“All the Flu that is fit to print” and some that is not…

1. “All the Flu that is fit to print” and some that is not… Amelia Muccio Director of Disaster Planning NEW JERSEY PRIMARY CARE ASSOCIATION

2. Seasonal Influenza • Influenza (the flu) is a contagious respiratory illness caused by influenza viruses. • It can cause mild to severe illness, and at times can lead to death. • The best way to prevent seasonal flu is by getting a seasonal flu vaccination each year. • Each year in the U.S. on average, 5% to 20% of the population gets the flu; on average, more than 200,000 people are hospitalized from flu-related complications, and about 36,000 people die from flu-related causes. • Some people, such as older people, young children, and people with certain health conditions, are at high risk for serious flu complications.

3. Influenza A • The Influenza A virus subtypes that have been confirmed in humans, ordered by the number of known human pandemic deaths, are: • H1N1 caused "Spanish Flu" and 2009 H1N1 outbreak • H2N2 caused "Asian Flu" • H3N2 caused "Hong Kong Flu" • H5N1 is "bird flu", endemic in avian • H7N7 has unusual zoonotic potential • H1N2 is currently endemic in humans and pigs • H9N2, H7N2, H7N3, H10N7 (avian) • The Influenza A virus subtypes are labeled according to an H number (for hemagglutinin) and an N number (for neuraminidase).

4. Influenza B • Influenza B viruses are only known to infect humans and seals giving them influenza. • This limited host range is apparently responsible for the lack of Influenza virus B caused influenza pandemics in contrast with those caused by the morphologically similar Influenza virus A as both mutate by both genetic drift and reassortment. • Further diminishing the impact of this virus in man, influenza B viruses evolve slower than A viruses and faster than C viruses. • Influenza virus B mutates at a rate 2-3 times lower than type A.

5. Influenza C • Influenza C viruses are known to infect humans and pigs giving them influenza. • Flu due to the type C species is rare compared to types A or B, but can be severe and can cause local epidemics.

6. Influenza Symptoms • Fever • Cough • Sore Throat • Runny or Stuffy Nose • Body Aches • Headache • Chills • Fatigue • Diarrhea • Vomiting

7. Seasonal Flu Vaccine • The annually updated trivalent influenza vaccine consists of hemagglutinin (HA) surface glycoprotein components from influenza H3N2, H1N1, and B influenza viruses. • The dominant strain in January 2006 is H3N2. • Measured resistance to the standard antiviral drugs amantadine and rimantadine in H3N2 has increased from 1% in 1994 to 12% in 2003 to 91% in 2005.

8. Who Should Get Seasonal Flu Shot? • Children aged 6 months up to their 19th birthday • Pregnant women • People 50 years of age and older • People of any age with certain chronic medical conditions • People who live in nursing homes and other long-term care facilities • People who live with or care for those at high risk for complications from flu, including: • Health care workers • Household contacts of persons at high risk for complications from the flu • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

9. Who Should NOT Get Seasonal Flu Shot? • People who have a severe allergy to chicken eggs. • People who have had a severe reaction to an influenza vaccination in the past. • People who developed Guillian-Barre syndrome within 6 weeks of getting an influenza vaccine previously. • Children less than 6 months of age (influenza vaccine is not approved for use in this age group). • People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen.

10. H5N1 “Avian/Bird Flu” • Avian influenza is an infection caused by avian (bird) influenza (flu) viruses. • These influenza viruses occur naturally among birds. • Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them. • However, avian influenza is very contagious among birds and can make some domesticated birds, including chickens, ducks, and turkeys, very sick and kill them. • Avian influenza is transmissible to humans (this requires extremely close contact with infected birds, particularly feces). • H7N1 and H9N2 (also bird flu)

11. H1N1 “Swine Flu” • 2009 H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people. • This new virus was first detected in people in the United States in April 2009. • This virus is spreading from person-to-person worldwide, probably in much the same way that regular seasonal influenza viruses spread. • On June 11, 2009, the WHO signaled that a pandemic of 2009 H1N1 flu was underway.

