1. Preparing for Fall: Pandemic Influenza A (H1N1) Seth Foldy, MD MPH State Health Officer/DPH Administrator August 19, 2009

2. Protecting and promoting the health and safety of the people of Wisconsin 2 Preparation With Uncertainty Much is unknown What we know now may change Check for latest guidance regularly – pandemic.wisconsin.gov – Local health department

3. Protecting and promoting the health and safety of the people of Wisconsin 3 Today’s To Do List for Individuals Obtain seasonal (“regular”) influenza vaccine soon Identify those in your household who are: – early targets for the new H1N1 vaccine – at higher risk for serious influenza complications Monitor local media for up-to-date information – Pandemic.Wisconsin.Gov – Local Health Department – Dial “211” for questions “Call before you go” to clinic or hospital, except for life- threatening symptoms Make a household plan for illness or other possible emergencies

4. Protecting and promoting the health and safety of the people of Wisconsin 4 Today’s To Do List for Institutions and Businesses Worker/client advice & supplies for – hand cleansing – cough/sneeze hygiene – cleaning highly-used surfaces Policies and practices for workers and clients with fever & respiratory symptoms like cough, sore throat Participate in influenza vaccination programs Plans for distancing workers and clients (6-foot “sneeze zone”) if needed Plans for operating with higher level of absenteeism

5. Protecting and promoting the health and safety of the people of Wisconsin 5 What is Pandemic Influenza A (H1N1)? Triple reassortment strain (pig/avian/human) PLUS 2 genes associated with Eurasian swine flu. Increased human-to human spread Illustration NEJM 360(25):2612

6. Protecting and promoting the health and safety of the people of Wisconsin 6 March - August 2009 Untypable influenza in Mexico – increased pneumonia deaths Spread rapidly through US Case reported in 168 countries/territories (Aug 4) Reported proportions of cases resulting in death – Worldwide 0.7% – US 0.7% (July 24) – Wisconsin 0.1% Median age of those becoming ill in Wisconsin = 13 years old

7. Protecting and promoting the health and safety of the people of Wisconsin 7 Hospital Resources Wisconsin: 3.7% of confirmed or probable H1N1 cases hospitalized – Mean age 28 years – 23% of hospitalized treated in ICU – 11% of hospitalized required ventilator

8. Protecting and promoting the health and safety of the people of Wisconsin 8 What We Did in Spring: Individual prevention Ill stay home until 7 days after onset Wash hands Cover coughs, sneezes Consult medical caregiver if high risk with symptoms Stay away from ill persons when possible

9. Protecting and promoting the health and safety of the people of Wisconsin 9 What We Did in Spring Social distancing School closures for H1N1 cases before May 5 School closures after May 5 - rare Public events – no restrictions Workplace behaviors – Healthcare infection control more strict – Access to frequent handwashing/cleansing – Ill go home – Masks, respirators optional

10. Protecting and promoting the health and safety of the people of Wisconsin 10 Epi curve

11. Protecting and promoting the health and safety of the people of Wisconsin 11 Map

12. Protecting and promoting the health and safety of the people of Wisconsin 12 Status Very low numbers of cases at present Reloading on antiviral medication and infection control equipment for healthcare Novel influenza H1N1 vaccine in production Seasonal trivalent influenza vaccine available soon Preparing for fall

13. Protecting and promoting the health and safety of the people of Wisconsin 13 Challenges for Fall: Co-circulation of multiple influenza viruses

14. Protecting and promoting the health and safety of the people of Wisconsin 14 Seasonal Flu versus Novel H1N1 Seasonal StrainsNovel H1N1 VaccineProduced, distributed early fall In production, mid- October availability? AntiviralsEach strain has unique sensitivity to anti- viral drugs Age-impactStrikes elders hardMany elders have some immunity

15. Protecting and promoting the health and safety of the people of Wisconsin 15 Challenges: Possible Mutation What could still happen? – Changes in antiviral drug resistance – Changes in vaccine effectiveness (drift away from vaccine strain) – Changes in severity of illness and death rates (virulence) Even small increases could impact healthcare capability

16. Protecting and promoting the health and safety of the people of Wisconsin 16 Challenges: Distributing vaccine First urgent large-scale campaign since 1976 Different target populations – Focus on healthcare workers, young, pregnant and chronically ill Different distribution pathways Uncertain when vaccine will arrive Uncertain what quantities will arrive early

