September 21, 2009

H1N1 Influenza A:H1N1 Influenza A:Preparing Suffolk County’s Preparing Suffolk County’s

Schools and School DistrictsSchools and School Districts

Humayun J. Chaudhry, DO, MS, SM, Humayun J. Chaudhry, DO, MS, SM, FACOI, FACP, FAODMEFACOI, FACP, FAODME

Commissioner, Suffolk County Department of Health Commissioner, Suffolk County Department of Health Services, NYServices, NY

andandClinical Associate Professor of Preventive Medicine,Clinical Associate Professor of Preventive Medicine,

Stony Brook University School of Medicine, N.Y. Stony Brook University School of Medicine, N.Y.

September 21, 2009

OutlineOutline

Suffolk County Department of Health Suffolk County Department of Health ServicesServices

Definitions and a History of PandemicsDefinitions and a History of Pandemics H1N1 Influenza A VirusH1N1 Influenza A Virus Symptoms and Transmission PatternsSymptoms and Transmission Patterns Suffolk County, New York, World StatisticsSuffolk County, New York, World Statistics Suffolk County Public Health ResponseSuffolk County Public Health Response CDC Guidance for School Officials (K-12)CDC Guidance for School Officials (K-12) Q&AQ&A

September 21, 2009

September 21, 2009

Suffolk CountySuffolk County, Long Island, New , Long Island, New YorkYork

September 21, 2009

Suffolk County Department of Suffolk County Department of Health Services Senior Health Services Senior

LeadershipLeadership

September 21, 2009

Endemic, Epidemic, and Endemic, Epidemic, and PandemicPandemic Defined Defined

EndemicEndemic——A disease that A disease that already occurs at a high rate already occurs at a high rate in a given populationin a given population EpidemicEpidemic——An outbreak of An outbreak of new cases of a disease in new cases of a disease in numbers that exceed what numbers that exceed what is expectedis expectedPandemicPandemic——An epidemic An epidemic that spreads worldwidethat spreads worldwide

Malarious Areawww.cbsnews.com

September 21, 2009

Pandemics Throughout Pandemics Throughout HistoryHistory

Plague of JustinianPlague of Justinian— — 541 A.D.541 A.D.

The The Black DeathBlack Death— — 1347-1347-1350 A.D.1350 A.D.

Typhus or Typhus or camp fevercamp fever— — 1515thth and16and16thth centuries centuries

SmallpoxSmallpox— — 1616thth to to 1818thth centuries centuries

““Spanish” FluSpanish” Flu— 1918— 1918 The Roof Rat

www.algonet.se

September 21, 2009

How Influenza Viruses ChangeHow Influenza Viruses Change Antigenic Drift:Antigenic Drift:

Small Small changes in viruses over timechanges in viruses over time New strains appearNew strains appear May not be recognized by antibodies May not be recognized by antibodies

Antigenic Shift:Antigenic Shift: Abrupt,Abrupt, majormajor change (reassortment) change (reassortment) Results in novel strain or Results in novel strain or newnew subtype subtype Can cause pandemic influenzaCan cause pandemic influenza

September 21, 2009

Seasonal Influenza, 2009Seasonal Influenza, 2009 Annual seasonal influenza Annual seasonal influenza epidemics epidemics

>>36,00036,000 deaths in US from seasonal influenza deaths in US from seasonal influenza ((~~100-200 deaths in Suffolk County each year100-200 deaths in Suffolk County each year))

