Novel H1N1 Influenza A Epidemiology, Clinical and Infection Control

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Novel H1N1 Influenza A Epidemiology, Clinical
and Infection Control

• New York City Department of Health and Mental
  Hygiene

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Overview

• Epidemiology in NYC
• How it started
• NYC Patient outcomes
• Clinical Presentation of H1N1
• Infection Control
• Personal protective equipment
• H1N1 Vaccine

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The call
100 students with Fever as high as
102.7? Headache Sore throat Dizziness Shortness
of breath
Call from School Nurse
April 23
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Context
Call from School Nurse
April 23
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St. Francis Preparatory School

• Catholic school in Queens
• Students from broad geographic area
• 2700 students
• Grades 912
• Returned from spring break April 20

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DOH Initial School Outbreak Response
Call from School Nurse
April 23
Phone survey of 213 students sent home
-Spectrum of illness -Travel over break
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DOH Initial School Outbreak Response
Call from School Nurse
April 23
DOH Team and Phone survey
51 NP specimens submitted for testing to NYC
Public Health Lab
April 24
DOH Incident Command System Activated
Decision to close school
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Novel Influenza (H1N1) (Swine Origin)March
May, 2009
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Swine Influenza - Background

• Triple-reassortant swine influenza A (H1) viruses
  in pigs 1990s
• 11 sporadic human cases 2005 09
• Median age 10 (16 mo-48 yr), 4 with high risk
  conditions
• 9 pig exposure, one suspected human-human
• Incub 3-9 days
• Fever (90), Cough (100), HA (60), Diarrhea
  (30)
• Four hospitalized, two ventilated
• Four received oseltamivir, all 11 recovered

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Worldwide Current Outbreak
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U.S. Epidemiology
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U.S. Epidemiology
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U.S. Epidemiology
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U.S. Epidemiology
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Infected Healthcare Personnel
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NYC Early Epi Links

• Mexico
• St. Francis Preparatory School
• PS 177
• Current epi links much less relevant

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NYC Surveillance

• Enhanced passive
• Active Laboratory
• Sentinel Provider
• Syndromic
• Outbreaks

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Number of Hospitalized Confirmed and Probable
Cases by Date of Illness Onset (n157)
Date of illness onset available for 137/164
hospitalized cases and 20/25 probable cases
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Clinical

• Mostly mild influenza-like Sxs
• More N/V/D
• Death
• Obese ( other underlying?)
• 2 d after Sx onset, resp distress, ICU admission
• ARDS, FiO2 100, PEEP 20
• Creat 3 to 4 to 5 - dialysis
• oseltamivir ribavirin ( Energex)
• Died hospital day 5

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Descriptive Epidemiology of Hospitalized
Confirmed Cases (n164)

• 80 female (49), 82 male (51)
• Median age 19 years (range 1 month-87 years)

Data available for 162/164 confirmed cases
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Descriptive Epidemiology of Hospitalized
Confirmed Cases

• Race/ethnicity (n95)
• 30 (32) White, non-Hispanic
• 33 (35) Hispanic
• 6 (6) Native Hawaiian or Asian Pacific Islander
• 4 (4) Black
• 2 (2) American Indian or Alaskan Native
• 20 (21) unspecified
• Travel to Mexico (n80) 13 (16)
• Contact of a confirmed case (n56) 10 (18)
• Influenza Vaccine Status (n62)
• 21 (34) vaccinated for 08-09 season
• Median time from onset of illness to hospital
  admission (n81)
• 4 days (range 1-13 days)
• Median length of stay (n81)

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Clinical Characteristics (n92)
Median temp 38.8C (range 36.1-42.5) for 82
patients for whom information was available
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Underlying Conditions (n93)

• 66 (71) patients with chronic conditions median
  age 31 (5 mo-86 yrs)

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32 people had more than one underlying
condition median 1 (range 1-5)
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Radiology Findings (n82)

• 43 (49) had abnormal findings c/w pna
• 25 (58) had findings of bilateral infiltrates
• 28 (65) of these patients had at least one
  underlying medical condition
• Median age 29 years (5 month-86 years)

