2010 GRANT COUNTY PUBLIC HEALTH POTPOURRI

Grant-Adams County Medical Society MeetingMonday, October 11th, 2010Alexander L. Brzezny, MD, MPH, FAAFPHealth Officer Grant County Health District (GCHD)

TOPICS AND OBJECTIVES State of the Public’s Health in

Grant County. Is our resident’s health better than 2 years

ago? H1N1 2009-2010 Pandemic in

Numbers. Who became infected and where?

2010-2011 Influenza Season. How to diagnose, what to report, what is

new? Pertussis Resurgence in the United

States. Why now, why here, and how to fight it?

GRANT COUNTY STATE OF THE PUBLIC’S HEALTH 2010

http://www.doh.wa.gov/HWS/GHS2007.shtmhttp://www.doh.wa.gov/PHIP/products/phi/indicator.htm\http://www.countyhealthrankings.org http://www.wspha.org/2010HealthChamps

Notifiable Conditions, Grant County, 2010

Chlamyd.

HCV

Salmonel.

Pertussis

Years of healthy life expected at age 20

(2009)

GRANT 46 years(66 years total)

Seattle-KING 55 yearsKITTITAS 54 years (74 years total)

CHELAN -DOUGLAS 51 years(71 years total)

Adult physical activity (2007)

GRANT 58%

SAN JUAN 74%

ADAMS 64%

Adults with diabetes (2008)

GRANT 9% (ADAMS 11%)

KITTITAS 5%Seattle-KING 6%CHELAN-DOUGLAS 7%

Low birth weight rate (per 1,000)

(2009)

GRANT 6/1,000ADAMS 6/1,000

KITTITAS 3/1,000

Teen birth rate (per 1,000)

GRANT 35 /1,000(ADAMS 57 /1,000)

Seattle-KING 10/1,000

Teens overweight

GRANT 32% ADAMS 34%

CHELAN-DOUGLAS 23%

Adult preventive cancer screening -

Colorectal

GRANT 61%

KITTITAS 70%

Adult dental care

GRANT 59%

BENTON FRANKLIN 78%

Food service safety

GRANT 92%

Counties with 100%

Reported child immunizations

GRANT 68% (ADAMS 71%)

SPOKANE 28%

Maternal cigarette smoking

GRANT 10%

SPOKANE 19%

ADAMS 2%

Adults with unmet medical

needs

GRANT 13%

OKANOGAN 19%ADAMS 22%

Teen physical activity

GRANT 50%

Seattle-KING 40%SNOHOMISH 41%YAKIMA 42%

ADAMS 54%

QUIZ QUESTION #1 (U. OF WI) Where does Grant County rank in

health factors and outcomes among WA State counties? A. Top 10% B. Top 30% C. Just about in the middle D. Bottom 30% E. Bottom 10%

Grant County Health Factors (#28 /39)

Grant County Health Factors (#28 /39)

• Health Behaviors: #30 (obesity, smoking, teen birth rate, Chlamydia rate, drinking); #1 San Juan

• Clinical Care: #31 (uninsured, DM2 screening, hospice use, primary care); #1 Sea-King

• Social and economic factors: #27 (HS graduation, income inequality, single-parent, children in poverty); #1 Whitman

• Physical environment: #7 (pollution, healthy foods access; liquor stores density); #1 Garfield

Grant Morbidity & Mortality (#28 /39)

Grant MORBIDITY and MORTALITY

• Mortality: #28 (premature death); #1-#3 Whitman, San Juan, King

• Morbidity: #27 (poor physical or mental health days (DAYS /YEAR), low birth weight, poor health (%)); #1-#3 San Juan, Douglas, Kittitas

QUIZ QUESTION #1 Where does Grant County rank in

health factors and outcomes among WA State counties? A. Top 10% B. Top 30% C. Just about in the middle D. Bottom 30% E. Bottom 10%

BAD NEWS (GRANT COUNTY) Population growth with socioeconomically

challenged in-migration Grant ranks at the bottom 30% for health

in WA Several indicators demonstrate a

persistent lack of improvement: lower life expectancy, less physical activity, higher rates of DM2, high teen overweight, lower preventative services utilization, low birth weight, and alarming teen pregnancy rate.

