Health and Medical SubpanelPan Flu Advisory Committee

Karen Remley, MD, MBA, FAAPState Health CommissionerMark J. Levine, MD, MPHDeputy Commissioner, Emergency

Preparedness

January 12, 2010Virginia Housing Center

The 2009 H1N1 influenza pandemic in Virginia

U.S. Department of Health and Human Services H1N1 Response Pillars

• Surveillance• Communication • Vaccination• Mitigation

Virginia addition• Direct Medical Care / Surge

Surveillance:Monitoring Flu Activity in Virginia

ED/UC visits for flu-like illness (ILI)• By age group, region

Lab surveillanceOutbreaks reportedDeaths confirmed*School absences*School and day care closures*

* New for 2009 H1N1

Visits for ILI, Virginia

0

2

4

6

8

10

12

14

16

Week Ending Date

Pe

rce

nt

of

Vis

its

fo

r IL

I

2007-08 2008-09 2009-10

Percent of Emergency Department and Urgent Care Visits for Influenza-like Illness (ILI) by Week, Virginia, 2009-10 Influenza Season Compared with the Previous Two Seasons

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Week Ending Date

Pe

rce

nt

of

Vis

its

fo

r IL

I

0-4 5-24 25-49 50-64 65+ All Ages

Percent of Emergency Department and Urgent Care Visits for Influenza-like Illness (ILI)by Age Group, Virginia, 2008-09 and 2009-10 Influenza Seasons

ILI Visits by Age Group

Laboratory Surveillance

Reports to VDH from all sources• DCLS• Private laboratories• Sentinel providers (ED, hospital, MD practice)

3428 positive flu results have been reported since August 1, 2009

3418 (99.7%) are 2009 H1N1 or A/unknown

The other 10 were: one H3 in October, 2 seasonal H1 in August, 3 seasonal A in Oct and 1 in December, and 2 B in August and 1 in October.

Lab SurveillancePositive Laboratory Reports* and ILI Visits

by Week, Virginia, 2008-09 and 2009-10 Influenza Seasons

0

100

200

300

400

500

600

700

800

900

1000

10/4

/200

8

10/1

8/20

08

11/1

/200

8

11/1

5/20

08

11/2

9/20

08

12/1

3/20

08

12/2

7/20

08

1/17

/200

9

1/31

/200

9

2/14

/200

9

2/28

/200

9

3/14

/200

9

3/28

/200

9

4/11

/200

9

4/25

/200

9

5/9/

2009

5/23

/200

9

6/6/

2009

6/20

/200

9

7/4/

2009

7/18

/200

9

8/1/

2009

8/15

/200

9

8/29

/200

9

9/12

/200

9

9/26

/200

9

10/1

0/20

09

10/2

4/20

09

11/7

/200

9

11/2

1/20

09

12/5

/200

9

12/1

9/20

09

1/2/

2010

Week Ending Date

Nu

mb

er o

f P

osi

tive

Lab

s R

epo

rts

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Per

cen

t o

f V

isit

s w

ith

ILI

B A/Unknown A Seasonal** A/H1, Seasonal A/H3 2009 H1N1 ILI Activity

*Positive laboratory reports are presented by week of specimen collection. Data are added as new test results become available; therefore, information for the most recent week will always be incomplete.

** 'A Seasonal' indicates a positive Influenza A finding that is negative for Novel H1N1 with no further subtyping.

Deaths

35 deaths confirmed to have 2009 H1N1 influenza• Ages 6-83

• 32 adults• 3 children

• 1 pregnant or post-partum• 34 with underlying medical conditions*

*chronic lung, metabolic, renal, cardiovascular disease; obesity; immunosuppression

School AbsencesDaily Public School Absenteeism

by School Type, Virginia, 2009-10 School Year

0

2

4

6

8

10

12

14

16

18

Date

Pe

rce

nt

Ab

se

nt

Elementary Middle High

*

*

*Day before holiday

Special Studies

VDH is also participating in special data collection projects led by CDC:• Death case series• Hospitalized patient case series• Severely ill pregnant women• Peramivir recipients• Guillian-Barre syndrome

