Pandemic Influenza Update

1. Pandemic Influenza Update Stacy Stevens Hall, RN MSN stacy.hall@la.gov Center for Community Preparedness June 2010

2. Disclosure • I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. • My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

3. Today’s Presentation • Pandemic Influenza Preparedness • Federal Evaluation Process and Results • Overview of H1N1 Response Activities • 2010 Federal Evaluation of H1N1 After Action Review Process • Planning for 2010 - 2011 • Future Preparedness and Evaluation

4. Pandemic Influenza Preparedness • Initially, OPH Immunization Program activity • HHS Pandemic Influenza Plan, 2005 • HHS Strategic Plan • HHS Public Health Guidance for State and Local Partners • Pandemic Influenza funding in CDC’s Public Health Emergency Preparedness Cooperative Agreement 2005 - 2007 • Evaluation Process began in 2008

5. Phases, Stages and Intervals

6. Severity Index of Pandemics

7. National Guidance • Purpose to prepare for, respond to and recover from an influenza pandemic • National Strategy for Pandemic Influenza: Implementation Plan and evaluation tools • Evaluation by 15 USG Departments, Agencies and Offices by Strategic Goals • A Ensure COOP of State Agencies and Government (6) • B Protect Citizens (15) • C Sustain/Support Critical Infrastructure Sectors and Key Resources (7)

8. 2008 Federal Evaluation http://www.azdhs.org/pandemicflu/pdf/Final_HHS_Operational_Plan_Grades_1.20.09.pdf

10. Overview of H1N1 Response • How we planned • When it happened • What we’re learning • OPH Activities by Target Capabilities • Communication • Public Information • Epidemiology • Laboratory • Community Mitigation • Medical Countermeasure • Antiviral medications • Vaccine

11. H1N1 Background • March 2009: ILI, severe pneumonia outbreak April 10-May 11 with increased hospitalizations of young adults with an unusual and nonsubtypeable influenza A virus in Mexico • April 17, 2009: First lab confirmed cases of H1N1 viruses in Southern California • April 26, 2009: US DHS declares public health emergency • April 28, 2009: LA receives Strategic National Stockpile • June 11, 2009: WHO declares H1N1 “pandemic” • June 19, 2009: All US states and territories report ILI activity

12. Current Influenza Situation • World Health Organization actively monitoring the progress of the pandemic with 214 countries impacted • Overall pandemic influenza virus transmission remains low • Active, but declining transmission of pandemic influenza virus in Southeast Asia and Caribbean • Southern hemisphere no evidence to suggest that winter influenza season has begun

13. Pandemic in United States • ILI doctor visits below baseline • Hospitalizations returned to expected levels • Deaths attributed to pneumonia and influenza is normally seen during summer • Most states reporting no or sporadic activity as typical for non-pandemic years • Majority of influenza viruses continues to be 2009 H1N1 influenza A • Viruses remain similar to the virus chosen for the 2009 H1N1 vaccine • Remain susceptible to oseltamivir and zanamivir http://www.cdc.gov/h1n1flu/update.htm

14. Pandemic in Louisiana • Update LA Stats • 2,409 lab confirmed cases • Week 15 extrapolated data estimated 292,000 cases • Hospitalized: 641 • Related deaths: 53 • H1N1 vaccine doses 491,131 • LA allocation 1,673,700 http://www.fighttheflula.com/index.cfm? md=static&tmp=forHCProvid

15. Media Frenzy! • Incredible interest in the H1N1 story at the beginning of the outbreak • Intense scrutiny at the beginning of the vaccination campaign • Diminished interest in H1N1 once vaccination campaign went public

16. Communication • Official national conference calls and briefs • National organizations and associations • State DHH OPH Brain Trust conference calls with notes shared • State coordination with agencies, associations, organizations, etc • Regional video conferences • Pandemic Influenza Summits • Regional coordination with Regional Coordinators, associations, calls, meetings, presentations, updates…