SOME GOOD NEWS (GRANT COUNTY) Grant Co. residents enjoy open spaces,

low traffic and pollution, proximity to healthy foods and outdoor recreation.

CHILD PROFILE utilization is high. Maternal smoking rate is low and

overall smoking rate is dropping (cost?).

Grant Co. teens are more active than those in most of the state.

Access to healthcare services is good.

PUBLIC HEALTH FUNDING AND STAFFING

2009: Budget ~$2.2mln (final) Staff ~27.0+ FTE

2011 (projected) Budget ~$1.7+mln (in 1999: $1.86mln) Staff ~22.0+ FTE (in 1999: 25.6 FTE) (Grant Co. population in 2000: 74,698) (Grant Co. population in 2010: ~90,000)

GRANT PUBLIC HEALTH, 20052011

2011 1,787,310

2010 1,876,259

2009 2,107,274

2008 2,072,423

2007 1,854,956

2006 1,820,951

2005 1,932,706

050000

100000150000200000250000300000350000400000450000500000550000600000650000

Revenue Sources

Permits Fed Grants State Grants County / CityMvet & McaidFees & Other

2011 & 2010 Budgeted 2009 - 2005 Actual Revenues

Reve

nue

In D

olla

rs

20052011

DRAFT DOCUMENT, GCHD, 10/11/2010

H1N1

GRANT COUNTY AND WASHINGTON STATE 2009-2010 H1N1 PANDEMIC IN NUMBERS

http://www.doh.wa.gov/notify/other/H1N1SummRpt.pdf

QUIZ QUESTION #2 (DOH) Which County in Washington experienced

the second highest severe pan-H1N1 disease rate during 2009-2010 season? Which one the highest?

A. Whatcom County (Bellingham) B. King County (Bellevue) C. Grant County (here) D. Adams County (near here) E. Pend Oreille County (Newport)

20

2009-2010 INFLUENZA A H1N1 VIRUS

A/Mexico/4108/2009 (H1N1)

neuraminidasetype of nuclear material

hemagglutinin

virus type geographicorigin

strain number

year isolated virus subtype

AvianInfluenza viruses

Pandemic H1N1 2009 Pedigree, 1979-2009Eurasian Swine

A/H1N1(1979-present)

Human “seasonal”A/H3N2

(1968-present)

North American SwineA/H1N1

(1918-present)

“Triple reassortant”Swine A/H1N2(1998-present)

2009 HumanA/H1N1

(2009-??)?

Human “seasonal”A/H1N1

(1977-present)

PANDEMIC H1N1 INFLUENZA VIRUS - TIMELINE

April 15 – first U.S. case confirmed by CDC (CA)

April 26 – U.S. Government declares a “public health emergency”

May – CDC provides prototype vaccine virus to manufacturers

June 11 – WHO raises pandemic level to 6 June 19 – H1N1 reported in all 50 states October 6 – first H1N1 vaccine doses

admin’d April 2010 – first confirmed H1N1 death in

Grant

Extrapolation ’08‘09 season

WASHINGTON LABORATORY SURVEILLANCE, 2009-2010

First WaveSecond Wave

NUMBER OF SEVERE H1N1 CASES (WA) (N=1667)

First Wave

Second Wave

?Third Wave

NUMBER OF SEVERE H1N1 (BY WA REGION)

NUMBER AND RATE OF H1N1 (1ST WAVE)

NUMBER AND RATE OF SEVERE 2009 H1N1 BY AGE GROUP, APRIL–AUGUST 2009 (N=188)

8.9

NUMBER AND RATE OF CRITICAL H1N1 BY AGE, APRIL–AUGUST 2009 (N=63); (2ND WAVE)

