Waukesha County 2009 H1N1 FluSchool SummitPeter Schuler, Health OfficerHealth and Human Services DirectorWaukesha County Public Health Division09/29/09

Waukesha County 2009 H1N1 Data

Benjamen Jones, MPH, Epidemiologist

Waukesha County Public Health Division

09/29/09

2009 H1N1 Flu (swine flu)Influenza-like-illness (ILI) is defined as fever (temperature of 100°F or

greater) and a cough and/or a sore throat

Case Definitions for Novel Influenza A (H1N1) Virus

A confirmed case of novel influenza A (H1N1) virus infection is defined as a person with an influenza-like illness with laboratory confirmed novel influenza A (2009 H1N1)

A probable case of novel influenza A (H1N1) virus infection is defined as a person with an influenza-like-illness who is positive for influenza A, but not sub-typed to be 2009 H1N1

A suspected case of novel influenza A (2009 H1N1) virus infection is defined as a person with influenza-like illness who has not been tested.

Waukesha County vs. WI and USWaukesha County (as of 09/01/09)

WI

(as of 09/02/09)

US

(as of 08/30/09)

Cases Reported 417 6,441 n/a

- Case Rate* 109.6 114.4 n/a

Hospitalizations 14 239 9,079

- % of total cases 3.4% 3.7% n/a

- Hospitalization Rate* 3.7 4.2 3.0

Deaths 1 8 593

- % of total cases 0.2% 0.1% n/a

- Death Rate* 0.26 0.14 0.20

•All rates per 100,000 population

•2008 Population estimates from US Census Bureau

•CDC discontinued case counts on 07/24/09

Waukesha County H1N1 Confirmed and Probable Cases by Age Group (as of 09/01/09)

  Incident Count

Age Group  

Under 1 4

1−4 41

5−9 74

10−14 100

15−19 42

20−24 29

25−29 22

30−34 12

35−39 19

40−44 14

45−49 23

50−54 19

55−59 9

60−64 4

65−69 3

70−74 0

75−79 0

80−84 0

85 and over 2

Total 417

Age Group  # %

Under 1 4 1%

1−24 286 69%

25−64 122 29%

65 and over 5 1%

Total 417 100%

Confirmed and Probable Cases of 2009 H1N1 in Waukesha County by age group as of 09/01/09

0

20

40

60

80

100

120

unde

r 1 1-4

5-9

10-1

415

-19

20-2

425

-29

30-3

435

-39

40-4

445

-49

50-5

455

-59

60-6

465

-69

70-7

475

-79

80-8

485

and

ove

r

Age group

Cas

es

Confirmed and Probable Cases of 2009 H1N1 in Waukesha County by City as of 9/01/09

0

20

40

60

80

100

120

140

160

Big Ben

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Brookfi

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Butler

Delafie

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Dousm

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Elm G

rove

Hartland

Lann

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Men

omonee

Falls

Muk

wonago

Mus

kego

New Berlin

Ocono

mow

oc

Pewauk

ee

Susse

x

Wauk

esha

City

Cas

es

Confirmed and Probable Cases of 2009 H1N1 in Waukesha County by Episode Week (episode is

first known date of illness) as of 09/01/09

1317 18

4031

58

30

149 7 10

4 39 6

6473

28

01020304050607080

25-A

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9-M

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16-M

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23-M

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Jun

13-J

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20-J

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27-J

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Jul

11-J

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18-J

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25-J

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1-Aug

8-Aug

15-A

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22-A

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29-A

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Episode Week

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Communication Fax Blasts

Health Care Providers, ICPs, hospitals Daycares Schools

Administrators/Superintendents Principals School Nurses

Esponder Communication with Influenza Taskforce

WEDSS Patient specific disease information

Surveillance Methods

School Absenteeism

Surveillance MethodsPassive Reporting School Absenteeism Infection Control Practitioners - Reports of

hospitalizations, deaths, and dramatic increase of cases Emergency Room – Reports of increase in upper

respiratory disease Medical Examiner – Reports of suspected deaths due to

influenza Lab Reports of Confirmed and Probable casesSystem Reporting RODS

RODS

Real-time Outbreak and Disease Surveillance

24 stores in Waukesha County reporting 18 over-the-counter medication categories

Both promotional and non-promotional sales

Over-the-counter medication categories

Antidiarrheal Electrolytes Pediatric Antifever Pediatric Antifever Adult Thermometers Hydrocortisones Nasal Products