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Antiviral Usage (n88)

• 63 (60) were treated with antivirals
• 55 received oseltamivir 7 received zanamivir
• 7 received amantidine in addition to oseltamivir
• 4 received rimantidine in addition to oseltamivir
• Median time from illness onset to antiviral
  initiation (n55)
• 4 days (1-25 days)
• Median time from admission to antiviral
  initiation (n54)
• 1 day (-6 to13 days)

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Antimicrobial Usage (n83)

• 70 (75) were treated with antibiotics
• Median of antibiotics 2 (range 1-7)
• All patients had antibiotics initiated on day of
  admission (time unknown)
• Most common abx azithromycin (29), ceftriaxone
  (29), levofloxacin (21), vancomycin (17)
• 3 were treated with antifungals
• fluconazole, amphotericin, voriconazole

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Other Etiologies

• Scant information available
• Two patients had group A strep prior to
  hospitalization
• One of these patients also had empyema with no
  growth
• One patient had Stenotrophomonas maltophilia from
  trach aspirate
• 49 people had negative blood cultures
• Most had antibiotics close to the time of the
  blood cultures
• Median time between abx and cultures
• 0 days (-8 to 6 days)

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Indicators of Severity

• 26/118 (22) were admitted to the ICU
• 13 required mechanical ventilation 9 had ARDS
• 6 required pressor support
• 6 had sepsis
• 4 had shock (either septic or cardiogenic)
• Median age of ICU patients (n23) 23 years (1
  month-86 yrs)
• Median length of ICU stay (n14) 9 days (2-34
  days)
• Time of onset to ICU admit (n13) 6 days (2-14
  days)

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Infection Control

• Use STANDARD and DROPLET precautions for routine
  medical care of patients with confirmed or
  probable H1N1 influenza, or influenza-like
  illness. Negative pressure AIIRs and N95
  respirators are not recommended for routine
  patient care for patients with H1N1 influenza or
  influenza-like illness.
• Aerosol-generating procedures (e.g.,
  bronchoscopy, intubation and extubation, and deep
  open tracheal suctioning) should be performed,
  when feasible, in a negative pressure airborne
  infection isolation room (AIIR). Disposable
  fit-tested N95 respirators and eye protection
  (goggles or face shield) should be worn by health
  care personnel performing these procedures.

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Antivirals

• Neuraminidase inhibitors
• oseltamivir (Tamiflu)
• zanamivir (Relenza)
• Not susceptible to adamantanes (amantadine,
  rimantadine)
• ? Ribavirin for severely ill
• ? IV peramivir, IV oseltamivir

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Treatment

• Hospitalized with flu A
• Hospitalized with ILI pending testing (clinical
  judgment)
• Mild illness with underlying high risk condition

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H1N1 Vaccine Recommendations Priority Groups

• Pregnant women
• Children and young adults 6 months through 24
  years of age
• Adults 25 through 64 years of age with underlying
  medical conditions
• Health care workers and EMS
• Household contacts and care givers of children lt6
  months of age

CDC, MMWR August 28,2009/Vol. 58/No. RR-10
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H1N1 Vaccine Recommendations Priority Groups
continued

• Once initial priority group is vaccinated, add
• Adults 25 through 64 years of age
• Following group is those 65 and older

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H1N1 Vaccine Dosing

• Clinical trials in progress
• Looking at 1 vs. 2 doses
• 7.5 mcg, 15 mcg and 30 mcg
• With and without adjuvant
• Different populations
• Initial results from adult studies released last
  week
• Pediatric results pending
• Vaccine licensed by FDA as a strain change
  supplement

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H1N1 Vaccine Presentation

• Inactivated and live attenuated intranasal
  vaccine
• Multidose vials
• Single use vials
• Single dose syringes
• Pediatric 0.25 mg syringes
• Information pending about number of doses of each
  presentation
• Availability of the different presentations may
  vary by time of distribution

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H1N1 Vaccine Reporting and Accountability

