11

WHEN PIGS FLU

JOHN C. PELLOSIE, JR., DO, MPH, FAOCOPMJOHN C. PELLOSIE, JR., DO, MPH, FAOCOPMINTERIM CHAIR DEPARTMENT PREVENTIVE MEDICINE INTERIM CHAIR DEPARTMENT PREVENTIVE MEDICINE NSU COLLEGE OF OSTEOPATHIC MEDICINENSU COLLEGE OF OSTEOPATHIC MEDICINECenter for Bioterrorism and All-Hazards PreparednessCenter for Bioterrorism and All-Hazards Preparedness

22

Continued Evolution of the Continued Evolution of the H1N1 Pandemic, and it’s virus: H1N1 Pandemic, and it’s virus:

A Basis for an Osteopathic A Basis for an Osteopathic Medical School ResponseMedical School Response

33

““WE WISH WE COULD PREDICT WE WISH WE COULD PREDICT EXACTLY WHAT IS GOING TO EXACTLY WHAT IS GOING TO

HAPPEN, BUT UNFORTUNATELY HAPPEN, BUT UNFORTUNATELY WE CANNOT.”WE CANNOT.”

Dr. Anne Schuchat, Director; National Center for Immunization and Dr. Anne Schuchat, Director; National Center for Immunization and Respiratory Diseases; CDC; 8 Sept 2009Respiratory Diseases; CDC; 8 Sept 2009

44

Distribution of H1N1 FluDistribution of H1N1 Flu

The H1N1 virus has caused infections in The H1N1 virus has caused infections in humans in 140 countries. Nowhere is it more humans in 140 countries. Nowhere is it more prevalent than in the U.S. prevalent than in the U.S.

The U.S. has more than 37,000 of the world's The U.S. has more than 37,000 of the world's 95,000 confirmed cases, 1,380 95,000 confirmed cases, 1,380 hospitalizations, and more than 196 hospitalizations, and more than 196 confirmed deaths (September 10, 2009, CDC).confirmed deaths (September 10, 2009, CDC).

55

IntroductionIntroduction

The number of confirmed cases represents The number of confirmed cases represents only a fraction of those infected.only a fraction of those infected.

Most people have only a mild illness and Most people have only a mild illness and don't require a doctor's care. don't require a doctor's care.

WHO estimates as many as a million people WHO estimates as many as a million people in the U. S. may be infected, but not all will in the U. S. may be infected, but not all will fall illfall ill..

66

We face an influenza challenge:We face an influenza challenge:Novel: Not circulated before, all population susceptible (especially Novel: Not circulated before, all population susceptible (especially young adult, infrastructure)young adult, infrastructure)

How severe; Increased morbidity and mortalityHow severe; Increased morbidity and mortality

How virulent or contagious and how spreadHow virulent or contagious and how spread

People and populations at increased riskPeople and populations at increased risk

Evolution: is it stable or undergoing rapid change in characteristics?Evolution: is it stable or undergoing rapid change in characteristics? Stability needed to create a vaccineStability needed to create a vaccine

Produce, test and distributeProduce, test and distributeA limited production and distribution requires risk assessment and possible A limited production and distribution requires risk assessment and possible prioritization of recipients and PODsprioritization of recipients and PODs

Antiviral medications and availabilityAntiviral medications and availability Effective or is virus resistantEffective or is virus resistant Use as treatment and/or prophylaxisUse as treatment and/or prophylaxis

How will it impact Health Systems (Surge) and Businesses (COOP)?How will it impact Health Systems (Surge) and Businesses (COOP)?

77

88

Until Vaccine is availableUntil Vaccine is available

Note: Vaccine is best form of preventionNote: Vaccine is best form of prevention

Delay onsetDelay onset Decrease numbers of people becoming infectedDecrease numbers of people becoming infected Delay onset of infection untilDelay onset of infection until

Vaccine availableVaccine availableDiscover if antivirals Discover if antivirals

Effective as treatment and/or prophylaxis Effective as treatment and/or prophylaxis Their availabilityTheir availability

HOW DO WE DELAY ONSET UNTILL WE GET HOW DO WE DELAY ONSET UNTILL WE GET VACCINE???VACCINE???

