Pandemic Influenza Update

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Pandemic Influenza Update

• Name, Credentials and Contact Information of
  Presenter

Location and Date
www.kdheks.gov
2
Acknowledgements for Content

• Jason Eberhart-Phillips, MD, MPH
• Kansas Department of Health and Environment
• Centers for Disease Control and Prevention
• World Health Organization
• US Health and Human Services

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Pandemic Influenza
Background
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What is a Pandemic?
A pandemic is a global disease outbreak. An
influenza pandemic occurs when a new influenza A
virus emerges for which there is little or no
immunity in the human population, begins to cause
serious illness and then spreads easily
person-to-person worldwide (Flu.gov, 2009). For
additional information on pandemic influenza
visit www.pandemicflu.gov
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Prerequisites for Pandemic Influenza

• A new influenza virus emerges to which the
  general population has little/no immunity

• The new virus must be able to replicate in humans
  and cause disease

• The new virus must be efficiently transmitted
  from one human to another

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Circulating Influenza Strains and Pandemics in
the 20th Century
1918 Spanish Flu
1968 Hong Kong Flu
1957 Asian Flu
1-4 million deaths
20-40 million deaths
1-4 million deaths
H3N2
H2N2
H1N1

• 1920 1940 1960 1980 2000

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What Weve Learned from History

• Pandemic influenza typically comes in waves. The
  great 1918-1919 pandemic came in 3 distinct
  waves
• The second wave was very different much more
  lethal
• Over the summer the virus had changed

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The First Flu Pandemic of the 21st Century

• On June 11, 2009
• WHO raised pandemic alert level to Phase 6
• A global pandemic was underway
• Community-level outbreaks in multiple parts of
  the world
• Declaration was reflection of the spread of the
  virus not of the severity of the disease it
  causes

World Health Organization, Retrieved July 7,
2009, form http//www.who.int/csr/disease/avian_i
nfluenza/phase/en/index.html
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Influenza A (H1N1) What We Do Know

• This is an entirely new virus
• Genetic bits come from flu viruses that infect
  pigs, birds and humans
• It is easily transmitted among humans, especially
  the young
• No one, except those who have been infected, is
  immune
• Illness from the virus could become widespread
  quickly
• No previous vaccine, including seasonal flu
  vaccine, protects against infection

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Seasonal Epidemics vs. Pandemics

• Seasonal Influenza
• A public health problem each year
• Usually some immunity built up from previous
  exposures to the same subtype
• Infants and elderly most at risk

• Influenza Pandemics
• Appear in the human population rarely and
  unpredictably
• Human population lacks any immunity
• All age groups, including healthy young adults

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How the Virus Spreads

• The same way seasonal flu viruses spread
• Respiratory droplets
• Coughs and sneezes
• Touching objects touched by an infectious person,
  then touching your nose or mouth
• Droplets arent able to travel long distances
  through the air
• 3-6 feet maximum
• Virus survives up to 72 hours on surfaces,
  depending on moisture

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The Clinical PictureSo Far

• Symptoms like other flu infections
• Abrupt fever, gt100 F
• Cough, sore throat, runny nose
• Aches, chills, fatigue
• Unusual diarrhea and vomiting
• Almost everyone infected so far has recovered
  fully, but
• Hospitalization rate higher than expected for
  seasonal flu
• The virus is affecting younger populations than
  seasonal flu
• This picture could change, as the virus changes
  its genetic make-up

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What can we do to Reduce the Spread of Influenza?
Plan, Prepare, Prevent, Protect - Be Healthy
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The Goal of Community Mitigation
Community Measures
Delay onset of outbreak
Reduce the peak burden on hospitals/infrastructure

• Pandemic Outbreak No Community Measures Used

Decrease a) number of cases of death and illness
and b) overall health impact

Number of Daily Cases

• Pandemic Outbreak With Measures Taken

Days Since First Case
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Key Community Mitigation Messages

• Wash your hands often with soap and water,
  especially after you cough or sneeze
• Alcohol-based cleaners okay
• Cover your nose and mouth when you cough or
  sneeze
• Not with your bare hands!
• Use a tissue throw it away
• Dracula cover is okay, or Sneeze in your
  sleeve

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What Social Distancing Means

• Educating the public
• To recognize the disease
• Keeping distance from other people who appear ill
• Stay home until no longer infectious, except to
  obtain medical care
• Educating employers and schools
• To recognize the disease
• Dismiss workers and students who develop symptoms
  immediately
• Consider closing, if severe

