1. H1N1 (Swine Flu) Pandemic Influenza Gordon C. Manin, MD, MPH Medical Director

2. Overview  Definitions/Background  Annual/Seasonal Influenza  H1N1 (Swine Flu)  Prevention & Treatment

3. Definitions  Influenza (Flu): three types of Flu in humans (A, B, C); only type A further classified by subtypes that differ based on different surface proteins (HA, NA)  H1N1 (Swine Flu A), Avian Flu A (H5N1)  Influenza Epidemic: caused by subtypes of virus already circulating among humans, “seasonal outbreaks”  Antigenic Shift: abrupt/sudden major change in influenza A virus  Influenza Pandemic: new influenza A virus effecting humans, global outbreak, causes serious illness, easily spread from person to person

4. Pandemic Influenza History DateSubtype Worldwide deaths Highest mortality Waves/ duration 1918-1919H1N150,000,000 20 – 50 year olds 3 waves 2 years 1957H2N22,000,000Elderly 2 waves 2 years 1968H3N21,000,000Elderly ? 2 waves 3 years 2009-?H1N1? 25 – 45 Year olds ?

5. Perspective from Seasonal Influenza Outbreaks  Usually Occur Dec-March  Primarily Spread Person to Person by Respiratory Droplets from Coughs and Sneezes  Complications Include: –Bacterial Pneumonia –Dehydration –Worsening of Chronic Medical Conditions

6. Perspective from Seasonal Influenza Outbreaks  Incubation Time 1-5 Days (Average 2 Days)  Typically Contagious 1 Day before Symptoms to 5 Days after Symptoms develop  5-20% Get the Flu Each Year in USA  200,000 Hospitalized Each Year in USA  36,000 Americans Die Annually

7. Awareness Phases  W.H.O.* created 6 phases of awareness 1 Low risk to humans 4 Small clusters human-human spread 2 High risk to humans 5 Large clusters human-human spread 3 Human disease, no spread 6 Sustained transmission in humans**  Level of risk/preparation increases as levels increase –Over time, levels may go up and down –Geographic regions may be at different phases simultaneously –Unclear how much publicity will be given to Phase changes * World Health Organization ** As of June 11 th, 2009

8. International Co-circulation of 2009 H1N1 and Seasonal Influenza (As of September 20, 2009)

9. International Co-circulation of 2009 H1N1 and Seasonal Influenza (As of October 16, 2009)

10. Weekly influenza activity estimates reported by state and territorial epidemiologists (activity levels indicate geographic spread of both seasonal and 2009 influenza A (H1N1) viruses, September 19, 2009

11. Weekly influenza activity estimates reported by state and territorial epidemiologists (activity levels indicate geographic spread of both seasonal and 2009 influenza A (H1N1) viruses, October 10, 2009

12. Current H1N1 Situation  H1N1 a novel influenza virus, isolated April 2009  Incubation period unknown (Could range 1-7 days, more likely 1-4 days)  Infectious period for a Confirmed case of H1N1, 1 day before symptoms to 7 days after onset  As of July 31 st, 2009, median age was 12 years, with highest infection incidence among those between 25 and 45 years of age  Lowest incidence of infection among persons age ≥ 65 years  WHO Declared Worldwide Pandemic June 11, 2009

13. Current H1N1 Situation  Relatively Few Severe Cases in Older Persons  As of July 31 st, 2009, Median Age of Hospitalized Persons was 20 years, with highest Incidence in those < 4years  Highest Hospitalization Rates Among Persons < 65 years  Median Age Among Persons who Died with Novel H1N1 was 37 Years  Signs and Symptoms Similar to Seasonal Influenza  Specific Diagnostic Testing Required to Distinguish H1N1 from Seasonal Influenza

14. Symptoms Seasonal Influenza Seasonal Influenza  Fever  Headache  Extreme Tiredness  Dry Cough  Sore Throat  Runny or Stuffy Nose  Muscle Aches *Children may also experience nausea, vomiting, or diarrhea nausea, vomiting, or diarrhea Swine/H1N1 Influenza Swine/H1N1 Influenza  All symptoms of Typical Influenza  Diarrhea and Vomiting

15. High Risk Patients  High risk for seasonal influenza (Patterns are emerging for H1N1) complications include: –Children < 5 years old; –Persons aged 50 years or older; –Children and adolescents (aged 6 months to 18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after an influenza infection; –Pregnant women; –Adults and children who have chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, or metabolic disorders