17. Pandemic in Louisiana • Bureau of Media and Communications coordinated public information • >60 press releases • Weekly “fight the flu” update • Flyers for campaigns • 2 TV PSA’s: ran 20 weeks • 3 radio PSA’s: ran 20 weeks • PSA which ran at high-school sporting events statewide • Reviewed internal and external partner materials

18. Pandemic in Louisiana • www.fighttheflula.com • Public • Provider • Updates • 1.4M visits • 5.3M pageviews

19. Pandemic in Louisiana Flu Shot Locator • Statewide internet database of public providers of H1N1 vaccine (Dec 15) • 4,000 visitors, 10,000 pageviews H1N1 Health Alert Network • Spring 2009: 55 • Fall/Winter 2009: 12 • 2010: 4

20. Pandemic in Louisiana • Epidemiological surveillance • Outbreak: first case • Pandemic: syndromes, changes and trends • Clinical protocol • Weekly Influenza Surveillance Report • Hotline • May 2009 100-200 calls/day

21. Pandemic in Louisiana • OPH Laboratory Sample Testing Protocol (April 2009) • Versions 1,2,3,4,5 • Syndromic testing • OPH Laboratory • 7,015 samples • May (2,696), Oct (779), Sept (698) • Antiviral resistance testing (CDC) • 1.5M equipment • 2 additional staff • >10,000 man-hours • Testing, data entry, reporting, communications

22. Pandemic in Louisiana • Community Mitigation Efforts • Hand hygiene, cough etiquette, stay home if sick guidance • Initially, school closure and public gathering recommendations from the Louisiana Office of Public Health • June 2009 • Recommendations continued to evolve with very few school, work place and public gathering closures

23. Pandemic in Louisiana • Medication in State Antiviral Cache • Secure, climate controlled location within Louisiana • Full allocation purchase received in May 2007 • Additional funding for pediatric medication which were received in April 2009 • Portion used for Community Pharmacy Network during H1N1 response * Children can also be treated with portion of adult dose

24. Pandemic in Louisiana • Strategic National Stockpile received on April 28, 2009 • Coordinated with response partners • Distributed on April 30 – May 1, 2009 • OPH executive leadership determined receiving locations • Pre-positioned allocation • Created local stockpiles • Initial guidance for use provided • Continuing guidance for storage, rotation and expiration • Communication will continue as the situation evolves

25. Pandemic in Louisiana Federal antivirals come with guidance and short expiration dates ~50 hours assets distributed: • 50% (93,366 regimens) shared by 120 Tier 1 hospitals • 40% (74,693 regimens) shared by 132 Tier 2 hospitals and 291 nursing homes • 10% (18,673 regimens) shared by 23 Federally Qualified Health Centers, Department of Corrections, military and federally recognized Indian Tribes with infirmaries • PPE allocated to limited number of sites in each region

26. Pandemic in Louisiana • Immunization Program • LINKS: Implemented Mass Immunization module • New Providers: 2,200 registered • Vaccine orders: Vaccine for Children model • Distribution/delivery: Central >100 doses • Accountability: doses administered • Adverse Events: validation • Only additional clerical/warehouse staff

27. Vaccination Campaign • Providers: • 2,200 registered • 1,425 Active • Public: 250 • Parish Health Units, Federally Qualified Health Centers, Rural Health Centers, Department of Corrections • Private • Private providers: 1,000 • VFC providers: 350 • Community pharmacies: 300

28. Vaccination Campaign • Training • LINKS Users (most used full LINKS) • 175 Public • 350 VFC • Non-LINKS Users (most used new module) • 1,200 others • Strike teams at Point of Dispensing Sites • Reluctance of providers and public • Perception of “new vaccine”

29. Vaccination Campaign • Differed from seasonal vaccine priority groups • Initial Priority Groups (October 12-December 31, 2009) • Pregnant women • Caregivers of infants <6mo • All children aged 6mo-24 yrs • Healthcare workers/EMS • Adults 25-64yrs with chronic illnesses • NOT in Priority Groups • All first responders • Seniors with chronic illnesses • All seniors