• All reporting through the CIR
• Already required for children 18 and younger
• Current State law requires consent for 19 and
  older
• Expect this to be waived through emergency
  regulations
• Future shipments based on accountability
• Adverse event reporting module in CIR

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Influenza Vaccine Uptake
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Influenza Vaccine Recommendations 2009-2010

• All persons who want to reduce their risk of
  influenza
• All children 6 months to 18 years of age
• Women who will be pregnant during the influenza
  season
• All persons gt 50 years of age
• Children on chronic aspirin therapy
• Adults with chronic medical conditions
• Residents of nursing homes and other chronic care
  facilities
• Persons who live with or care for persons at high
  risk for influenza-related complications,
  including healthy household contacts and
  caregivers of children from birth -59 months of
  age
• Health care workers

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Influenza Vaccine Recommendations for All
Persons with Chronic Illness

• Heart disease
• Pulmonary disease (e.g., emphysema, asthma)
• Metabolic disease (e.g., diabetes)
• Renal dysfunction
• Any condition that can compromise respiratory
  function
• Neuromuscular diseases, seizures, spinal cord
  injury, cognitive dysfunction
• Hemoglobinopathies
• Immunosupression
• HIV/AIDS
• Medications and other treatments

gt 6 months of age
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Implementation
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Getting Ready for Flu Season

• Order sufficient vaccine
• Vaccinate all office staff
• Develop protocols within the health care setting
• Have patient information available (posters,
  flyers)
• Flag charts of high-risk patients
• Use standing orders
• Have special designated vaccination hours
• Make every encounter an opportunity to vaccinate
• Use signed declination forms if is vaccine
  refused
• Offer vaccine once available continue
  vaccinating into the spring

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2009-2010 Influenza Vaccine

• A/Brisbane/59/2007 (H1N1) - like
• A/Brisbane/10/2007 (H3N2) - like
• B/Brisbane/60/2008 like
• .

Strains included in the vaccine change every year
based on surveillance data You need this
years flu vaccine to protect against this years
flu!!
Vaccine supply information will be available at
www.cdc.gov/flu
New strain
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Timing of Annual Influenza Vaccine

• In the past we would say influenza activity
  peaks between late December and early March
• However, we have learned that seasonal flu
  circulates earlier and longer than previously
  appreciated
• Optimal time for vaccination programs may be
  September through November, however, vaccination
  should continue into the new year
• Persons should be vaccinated against influenza as
  soon as vaccine is available

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Additional Guidance

• Can provide H1N1 and seasonal vaccine at the same
  time, but at different sites
• Exception is that both LAIVs presentations can
  not be given together
• Do not hold back second doses
• There will be sufficient vaccine available for
  all who want to be vaccinated

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Challenges

• Need to provide both seasonal and H1N1 vaccine
• Some young children will require 2 doses of
  seasonal vaccine plus H1N1 (1 or 2 doses)
• Safety concerns
• Transmission may occur prior to vaccine being
  available
• Adverse event reporting module in CIR

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Implementation Considerations

• Consider expanding access to flu vaccine
• Hold evening, weekend flu clinics
• If a large practice or facility, ensure
  implementation of non-patient specific standing
  orders
• Reminder recall/postcards/phone calls
• Distribute education materials
• Health bulletinss
• Display posters in the waiting/exam rooms

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Resources

• Nyc.gov/flu
• Nyc.gov/health/cir or 212-676-2323
• CHI
• Cdc.gov/flu
• ACIP
• Recommendations August 28, 2009/Vol. 58/No.
  RR-10 cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm?
  s_cidrr5810a1_e
• July 31/vol58/No. RR 8 cdc.gov/mmwr/preview/mmwr
  html/rr5808a1.htm?s_cidrr5808a1_e
• ACIP presentations at cdc.gov/vaccines/recs/acip/
  meetings.htm
• NFID at nfid.org

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Information from DOHMH

• Provider Access Line
• 1-800-NYC-DOH1
• Health Alert
• Sign up on DOHMH Website

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