16. Prevention  Cover your nose and mouth with a tissue when you cough or sneeze, dispose of tissue  Wash your hands often with soap and water (alcohol-based hand cleaners are also effective)  Avoid close contact with people: –Stay home if you are sick for 7 days after your symptoms begin or until you have been fever (100 o F) free for 24 hours, whichever is longer vs. 24 hours free of fever

17. Current Seasonal Influenza Vaccination Recommendations Should Get Vaccinated  People at High Risk  All Children 6 months- 18 years  People over 50  People Who Can Transmit to Others at High Risk  Residents of Chronic- Care Facilities  Pregnant in Flu Season  Anyone Who Wants to Reduce their Risk Should not Get Vaccinated  Severe Allergy to Eggs  Severe Reaction to Flu Vaccine in Past  GBS within 6 Weeks of Getting Flu Vaccine in Past  Children < 6 Months of Age  People with Moderate or Severe Illness Should Wait

18. H1N1 Vaccination  Sept. 15 th, 2009, FDA Approved Four H1N1 Vaccine Manufacturers  State Health Departments Received First Shipments September 30 th, 2009  Immune Response in Most Healthy Adults 8-10 Days After a Single Dose  Manufactured with and without Thimerosal  Same Contraindications and Side Effects as Seasonal Influenza Vaccine

19. Current ACIP H1N1 Influenza Vaccination Recommendations  Initial Target Groups (order of target groups does not indicate priority): –Pregnant women –Persons who live with or provide care for infants aged < 6 months (i.e. parents, siblings, and daycare providers) –Health-care and emergency medical services personnel –Persons aged 6 months to 24 years, and –Persons aged 25-64 years who have medical conditions that put them at higher risk for influenza-related complications

20. Current ACIP H1N1 Influenza Vaccination Recommendations  Subset of Target Groups During Limited Vaccine Availability: –Pregnant women, –Persons who live with or provide care for infants aged < 6 months (i.e. parents, siblings, and daycare providers), –Health-care and emergency medical services personnel who have direct contact with patients or infectious material, –Children aged 6 months to 4 years, and –Children and adolescents aged 15-18 years who have medical conditions that put them at higher risk for influenza-related complications

21. What Should I Do If I Get Sick?  Contact a Health Care Provider if: –You live in areas where cases have been identified and you develop influenza-like symptoms –You are a high risk patient and develop influenza- like symptoms –You are worried about your symptoms  CALL BEFORE GOING TO PHYSICIAN’S OFFICE!! –Not everyone needs to be seen, tested, or treated –Medical providers need to be prepared –Should patient be seen by personal physician or company physician

22. Current Antiviral Oral Medications  Amantadine: Swine (H1N1) Flu Currently Resistant  Rimantadine: Swine (H1N1) Flu Currently Resistant  Oseltamivir (Tamiflu)  Zanamivir (Relenza) *Avoid Aspirin if 18 years or younger

23. Other Recommendations  Dietary Restrictions  Contact with Pigs  Travel  Vaccination for Seasonal Flu  Oral Medications  Masks

24. Possible Scenarios  If pandemic occurs: –High absentee rate  Employee illness (30 – 40%)  Family illness/death  “Precautionary absence” –Likely to occur in waves of 3-6 months over total duration of 1-2 years –Medical care system will be severely tested

25. Issues Disaster Preparedness Teams Must Consider  Relapsing high absentee/death rates in employees  Protective measures (masks, gloves, surface disinfectants) for those at work  Virtual Office  Pay policies for “precautionary absence”  Insufficient vaccine/medication  Federal/state/local coordination  Employee communications  Other …

26. Resources  Occupational Health Disaster Expert Network www.ohden.sph.unc.edu:9002/pandemic www.ohden.sph.unc.edu:9002/pandemic  Department of Health and Human Services www.pandemicflu.gov www.pandemicflu.gov  Centers for Disease Control www.cdc.gov  World Health Organization www.who.org  Pennsylvania Department of Health www.health.state.pa.us/health/site www.health.state.pa.us/health/site

27. Conclusions  Pandemic H1N1 Influenza is Upon Us  Experts have been Predicting that Pandemic Influenza will Return at Some Point  Base Actions on Best Available Evidence  Communicate with Your Providers, Employees, and Stakeholders  Organizations Should Take the Time Now to Gather Accurate Information and Plan for How Your Organization will Respond to any Disaster (Intentional, Unintentional, or Natural)