Novel Influenza A (Pandemic) H1N1 Rachel Long, MT MSEd, CIC Public Health Epidemiologist Infection Control

1. Novel Influenza A (Pandemic)H1N1Rachel Long, MT MSEd, CICPublic Health EpidemiologistInfection Control

2. Objectives • Describe the Epidemiology of H1N1 • Identify signs and symptoms of H1N1 • Discuss ways to prevent illness from spreading • Describe vaccines for this season • Describe anti-virals and their use

3. Influenza Overview Structure: 16H and 9N Terms: • Pathogenic • Virulent H1N1 • Pathogenic (spreads easily) • Low virulence (can cause death

4. Vocabulary • Endemic • Epidemic • Pandemic

5. Pandemic Levels

6. Past Pandemics due to Flu • 1918: 20- 100 million deaths world wide • 500,000 to 675,000 in US • Came in waves • 1957: 45 million infected, 70,000 died • 1968-69: 50 million infected, 33,000 died • 1976: swine flu event/500 cases recorded

7. Differences in Seasonal and Pandemic Strain • Age groups affected • Seasonal: • >65 and <1 year of age • 90% of death in >65 year old group • Pandemic H1N1: • young >5 <24 years of age • Death in adults under the age of 50 is most common • Severe disease in young otherwise healthy (ICU stays)

8. Differences in Seasonal and Pandemic Strain • Age groups affected • Seasonal: • >65 and <1 year of age • 90% of death in >65 year old group • Pandemic H1N1: • young >5 <24 years of age • Death in adults under the age of 50 is most common • Severe disease in young otherwise healthy (ICU stays)

10. World Preparing for Second Wave • Monitoring in other parts of world now • Has not changed (mutated) at this time • H1N1 (Pandemic strain) is dominant • Clinical picture consistent across all countries • Mild illness for most • Monitoring Drug Resistance • Some found but not propagated at this time

11. 2 flu Seasons? • Regular Flu Season • H1N1 Flu season • Could get here before vaccine • Shouldn’t be any more sever than the spring • Vaccination important for HCW

12. ED Visits and Admissions for Influenza-Like Illness

13. How does Flu Spread • By droplets: 3-6 feet • Droplets are spread when: • Cough • Sneeze • Talk • Breathe

14. Clinical Features among NC Cases * Reflects disproportionate testing of hospitalized patients

15. Spread of H1N1 • Infectious Period • For a confirmed case is 1 day prior to the cases illness onset to 7 days after onset • Close Contact • Being within 3 feet of an ill person who is a suspected or confirmed case of H1N1 during the” infectious period” • Clinical care givers: Use Standard Precautions for your protection as well as your patients when dealing with respiratory regardless of isolation

16. Flu Vaccine • Inactivated virus (dead)/lasts 1 year • Many will need a seasonal (1) and H1N1 (1) • Both this year are made exactly the same way • Works by stimulating the immune system to provide protection

17. NationalH1N1 Vaccination Program • H1N1 Vaccine Not Yet Available – Release date mid October 2009 • Initial Amount – 40 Million Doses During First Month • Subsequent Weekly Production – 10 to 30 Million Doses Mission will receive weekly allotments after initial

18. High Risk Groups For H1N1 Vaccine • Pregnant women • Children under 4 years old • Contacts of infants less than 6 months old • Healthcare workers • Those aged 25 to 64 with high risk conditions

19. H1N1 Vaccine Facts( as of Sept 7, 2009) • 2009 H1N1 influenza vaccines are well tolerated and induce a strong immune response in most healthy adults when administered in a single unadjuvanted 15-microgram dose • Vaccine availability depends on several factors including manufacturing time and time needed to conduct clinical trials • seasonal flu vaccine is not expected to protect against the 2009 H1N1 flu • do not expect that there will be a shortage of 2009 H1N1 vaccine • availability and demand can be unpredictable *1976 swine flu virus and the 2009 H1N1 virus are different enough that its unlikely a person vaccinated in 1976 will have full protection from the 2009 H1N1 http://www.hhs.gov/news/press/2009pres/09/20090911a.html