12. H1N1 • This virus was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs (swine) in North America. • But further study has shown that this new virus is very different from what normally circulates in North American pigs. • It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and bird (avian) genes and human genes • Scientists call this a "quadruple reassortant" virus

13. Summer Flu? (Sept 10, MMWR) • During the last 2 weeks of August, influenza activity increased in the southeastern United States to levels of ILI usually seen during winter seasonal influenza peaks • Approximately 97% of all influenza viruses currently circulating in the United States are pandemic H1N1 viruses that are sensitive to Oseltamivir or Zanamivir

14. The Makings of a Pandemic • The gene’s segmented nature facilitates genetic reassortment which leads to genetic diversity in type A. • Antigen drifts (minor) • Antigen shifts (major) • The major antigenic variations underlie the deadly worldwide pandemics (1918 ‘Spanish’, 1957 ‘Asian’, 1967 ‘Hong Kong’) due to population’s lack of immunityto novel virus subtype. • New concerns regarding disease epidemiology surfaced in 1997 as direct disease transmission from animals to humans caused fatalities in Hong King. • In pandemic, virus is transmissible human to human.

15. Pandemic Influenza • An influenza pandemic is an epidemic of an influenza virus that spreads on a worldwide scale and infects a large proportion of the human population. • The 1918 Spanish flu is the most serious pandemic in recent history, killing 50 million people (500,000 U.S. deaths). • There have been about three influenza pandemics in each century for the last 300 years. • The most recent ones were the Asian Flu in 1957 (70,00 U.S. deaths) and the Hong Kong Flu in 1968 (34,000 U.S. deaths).

16. More Flu… • The “canine influenza virus” is an influenza H3N8 influenza virus (not a human influenza virus) that was originally an equine (horse) influenza virus. • This virus has spread to dogs and can now spread between dogs. • Vaccination is available . • H7N7 and H3N8 “Horse Flu” • The disease has a nearly 100% infection rate in an unvaccinated horse population with no prior exposure to the virus. • While equine influenza is historically not known to affect humans, the impact of an outbreak among even the animal population would have been devastating.

17. Seasonal Influenza vs. H1N1Influenza • One thing that appears to be different from seasonal influenza is that adults older than 64 years do not yet appear to be at increased risk of 2009 H1N1-related complications thus far. • CDC laboratory studies have shown that no children and very few adults younger than 60 years old have existing antibody to 2009 H1N1 flu virus; however, about one-third of adults older than 60 may have antibodies against this virus.

18. Estimated influenza activity levels reported by state epidemiologists, by level of activity --- United States, week ending August 29, 2009

19. Current Situation • Visits to doctors for influenza-like illness (ILI) are increasing nationally. Visits to doctors for influenza-like illness are higher than what is expected during this time of year and have increased for five consecutive weeks now. This is very unusual for this time of year.

20. “In Their Prime” • The information analyzed by CDC supports the conclusion that 2009 H1N1 flu has caused greater disease burden in people younger than 25 years of age than older people. • At this time, there are few cases and few deaths reported in people older than 64 years old, which is unusual when compared with seasonal flu.

21. Medical Complications • The virus targets and reproduces in the respiratory tract. • Medical complications due to the flu include • Pneumonia (viral and secondary bacterial) • Sinusitis, croup, bronchitis • Myocarditis, myositis, pericarditis • Reye Syndrome • Fatigue (persists for weeks) • Subsequent convalescence phase can last for weeks with lingering respiratory symptoms and malaise (post-influenza asthenia).

