novel h1n1 virus: planning and response october 12, 2009 adolfo valadez, md, mph assistant...

Novel H1N1 Virus:Planning and Response

October 12, 2009

Adolfo Valadez, MD, MPHAssistant Commissioner, Division for Prevention and

Preparedness ServicesTexas Department of State Health Services (DSHS)

September 16, 2009

Pandemic

Definition: A disease outbreak occurring over a wide geographic area and affecting an exceptionally high proportion of the population

The June 2009 declaration of a pandemic by the World Health Organization is an indication of the spread of the disease,

not the severity.

Pandemic Severity Index

Case Fatality Ratio

Number Deaths in Texas

> 2% > 144,000

1 - 2% 72,000 - 144,000

0.5 - 1% 36,000 - 72,000

0.1 - 0.5% 7,200 – 36,000

< 0.1% < 7,200

CDC Recommended Community-based Strategies

Pandemic Severity Index

Interventions by settingMild

(Category 1)

Moderate

(Cat. 2-3)

Severe

(Cat. 4-5)

Workplace/Community/SchoolDecrease number of social contacts:Adults: teleconferences/webinarsStudents : altered curriculum; computer-based classes

Generally not recommended

Consider Recommend

Modify workplace/school schedules and practices Adults: telecommute; staggered shiftsStudents : staggered school schedules


Consider Recommend

Increase distance between personsAdults: Increase space between people in mtgs, public transitStudents: Increase space between students in school buses; schools


Consider Recommend

Modify, postpone, or cancel public events Adults: UT/TAMU football game, theatre eventsStudents: UIL, graduation


Consider Recommend

Texas Confronts Novel H1N1 Virus

April 17: - The CDC lab confirmed the first novel H1N1 virus (California)

April 23: - Confirmation of novel H1N1 virus in two teenagers from the same school in Guadalupe County

April 25: - Decision to close Schertz-Cibolo High School was made

April 26: - All 14 schools in the Schertz-Cibolo Universal City ISD closed

May 5: - CDC announces new guidelines for school closure

May / June - End of school year

June 17: - Lab confirmed case at summer camp in Tyler

August 24: - School starts

831 Texas school campuses were closed one or more days during April 29 – May 5, 2009

Pandemic Influenza Planning Assumptions Prior to April

2009

Pre-April Assumptions Reality

H5N1 (bird flu) would be the pandemic strain

H1N1 was the pandemic strain

Need to plan for high mortality and morbidity Low mortality

Outbreak would occur overseas (Asia) Outbreak began in Mexico

Potential for rapid spread Rapid spread

Elderly, chronically ill, and very young would be the most affected

Primarily affected school age

Vaccine would not be available Vaccines will be available

Key role for community mitigationSchools were closed as a precaution

Unpredictability of influenza virusConducted surveillance for changes

in the virus strains

www.texasflu.orgH1N1 Influenza and Schools

Influenza Virus Infection

• Sudden onset of symptoms

• Incubation period: ~1-4 days

• Infectious period: 5+ days, starting 1 day before symptoms (longer in children)

• Fever, headache, cough, sore throat, aches, possibly vomiting and diarrhea

• 50% of individuals with typical “seasonal” influenza have contact with the health care system (ranging from a doctor visit to hospital admission)

General Characteristics

Several types of influenza

virus are circulating.

Signs and Symptoms of Novel A (H1N1) Cases Reported to

DSHS April – May 2009

Symptoms reported in confirmed cases

Fever (>100ºF)

(median temp: 102.0ºF)94%

Cough 87%

Sore throat 61%

Diarrhea and/or vomiting 47%

*Based on early cases when we were doing general surveillance

Critical point:

88% of the confirmed H1N1 cases met Influenza Like Illness (ILI) case definition (fever > 100ºF and sore throat or cough)

Descriptive Statistics of Novel A (H1N1) Cases Reported to

DSHS April – May 2009*

Demographic %Sex

Male 49%

Female 51%

Age (median 10 yrs, range 1 mos – 84 yrs)