>>200,000200,000 hospitalizations from flu each year hospitalizations from flu each year Over 85% mortality in persons Over 85% mortality in persons ≥ ≥ 65 yrs65 yrs Severe disease in infants, young children, Severe disease in infants, young children,

and elderly individualsand elderly individuals Attack rate of Attack rate of 5-15% 5-15% (Nursing home attack (Nursing home attack

rate of rate of 60%60%)) Potential for Potential for pandemicpandemic

September 21, 2009

Novel H1N1 Influenza A Novel H1N1 Influenza A VirusVirus

September 21, 2009

H1N1 Influenza A (Swine Flu), H1N1 Influenza A (Swine Flu), 20092009

WHO Phase 6 Pandemic (declared June 11, 2009)WHO Phase 6 Pandemic (declared June 11, 2009) >>1 million cases1 million cases in the U.S. in the U.S. >>40,617 40,617 confirmedconfirmed cases cases in U.S. in U.S. >>263 confirmed deaths 263 confirmed deaths inin U.S.U.S. >>180 confirmed cases180 confirmed cases in Suffolk County (6 deaths) in Suffolk County (6 deaths)

Imminent Public Threat declared by NYSDOH August Imminent Public Threat declared by NYSDOH August 6, 20096, 2009

A brand new virusA brand new virus A “quadruple reassortment of 2 swine strains, 1 A “quadruple reassortment of 2 swine strains, 1

human strain, and 1 avian strain of influenza virus”human strain, and 1 avian strain of influenza virus” Mean age of cases in Suffolk County and in U.S.: 12 Mean age of cases in Suffolk County and in U.S.: 12 Severe infection occurs in individuals who are Severe infection occurs in individuals who are not at not at

the extremes of agethe extremes of age Attack rate of Attack rate of 22-30% 22-30% initially initially

September 21, 2009

Novel H1N1 Influenza A Novel H1N1 Influenza A SymptomsSymptoms

(Fever(Fever, , coughcough, and/or , and/or sore throat)sore throat), , malaise, and headachemalaise, and headache

Vomiting and diarrhea (unusual for Vomiting and diarrhea (unusual for seasonal influenza)seasonal influenza)

Chills, myalgias, and arthralgiasChills, myalgias, and arthralgias Infants: fever, lethargy, +/- coughInfants: fever, lethargy, +/- cough Elderly individuals and Elderly individuals and

immunocompromised hosts may also immunocompromised hosts may also have atypical presentations have atypical presentations

September 21, 2009

Risk Factors for Novel H1N1 Risk Factors for Novel H1N1 Influenza A Virus ComplicationsInfluenza A Virus Complications

Chronic lung disease (especially asthma, Chronic lung disease (especially asthma, COPD)COPD)

Immunocompromised states (including Immunocompromised states (including pregnancy, kidney disease, cancer)pregnancy, kidney disease, cancer)

Heart disease (other than HTN)Heart disease (other than HTN) Diabetes MellitusDiabetes Mellitus Obesity?Obesity? **Most Common Reasons for Most Common Reasons for

Hospitalization: Hospitalization: PneumoniaPneumonia and and DehydrationDehydration

September 21, 2009

Management of Novel H1N1 Management of Novel H1N1 Influenza A InfectionInfluenza A Infection

This virus is sensitive to Tamiflu and Relenza, This virus is sensitive to Tamiflu and Relenza, two antiviral medications (only available by two antiviral medications (only available by prescription)prescription)

It is resistant to other antiviral medicationsIt is resistant to other antiviral medications TreatmentTreatment is recommended for is recommended for

All hospitalized patients with confirmed, probable All hospitalized patients with confirmed, probable or suspected cases or suspected cases

Patients who are at higher risk for seasonal Patients who are at higher risk for seasonal influenza complications influenza complications

Tamiflu and Relenza are Tamiflu and Relenza are not like antibioticsnot like antibiotics and are most effective when used and are most effective when used within 24-within 24-48 hours48 hours of an influenza illness of an influenza illness

September 21, 2009

Testing for H1N1 in Fall, Testing for H1N1 in Fall, 20092009

NotNot a priority of the CDC, NYSDOH, or a priority of the CDC, NYSDOH, or the Suffolk County Department of the Suffolk County Department of Health Services except Health Services except Pediatric hospitalizations for “influenza-Pediatric hospitalizations for “influenza-

like illness”like illness” Any deaths attributed to, or linked with, Any deaths attributed to, or linked with,

a diagnosis of pneumonia or other a diagnosis of pneumonia or other respiratory infectionrespiratory infection

