1. Texas Pediatric Society Texas Department of State Health Services October 6, Novel H1N1 in Texas
Update for Providers
Susan Penfield, MD
David Scott
Monica Gamez
Infectious Disease Prevention Section DSHS

2. Novel H1N1 Update
Epidemiology update
Vaccine update
Questions

3. Texas Confronts Novel Influenza
April 17: - The CDC lab confirmed the first novel H1N1 result from California 
April 23: - DSHS received laboratory confirmation of H1N1 virus in 2 teenagers from the same school in Guadalupe County
April 29: - Confirmation of 1st death in Texas/United States
June 11: W.H.O. declares pandemic
August 24: - School started

4. ILINet: Influenza Like Illness Surveillance in Texas

6. From CDC Fluview Outpatient Illness Surveillance:
Nationwide during week 38, 4.2% of patient visits reported through the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) were due to influenza-like illness (ILI). This percentage is above the national baseline of 2.4%.
From CDC Fluview

7. Enrolled Texas ILINet Providers as of 10/05/09 (n=196)

8. ILINet Providers Reporting Data for Week 38 (9/20/09-9/26/09) as of 10/05/09 (n=39)

9. National Data From CDC Fluview
                                                                                                                                                                                    
Data through 9/26/09
From CDC Fluview

10. National Data
                                                                                                                                                                                     .
Data through 9/26/09
From CDC Fluview

11. Enterococcus.
                                                                                                                                                                                     View Full Screen
From CDC Fluview

12. Age Distribution for Certain Novel Influenza A (H1N1) Cases Compared to Texas Population
Reported Texas hospitalized cases and deaths
There have been 270 hospitalizations as of 7/31/2009, 35 deaths as of 9/1/09, of the deaths 4 among the pediatric population
Majority of hospitalized patients infected with novel H1N1 virus were between 5 years and 49 years of age.
Over one quarter were under the age of four.
* Hospitalizations reported for 9/20-9/26/09
** Confirmed deaths from April to 9/26/09 12

13. Novel Influenza A (H1N1) Deaths in Texas
Confirmed Novel H1N1 deaths
from end of April to 09/26/09
Patient Age
Number of deaths
< 6 months of age 1
6 – 11 months of age
1 – 4 yrs of age 2*
5 – 9 yrs 2
10 – 18 yrs 6
19 – 24 yrs 3
25 – 49 yrs 24
50 – 64 yrs 10
65 + yrs 4
TOTALS 52
* Includes Mexico City resident

14. 52 confirmed novel influenza A (H1N1) deaths – pediatric and adult
Confirmed Novel Influenza A (H1N1) Deaths Underlying conditions, Obesity, Co-infections as of 9/26/09
52 confirmed novel influenza A (H1N1) deaths – pediatric and adult
37 (71%) had at least one underlying condition (including pregnancy)
8 (15%) did not have an underlying condition
7 (14%) unknown if underlying condition (including pregnancy)
Among the 11 confirmed novel influenza A (H1N1) pediatric deaths (age <18):
8 (73%) had at least one underlying condition
3 (27%) did not have an underlying condition

15. Who Should Get Tested?
Do not delay treatment while waiting for testing
Most patients with clinical illness consistent with uncomplicated influenza do not require influenza testing for clinical management.
A negative rapid flu test does not mean the person does not have flu
Patients who should be considered for influenza diagnostic testing include:
Seriously ill hospitalized patients with suspected influenza
Patients for whom a diagnosis of influenza will inform decisions regarding clinical care, infection control, or management of close contacts.
Patients who died of an acute illness in which influenza was suspected.
When a decision is made to use antiviral treatment for influenza, treatment should be initiated as soon as possible without waiting for influenza test results. Antiviral treatment is most effective when administered as early as possible in the course of illness. (
“Negative H1N1 test” should not be a requirement for school or work re-entry 15

16. Laboratory Testing
For PCR testing for novel H1N1, use reference laboratories first
DSHS and Laboratory Response Network laboratories are for surveillance purposes and can do limited diagnostic testing.
Accept: new guidance

17. Novel H1N1 Vaccine
Vaccine for novel H1N1 is going to be available more slowly than originally anticipated
Texas will receive 142,000 doses initially
In the future, weekly allocations to states are expected to be larger
Had expected 237,000

18. Vaccine
DSHS is distributing vaccine according to the recommendations of the CDC’s Advisory Committee on Immunization Practices (ACIP), however there is insufficient supply at this time to vaccinate all members of the priority groups.
The type (formulation - preservative free, live virus, etc.), packaging (single dose, multi-dose, etc.) of available vaccine, and shipping capacity will also limit the number of providers receiving initial supplies of vaccine.
As more vaccine becomes available, DSHS expects shipments to be made in weekly intervals.

