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Region 2 Public Health Update for School Nurses September 17, 2010

Region 2 Public Health Update for School Nurses September 17, 2010. Carole Kirby, RN, NMD Region 2 School Health Advocate Christopher Novak, MD, MPH Health Officer, Region 2. Topics. Influenza and NMDOH School Health Manual Updates Immunizations The School Immunization Survey

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Region 2 Public Health Update for School Nurses September 17, 2010

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  1. Region 2Public Health Update for School NursesSeptember 17, 2010 Carole Kirby, RN, NMD Region 2 School Health Advocate Christopher Novak, MD, MPH Health Officer, Region 2

  2. Topics • Influenza and NMDOH • School Health Manual Updates • Immunizations • The School Immunization Survey • School-based BMI Surveillance (and Screening)

  3. Influenza • Review the importance of influenza vaccine as a disease prevention strategy • Review changes to the 2010/2011 recommendations • Outline the Dept of Health plans for school influenza vaccination for 2010/2011 • Review the algorithm for identifying students who need one versus two doses of vaccine

  4. Influenza A Virus • Causes resp tract (e.g., lung) infection in humans • Mild-severe illness => 36,000 deaths/yr • Abrupt onset of fever, myalgia, sore throat, nonproductive cough • Complications include: • Primary influenza viral pneumonia • Secondary bacterial pneumonia • Myocarditis • Exacerbation of chronic illness (e.g., asthma, heart disease, diabetes) • Reye’s syndrome (children) • Death

  5. Influenza (con’t) • Agent: influenza virus • Antibiotics not effective • Anti-virals may decr illness duration, severity • Transmission: • Airborne spread and respiratory droplet • Direct contact less important • Seasonal pattern – peaks late fall/early winter • Timing, duration, and severity vary

  6. Influenza • Incubation = 1-4 d (avg = 2 d) • Adults infectious 1 d before sx to 5 d after onset • Children may transmit the virus >7 days • Illness usually resolves within 3-7 d • Once infected, (some) immunity from that strain • But small changes in virus over time (antigenic drift) lead to seasonal epidemics

  7. Prevention • Medications (e.g., adamantanes, neurominadase inhibitors) somewhat effective • Vaccine • Influenza is unpredictable • Likely 2009 H1N1 viruses and regular seasonal viruses will circulate this influenza season • 2010-2011 influenza vaccine contains: • A/California/7/2009 (H1N1)-like antigens (same strain as the 2009 H1N1 monovalent vaccine) • A/Perth/16/2009 (H3N2)-like antigens • B/Brisbane/60/2008-like antigens • Trivalent Inactivated Influenza Vaccine (TIV) – IM injection • Live Attenuated Influenza Vaccine (LAIV) - nasal spray

  8. Efficacy (General) • Protective efficacy: • Most children and young adults develop high post-vaccination antibody titers • Protective against illnesses caused by virus strains similar to those in the vaccine • 90% efficacious in healthy young persons in preventing illness (for vaccine strains matched by the vaccine) • Elderly: 30%-40% efficacious in preventing illness, 50%-60% in preventing influenza-related hospitalization

  9. NMDOH Vaccination Strategy (2010/2011) ACIP recommends that • Children6 months through 8 years of age who have NOT received • At least one dose of 2009 H1N1 last season; AND • At least one dose of seasonal vaccine prior to last season OR two doses of seasonal vaccine last season Need • Twodoses of influenza vaccine during the 2010/2011 season • ALL others (children and adults) need only one dose of vaccine during the 2010/2011 season

  10. Who? • Advisory Committee for Immunization Practice (ACIP) recommends seasonal influenza vaccination for all people 6 months of age and older • DOH vaccination efforts focus on: • Those at high-risk for complications from influenza • Pregnant women • Young children • Chronic health conditions (asthma, diabetes, etc.) • Those more likely to transmit the infection to high-risk groups

  11. High Risk Children • Children at the greatest risk of complications - includes: • Ages 6-59 months • On long-term ASA therapy (risk of Reye’s) • Chronic medical disorders (pulmonary or CV, incl asthma) • Required regular medical follow-up or hospitalization in past year due to chronic metabolic diseases, such as • Diabetes mellitus • Renal dysfunction • Hemoglobinopathies • Immunodeficiency (including HIV) • Condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function, handling of respiratory secretions, or increase risk for aspiration

  12. Other Priority Groups • Household and other close contacts of infants <6 months of age • Pregnant women • Persons age > 50 years • Chronic medical disorders of the pulmonary or cardiovascular systems, including asthma (not HTN) • Adults who have required regular medical follow-up or hospitalization in the past year for: • Chronic metabolic diseases (e.g., diabetes) • Renal dysfunction • Hemoglobinopathies • Immunodeficiency (including that caused by HIV)