Bronchial Remedies Chest Rubs Cold Relief Adult Cold Relief Pediatric Cough Syrup Adult Cough Syrup Pediatric Throat Lozenges

Surveillance MethodsPassive Reporting School Absenteeism Infection Control Practitioners - Reports of

hospitalizations, deaths, and dramatic increase of cases Emergency Room – Reports of increase in upper

respiratory disease Medical Examiner – Reports of suspected deaths due to

influenza Lab Reports of Confirmed and Probable casesSystem Reporting RODS WHIE

WHIE

Wisconsin Hospital Information Exchange 14 Emergency Departments download

data in real-time Pulling data from admitting complaint field One ED in Waukesha County is Elmbrook

WHIE Emergency Department Visit Report Flu/Fever

0

100

200

300

400

500

600

700

800

01/0

3/09

01/1

7/09

02/0

7/09

02/2

8/09

03/2

1/09

04/1

1/09

05/0

2/09

05/2

3/09

06/1

3/09

07/0

4/09

07/2

5/09

08/1

5/09

09/0

5/09

Co

un

t o

f v

isit

s

00?01 Visit Count

02?04 Visit Count

05?12 Visit Count

13?17 Visit Count

18?39 Visit Count

40?64 Visit Count

65+ Visit Count

Total Visit Count

Symptoms of 2009 H1N1 Influenza

Laura Radke, MD, Medical Consultant

Waukesha County Public Health Division

09/29/09

Symptoms of H1N1 Influenza Fever > 100.0° F Cough Sore throat Runny or stuffy nose Body aches Chills Headaches Fatigue

Symptoms of H1N1 Influenza Symptoms less classic for influenza but

found not infrequently in H1N1NauseaVomitingDiarrhea

Symptoms of Severe H1N1 Influenza Children

Rapid breathing or trouble breathing Bluish or gray skin color Not drinking enough fluids Severe/persistent vomiting Not waking up or interacting Irritability Flu symptoms resolve but then recur with fever and

worse cough

Symptoms of Severe H1N1 Influenza Adults

Difficulty breathing or shortness of breathPain or pressure in the chest or abdomenSudden dizzinessConfusionSevere/persistent vomitingFlu symptoms resolve but then recur with fever

and worse cough

Symptoms of Severe H1N1 Influenza Warrant emergency medical care Do not delay treatment

Use emergency medical services; do not wait for an appointment or for a clinic to open

Delays in treatment can be life-threatening

Antiviral Medications

Prescription medications that make it more difficult for the influenza virus to reproduce

Come in pill, liquid and inhaler forms Can be used for both treatment and prevention

of influenza, including H1N1 influenza For H1N1, two available medications

Tamiflu (oseltamivir) Relenza (zanamivir) Other medications used for seasonal influenza

Use of Antiviral Medications Most people with influenza recover without

complications. Medication should be used for people at high risk for complications of influenza People hospitalized with suspected or confirmed

influenza People with suspected or confirmed influenza at

higher risk for complications Children < 5 years of age Adults > 65 years of age Pregnant women People with certain chronic medical or immunosuppressive

conditions People<19 years of age on long-term aspirin therapy

Use of Antiviral Medications

Treatment is generally not indicated for people who are not at high risk for complications

Physicians may use their clinical judgment to treat some people who are not in risk groups. You should discuss treatment with your physician.

Use of Antiviral Medications

Antiviral medications should be started early – generally within 48 hours of the onset of illness No need to wait for test results

Antiviral medications can decrease the severity of flu symptoms

Antiviral medications may shorten the length of illness by 1-2 days

Antiviral medications may prevent serious flu complications

Use of Antiviral Medications Treatment is generally given for 5 days Hospitalized patients may be treated for

longer periods of time People receiving antiviral medications are

still infectious while on the medication Recommendations may change later in

the season based on the susceptibility of the circulating viruses

Use of Antiviral Medications Prevention of Influenza

Medications are 70-90% effective at preventing infection with susceptible viruses

Can be administered either prior to exposure or after a person has already been exposed to known influenza

Pre-exposure use only recommended in very limited circumstances and in consultation with local public health

Use of Antiviral Medications Post-exposure Prevention

Reserved for individuals in higher risk groups, healthcare workers and first responders exposed to a case of H1N1 influenza

Not a substitute for vaccine Not recommended for healthy individuals Okay for use in pregnant women Treatment is for 10 days after the last known

exposure Can be taken with killed flu vaccine but not with

FluMist®

Side Effects of Antiviral Medications Tamiflu (oseltamivir)

