Influenza Update Influenza Update 20092009

John Kulig MD MPHJohn Kulig MD MPHPrincipal Medical ConsultantPrincipal Medical Consultant

Shannon Bentley RN - FacilitatorShannon Bentley RN - FacilitatorRegional Nursing ConsultantRegional Nursing Consultant

Job Corps Health and Wellness Job Corps Health and Wellness WebinarWebinar

October 9, 2009October 9, 2009

Seasonal vs novel H1N1 Seasonal vs novel H1N1 influenzainfluenza

SeasonalSeasonal• ““regular” influenza A regular” influenza A

(H1N1), A (H3N2), and (H1N1), A (H3N2), and influenza B virusesinfluenza B viruses

• affects 5% to 20% of affects 5% to 20% of the population the population annuallyannually

• typical seasonal typical seasonal epidemiologyepidemiology

• serious infection serious infection more likely in older more likely in older people and infantspeople and infants

Novel H1N1Novel H1N1• 2009 H1N1 (referred 2009 H1N1 (referred

to as “swine flu” to as “swine flu” early on) is a new early on) is a new influenza virusinfluenza virus

• first detected in first detected in people in the United people in the United States in April 2009States in April 2009

• atypical non-seasonal atypical non-seasonal epidemiologyepidemiology

• serious infection serious infection more likely in more likely in younger peopleyounger people 22

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Percentage of Visits for Influenza-like Illness (ILI) Percentage of Visits for Influenza-like Illness (ILI) Reported by the U.S. Outpatient Influenza-like Illness Reported by the U.S. Outpatient Influenza-like Illness

Surveillance Network (ILINet), National Summary Surveillance Network (ILINet), National Summary 2008-2009 and Previous Two Seasons2008-2009 and Previous Two Seasons

PlanningPlanning• Job Corps centers are encouraged to Job Corps centers are encouraged to

review their pandemic flu plans to review their pandemic flu plans to prepare for the potential of influenza prepare for the potential of influenza outbreaks on center. outbreaks on center.

• Center health staff are also strongly Center health staff are also strongly encouraged to contact their state encouraged to contact their state and/or local health department to and/or local health department to obtain the latest information about obtain the latest information about vaccine availability and vaccine availability and recommendations for testing, recommendations for testing, treatment and prophylaxis in response treatment and prophylaxis in response to influenza cases among students.to influenza cases among students.

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VaccinationVaccination• As vaccines are the best way to As vaccines are the best way to

prevent influenza, CDC encourages prevent influenza, CDC encourages vaccination against vaccination against seasonalseasonal influenza influenza as soon as vaccines become available.  as soon as vaccines become available. 

• A A novel H1N1 novel H1N1 vaccine is currently in vaccine is currently in production and is expected be ready production and is expected be ready for the public in October. for the public in October.

• The novel H1N1 vaccine is not The novel H1N1 vaccine is not intended to replace the seasonal flu intended to replace the seasonal flu vaccine, rather to be used in addition vaccine, rather to be used in addition to seasonal flu vaccine. to seasonal flu vaccine. 

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Seasonal influenza Seasonal influenza vaccinevaccine• The The seasonalseasonal influenza vaccine protects influenza vaccine protects

against the three main flu strains that against the three main flu strains that research indicates will cause the most research indicates will cause the most illness during the flu season. illness during the flu season.

• This year’s influenza vaccine contains This year’s influenza vaccine contains three three newnew influenza virus strains: influenza virus strains: A/Brisbane/59/2007(H1N1)-like virusA/Brisbane/59/2007(H1N1)-like virus A/Brisbane/10/2007 (H3N2)-like virusA/Brisbane/10/2007 (H3N2)-like virus B/Brisbane 60/2008-like antigensB/Brisbane 60/2008-like antigens

• This is the trivalent influenza vaccine This is the trivalent influenza vaccine (TIV).(TIV). 77

CDC recommendations for CDC recommendations for seasonalseasonal influenza influenza

vaccinationvaccinationIndications for Indications for seasonalseasonal influenza vaccination influenza vaccination

during the 2009-10 season remain the same during the 2009-10 season remain the same asas

the previous year:the previous year:Children from age 6 months through 18 Children from age 6 months through 18

years years People 50 years of age and older People 50 years of age and older People of any age with certain chronic People of any age with certain chronic

medical conditions medical conditions Pregnant women Pregnant women

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CDC recommendations for CDC recommendations for seasonalseasonal influenza influenza

vaccinationvaccinationHealth care workers and emergency Health care workers and emergency

medical service personnelmedical service personnelHousehold contacts of persons at Household contacts of persons at

high risk for complications from the high risk for complications from the flu flu

