Novel H1N1 Virus: Planning and Response October 12, 2009 Adolfo Valadez, MD, MPH Assistant Commissioner, Division for Prevention and Preparedness Services Texas Department of State Health Services (DSHS) September 16, 2009

Page 2 Pandemic Definition: A disease outbreak occurring over a wide geographic area and affecting an exceptionally high proportion of the population The June 2009 declaration of a pandemic by the World Health Organization is an indication of the spread of the disease, not the severity.

Page 3 Pandemic Severity Index Case Fatality Ratio Number Deaths in Texas > 2%> 144, %72, , %36, , %7,200 – 36,000 < 0.1%< 7,200

Page 4 CDC Recommended Community-based Strategies Pandemic Severity Index Interventions by setting Mild (Category 1) Moderate (Cat. 2-3) Severe (Cat. 4-5) Workplace/Community/School  Decrease number of social contacts:  Adults: teleconferences/webinars  Students : altered curriculum; computer-based classes Generally not recommended ConsiderRecommend  Modify workplace/school schedules and practices  Adults: telecommute; staggered shifts  Students : staggered school schedules Generally not recommended ConsiderRecommend  Increase distance between persons  Adults: Increase space between people in mtgs, public transit  Students: Increase space between students in school buses; schools Generally not recommended ConsiderRecommend  Modify, postpone, or cancel public events  Adults: UT/TAMU football game, theatre events  Students: UIL, graduation Generally not recommended ConsiderRecommend

Texas Confronts Novel H1N1 Virus April 17:- The CDC lab confirmed the first novel H1N1 virus (California) April 23:- Confirmation of novel H1N1 virus in two teenagers from the same school in Guadalupe County April 25:- Decision to close Schertz-Cibolo High School was made April 26: - All 14 schools in the Schertz-Cibolo Universal City ISD closed May 5: - CDC announces new guidelines for school closure May / June- End of school year June 17: - Lab confirmed case at summer camp in Tyler August 24: - School starts Page Texas school campuses were closed one or more days during April 29 – May 5, 2009

Page 6 Pandemic Influenza Planning Assumptions Prior to April 2009 Pre-April AssumptionsReality H5N1 (bird flu) would be the pandemic strain H1N1 was the pandemic strain Need to plan for high mortality and morbidityLow mortality Outbreak would occur overseas (Asia)Outbreak began in Mexico Potential for rapid spreadRapid spread Elderly, chronically ill, and very young would be the most affected Primarily affected school age Vaccine would not be availableVaccines will be available Key role for community mitigation Schools were closed as a precaution Unpredictability of influenza virus Conducted surveillance for changes in the virus strains

H1N1 Influenza and Schools Influenza Virus Infection Sudden onset of symptoms Incubation period: ~1-4 days Infectious period: 5+ days, starting 1 day before symptoms (longer in children) Fever, headache, cough, sore throat, aches, possibly vomiting and diarrhea 50% of individuals with typical “seasonal” influenza have contact with the health care system (ranging from a doctor visit to hospital admission) General Characteristics Several types of influenza virus are circulating. Page 7

Page 8 Signs and Symptoms of Novel A (H1N1) Cases Reported to DSHS April – May 2009 Symptoms reported in confirmed cases Fever (>100ºF) (median temp: 102.0ºF) 94% Cough87% Sore throat61% Diarrhea and/or vomiting47% *Based on early cases when we were doing general surveillance Critical point: 88% of the confirmed H1N1 cases met Influenza Like Illness (ILI) case definition (fever > 100ºF and sore throat or cough)

Page 9 Descriptive Statistics of Novel A (H1N1) Cases Reported to DSHS April – May 2009* Demographic% Sex Male49% Female51% Age (median 10 yrs, range 1 mos – 84 yrs) <5 years16% 5-18 years65% years15% >45 years4% *Based on early cases when we were doing general surveillance