As determined by a health care provider As determined by a health care provider in consultation with the NYSDOH in consultation with the NYSDOH

September 21, 2009

Transmission of H1N1Transmission of H1N1

Primarily by respiratory dropletsPrimarily by respiratory droplets ((sneezing and coughingsneezing and coughing))

Incubation Period:Incubation Period: 1-4 days 1-4 days Viral shedding (contagiousness)Viral shedding (contagiousness)

Begins 1 day Begins 1 day beforebefore symptoms symptoms Peak shedding is during first 3 days Peak shedding is during first 3 days

of illness of illness with feverwith fever Lasts 7 days in adults or 10+ days in Lasts 7 days in adults or 10+ days in

childrenchildren

September 21, 2009

Flu Pandemics: A ComparisonFlu Pandemics: A Comparison

YEARYEAR 19181918 20092009World PopulationWorld Population 1.8 Billion 1.8 Billion 6.8 Billion6.8 Billion

Primary Mode ofPrimary Mode of Ships, Ships, Jet Aircraft, Jet Aircraft,TransportationTransportation RailroadRailroad AutomobileAutomobile

Time for Virus toTime for Virus to 4 months 4 months 4 days4 daysCircle the GlobeCircle the Globe

Estimated DeadEstimated Dead 20+ Million20+ Million ? ?WorldwideWorldwide

September 21, 2009

Influenza Viral MorphologyInfluenza Viral Morphology

Influenza Type A, B, CInfluenza Type A, B, C - based on - based on antigenic properties of nucleoproteins antigenic properties of nucleoproteins (NP) and matrix (M) proteins(NP) and matrix (M) proteins

HemagglutininHemagglutinin – protein that helps – protein that helps the virus attach to a healthy cell (15 the virus attach to a healthy cell (15 types)types)

NeuraminidaseNeuraminidase – protein that helps – protein that helps release viruses into the body (9 types)release viruses into the body (9 types)

September 21, 2009 Source: MMWR, September 26, 2008

How Are We Doing With Seasonal How Are We Doing With Seasonal Influenza Vaccination Rates in the Influenza Vaccination Rates in the

U.S.?U.S.? Healthy People 2010Healthy People 2010 influenza influenza

vaccination targets arevaccination targets are 90% among persons aged 90% among persons aged ≥65 years≥65 years 60% among persons aged 18-64 years60% among persons aged 18-64 years

CDC Data from the CDC Data from the 2006-07 Influenza 2006-07 Influenza SeasonSeason indicate vaccination rates of indicate vaccination rates of 72.1% among persons aged ≥65 years72.1% among persons aged ≥65 years 35.1% among persons aged 18-4935.1% among persons aged 18-49 42.0% among persons aged 50-6442.0% among persons aged 50-64

September 21, 2009

H1N1 in the Fall, 2009H1N1 in the Fall, 2009

Washington has had the nation’s Washington has had the nation’s highest rate of H1N1 during the peak highest rate of H1N1 during the peak period in the state (2,500 suspected period in the state (2,500 suspected cases)cases) 366.8 cases of the flu for every 10,000 366.8 cases of the flu for every 10,000

studentsstudents New York State has hadNew York State has had

6.5 cases of the flu for every 10,000 6.5 cases of the flu for every 10,000 studentsstudents

September 21, 2009

Cornell University “ILI” Cornell University “ILI” OutbreakOutbreak

A student at Cornell A student at Cornell University dispensing University dispensing soap to students on soap to students on Sept. 18Sept. 18

Cornell University in Cornell University in Ithaca, New York, on Ithaca, New York, on Sept. 18 reported more Sept. 18 reported more than than 700 cases700 cases of “ILI” of “ILI” since classes begansince classes began

A 20 year-old student A 20 year-old student at Cornell with an at Cornell with an underlying medical underlying medical condition died of condition died of complications from the complications from the H1N1 virus two weeks H1N1 virus two weeks agoago

3 adjoining college 3 adjoining college campuses have had a campuses have had a total of 100 casestotal of 100 cases

September 21, 2009

Legal AuthorityLegal Authority

Pursuant to the New York Public Health Law, Pursuant to the New York Public Health Law, the Suffolk County Commissioner of Healththe Suffolk County Commissioner of HealthServices has the legal authority to order theServices has the legal authority to order theisolation and/or quarantine of any person orisolation and/or quarantine of any person orthing “infected with or exposed to” athing “infected with or exposed to” acommunicable disease.communicable disease.

