H1N1 (Swine Flu) H1N1 (Swine Flu) Pandemic InfluenzaPandemic Influenza

Gordon C. Manin, MD, MPHGordon C. Manin, MD, MPHMedical DirectorMedical Director

OverviewOverview

Definitions/BackgroundDefinitions/Background Annual/Seasonal InfluenzaAnnual/Seasonal Influenza H1N1 (Swine Flu)H1N1 (Swine Flu) Prevention & TreatmentPrevention & Treatment

DefinitionsDefinitions Influenza (Flu):Influenza (Flu): three types of Flu in humans (A, three types of Flu in humans (A,

B, C); only type A further classified by subtypes B, C); only type A further classified by subtypes that differ based on different surface proteins that differ based on different surface proteins (HA, NA)(HA, NA)

H1N1 (Swine Flu A), Avian Flu A (H5N1)H1N1 (Swine Flu A), Avian Flu A (H5N1) Influenza Epidemic:Influenza Epidemic: caused by subtypes of caused by subtypes of

virus already circulating among humans, virus already circulating among humans, “seasonal outbreaks”“seasonal outbreaks”

Antigenic Shift:Antigenic Shift: abrupt/sudden major change in abrupt/sudden major change in influenza A virusinfluenza A virus

Influenza Pandemic:Influenza Pandemic: new influenza A virus new influenza A virus effecting humans, global outbreak, causes serious effecting humans, global outbreak, causes serious illness, easily spread from person to personillness, easily spread from person to person

Pandemic Influenza HistoryPandemic Influenza History

DateDate

SubtypeSubtypeWorldwide Worldwide deathsdeaths

Highest Highest mortalitymortality

Waves/ Waves/ durationduration

1918-19191918-1919

H1N1H1N1 50,000,00050,000,00020 – 50 20 – 50 year oldsyear olds

3 waves3 waves

2 years2 years

19571957

H2N2H2N2 2,000,0002,000,000 ElderlyElderly2 waves2 waves

2 years2 years

19681968

H3N2H3N2 1,000,0001,000,000 ElderlyElderly? 2 waves? 2 waves

3 years3 years

2009-?2009-?

H1N1H1N1?? 25 – 4525 – 45

Year oldsYear olds??

Perspective from Seasonal Perspective from Seasonal Influenza OutbreaksInfluenza Outbreaks

Usually Occur Dec-MarchUsually Occur Dec-March Primarily Spread Person to Person by Primarily Spread Person to Person by

Respiratory Droplets from Coughs Respiratory Droplets from Coughs and Sneezesand Sneezes

Complications Include:Complications Include:– Bacterial PneumoniaBacterial Pneumonia– DehydrationDehydration– Worsening of Chronic Medical ConditionsWorsening of Chronic Medical Conditions

Perspective from Seasonal Perspective from Seasonal Influenza OutbreaksInfluenza Outbreaks

Incubation Time 1-5 Days (Average 2 Incubation Time 1-5 Days (Average 2 Days)Days)

Typically Contagious 1 Day before Typically Contagious 1 Day before Symptoms to 5 Days after Symptoms Symptoms to 5 Days after Symptoms developdevelop

5-20% Get the Flu Each Year in USA5-20% Get the Flu Each Year in USA 200,000 Hospitalized Each Year in 200,000 Hospitalized Each Year in

USAUSA 36,000 Americans Die Annually36,000 Americans Die Annually

Awareness PhasesAwareness Phases

W.H.O.* created 6 phases of awarenessW.H.O.* created 6 phases of awareness1 Low risk to humans 1 Low risk to humans 4 Small clusters human-human spread 4 Small clusters human-human spread 2 High risk to humans2 High risk to humans 5 Large clusters human-human spread 5 Large clusters human-human spread3 Human disease, no spread 3 Human disease, no spread 6 Sustained transmission in humans** 6 Sustained transmission in humans**

Level of risk/preparation increases as Level of risk/preparation increases as levels increaselevels increase– Over time, levels may go up and downOver time, levels may go up and down– Geographic regions may be at different phases Geographic regions may be at different phases

simultaneouslysimultaneously– Unclear how much publicity will be given to Unclear how much publicity will be given to