99

EASIEST WAY TO PREVENT MOST EASIEST WAY TO PREVENT MOST COMMUNICABLES?COMMUNICABLES?

FREQUENT AND PROPER HAND WASHING!FREQUENT AND PROPER HAND WASHING!

Keep potentially contaminated hands away Keep potentially contaminated hands away from face (self-inoculate via eyes, nose, from face (self-inoculate via eyes, nose, mouth).mouth).

1010

ILI ILI (coined at time of SARS)(coined at time of SARS)

Influenza Like Illness (Influenza Like Illness (ILI)ILI); nonspecific:; nonspecific: AnnuallyAnnually::

Adults average 1 to 3 ILIs per yearAdults average 1 to 3 ILIs per yearChildren can average 3 to 6 ILIs per yearChildren can average 3 to 6 ILIs per year

Symptoms includeSymptoms include Fever, fatigue, cough, sometimes GIFever, fatigue, cough, sometimes GI

Most ILI is Most ILI is notnot influenza influenza but caused by other viruses, such as: but caused by other viruses, such as:

Rhinoviruses and respiratory syncytial virus (RSV) adenoviruses, Rhinoviruses and respiratory syncytial virus (RSV) adenoviruses, and parainfluenza virusesand parainfluenza virusesBacteria such as Bacteria such as Legionella spp.Legionella spp., , Chlamydia pneumoniaeChlamydia pneumoniae, , Mycoplasma pneumoniaeMycoplasma pneumoniae, and , and Streptococcus pneumoniaeStreptococcus pneumoniae

1111

JUST LIKE HURRICANESJUST LIKE HURRICANES SEASONAL CHALLENGE WITH FLUSEASONAL CHALLENGE WITH FLU

Seasonal Influenza symptoms include:Seasonal Influenza symptoms include:

Fever >100FFever >100FHeadache Headache Fatigue Fatigue Cough Cough Sore throat Sore throat Runny nose Runny nose MyalgiasMyalgias[Stomach symptoms (nausea, vomiting, and diarrhea) can occur [Stomach symptoms (nausea, vomiting, and diarrhea) can occur but are more common in children than adults]but are more common in children than adults]

Complications of flu can include: Complications of flu can include: bacterial pneumonia, ear bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or medical conditions, such as congestive heart failure, asthma, or diabetes.diabetes.

1212

USA USA SEASONAL FLU ANNUAL STATISTICSSEASONAL FLU ANNUAL STATISTICS

5% - 20% of population get flu5% - 20% of population get flu

36,000 people die of flu-related causes36,000 people die of flu-related causes 250K TO 500K WORLDWIDE250K TO 500K WORLDWIDE

> 200,000 people hospitalized> 200,000 people hospitalized due to complications   due to complications  

Peak MonthPeak Month of Past 26 flu seasons of Past 26 flu seasons November for 1 seasonNovember for 1 season December for 4 seasonsDecember for 4 seasons January for 5 seasonsJanuary for 5 seasons February for 12 seasonsFebruary for 12 seasons March for 4 seasonsMarch for 4 seasons

1313

Types of Influenza VirusesTypes of Influenza Viruses Types A, B and CTypes A, B and C A and B cause Seasonal FluA and B cause Seasonal Flu Type C cause mild respiratory illness Type C cause mild respiratory illness

Not thought to cause epidemicsNot thought to cause epidemics

Type A InfluenzaType A Influenza; divided into subtypes based on ; divided into subtypes based on two proteins on the surface of the virustwo 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 Current subtypes of influenza A viruses found in people are A (H1N1) and A (H3N2).(H1N1) and A (H3N2).

