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H1N1 Influenza A. Julie Casani, MD, MPH Public Health Preparedness and Response. How Flu Spreads. Most spread through coughing and sneezing Contact transmission also important Hand to hand, contaminated surfaces Airborne transmission also possible.

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h1n1 influenza a

H1N1 Influenza A

Julie Casani, MD, MPH

Public Health Preparedness and Response

how flu spreads
How Flu Spreads
  • Most spread through coughing and sneezing
  • Contact transmission also important
    • Hand to hand, contaminated surfaces
  • Airborne transmission also possible
influenza survival on the environmental surfaces
Influenza Survival on the Environmental Surfaces
  • Hard surfaces: 12–48 hours
  • Cloth/paper: 8–12 hours
  • Hands: 5 minutes
  • Survives longer with low humidity, low UV

Weber & Stilianakis, Journal of Infection 57(5): 361-73

novel influenza virus infection
Novel Influenza Virus Infection
  • Human infection with influenza A virus subtype different from the circulating human subtypes
pandemic influenza
Pandemic Influenza
  • Three Conditions:
    • Novel virus (all or most susceptible)
    • Transmissible from person to person
    • Wide geographic spread
summary of events
Summary of Events
  • March 28–30, 2009: 2 children from California seen for influenza-like illness
    • Same influenza A (H1N1) virus; not previously recognized among swine or human
  • April 26, 2009: US Government declares Public Health Emergency
  • June 11, 2009: WHO declares pandemic
    • Infections occurring around the world
what s in a name
What’s in a Name?
  • Swine flu
  • Swine-origin influenza virus (S-OIV)
  • Mexican flu
  • American flu
  • H1N1
  • Novel H1N1
  • 2009 H1N1
  • Pandemic H1N1
  • Others?
where we are now
Where We Are Now
  • WHO Phase 6 Pandemic
    • Determined by global spread, not severity
  • Above normal flu activity across NC
  • “Second wave” in Fall
    • Likely mixed season with many strains circulating
  • Monitoring for increased transmissibility, increased virulence
pandemic h1n1 clinical features
Pandemic H1N1: Clinical Features
  • Most cases uncomplicated, typical influenza-like illness (ILI)
  • Diarrhea and vomiting might be more prominent than with seasonal flu
  • As of late July, 2009:
    • 12% reported US cases hospitalized*
    • 0.7% reported US cases died*

* Skewed by testing of more severe cass

hospitalizations
Hospitalizations
  • Detailed clinical data presented on >200 hospitalized patients (CDC)
    • 43 (21%) admitted ICU
    • 17 (8%) died
  • Median time from onset of illness to hospital admission
    • 3 days (range 1-14 days)
  • Median length of stay
    • 3 days (range 1-53)
confirmed nc cases by county of residence august 12 2009
Confirmed NC Cases by County of ResidenceAugust 12, 2009

Alleghany

Gates

Vance

Currituck

Rockingham

Northampton

Surry

Camden

Caswell

Ashe

Granville

Stokes

Warren

Person

Hertford

Pasquotank

Halifax

Watauga

Perquimans

Wilkes

Alamance

Yadkin

Forsyth

Chowan

Avery

Mitchell

Franklin

Bertie

Guilford

Orange

Nash

Davie

Caldwell

Durham

Alexander

Yancey

Edgecombe

Tyrrell

Madison

Davidson

Iredell

Wake

Martin

Washington

Dare

Burke

Randolph

Chatham

Wilson

Catawba

Rowan

Pitt

McDowell

Buncombe

Beaufort

Greene

Swain

Haywood

Johnston

Hyde

Lincoln

Lee

Rutherford

Cabarrus

Montgomery

Graham

Henderson

Harnett

Wayne

Gaston

Jackson

Polk

Moore

Cleveland

Stanly

Lenoir

Craven

Mecklenburg

Cherokee

Macon

Transylvania

Pamlico

Cumberland

Clay

Sampson

Hoke

Jones

Anson

Richmond

Duplin

Union

Onslow

Scotland

Carteret

Robeson

Bladen

Pender

Columbus

New Hanover

Brunswick

Confirmed Cases, N=687 (75 counties)

influenza surveillance
Influenza Surveillance

Relies on:

  • Surveillance for influenza-like illness (ILI)
    • Sentinel Provider Network
    • Electronic syndromic surveillance
  • Systematic laboratory testing
  • Morbidity and mortality monitoring
pandemic h1n1 testing in nc
Pandemic H1N1 Testing in NC
  • Testing at State Laboratory of Public Health
    • Hospitalized patients with ILI
    • Patients with ILI seen by sentinel providers
  • Algorithm for clinicians at www.flu.nc.gov
  • Testing also performed at some commercial and hospital-based laboratories
rapid flu tests and novel h1n1
Rapid Flu Tests and Novel H1N1
  • Sensitivity ranges 10–70% for novel H1N1
    • Low negative predictive value
    • If negative, cannot be used to rule out novel H1N1 infection
  • High specificity
    • Good positive predictive value only if novel H1N1 prevalent in the community
pandemic flu testing take home
Pandemic Flu Testing: Take Home
  • Treatment and control measure decisions should be based on clinical and epidemiologic information; not on testing
pandemic mitigation strategies
Pandemic Mitigation Strategies
  • Vaccination
  • Targeted antiviral treatment and prophylaxis
  • Nonpharmaceutical interventions
    • Hand hygiene, respiratory etiquette
    • Isolation and quarantine
    • Social distancing (school dismissal, cancellation of large gatherings, teleworking, etc.)
pandemic mitigation strategies1
Pandemic Mitigation Strategies
  • Mitigation strategies guided by severity of illness
pandemic h1n1 vaccine
Pandemic H1N1 Vaccine
  • Monovalent vaccine
    • Separate from seasonal vaccine
    • Likely two doses, 3–4 weeks apart
  • Five manufacturers
    • Live attenuated vaccine available (~15%)
  • Clinical trials in progress, evaluating
    • Safety / adverse events
    • Interval between doses
    • Administration with seasonal vaccine
pandemic vaccine availability
Pandemic Vaccine Availability*
  • Considering “early roll out” of some doses in late September
  • First large bolus expected mid-October
  • Near-Weekly shipments
    • Total amount dependent on uptake

*Planning assumptions

pandemic vaccine distribution
Pandemic Vaccine Distribution
  • Vaccinators:
    • providers who agree to provide vaccine
    • Local Health Departments
    • Hospitals (for health care workers)
  • Vaccine costs:
    • Vaccine free
    • Administration fees
pandemic vaccine priority groups
Pandemic Vaccine: Priority Groups
  • Pregnant women
  • People who live with or care for children younger than 6 months of age
  • Health care and emergency services workers
  • Persons 6 months through 24 years of age
  • People 25 through 64 years of age at high risk for complications of influenza
high risk for complications
High Risk for Complications
  • Chronic pulmonary, cardiovascular, renal, hepatic, hematologic, neurologic, neuromuscular, or metabolic disorders
  • Immunosuppression
  • Persons younger than 19 years of age who are receiving long-term aspirin therapy
  • Residents of nursing homes and other chronic-care facilities
seasonal influenza vaccine
Seasonal Influenza Vaccine
  • Available now!
    • Should not delay
  • Recommended for
    • Children 6 months – 18 years
    • Adults ≥50 years
    • Pregnant women
    • Health care workers
    • Persons with certain medical conditions
    • Household contacts of children <5, adults >50, persons with certain medical conditions
community mitigation
Community Mitigation
  • Recommendations based on disease severity
  • Guidance issued for specific settings
    • Schools
    • Camps
    • Workplace
    • Health care facilities
    • Long-term care facilities
  • www.flu.nc.gov and www.cdc.gov/h1n1flu
school guidance similar severity
School Guidance: “Similar Severity”
  • Stay home when sick
    • At least 24 hours after fever resolves without use of fever-reducing medicines
  • Separate ill students/staff
  • Emphasize hand hygiene
  • Routine environmental cleaning
  • Early treatment of high-risk students and staff
  • Consider of selective dismissal of schools with predominantly high-risk students
health care settings nc recommendations
Health Care Settings: NC Recommendations*
  • Standard precautions
    • Gown, gloves, mask, eye protection as warranted
  • Droplet precautions
    • Surgical mask
  • Private room or cohorting
  • Strict hand hygiene and respiratory etiquette
  • Restriction of ill healthcare workers & visitors
  • Airborne precautions for aerosol-generating procedures

*Consistent with SHEA/APIC/IDSA recommendations

specific sector planning
Specific Sector Planning
  • Dept of Corrections
  • EMS
  • Law Enforcement-Judicial TTX
what some locales are doing
What some locales are doing
  • Seasonal flu vaccine messages as “hold” messages
  • Planning for absentees
  • Coordination for homebound people
  • Scrolling marquees on gov’t TV panels
  • Alamance Reads project
resources
Resources
  • www.flu.nc.gov
  • www.cdc.gov/h1n1flu
  • www.pandemicflu.gov