17. Protecting and promoting the health and safety of the people of Wisconsin 17 Challenges: Large susceptible population Only about 1.2 million US residents infected in Spring Why? – Onset of warm weather? – Less capable of person-to-person spread? Could have many more infections through long fall/winter/spring seasons

18. Protecting and promoting the health and safety of the people of Wisconsin 18 We Can Make A Difference! Reduce infections – Voluntary vaccination – Personal hygiene and behavior Sick stay home Hand cleansing Coughing and sneezing – Workplaces and school policies Reduce complications Prompt antiviral treatment of high risk people with symptoms Protect our healthcare capacity

19. Protecting and promoting the health and safety of the people of Wisconsin 19 Today’s To Do List for Individuals Obtain seasonal (“regular”) influenza vaccine soon Identify those in your household who are: – early targets for the new H1N1 vaccine – at higher risk for serious influenza complications Monitor local media for up-to-date information – Pandemic.Wisconsin.Gov – Local Health Department – Dial “211” for questions “Call before you go” to clinic or hospital, except for life- threatening symptoms Make a household plan for illness or other possible emergencies

20. Protecting and promoting the health and safety of the people of Wisconsin 20 Today’s To Do List for Institutions and Businesses Worker/client advice & supplies for – hand cleansing – cough/sneeze hygiene – cleaning highly-used surfaces Policies and practices for workers and clients with fever & respiratory symptoms like cough, sore throat Participate in influenza vaccination programs Plans for distancing workers and clients (6-foot “sneeze zone”) if needed Plans for operating with higher level of absenteeism

21. Protecting and promoting the health and safety of the people of Wisconsin 21 Goals Communication Voluntary vaccination of targeted populations Reduce Transmission Manage Medical Surge Surveillance of illness and impact Continuity of Operations: Prepare for absenteeism

22. Protecting and promoting the health and safety of the people of Wisconsin 22 Communication Coordinated mass media communication pandemic.wisconsin.gov – email drop-box 211 Wisconsin – information and referral Guidance for specific sectors – (pandemic.wisconsin.gov) Public service announcements Local health department Internal employee and agency communication – Quell rumor and misinformation – Assure consistent information (but prepare for change) – Retain trust and confidence (accurate & useful)

23. Protecting and promoting the health and safety of the people of Wisconsin 23 VOLUNTARY VACCINATION

24. Protecting and promoting the health and safety of the people of Wisconsin 24 Vaccination Voluntary Supply of NOVEL H1N1 vaccine planned to arrive later in fall Uncertain quantities of novel H1N1 vaccine Likely some period of shortages Focused outreach to highest priority groups Over time, hope for enough vaccine for all

25. Protecting and promoting the health and safety of the people of Wisconsin 25 Vaccination – Target groups (US-CDC recommendations) Seasonal (trivalent) Vaccine Normal distribution channels – Health care & EMS personnel – All 6 mos.-18 years – Pregnant women – Chronic illnesses – Household/caregivers of higher risk groups – Residents of long-term care facilities – Over age 50 Novel H1N1 initial targets Also possible mass clinics – Healthcare and EMS personnel – All 6 mos. to 24 years – Pregnant women – 25-64 with chronic illnesses – Household contacts/caregivers of infants < 6 mos. – Then remainder: NOTE: elderly not specifically targeted (higher levels of immunity)

26. Protecting and promoting the health and safety of the people of Wisconsin 26 Vaccination: Novel H1N1 Uncertain initiation time and vaccine quantity After initial release--continuing supply Distribution directed by public health agencies Desire rapid distribution among target populations Within several weeks of first vaccine hope to have plenty for all who desire it

27. Protecting and promoting the health and safety of the people of Wisconsin 27 Reducing Transmission

28. Protecting and promoting the health and safety of the people of Wisconsin 28 Reducing Transmission Recommendations may change with the severity of illness caused by the virus If similar to spring: control measures similar to late spring If causing more serious disease (or disruption of health and other sectors) may need more disruptive measures

29. Protecting and promoting the health and safety of the people of Wisconsin 29 Reducing Transmission: Healthcare Is Different – Point of contact between influenza patients and many vulnerable chronically ill populations – Some healthcare procedures increase the risk of spread – Health care workers can spread infections between healthcare and community settings – Long-standing infection control programs in place Includes mandatory respiratory protection programs