Page 10 Novel H1N1 Deaths in Texas Confirmed Novel H1N1 deaths from end of April to 10/03/09 * Mexico City resident Patient AgeNumber of H1N1 deaths < 6 months of age1 6 – 11 months of age1 1 – 4 yrs of age2* 5 – 9 yrs2 10 – 18 yrs11 19 – 24 yrs3 25 – 49 yrs35 50 – 64 yrs yrs4 TOTALS69

Page 11 Perspective Based on CDC estimates of national annual flu burden Texas DataSeasonal flu, annual estimates* Novel flu reported Cases1.2 – 4.9 million5,200** Hospitalizations16, Deaths2,88069*** * Bigger effect with H1N1 and seasonal flu combined ** Only represents confirmed cases reported prior to 7/31/09 *** As of 10/03/09

Page 12 Lessons Learned in 2009 Young adults MAY experience higher than expected mortality rates from a “novel” (new) strain of influenza virus Severity of illness MAY be lessened by prior exposure to a genetically related influenza virus Targeted, layered non-pharmaceutical interventions (NPI) MAY help mitigate the impact of flu on communities

Page 13 Timely closure of large public gatherings MAY help diminish the “peak” number of people who are ill with the flu in a community at any one time Outpatient and inpatient medical care facilities WILL be overwhelmed when the number of people who are seriously ill at any one time exceeds each community’s medical surge capacity. Lessons Learned in 2009 (cont’d)

Page 14 Roles and Responsibilities Role of DSHS Role of Universities Provide guidance based on Federal recommendations and evidence-based science Establish a relationship with state and local health departments Keep informed ( Develop educational messages Plan for assistance for students with influenza-like illness Develop plans for how to reduce exposure Consider alternative educational delivery Role of Local Health Departments Provide local guidance on specific recommendations Partner with other community entities including schools and universities Role of Texas Higher Education Coordinating Board Maintain communication with DSHS and Texas Division of Emergency Management and monitor situation Provide information and links on website (

Page 15 Preventive Measures in Schools / Universities DSHS concurs with CDC that the primary ways to reduce spread of flu in schools / universities are: Vaccination – seasonal and novel H1N1 influenza Staying home when ill Early identification of ill students, faculty and staff Practicing prevention strategies (good cough etiquette and hand hygiene) At this time, school closure is not advised for a single suspected or confirmed H1N1 case (this recommendation may change if pandemic changes: check for updates) Schools / universities in consultation with local heath authority decide to close public schools

Page 16 Texas’ Planning Efforts Some of Texas’ planning efforts involve: Non-Pharmaceutical Interventions (NPI) Detection and Monitoring Laboratory Surveillance Antivirals Distribution Vaccination Distribution Medical Surge MACC Activation / Provider Call Center Communications / Public Health Messages

Page 17 Non-Pharmaceutical Interventions (NPI) Activities used to limit the spread of an infectious disease Does not include medications or medical interventions Addresses two main areas: Infection Control (wash hands, cough etiquette, disinfect shared surfaces, keep hands away from face, etc.) Social Distancing (stay home when sick – staff and students) Benefits: Immediately available Limited cost Applied by anyone Scalable to Individual/Family, Community, or International levels Reduce the spread of disease in a community or campus Reduce stress on health and medical services Guided by science Decisions whether to cancel classes or events are university decisions

Page 18 Antiviral Medications for Influenza Inhibits the growth or reproduction of the virus Antiviral medications are available in the normal marketplace Antiviral medications are just one piece of the response effort If given within 48 hours of exposure or before exposure antivirals may: Prevent disease, but only while medication is taken No long term protection If given within 48 hours of symptoms antivirals may: Reduce length of illness by 1-2 days Prevent severe complications

Page 19 Antiviral Distribution: Strategic National Stockpile (SNS) State Stockpile: Approximately 2.5 million antiviral courses available in Texas 2.5 million more reserved for Texas in SNS Distribution: If your healthcare provider prescribes an antiviral, visit one of the participating pharmacies in your county ( and click on “Families and Individuals”) Recommendation is that antivirals be prescribed to high-risk individuals, including: Pregnant women People with acute or chronic respiratory disease, particularly those age groups more at risk for complications from H1N1 Children less than 5 years of age Immuno-suppressed people caused by medications or HIV

