1. Community Containment Measures & H1N1 Influenza Kelly Jolliff Epidemiologist & Emergency Preparedness Supervisor St. Joseph County Health Department

2. Contributions from: Lesley Craft, MPH, CHES Director of Health Education St. Joseph County Health Department Indiana State Department of Health

3. Our Mission Limit the spread of H1N1 (this virus is not going away)

4. Community Containment Measures GOAL: Slow and limit viral transmission

5. What is Community Containment… Using public health strategies to prevent the transmission of a disease by person to person contact. Separating those with the disease from those who are at greater risk of developing the disease.

6. Community Containment Options Isolation Quarantine School Closure Cancellation of Public Events

7. Isolation & Quarantine Isolation refers to the separation of ill persons with a communicable disease from those who are healthy. Quarantine is the separation or restriction of activities of persons who are not ill but who are believed to have been exposed to a communicable disease and are therefore at highest risk of becoming infected.

8. Isolation & Quarantine Containment measures applied to individuals (i.e. – isolation and quarantine) may have limited impact in preventing the transmission of H1N1 influenza due to the ability of persons with asymptomatic infection to transmit the virus.

9. Isolation & Quarantine Law Ind. Code § 16-41-9-1.5 Three types of orders: (1) Order for isolation or quarantine (2) Emergency order for isolation or quarantine (3) Immediate order for isolation or quarantine

10. Both the ISDH and Local Health Officer may: (1) Close schools (2) Close churches (3) Forbid public gatherings *Ind. Code § 16-19-3-10 and § 16-20-1-24

11. Additional Authorities Ind. Code §16-20-1-21: Each local health board has the responsibility and authority to take any action authorized by statute or rule of the state department to control communicable diseases. Ind. Code §16-41-9-1.6: A public health authority may close schools, athletic events, and other nonessential situations in which people gather.

12. To Close or Not to Close… K – 12 Daycares Colleges and universities Technical schools Private schools Charter schools 13

13. 14 CDC Pandemic Severity Index Early and prolonged closure ← (4 & 5) Short term closure ← (3) Perhaps no school closure ← (1 & 2)

14. CDC Interim Guidance and Schools… School dismissal is not advised for a suspected or confirmed case of novel influenza A (H1N1) and, in general, is not advised unless there is a m agnitude of faculty or student absenteeism that interferes with the school’s ability to function. CDC H1N1 Flu (Swine Flu): Resources for K-12 Schools: http://cdc.gov/h1n1flu/schools/http://cdc.gov/h1n1flu/schools/

15. Schools The best place for well children is in school. The best place for ill children is at home.

16. CDC Interim Guidance For Schools… Students, faculty or staff with influenza-like illness (fever with a cough or sore throat) should stay home and not attend school or go into the community except to seek medical care for at least 24 hours after they are fever free with out fever reducing medication ( i.e. Tylenol or Advil). CDC H1N1 Flu (Swine Flu): Resources for K-12 Schools: http://cdc.gov/h1n1flu/schools/http://cdc.gov/h1n1flu/schools/

17. CDC Interim Guidance For Schools… Students, faculty and staff who appear to have an influenza-like illness at arrival or become ill during the day should be isolated promptly in a room separate from other students and sent home. CDC H1N1 Flu (Swine Flu): Resources for K-12 Schools: http://cdc.gov/h1n1flu/schools/http://cdc.gov/h1n1flu/schools/

18. CDC Interim Guidance For After School Programs… Ill students should not attend alternative child care or congregate in other neighborhood and community settings outside of school. CDC H1N1 Flu (Swine Flu): Resources for K-12 Schools: http://cdc.gov/h1n1flu/schools/http://cdc.gov/h1n1flu/schools/

19. Reporting to the St. Joseph County Health Department School Absenteeism rates are normally not reportable until levels are at or above 20% as per IC 20-8.1-18-1, however during a pandemic flu outbreak notification of any significant increase in influenza like illnesses may be critical in identifying a local impact. Recommended to monitor daily attendance for increased reports of absence due to flu-like illness. Question: How best to communicate?