New York Public Health Law § 2100 (1);New York Public Health Law § 2100 (1); 10 N.Y.C.R.R. §§ 2.1, 2.25 & 2.29.10 N.Y.C.R.R. §§ 2.1, 2.25 & 2.29.

September 21, 2009

September 21, 2009

Personal Hygiene is Best Personal Hygiene is Best ToolTool

Handwashing with soap Handwashing with soap and water is and water is criticalcritical Virus can spread by Virus can spread by

contamination of hands contamination of hands that is then followed by that is then followed by hand contact with hand contact with mucous membranesmucous membranes

Alternatives to soap and Alternatives to soap and water existwater exist Alcohol-based hand Alcohol-based hand

gelsgels

September 21, 2009

Masks May Also Play a RoleMasks May Also Play a Role Use of masks Use of masks maymay

decrease the spread decrease the spread of virus between of virus between peoplepeople

Widespread use Widespread use during SARS during SARS outbreakoutbreak

May prevent children May prevent children from putting from putting hands/objects into hands/objects into their mouthstheir mouths

September 21, 2009

This Might Help…This Might Help…

Chicken SoupChicken Soup Orange JuiceOrange Juice Vitamin CVitamin C MultivitaminsMultivitamins

September 21, 2009

Kobe, JapanKobe, JapanMay 19, 2009May 19, 2009

September 21, 2009

Daily Swine Flu Exam: China, May, Daily Swine Flu Exam: China, May, 20092009

September 21, 2009

School Closure, Deer Park School School Closure, Deer Park School District, Suffolk County, N.Y., May, District, Suffolk County, N.Y., May,

20092009

September 21, 2009

PurposePurpose Provide guidance on suggested means Provide guidance on suggested means for for reducing exposure of students and reducing exposure of students and staffstaff to H1N1 and seasonal influenza to H1N1 and seasonal influenza during the 2009-2010 school yearduring the 2009-2010 school year

GoalsGoals Decrease spread of fluDecrease spread of flu among among students and staffstudents and staff

Minimize disruptionMinimize disruption of day-to-day of day-to-day social, educational, and economic social, educational, and economic activitiesactivities

CDC Guidance for K-12 School CDC Guidance for K-12 School ResponseResponse

September 21, 2009

Stay home when sickStay home when sick Separate ill students and staffSeparate ill students and staff Teach hand hygiene and respiratory Teach hand hygiene and respiratory

etiquette!etiquette! Early identification and treatment of Early identification and treatment of

high-risk students and staff high-risk students and staff Routine cleaningRoutine cleaning Consideration of selective school Consideration of selective school

dismissaldismissal

Recommended School Recommended School Responses Responses (If (If similar severitysimilar severity as as

in Spring 2009)in Spring 2009)

September 21, 2009

““Active” screeningActive” screening High-risk students and staff High-risk students and staff stay homestay home Students with ill household members Students with ill household members stay stay

home for 5 dayshome for 5 days Increase distance between people at Increase distance between people at

schoolsschools Extend the period for ill persons to stay Extend the period for ill persons to stay

homehome Selective, reactive, and pre-emptive Selective, reactive, and pre-emptive

school dismissalsschool dismissals

Recommended School Responses Recommended School Responses (If (If increased severityincreased severity))