H1N1 Vaccinations: Expected in October 2009 INITIAL TARGETED GROUPS: Pregnant women Household contacts and caregivers for children < 6 months Healthcare and emergency medical services personnel All people 6 months - 24 years of age Persons 25 years through 64 years of age who have health conditions associated with higher risk of medical complications from influenza disease IF LIMITED VACCINE AVAILABILITY: Pregnant women Household contacts and caregivers for children < 6 months Healthcare and emergency medical services personnel who have direct contact with patients or infectious material Children aged 6 months – 4 years Children and adolescents aged 5 – 18 years who have health conditions associated with higher risk of medical complications from influenza Page 20

Page 21 Vaccinations Vaccine: CDC has provided a new planning scenario that includes 3.3 million doses potentially coming to Texas in October. Followed by weekly availability of vaccine Allocation for states is population based For Texas this is about 7.6% Some university health centers will likely be offering vaccine Mass Vaccination Plan posted on website

Page 22 Vaccine Safety Modern vaccine development: Improved process for manufacturing vaccines FDA must approve after testing on animals and humans Method for developing H1N1 vaccine is the same as that used for seasonal flu This method is both proven and safe Made with much of the same ingredients for seasonal flu vaccines Clinical trials for effectiveness and safety are still underway Ongoing monitoring after release

Page 23 Priority Vaccine Recommendations Target GroupsSeasonal Flu Vaccination H1N1 Vaccination Pregnant women XX People who live with or care for babies under 6 months XX Children & young people age 6 months through 18 yrs XX All young adults X People 50 years of age and older X--- People age with certain chronic medical conditions XX Health care and emergency medical services workers XX People who live in nursing homes and other long-term care facilities X--- People who live with or care for those at high risk for complications from flu (except infants) X---

Page 24 At-Risk Priority Populations Antiviral MedicationH1N1 Vaccinations Children less than 5 years old Persons 65 years or older Pregnant women Adults and children with: –Chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, metabolic disorders and/or immunosuppression including those caused by medications or HIV Residents of nursing homes Health care and emergency medical services workers Pregnant Women Those who live with or provide care to infants <6 months Children and young people age 6 months through 24 years People between 25 and 64 years who have chronic medical conditions

Page 25 Medical Surge Capacity: Alternative Care Systems Try to care for ill people at home if possible Home care guidance (provided through call centers) Guidance on when to seek medical care Expand outpatient capacity Flu clinics ER capacity (tool kits available) Postpone non-essential healthcare activities if needed Identify local nursing home capacity Identify hospital surge capacity strategies for critical populations (Pediatrics, OB, Critical care) Develop alternate care sites as last option. Texas has approximately 22,000 alternate care site beds identified

Page 26 H1N1 Call Center Texas Information and Referral Network (TIRN) Joint call center, using existing Area Information Centers (AICs) and DSHS nurses Respond to callers on vaccination clinic locations, emergency clinic locations, information to dispel rumors, and other general H1N1 information

Page 27 Communications Information for public, stakeholders, professionals Guidance documents, FAQs, tools Sign up for updates News media relations Ongoing contact with news media Public awareness campaign Multimedia campaign: information for the public and tools for stakeholders Conference calls with partners and stakeholders Situational awareness and response activities

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Page 29 Public Health Messages Practice good hand hygiene Practice cough/sneeze etiquette Be prepared to get sick Stay home when you get sick Get your flu vaccinations (shots or sprays) No aspirin for kids when they are sick Get pneumococcal vaccine as recommended

Page 30 Summary Get seasonal flu vaccine now; get H1N1 vaccine as available H1N1 vaccine available in October for targeted populations Non-pharmaceutical interventions are the most readily available and an effective means of reducing the spread of infectious diseases Guidance documents are available. Refer to or sign up for alerts when updates occur. Plan now with others in your community / university Encourage common sense measures like washing hands, covering coughs and sneezes, staying at home when sick with flu-like symptoms, etc. Engage in continuity of operations planning at work, personal readiness planning at home