Response to Pandemic Influenza during the 2009–2010 School Year

Jeffrey Engel, MD

State Health Director

North Carolina Division of Public Health

Outline

I. Influenza overview

II. Pandemic H1N1: The current situation

III. Mitigation strategies/control measures

IV. Pandemic influenza vaccination

V. Specific guidance for school settings

The Enemy

How Flu Spreads

• Most spread through coughing and sneezing• Contact transmission also important

– Hand to hand, contaminated surfaces

• Airborne transmission possible

www.cdc.gov/h1n1flu/surveillanceqa.htm

Pandemic H1N1 Case Rates by Age Group

Cleveland

Buncombe

Anson

Ashe

Beaufort

Bertie

Bladen

Brunswick

Burke

Caldwell

Carteret

Caswell

CatawbaChatham

Cherokee Clay

Columbus

Dare

Davie

Duplin

Forsyth Franklin

Gaston

Gates

Graham

Greene

Guilford

Halifax

Harnett

Hertford

Hoke

Hyde

Iredell

Jackson

Johnston

Jones

Lee

Lenoir

McDowell

Macon

MadisonMartin

Moore

Nash

Onslow

Orange

Pamlico

Pender

Person

Pitt

Polk

Randolph

Robeson

Rockingham

Rowan

Rutherford

Sampson

Scotland

Stanly

Stokes

Surry

Swain

Transylvania

Tyrrell

Union

Wake

Warren

Washington

Watauga

Wayne

Wilkes

Wilson

Yadkin

Yancey

Chowan

PasquotankPerquimans

CamdenCurrituck

MontgomeryHenderson

GranvilleVance

Durham

Mecklenburg

LincolnCabarrus

RichmondCumberland

Alexander

Craven

Haywood

Alleghany

Mitchell AveryAlamance

Davidson Edgecombe

New Hanover

Confirmed NC Cases by County of Residence — August 12, 2009

Confirmed Cases, N=687 (75 counties)

Northampton

Percent of Visits due to Influenza-Like Illness -- North Carolina, 2008-2009: Sentinel provider Network (SPN) and Hospital Emergency Department (ED)

0

1

2

3

4

5

6

7

8

9

10

40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

WEEK#

%IL

I

ED SPN

Emergency Departments

Doctors’ Offices

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

Influenza Positive Tests Reported by the N.C. State Laboratory of Public Health by Week

0

10

20

30

40

50

60

70

80

40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

MMWR Week

#Pos

itive

Spe

cimen

s

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% P

ositi

ve†

Seasonal A (H1) Seasonal A (H3) A unsubtypable* Seasonal B Novel A (H1N1) Percent Positive†

Pandemic Mitigation Strategies

1. Vaccination

2. Antiviral treatment and prophylaxis

3. Non-pharmaceutical interventions• Respiratory hygiene • Isolation and quarantine• Social distancing (school closures, cancellation

of large gatherings, teleworking, etc.)

Strategies are guided by severity of illness

Pandemic H1N1 Vaccine

• Separate from seasonal flu vaccine– Both vaccines important for protection

• Pandemic vaccine will probably require two doses

• Clinical trials in progress, evaluating– Safety / adverse events– Interval between doses– Administration with seasonal vaccine

Pandemic Vaccine Availability

• Considering “early roll out” in late September – 20 million doses

• First large bolus expected mid-October– 40 million doses

• Monthly shipments of 40 million doses – Total amount dependent on uptake

Pandemic Vaccine Distribution

• Centralized distribution– Supplies shipped with vaccine – needles,

syringes, etc.

• List of pandemic vaccine providers compiled by Local Health Departments– 100 dose minimum shipments

• Need for state and local coordination on school vaccination programs

Vaccination in Schools

Benefits:• Brings vaccine to target population• Many districts experienced with seasonal flu

and hepatitis B campaigns

Obstacles:• Issues with parental consent• Potential disruption

Pandemic Vaccine: Priority Groups

1. Pregnant women

2. People who live with or care for children younger than 6 months of age

3. Health care and emergency services workers

4. People 6 months through 24 years of age

5. People 25 through 64 years of age at high risk for complications of influenza

* If supply is limited

Priority Groups: Smaller *

1. Pregnant women

2. People who live with or care for children younger than 6 months of age

3. Health care and emergency services workers with direct patient contact

4. Children 6 months through 4 years of age

5. Children 5 through 18 years of age who have chronic medical conditions

School Guidance: Goals

• Decrease risk of hospitalization and death• Minimize disruption of day-to-day social,

educational, and economic activities

• Goal is NOT to eliminate all transmission of influenza in schools– Might change if severity increases

School Guidance: “Similar Severity”

• Stay home when sick– At least 24 hours after fever resolves without use of

fever-reducing medicines

• Separate ill students/staff• Emphasize hand hygiene• Routine environmental cleaning• Early treatment of high-risk students and staff• Consideration of selective dismissal

*Recently revised by CDC

Current Isolation Recommendations*

• Home until at least 24 hours after fever resolves (without fever-reducing medications)– 3–5 days in most cases– Duration NOT influenced by use of antivirals

• Longer isolation period for health care settings, other settings with many high-risk persons

• Practice good respiratory hygiene after return– Might still be shedding virus

School Dismissal Considerations

• Number and severity of cases– Local, state, and national levels

• Balance between risk of infection and problems that school dismissal can cause

• Different types of dismissal (selective, reactive, and preemptive).

Categories of Dismissal

• Selective– Most students in the school are high risk – May close while other schools in the community

are open

• Reactive– Used when many students and staff are sick

• Preemptive – Used early during a flu response to decrease

spread before many students and staff get sick– Only considered if severity increases– Probable declared state of emergency

School Guidance: “Increased Severity”

• Active screening for illness• High risk students/staff stay home• Students with ill household members stay

home• Increase social distancing• Extend exclusion period to at least 7 days• Consider preemptive dismissals

Roles and Responsibilities

• State and local health agencies– Collect and share relevant epidemiological data– Have regular channels of communication to share

information– Jointly make decisions with school officials

• State and local education agencies– Work with public health and social service

counterparts to ensure health and safety for students and staff

– Disseminate emerging guidance– Promote teaching and learning – even if school is

dismissed

ABCD of School GuidanceDo this now…

• Respiratory hygiene• Hand hygiene• Exclusion of ill students• Routine cleaning

School Dismissal Reporting

• Reporting of all flu-related school dismissals requested by CDC

• Report via www.cdc.gov/FluSchoolDismissal

Public Health Resources

• www.flu.nc.com

• www.cdc.gov/h1n1flu