30. Vaccination Campaign • Vaccines • 5 manufacturers • 9 preparations • Intranasal • Intramuscular • Pediatric • Single use adult • Multi dose vials • Each with specific indications • Vaccine preparations and availability led to confusion for providers and public

31. Vaccination Campaign • LINKS: H1N1 Mass Immunization Module • Registration • Profile • Communication • Documentation • Utilization • Reordering • Adverse events follow up • Lab test follow up

32. Vaccination Campaign • New partnerships are good…. • Outreach, planning, coordination, organization, strategies, roles, responsibilities, beta testing… • H1N1 needed immediate and unconventional partnerships • Pharmacist Vaccinators • Louisiana Board of Pharmacy • Vaccination by protocol • 270 community pharmacists • Both H1N1 and Seasonal

33. Vaccination Campaign • Campaign Rollout • Predicted • 1st doses mid October • 100 million doses by January 1, 2010 • Actual • 1st doses by mid October • 25% of predicted in Oct/November • 57% of predicted in December • Challenges • Slow rollout of vaccine

34. Vaccination Campaign • Public Health Effort • All Parish Health Units • 22 Westaff Temps • 126 Nurses • 41 Administrative • 19 Program Monitor/Coordinator • 545 Volunteers • Challenges • Alternate model of delivery • Free to providers • Requesting providers to give to all persons

35. Vaccination Campaign • School Campaign • 1963 Schools (DOE) with varying levels of participation • Self sufficient • Strike Teams, even some as open Point of Dispensing Sites • Educational packets with community based use of Parish Health Units and private providers Private Schools • Educational packet with most using community based resources • Expanded partnerships in short period of time with evolving roles and responsibilities

36. Vaccination Campaign • Coordination with Department of Social Services for Foster/Day Care/Child Care Centers • >150,000 Children • Educational campaign • Letters to EVERY child • Web messages • Vaccination resources

37. Vaccine Campaign Conclusion • Spring “Closeout” • Last “push” for vaccination • Focus on high risk groups • Media event • Health Unit open clinics • Outreach clinics

38. Vaccination Campaign • Summary • Reluctance of providers, healthcare professionals and public • Internet rumors • LINKS completed 3 reminder recall campaigns • Initially, available vaccine didn’t match priority groups • Formulation changes • Vaccine recalls • Expiration date changes

39. Pandemic in Louisiana • Preparedness Grants: Public Health Emergency Response Cooperative Agreement • PHER 1,2 $ 7,481,583 Aug 9, 2009 • Epidemiology and Laboratory • PHER 3 $12,130,180 Sept 25, 2009 • Vaccination Campaign

40. Funding • Incompatibility of grant funding process with response actions • Many actions that the grant was intended to fund were in process or over before funding was awarded • Limited options for vaccination campaigns

41. Planning for 2010 -2011 • Seasonal influenza vaccine will contain 2009 H1N1 component • Federal Government will NOT purchase the vaccine this year • State will not have free vaccine or host mass vaccination campaigns • NOW is the time to order vaccine for next season • Advisory Committee on Immunization Practices is expanding the recommendation for annual influenza vaccination to all people aged 6 months and older

42. Evaluation Process • 9 Regional After Action Conferences • 9 Regional After Action Reports with Improvement Plans • State DHH OPH After Action Conference on June 24, 2010 • State DHH OPH After Action Report-Improvement Plan • 9 Regional Corrective Action Plans • State Corrective Action Plan

43. Preparedness and Evaluation • After Action Review met exercise requirements for 2009-2010 with required HSEEP documentation • Public Health Emergency Preparedness Cooperative Agreement • Strategic National Stockpile and Cities Readiness Initiative • Emphasis on Lessons Learned and Best Practices • Annual Evaluation due date of November 30, 2010 • Guidance with evaluation tools expected soon

44. Conclusion • Many lessons from H1N1 response for future pandemic planning • Pandemic planning was VERY effective and will continue • Response was HUGE public health and community success • Don’t let your guard down