22. H1N1 Hospitalizations Reported to the CDC: Underlying Medical Conditions, as of June 19, 2009 (N=268) • Asthma H1N1 Hospitalized, 32% • COPD H1N1 Hospitalized, 32% • Diabetes, H1N1 Hospitalized, 15% • Chronic CVD, H1N1 Hospitalized 14% • Immunocompromised, H1N1 Hospitalized, 13% • Current Smoker, H1N1 Hospitalized, 10% • Chronic Renal Dis III/IV, H1N1 Hospitalized, 9% • Obesity, H1N1 Hospitalized, 8% • Neurocognitive Dis. H1N1 Hospitalized, 7% • Pregnant, H1N1 Hospitalized, 6% • Seizure, H1N1 Hospitalized, 6% • Cancer, H1N1 Hospitalized, 3%

23. High Risk Conditions • High-risk conditions. Because persons with intellectual disabilities may not be able to communicate that they feel sick, additional attention needs to be devoted to recognizing when they are ill. • Neurodevelopmental delays, including Down syndrome • Asthma or other problems of the lungs • Any condition that affects respiratory function • Diabetes • Heart disease • Chronic kidney disease • Underlying metabolic disorder • Immune suppression (including HIV/AIDS) • Sickle cell disease • Children taking long-term aspirin therapy for chronic disorders

24. Emergency Signs • In adults, emergency warning signs that need urgent medical attention include: • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then return with fever and worse cough • In children, emergency warning signs that need urgent medical attention include: • Fast breathing or trouble breathing • Bluish or gray skin color • Not drinking enough fluids • Severe or persistent vomiting • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with fever and worse cough

25. Prioritized H1N1 Vaccine • Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated; • Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by “cocooning” them from the virus; • Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity; • All people from 6 months through 24 years of age • Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and • Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and, • Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

26. H1N1 Vaccination • Vaccination is VOLUNTARY. • Clinical trials for the H1N1 vaccine are underway, and if found to be safe and effective, the first doses of vaccine are expected to be available in mid-October, 2009. • Federal government is providing the H1N1 vaccine, syringes, gauze and sharps containers to providers at NO CHARGE. • Providers may charge a fee to administer the vaccine; insurance companies have made an initial commitment to cover the administration fee. This includes Medicare beneficiaries and NJ Medicaid – patients in fee-for-service Medicaid as well as Medicaid HMOs and NJ Family Care. • Some parents of young children may be concerned about Thimerosol in the H1N1 vaccine. The multi-dose vials of H1N1 vaccine do have a small amount Thimerosol (which is a preservative). However, there is no Thimerosol in the single-dose vials. If parents are concerned about this, they should request that their child receive the injection from a single-dose vial. • Because of a shortage of the H1N1 vaccine, the CDC has determined that members of the following priority groups will receive this vaccine first. (NOTE: There is no shortage of vaccine for the seasonal flu, and that vaccine is expected to be widely available in September, 2009.)

27. H1N1 Vaccine • Five manufacturers are producing vaccine for the U.S.: Sanofi Pasteur, Novartis, GSK, Medimmune and CSL.

28. Influenza A (H1N1) 2009 Monovalent Vaccines • Injectable Vaccines • Influenza A (H1N1) 2009 Monovalent Vaccine (CSL Limited) • Influenza A (H1N1) 2009 Monovalent Vaccine (Novartis Vaccines and Diagnostics Limited) • Influenza A (H1N1) 2009 Monovalent Vaccine (Sanofi Pasteur, Inc.) • Intranasal Vaccine • Influenza A (H1N1) 2009 Monovalent Vaccine (MedImmune LLC) • For the injectible vaccines, or shots, the virus is inactivated (killed), using the same processes the manufacturers use for seasonal influenza vaccines.  The vaccine administered via nasal spray contains a live, attenuated virus. 

29. How to Diagnosis the Flu? • Diagnosis is often based on clinical presentation (symptoms). • Rapid viral diagnostic tests (viral subtype not detected) • Enzyme immunoassays (EIA) • Tissue cultures (viral subtype detected) • Novel viruses

30. 20 to 1 • It is estimated that there are 20 cases of the H1N1 flu for every confirmed case.Currently, testing to confirm that the ill person has the H1N1 influenza is being done only for hospitalized and other seriously ill persons. No testing is being done on people who can be appropriately treated in the community. Therefore, in discussing the number of persons who are ill and who are likely to have the H1N1 influenza, health care professionals are using the term ILI, which stands for “influenza-like illness”.