  13. Other Groups (con’t) • Adults w/any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function, handling of respiratory secretions, or increase the risk for aspiration • Residents of long-term care/chronic-care facilities • Caregivers at long-term care/chronic care facilities; • Household contacts or caregivers of persons at high-risk for influenza-related complications • Includes healthy household contacts and caregivers of children <5 years • Healthcare workers

  14. Bottom Line • Pretty much everyone should be vaccinated…

  15. NMDOH Target Population • NM public health offices should vaccinate persons from the above high-risk groups as vaccine supplies allow • Persons w/insurance or ability to pay for their vaccine should be served by their primary care provider or mass immunization clinic (e.g., retail clinics) • Persons w/o other sources of care, whose provider does not have the vaccine, or who have Medicare can receive NMDOH vaccine • Pregnant women seen in NMDOH public health clinics should be vaccinated • NMDOH supply of FluMist targeted for children < 19 years of age only • Adults who request vaccination will be offered TIV – if decline, will be provided a referral to another vaccine provider to obtain FluMist

  16. TIV Administration • TIV: intramuscularly (IM) – • Deltoid muscle of adults, adolescents, and older children • Antero-lateral thigh of infants and young children w/o adequate deltoid mass • 22-25g needle • Needle length: • adult, adolescents and older children IM injections: ≥ 1 inch • children with adequate deltoid mass IM injections: ≥7/8 – 1 inch • infants and young children in anterolateral thigh: 7/8-1 inch • May be administered simultaneously with other vaccines, using a separate syringe at a different anatomical site

  17. LAIV Administration • LAIV - nasal spray • Each sprayer = single dose of FluMist - approx one-half of the contents (0.1 mL) administered into each nostril: • Recipient upright: insert tip of sprayer just inside nose and rapidly depress the plunger until dose-divider clip stops the plunger • Remove dose-divider clip • Spray second half of dose into other nostril • Once administered, dispose of sprayer according to standard procedures for medical waste (e.g., sharps container or biohazard container)

  18. Adverse Reactions • TIV: • Soreness, erythema, induration at injection site lasting up to 2 days (15%- 20% of those vaccinated) • Fever, malaise, myalgia, and other systemic symptoms beginning 6-12 hours after vaccination for 1-2 days (<1% of those vaccinated) • Immediate hypersensitivity reactions (presumably to egg component) • LAIV: • Runny nose, nasal congestion, headache, sore throat

  19. General Contraindications Contraindications to ANY seasonal influenza vaccination (TIV or LAIV) are: • Babies <6 months of age • Anyone w/ • Allergy to any component of the vaccine (such as MSG, arginine, gentamicin, or gelatin) • Severe allergy to eggs • Anaphylactic hypersensitivity to previous dose of influenza vaccine, or to any component of the vaccine (e.g., thimerosal, eggs) • History of Guillain-Barré Syndrome after receiving influenza vaccination

  20. LAIV Contraindications • Contraindications to LAIV: • Pregnant women • Children < 2 years of age • Adults > 49 years of age • Anyone w/ • Asthma, reactive airway disease, other chronic lung or heart disease • Diabetes • Kidney disease or renal dysfunction • Abnormal hemoglobin (e.g., sickle cell anemia) • Immunosuppressive states (e.g., chemotherapy) • Close contact with a person with a severely weakened immune system • Children/adolescents on ASA or other salicylates • Children ages 2-4 years who had wheezing or asthma in the last 12 months • Relative Contraindication • Moderate or severe acute febrile illness: have client return when they are feeling better

  21. Administration Notes • Minor illness with or without fever (e.g., mild URTI, allergic rhinitis) is not a contraindication • Pregnancy and breastfeeding are not contraindications to TIV • Use thimerosal-free vaccine if available – but do not postpone • Options for patients with contraindications to vaccine: • Refer to primary care physician for advice about chemoprophylaxis options available to them

  22. Prevention • Don’t forget: • Respiratory etiquette • Hand hygiene • Exclusion of ill • Stay home if sick!

  23. NM DOH Response • Education • Community • Government • Businesses • Planning • Internal • Assist partners • Coordination (e.g., w/local and federal) • Prioritization and distribution of assets • Antivirals • PPE • Vaccine

  24. Take-Home Points • Influenza can cause significant illness, death, and disruption • Vaccine is a critical tool for reducing disruption/illness/death • Interventions, when used in a layered manner, may be highly effective in controlling the spread of influenza

  25. SCHOOL HEALTH MANUAL UPDATES • Section II – Regulation/Policy (4/2010) • Section III – Screenings (4/2010) • Section XI – School Safety (7/2010) • Section XIII – Dental Health (8/2010) • Section XVI – SH Services Report (2/2010) • Section IV – Special Needs (11/2009)

