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H1N1 Influenza A: Preparing Suffolk County’s Schools and School Districts. Humayun J. Chaudhry, DO, MS, SM, FACOI, FACP, FAODME Commissioner, Suffolk County Department of Health Services, NY and Clinical Associate Professor of Preventive Medicine,

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H1N1 Influenza A:Preparing Suffolk County’s Schools and School Districts

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

Commissioner, Suffolk County Department of Health Services, NY

and

Clinical Associate Professor of Preventive Medicine,

Stony Brook University School of Medicine, N.Y.


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Outline

  • Suffolk County Department of Health Services

  • Definitions and a History of Pandemics

  • H1N1 Influenza A Virus

  • Symptoms and Transmission Patterns

  • Suffolk County, New York, World Statistics

  • Suffolk County Public Health Response

  • CDC Guidance for School Officials (K-12)

  • Q&A


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Suffolk County, Long Island, New York



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Endemic, Epidemic, and Pandemic Leadership Defined

  • Endemic—A disease that already occurs at a high rate in a given population

  • Epidemic—An outbreak of new cases of a disease in numbers that exceed what is expected

  • Pandemic—An epidemic that spreads worldwide

Malarious Area

www.cbsnews.com


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Pandemics Throughout History Leadership

  • Plague of Justinian— 541 A.D.

  • The Black Death— 1347-1350 A.D.

  • Typhus or camp fever— 15th and16th centuries

  • Smallpox— 16th to 18th centuries

  • “Spanish” Flu— 1918

The Roof Rat

www.algonet.se


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How Influenza Viruses Change Leadership

  • Antigenic Drift:

    • Small changes in viruses over time

    • New strains appear

    • May not be recognized by antibodies

  • Antigenic Shift:

    • Abrupt,major change (reassortment)

    • Results in novel strain or new subtype

    • Can cause pandemic influenza


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Seasonal Influenza, 2009 Leadership

  • Annual seasonal influenza epidemics

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

    • >200,000 hospitalizations from flu each year

  • Over 85% mortality in persons ≥ 65 yrs

  • Severe disease in infants, young children, and elderly individuals

  • Attack rate of 5-15% (Nursing home attack rate of 60%)

  • Potential for pandemic



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H1N1 Influenza A (Swine Flu), 2009 Leadership

  • WHO Phase 6 Pandemic (declared June 11, 2009)

    • >1 million cases in the U.S.

    • >40,617 confirmed cases in U.S.

    • >263 confirmed deaths inU.S.

    • >180 confirmed cases in Suffolk County (6 deaths)

  • Imminent Public Threat declared by NYSDOH August 6, 2009

  • A brand new virus

  • A “quadruple reassortment of 2 swine strains, 1 human strain, and 1 avian strain of influenza virus”

  • Mean age of cases in Suffolk County and in U.S.: 12

  • Severe infection occurs in individuals who are not at the extremes of age

  • Attack rate of 22-30% initially


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Novel H1N1 Influenza A Symptoms Leadership

  • (Fever, cough, and/or sore throat), malaise, and headache

  • Vomiting and diarrhea (unusual for seasonal influenza)

  • Chills, myalgias, and arthralgias

  • Infants: fever, lethargy, +/- cough

  • Elderly individuals and immunocompromised hosts may also have atypical presentations


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Risk Factors for Novel H1N1 Influenza A Virus Complications Leadership

  • Chronic lung disease (especially asthma, COPD)

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

  • Heart disease (other than HTN)

  • Diabetes Mellitus

  • Obesity?

  • *Most Common Reasons for Hospitalization: Pneumonia and Dehydration


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Management of Novel H1N1 Influenza A Infection Leadership

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

  • It is resistant to other antiviral medications

  • Treatment is recommended for

    • All hospitalized patients with confirmed, probable or suspected cases

    • Patients who are at higher risk for seasonal influenza complications

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


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Testing for H1N1 in Fall, 2009 Leadership

  • Not a priority of the CDC, NYSDOH, or the Suffolk County Department of Health Services except

    • Pediatric hospitalizations for “influenza-like illness”

    • Any deaths attributed to, or linked with, a diagnosis of pneumonia or other respiratory infection

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


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Transmission of H1N1 Leadership

  • Primarily by respiratory droplets (sneezing and coughing)

  • Incubation Period: 1-4 days

  • Viral shedding (contagiousness)

    • Begins 1 day before symptoms

    • Peak shedding is during first 3 days of illness with fever

  • Lasts 7 days in adults or 10+ days in children


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Flu Pandemics: A Comparison Leadership

YEAR19182009

World Population 1.8 Billion 6.8 Billion

Primary Mode of Ships, Jet Aircraft,

Transportation Railroad Automobile

Time for Virus to 4 months 4 days

Circle the Globe

Estimated Dead 20+ Million ?

Worldwide


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Influenza Viral Morphology Leadership

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

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

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


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How Are We Doing With Seasonal Influenza Vaccination Rates in the U.S.?

  • Healthy People 2010 influenza vaccination targets are

    • 90% among persons aged ≥65 years

    • 60% among persons aged 18-64 years

  • CDC Data from the 2006-07 Influenza Season indicate vaccination rates of

    • 72.1% among persons aged ≥65 years

    • 35.1% among persons aged 18-49

    • 42.0% among persons aged 50-64

Source: MMWR, September 26, 2008


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H1N1 in the Fall, 2009 in the U.S.?