September 21, 2009

Ask about fever and other symptomsAsk about fever and other symptoms Send home people with symptoms of Send home people with symptoms of

acute respiratory infectionacute respiratory infection Be vigilant throughout the dayBe vigilant throughout the day Send students and staff who appear Send students and staff who appear

ill for further screening by school-ill for further screening by school-based health care workerbased health care worker

If possible, have ill person wear a If possible, have ill person wear a mask until sent homemask until sent home

““Active” Screening for Active” Screening for IllnessIllness

September 21, 2009

Explore innovative methodsExplore innovative methods Rotate teachers rather than students Rotate teachers rather than students Cancel classes that bring students together Cancel classes that bring students together

from multiple classroomsfrom multiple classrooms Outdoor classesOutdoor classes Move desks farther apartMove desks farther apart Move classes to larger spacesMove classes to larger spaces Discourage use of school buses and public Discourage use of school buses and public

transittransit Postpone some class tripsPostpone some class trips

IfIf severity increases: severity increases: Increase Distance between Increase Distance between

PeoplePeople

September 21, 2009

Suffolk County’s H1N1 Plan for Suffolk County’s H1N1 Plan for FallFall

1) 1) Two possible scenariosTwo possible scenarios Moderately severe illnessModerately severe illness

Slightly more cases than in Spring, 2009Slightly more cases than in Spring, 2009 Increased severity of illnessIncreased severity of illness

No indication from CDC or WHO that this is No indication from CDC or WHO that this is happening, or will happen, but we will be happening, or will happen, but we will be preparedprepared

2) 2) “Stay Home if You Are Ill”“Stay Home if You Are Ill” Influenza-like Illness (ILI):Influenza-like Illness (ILI): Fever, Cough Fever, Cough

Suffolk County’s definition of fever: >100Suffolk County’s definition of fever: >100ºF ºF or feeling warm/hot plus chills/sweatsor feeling warm/hot plus chills/sweats

September 21, 2009

Suffolk County’s H1N1 Plan for Suffolk County’s H1N1 Plan for FallFall

3) H1N1 vaccination and seasonal 3) H1N1 vaccination and seasonal influenza vaccination will be urged for influenza vaccination will be urged for target populationstarget populations Hospitals, Private Physician Practices, PharmaciesHospitals, Private Physician Practices, Pharmacies 10 SCDHS Health Centers and >50 Vaccination 10 SCDHS Health Centers and >50 Vaccination

Clinic PODs (Points of Dispensing) throughout Clinic PODs (Points of Dispensing) throughout CountyCounty

Schools, if they wish to have vaccination clinicsSchools, if they wish to have vaccination clinics Mandatory in NYS for all physicians and staff at Mandatory in NYS for all physicians and staff at

hospitals, Article 28 facilities, Home Health Care, hospitals, Article 28 facilities, Home Health Care, Hospice (NYSDOH Emergency Regulation)Hospice (NYSDOH Emergency Regulation)

4) Upon request, SCDHS will provide4) Upon request, SCDHS will provide guidance and education to public and private guidance and education to public and private school nurses and physiciansschool nurses and physicians about H1N1 about H1N1 vaccination procedures, techniques and vaccination procedures, techniques and precautionsprecautions

September 21, 2009

Suffolk County’s H1N1 Plan for Suffolk County’s H1N1 Plan for FallFall

5) SCDHS will provide, upon 5) SCDHS will provide, upon request, educational and other request, educational and other curricular material about H1N1curricular material about H1N1 and and preventive hygienepreventive hygiene to public and to public and private schoolsprivate schools

6) Regular schedule of meetings 6) Regular schedule of meetings and communicationsand communications between between SCDHS and the SCSSA, Eastern Suffolk SCDHS and the SCSSA, Eastern Suffolk BOCES and Western Suffolk BOCESBOCES and Western Suffolk BOCES

September 21, 2009

Suffolk County’s H1N1 Plan for Suffolk County’s H1N1 Plan for FallFall

7) Communication to the public7) Communication to the public Posters Posters on buses, PSAs (radio, TV, print on buses, PSAs (radio, TV, print

media),media), press releases, weekly press releases, weekly electronic updates, SCDHS website electronic updates, SCDHS website announcements, press conferencesannouncements, press conferences