Influenza other than H1N1

Rare reports of seasonal influenza A and B so far in 2009-2010 • Very few seen in Virginia• No sustained transmission in U.S. to date• WHO has no reports of seasonal influenza

activity to date during 2009-2010 flu season

H5N1 (Avian Flu)- Cumulative data

2009 activity seen in:Cambodia (2 cases), China (8 cases, 2 deaths)Egypt (40 cases, 5 deaths)Indonesia (24 cases, 22 deaths)Vietnam (6 cases, 5 deaths)

Dec 2008 Dec 2009

387 cases 467 cases

245 deaths 282 deaths

15 countries 15 countries

H1N1 Communications:A critical pillar with three key components

Prepare Respond

Prevent

H1N1 Communications:Audiences

CDCState Agencies and Local Governments Governor and Senior LeadershipMaryland and DC Health LeadershipHealthcare facilitiesClinical CommunitySchools and UniversitiesPrisons and Jails PressPublic High Priority Groups

Vulnerable Populations

Phases1. Crisis Communications- credible, timely, accurate 2. Disease education and prevention campaign3. Vaccination campaign

Overarching theme of education, collaboration and partnerships

Establish VDH as trusted source of information

H1N1 Communications:

Information Sources:H1N1GET1 website

Phone line 877-1-ASK-VDH3Opened 4/0989% of calls were from the general public88% phone, 12% emailVolume peak >700 calls/day84% in reference to vaccine

Information Sources

Press Conferences> 15Press Releases- >15Media Briefings by phone- >15Meetings/Lectures to various groups > 90

local and state levelSchool nurses, PTA, local government,

Grand RoundsAARP- magazine and Internet

Targeted communications- over 400Schools- parentsEmployersExecutive, Legislative and Judicial Branch of

State GovernmentVirginia Federal Congressional DelegationOther state agenciesTribal leadersHome school community Private SchoolsConstituent responses

Internal Communications

Local Health Director Conference callsPolycom with relevant staffDaily Senior Leadership meetingsWeekly Governor’s report

“Dear Colleague” Letters

Forum for sharing actionable information using four pillars approach including CDC updates

DHP emergency contact information- over 120,000 providers

MD, other clinical specialty organizations distribute23 letters to date

Positive Laboratory Isolates and ILI Reports by Week in Virginia,2008-2009 Influenza Season

0

20

40

60

80

100

120

Week Ending Date

Nu

mb

er o

f P

osi

tive

Lab

s

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Per

cen

t IL

I

2009 H1N1

A/H3

A/H1, Seasonal

A/Unknown

B

ILI Activity

Health Commissioner’s Infectious Disease Advisory Committee

Frederick G. Hayden, MDProfessor of Internal Medicine and Pathology, Division of Infectious DiseasesUniversity of Virginia Health Systems

Thomas M. Kerkering, MDChief of Infectious DiseasesVirginia Tech, Carilion School of Medicine

Edward C. Oldfield, III, MDChief of Division of Infectious Disease Eastern Virginia Medical School

Donald Poretz, MD, FACP, IDSA Clinical Professor of Medicine, MCV School of MedicineAnd Georgetown University School of Medicine

Richard P Wenzel, MD, MSc Chair of Internal MedicineVirginia Commonwealth University School of Medicine Michael B. Edmond, MD, MPH, MPAChair of the Division of Infectious Disease Virginia Commonwealth University Health System

James L. Pearson, DPh, BCLD Director, Division of Consolidated LaboratoriesDepartment of General Services

Ronald B. Turner, MDProfessor of PediatricsAssociate Dean for Clinical ResearchDepartment of PediatricsUniversity of Virginia School of Medicine

Mark J. Levine, MD, MPHDeputy Commissioner of Emergency Preparedness & Response ProgramsVirginia Department of Health

Diane Helentjaris, MD, MPHDeputy Director, Office of EpidemiologyVirginia Department of Health

James E. Burns, MD, MBADeputy Commissioner of Public HealthVirginia Department of Health

