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

Cleveland Buncombe Anson Ashe Beaufort Bertie Bladen Brunswick Burke Caldwell Carteret Caswell Catawba Chatham 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 Madison Martin 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 Pasquotank Perquimans Camden Currituck Montgomery Henderson Granville Vance Durham Mecklenburg Lincoln Cabarrus Richmond Cumberland Alexander Craven Haywood Alleghany Mitchell Avery Alamance Davidson Edgecombe New Hanover Confirmed NC Cases by County of Residence August 12, 2009 Confirmed Cases, N=687 (75 counties) Northampton

Emergency Departments Doctors Offices

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

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 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

Public Health Resources