Maricopa County by alicejenny

VIEWS: 4 PAGES: 82

									Lessons from the “Great Pandemic”
of 2009
  (and other
 Tales of Herd
  Immunity)

Disaster Preparedness:
 Is Child Care Ready?

 Bob England, MD, MPH

   Maricopa County
  Dept of Public Health
     July 31, 2010
                But first…
•   Get shot in the lobby (Tdap)
•   Participant bags & conference folders
•   Two-part questions
•   But wait, there’s more… pre- & post-
•   Evaluation
•   THANK YOU sponsors! (Check out tables)
•   CCHC – table, brochure, 602-506-6380
•   First Things First
What are we gonna talk about?
• How vaccines really work
• What on earth was that?
  – A whirlwind review of the pandemic
• What did we learn?
  – How to apply lessons to future flu
• The flip side: pertussis and Tdap
• Be afraid, be very afraid
  – The emotional side
This is us…
One of us gets a disease…
It will spread to others…
and from there to others…
“Building walls” around disease
                    Measles – United States, 1950-2001

                    900
                    800             Vaccine Licensed
Cases (thousands)




                    700
                    600
                    500
                    400
                    300
                    200
                    100
                     0
                     1950          1960         1970   1980   1990   2000
                       *2001 provisional data
                Diphtheria - United States, 1940-
                              2007
        20000
        18000
        16000
        14000
        12000
Cases




        10000
         8000
         6000
         4000
         2000
            0
            1940   1950      1960   1970   1980   1990   2000
                      Year
NUMBER OF YEARS REPORTED INCIDENCE OF
HEPATITIS A EXCEEDED 10 CASES PER 100,000,
            BY COUNTY, 1987-1997




       0-1    2-3   4-5    6-7   8-11
 Evidence of day care amplification
• 1997: 51% of cases vs. 18% of controls:
   • attended or worked in child care (direct contact, OR 6.0,
     95% CI 2.1-23.0) , or
   • were a household contact of such a person (indirect
     contact, OR 3.0; 95% CI 1.3-8.0)
• 1998: Day care vaccination requirement
• 1999: No longer associated with day care
        State rate drops 6-fold, from 48 to 8/100K
Venczel CV et al. Pediatrics 2001;108:E78;
Duggirala HJ et al. Pediatr Infect Dis J 2005;24:974-8.
                              Pneumonia and Influenza Mortality
                              for 122 U.S. Cities
                              Week Ending 05/17/2008
                             12
% of All Deaths Due to P&I




                             10




                             8                                                                Epidemic Threshold




                             6


                                                 Seasonal Baseline
                                                                                                                                               2008
                                        2004                     2005                     2006                      2007
                             4
                                  50   10   20   30   40   50   10   20   30   40   50   10     20   30   40   50   10     20   30   40   50   10

                                                                                    Weeks
   No Small Potatoes…

        Influenza Estimates for the US
          Cases:                            25 – 50+ million cases
          Infection rate                    7% to 20% of general pop
          (among kids 5-14 y.o.)            16% to 38%
          Days of illness:                  100 – 200 million days
          Work loss:                        ~75 million days
          Hospitalizations:                 >200,000 (57% < 65 y.o.)
          Deaths (avg in 1990s):            ~36,000
          Costs:                            ~$3-5 billion
MMWR 2003; 52 (RR-8); Thompson et al. JAMA 2003; 289: 179;
Adams PF et al. Vital Health Stat 1999; 10(200).
ACIP (Advisory Committee on Immunization Practices). MMWR. 2004/Apr 30;53:1-40.
AAP (American Academy of Pediatrics). Pediatrics. 2004/May;113:1441-47.
Sullivan K. Pharmacoeconomics. 1996;9 (Suppl 3):26-33.
2003-04 Flu Vaccination Rates
  non-priority persons <50 yrs                14.8



 healthcare personnel <65 yrs                                          40.1



household contact 50 to 64 yrs                                     38.4



household contact 18 to 49 yrs                14.9



 household contact 2 to 17 yrs              12.3



                        65+ yrs                                                             65.5



        50 to 64 yrs (high risk)                                              46.3



        18 to 49 yrs (high risk)                        24.2



         2 to 17 yrs (high risk)                                34.8



                   6 to 23 mos                                                  48.4


                                   0   10          20      30      40          50      60     70   80   90   100

                                                                        percentage
    Influenza Vaccine Efficacy
      70% to 90% effective among persons
       <65 years of age