Karen Remley, MD, MPH, FAAPCommissionerVirginia Department of Health

Health Commissioner’s Primary Care Advisory GroupAlfred Abuhamad EVMS

Alice Ackerman Carilion

David Ascher Inova

Mike AshbyMartha Jefferson Hospital

Bob Chevalier University of Virginia

Tom Cleary Emergency Med

David Davidow Psy Solutions

Phil Dawson West End Pediatrics

Diane Dubinsky Fairfax Pediatrics

Tom EppesCentral VA Family Physicians

Bob Gunther

President, VA Chap. Of AAP; Augusta Pediatrics

Fred Hayden University of Virginia

Jon KatzVirginia Hospital Center

Tom Kayrouz Carilion PICU

William Koch MCVH-VCU

Donald LewisChildren's Hospital Kings Daughters

Doug MitchellChildren's Hospital Kings Daughters

Wade Neiman OB/GYN

Wayne Reynolds Sentara Medical Group

Mark Ryan VCU Medical Group

Sofia Teferi Bon Secours

Ron Turner University of Virginia

Arno ZarnitskyChildren's Hospital Kings Daughters

Vaccination media campaign

• Television and Cable- >10,000 plays• Radio- >4,750 plays• Internet 3,7 million impressions • Bus and Rail boards- 185• Movie theaters- 260• Media Buy share with DC/MD for NOVA

Vaccine information - Google Flu Vaccine Locator

Allows users to find vaccination locations by ZIP code

H1N1 Vaccine Development

CDC- Advisory Committee on Immunization Practices- September 2009

H1N1 Vaccine Planning- High Priority Groups

Pregnant womenHousehold contacts and caregivers of infants <6 mo

of ageHealthcare and EMS personnelAll persons 6 mo – 24 years of agePersons 25 – 64 years of age who have health

conditions associated with higher risk of medical complications from influenza

Up to 4.1 million Virginians in these categories

Vaccine free in all settingsAll supplies providedPrivate Providers can charge administration feeStates to determine allocation and documentation

process

H1N1 Vaccine Planning

Established 2006August 2009 75 users including MDs, HospitalsJanuary 2010 2,732 users including MDs,

Hospitals and Pharmacies

Vaccination Campaign Tenets

• Combined Public/Private • Focus on priority groups with special attention

pregnant women• Local Health Departments- School age large scale

vaccination plans • Documentation to occur through VIIS with

minimal information- Name, DOB, vaccine type and lot number

Vaccine Manufacturers

National Distributor (McKesson)

Internal Distributor

(GIV)

Vaccinators

Vaccinators

Orders ≥100 doses

Orders < 100 doses

Vaccine Distribution Process

VDH Guiding principles for vaccine allocation

strive to be fair and ethical throughout the vaccination campaign.

focus on CDC’s target groups. partner with thousands of public and private

vaccinators in communities throughout the Commonwealth.

rely on the judgment of the vaccine providers in the healthcare community to help it reach CDC’s target groups.

VDH Guiding principles for vaccine allocation

Local health departments (LHs) will work with these partners to assure that all persons have an opportunity to be vaccinated.

There will be no charges for any H1N1 vaccinations administered by or under the supervision of LHDs.

All persons, regardless of whether they live in Virginia or not, will be provided H1N1 vaccine by any LHD once the vaccine is available to the general public through pharmacies and other retail outlets.

The specific focus of LHD’s vaccination efforts will include their own patients and staff, CDC’s target groups, as well as assuring that vulnerable populations have access to the vaccine.

Variables affecting allocation process

Flow of vaccine from manufacturers and CDC Formulation of available vaccine Reliability of the distribution process from

manufacturer to patient Provider preferences (patient population,

formulation, storage capacity, staff capacity)

Guiding principles for reaching target groupsFocus on:

• High-risk for hospitalization and death from flu• Act as source for outbreaks in high-risk group settings • Easily accessible through specific providers

Target group High-risk Outbreak prevention

Easily accessible

Pregnant women X X

Healthcare workers X X

Parents of infants <6mo By proxy

Children 6mo-4y/o X X (daycare) X

Children 5-18y/o X X (schools) X

Young adults 19-24y/o X X (colleges) +/-

25-64y/o with medical conditions X

Vaccine Administration sites

MD officesLocal Health Depts.Schools HospitalsMallsStoresZooEtc…….