0.9 0.9

NUMBER AND RATE OF SEVERE FLU A BY AGE, SEPT 2009–APRIL 2010 (N=1479), (2ND WAVE)

NUMBER AND RATE OF CRITICAL INFLUENZA A BY AGE, SEPT 09–APRIL 10 (N=360); (2ND WAVE)

8.2

NUMBER AND RATE OF FATAL FLU A BY AGE GROUP, SEPT 09–APRIL 10 (N=81); (2ND WAVE)

2.32.2

0.2

1.2

NUMBER OF FATAL 2009 H1N1 BY COUNTY, APRIL–AUGUST 2009 (N=17)

NUMBER OF FATAL INFLUENZA A BY COUNTY, SEPTEMBER 2009–APRIL 2010 (N=81)

RATE OF SEVERE 2009 H1N1 BY WA COUNTY, APRIL–AUGUST 2009 (N=188)

RATE OF SEVERE INFLUENZA A BY WA COUNTY, SEPTEMBER 2009–APRIL 2010 (N=1479)

QUIZ QUESTION #2 Which County in Washington experienced the

second highest severe pan-H1N1 disease rate during 2009-2010 season? A. Whatcom County (Bellingham) B. King County (Bellevue) C. Grant County (here) D. Adams County (near here) 2nd

highest E. Pend Oreille County (Newport)

highest

SUMMARY OF THE 2009-2010 H1N1 (I.) Two distinct pandemic waves. Grant County: 1 fatality, 31 severe cases. Grant County severe disease rate: 36 /100,000 WA State: at minimum confirmed 1,650

hospitalizations and deaths in WA were due to this novel influenza virus (4,459 CDC estimate).

Severe disease rate greater in E. Washington (especially 2nd Wave).

Pre-school children: highest hospitalization rate. 5-24 y.o. age group had highest attack rate.

SUMMARY OF THE 2009-2010 H1N1 (II.) Pregnant 8-11x more likely to be

hospitalized and 3-4x more likely to be admitted to an ICU.

Fatal and critical cases treated later than those with less severe disease.

Most hospitalized and fatal cases had an ACIP-recognized high risk medical condition (asthma, chronic lung disease, and diabetes).

Overall, H1N1 less severe than anticipated.

SUMMARY OF THE 2009-2010 H1N1 (III.) 1.4 influenza deaths per 100,000. 24.7 severe influenza cases per 100,000. 5% of severe cases died in the 1st Wave

compared to 9% deaths among the severe cases in the 2nd Wave.

GRANT COUNTY HEALTH DISTRICT Cost: $360,000 (or $4.50 per resident) 70 volunteers augmenting 28 staff (100 individuals) 8,920 vaccines given in 8 weeks (11% population) WSPHA recognized GCHD for “exemplary public

service”.

Estimates of child and adult state-specific seasonal influenza vaccination coverage, 2009-2010

MMWR April 30, 2010 / 59(16);477-484

NUMBER OF PERSONS REPORTING SEASONAL FLU VACCINE (2008-2010); BRFSS

MMWR April 30, 2010 / 59(16);477-484

PRACTICE-CHANGING KNOWLEDGE 20% influenza cases are ASYMPTOMATIC. Surgical face masks decrease transmission. Early treatment improves outcomes. Pregnancy is a major risk factor for influenza. You can get fooled (infected) TWICE with the

same virus during the same season /pandemic.

Emergency declaration proved useful in increasing the number of “public health workers.”

GRANT COUNTY 2010-2011 INFLUENZA SEASON

http://www.phac-aspc.gc.ca/fluwatch/index-eng.phphttp://www.who.int/csr/disease/influenza/influenzanetwork/en/index.html

http://gamapserver.who.int/maplibrary/

QUIZ QUESTION #3 (WHO) So where is the avian H5N1 influenza

now??? A. Mutated into the pandemic H1N1 B. Affecting only birds C. Doing well and infecting humans D. Doing well and infecting humans in

China only E. Already in Washington

SO WHAT HAPPENED TO THE H5N1?

