1. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON 2009 (Pandemic) H1N1 Influenza Virus Washington State Department of Health Based on slides from: Anthony A Marfin Marcia Goldoft

2. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Outline Influenza, the illness Seasonal vs. pandemic influenza Current pandemic situation reports What to expect this fall / winter Public health response

3. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON What Is “Influenza-like Illness” (ILI)? Virus causing two respiratory disease syndromes ILI (upper respiratory tract) Fever plus cough or sore throat Lots of other symptoms Severe acute respiratory illness (SARI) ILI plus SOB, tachypnea, hypoxia Lower lung involvement ILI or SARI not only from influenza

4. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON You can have a mild case of influenza, but influenza is not a mild illness.

5. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Seasonal Influenza Viruses Seasonal A H3N2, A H1N1, and B viruses spread by respiratory secretions Toddlers, children, and adolescents transmit readily Most cases in these age groups Very young/old persons at risk for severe illness Most deaths in these age groups Vaccine is the best and most cost-effective control

6. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Each year, seasonal flu accounts for: 36,000 deaths 200,000 hospitalizations 20,000,000 ILIs (may or may not be medically attended) ? Asymptomatic infections

7. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Seasonal vs. Pandemic Influenza Every year, viruses change a little (“drift”) Seasonal flu epidemics each winter Quickly adjust vaccine annually Rarely, viruses change a lot (“shift”) Entirely new viruses so nobody immune Spread easily among non-immune humans Worldwide epidemic transmission (pandemic) Develop new vaccine over many months

8. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Pandemic Influenza 1918 Estimated 675,000 deaths / 105 million US population (0.6%) Public health challenges compared to now: war troop transport, lack of health care, lack of public health planning, interrupted public services (garbage, mail, telegraph, telephone) Deaths due to infectious diseases, United States 1900-1994 1918 influenza pandemic Philadelphia was overwhelmed by the number of dead. Burials were done without coffins, eventually in mass graves dug by steam shovels.

9. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Influenza Deaths, 1918 Compared to 1915 9

10. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Current Situation United States and Washington Beginning April 2009

11. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Avian influenza viruses H1N1 2009 Influenza Virus Pedigree Eurasian swine A/H1N1 (1979-present) Human “seasonal” A/H3N2 (1968-present) North American swine A/H1N1 (1918-present) “Triple reassortant” Swine A/H1N2 (1998-present) 2009 Human A/H1N1 (2009-??) ? Human seasonal A/H1N1 (1977-present)

12. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON 2009 H1N1 Influenza Entirely new virus so nobody immune First identified in California and Mexico, April 2009 Initial investigations → virus found in many states Summer 2009, worldwide spread Globally, most flu cases due to 2009 H1N1 Flu pandemic declared by WHO June 2009 Flu cases in U.S. and Washington continued through summer into fall (unusual) Severe cases and deaths

13. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Risk for severe infections with 2009 H1N1 Lung disease (asthma, smoking, COPD) Diabetes Pregnant Heart disease Other chronic medical conditions Neuro-developmental disease in children 2009 H1N1 Influenza

14. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Flu virus testing in typical flu season in early 2009 with mix of seasonal H1N1, H3N2, A not typed, and B viruses.

15. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON New H1N1 virus in April.

16. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Percentage of ER Visits for ILI by CDC Week, Western Washington 2009 May October

17. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON What Can We Expect This Winter? More cases of flu than in typical years, particularly in younger ages Absenteeism due to own or family illness More deaths because more cases More deaths in younger ages because more cases in younger ages With seasonal flu, 90+ % deaths are ≥ 65 years With H1N1 flu, 90+ % death are < 65 years

18. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Public Health Response

19. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Components of Response Surveillance Community Mitigation Healthcare Planning Communication Continuity of Operations Planning

20. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Influenza Surveillance in Washington Asymptomatic ILI cared for at home Medically attended ILI Hospitalized Died Mandatory reporting in Washington Sentinel physicians, aggregate lab data, syndromic surveillance Community survey, school absenteeism

21. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Community Mitigation Interventions that lessen the impact of a pandemic Community mitigation can include: Non-pharmaceutical interventions Isolation (ill) Quarantine (exposed to ill) School Closure Community Social Distancing Community Infection control Pharmaceutical Interventions Antivirals Vaccine

22. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Goals of Community Mitigation Days Since First Case Daily Cases Pandemic Outbreak: No Intervention Pandemic Outbreak: With Intervention Delay outbreak peak Decompress peak burden on hospitals/infrastructure Diminish overall cases and health impacts 2 1 3

23. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON What you can do  Wash your hands.  Cover your cough.  Don’t touch your eyes, nose and mouth  Try to avoid contact with sick people.  Make a family plan.  Stay home if you’re sick.  Get vaccinated (flu and maybe pneumococcal).

24. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Current CDC and DOH Community Mitigation Strategy for 2009 H1N1 H1N1 not severe enough for widespread community social distancing (e.g., school closures) Protect overall public health by: Reducing community transmission Minimizing severe cases Preventing social disruption May change – influenza is unpredictable! Still need to prepare for a major epidemic like 1918

25. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Antiviral and Vaccine Distribution DOH received antivirals and N95 masks from the Strategic National Stockpile (SNS) this spring DOH receiving H1N1 vaccine this fall as available DOH distributed antivirals and vaccine to LHJs Monitoring the usage of antiviral medications Usage has rapidly increased over the past few weeks

26. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON ACIP Target Populations for H1N1 Vaccination* Pregnant women Household contacts and caregivers for children younger than 6 months of age Healthcare and emergency medical services personnel All people from 6 months through 24 years of age Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza *MMWR 2009;58:1-8

27. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON http://www.statesman.com/news/content/news/stories/local/2009/09/22/rbz-Hospital-Flu-Tents-05.html Dell Children's Medical Center in Austin is seeing hundreds of patients a day with flu-like symptoms and is preparing triage tents to handle the volume. Hospitals are screening and limiting visitors.

28. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Communication Complex messages need to be communicated to the public and healthcare providers Complex public messages Disease severity Seeking medical care Vaccine safety Complex healthcare provider messages Purpose of the Public Health Laboratories Treatment recommendations

29. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON COOP Identify who will be affected Plan for workforce reduction and support of workers Cross-training for critical jobs Consider flexible work schedules Reduce spread of influenza Promote cough etiquette and hand cleaning Promote vaccination (flu and pneumococcal) Provide routine environmental cleaning Encourage use of sick leave for self-isolation at home

30. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON More information Washington State Department of Health http://www.doh.wa.gov/H1N1/ Local public health departments http://www.doh.wa.gov/LHJMap/ Federal government http://www.flu.gov/

31. PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON Thank you. Questions?