SCDHS H1N1 Telephone HotlineSCDHS H1N1 Telephone Hotline, starting , starting September 9September 9

8) 8) If increased severity of illnessIf increased severity of illness, , selective or pre-emptive school selective or pre-emptive school closures closures maymay be considered as a last be considered as a last resort,resort, especially if school operations especially if school operations disrupteddisrupted

September 21, 2009

Suffolk County’s H1N1 Plan for Suffolk County’s H1N1 Plan for FallFall

9) 9) If increased severity of diseaseIf increased severity of disease, , communications will be enhanced and communications will be enhanced and more frequentmore frequent SCDHS H1N1 Hotline Hours ExtendedSCDHS H1N1 Hotline Hours Extended Enhanced surveillance of severity of diseaseEnhanced surveillance of severity of disease Daily electronic updatesDaily electronic updates

10) First Responders (EMS, Police)10) First Responders (EMS, Police) may may be asked to wear be asked to wear N-95 masks N-95 masks this Fall. All this Fall. All other health care personnel may be asked other health care personnel may be asked to wear N-95 masks or disposable masksto wear N-95 masks or disposable masks

September 21, 2009

Points of Distribution (POD)Points of Distribution (POD)

September 21, 2009

Why do we think vaccines work?Why do we think vaccines work?

Viral DiseaseYear of Peak

U.S. Prevalence

Peak Number of Cases per Year

in U.S.

Number of Annual U.S. Cases in

Modern Vaccine Era (2007)

Hepatitis AHepatitis A 19711971 59,60659,606 35793579

Hepatitis BHepatitis B 19851985 26,65426,654 47134713

MeaslesMeasles 1958-19621958-1962 503,282503,282 715715

MumpsMumps 19671967 185,691185,691 3030

PolioPolio 1951-19541951-1954 16,31616,316 00

RubellaRubella 1966-19681966-1968 47,74547,745 1111

Congenital Congenital RubellaRubella 1966-19681966-1968 823823 00

SmallpoxSmallpox 1900-19041900-1904 48,16448,164 00

September 21, 2009

Preemptive dismissalsPreemptive dismissals CDC will consider need to recommend based on CDC will consider need to recommend based on

global and national risk assessmentsglobal and national risk assessments Goal: decrease spread of influenza virus and Goal: decrease spread of influenza virus and

reduce demand on health care systemreduce demand on health care system Use early and in conjunction with other Use early and in conjunction with other

strategiesstrategies Time to vaccine-induced immunity may be Time to vaccine-induced immunity may be

considered considered If dismissing, do so for 5 to 7 days and reassessIf dismissing, do so for 5 to 7 days and reassess Allow staff to continue to use facilitiesAllow staff to continue to use facilities Plan for prolonged dismissals and secondary Plan for prolonged dismissals and secondary

effectseffects

IfIf severity increases: severity increases: School DismissalsSchool Dismissals

September 21, 2009

ReviewReview

Suffolk County Department of Health Suffolk County Department of Health ServicesServices

Definitions and a History of PandemicsDefinitions and a History of Pandemics Novel H1N1 Influenza A VirusNovel H1N1 Influenza A Virus Symptoms and Transmission PatternsSymptoms and Transmission Patterns Suffolk County, New York, World StatisticsSuffolk County, New York, World Statistics Suffolk County Public Health ResponseSuffolk County Public Health Response CDC Guidance for School Officials (K-12)CDC Guidance for School Officials (K-12) Q&AQ&A

September 21, 2009

How Bad will the How Bad will the Novel H1N1 Novel H1N1 Influenza A VirusInfluenza A Virus be in the be in the

Fall/Winter of 2009?Fall/Winter of 2009?

September 21, 2009

September 21, 2009

Thank You!Thank You!

Humayun.chaudhry@suffolkcountynyHumayun.chaudhry@suffolkcountyny.go.govv