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Droplet Precautions Surgical Masks
Source Rosie Sokas, MD MOH UIL at Chicago
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Current Status of H1N1 Response

• No vaccine is currently available, but is being
  produced and will likely be available in October
• Vaccine will be given first to priority groups
• Antiviral treatment will be targeted
• Everyone must practice good hygiene and use
  guidelines to prevent disease

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Implications

• During peak periods of peak influenza illness we
  will need to consider how to
• Care for sick family members
• Care for children if schools or daycare providers
  are closed
• Remain home or leave work if ill
• Keep schools and business open with potentially
  significant absences.
• Failure to educate the public and be prepared
  could result in increased incidence of viral
  spread

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Steps We All Can Take

• Seek guidance on pandemic influenza ask
  questions!
• Your state health departments are providing the
  most appropriate and current information
• In your communities
• Local health departments
• Local emergency planning
• Local physicians and other healthcare providers
• Be vaccinated with seasonal influenza vaccine

Image source Retrieved July 24, 2009
fromhttp//flushots2009.com/images/flu_vaccine_200
9.jpg,
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Use of Vaccine and Medication
Pharmaceuticals
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Vaccination for Influenza Will Prioritize Groups
at Risk
Pregnant women Health care workers and emergency
medical responders People caring for infants
under 6 months of age Children and young adults
from 6 months to 24 years People aged 25 to 64
years with underlying medical conditions (e.g.
asthma, diabetes)
July 29, 2009, the Advisory Committee on
Immunization Practices (ACIP), http//www.pandemic
flu.gov/
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Mobilizing for a Vaccine Campaign

• For public health, a challenge of unprecedented
  scale this fall
• Planning is already underway

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Treatment
Antivirals arent usually necessary for mild
illness (except perhaps for those who are at high
risk for complications) Rest and fluids work
best Virus is currently sensitive to two
antiviral drugs Tamiflu (pills, liquid) Relenza
(inhaled powder) Should be started early for
maximum effectiveness State/federal stockpiles
have been sent to designated providers
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Planning for Staying Healthy
Healthy People, Healthy Families, Healthy
Workforce, Healthy Kansas
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What Basic Steps Can You Take to Assure Health?
Eat healthy and get rest
http//healthy-values.info/images/apple.jpg
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Wash Your Hands the Right Way

• Wet your hands with clean running water and apply
  soap. Use warm water if it is available.
• Rub hands together to make a lather and scrub all
  surfaces.
• Continue rubbing hands for 15-20 seconds. Need a
  timer? Imagine singing "Happy Birthday" twice
  through to a friend.
• Rinse hands well under running water.
• Dry your hands using a paper towel or air dryer.
  If possible, use your paper towel to turn off the
  faucet.
• Always use soap and water if your hands are
  visibly dirty.

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If Soap and Clean Water Are Not Available Use
Alcohol-based Hand Sanitizer

• Effective if hands not visibly soiled
• More costly than soap water
• Alcohol-based hand rubs significantly reduce the
  number of germs on skin and are fast-acting.
• When using an alcohol-based hand sanitizer
• Method
• Apply appropriate amount to palms (about 1
  coin-sized drop)
• Rub hands together, covering all surfaces until
  dry

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Cough etiquette

• Respiratory etiquette
• Cover nose / mouth when coughing or sneezing
• Practice infection prevention by educating and
  displaying posters on respiratory hygiene, cough
  etiquette, and proper hand washing

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Steps We All Can Take

• Know the symptoms of influenza and monitor your
  health
• Stay home and away from school and workplace
  when sick

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What About Home?
Keeping Yourself and Your Family Healthy
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What Should Your Home Checklist Include?

• Personal planning for stockpiles of food, bottled
  water, and medication. Store a two week supply of
  food and water, Periodically check your regular
  prescription drugs to ensure a continuous supply
  in your home.
• Have any nonprescription drugs and other health
  supplies on hand, including pain relievers,
  stomach remedies, cough and cold medicines,
  fluids with electrolytes, and vitamins.

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What Should Your Home Checklist Include?