Household contacts and caregivers Household contacts and caregivers for children less than 6 months of for children less than 6 months of age, who are at higher risk of age, who are at higher risk of influenza-related complications and influenza-related complications and too young to be vaccinatedtoo young to be vaccinated

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Novel H1N1 influenza Novel H1N1 influenza vaccinevaccine

Some issues still unknown:Some issues still unknown:How severe H1N1 influenza How severe H1N1 influenza

infection will be during the fall infection will be during the fall and winter months – no current and winter months – no current evidence of increased severityevidence of increased severity

How much vaccine will be How much vaccine will be availableavailable

Timing of vaccine availabilityTiming of vaccine availabilityNeed for booster doses of vaccine Need for booster doses of vaccine

(for children)(for children)1010

CDC recommendations for CDC recommendations for H1N1H1N1 influenza influenza

vaccinationvaccinationIndications for Indications for H1N1H1N1 influenza influenza

vaccinationvaccination

during the 2009-10 season include:during the 2009-10 season include:Children from age 6 months through 18 Children from age 6 months through 18

yearsyearsYoung adults age 19 through 24 yearsYoung adults age 19 through 24 yearsPersons aged 25 through 64 years who Persons aged 25 through 64 years who

have health conditions associated with have health conditions associated with higher risk of medical complications higher risk of medical complications from influenzafrom influenza 1111

CDC recommendations for CDC recommendations for H1N1H1N1 influenza influenza

vaccinationvaccinationPregnant women Pregnant women Healthcare workers and Healthcare workers and

emergency medical services emergency medical services personnel personnel

Household contacts and caregivers Household contacts and caregivers for children less than 6 months of for children less than 6 months of age, who are at higher risk of age, who are at higher risk of influenza-related complications influenza-related complications and too young to be vaccinatedand too young to be vaccinated

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High risk medical High risk medical conditionsconditions

• Associated with increased risk Associated with increased risk of complications from influenzaof complications from influenza

• Asthma, diabetes, suppressed Asthma, diabetes, suppressed immune systems, heart immune systems, heart disease, kidney disease, disease, kidney disease, neurocognitive and neurocognitive and neuromuscular disorders neuromuscular disorders

• PregnancyPregnancy

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Job Corps policyJob Corps policy

• Job Corps centers should plan to Job Corps centers should plan to offer seasonal influenza vaccine offer seasonal influenza vaccine andand H1N1 influenza vaccine on a H1N1 influenza vaccine on a voluntary basis to voluntary basis to allall students, students, not just to students with health not just to students with health conditions placing them at higher conditions placing them at higher risk of medical complications. risk of medical complications.

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Job Corps policyJob Corps policy

• One dose of One dose of seasonal flu seasonal flu vaccine vaccine should be administered as early as should be administered as early as September, followed by September, followed by H1N1H1N1 flu flu vaccine in October or November vaccine in October or November when available.when available.

• Influenza vaccine should remain Influenza vaccine should remain available on center throughout the available on center throughout the flu season for new students and for flu season for new students and for students who may initially decline students who may initially decline to be immunized.to be immunized. 1515

Early or late vaccine Early or late vaccine administrationadministration

• Early administration of flu Early administration of flu vaccine (September) is not vaccine (September) is not associated with loss of associated with loss of protection, and late protection, and late administration of flu vaccine administration of flu vaccine (March) still affords protection (March) still affords protection as cases of seasonal flu often as cases of seasonal flu often peak in late winter.peak in late winter.

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Vaccine purchaseVaccine purchase

• Centers should first contact their Centers should first contact their state and/or local health state and/or local health departments to inquire if influenza departments to inquire if influenza vaccine is available for vaccine is available for administration on center. administration on center.

• If not, influenza vaccine can be If not, influenza vaccine can be purchased from the HHS Supply purchased from the HHS Supply Service Center in Perry Point, Service Center in Perry Point, Maryland, or from private vendors. Maryland, or from private vendors.

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Vaccine promotionVaccine promotion• Centers may wish to offer influenza Centers may wish to offer influenza

vaccine administration to students vaccine administration to students in alternate locations, such as the in alternate locations, such as the cafeteria during the lunch break or cafeteria during the lunch break or the dormitories after hours, to the dormitories after hours, to increase voluntary participation. increase voluntary participation.

• Members of the Student Members of the Student Government Association (SGA) Government Association (SGA) should be engaged in promoting should be engaged in promoting influenza vaccination among their influenza vaccination among their peers.peers. 1818

Center health staffCenter health staff• Influenza vaccination is strongly Influenza vaccination is strongly

encouraged for all center health encouraged for all center health staff members, who could staff members, who could potentially transmit infection to potentially transmit infection to students.students.