30. Protecting and promoting the health and safety of the people of Wisconsin 30 Reducing Transmission: Schools

31. Protecting and promoting the health and safety of the people of Wisconsin 31 Reduce transmission–School and child-care setting Many susceptible youth from diverse areas in prolonged contact—excellent for spread! Less-than-ideal hygiene Relatively low hospitalization and death rates Large community consequences with school closure – Increased absenteeism in other sectors – Some children at risk of neglect, poor nutrition, etc. – Lost education opportunities Some children and adults with chronic conditions that put them at risk

32. Protecting and promoting the health and safety of the people of Wisconsin 32 Reduce transmission–School and child-care setting Vaccination is an ideal strategy—encourage it! If relatively low rates of serious illness (similar to spring): – Separate and exclude ill youth and staff until 24 hours without fever (off anti-fever medications) – Increase hand cleansing, cover coughs and sneezes, avoid touching face – Clean frequently-touched surfaces with routine cleaning products – At-risk students and staff should seek prompt treatment if symptomatic – Consider school discharge in unique cases only More aggressive measures possible if virus severity increases

33. Protecting and promoting the health and safety of the people of Wisconsin 33 Reduce transmission–Other Occupational Settings Encourage sick (fever/cough or sore throat) stay home from work and other activities – Wait until fever-free 24 hours without anti-fever drugs – Contacts to flu without symptoms may work Provide handwashing/sanitizer access Posters and circulars on hand and cough hygiene Clean frequently touched surfaces with normal cleaners Provide additional cleaning materials to employees

34. Protecting and promoting the health and safety of the people of Wisconsin 34 Reducing Transmission: Other Occupational Settings Encourage vaccination Maintain 6 foot separation from sick individuals – Offer masks to coughing persons – Masks and respirators for general workforce of uncertain benefit Consider accommodations for high risk persons to reduce influenza contact High risk persons should consult healthcare promptly for flu symptoms Monitor travel advisories Insufficient evidence to cancel group activities

35. Protecting and promoting the health and safety of the people of Wisconsin 35 Keep Your Wits Influenza contact likely in all parts of the community (schools, stores, transit, recreation, home as well as work) When available, vaccination may reduce risk of infection Hand washing and other simple measures Barring a significant change in the virus: – The overall risk of serious illness is low – Medication may reduce illness (if taken early)

36. Protecting and promoting the health and safety of the people of Wisconsin 36 MEDICAL SURGE Photo New York Times

37. Protecting and promoting the health and safety of the people of Wisconsin 37 Manage Medical Surge Vaccination and transmission reduction Call before you go —telephone management Strengthening supply of antiviral medication and equipment Healthcare emergency preparedness program – Healthcare resource management – Healthcare workforce management – Coordination and Mutual aid

38. Protecting and promoting the health and safety of the people of Wisconsin 38 Surveillance Detect increasing virulence (illness severity) by tracking – Hospitalizations – Deaths Detect anti-viral medication resistance Track movement of multiple flu viruses through population – Advise professionals on appropriate treatment Track impact on health care sector Detect signs of other sector stress (e.g., absenteeism)

39. Protecting and promoting the health and safety of the people of Wisconsin 39 Continuity of Operations: Absenteeism Absenteeism may be from: – Fear Re-establish sense of control-sensible things to do! Good information – Illness – Family care for illness – Family care for school and other closings Templates for businesses at pandemic.wisconsin.gov

40. Protecting and promoting the health and safety of the people of Wisconsin 40 Today’s To Do List for Individuals Obtain seasonal (“regular”) influenza vaccine soon Identify those in your household who are: – early targets for the new H1N1 vaccine – at higher risk for serious influenza complications Monitor local media for up-to-date information – Pandemic.Wisconsin.Gov – Local Health Department – Dial “211” for questions “Call before you go” to clinic or hospital, except for life- threatening symptoms Make a household plan for illness or other possible emergencies

41. Protecting and promoting the health and safety of the people of Wisconsin 41 Today’s To Do List for Institutions and Businesses Worker/client advice & supplies for – hand cleansing – cough/sneeze hygiene – cleaning highly-used surfaces Policies and practices for workers and clients with fever & respiratory symptoms like cough, sore throat Participate in influenza vaccination programs Plans for distancing workers and clients (6-foot “sneeze zone”) if needed Plans for operating with higher level of absenteeism

42. Protecting and promoting the health and safety of the people of Wisconsin 42 Thank You! Send questions or comments: DHSWiPanflu@wisconsin.gov DHSWiPanflu@wisconsin.gov