Phase changesPhase changes

* World Health Organization* World Health Organization** As of June 11** As of June 11thth, 2009, 2009

International Co-circulation of 2009 H1N1 and Seasonal Influenza(As of September 20, 2009)

International Co-circulation of 2009 H1N1 and Seasonal Influenza(As of October 16, 2009)

Weekly influenza activity estimates reported by state and territorial epidemiologists (activity levels indicate geographic spread of both seasonal and 2009 influenza A (H1N1) viruses, September 19, 2009

Weekly influenza activity estimates reported by state and territorial epidemiologists (activity levels indicate geographic spread of both

seasonal and 2009 influenza A (H1N1) viruses, October 10, 2009

Current H1N1 SituationCurrent H1N1 Situation

H1N1 a novel influenza virus, isolated April 2009H1N1 a novel influenza virus, isolated April 2009 Incubation period unknown (Could range 1-7 days, Incubation period unknown (Could range 1-7 days,

more likely 1-4 days)more likely 1-4 days) Infectious period for a Confirmed case of H1N1, 1 Infectious period for a Confirmed case of H1N1, 1

day before symptoms to 7 days after onsetday before symptoms to 7 days after onset As of July 31As of July 31stst, 2009, median age was 12 years, , 2009, median age was 12 years,

with highest infection incidence among those with highest infection incidence among those between 25 and 45 years of agebetween 25 and 45 years of age

Lowest incidence of infection among persons age Lowest incidence of infection among persons age ≥ 65 years ≥ 65 years

WHO Declared Worldwide Pandemic June 11, 2009WHO Declared Worldwide Pandemic June 11, 2009

Current H1N1 SituationCurrent H1N1 Situation Relatively Few Severe Cases in Older PersonsRelatively Few Severe Cases in Older Persons As of July 31As of July 31stst, 2009, Median Age of Hospitalized , 2009, Median Age of Hospitalized

Persons was 20 years, with highest Incidence in Persons was 20 years, with highest Incidence in those < 4yearsthose < 4years

Highest Hospitalization Rates Among Persons < Highest Hospitalization Rates Among Persons < 65 years65 years

Median Age Among Persons who Died with Novel Median Age Among Persons who Died with Novel H1N1 was 37 YearsH1N1 was 37 Years

Signs and Symptoms Similar to Seasonal Signs and Symptoms Similar to Seasonal InfluenzaInfluenza

Specific Diagnostic Testing Required to Specific Diagnostic Testing Required to Distinguish H1N1 from Seasonal InfluenzaDistinguish H1N1 from Seasonal Influenza

SymptomsSymptoms

Seasonal InfluenzaSeasonal Influenza FeverFever HeadacheHeadache Extreme TirednessExtreme Tiredness Dry CoughDry Cough Sore ThroatSore Throat Runny or Stuffy NoseRunny or Stuffy Nose Muscle AchesMuscle Aches*Children may also experience*Children may also experience

nausea, vomiting, or diarrheanausea, vomiting, or diarrhea

Swine/H1N1 InfluenzaSwine/H1N1 Influenza All symptoms of All symptoms of

Typical InfluenzaTypical Influenza Diarrhea and VomitingDiarrhea and Vomiting

High Risk PatientsHigh Risk Patients High risk for seasonal influenza (Patterns High risk for seasonal influenza (Patterns

are emerging for H1N1) complications are emerging for H1N1) complications include:include:– Children < 5 years old;Children < 5 years old;– Persons aged 50 years or older;Persons aged 50 years or older;– Children and adolescents (aged 6 months to 18 Children and adolescents (aged 6 months to 18

years) who are receiving long-term aspirin years) who are receiving long-term aspirin therapy and who might be at risk for therapy and who might be at risk for experiencing Reye syndrome after an influenza experiencing Reye syndrome after an influenza infection;infection;

– Pregnant women;Pregnant women;– Adults and children who have chronic Adults and children who have chronic

pulmonary, cardiovascular, hepatic, pulmonary, cardiovascular, hepatic, hematological, neurologic, or metabolic hematological, neurologic, or metabolic disordersdisorders