19. Vaccine Novel H1N1 vaccine is free
DSHS will be coordinating the distribution of the H1N1 vaccine
CDC notifies DSHS when an allocation of vaccine is available to Texas
The first order for Texas was submitted late last week

20. Vaccine
Over 11,000 providers in Texas have pre-registered to obtain novel H1N1 vaccine
Over 8,000 have completed the registration process
If you have not done either, go to to become a novel H1N1 vaccine provider

21. Vaccine Register for each site at which you want to receive vaccine
Estimate the numbers and age groups and numbers, including healthcare workers; that you plan to vaccinate. This is just an estimate to help with planning
You will also be asked about available vaccine storage capacity

22. Vaccine
Information for providers on registering, ordering, and providing novel H1N1 vaccine is on at
This includes training on
Vaccine Ordering and Reporting System (VORS) for ordering vaccine and making weekly reports on vaccine used, by age group
ImmTrac for reporting individual immunization information
The Vaccine Adverse Events Reporting System (VAERS)
Provider toolkit

23. » Vaccine Ordering and Reporting
Novel H1N1 Vaccine Ordering and Reporting System (VORS)
Novel H1N1 Vaccine Ordering and Reporting System (VORS) Training – A computer based training on how to use the web-based system to order the H1N1 vaccine.
» Provider Tool Kit
A list of materials for the novel H1N1 influenza vaccine provider
Novel H1N1 Influenza Vaccine Information Statements (VIS)
» Registration
All health care providers in Texas who would like to vaccinate against this disease are encouraged to do so. Those visiting for the first time are asked to complete both the pre-registration and final registration forms. Those who have already pre-registered may proceed directly to final registration.
Pre-registration
Final Registration
Novel H1N1 Vaccine Registration and Ordering Instructions (9/01/09) (pdf, 40 kb)
» ImmTrac Training
ImmTrac Reporting Processes for 2009 H1N1 Vaccine Trainng (9/28/09) (ppt, 1.34 mb) – A PowerPoint based training on how to report H1N1 number of  doses administered to ImmTrac, the Texas Immunization Registry
Last Updated October 2, 2009

24. Vaccine Order Process
Registered providers will receive s asking them to confirm their orders
There may be a ceiling on the order; providers can confirm a smaller amount
For the initial vaccine available to Texas, the s to providers are prioritized to those with larger volumes of pediatric patients
Each week providers will receive s asking them to confirm their orders. The number will be based on the amount of vaccine made available to Texas that week.

25. Vaccine
DSHS staff will review the confirmed orders and submit an order for vaccine for those providers
It will usually take from 5 to 10 days from when the order is placed for the provider to receive the vaccine
Supplies are shipped at the same time but in different packages

26. Vaccine
Vaccine Information Statements are now available online in English and soon will be available in Spanish at TexasFlu.org
Initial supplies of the VIS forms will be sent to registered providers
They can be downloaded in pdf form
Beginning October 19, can order additional forms
All providers who have completed their registration to receive H1N1 vaccine will receive an initial supply of copies. This initial supply will be sent separately from shipments of vaccine or other supplies.
Additional copies may be ordered beginning Monday, October 19 through the Immunization Branch web-based ordering system at For more information on how to order novel H1N1 influenza vaccine information statements please call

27. Vaccine
The bulk of the 142,400 doses for Texas will be sent to some pre-registered doctors, clinics and other providers to vaccinate healthy 2- and 3-year-olds, part of a priority group to receive the vaccine. 
It may also be feasible to vaccinate the healthcare workers who care for them
All of the doses are the FluMist brand nasal spray form of the vaccine. 
FluMist is only approved for use in vaccinating people 2 years through 49 years of age who are not pregnant and do not have certain chronic health conditions.

28. Vaccine Safety Modern vaccine development:
Improved process for manufacturing vaccines
FDA must approve after testing on animals and humans
Method for developing H1N1 vaccine is the same as that used for seasonal flu
This method is both proven and safe
Made with much of the same ingredients for seasonal flu vaccines
Clinical trials for effectiveness and safety are still underway
Ongoing monitoring after release 28

29. Vaccine Administration Intervals
Inactivated vaccine – seasonal and novel H1N1 – any interval or simultaneously
Seasonal and H1N1 at same time– can give 2 inactivated or one inactivated and one intranasal LAIV; can also give at any interval between
Interval between live (LAIV) vaccinations of any type should be 28 days but could be at least 21 days