31. Communicability • The virus is spread by respiratory secretions from an infected person who is coughing and sneezing. • People infected with seasonal and 2009 H1N1 flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days after. • This can be longer in some people, especially children and people with weakened immune systems and in people infected with the new H1N1 virus.

32. Fomite • A fomite is any inanimate object or substance capable of carrying infectious organisms (such as germs or parasites) and hence transferring them from one individual to another • Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on the surface • Door knobs/Toys/Phones

33. Flu Etiquette • Cover your nose and mouth with a tissue when you cough or sneeze; dispose of the tissue. • If you don't have a tissue, cough or sneeze into your sleeve. • Avoid touching your eyes, nose, or mouth. Avoid sharing or lending pens. • Bring your own writing utensils to meetings. • If you get the flu, avoid exposing others—stay home from work!

34. Hand Washing Etiquette • Frequently washing your hands dislodges and washes away germs that you've picked up from other people or contaminated surfaces. • Happy Birthday Song (time needed to wash hands) • Wash hands with soap and water or use alcohol based hand sanitizers before direct patient contact, after contact with respiratory secretions, after removal of gloves, or after contact with contaminated surfaces. • Wash hands before eating and drinking.

35. “Swine Flu Parties” • Gatherings during which people have close contact with a person who has 2009 H1N1 flu in order to become infected with the virus • The intent of these parties is for a person to become infected with what for many people has been a mild disease, in the hope of having natural immunity 2009 H1N1 flu virus that might circulate later and cause more severe disease • CDC does not recommend "swine flu parties" as a way to protect against 2009 H1N1 flu in the future

36. N-95s and Fit-Testing • All respirators that rely on a mask-to-face seal need to be annually checked with either qualitative or quantitative methods to determine whether the mask provides an acceptable fit to a wearer. • The qualitative fit test procedures rely on a subjective sensation (taste, irritation, smell) of the respirator wearer to a particular test agent while the quantitative use measuring instruments to measure face seal leakage.

37. PPE • Personal protective equipment is designed to protect employees from serious workplace injuries or illnesses resulting from contact with biological, chemical, radiological, physical, electrical, mechanical, or other workplace hazards. • Face shields, booties, goggles, aprons, gloves, vests, and respirators. • Proper Selection • Proper Training • Proper Usage (when and where) • Proper Maintenance • What PPE would use need for pandemic influenza outbreak? How much? What do you do when PPE becomes a scarce resource? • Has all staff been FIT-TESTED on N-95s???

38. Treatment—Antiviral Use • Oseltamivir or Zanamivir for the treatment and/or prevention of infection with 2009 H1N1 flu virus. • Antiviral drugs are prescription medicines (pills, liquid or an inhaled powder) that fight against the flu by keeping flu viruses from reproducing in your body. • If you get sick, antiviral drugs can make your illness milder and make you feel better faster. • They may also prevent serious flu complications.

39. Antivirals • Clinical judgment is an important factor in antiviral treatment decisions for all patients presenting for medical care who have illnesses consistent with influenza. • Treatment should be initiated as early as possible because studies show that treatment initiated early (i.e., within 48 hours of illness onset) is more likely to provide benefit. • No role for antiviral treatment in patients with mild flu. • Patients hospitalized with suspected or confirmed H1N1 flu should be treated with oseltamivir (Tamiflu) or zanamivir (Relenza). • Duration of treatment: 5 days. • “High risk” outpatients with suspected or confirmed H1N1 virus infection.

40. Antiviral Chemoprophylaxis • Consideration of antiviral chemoprophylaxis: prescribing antiviral medication to prevent the H1N1 flu in healthy persons who are at high risk of becoming ill • Health care professionals should consider prophylactic treatment with antiviral medication for: • Close contacts of patients with the flu when the non-ill person is at high risk for complications of influenza. • Health care personnel, public health workers, and first responders with unprotected close contact exposure to an ill person during infectious period. • Duration of prophylactic treatment: for 10 days after last known exposure.