VACCINATOR CATEGORY Type % of Total#

Allocated

# Requeste

d

% of Requeste

d Order

Local Health Departments distribution through appts., mass clinics, walk-ins, school based programs   27%

1,049,084

1,222,270 86%

Hospital & EMS focus on direct patient care employees, EMS patients with chronic disease   15% 579,174 762,810 76%

Federally Qualified Health Centers, Community Health Centers, Rural Health Centers, and Free Clinics low-income, vulnerable and uninsured   3% 102,490 127,230 81%

Physician Practices OB/GYN, PEDS., Internists, FP and other specialties who see chronic disease   36%

1,393,444

1,838,260 76%

  Pediatric 12% 451,740 500,470 90%

 

Obstetric/Gynecology 2% 73,760 79,560 93%

  All Others 22% 867,944 1,258,230 69%

Congregate Living Facilities universities, private schools, long term care, assisted living, correctional facilities   7% 266,328 328,390 81%

 School & Colleges 5% 193,169 232,570 83%

  All Others 2% 73,159 95,820 76%

Other Occupational Health, Retail Pharmacy   12% 478,310

1,476,750 32%

Misclassification   0% 650 4,900 13%

Total   100%3,869,48

05,760,61

0  

Mitigation - Protecting Healthcare Workers

Distribution of PPE from State SNS Stockpile 57 Free Clinics & 27 Community Health Centers

60,000 surgical masks122,000 N-95 respirators10,000 face shields Gloves & Gowns

Mitigation - EMS Agencies

PPE Distributed to 520 EMS Agencies245,000 N-95 respirators120,000 surgical masks

Augmented hospital PPE as requested from the remaining 25% of the SNS allocation

810,000 additional respirators and 1 million surgical masks purchased with Federal grant funds; now stocked at the Virginia Distribution Center for distribution as needed

Direct Medical Care /Surge

State antiviral stockpile• Oseltamivir

Surge

State Antiviral Stockpile release

VDH Stockpile Tamiflu Rx ClaimsWeekly summary

050

100150200250300350400

10/2

4/20

09

11/7

/200

9

11/2

1/20

09

12/5

/200

9

12/1

9/20

09

Date

Rx

Cla

ims

Suspension Claims

75 mg Tab Claims

Hospital Surge

Hospitals coped with heavy ER traffic - near normal diversion incidents

Signage and physical barriers to divert ILI patients to appropriate triage area

Establishment of triage and treatment sites outside of ER area

Use of PPE to protect hospital staff and patients

Hospital Surge (con’t)

ICUs moderately stressedHigher than normal occupancy ratesDid not exceed capacity

Scarce, Specialized Equipment and Trained StaffIsolated incidents of serious respiratory cases and

limited equipment/staff Identified need to continue efforts to develop scarce

resource allocation protocols.

Situational Awareness

Hospital bed-tracking/status system

Provided timely and accurate information on healthcare system status

Effective means of sharing information

Information provided weekly to National hospital bed-tracking and status system (HAvBED)

CMS Waiver for EMTALA and HIPAASection 1135 of the Social Security Act permits

the HHS Secretary to waive certain regulatory requirements for healthcare facilities in response to emergencies provided that:

1) the President has declared an emergency or disaster under the Stafford Act or the National Emergencies Act and

2) the HHS Secretary has declared a Public

Health Emergency (PHE)

CMS Waiver for EMTALA and HIPAA (con’t)

HHS Secretary exercised her waiver authority effective October 23, 2009. CMS was delegated the authority to determine the waiver for each case justified by necessity and extent.

Waived certain provisions including EMTALA & HIPAA for healthcare providers who are unable to comply with these requirements as a result of the H1N1 influenza pandemic

Hospitals were notified of the process for applying for a 1135 waiver, either directly to CMS via the regional CMS office or via the State Survey Agency (our VDH OLC)

Next Steps

Targeted Vaccination and After Action Analysis

Vaccination Strategy

First of Regular Shipments (Bolus)

Pre-campaign shipments for most at risk

School Based Clinics

LHD Clinics

Private Providers

and Pharmacies

Community Mass Vax EventsVac

cine

Dos

es

Adm

inis

tere

d

Targeted Outreach to Specific Groups

The most at risk

Children 6 months to 18 years; their caregivers

General Public

1st Drip Phase I Phase IIApprox. Date

Healthcare Providers

ResourcesVirginia Department of Health Web site:

www.vdh.virginia.gov; www.H1N1Get1.com Toll-free VDH Inquiry Center:

1-877-ASK-VDH3 (1-877-275-8343)Google Flushot Locator

www.google.com/flushot

CDC H1N1 Web site:www.cdc.gov/h1n1flu

U.S. Dept. of Health & Human Services Flu center:www.flu.gov