PreventionPrevention

Cover your nose and mouth with a tissue Cover your nose and mouth with a tissue when you cough or sneeze, dispose of when you cough or sneeze, dispose of tissuetissue

Wash your hands often with soap and Wash your hands often with soap and water (alcohol-based hand cleaners are water (alcohol-based hand cleaners are also effective)also effective)

Avoid close contact with people:Avoid close contact with people:– Stay home if you are sick for 7 days after your Stay home if you are sick for 7 days after your

symptoms begin or until you have been fever symptoms begin or until you have been fever (100(100oo F) free for 24 hours, whichever is longer F) free for 24 hours, whichever is longer vs. 24 hours free of fevervs. 24 hours free of fever

Current Seasonal Influenza Current Seasonal Influenza Vaccination RecommendationsVaccination Recommendations

Should Get Vaccinated People at High RiskPeople at High Risk All Children 6 months-All Children 6 months-

18 years18 years People over 50People over 50 People Who Can People Who Can

Transmit to Others at Transmit to Others at High RiskHigh Risk

Residents of Chronic-Residents of Chronic-Care FacilitiesCare Facilities

Pregnant in Flu SeasonPregnant in Flu Season Anyone Who Wants to Anyone Who Wants to

Reduce their RiskReduce their Risk

Should not Get VaccinatedShould not Get Vaccinated Severe Allergy to EggsSevere Allergy to Eggs Severe Reaction to Flu Severe Reaction to Flu

Vaccine in PastVaccine in Past GBS within 6 Weeks of GBS within 6 Weeks of

Getting Flu Vaccine in Getting Flu Vaccine in PastPast

Children < 6 Months of Children < 6 Months of AgeAge

People with Moderate or People with Moderate or Severe Illness Should Severe Illness Should WaitWait

H1N1 VaccinationH1N1 Vaccination

Sept. 15Sept. 15thth, 2009, FDA Approved Four H1N1 , 2009, FDA Approved Four H1N1 Vaccine ManufacturersVaccine Manufacturers

State Health Departments Received First State Health Departments Received First Shipments September 30Shipments September 30thth, 2009, 2009

Immune Response in Most Healthy Adults Immune Response in Most Healthy Adults 8-10 Days After a Single Dose8-10 Days After a Single Dose

Manufactured with and without ThimerosalManufactured with and without Thimerosal Same Contraindications and Side Effects Same Contraindications and Side Effects

as Seasonal Influenza Vaccineas Seasonal Influenza Vaccine

Current ACIP H1N1 Influenza Current ACIP H1N1 Influenza Vaccination RecommendationsVaccination Recommendations

Initial Target Groups (order of target Initial Target Groups (order of target groups does not indicate priority):groups does not indicate priority):– Pregnant womenPregnant women– Persons who live with or provide care for Persons who live with or provide care for

infants aged < 6 months (i.e. parents, siblings, infants aged < 6 months (i.e. parents, siblings, and daycare providers)and daycare providers)

– Health-care and emergency medical services Health-care and emergency medical services personnelpersonnel

– Persons aged 6 months to 24 years, andPersons aged 6 months to 24 years, and– Persons aged 25-64 years who have medical Persons aged 25-64 years who have medical

conditions that put them at higher risk for conditions that put them at higher risk for influenza-related complicationsinfluenza-related complications

Current ACIP H1N1 Influenza Current ACIP H1N1 Influenza Vaccination RecommendationsVaccination Recommendations

Subset of Target Groups During Limited Subset of Target Groups During Limited Vaccine Availability:Vaccine Availability:– Pregnant women,Pregnant women,– Persons who live with or provide care for Persons who live with or provide care for

infants aged < 6 months (i.e. parents, siblings, infants aged < 6 months (i.e. parents, siblings, and daycare providers),and daycare providers),

– Health-care and emergency medical services Health-care and emergency medical services personnel who have direct contact with personnel who have direct contact with patients or infectious material,patients or infectious material,

– Children aged 6 months to 4 years, andChildren aged 6 months to 4 years, and– Children and adolescents aged 15-18 years Children and adolescents aged 15-18 years

who have medical conditions that put them at who have medical conditions that put them at higher risk for influenza-related complicationshigher risk for influenza-related complications

What Should I Do If I Get Sick?What Should I Do If I Get Sick?

