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
Pandemic H1N1 Case Rates
by Age Group
www.cdc.gov/h1n1flu/surveillanceqa.htm
Confirmed NC Cases by County of
Residence — August 12, 2009
Alleghany Vance Gates Currituck
Surry Rockingham Northampton
Ashe Stokes Caswell Granville Warren
Person Hertford
Watauga Wilkes Halifax
Yadkin Forsyth Alamance
Mitchell Avery Guilford Orange Franklin Bertie
Caldwell Alexander Davie Nash
Durham
Madison Yancey Edgecombe Tyrrell
Burke Iredell Davidson Wake Martin Washington Dare
Randolph Chatham Wilson
McDowell Catawba Rowan Pitt
Buncombe Beaufort
Swain Haywood Lincoln Johnston Greene Hyde
Rutherford Cabarrus Montgomery Lee
Graham Henderson Gaston Harnett Wayne
Jackson Polk Cleveland Stanly Moore
Lenoir Craven
Cherokee Macon Transylvania Mecklenburg Pamlico
Clay Cumberland
Anson Richmond Hoke Sampson Jones
Union Duplin
Scotland Onslow Carteret
Robeson Bladen
Pender
Columbus
New
Brunswick Hanover
Confirmed Cases, N=687 (75 counties)
Percent of Visits due to Influenza-Like Illness -- North Carolina, 2008-2009:
Sentinel provider Network (SPN) and Hospital Emergency Department (ED)
10
9
8
Emergency
7
Departments
6
%ILI
5
4
3
Doctors’
2
Offices
1
0
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#
ED SPN
Influenza Positive Tests Reported by the N.C. State Laboratory of Public Health by Week
NC State Lab Influenza Virus Testing
80 90%
Results by MMWR Week, 2008–2009
70 80%
70%
60
#Positive Specimens
60%
50
% Positive†
50%
40
40%
30
30%
20
20%
10 10%
0 0%
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
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
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
* If supply is limited
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
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
*Recently revised by CDC
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 Guidance
Do 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