41. The “Must Have” Kit this Fall • Assembly a Flu Kit • Hand sanitizers • Cough drops • Tea bags • Gatorade • Facial tissues • Masks (N-95) • Gloves • Chicken soup • Prevention messages

42. NJDHSS • NJDHSS HIPER—is responsible of the command, control and coordination of state health operations. • MCCs • Pharmaceutical/Medical/Antiviral distribution sites (SSS and SNS) • DHSS emergency call center • State EOC (ROIC) • Exchange health and health support information • JIC is located • MCC/HCC/HACC (backbone) • HACC includes NJPCA

43. H1N1 and the Healthcare Continuum • Hospitals • Acute flu cases only • Home Care • Valuable resource and option for caring for the sick at home • Home care increases social isolate and can reduce transmission • Long Term Care • Surge for hospitals (accommodate discharges) • FQHCs • POD • Mass vaccinations • Alternate care sites • Treat non-acute • Screen and triage worried well • Serve existing population (stay open)

44. Triage Policies • Ask patients if they have influenza-like illnesses to identify themselves upon arrival. • Ensure that patients with ILI are evaluated expeditiously. • Consider scheduling patients with ILI at the end of the day or at a time separate from well visits. • Consider having patients with ILI arrive through a separate entrance or wait in separate areas. • Ensure that a member of your staff calls ahead if you are referring a patient with an ILI to another facility. • Encourage your staff and your patients with ILI to remain at home.

45. Flu Signage • Place signs in waiting areas describing Universal Respiratory Precautions and Respiratory Etiquette. • What else can we do to flu-proof the waiting areas?

46. Flu-Proof Waiting Areas • Provide tissues in waiting areas • Provide no-touch receptacles • Provide alcohol based hand sanitizers • Provide symptomatic individuals with a surgical mask • Encourage staff with direct patients contact to wear masks (ILI)

47. Incident Command SystemWho Are You? • Incident Commander (IC) • Safety (SNO) • Public Information Officer (PIO) • Liaison (LNO) • Planning • Operations • Logistics • Finance/Administration

48. Job Action Sheets • Developing good JAS that are appropriate for a specific agency’s personnel and emergency response role can take a lot of time, effort, and collaboration. • Lets planners and potential responders (the people who are actually going to perform roles) clarify responsibilities and identify gaps or overlaps. • They can also serve as guides for the development of a training curriculum.

49. Sample JAS for Safety Officer • Safety Officer: Reports to: Agency Incident Commander • Mission: Develop and recommend measures for assuring health department personnel safety (including psychological and physical), and to assess and/or anticipate hazardous and unsafe situations. • Immediate: • Receive appointment from Agency Incident Commander. • Read this entire Job Action Sheet and review organizational chart. • Obtain a briefing from Agency Incident Commander. • Establish Safety Command Post in proximity to the agency Emergency Operations Center (EOC). • Review the Incident Action Plan (IAP) for safety implications.  • Intermediate: • Exercise emergency authority to stop and prevent unsafe acts. • Keep all staff alert to the need to identify and report all hazards and unsafe conditions and ensure that all accidents involving personnel are investigated and actions and observations documented. • Arrange with Logistics to secure areas all areas as needed to limit unauthorized access. • Advise the Agency Incident Commander and Section Chiefs immediately of any unsafe, hazardous situation (review Hazardous Materials Plan). • Schedule routine briefings with Agency Incident Commander. • Schedule routine briefings with Finance/Administration Section Chief.  • Extended: • Observe all staff, for signs of stress. Report issues to Agency Incident Commander. Provide rest periods and relief for staff. • Prepare end of shift report and present to oncoming Safety Officer.

50. Mental Health Resources • What mental health resources do you need for your staff? • Families? • Patients? • Are these resources realistically available? • What trainings might help staff and patients cope? • What else can you do to keep up morale and hinder burnout?