Note: SNote: Seasonal flu vaccineeasonal flu vaccine contains:contains: Influenza A (H1N1), A (H3N2) and Influenza A (H1N1), A (H3N2) and Influenza B strainsInfluenza B strains

1414

Properties of Pandemic InfluenzaProperties of Pandemic Influenza

Novel: universal vulnerability to infectionNovel: universal vulnerability to infection While not all become infected during a pandemic, nearly all people While not all become infected during a pandemic, nearly all people

are susceptibleare susceptible

Large numbers of people fall ill about same timeLarge numbers of people fall ill about same time Pandemics, socially and economically disruptivePandemics, socially and economically disruptive

Many young adults become illMany young adults become ill Adversely impacting Community InfrastructuresAdversely impacting Community Infrastructures

Potential to overburden all servicesPotential to overburden all services Health System SurgeHealth System Surge

Actual ill with complications needing professional servicesActual ill with complications needing professional servicesActual Ill without complications requiring servicesActual Ill without complications requiring services““Worried Well”Worried Well”

CommunicabilityCommunicability 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 Severity of impact, increasing the number of people falling ill and

needing care within a short timeneeding care within a short time

1515

Type A, H1N1, “Swine Flu”Type A, H1N1, “Swine Flu”

11 June 2009; Pandemic declared; WHO 11 June 2009; Pandemic declared; WHO Pandemic Worldwide Alert raised to Phase-6Pandemic Worldwide Alert raised to Phase-6

Novel influenza originated from Swine Novel influenza originated from Swine

Spread similar to “Seasonal Flu”Spread similar to “Seasonal Flu” Infected respiratory dropletInfected respiratory droplet

Cough sneezeCough sneezeContaminated surfaceContaminated surface

First noted in Mexico then US in March / AprilFirst noted in Mexico then US in March / April 19 June all 50 states in US, DC, Puerto Rico, US Virgin 19 June all 50 states in US, DC, Puerto Rico, US Virgin

Islands reported cases Islands reported cases

1616

Influenza Pandemic Influenza Pandemic WHO declared Influenza Pandemic 11 June 2009 WHO declared Influenza Pandemic 11 June 2009

Novel, Type A, H1N1 “Swine Flu”Novel, Type A, H1N1 “Swine Flu”

Gone through the 1Gone through the 1stst “Wave” “Wave”

Expect 2nd waveExpect 2nd wave How bad will the 2How bad will the 2ndnd wave be (continued monitoring) wave be (continued monitoring) What are we doing What are we doing

When planning response activities and resources; When planning response activities and resources; “Plan for the worst and hope for the best.”“Plan for the worst and hope for the best.”

1717

Influenza Pandemics 20Influenza Pandemics 20thth Century Century

A(H1N1) A(H2N2) A(H3N2)1918: “Spanish Flu” 1957: “Asian Flu” 1968: “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

1818

Will past dictate what will occur?Will past dictate what will occur?

ModelModel response plans; reference to past experiences and response plans; reference to past experiences and the documentation of eventsthe documentation of events

TechnologyTechnology; ; then to nowthen to now Advantages:Advantages:

More advanced technology, diagnostics, pharmaceutics, vaccines…More advanced technology, diagnostics, pharmaceutics, vaccines… Some Challenges:Some Challenges:

Higher population densities common courtesy waning Higher population densities common courtesy waning World wide travel World wide travel More reliance (less individualism)More reliance (less individualism)More immune compromise More immune compromise

Older population, naturally occurringOlder population, naturally occurring Induced compromiseInduced compromise

Ca treatmentCa treatmentTransplantsTransplants

HIVHIV

Medically fragile and complexMedically fragile and complex

1919

Specifically, who is monitoring?Specifically, who is monitoring?

WHO;WHO; is monitoring, globally is monitoring, globally

Nationally: Nationally: CDCCDC

State: State: DOHDOH

We work collaboratively with We work collaboratively with DOH County Health DepartmentDOH County Health Department DOHDOH

We participate in We participate in DOH and DOE Advisory Committee on PandemicDOH and DOE Advisory Committee on Pandemic Deans Advisory Committee for Medical Schools in StateDeans Advisory Committee for Medical Schools in State

2020

Monitoring Through:Monitoring Through:1.1. ESSENCEESSENCE; (ED) Electronic Surveillance System for the ; (ED) Electronic Surveillance System for the

Early Notification of Community-based EpidemicsEarly Notification of Community-based Epidemics

2.2. Sentinel PhysiciansSentinel Physicians; report to DOH clinical flu activity; report to DOH clinical flu activity

3.3. State Bureau of LaboratoriesState Bureau of Laboratories

4.4. DOH DOH CHD Epidemiology reportsCHD Epidemiology reports of flu activities of flu activities

5.5. State Pneumonia and Influenza Mortality SurveillanceState Pneumonia and Influenza Mortality Surveillance SystemSystem