<5 years 16%

5-18 years 65%

19-45 years 15%

>45 years 4%

*Based on early cases when we were doing general surveillance

Novel H1N1 Deaths in Texas

Confirmed Novel H1N1 deaths from end of April to 10/03/09

* Mexico City resident

Patient Age Number of H1N1 deaths

< 6 months of age 1

6 – 11 months of age 1

1 – 4 yrs of age 2*

5 – 9 yrs 2

10 – 18 yrs 11

19 – 24 yrs 3

25 – 49 yrs 35

50 – 64 yrs 10

65 + yrs 4

TOTALS 69

Perspective

Based on CDC estimates of national annual flu burden

Texas Data Seasonal flu, annual estimates*

Novel flu reported

Cases 1.2 – 4.9 million 5,200**

Hospitalizations 16,000+ 282

Deaths 2,880 69***

* Bigger effect with H1N1 and seasonal flu combined

** Only represents confirmed cases reported prior to 7/31/09

*** As of 10/03/09

Lessons Learned in 2009

• Young adults MAY experience higher than expected mortality rates from a “novel” (new) strain of influenza virus

• Severity of illness MAY be lessened by prior exposure to a genetically related influenza virus

• Targeted, layered non-pharmaceutical interventions (NPI) MAY help mitigate the impact of flu on communities

• Timely closure of large public gatherings MAY help diminish the “peak” number of people who are ill with the flu in a community at any one time

• Outpatient and inpatient medical care facilities WILL be overwhelmed when the number of people who are seriously ill at any one time exceeds each community’s medical surge capacity.

Lessons Learned in 2009 (cont’d)

Roles and Responsibilities

Role of DSHSRole of DSHS

Role of UniversitiesRole of Universities

• Provide guidance based on Federal recommendations and evidence-based science

• Establish a relationship with state and local health departments

• Keep informed (www.TexasFlu.org)

• Develop educational messages

• Plan for assistance for students with influenza-like illness

• Develop plans for how to reduce exposure

• Consider alternative educational delivery

Role of Local Health DepartmentsRole of Local Health Departments

• Provide local guidance on specific recommendations

• Partner with other community entities including schools and universities

Role of Texas Higher Education Coordinating Board

Role of Texas Higher Education Coordinating Board

• Maintain communication with DSHS and Texas Division of Emergency Management and monitor situation

• Provide information and links on website (www.thecb.state.tx.us)

Preventive Measures in Schools / Universities

• DSHS concurs with CDC that the primary ways to reduce spread of flu in schools / universities are:• Vaccination – seasonal and novel H1N1 influenza• Staying home when ill• Early identification of ill students, faculty and staff

• Practicing prevention strategies (good cough etiquette and hand hygiene)

• At this time, school closure is not advised for a single suspected or confirmed H1N1 case (this recommendation may change if pandemic changes: check www.texasflu.org for updates)

• Schools / universities in consultation with local heath authority decide to close public schools

Texas’ Planning Efforts

Some of Texas’ planning efforts involve:• Non-Pharmaceutical Interventions (NPI)• Detection and Monitoring• Laboratory Surveillance• Antivirals Distribution• Vaccination Distribution• Medical Surge• MACC Activation / Provider Call Center• Communications / Public Health Messages

Non-Pharmaceutical Interventions (NPI)

• Activities used to limit the spread of an infectious disease• Does not include medications or medical interventions• Addresses two main areas:

• Infection Control (wash hands, cough etiquette, disinfect shared surfaces, keep hands away from face, etc.)

• Social Distancing (stay home when sick – staff and students)

• Benefits:• Immediately available• Limited cost • Applied by anyone• Scalable to Individual/Family, Community, or International levels• Reduce the spread of disease in a community or campus• Reduce stress on health and medical services• Guided by science

• Decisions whether to cancel classes or events are university decisions

Antiviral Medications for Influenza

• Inhibits the growth or reproduction of the virus

• Antiviral medications are available in the normal marketplace

• Antiviral medications are just one piece of the response effort

• If given within 48 hours of exposure or before exposure antivirals may:• Prevent disease, but only while medication is taken

• No long term protection

• If given within 48 hours of symptoms antivirals may:• Reduce length of illness by 1-2 days

• Prevent severe complications

Antiviral Distribution: Strategic National Stockpile (SNS)

• State Stockpile: • Approximately 2.5 million antiviral courses available in Texas• 2.5 million more reserved for Texas in SNS

• Distribution: • If your healthcare provider prescribes an antiviral, visit one of the

participating pharmacies in your county (www.TexasFlu.org and click on “Families and Individuals”)

• Recommendation is that antivirals be prescribed to high-risk individuals, including:• Pregnant women• People with acute or chronic respiratory disease, particularly those age

groups more at risk for complications from H1N1• Children less than 5 years of age• Immuno-suppressed people caused by medications or HIV