20. Public Gatherings… Cancellation or postponement of large gatherings, such as:  Concerts or theatre showings  Church Services  Sporting events  Conferences Possible modifications to mass transit to decrease passenger density. Goal to reduce community transmission pressures to slow or limit transmission.

21. CDC interim guidance for public gatherings… Decisions regarding large public gatherings in the context of novel Influenza A (H1N1) outbreak should be made based on local influenza activity, evolving information about severity of illness, and other local considerations. Persons with influenza-like-illness (fever with cough or sore throat) should be advised to stay home at least 24 hours after their fever has resolved. All persons should be reminded to use appropriate respiratory and hand hygiene precautions. http://cdc.gov/h1n1flu/guidance/public_gatherings.htm

22. When to implement… Community Mitigation strategies based on severity of pandemic virus. Currently at category 1 severity. Should be used in combination with individual infection control measures.

23. Current H1N1 Severity

24. How will we know if the flu is more severe and should consider taking additional action steps? CDC and its partners will continue to monitor the spread of flu, the severity of the illness it’s causing, and whether the virus is changing. State and local health departments will also be on the lookout for increases in severe illness in their areas and will provide guidance to their communities. Public health agencies will communicate changes in severity and the extent of flu-like illness to ensure that organizations have the information they need to choose the right steps to reduce the impact of flu. http://cdc.gov/h1n1flu/institutions/toolkit/

25. Prevention Wash your hands frequently for at least 20 seconds, especially after sneezing or coughing. Alcohol-based hand cleaners are also effective. Avoid close contact with those who appear unwell and have a fever and cough. Cover your mouth and nose with disposable tissues when coughing or sneezing. Cough or sneeze into your sleeve if a tissue is not available. Avoid touching your eyes, nose, or mouth. Get enough sleep, eat nutritious foods, and keep physically active. If you feel unwell, stay home from work or school, and avoid crowds as much as possible. Rest, drink plenty of fluids and seek help for chores that require contact with other people.

26. Action steps for schools to prevent spread of the flu… Remind teachers, staff, and students to practice good hand hygiene and provide the time and supplies for them to wash their hands as often as necessary. Send sick students, teachers, and staff home and advise them and their families that sick people should stay home until at least 24 hours after they no longer have a fever. Clean surfaces and items that are more likely to have frequent hand contact such as desks, door knobs, keyboards, or pens, with cleaning agents that are usually used in these areas. Stay in regular communication with local public health officials. CDC H1N1 Flu (Swine Flu): Resources for K-12 Schools: http://cdc.gov/h1n1flu/schools/http://cdc.gov/h1n1flu/schools/

27. Action steps for businesses and employers… Send sick employees home and advise them and their families that sick people should stay home until at least 24 hours after they no longer have a fever (expect sick employees to be out for about 3-5 days in most cases). Clean surfaces and items that are more likely to have frequent hand contact with cleaning agents that are usually used in these areas. Improve hand hygiene and cough etiquette. Place posters in the worksite that encourages cough and sneeze etiquette. Ensure soap and water, and alcohol-based hand sanitizers are in the workplace. Encourage employee vaccination for seasonal influenza and 2009 H1N1 (as available). Prepare for increased numbers of employee absences, and plan ways for essential functions to continue. Prepare for possibility of school dismissal or temporary closure of child care programs. Ensure that your leave policies are flexible and non-punitive. Plan for possibility of increased severity. http://cdc.gov/h1n1flu/business/guidance/

28. What kills influenza viruses? Influenza virus can survive on environmental surfaces for 2-8 hours. Influenza viruses (including H1N1) are destroyed by heat (167- 212°F [75-100°C]). Several chemical germicides including: –Chlorine –Hydrogen peroxide –Detergents (soap) –Iodophors (iodine-based antiseptics) –Alcohols http://cdc.gov/h1n1flu/qa.htm

29. Three C’s Clean Cover Contain

30. Additional Information United Way 211 www.cdc.gov/H1N1FLU www.nd.edu/~pandflu www.in.gov/isdh www.in.gov/flu www.who.int www.pandemicflu.gov Kelly Jolliff Epidemiologist & Emergency Preparedness Supervisor St. Joseph County Health Department 227 W Jefferson Blvd. South Bend, IN 46601 574-245-6744 kjolliff@co.st-joseph.in.us