• Get vaccinated with seasonal flu and pneumococcal
  vaccine (if indicated)
• Planning for extended care of family at home
• Monitoring of own health and staying home when
  sick
• Find healthy ways to deal with stress and anxiety
  
• Use PPE and implement infection control guidance
  at home

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Patients Cared for at Home

• Contact a health care provider if pregnant, five
  years of age and under or have a health condition
  such as diabetes, heart disease, or asthma.
• Get plenty of rest.
• Drink clear fluids (such as water, broth, sports
  drinks, electrolyte beverages for infants) to
  keep from being dehydrated.
• A sick person should stay away from other people
  as much as possible.
• Sick persons should use proper hand hygiene and
  respiratory etiquette.
• Wear a facemask if available and tolerable
  when sharing common spaces with other household
  members to help prevent spreading the virus to
  others. This is especially important if other
  household members are at high risk for
  complications from influenza. 
• Stay home until free of fever for at least 24
  hours without the use of fever reducing
  medications such as Tylenol.

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Emergency Warning Signs
Be watchful for emergency warning signs that
might indicate you or family members need to
seek medical attention.

• Get medical care right away if the sick person at
  home
• has difficulty breathing or chest pain
• has purple or blue discoloration of the lips
• is vomiting and unable to keep liquids down
• has signs of dehydration such as dizziness when
  standing, absence of urination, or in infants, a
  lack of tears when they cry
• has seizures (for example, uncontrolled
  convulsions)
• is less responsive than normal or becomes
  confused
• Warning! Do not give aspirin (acetylsalicylic
  acid) to children or teenagers who have the flu
  this can cause a rare but serious illness called
  Reyes syndrome.

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What about Schools?
Considering Students and Staff
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Key Issues for Schools

• Absenteeism is likely to be increased for
  students and staff.
• Normal flu produces a 4 to 5 peak rate.
• Experience in other countries suggests peak may
  be 10 to 15.
• Infection control policies will be very
  important.
• Aimed at reducing risk of school dismissals and
  unnecessary absenteeism
• Schools as venues for mass immunization.
• Coordinate with local health departments

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Stepped up Hygiene and Cleaning

• Frequent hand washing, with adequate facilities
  and time made available.
• Alcohol-based hand sanitizers can be used others
  if last resort.
• Respiratory etiquette, modeled by staff
• Coughing/sneezing into tissues followed by hand
  washing
• Cough or sneeze into sleeve as alternative.
• Routine cleaning around school.
• Viruses can be transmitted from flu droplets on
  surfaces
• Regular detergent cleansers are sufficient.

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Primary Strategy

• Separate ill students and staff from the well
  population.
• Ill students need to remain at home and avoid
  contact with others except to seek necessary
  medical care.
• Exclude sick students and staff from school until
  24 hours after fever has resolved (without use of
  fever-reducing medications). Antiviral drug use
  does not effect this rule.
• Rapidly isolate students and staff who become ill
  at school until they can be sent home.
• Set aside space to separate sick persons until
  they can be sent home.
• Limit staff assigned to care for ill students
• Consider providing surgical masks to place on ill
  person.

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Selective School Dismissal

• These steps should prevent most schools from
  closing, but
• If absenteeism in any particular school is too
  large, school dismissal may be necessary
• Earlier dismissal also may be necessary in
  schools that serve pregnant or medically fragile
  students, if they cannot be protected.
• Decisions should be made in collaboration with
  local and state health officials
• Dismissal should last 5 7 days, then reassess.
• Consider continuing to allow well staff access to
  buildings.
• Other measures will be recommended if the
  pandemic strain becomes more virulent.

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New Mindset

• Expect the unexpected
• Parents, teachers and administrators all need to
  work hard to keep schools open, and be ready if
  schools must close suddenly
• Give up the notion that absences are to be
  avoided at all costs

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Immunizations in Schools

• Immunizing in schools offers advantages
• Convenient for parents
• Excludes no one
• Enables followup
• Efforts will be made to minimize the disruption
  of normal school activities
• With cooperation and guidance of school boards
  and administration
• No child would be immunized without written
  consent from parent or guardian
• All immunizations would be performed by persons
  qualified to give injections

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What About the Child Care?
What can providers and parents do?
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Steps Child Care Providers Can Take Now

• Maintain regular communication with the local
  health department to obtain guidance about
  reporting flu-like illness in child care.
• Visit the KDHE website at http//www.kdheks.gov
  for additional materials and updated resources.
  Child care providers are encouraged to check the
  website regularly for the most current guidance
  concerning H1N1 flu.
• The Centers for Disease Control and Prevention
  (CDC) at http//www.cdc.gov/h1n1flu/

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Steps Child Care Providers Can Take Now

• Develop a plan to address possible disruptions in
  learning and program operation. A useful planning
  tool is available at http//www.pandemicflu.gov/pl
  anpdf/child care.pdf
• Higher absentee rates among children and staff
• Disruptions in supportive services and the
  delivery of supplies
• Loss of income or delay in payments
• Review policies for the exclusion of sick
  children and staff.
• Review childrens files and update contact
  information.