H1N1 Vaccinations:Expected in October 2009

INITIAL TARGETED GROUPS:• Pregnant women• Household contacts and caregivers for children < 6 months • Healthcare and emergency medical services personnel• All people 6 months - 24 years of age• Persons 25 years through 64 years of age who have health conditions

associated with higher risk of medical complications from influenza disease

IF LIMITED VACCINE AVAILABILITY:• Pregnant women• Household contacts and caregivers for children < 6 months• Healthcare and emergency medical services personnel who have direct

contact with patients or infectious material• Children aged 6 months – 4 years• Children and adolescents aged 5 – 18 years who have health conditions

associated with higher risk of medical complications from influenza

Vaccinations

• Vaccine: • CDC has provided a new planning scenario that

includes 3.3 million doses potentially coming to Texas in October.

• Followed by weekly availability of vaccine

• Allocation for states is population based• For Texas this is about 7.6%

• Some university health centers will likely be offering vaccine

• Mass Vaccination Plan posted on website

Vaccine Safety

• Modern vaccine development: • Improved process for manufacturing vaccines• FDA must approve after testing on animals and humans

• Method for developing H1N1 vaccine is the same as that used for seasonal flu• This method is both proven and safe• Made with much of the same ingredients for seasonal flu vaccines

• Clinical trials for effectiveness and safety are still underway

• Ongoing monitoring after release

Priority Vaccine Recommendations

Target Groups Seasonal Flu Vaccination

H1N1 Vaccination

Pregnant women X X

People who live with or care for babies under 6 months X X

Children & young people age 6 months through 18 yrs X X

All young adults 19-24 --- X

People 50 years of age and older X ---

People age 24-64 with certain chronic medical conditions

X X

Health care and emergency medical services workers X X

People who live in nursing homes and other long-term care facilities

X ---

People who live with or care for those at high risk for complications from flu (except infants)

X ---

At-Risk Priority Populations

Antiviral Medication H1N1 Vaccinations• Children less than 5 years old

• Persons 65 years or older

• Pregnant women

• Adults and children with:– Chronic pulmonary, cardiovascular,

hepatic, hematological, neurologic, neuromuscular, metabolic disorders and/or immunosuppression including those caused by medications or HIV

• Residents of nursing homes

• Health care and emergency medical services workers

• Pregnant Women

• Those who live with or provide care to infants <6 months

• Children and young people age 6 months through 24 years

• People between 25 and 64 years who have chronic medical conditions

Medical Surge Capacity:Alternative Care Systems

• Try to care for ill people at home if possible• Home care guidance (provided through call centers)• Guidance on when to seek medical care

• Expand outpatient capacity• Flu clinics• ER capacity (tool kits available)

• Postpone non-essential healthcare activities if needed

• Identify local nursing home capacity

• Identify hospital surge capacity strategies for critical populations (Pediatrics, OB, Critical care)

• Develop alternate care sites as last option. Texas has approximately 22,000 alternate care site beds identified

H1N1 Call Center

2-1-1 Texas Information and Referral Network (TIRN)• Joint call center, using existing Area Information

Centers (AICs) and DSHS nurses• Respond to callers on vaccination clinic locations,

emergency clinic locations, information to dispel rumors, and other general H1N1 information

Communications

• www.TexasFlu.org• Information for public, stakeholders, professionals• Guidance documents, FAQs, tools• Sign up for e-mail updates

• News media relations• Ongoing contact with news media

• Public awareness campaign• Multimedia campaign: information for the public and tools for

stakeholders

• Conference calls with partners and stakeholders• Situational awareness and response activities

www.TexasFlu.org

Public Health Messages

• Practice good hand hygiene

• Practice cough/sneeze etiquette

• Be prepared to get sick

• Stay home when you get sick

• Get your flu vaccinations (shots or sprays)

• No aspirin for kids when they are sick

• Get pneumococcal vaccine as recommended

Summary

• Get seasonal flu vaccine now; get H1N1 vaccine as available

• H1N1 vaccine available in October for targeted populations

• Non-pharmaceutical interventions are the most readily available and an effective means of reducing the spread of infectious diseases

• Guidance documents are available. Refer to www.texasflu.org or sign up for email alerts when updates occur.

• Plan now with others in your community / university

• Encourage common sense measures

• like washing hands, covering coughs and sneezes, staying at home when sick with flu-like symptoms, etc.

• Engage in continuity of operations planning at work, personal readiness planning at home

novel h1n1 virus: planning and response october 12, 2009 adolfo valadez, md, mph assistant...

Documents

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