H1N1 Influenza A: Preparing Suffolk County

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H1N1 Influenza APreparing Suffolk Countys
Schools and School Districts

• Humayun J. Chaudhry, DO, MS, SM, FACOI, FACP,
  FAODME
• Commissioner, Suffolk County Department of Health
  Services, NY
• and
• Clinical Associate Professor of Preventive
  Medicine,
• Stony Brook University School of Medicine, N.Y.

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Outline

• Suffolk County Department of Health Services
• Definitions and a History of Pandemics
• H1N1 Influenza A Virus
• Symptoms and Transmission Patterns
• Suffolk County, New York, World Statistics
• Suffolk County Public Health Response
• CDC Guidance for School Officials (K-12)
• QA

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Suffolk County, Long Island, New York
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Suffolk County Department of Health Services
Senior Leadership
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Endemic, Epidemic, and Pandemic Defined

• EndemicA disease that already occurs at a high
  rate in a given population
• EpidemicAn outbreak of new cases of a disease in
  numbers that exceed what is expected
• PandemicAn epidemic that spreads worldwide

Malarious Area www.cbsnews.com
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Pandemics Throughout History

• Plague of Justinian 541 A.D.
• The Black Death 1347-1350 A.D.
• Typhus or camp fever 15th and16th centuries
• Smallpox 16th to 18th centuries
• Spanish Flu 1918

The Roof Rat www.algonet.se
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How Influenza Viruses Change

• Antigenic Drift
• Small changes in viruses over time
• New strains appear
• May not be recognized by antibodies
• Antigenic Shift
• Abrupt, major change (reassortment)
• Results in novel strain or new subtype
• Can cause pandemic influenza

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Seasonal Influenza, 2009

• Annual seasonal influenza epidemics
• gt36,000 deaths in US from seasonal influenza
  (100-200 deaths in Suffolk County each year)
• gt200,000 hospitalizations from flu each year
• Over 85 mortality in persons 65 yrs
• Severe disease in infants, young children, and
  elderly individuals
• Attack rate of 5-15 (Nursing home attack rate of
  60)
• Potential for pandemic

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Novel H1N1 Influenza A Virus
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H1N1 Influenza A (Swine Flu), 2009

• WHO Phase 6 Pandemic (declared June 11, 2009)
• gt1 million cases in the U.S.
• gt40,617 confirmed cases in U.S.
• gt263 confirmed deaths in U.S.
• gt180 confirmed cases in Suffolk County (6 deaths)
• Imminent Public Threat declared by NYSDOH August
  6, 2009
• A brand new virus
• A quadruple reassortment of 2 swine strains, 1
  human strain, and 1 avian strain of influenza
  virus
• Mean age of cases in Suffolk County and in U.S.
  12
• Severe infection occurs in individuals who are
  not at the extremes of age
• Attack rate of 22-30 initially

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Novel H1N1 Influenza A Symptoms

• (Fever, cough, and/or sore throat), malaise, and
  headache
• Vomiting and diarrhea (unusual for seasonal
  influenza)
• Chills, myalgias, and arthralgias
• Infants fever, lethargy, /- cough
• Elderly individuals and immunocompromised hosts
  may also have atypical presentations

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Risk Factors for Novel H1N1 Influenza A Virus
Complications

• Chronic lung disease (especially asthma, COPD)
• Immunocompromised states (including pregnancy,
  kidney disease, cancer)
• Heart disease (other than HTN)
• Diabetes Mellitus
• Obesity?
• Most Common Reasons for Hospitalization
  Pneumonia and Dehydration

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Management of Novel H1N1 Influenza A Infection

• This virus is sensitive to Tamiflu and Relenza,
  two antiviral medications (only available by
  prescription)
• It is resistant to other antiviral medications
• Treatment is recommended for
• All hospitalized patients with confirmed,
  probable or suspected cases
• Patients who are at higher risk for seasonal
  influenza complications
• Tamiflu and Relenza are not like antibiotics and
  are most effective when used within 24-48 hours
  of an influenza illness

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Testing for H1N1 in Fall, 2009

• Not a priority of the CDC, NYSDOH, or the Suffolk
  County Department of Health Services except
• Pediatric hospitalizations for influenza-like
  illness
• Any deaths attributed to, or linked with, a
  diagnosis of pneumonia or other respiratory
  infection
• As determined by a health care provider in
  consultation with the NYSDOH