6.6. DOH DOH Merlin, Merlin, aa computer based epidemiology system on computer based epidemiology system on novel influenza on special at risk population groupsnovel influenza on special at risk population groups

2121

State Regional Domestic Security State Regional Domestic Security Task Force (RDSTF)Task Force (RDSTF)

RDSTF Regions (Multi County)RDSTF Regions (Multi County) Developed from of RDTTF ; 9.11 and Bio/ChemDeveloped from of RDTTF ; 9.11 and Bio/Chem Evolved to include all natural and man-made Evolved to include all natural and man-made

challengeschallenges

ESSENCE (ED Surveillance) for RDSTFESSENCE (ED Surveillance) for RDSTF All Regions show increases in Flu activity in last few All Regions show increases in Flu activity in last few

weeksweeks Some regions reporting higher levels than peak of Some regions reporting higher levels than peak of

normal Seasonal Flunormal Seasonal Flu Exceeds initial surge of “Worried Well”Exceeds initial surge of “Worried Well”

2222

Why Do We Monitor?Why Do We Monitor?((We know it’s out there!)We know it’s out there!)

At a point, no need nor value in testing At a point, no need nor value in testing allall ILI ILI to document H1N1to document H1N1 Once documented as occurring and prevalent in Once documented as occurring and prevalent in

the population; then clinical diagnosis acceptedthe population; then clinical diagnosis accepted

Selected sampling / testing allowsSelected sampling / testing allows Tracking of infection Tracking of infection Determining if virus has changed or altered its Determining if virus has changed or altered its

characteristicscharacteristics

2323

COMMUNICABLESCOMMUNICABLES

How and where people are infectedHow and where people are infected HomeHome Public PlacesPublic Places

Work (School)Work (School)PlayPlaySocial gatheringsSocial gatheringsTravelTravel

How can we prevent infectionHow can we prevent infection Non-Medical meansNon-Medical means Medical / Pharmaceuticals Medical / Pharmaceuticals

2424

A Layered ApproachA Layered Approach

Individual/Household/ Agency

Hand hygieneCough etiquetteInfection controlLiving space controlIsolation of illDesignated care providerFacemasks where indicated

Community,Colleges/UniversitiesIsolation of illTreatment of illProtective sequestration of childrenSocial distancing

- Community- Workplace

-Self IsolationLiberal leave policies

International

Containment-at-sourceSupport efforts toreduce transmissionTravel advisoriesLayered screening of

travelersHealth advisoriesLimited points of entry

2525

DROPLET PRECAUTIONSDROPLET PRECAUTIONS

Diseases spread by infected large particles / droplets Diseases spread by infected large particles / droplets during cough, sneeze, spittle, procedures:during cough, sneeze, spittle, procedures: InfluenzaInfluenza Hemophilus influenzae; meningitis, pneumonia (in infants), Hemophilus influenzae; meningitis, pneumonia (in infants),

epiglottitisepiglottitis Neisseria meningitis; meningitis, pneumonia, bacteremiaNeisseria meningitis; meningitis, pneumonia, bacteremia Mycoplasm pneumoniaMycoplasm pneumonia Group A streptococcal pneumonia, pharyngitis, scarlet feverGroup A streptococcal pneumonia, pharyngitis, scarlet fever AdenovirusAdenovirus RubellaRubella Parvovirus B19Parvovirus B19

2626

Transmission of novel influenza A (H1N1)Transmission of novel influenza A (H1N1)

Same as Seasonal Influenza virus and many URIsSame as Seasonal Influenza virus and many URIs

Person to person spread:Person to person spread: Large-particle respiratory droplet transmission when an infected Large-particle respiratory droplet transmission when an infected

person coughs or sneezes near a susceptible personperson coughs or sneezes near a susceptible person

Proximity as droplets do not remain suspended in the air and fall Proximity as droplets do not remain suspended in the air and fall generally only short distance; personal distancing the - “6 foot bubble”generally only short distance; personal distancing the - “6 foot bubble”

