1. The H1N1 Influenza Pandemic Kentucky Optometric Association September 8, 2009 Kraig E. Humbaugh, M.D., M.P.H. Kentucky Department for Public Health

2. Cabinet for Health and Family Services What is a Pandemic? Pandemic = Global Epidemic An epidemic (or outbreak) occurs when more than the usual number of expected cases occurs An influenza pandemic results when a new strain of influenza that the living human population is not immune to begins circulating human-to-human

3. Cabinet for Health and Family Services Why Do influenza Pandemics Occur? Influenza is a very changeable virus Minor genetic changes occur from season to season When major changes occur, a new pandemic strain can emerge

4. Cabinet for Health and Family Services How Humans Spread the Flu Droplet or contact spread Infectious period –Adults: 1 day prior to symptoms to about 5 days after onset –Young children and immunocompromised, much longer Incubation period –1 to 4 days Image Source: Human Biology, Starr and McMillan

5. Cabinet for Health and Family Services Children/Teenagers 29% Adults 59% Seniors 12% Demographics Glass, RJ, et al. Local mitigation strategies for pandemic influenza. NISAC, SAND Number: 2005-7955J School Household Workplace Likely sites of transmission Who Infects Whom? To ChildrenTo TeenagersTo AdultsTo SeniorsTotal From From Children 21.4 3.017.41.643.4 From Teenagers 2.410.4 8.50.721.9 From Adults 4.6 3.122.41.831.8 From Seniors 0.2 0.1 0.81.7 2.8 Total To 28.616.649.05.7

6. Cabinet for Health and Family Services Seasonal Influenza: A Yearly Threat About 200,000 hospitalized each year and about 36,000 die annually in US of influenza and its complications Seasonal influenza vaccine is expected to be readily available this year Almost anyone 6 months and older who wants protection from influenza infection or wants to prevent transmission can get a flu vaccination

7. Cabinet for Health and Family Services Novel H1N1: the New Pandemic Strain H1N1 influenza: first recognized in Mexico in April 2009 World Health Organization: pandemic phase 6 declared on June 11, 2009 Centers for Disease Control and Prevention (CDC) estimates over 1 million infections in the U.S., most unconfirmed. 8,000 hospitalizations and 500 deaths nationally. CDC has ceased counting individual cases

8. Cabinet for Health and Family Services Compare & Contrast: H1N1 vs. Seasonal Similar mechanism of spread Comparable severity of illness Attack rate for H1N1 likely higher, because more of the population is susceptible Incidence of H1N1 infection highest in children Incidence of H1N1 infection lowest in seniors More complications for illness in pregnant women and those with chronic diseases Similar public health strategies

9. Cabinet for Health and Family Services KYs H1N1 Snapshot: Sept. 2009 Almost all influenza this summer has been H1N1, per statewide surveillance and testing at KDPHs Division of Laboratory Services Outbreaks in schools, correctional facilities and other institutional residential settings Progression from containment to mitigation phase, due to sustained persistence of human-to-human transmission Transition from individual case reporting to reporting by statewide activity level

10. Cabinet for Health and Family Services KY: Regional Flu Activity in Summer!

11. Cabinet for Health and Family Services Worst Case Scenarios Attack rate of 20-40% (40% of the population ill, probably in waves weeks to months apart) Virulence of H1N1 virus increases, so that severity is greater than seasonal influenza H1N1 virus becomes resistant to antiviral medicines Kentucky Health Projections: –Deaths: 3000 – 7000 –Hospitalizations: 9,200 – 21,400 –Outpatient visits: 455,000 – 1.06 million Kentucky Economic Projections: –Infrastructure: Thousands at home either ill or caring for ill –Potential economic losses in the billions $$$

12. Cabinet for Health and Family Services Mortality rate by age: 1918 pandemic

13. Cabinet for Health and Family Services 1918 Pandemic 2 nd and 3 rd waves 13

14. Cabinet for Health and Family Services Pandemic Influenza Planning: Global Epidemic-Local Response Kentucky Emergency Management: Lead agency for all hazards State pandemic influenza plan since 2003, updated in April 2007 and July 2008, with input from multidisciplinary stakeholder group 50 community-based summits sponsored by local health departments held throughout the commonwealth in summer 2006 Each local health department planning; communities should prepare to be self- sufficient