  • Washington has had the nation’s highest rate of H1N1 during the peak period in the state (2,500 suspected cases)

    • 366.8 cases of the flu for every 10,000 students

  • New York State has had

    • 6.5 cases of the flu for every 10,000 students


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

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

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

3 adjoining college campuses have had a total of 100 cases

Cornell University “ILI” Outbreak


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Legal Authority on Sept. 18

Pursuant to the New York Public Health Law,

the Suffolk County Commissioner of Health

Services has the legal authority to order the

isolation and/or quarantine of any person or

thing “infected with or exposed to” a

communicable disease.

New York Public Health Law § 2100 (1);

10 N.Y.C.R.R. §§ 2.1, 2.25 & 2.29.


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Personal Hygiene is Best Tool on Sept. 18

  • Handwashing with soap and water is critical

    • Virus can spread by contamination of hands that is then followed by hand contact with mucous membranes

  • Alternatives to soap and water exist

    • Alcohol-based hand gels


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Masks May Also Play a Role on Sept. 18

  • Use of masks may decrease the spread of virus between people

  • Widespread use during SARS outbreak

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


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This Might Help… on Sept. 18

  • Chicken Soup

  • Orange Juice

  • Vitamin C

  • Multivitamins


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Kobe, Japan on Sept. 18May 19, 2009




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CDC Guidance for K-12 School Response N.Y., May, 2009

  • Purpose

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

  • Goals

    • Decrease spread of flu among students and staff

    • Minimize disruption of day-to-day social, educational, and economic activities


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Recommended School Responses N.Y., May, 2009(If similar severity as in Spring 2009)

  • Stay home when sick

  • Separate ill students and staff

  • Teach hand hygiene and respiratory etiquette!

  • Early identification and treatment of high-risk students and staff

  • Routine cleaning

  • Consideration of selective school dismissal


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Recommended School Responses N.Y., May, 2009(If increased severity)

  • “Active” screening

  • High-risk students and staff stay home

  • Students with ill household members stay home for 5 days

  • Increase distance between people at schools

  • Extend the period for ill persons to stay home

  • Selective, reactive, and pre-emptive school dismissals


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“Active” Screening for Illness N.Y., May, 2009

  • Ask about fever and other symptoms

  • Send home people with symptoms of acute respiratory infection

  • Be vigilant throughout the day

  • Send students and staff who appear ill for further screening by school-based health care worker

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


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If N.Y., May, 2009 severity increases: Increase Distance between People

  • Explore innovative methods

    • Rotate teachers rather than students

    • Cancel classes that bring students together from multiple classrooms

    • Outdoor classes

    • Move desks farther apart

    • Move classes to larger spaces

    • Discourage use of school buses and public transit

    • Postpone some class trips


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Suffolk County’s H1N1 Plan for Fall N.Y., May, 2009

  • 1) Two possible scenarios

    • Moderately severe illness

      • Slightly more cases than in Spring, 2009

    • Increased severity of illness

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

  • 2) “Stay Home if You Are Ill”

    • Influenza-like Illness (ILI): Fever, Cough

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


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Suffolk County’s H1N1 Plan for Fall N.Y., May, 2009

  • 3) H1N1 vaccination and seasonal influenza vaccination will be urged for target populations

    • Hospitals, Private Physician Practices, Pharmacies

    • 10 SCDHS Health Centers and >50 Vaccination Clinic PODs (Points of Dispensing) throughout County

    • Schools, if they wish to have vaccination clinics

    • Mandatory in NYS for all physicians and staff at hospitals, Article 28 facilities, Home Health Care, Hospice (NYSDOH Emergency Regulation)

  • 4) Upon request, SCDHS will provideguidance and education to public and private school nurses and physicians about H1N1 vaccination procedures, techniques and precautions


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Suffolk County’s H1N1 Plan for Fall N.Y., May, 2009

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

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


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Suffolk County’s H1N1 Plan for Fall N.Y., May, 2009

  • 7) Communication to the public

    • Posters on buses, PSAs (radio, TV, print media), press releases, weekly electronic updates, SCDHS website announcements, press conferences

    • SCDHS H1N1 Telephone Hotline, starting September 9

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


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Suffolk County’s H1N1 Plan for Fall N.Y., May, 2009

  • 9) If increased severity of disease, communications will be enhanced and more frequent

    • SCDHS H1N1 Hotline Hours Extended

    • Enhanced surveillance of severity of disease

    • Daily electronic updates

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




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If N.Y., May, 2009 severity increases: School Dismissals

  • Preemptive dismissals

    • CDC will consider need to recommend based on global and national risk assessments

    • Goal: decrease spread of influenza virus and reduce demand on health care system

    • Use early and in conjunction with other strategies

    • Time to vaccine-induced immunity may be considered

    • If dismissing, do so for 5 to 7 days and reassess

    • Allow staff to continue to use facilities

    • Plan for prolonged dismissals and secondary effects


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Review N.Y., May, 2009

  • Suffolk County Department of Health Services

  • Definitions and a History of Pandemics

  • Novel H1N1 Influenza A Virus

  • Symptoms and Transmission Patterns

  • Suffolk County, New York, World Statistics

  • Suffolk County Public Health Response

  • CDC Guidance for School Officials (K-12)

  • Q&A


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How Bad will the N.Y., May, 2009Novel H1N1 Influenza A Virus be in the Fall/Winter of 2009?



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