  26. School Health Manual: Section II • Statutes for Vision Screening • Instructions for accessing statutes website

  27. School Health Manual: Section III • Vision Screening • Hearing Screening • H/W/BMI Assessment • Scoliosis Screening • Student Health Assessment • Special Education Assessment • CYFD & Sports Physicals

  28. Vision Screening Requirements • Section III, pp. 4-9 • Past Hx: Legislation passed 2007 creating statutes regarding the following: • Requirements to screen targeted grades • Funding source

  29. Vision Screening (con’t) • Funding source for children w/o insurance and referred by the school nurse to obtain a comprehensive eye exam and/or eyewear • DOH authority to manage the funds and to develop vision screening standards

  30. Vision Screening (con’t) • Rule developed to implement screening requirement and screening standard • Rule developed for distribution of Save Our Children Sight Fund (SOCS Fund)

  31. BMI Testing •  Review the current evidence related to obesity surveillance (and screening), effectiveness of interventions, and outline current NMDOH activities related to BMI surveillance

  32. BMI: Background • BMI = Body Mass Index • Correlates to body fat • Ratio of weight (in kilograms) and height (in meters squared) • BMI = Weight (Kg) [Height (m)]² • Group data calculator (e.g., class, school) http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/tool_for_schools.html

  33. BMI: Surveillance • Surveillance: assess BMI status across a specific population to identify the percentage of students potentially at risk for weight-related health problems • This data is collected for assessing population trends and monitor intervention outcomes

  34. BMI: Screening • Screening: assess the weight status of individual students to identify those at risk and provide that information to the student and parent so that appropriate actions can be made

  35. BMI Measurement Recommendations • New Mexico has no requirements for screening students for height/weight/BMI • The DOH/UNM Medical Oversight Committee (MOC) does not endorse school-based BMI screening • Not proven effective nor cost-effective • January (2010) MOC position paper states that surveillance for BMI might be appropriate if done well, safeguards are in place, and costs are considered

  36. Addressing Obesity in Children • 10 Evidence-based Strategies to Address Obesity in Children and Adolescents • School-based practices and policies identified by the CDC to promote physical activity and healthy eating • BMI not listed… • See Section III, p.16.

  37. BMI: Considerations • Safeguards: CDC proposed 8 safeguards to protect children from harm that could occur in a BMI measurement program • See section III, p.15.

  38. Hearing ScreeningsRecommendations • Targeted population for testing: • Pre-K, K, 1st, 3rd, 8th, Sp Ed • All new and transfer students w/o a record of hearing screening result • Any student referred by a teacher with a potential hearing problem • Section III, pp. 10 – 14

  39. Hearing Screening (con’t) • Sweep testing is the preferred pure tone conduction hearing test method • Frequencies (at 20dB) are: • 1,000 Hz • 2,000 Hz • 4,000 Hz • 6,000 Hz dropped as recommendation

  40. Hearing Screening: Fail • Fail = unable to hear test frequency at 20dB in either ear • Follow-up w/otoscopic exam • If no abnormalities found, repeat test in 3 weeks

  41. Scoliosis Screening • (1995) DOH Chief Medical Officer recommendations were not to screen for scoliosis in a school setting • See Section III, p. 16

  42. Student Health Assessment • Resources and forms for student health assessments • New BP percentile tables: • Based on height, sex, and age • Classifications are: normal, pre-hypertension, stage1 hypertension, and stage 2 hypertension. • Currently, no recommendations for BP screenings in schools • See Section III, pp. 17-18

  43. Special Education Assessment • New tools and detailed guidelines regarding special education student assessments • See Section III, pp. 19 – 22

  44. CYFD and Sports Physicals • No changes at this time

  45. IMMUNIZATIONS 2010-2011 School Year Requirements • Tdap • Grades 7-10: Required • Grades 11 and 12: • Encouraged if ≥5 years since last tetanus-containing vaccination • Required if >10 years since last tetanus-containing vaccination

  46. Immunizations (con’t) • Polio • 3 doses sufficient if all IPV or all OPV and the one dose after or on the 4th year of age is administered at least 6 months after the previous dose or • 4 doses of any combination of IPV or OPV sufficient with 6 months or more between last two doses regardless of age

  47. Immunizations (con’t) • Hepatitis B • When the birth dose initiates the 3 dose series, final dose should be given no earlier than age 24 weeks • Varicella • Grades K-2 • 2 doses required on/after 1st birthday Or • Documentation of disease hx Or • Immunity by medical or lab record • Grades 3-12: 2 doses recommended if no documentation of immunity

  48. Immunizations (con’t) New Mexico Childcare/Preschool Entry Immunization Requirements • Minimum number of vaccine doses required by childcare & preschool age levels > 48 months

  49. School Immunization Survey • Review the School Immunization Survey (purpose, methods) – identify and highlight major findings, successes, and areas for improvement

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