QUIZ QUESTION #3 So where is the “avian” H5N1 influenza

now??? A. Mutated into the pandemic H1N1 B. Affecting only birds C. Doing well and infecting

humans D. Doing well and infecting humans in

China only E. Already in Washington

H1N1, SEASONAL FLU, WHERE ARE THEY? Pandemic influenza A(H1N1) 2009 virus:

Widespread activity in India and New Zealand. Regional outbreaks in Australia, Bangladesh,

Cambodia, Costa Rica, Cuba, Honduras, Laos, Malaysia, Panama, Peru, Singapore and Thailand.

Seasonal flu (non-pandemic H1N1, H3N2, and influenza B): Sporadic H1 was reported only in China and Pakistan. Regional outbreak of H3 in China Local outbreaks of H3 in Mexico and South Africa Regional and local outbreaks of influenza B:

Argentina, China, El Salvador, Australia, France - New Caledonia, South Africa.

US: sporadic activity of H3N2 and influenza B

ILI=INFLUENZA-LIKE ILLNESS

Influenza-like illness (ILI): Fever>100F (37.8C) AND

Cough AND/OR Sore Throat

Many other symptoms Absence of other obviously known cause

ILI VS. SARI (SEVERE RESP. DISTRESS SY)

Causes two respiratory disease syndromes ILI (upper respiratory tract)

Fever (100F) plus cough or sore throat Lots of other symptoms

Severe acute respiratory illness (SARI) ILI + progressive SOB/ tachypnea/ hypoxia

Lower lung involvement ILI or SARI not specific to influenza virus

infections (parainfluenza, coronaviruses [SARS], adenovirus, HMP virus, rhinovirus, RSV)

LABORATORY CRITERIA FOR DIAGNOSIS Influenza virus in respiratory cell culture; RT-PCR testing of respiratory specimens; Immunofluorescent antibody staining (direct or

indirect); Rapid influenza diagnostic testing; Immunohistochemical (IHC) staining for influenza

viral antigens in respiratory tract (autopsy); Four-fold rise in influenza hemagglutination

inhibition (HI) antibody titer in paired acute and convalescent sera.

WHAT IS THE BEST TEST? WELL, THAT DEPENDS…

Viru

s co

ncen

trat

ion

Days from infection

0 4 5 6 7 8 91 2 3

Symptoms onset Detection thresholds

rtPCR

Virus cell culture

Direct fluorescentantibody assays (DFA)

Antigen detect (“RDT /RIT”)

INFLUENZA CONTROL: FOUR NUMBERS + 2 6 (feet of separation) 100 (Fahrenheit) 7 (days of exclusion) 24 (hours w/o fever) Influenza vaccine Surgical face mask+handwashing

INFLUENZA HIGH-RISK INDIVIDUALS Pregnant women, People with asthma and other lung disease, Diabetics, Morbidly obese person, People with blood disorders (sickle cell, etc.) People with compromised immune systems, People with heart disease, stroke or similar, Those with neuromuscular diseases (CP,

etc.), Hemodialysis patients (and other ESRD), Infants, elderly, nursing home residents, Individuals with a recent illness.

2010-2011 INFLUENZA VACCINE 11 trivalent vaccines: A/California/7/2009

(H1N1), A/Perth/16/2009 (H3N2), and B/Brisbane/60/2008

Annual influenza vaccination is recommended for every person in the United States 6 months of age and older (“almost universal”)

MMWR 2010;59 (early release)

SEASONAL INFLUENZA VACCINE IN PREGNANCY

In 2000-2003 a total of 2 million influenza vaccines administered to pregnant women: 20 VAERS reports received (9 injection site reactions; 8 systemic reactions; 3 unrelated miscarriages).