20. Declination Statement Mission Hospitals has recommended that I receive influenza vaccination in order to protect myself and the patients I serve. The reason I am choosing not to take the influenza vaccine is: (Circle all that apply) I have gotten the vaccine in the past and it made me sick. I received the vaccine elsewhere. Fear of Gillian Barre Syndrome. I am allergic to eggs. I never get the flu. I acknowledge that I am aware of the following facts: Influenza is a serious respiratory disease that kills as average of 36,000 persons and hospitalizes more than 200,000 persons in the United States per year. Influenza vaccination is recommended for me and all other healthcare workers to prevent influenza diseases and its complications, including death. If I become infected with influenza, even when my symptoms are mild, I can spread severe illness to others. I understand that the strains of virus that cause influenza infection change almost every year, which is why a different influenza vaccine is recommended each year. I cannot get the influenza disease from the influenza vaccine. The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including: Patients at Mission Hospitals My Family My Co-workers My Community Despite these facts, I am choosing to decline influenza vaccination right now. Mission Hospital will require either vaccination or sign declination statement

21. Flu Myths Some common myths that are NOT true include: Myth 1: "The flu shot will give you the flu.“ Myth 2: "The flu shot does not work.“ Myth 3: "The flu shot makes me sick.” Myth 4: "I never get sick, so I don't need to get vaccinated

22. Fall 2009: What to Expect in the Workplace Absenteeism • H1N1 Illness is now in the general population – Up to 30% of Population (according to CDC) • 50 to 100 Million People will get H1N1 Will Have a Greater Affect on Workforce Population • We are expecting a 10‐Fold Increase in Absenteeism at the Pandemic’s Peak

23. Mission Informationwww.missionhospitals.org

25. Visitation Limited at 2% ILI Activity in State H1N1 flu is widespread For our patients’ health – and yours – please: Visit only if you are immediate family or patient’s caregiver No teens or children Do not visit if you are sick Wash your hands frequently Thank you for helping prevent the spread of flu. September 7, 2009 Policy number: 200.096

26. If you are Sick with H1N1 flu • Stay home : • 24 hours after their fever is gone(without the use of fever-reducing medicine). A fever is defined as having a temperature of 100 degrees Fahrenheit or 37.8 degrees Celsius or greater. • Get plenty of rest; • Drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to keep from getting dehydrated (loosing too much fluid); • Cover coughs and sneezes; • Clean hands with soap and water or an alcohol-based hand rub often, especially after using tissues and after coughing or sneezing into hands; • Avoid close contact with others, including staying home from work or school; and • Be watchful for emergency warning signs that might indicate you need to seek medical attention

27. Signs of Severe Illness Pediatric Adult Difficulty breathing or shortness of breath Chest pain or pressure Sudden dizziness Altered Mental Status Severe or persistent vomiting • Tachypnea • Blue or Grey Skin color • Not Drinking enough fluids • Alterations in mental status • Irritability beyond normal • Fever with rash • Flu symptoms that improve and then return

28. Antiviral Uses • Treatment: timing critical first 48 hours of symptoms. • Everyone does not need Tamiflu who has Influenza… • hcw with direct patient care who is high risk • Ill person with co-morbitidies • Prophylaxis: Prevention/Post Exposure timing (1-2 days)

29. Face Mask and Respirator Use • Droplet/Contactuntil test comes back • Dropletfor confirmed A or confirmed H1N1 • Except for aerosol generating procedures • Use N-95 or PAPR..this includes • collection of specimen • Suctioning • Nebulizer Treatment • Respiratory specimen • Intubation • Bronchoscopy

30. http://flu.nc.gov/epi/gcdc/H1N1flu.html Website for Division of Public Health Information

32. Patient Information

33. Nursing Policy 5.08: Nasopharyngeal Specimens Collection Steps Explain procedure to patient Have needed supplies/PPE Place head slightly tilted back Have patient blow nose to remove mucous (no snot)

36. NC State Lab Influenza Virus Testing Results by MMWR Week, 2008–2009

37. Accuracy of Flu Screens • Accuracy Depends Upon Prevalence • The positive and negative predictive values vary considerably depending upon the prevalence of influenza in the community. • False-positive (and true-negative) influenza test results are more likely to occur when disease prevalence is low, which is generally at the beginning and end of the influenza season. • False-negative (and true-positive) influenza test results are more likely to occur when disease prevalence is high, which is typically at the height of the influenza season. • Viral Panels do not guarantee identification of H1N1 • Flu Screens are only 50% sensitive for H1N1

38. It’s a “FARES” Event • Fluid • And • Rapidly • Evolving • Situation