 75 mg bid 75 mg od Zanamivir (Relenza) Adults Two 5 mg inhalations bid Two 5 mg inhalations od Children Two 5 mg inhalations bid (> 7 yo) Two 5 mg inhalations od (> 5 yo)

22. 22 H1N1 Oseltamivir doses for < 1yo Age Rx for 5 days Chemoprophylaxis for 10 days < 3 mo 12 mg bid Not recommended unless critical 3-5 mo 20 mg bid 20 mg od 6-11 mo 25 mg bid 25 mg od

23. 23 Prophylaxis  Close contact of cases (confirmed, probable or suspected) who are at high- risk for complications  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)

24. 24 Close contact  Care for or live with a person who is a confirmed, probable or suspect case  Having been in a setting where there is a high likelihood of contact with respiratory droplets and or other bodily fluids  Activities like kissing, embracing, sharing of eating/drinking utensils, physical examination

25. 25 Pregnant women  Treatment – oseltamivir preferred  Prophylaxis – zanamivir

26. 26 Prepositioning of Antivirals in the Home  Relationship well established between the clinician and patient or family  Medical history of all family members well known including medication allergies and underlying conditions  Compliance with physician instructions assured  Physician office capable of handling phone calls to triage families / patients having antivirals in the home  System to monitor expiration dates in place  Physician willing to accept liability for this practice  Patient willingness to pay for this medication

27. Vaccination Strategy Molly Sander, MPH Immunization Program Manager

28. Vaccine   Separate novel H1N1 influenza vaccine from seasonal trivalent vaccine.   45 million doses in mid-October Followed be 20 million doses per week there after.   Five manufacturers: same age indications as seasonal vaccine.   Assume 2 doses required for everyone, separated by 3 to 4 weeks.   Remember to report any suspect vaccine adverse events to the NDDoH.

29. ACIP Recommendations   Pregnant women.   Household contacts and caregivers for children younger than 6 months of age.   Healthcare and emergency medical services personnel.   All people from 6 months through 24 years of age. Children from 6 months through 18 years of age. Young adults 19 through 24 years of age.

30. ACIP Recommendations   Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza. Chronic pulmonary disease, including asthma Cardiovascular disease Renal, hepatic, neurological/neuromuscular, or hematologic disorders Immunosuppresion Metabolic disorders, including diabetes mellitus

31. ACIP Recommendations   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.   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.

32. ACIP Recommendations   If demand exceeds supply: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children 5 through 18 years of age who have chronic medical conditions.

33. Distribution   H1N1 vaccine purchased from manufacturers by the federal government.   Vaccine is allocated to states based on population.   H1N1 vaccine will be distributed through a third party distributor (McKesson) Same distributor as Vaccines For Children (VFC) vaccine. Will also ship ancillary supplies.

34. Enrollment  Providers are required to sign an enrollment form in order to receive H1N1 vaccine. CDC is creating a standardized form. It is currently unavailable. CDC is creating a standardized form. It is currently unavailable.  Enrollment requirements unknown, but most likely include: Proper storage and handling Proper storage and handling Following of ACIP recommendations Following of ACIP recommendations Reporting of doses administered? Reporting of doses administered?

35. Administration Fee  The federal government will set a maximum administration fee. Most likely at the Medicare rate: $18.45/dose in North Dakota. (Different than Medicaid fee cap for VFC:$13.90) Most likely at the Medicare rate: $18.45/dose in North Dakota. (Different than Medicaid fee cap for VFC:$13.90)  Administration fee may be billed to patient, Medicaid, Medicare, private insurance, etc.  Local public health units cannot refuse to vaccinate based on inability to pay. Private providers will probably be able to refuse vaccination if patient is unable to pay. Private providers will probably be able to refuse vaccination if patient is unable to pay.

36. NDIIS   The North Dakota Immunization Information System (NDIIS) will be used to track doses administered. Similar data entry to other vaccines, but includes high-risk groups for vaccination.   Doses administered must be reported to CDC by the state on a weekly basis. Report each Tuesday for the previous week.   Contact the NDDoH at 701.328.3386 or toll- free at 800.472.2180 if interested in obtaining access.