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Steps Child Care Providers Can Take Now

• Make plans for the isolation and supervision of
  sick children, until their parents can pick them
  up.
• Recognize the symptoms of H1N1 flu and exclude
  sick children and staff promptly.
• Clean toys and commonly shared items, and
  touched surfaces like handrails and doorknobs at
  least daily and whenever visibly soiled.

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Steps Child Care Providers Can Take Now

• Avoid over-crowded conditions.
• Spread out during story and circle times
• Allow more than the 2 ft. required by regulation
  between cribs, cots and sleep mats.
• Place cribs, cots, and sleep mats so that
  children rest head to toe rather than face to
  face.
• Have adequate supplies on hand
• Hand soap and paper towels
• Facial tissues and waste containers
• Cleaning supplies

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Steps Child Care Providers Can Take Now

• Incorporate learning activities that promote
  healthy practices and good hygiene.
• Teach parents simple things they can do to keep
  their families health and to reduce the spread of
  disease. Check the KDHE website at
  http//www.kdheks.gov and the CDC website
  http//www.cdc.gov/h1h1flu/ for downloadable
  resource materials.

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Parents Can help

• Parents can help reduce the spread of flu like
  illness and other diseases in child care settings
  by
• Keeping sick children home. Sick children should
  not attend school, child care or other group
  setting. Children should be fever free, without
  the use of fever-reducing medications for at
  least 24 hours before returning to school, child
  care or other group setting.
• Having a back up plan in place in case your child
  is sick or in case your school or child care
  closes due to illness
• Practicing good health habits at home and
  encouraging your children to do the same.

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What About the Workplace?
Employer and Employees
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Principles of Mitigation Apply

• Good hygiene practices
• Social distancing at work
• Avoid handshakes (and kissing!)
• Stay home when sick

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Considerations for Business, Industry, and
Government

• Protection of workforce
• Continuation of service or business
• Economic impact for organization and employees
• Consideration of current policy related to sick
  leave
• Alternate plans for conducting business /
  providing services

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What About Faith based and Community
Organizations?
Remembering the Most Vulnerable
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Faith-Based and Service Organizations

• Consider suspending faith-based practices or
  rituals that may involve contact with hands, i.e.
  communion, greeting, etc.
• The impact of school closures and loss of income,
• differentially impacts low income individuals and
  groups.
• In the United States, 48 of workers have no sick
  leave
• Many low income families rely on free and reduced
  breakfast and lunch programs to help feed their
  children
• Children who are released from school may be left
  unattended and/or be at risk for greater violence
  in their communities

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Faith-Based and Service Organizations

• Other vulnerable populations include
• Single individuals, especially the elderly, who
  may have no assistance if they fall ill or run
  out of supplies
• People with disabilities who may rely on others
  for their basic care
• Individuals who may not speak or understand
  English
• Shelters serving homeless persons

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Plan, Prepare, Prevent, Protect - Be Healthy
What can you do to Reduce Risk of Influenza?
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PLAN Take Time to Plan
Vulnerable populations
Family and community
Schools, universities and child care
Work, business and government
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PREPARECaring for Self, Family and Community
School closing arrangements
Medications and health supplies
Alternative child care arrangements
Non-perishable foods and water
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PREVENTHealthy Habits to Reduce Risk of
Infection and Illness
Cover your cough
Vaccinate against disease
Wash hands often and use alcohol-based hand
sanitizer
Prevent and manage chronic disease
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PROTECTResponding to Influenza to Reduce Risk of
Exposure
Know when to see doctor
Know symptoms of flu
Protect vulnerable people
Breastfeed your baby
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Plan, Prepare, Prevent, Protect - Be Healthy!
YOU CAN Reduce THE SPREAD AND RISK of Influenza
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Learn More!

• Centers for Disease Control and Prevention
  http//www.cdc.gov/h1n1flu/
• Pandemic Flu Planning http//www.pandemicflu.gov/
  
• Kansas Department of Health and Environment
  http//www.kdheks.gov/
• Things you can do http//www.kdheks.gov/H1N1/H1N1_
  things_you_can_do.htm
• Individual Planning http//www.pandemicflu.gov/pla
  n/individual/index.html

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Thanks for Listening!
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