• Increased absenteeism among Increased absenteeism among health staff could also reduce the health staff could also reduce the capacity of a center to respond to capacity of a center to respond to increased demand for care in the increased demand for care in the event of an influenza outbreak on event of an influenza outbreak on center. center. 1919

Center staffCenter staff

• Health staff who decline Health staff who decline influenza vaccination should sign influenza vaccination should sign a waiver to be placed in their a waiver to be placed in their personnel file, as is currently personnel file, as is currently required for hepatitis B vaccine. required for hepatitis B vaccine.

• All other center staff are also All other center staff are also encouraged to be immunized encouraged to be immunized against influenza, but a written against influenza, but a written waiver is not required for those waiver is not required for those who decline.who decline.

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Controlling the spread Controlling the spread of influenza on centerof influenza on center

• Cover your nose and mouth with a Cover your nose and mouth with a tissue when you cough or sneeze. tissue when you cough or sneeze. Throw the tissue in the trash after Throw the tissue in the trash after use. use.

• Wash your hands often with soap Wash your hands often with soap and water, especially after you and water, especially after you cough or sneeze. Alcohol-based cough or sneeze. Alcohol-based hand cleaners are also effective. hand cleaners are also effective.

• Avoid touching your eyes, nose, or Avoid touching your eyes, nose, or mouth. Germs spread that way. mouth. Germs spread that way.

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Controlling the spread Controlling the spread of influenza on centerof influenza on center

• Try to avoid close contact with sick Try to avoid close contact with sick people. people.

• Encourage residential students to Encourage residential students to report to the Wellness Center if report to the Wellness Center if they become ill. they become ill.

• Sick nonresidential students Sick nonresidential students andand center staff should be encouraged center staff should be encouraged to stay home and limit contact with to stay home and limit contact with others. others.

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Clinical presentationClinical presentation

SeasonalSeasonal• fever, cough, fever, cough,

sore throatsore throat, , runny or stuffy runny or stuffy nose, body nose, body aches, aches, headache, headache, chills, fatiguechills, fatigue

Novel H1N1Novel H1N1• fever, cough, fever, cough,

sore throatsore throat, , runny or stuffy runny or stuffy nose, body nose, body aches, headache, aches, headache, chills, fatiguechills, fatigue

• diarrhea and diarrhea and vomiting (25%)vomiting (25%)

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Indications for urgent Indications for urgent medical attentionmedical attention

• Difficulty breathing or shortness of Difficulty breathing or shortness of breath breath

• Pain or pressure in the chest or Pain or pressure in the chest or abdomen abdomen

• Sudden dizziness Sudden dizziness • Confusion Confusion • Severe or persistent vomiting Severe or persistent vomiting • Flu-like symptoms improve but then Flu-like symptoms improve but then

return with fever and worse cough return with fever and worse cough 2626

Epidemic influenza on Epidemic influenza on centercenter

• Centers should continue to use the Centers should continue to use the Significant Incident Report (SIR) Significant Incident Report (SIR) system to keep the National and system to keep the National and Regional Offices of Job Corps informed Regional Offices of Job Corps informed about epidemic influenza on center. about epidemic influenza on center.

• For the purpose of reporting, epidemic For the purpose of reporting, epidemic influenza will be defined by Job Corps influenza will be defined by Job Corps as cases affecting 10% or more of on as cases affecting 10% or more of on board strength (OBS).board strength (OBS).

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Epidemic influenza on Epidemic influenza on centercenter

• Non-epidemic cases of influenza should Non-epidemic cases of influenza should notnot be reported through the SIRS, unless be reported through the SIRS, unless the incident otherwise qualifies as the incident otherwise qualifies as significant per PRH 5.5, R1 (i.e. flu-significant per PRH 5.5, R1 (i.e. flu-related hospitalization, emergency room related hospitalization, emergency room treatment or reaction to treatment or reaction to medication/immunization).medication/immunization).

• Influenza cases should Influenza cases should notnot be be documented in the Safety and Health documented in the Safety and Health Information Management System Information Management System (SHIMS), as these illnesses are not (SHIMS), as these illnesses are not compensable by the OWCP.compensable by the OWCP. 2828

Epidemic influenza on Epidemic influenza on centercenter

• Closing of Job Corps centers is not Closing of Job Corps centers is not anticipated, although new intakes anticipated, although new intakes might be restricted if cases reach the might be restricted if cases reach the epidemic threshold on center. epidemic threshold on center.