37. Strategies for Vaccination   Check with local public health unit to determine local strategies. Mass Immunization Clinics School Clinics Vaccination similar to seasonal influenza vaccination. (private and public mix)

38. Seasonal Influenza Vaccination   May be started when vaccine is available. Immunity lasts for at least one year according to CDC.   ACIP recommendations published and available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5808a1.htm?s_cid=rr5808a1_e. http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5808a1.htm?s_cid=rr5808a1_e No changes from last season.   Some private vaccine has already shipped.

40. Pneumococcal Vaccination  The ACIP recommends that persons recommended for pneumococcal vaccine receive it in light of the potential for increased risk of pneumococcal disease associated with influenza.  There are at present no recommendations to give pneumococcal vaccine to groups for whom it is not currently recommended.  ACIP will revisit this question over the summer as epidemiologic data from the Southern hemisphere influenza season and from the U.S. become available.

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

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

43. Community Mitigation  Schools  Childcare settings  Healthcare settings  Businesses  General Public  Home care

44. Community Mitigation  Isolation or exclusion Voluntary and passive Voluntary and passive 24 hours after fever subsides and not using fever reducing medication 24 hours after fever subsides and not using fever reducing medication  Hand hygiene  Respiratory etiquette

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

46. Infection Control Healthcare Facilities  CDC still recommending airborne precautions(N95) with all encounters with patients with ILI  HICPAC Has endorsed standard precautions plus droplet precautions Has endorsed standard precautions plus droplet precautions  WHO – same as HICPAC  NDDoH Similar to HICPAC and WHO

47. Homecare  Infection control  Drink plenty of clear fluids  OTC medications (no aspirin)  Monitor fever and other symptoms  When to seek medical care Difficulty breathing or chest pain Difficulty breathing or chest pain Purple or blue color in lips Purple or blue color in lips Severe vomiting Severe vomiting Signs of dehydration (dizzy, low urine output, no tears, loss of elasticity in skin) Signs of dehydration (dizzy, low urine output, no tears, loss of elasticity in skin) Less responsive than usual or confusion Less responsive than usual or confusion

48. Infection Control in the Home  Place ill person in a private room try to designate one bathroom for ill person  Have ill person wear a surgical mask  No visitors  One non-pregnant person should provide care  Caregiver should consider wearing mask  Caregiver should consider N95 if assisting with respiratory treatment  Hand hygiene and respiratory etiquette for household  Use paper towels to dry hands

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

50. What have we seen in ND?

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

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

53.  Outbreak Support Increase the number of facilities that can report outbreaks and receive free testing Increase the number of facilities that can report outbreaks and receive free testing Surveillance

54. Testing  Limited testing in all areas of North Dakota where novel H1N1 has not been demonstrated Testing will be stopped once ongoing transmission is likely (2-5 positive tests) Testing will be stopped once ongoing transmission is likely (2-5 positive tests) Current restriction on testing Current restriction on testing Ward, Cass and Burleigh CountiesWard, Cass and Burleigh Counties  All areas can continue to test for novel H1N1 in hospitalized patients in which H1N1 infection has not been ruled out

55. Rapid Testing - 1 Frequency Row Percent Column PercentH1N1 PositiveH1N1 NegativeTotal Rapid A Positive 21 53.85 80.77 18 46.15 25.35 58 Rapid A Negative 5 8.62 19.23 53 91.38 74.65 39 Total267197* Sensitivity = 80.77% Proportion of actual positives that were correctly identified. Specificity = 74.65% Proportion of actual negatives that were correctly identified.

56. Rapid Testing

57. Resources   NDDoH flu web-page (updated every Wednesday) http://www.ndflu.com/ http://www.ndflu.com/ http://www.ndflu.com/   CDC flu web-page http://www.cdc.gov/flu/ http://www.cdc.gov/flu/

58. Questions and Answers