2 studies (N=2,252): no adverse events. Influenza more severe in pregnancy. ACIP: Seasonal Inactivated Influenza

Vaccine (TIV) INDICATED in pregnancy (not LAIV).

IMMEDIATELY REPORTABLE TO GCHD IN 2010-11

(Pediatric) influenza deaths are currently reportable in Washington (death resulting directly or indirectly from a disease clinically compatible and laboratory-proven as influenza).

Suspected and laboratory-confirmed infections with a novel influenza including avian influenza A (H5N1) virus (excluding 2009 H1N1).

Unexplained critical illnesses and deaths in persons <50 years old

Laboratory-confirmed influenza hospitalizations are not legally reportable statewide, HOWEVER, CDC requested.

GRANT COUNTY AND NATION’S HEALTH RESURGENCE OF PERTUSSIS IN UNITED STATES

http://www.cdc.gov/vaccines/vpd-vac/pertussis/default.htmhttp://www.cdph.ca.gov/programs/immunize/Documents/PertussisReport10-6-2010.pdf

http://www.who.int/vaccines-documents/DocsPDF-IBI-e/mod4_e.pdf

QUIZ QUESTION #4 (USMLE) The 3-year-old sister of an infant boy is diagnosed with

pertussis by nasopharyngeal swab. The mother gives a history of being immunized as a child. Which one is correct.

A. Mother has no risk of acquiring the disease because of her immunization status.B. Hyperimmune globulin is effective in protecting the infant.C. Erythromycin should be prescribed to the infant.D. The risk to the infant depends on the immunity of the mother E. The 3-year-old sister should be immediately immunized with an additional dose of pertussis vaccine.

QUIZ QUESTION #4 The 3-year-old sister of an infant boy is diagnosed with

pertussis by nasopharyngeal swab. The mother gives a history of being immunized as a child. Which one is correct.

A. Mother has no risk of acquiring the disease because of her immunization status.B. Hyperimmune globulin is effective in protecting the infant.C. Erythromycin should be prescribed to the infant.D. The risk to the infant depends on the immunity of the mother E. The 3-year-old sister should be immediately immunized with an additional dose of pertussis vaccine.

PERTUSSIS IN GRANT COUNTY 2010 TOTAL CASES: 9 ONE FATALITY (2 week old)

eight (8) laboratory proven cases, one (1) epidemiologically-linked, age 2 w.o.– 60’s y.o.

First case: 8/23/2010; Last case: 9/23/2010 Total suspects: 19 (all culture or PCR or both

NEG) Total contacts: 222 (185 case contacts: of those

58 HEALTHCARE WORKERS, 37 suspect contacts)

CLOSE CONTACTS PEP rate: 100% TOTAL COST: $24,835; staff hours:480 (9/30)

Incidence increasing since the 1990s Cyclical: peaks every 2-5 years as numbers of

susceptible people increase enough to allow sustained transmission; last peak year 2005 with 25,616 U.S. cases, a 45 year high

Adults are vulnerable to pertussis 27% of reported cases are among adults Pertussis immunity wanes 5 to 10 years after DTaP* series

(immunity from disease wanes in 15 years) ONLY 25% of cough illness lasting >2 weeks is pertussis

First pertussis vaccines (Tdap)† for adolescents and adults licensed in 2005; uptake suboptimal

*Diphtheria and tetanus toxoids and acellular pertussis vaccine†Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine

PERTUSSIS: MOST POORLY CONTROLLED VACCINE-PREVENTABLE DISEASE

SYMPTOMS OF INFANT PERTUSSIS Initially infant looks deceptively well:

coryza, no fever, mild cough Leukocytosis with lymphocytosis Apneic episodes Seizures Respiratory distress Pneumonia Adenovirus or RSV co-infection can

confuse picture

“TYPICAL” SYMPTOMS OF PERTUSSIS Three-stage bacterial illness (catarrhal,

paroxysmal and convalescent) that lasts 4-12 weeks

“Typical” symptoms paroxysmal cough lack of fever no systemic illness coryza; no pharyngitis post-tussive vomiting post-tussive whoop absolute lymphocytosis

Adults with pertussis often report feeling as if they’re choking on something, sweating episodes

Adults transmit pertussis to infants Among 264 known source-cases:

Almost 50% were parents, most often mothers 51% were adults >19 years of age

Bisgard KM, et al. Infant pertussis: who was the source? Pediatr Infect Dis J 2004; 23(11):985-989. Wendelboe AM, et al. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J 2007; 26(4):293-299.