      30%-40% effective among frail elderly
       persons

      50%-60% effective in preventing
       hospitalization

      80% effective in preventing death
Source: CDC Pink Book. Epidemiology and Prevention of Vaccine Preventable Diseases
             Savings for workers

 Yearly influenza vaccination provides a cost
  savings for workers:
     Immunized employees save approximately
      $47 in medical costs annually
     Healthy workers who receive an annual
      influenza vaccination have about 44% fewer
      doctor visits
        A no-brainer, right?


  • Only 45.3 percent of U.S.
    health-care personnel were
    vaccinated in 2007


MMWR 2006;55 (RR-2). February 24, 2006.
       “I’ll catch the flu from a flu shot”

     n     Widely held belief (still)
     n     Not supported by randomized clinical trials
                               Placebo Group   Vaccine Group
                    Fever           6.1%           6.2%
            Tiredness             19.4 %           18.9%
       Feeling “under the
                                  17.5 %           16.0%
            weather”
            Muscle aches           5.7%             6.2%
             Headaches            14.4%            10.8%
            Arm soreness          24.1%            63.8%
Nichol, NEJM 1995.
CDC Influenza Q&A: Flu Shot.
               Kids are the vectors
    Attack rates highest in children
    Viral shedding longer in children (>10 days,
     compared to 6 in adults)
    Viral shedding starts earlier (up to 6 days
     before symptoms)

 Children are the main disseminators of flu
Monto AS, Sullivan KM. Epidemiol Infect. 1993;110:145-160; Blezen WP. Rev Infect Dis.
1980;2:408-420; Neuzil KM et al. Arch Ped Adol Med. 2002;156:986-991.
 Indirect protection of household
             contacts
   Unvaccinated HH contacts of vaccinated
    day care kids had 42% fewer resp illnesses
   Unvaccinated school-aged HH contacts of
    vaccinated day care kids had
       80% less febrile resp illness
       >70% fewer missed school days, earaches,
        provider visits, and work days missed for adults
        to care for sick kids
Hurwitz ES et al. J Infect Dis. 2000;182:1218-21 & JAMA. 2000;284:1677-82.
  Mass Vaccination of Children
in Japan Reduced Overall Deaths
                               14
                                              Pneumonia and influenza deaths
Pneumonia and Influenza (per




                               12
 Excess Deaths Attributed to




                               10
         100,000)




                                8


                                6
                                          1962
                                                                                          1994
                                4   School children
                                                                                       Program is
                                    flu vaccination
                                                             1977                     discontinued
                                        program                                1987
                                2                       Flu vaccination
                                         begins                         Parents allowed to
                                                      becomes mandatory
                                                                        refuse vaccination
                               0                                                                     0




              Reichert TA et al. N Engl J Med. 2001;344:889-96.
              Flu Pandemics
         • Irregular, ~2-3 per century



1510   1580    1688 1699 1708             1781    1830 1847   1890 1918 1957 1968




                Influenza Pandemics 16th – 20th Centuries
Trends in Infectious Disease Mortality in the
   United States During the 20th Century




                     Armstrong, GL. JAMA. 1999 Jan 6;281(1):61-6.
“These men start with what appears to be an
ordinary attack of… influenza… rapidly develop
the most vicious type of Pneumonia that has ever
been seen… a few hours later you can begin to
see the Cyanosis… until it is hard to distinguish
the colored men from the white. It is only a
matter of a few hours then until death comes… It
is horrible. One can stand to see one, two or 20
men die, but to see these poor devils dropping
like flies… We have been averaging about 100
deaths per day… We have lost an outrageous
number of Nurses and Drs. It takes special trains
to carry away the dead.”
                    --letter from physician at U.S. Army camp
20th Century Influenza Pandemics
• 1968-69 “Hong Kong flu,” (H3N2)
  – 34,000 US deaths (1-4 million worldwide)
• 1957-58 “Asian flu,” (H2N2)
  – 70,000 US deaths (1-4 million worldwide)
• 1918-19 “Spanish flu,” (H1N1)
  – >600,000 US deaths (20-100 M worldwide)
  – 2.5% overall mortality
  – Most deaths among young, healthy adults
Three pandemic waves: weekly
 combined flu and pneumonia
  mortality, U K, 1918–1919
Deaths Rates / 100,000 Population      1918 Death Rates: Philadelphia v St. Louis