Contamination of surfaces is possible source of transmissionContamination of surfaces is possible source of transmission

Keep hands clean and away from face, food, smokes …Keep hands clean and away from face, food, smokes …

Keep pens and other objects away from face / mouth Keep pens and other objects away from face / mouth

Keep equipment clean (stethoscope…) Keep equipment clean (stethoscope…)

2727

Non-Medical PreventionNon-Medical Prevention

Personal hygiene and courtesyPersonal hygiene and courtesy ““Cough and Sneeze Etiquette”Cough and Sneeze Etiquette”

Away from others and coverAway from others and coverDispose of dirty tissues appropriatelyDispose of dirty tissues appropriatelyWash hands thoroughlyWash hands thoroughly

Social DistancingSocial DistancingIf ill stay away from othersIf ill stay away from others

Self isolate till not communicableSelf isolate till not communicable

Personal bubble (6 feet)Personal bubble (6 feet)

Teach and Teach and ModelModel for children and others for children and others

Use of mask for close contact such as caring for ill Use of mask for close contact such as caring for ill family membersfamily members

2828

Non-Medical PreventionNon-Medical Prevention

Active screening: Check staff & students in morning Active screening: Check staff & students in morning when they get to school when they get to school

Consider not requiring a physician’s note when out Consider not requiring a physician’s note when out or when cleared for duty especially if “Surge” or when cleared for duty especially if “Surge” conditions occur.conditions occur.

Students, staff and faculty with ill household Students, staff and faculty with ill household members should stay home for five days from the members should stay home for five days from the day the first household member got sick.day the first household member got sick.

Strongly discourage “Swine Flu Parties”Strongly discourage “Swine Flu Parties”

2929

Medical / Pharmaceutical PreventionMedical / Pharmaceutical Prevention

ImmunizationsImmunizations: keep them up-to-date: keep them up-to-date

Antiviral MedicationsAntiviral Medications use (availability and use (availability and resistance)resistance)

Vaccines against influenzaVaccines against influenza Seasonal Influenza (important to get it Seasonal Influenza (important to get it

annually)annually) Novel flu vaccine when availableNovel flu vaccine when available

3030

FLU VACCINESFLU VACCINES

Seasonal Flu Vaccine should be encouraged Seasonal Flu Vaccine should be encouraged Vaccine is currently availableVaccine is currently available Does notDoes not protect against H1N1 flu protect against H1N1 flu Will protect against a possible complication to Novel flu Will protect against a possible complication to Novel flu

infectioninfection

Pandemic Novel Type A H1N1 VaccinePandemic Novel Type A H1N1 Vaccine Anticipated in October 2009.Anticipated in October 2009. Likely to be a single doseLikely to be a single dose

Production and Availability will dictate risk groups Production and Availability will dictate risk groups

3131

H1N1 Vaccine Priority GroupsH1N1 Vaccine Priority GroupsPregnant WomenPregnant Women

Household contacts and care givers for infants Household contacts and care givers for infants <6 months of age<6 months of age

Healthcare workers and Emergency Medical Healthcare workers and Emergency Medical Services personnelServices personnel

Children and Young adults (6 months to 24 Children and Young adults (6 months to 24 years) – not approved for <6 monthsyears) – not approved for <6 months

People 25 to 64 years with underlying chronic People 25 to 64 years with underlying chronic medical conditionsmedical conditions

3232

Person with ILIPerson with ILI

Person should be: 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 trashTissues to be disposed of in the trash

Providing servicesProviding services Limit interaction and other potential staff exposuresLimit interaction and other potential staff exposures

Don’t go in and out of room repeatedly and limit the number of Don’t go in and out of room repeatedly and limit the number of different people who enter the roomdifferent people who enter the room

Distancing: maintain 6 foot separation as much as possibleDistancing: maintain 6 foot separation as much as possible Mask use if coughing and sneezing presentMask use if coughing and sneezing present Wear gloves and wash hands after useWear gloves and wash hands after use Clean equipment (stethoscope)Clean equipment (stethoscope) Sanitize potentially contaminated surfacesSanitize potentially contaminated surfaces Wash hands frequentlyWash hands frequently

3333

QUESTIONSQUESTIONS