PERTUSSIS TRANSMISSION TO INFANTS

PERTUSSIS RESURGENCE SINCE THE 1990S Genetic changes in B. pertussis; greater

virulence? Variable vaccine efficacy (acellular pertussis

vaccines licensed in 1991 for 4th/5th doses; entire series in 1996)

Waning of vaccine-induced immunity and lack of natural booster events

General availability of better laboratory tests Greater awareness of pertussis by clinicians

http://www.doh.wa.gov/PHIP/products/phi/indicator.htm

PERTUSSIS IN CALIFORNIA 1950-2010

PERTUSSIS INCIDENCE BY AGE -- CALIFORNIA, 2010

0

5

10

15

20

25

30

<1 1-6 7-9 10-18 19-64 65+age group

case

s pe

r 10

0,00

0

PERTUSSIS COMPLICATIONS BY AGE*

*Cases reported to CDC 1997-2000 (N=28,187)

0

10

20

30

40

50

60

<1 1-4 5-14 15-24 >25Age group (years)

Rat

e pe

r 100

,000

pop

ulat

ion

PERTUSSIS INCIDENCE BY AGE GROUP (EXCLUDING INFANTS), CALIFORNIA 2005-10-- CALIFORNIA, 2005-2010

0

2

4

6

8

10

12

14

16

2005 2006 2007 2008 2009 2010year

case

s pe

r 10

0,00

0

1-6

7-10

11-18

19-64

65+

All ages

STANDARD TDAP/DTAP RECOMMENDATIONS

DTap for children at 2, 4, 6, & 15‐18 monthswith a booster at 4‐6 years Tdap for adolescents at 11‐17 years Tdap for adults 18‐64 years Tdap for all household contacts &

caregivers ofinfants; especially post‐partum mothers

Tdap should replace one dose of Td

Promote the use of Tdap - particularly in those who have contact with infants Postpartum Tdap policies (standing orders for Tdap

postpartum); encourage ED use of Tdap instead of Td Tdap for grandparents, daycares, caregivers, HCW’s! Work with payers re: Tdap reimbursement

Clinician education Tdap recommendations Pertussis signs and symptoms: if you’re testing,

TREAT Exclude immediately; once antibiotic started for

a minimum of 5 days (7days in HCW’s)!Public education

Vaccination/cocooning Limitation of visits Pertussis signs and symptoms Keep ill people away from infants

PERTUSSIS MITIGATION

ALTERNATIVE MITIGATION VIA VACCINATION (NOT ACIP /CDC)

Tdap workplace requirement:L&D, PEDI, daycares Off-label Tdap use:

>65 years old (very likely to be approved by ACIP late October 2010)

<10 years old (7-9 y.o.; possibly to be endorsed by ACIP with VFC annotation)

Use in pregnancy (not a contraindication, but category C; little to no risk with inactivated vaccine; important in local outbreaks or when working with children /adolescents)

DTaP changes Starting as early as 6 weeks of age, and accelerate Adding another shot at 6 y.o. (not just 4-6 range)

PERTUSSIS: WHO SHOULD BE TESTED? Patients of any age with cough >2

weeks. Patients with respiratory illness of

any duration who are contacts to a pertussis or to persons with prolonged cough illness.

Infants <12 months old with any respiratory symptoms of any duration, even those immunized against pertussis or test positive for RSV.