Contact a Health Care Provider if:Contact a Health Care Provider if:– You live in areas where cases have been identified You live in areas where cases have been identified

and you develop influenza-like symptomsand you develop influenza-like symptoms– You are a You are a high risk patienthigh risk patient and develop influenza- and develop influenza-

like symptomslike symptoms– You are worried about your symptomsYou are worried about your symptoms

CALL BEFORE GOING TO PHYSICIAN’S OFFICE!!CALL BEFORE GOING TO PHYSICIAN’S OFFICE!!– Not everyone needs to be seen, tested, or treatedNot everyone needs to be seen, tested, or treated– Medical providers need to be preparedMedical providers need to be prepared– Should patient be seen by personal physician or Should patient be seen by personal physician or

company physiciancompany physician

Current Antiviral Oral Current Antiviral Oral MedicationsMedications

Amantadine: Amantadine: Swine (H1N1) Flu Currently Swine (H1N1) Flu Currently ResistantResistant

Rimantadine: Rimantadine: Swine (H1N1) Flu Currently Swine (H1N1) Flu Currently ResistantResistant

Oseltamivir (Tamiflu)Oseltamivir (Tamiflu) Zanamivir (Relenza)Zanamivir (Relenza)

*Avoid Aspirin if 18 years or younger*Avoid Aspirin if 18 years or younger

Other RecommendationsOther Recommendations

Dietary RestrictionsDietary Restrictions Contact with PigsContact with Pigs TravelTravel Vaccination for Seasonal FluVaccination for Seasonal Flu Oral MedicationsOral Medications MasksMasks

Possible ScenariosPossible Scenarios

If pandemic occurs:If pandemic occurs:– High absentee rateHigh absentee rate

Employee illness (30 – 40%)Employee illness (30 – 40%)Family illness/deathFamily illness/death““Precautionary absence”Precautionary absence”

– Likely to occur in waves of 3-6 months Likely to occur in waves of 3-6 months over total duration of 1-2 yearsover total duration of 1-2 years

– Medical care system will be severely testedMedical care system will be severely tested

Issues Disaster Preparedness Issues Disaster Preparedness Teams Must ConsiderTeams Must Consider

Relapsing high absentee/death rates in Relapsing high absentee/death rates in employeesemployees

Protective measures (masks, gloves, surface Protective measures (masks, gloves, surface disinfectants) for those at workdisinfectants) for those at work

Virtual OfficeVirtual Office Pay policies for “precautionary absence”Pay policies for “precautionary absence”

Insufficient vaccine/medicationInsufficient vaccine/medication Federal/state/local coordinationFederal/state/local coordination Employee communicationsEmployee communications Other …Other …

ResourcesResources

Occupational Health Disaster Expert Network Occupational Health Disaster Expert Network www.ohden.sph.unc.edu:9002/pandemic

Department of Health and Human Services Department of Health and Human Services www.pandemicflu.gov

Centers for Disease ControlCenters for Disease Controlwww.cdc.gov

World Health OrganizationWorld Health Organizationwww.who.org

Pennsylvania Department of Health Pennsylvania Department of Health www.health.state.pa.us/health/site

ConclusionsConclusions Pandemic H1N1 Influenza is Upon UsPandemic H1N1 Influenza is Upon Us Experts have been Predicting that Experts have been Predicting that

Pandemic Influenza will Return at Some Pandemic Influenza will Return at Some PointPoint

Base Actions on Best Available EvidenceBase Actions on Best Available Evidence Communicate with Your Providers, Communicate with Your Providers,

Employees, and StakeholdersEmployees, and Stakeholders Organizations Should Take the Time Now Organizations Should Take the Time Now

to Gather Accurate Information and Plan to Gather Accurate Information and Plan for How Your Organization will Respond to for How Your Organization will Respond to any Disaster (Intentional, Unintentional, or any Disaster (Intentional, Unintentional, or Natural)Natural)