                                     16000
                                                                                                                          Philadelphia
                                     14000                                                                                St. Louis
                                     12000
        (Annual Basis)




                                     10000

                                       8000

                                       6000

                                       4000

                                       2000

                                            0




                                              0/ 8




                                           /2 18
                                              9/ 8

                                              6/ 8

                                             /2 8




                                          /2 18



                                             /7 8



                                          /2 18



                                                    18
                                            21 8




                                              2/ 8




                                             /9 8
                                         9/ 918




                                              6/ 8




                                          /1 18
                                         10 918




                                         12 91
                                        11 /191
                                        10 191

                                        10 191

                                         11 91
                                         9/ 91




                                        11 /191
                                        10 / 191




                                         11 91




                                        12 /19
                                        11 19




                                        12 /19



                                                 19
                                        12 /19
                                                /1




                                               /1
                                                 1




                                                 1
                                               /1

                                               /1




                                              8/
                                              3




                                              1
                                              4
                                      14




                                             /5
                                            28




                                          /1




                                          /1



                                          /3
                                          /1



                                          /2
                                    9/




                                                                                            Date
                                    Collins SD, Frost WH, Gover M, Sydenstricker E: Mortality from influenza and pneumonia in the 50
                                    largest cities of the United States First Edition Washington: U.S. Government Printing Office 1930.   16
           Moving crazy fast
• Fri, 4/24 – Cases confirmed in Mexico
• Sat, 4/25 – 1st CDC conf call
• Wed, 4/29 – 1st (of 4) press conferences,
  1st confirmed case that closed 1st school
• Fri, 5/1 – Lots of pending labs, all over
  valley, involving dozens of schools
• Fri night, 5/1 – Decision re: school opening
• Sat, 5/2 – School Superintendent Conf
  call, announcement of schools reopening
How do I put this
in a sound bite?
        Timing is Everything

• CDC School closure policy revision – (5/6)
  4 days later
• School policies for 2nd wave in place
  before late July
• Mass media, school, health care, cities,
  tribes, churches, and employer education
  campaigns running by summer
                  Outreach

•   Presentations (50 by me)
•   Media (separately Spanish media)
•   Focus groups with parents (and surveys)
•   Website, handouts, posters, PSAs
•   Daily updates, twitter, lots of interviews
•   Sample letters (for schools)
•   Newsletter articles, email updates…
      ACIP Vaccine Guidelines

•   Everyone 6 mo - 24 yrs
•   25 - 64 yrs with risk factors
•   Caregivers of infants < 6 mo
•   Pregnant women
•   HCWs & Emergency medical workers
       ACIP Vaccine Guidelines
          During a Shortage

•   Children 6 mo - 4 yrs
•   Children 5 yrs - 18 yrs with risk factors
•   Caregivers of infants < 6 mo
•   Pregnant women
•   HCWs & Emergency medical workers
Are we
missing the
big picture?
       Role of School Health
• Push hygiene messages
  – Teach kids
  – Info to parents
  – Teach the teachers
• Vigilance & Enforcement
  – NO sick kids in school
  – Call Local Health Dept for dramatic changes
• Mass vaccine effort
      The Search for Immunizers
• RFP during the summer
  – Bill insurance first
  – Turn no one away
  – We’ll reimburse < $8 admin fee for uninsured
• Handful of immunizers signed up
  – But only one willing to do schools
• School-based vaccines:
  –   Mesa schools done by Mesa Fire Dept
  –   Scottsdale schools by Scottsdale Health Care
  –   All others solicited by ONE private mass immunizer
  –   We urged all schools to participate
   Provider type         # enrolled   LAIV ~9/30   Wk 1 (10/9)     Wk 2 (10/16)
Hospitals                       38
Urgent Care                     38
CHCs                              6
LTC facilities                  35
EMS                             17
Tribal                            5
Military                          1
Corrections                     13
Mass Immunizers                 15
School-based                      5
Pharmacies                     128
Pvt – Family Practice          314
 “ - Pediatrics                149
 “ - OB/Gyn                     63
 “ - Internal Med               37
 “ - Very Lg Providers            4
 “ - Other hi-risk              53
 “ - “Retail” clinics           32
 “ - Other                      88
MCDPH                             1
Total                     ~7.4M pts       37,500          61,800        41,200
   What happened with vaccine?