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Transmission of H1N1

• Primarily by respiratory droplets (sneezing and
  coughing)
• Incubation Period 1-4 days
• Viral shedding (contagiousness)
• Begins 1 day before symptoms
• Peak shedding is during first 3 days of illness
  with fever
• Lasts 7 days in adults or 10 days in children

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Flu Pandemics A Comparison

• YEAR 1918 2009
• World Population 1.8 Billion 6.8 Billion
• Primary Mode of Ships, Jet
  Aircraft,
• Transportation Railroad Automobile
• Time for Virus to 4 months 4 days
• Circle the Globe
• Estimated Dead 20 Million ?
• Worldwide

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Influenza Viral Morphology

• Influenza Type A, B, C - based on antigenic
  properties of nucleoproteins (NP) and matrix (M)
  proteins
• Hemagglutinin protein that helps the virus
  attach to a healthy cell (15 types)
• Neuraminidase protein that helps release
  viruses into the body (9 types)

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How Are We Doing With Seasonal Influenza
Vaccination Rates in the U.S.?

• Healthy People 2010 influenza vaccination targets
  are
• 90 among persons aged 65 years
• 60 among persons aged 18-64 years
• CDC Data from the 2006-07 Influenza Season
  indicate vaccination rates of
• 72.1 among persons aged 65 years
• 35.1 among persons aged 18-49
• 42.0 among persons aged 50-64

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H1N1 in the Fall, 2009

• Washington has had the nations highest rate of
  H1N1 during the peak period in the state (2,500
  suspected cases)
• 366.8 cases of the flu for every 10,000 students
• New York State has had
• 6.5 cases of the flu for every 10,000 students

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Cornell University ILI Outbreak

• Cornell University in Ithaca, New York, on Sept.
  18 reported more than 700 cases of ILI since
  classes began
• A 20 year-old student at Cornell with an
  underlying medical condition died of
  complications from the H1N1 virus two weeks ago
• 3 adjoining college campuses have had a total of
  100 cases

• A student at Cornell University dispensing soap
  to students on Sept. 18

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Legal Authority

• Pursuant to the New York Public Health Law,
• the Suffolk County Commissioner of Health
• Services has the legal authority to order the
• isolation and/or quarantine of any person or
• thing infected with or exposed to a
• communicable disease.
• New York Public Health Law 2100 (1)
• 10 N.Y.C.R.R. 2.1, 2.25 2.29.

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Personal Hygiene is Best Tool

• Handwashing with soap and water is critical
• Virus can spread by contamination of hands that
  is then followed by hand contact with mucous
  membranes
• Alternatives to soap and water exist
• Alcohol-based hand gels

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Masks May Also Play a Role

• Use of masks may decrease the spread of virus
  between people
• Widespread use during SARS outbreak
• May prevent children from putting hands/objects
  into their mouths

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This Might Help

• Chicken Soup
• Orange Juice
• Vitamin C
• Multivitamins

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Kobe, JapanMay 19, 2009
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Daily Swine Flu Exam China, May, 2009
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School Closure, Deer Park School District,
Suffolk County, N.Y., May, 2009
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CDC Guidance for K-12 School Response

• Purpose
• Provide guidance on suggested means for reducing
  exposure of students and staff to H1N1 and
  seasonal influenza during the 2009-2010 school
  year
• Goals
• Decrease spread of flu among students and staff
• Minimize disruption of day-to-day social,
  educational, and economic activities

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Recommended School Responses (If similar severity
as in Spring 2009)

• Stay home when sick
• Separate ill students and staff
• Teach hand hygiene and respiratory etiquette!
• Early identification and treatment of high-risk
  students and staff
• Routine cleaning
• Consideration of selective school dismissal

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Recommended School Responses (If increased
severity)

• Active screening
• High-risk students and staff stay home
• Students with ill household members stay home for
  5 days
• Increase distance between people at schools
• Extend the period for ill persons to stay home
• Selective, reactive, and pre-emptive school
  dismissals

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Active Screening for Illness

• Ask about fever and other symptoms
• Send home people with symptoms of acute
  respiratory infection
• Be vigilant throughout the day
• Send students and staff who appear ill for
  further screening by school-based health care
  worker
• If possible, have ill person wear a mask until
  sent home