15. Cabinet for Health and Family Services Public Health Strategies 3 Public Health strategies for successfully responding to an influenza pandemic: –Antiviral medicines –Vaccine –Behavioral interventions that decrease spread Individual health behaviors Community-based mitigation interventions, such as social distancing, and other activities

16. Cabinet for Health and Family Services Antivirals: Treatment for Flu Antiviral medicines do not cure the flu, but help to lessen flus severity and course To be effective, antivirals should be given ASAP after first symptoms develop Antivirals are available in limited supply, though supply is increasing H1N1 appears to be susceptible to oseltamivir (Tamiflu) and zanamivir (Relenza), so far Govt-purchased antivirals can be used if commercial supplies depleted

17. Cabinet for Health and Family Services Clinician Guidance Most patients will not need testing or treatment while H1N1 severity remains comparable to seasonal flu Consider treating with antivirals high-risk patients with flu-like symptoms and those asymptomatic high-risk household contacts of ill patients (young children, pregnant women, health care workers)

18. Cabinet for Health and Family Services Novel H1N1 Vaccine Expected to be available from the federal government through public health in the fall Public & private partnership needed for vaccine coverage Demand could exceed supply, necessitating the limitation of first shipments to target groups Delivery will be complicated by simultaneous administration of seasonal flu vaccine 2 doses likely required for immunity

19. Cabinet for Health and Family Services H1N1 Vaccine Target Groups Target Groups, when vaccine becomes available: –pregnant women –household contacts and caregivers of children <6 mos. –health care workers –persons 6 mos.-24 years –persons 25-64 yrs. w/ a chronic medical condition Priority Groups, if limited vaccine availability: –pregnant women –health care workers with direct patient contact –household contacts and caregivers of children <6 mos. –children 6 mos.- 4 years –children 5-18 yrs. w/ a chronic medical condition

20. Cabinet for Health and Family Services Vaccine Distribution Vaccine allotment to KY determined by population Determination of KYs jurisdictional allotment by state health department Determination of vaccine shipments to providers by local health departments Vaccine shipments through centralized federal system directly to providers Prioritization of providers serving target pop.s Ancillary vaccine supplies sent separately

21. Cabinet for Health and Family Services Provider Participation Enrollment through https://khelps.chfs.ky.gov/ Public and private providers are needed to vaccinate Providers will be requirement to sign a provider agreement with Public Health Providers will be able to charge for vaccine administration, but not for the vaccine itself

22. Cabinet for Health and Family Services H1N1 Vaccine Demand Unknown ??? Likely a function of: Perceived Safety of Vaccine versus Severity of Illness

23. Cabinet for Health and Family Services Behavioral Interventions Promoting barriers to spread, from individual level to community: Hand washing Personal Protective Equipment (masks, etc..) for health care workers Isolation and treatment of ill persons at home, when feasible Dismissal of students from school and employees from work: social distancing Targeted Layered Containment (TLC): The sum of various strategies is likely to be greater than the parts.

24. Cabinet for Health and Family Services How every Kentuckian can prepare... Wash hands frequently Cough / sneeze into tissue or elbows Avoid crowds during outbreaks If sick, stay home from work / school Develop an all hazards emergency preparedness family plan and kit Get a seasonal flu immunization each fall Advice for both seasonal and pandemic influenza

25. Cabinet for Health and Family Services Handwashing! The scientific evidence supports the conclusion that handwashing helps to decrease respiratory infections. Alcohol-based hand gels can be an effective alternative to handwashing, but only if the hands are not visibly soiled.