• Fluctuating daily vaccine allocation
  – (~1/3 of projections through Oct)
• Much more LAIV than providers preferred
• Early MCDPH principles:
  – Push it toward highest risk groups
  – Keep it moving (nothing in the ’fridge)
   What happened with vaccine?

• Fluctuating daily vaccine allocation
  – (~1/3 of projections through Oct)
• Much more LAIV than providers preferred
• Early MCDPH principles:
  – Push it toward highest risk groups
  – Keep it moving (nothing in the ’fridge)
• Later: divert to schools (herd effect)
• Then: pleeeeeze take it, anyone, everyone
                                                   ILI Visits - US Total vs Maricopa County                                              Maricopa County
                                                                                                                                         USA Total

70,000                                                                                                                                                     300



60,000
                                                                                                                                                           250


50,000
                                                                                                                                                           200

40,000

                                                                                                                                                           150

30,000

                                                                                                                                                           100
20,000


                                                                                                                                                           50
10,000



    0                                                                                                                                                      0
         3/7   3/21   4/4   4/18   5/2   5/16   5/30   6/13   6/27   7/11   7/25   8/8   8/22   9/5   9/19   10/3 10/17 10/31 11/14 11/28 12/12 12/26
                                                   ILI Visits - US Total vs Maricopa County                                              Maricopa County
                                                                                                                                         USA Total

70,000                                                                                                                                                     300



60,000
                                                                                                                                                           250


50,000
                                                                                                                                                           200

40,000

                                                                                                                                                           150

30,000

                                                                                                                                                           100
20,000

                                                                                                      1st vaccine
                                                                                                                                                           50
10,000



    0                                                                                                                                                      0
         3/7   3/21   4/4   4/18   5/2   5/16   5/30   6/13   6/27   7/11   7/25   8/8   8/22   9/5   9/19   10/3 10/17 10/31 11/14 11/28 12/12 12/26
                                                   ILI Visits - US Total vs Maricopa County                                              Maricopa County
                                                                                                                                         USA Total

70,000                                                                                                                                                     300



60,000
                                                                                                                                                           250


50,000
                                                                                                                                                           200

40,000

                                                                                                                                                           150

30,000

                                                                                                                                                           100
20,000

                                                                                                                   to schools
                                                                                                                                                           50
10,000



    0                                                                                                                                                      0
         3/7   3/21   4/4   4/18   5/2   5/16   5/30   6/13   6/27   7/11   7/25   8/8   8/22   9/5   9/19   10/3 10/17 10/31 11/14 11/28 12/12 12/26
                                                   ILI Visits - US Total vs Maricopa County                                              Maricopa County
                                                                                                                                         USA Total

70,000                                                                                                                                                     300



60,000
                                                                                                                                                           250


50,000
                                                                                                                                                           200

40,000

                                                                                                                                                           150

30,000

                                                                                                                                                           100
20,000

                                                                                                                        to ASU
                                                                                                                                                           50
10,000



    0                                                                                                                                                      0
         3/7   3/21   4/4   4/18   5/2   5/16   5/30   6/13   6/27   7/11   7/25   8/8   8/22   9/5   9/19   10/3 10/17 10/31 11/14 11/28 12/12 12/26
                                                   ILI Visits - US Total vs Maricopa County                                              Maricopa County
                                                                                                                                         USA Total

70,000                                                                                                                                                     300



60,000
                                                                                                                                                           250


50,000
                                                                                                                                                           200

40,000

                                                                                                                                                           150

30,000

                                                                                                                                            open           100
20,000                                                                                                                                      to all
                                                                                                                                                           50
10,000