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If severity increases Increase Distance between
People

• Explore innovative methods
• Rotate teachers rather than students
• Cancel classes that bring students together from
  multiple classrooms
• Outdoor classes
• Move desks farther apart
• Move classes to larger spaces
• Discourage use of school buses and public transit
• Postpone some class trips

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Suffolk Countys H1N1 Plan for Fall

• 1) Two possible scenarios
• Moderately severe illness
• Slightly more cases than in Spring, 2009
• Increased severity of illness
• No indication from CDC or WHO that this is
  happening, or will happen, but we will be
  prepared
• 2) Stay Home if You Are Ill
• Influenza-like Illness (ILI) Fever, Cough
• Suffolk Countys definition of fever gt100ºF or
  feeling warm/hot plus chills/sweats

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Suffolk Countys H1N1 Plan for Fall

• 3) H1N1 vaccination and seasonal influenza
  vaccination will be urged for target populations
• Hospitals, Private Physician Practices,
  Pharmacies
• 10 SCDHS Health Centers and gt50 Vaccination
  Clinic PODs (Points of Dispensing) throughout
  County
• Schools, if they wish to have vaccination clinics
• Mandatory in NYS for all physicians and staff at
  hospitals, Article 28 facilities, Home Health
  Care, Hospice (NYSDOH Emergency Regulation)
• 4) Upon request, SCDHS will provide guidance and
  education to public and private school nurses and
  physicians about H1N1 vaccination procedures,
  techniques and precautions

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Suffolk Countys H1N1 Plan for Fall

• 5) SCDHS will provide, upon request, educational
  and other curricular material about H1N1 and
  preventive hygiene to public and private schools
• 6) Regular schedule of meetings and
  communications between SCDHS and the SCSSA,
  Eastern Suffolk BOCES and Western Suffolk BOCES

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Suffolk Countys H1N1 Plan for Fall

• 7) Communication to the public
• Posters on buses, PSAs (radio, TV, print media),
  press releases, weekly electronic updates, SCDHS
  website announcements, press conferences
• SCDHS H1N1 Telephone Hotline, starting September
  9
• 8) If increased severity of illness, selective or
  pre-emptive school closures may be considered as
  a last resort, especially if school operations
  disrupted

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Suffolk Countys H1N1 Plan for Fall

• 9) If increased severity of disease,
  communications will be enhanced and more frequent
• SCDHS H1N1 Hotline Hours Extended
• Enhanced surveillance of severity of disease
• Daily electronic updates
• 10) First Responders (EMS, Police) may be asked
  to wear N-95 masks this Fall. All other health
  care personnel may be asked to wear N-95 masks or
  disposable masks

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Points of Distribution (POD)
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Why do we think vaccines work?
Viral Disease Year of Peak U.S. Prevalence Peak Number of Cases per Year in U.S. Number of Annual U.S. Cases in Modern Vaccine Era (2007)
Hepatitis A 1971 59,606 3579
Hepatitis B 1985 26,654 4713
Measles 1958-1962 503,282 715
Mumps 1967 185,691 30
Polio 1951-1954 16,316 0
Rubella 1966-1968 47,745 11
Congenital Rubella 1966-1968 823 0
Smallpox 1900-1904 48,164 0
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If severity increases School Dismissals

• Preemptive dismissals
• CDC will consider need to recommend based on
  global and national risk assessments
• Goal decrease spread of influenza virus and
  reduce demand on health care system
• Use early and in conjunction with other
  strategies
• Time to vaccine-induced immunity may be
  considered
• If dismissing, do so for 5 to 7 days and reassess
• Allow staff to continue to use facilities
• Plan for prolonged dismissals and secondary
  effects

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Review

• Suffolk County Department of Health Services
• Definitions and a History of Pandemics
• Novel H1N1 Influenza A Virus
• Symptoms and Transmission Patterns
• Suffolk County, New York, World Statistics
• Suffolk County Public Health Response
• CDC Guidance for School Officials (K-12)
• QA

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How Bad will the Novel H1N1 Influenza A Virus be
in the Fall/Winter of 2009?
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Thank You!Humayun.chaudhry_at_suffolkcountyny.gov