26. Cabinet for Health and Family Services Handwashing According to a 2007 study done by the American Society for Microbiology: Only about three-quarters of adults were observed to have washed their hands after using public restrooms, despite the fact that 9 of 10 adults claimed to always wash their hands Men washed their hands less often than women ( 66% vs. 88%)

27. Cabinet for Health and Family Services Community-Based Mitigation Interventions: Balancing Act Examples of activities that promote distancing: School dismissals Workplace closures Self-isolation strategies Unintended consequences: Economic and personal impact Disproportionate impact among vulnerable populations

28. Cabinet for Health and Family Services Basis for Community-Based Strategies Evidence from 1918 pandemic Epidemiologic studies Modeling Common sense Which interventions to use when? From least restrictive to more restrictive, based on severity of pandemic, since non- pharmaceutical interventions also have unintended consequences.

29. Cabinet for Health and Family Services Collins SD, Frost WH, Gover M, Sydenstricker E: Mortality from influenza and pneumonia in the 50 largest cities of the United States First Edition Washington: U.S. Government Printing Office 1930. 16

30. Cabinet for Health and Family Services Unintended Consequences of Community-Based Strategies Economic impact on families and individuals and potential disruption of services due to workplace closures or dismissal of students Issues with keeping children and teens from re-congregating in the community Disproportionate impact on certain populations

31. Cabinet for Health and Family Services 29.6 million 9.3 million 2.0 million School Meal Programs FY05 Source: http://www.fns.usda.gov/pd/cnpmain.htm

32. Cabinet for Health and Family Services No One to Care for You If Sick, by Income % saying they have no one to take care of them at home if they were sick for 7-10 days Poll results from representative national sample of 1,697 adults conducted in September-October, 2006 by Harvard School of Public Health Project on the Public and Biological Security

33. Cabinet for Health and Family Services Whitley Co. School Dismissal Investigation Joint effort between CDC, KDPH, and Whitley Co. HD in March 2008 What happens to community dynamics when schools close? Random telephone survey: 262 surveys completed Results: –Most parents agreed with decision to close schools –Most had arrangements for child care for children –More than 40% had children who visited malls, large department stores or family during the closure –Most understood importance of handwashing as a prevention strategy, but small percentage mentioned vaccination

34. Cabinet for Health and Family Services School and Child Care Guidance When severity is comparable to seasonal flu, schools can remain open in most instances. Exclusion period for ill students and staff is at least 24 hours after they have become fever- free (without the use of anti-fever medicines). Special environmental cleaning, beyond the routine, is not required. http://www.cdc.gov/h1n1flu/schools/schoolgu idance.htm

35. Cabinet for Health and Family Services Business Guidance Develop/ Refine Continuity of Operations Plans (COOP) to prepare for 40% absenteeism or closure of child care facilities Ensure work environment allows for hand washing and social distancing, if possible Discuss/disseminate plans and preparations for keeping workers healthy with employees Encourage/allow sick workers to stay home

36. Cabinet for Health and Family Services University H1N1 Guidance Request residential students who are ill to self-isolate until fever-free for 24 hours Encourage routine cleaning Discourage visits to campus from ill persons Remind health-care students and staff to follow appropriate infection control policies Continuity of operations planning (COOP) http://www.cdc.gov/h1n1flu/institutions/guidan ce/

37. Cabinet for Health and Family Services Challenges for Institutions Cant send residential students home Living and working in close quarters Many international faculty and students with different backgrounds and cultures

38. Cabinet for Health and Family Services If Severity Worsens… Consider: Activating COOP Liberalizing leave policies Extending exclusion periods Suspending events/ dismissing child cares, schools and workplaces

39. Cabinet for Health and Family Services Closing Thoughts Current status: –Transmission mechanisms and severity seem comparable to seasonal influenza –Higher incidence in children; more complications in pregnant women and in those with chronic diseases Situation rapidly evolving –maintain vigilance while waiting to see what clinical course the virus takes (not alarmed, but concerned) Prepare and respond appropriately now –Get a seasonal flu shot, practice good personal behaviors, remember 3 basic public health strategies –A pandemic affects all sectors of society, so all should share in the responsibility of addressing the challenge

40. Cabinet for Health and Family Services Good General Resources Your local health department http://www.healthalerts.ky.gov http://www.cdc.gov http://www.pandemicflu.gov/: planning checklists http://www.ready.gov/

41. Cabinet for Health and Family Services Kentucky Public Health Prevent. Promote. Protect.