    0                                                                                                                                                      0
         3/7   3/21   4/4   4/18   5/2   5/16   5/30   6/13   6/27   7/11   7/25   8/8   8/22   9/5   9/19   10/3 10/17 10/31 11/14 11/28 12/12 12/26
Schools Served by Mass Immunizer
Mean % of Students Vaccinated at
 each School by Mass Immunizer
Where Students were Vaccinated
Parental Satisfaction with School
         Immunization
           Bob’s nightmare

• Public memory afterward:
  – “They made a big deal of flu shots, and
    everyone got sick anyway”
  – “I got my flu shot and I got sick”
  – “Flu shots don’t work / don’t matter”


• Much evaluation ongoing
             Optimistic Notes

• In a HUGE community, with very little time:
  – Vast majority of schools participated
  – Nearly half of kids vaccinated
  – Only 21% cited objections (often due to perception of
    vaccine as “new” or “experimental”)
  – Complicated billing may have led to some passive
    missed vaccinations
• With planning and simpler system, school
  based flu vaccination may reach herd effect
PERTUSSIS-WHOOPING COUGH
      CALIFORNIA PERTUSSIS UPDATE
               6/17/2010

•   910 cases of pertussis
•   4-fold increase from previous year
•   5 deaths, all Hispanic infants <3 m.o.
•   Age at onset of sx: 5 days - 8wks
ARIZONA PERTUSSIS UPDATE
          2010
• 2010-thru May 31:
  – 22 confirmed (5 infants, 4 ≤ 5 y.o.)
  – 107 probable
• 2009-thru May 31:
  – 25 confirmed (10 infants, 5 ≤ 5 y.o.)
  – 62 probable
        Pertussis—United States, 1940-2007
        250000


        200000       Gradual herd effect


        150000
Cases




        100000                                     Waning immunity


         50000


             0
             1940   1950    1960     1970   1980   1990     2000


                                     Year
MUCH WORSE IN LITTLE ONES
90% of pertussis deaths are < 4 m.o.
72% of babies < 6 m.o. with pertussis are
   hospitalized
1 in 10 children with pertussis also develop
   pneumonia
1 in 50 children with pertussis also have
   seizures or convulsions
MUCH MORE COMMON IN OLDER
 • Easier to recognize in younger pts
 • ~8,000 reported cases in adults,
   ~600,000 in reality
 • 10-20% of all “chronic bronchitis”
   in adults may actually be pertussis
       NEARLY 50% OF PERTUSSIS
        SOURCES ARE PARENTS

• A FAMILY MEMBER IS
  THE SOURCE OF
  PERTUSSIS IN 75%
 OF INFANT CASES
• CHILD CARE
  WORKERS COMMON
               Tdap
Licensed in 2005 for ages 10-64 y.o.
The acellular pertussis component added to
  the old “tetanus shot”
Especially important for those who have close
  contact with infants
“Cocoon” newborns by vaccinating others
  before the child goes home
All California hospitals and outpt facilities
  required to offer Tdap as of 9/1/10
So what have we learned?

• Some vaccine-preventable
  diseases can be controlled by
  “targeted herd immunity”
• HAV
• Flu
• Pertussis
               Targets
• HAV
  – Day Care Centers
• Flu
  – Kids (Day Care & Schools)
  – HCWs, Day Care & School Staff
• Pertussis
  – Family of infants (and all older kids / adults)
  – HCWs, Day Care Workers
       We can do this

• Even large population targets
  – School children
• Even under the worst of
  circumstances
  – During a pandemic (and controversy)
  – During vaccine shortage
FEAR
Be afraid.

Be very
afraid.
             Thanks
Gina T. Mootrey, DO, MPH (CDC)
Katrina Kretsinger, MD, MA (CDC)
Bill Atkinson, MD, MPH (CDC)
Richard K Zimmerman (U Pittsburgh)
Karen Lewis, MD (ADHS)
APIC
Machrina Leach, RN, et al. (Community
  Health Nursing, MCDPH)
WeArePublicHealth.org
  ( StopTheSpreadAZ.org )


   bobengland@mail.maricopa.gov

								
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