• Non-residential students will be Non-residential students will be encouraged to remain at home at encouraged to remain at home at onset of influenza symptoms onset of influenza symptoms including fever, chills, sore throat, including fever, chills, sore throat, coughing and muscle pain. coughing and muscle pain.

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Epidemic influenza on Epidemic influenza on centercenter

• Residential students may be Residential students may be transported home by a family transported home by a family member member oror treated on center. treated on center.

• Public transportation should Public transportation should notnot be used for students exhibiting be used for students exhibiting symptoms of influenza. symptoms of influenza.

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Epidemic influenza on Epidemic influenza on centercenter

• Consider limiting new student intakes Consider limiting new student intakes until the epidemic on center has until the epidemic on center has abated.abated.

• Decisions regarding student exclusion Decisions regarding student exclusion as a as a preventive measurepreventive measure should be should be made on a case-by-case basis.made on a case-by-case basis.

• Students at increased medical risk Students at increased medical risk should should notnot routinely be excluded. routinely be excluded.

• Pregnant students should Pregnant students should notnot routinely be excluded.routinely be excluded.

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Medical leaves for Medical leaves for influenzainfluenza

• Public health recommendations Public health recommendations encourage symptomatic treatment encourage symptomatic treatment at home and discourage visits to a at home and discourage visits to a physician’s office to obtain physician’s office to obtain documentation and clearance for documentation and clearance for return to school or work. return to school or work.

• For Job Corps students, medical For Job Corps students, medical leaves for influenza will leaves for influenza will notnot require require third party verification.third party verification.

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Return to class or workReturn to class or work

• Patients can shed influenza virus 1 Patients can shed influenza virus 1 day before symptoms appear and day before symptoms appear and up to 5 days after onset of illness. up to 5 days after onset of illness.

• Students with influenza should not Students with influenza should not return to class or to work until return to class or to work until fever has resolved without fever has resolved without medication, and 5 days have medication, and 5 days have passed since onset of symptoms.passed since onset of symptoms.

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Diagnostic testingDiagnostic testing

• This season, diagnostic testing This season, diagnostic testing for influenza may be limited.for influenza may be limited.

• Commercially available rapid Commercially available rapid influenza antigen testing can influenza antigen testing can differentiate influenza A from differentiate influenza A from influenza B, but cannot influenza B, but cannot distinguish seasonal influenza distinguish seasonal influenza A from novel H1N1 influenza A.A from novel H1N1 influenza A.

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Antiviral treatmentAntiviral treatment

• This season, antiviral medications This season, antiviral medications may be prioritized for persons may be prioritized for persons hospitalized with severe illness or hospitalized with severe illness or for those at high risk for flu for those at high risk for flu complications.complications.

• Limiting use of antiviral Limiting use of antiviral medications will reduce the medications will reduce the development of drug resistant development of drug resistant strains of influenza.strains of influenza.

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Testing and treatment on Testing and treatment on centercenter

• At this time, centers should At this time, centers should notnot stockpile diagnostic materials stockpile diagnostic materials oror antiviral medications for antiviral medications for influenza, and should influenza, and should onlyonly conduct diagnostic testing and conduct diagnostic testing and begin antiviral treatment or begin antiviral treatment or prophylaxis based upon specific prophylaxis based upon specific recommendations from the local recommendations from the local health department.health department.

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ResourcesResourcesFor the most current information on For the most current information on

influenza, visit the following CDC influenza, visit the following CDC websites: websites:

• http://www.cdc.gov/flu/http://www.cdc.gov/flu/ - influenza - influenza overviewoverview

• http://www.cdc.gov/flu/professionals/http://www.cdc.gov/flu/professionals/flugallery/index.htmflugallery/index.htm - free influenza - free influenza material downloadsmaterial downloads

• http://www.cdc.gov/h1n1flu/http://www.cdc.gov/h1n1flu/ - novel - novel H1N1 influenza H1N1 influenza

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ResourcesResources

• http://www.cdc.gov/mmwr/http://www.cdc.gov/mmwr/preview/mmwrhtml/preview/mmwrhtml/rr58e0724a1.htmrr58e0724a1.htm - MMWR 58:1- - MMWR 58:1-52, July 24, 2009: Prevention and 52, July 24, 2009: Prevention and Control of Seasonal Influenza with Control of Seasonal Influenza with Vaccines: Recommendations of Vaccines: Recommendations of the Advisory Committee on the Advisory Committee on Immunization Practices (ACIP), Immunization Practices (ACIP), 20092009

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Stay tuned . . .Stay tuned . . .

• Further guidance will be Further guidance will be forthcoming when available.forthcoming when available.

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