Nausea Vomiting Confusion (reported in Japan; unknown relationship to medication)

Relenza (zanamivir) Wheezing Bronchitis Cough Headache Nausea Diarrhea Dizziness

2009 H1N1 FLU PREPAREDNESS FORCHILD CARE CENTERS AND COLLEGES/UNIVERSITIES

Rosie Kapp, RN, Communicable Diseases Supervisor

Waukesha County Public Health Division

09/29/09

General Measures to Stop the Spread of Flu

Have a Preparedness Plan Vaccination Personal health practices Isolation/exclusion Social distancing Communication

Preparedness Plan Coordinate with state and local public

health officials Communication Risk assessment and OSHA compliance

High exposure risk = healthcare workersMedium exposure risk = high-frequency

contact with the publicLower exposure risk = minimal contact with

public and co-workers

Preparedness Plan

Plan needs to be flexible

Two scenariosCurrent level of moderate flu severityFlu becomes severe

Vaccination Encourage seasonal flu vaccine NOW!

Encourage 2009 H1N1 flu vaccine for “Target Group” when it is available Children, students, & others age 6 mo - 24 yrs Persons who live with or care for children under 6

months of age Pregnant women Adults through age 64 with chronic health conditions Healthcare workers and EMS

Cover Coughs and Sneezes Flu is spread mainly from person-to-

person when a person coughs or sneezes Cover coughs and sneezes with a tissue

or one’s sleeve if tissue not available Encourage use of tissues Provide no-touch trash bins Place Posters to encourage this behavior

Hand Hygiene Flu may be spread by contaminated hands Wash hands often with soap and water or

alcohol-based hand cleaner Wash hands after coughing or sneezing Avoid touching face Provide supplies for hand cleaning Place posters to encourage hand hygiene

Keep Sick People Home Advise to watch for symptoms of flu-like

illness and stay home if illFever >100° F with cough or sore throatStay home until fever-free for 24 hours without

use of fever-reducing medicationExpect to be home 3-5 days

Send Sick People Home Separate from others and ask to go home

promptly If possible, ill person may wear a surgical

mask Be prepared for absenteeism

Cleaning Surfaces Consider cleaning frequently touched

surfaces more often Consider cleaning shared equipment

between users e.g. phones Usual cleaning agents are effective Follow directions on the label

Child Care Programs Day Care Centers

Child Care Programs

Early Childhood Programs

Child Care - Special Considerations Children < 5 years of age at increased risk

of complications, esp. for < age 2 years of age

Infants < 6 months can not be vaccinated Close contact between children and staff Inability to follow hygiene precautions Disease spread can not be completely

prevented

Child CareSteps to Reduce Spread All children > 6 months and staff are

recommended to receive both flu vaccines Educate parents to keep sick children

home Encourage sick staff to stay home Do not require a doctor’s note

Child CareSteps to Reduce Spread Conduct daily checks of children and staff Separate ill children and staff Sick staff members should wear a surgical

mask, if tolerable Consider PPE for staff May elect a longer exclusion policy

7 days after illness onset even if recovered If still ill after 7 days, 24 hours after symptom free

Child CareSteps to Reduce Spread

Standard cleaning and sanitizing is all that is neededClean toys and high touch surfaces more

often

Flu Treatment for Children Encourage parents to contact their doctors

about early treatment for children less than 5 years of age and others at high risk of complications

Antiviral medication should be started in the first 48 hours of illness

Inform parents not to use aspirin for treating the flu for children under 19 years of age

Additional steps if flu outbreak becomes severe Permit staff who are high risk to stay home Increase distance between children

Smaller groupsDo not mix children between groups

Extend the time ill people stay home7 days after illness onset even if recovered If still ill after 7 days, 24 hours after symptom free

Center closure – consult public health

INSTITUTIONS OF HIGHER LEARNING Post-secondary education Colleges Universities Residential and non-residential

COLLEGES/UNIVERSITIES

Review absenteeism policies and remove barriers Do not require a doctor’s noteMissed classes, late assignments and

examinations Students or staff may be caring for ill

family members

COLLEGES/UNIVERSITIES Stay home if ill

Fever >100° F with cough or sore throatStay home until fever-free for 24 hours without

use of fever-reducing medication Discourage attendance at campus events Self-isolation at home by non-resident

students and staff

COLLEGES/UNIVERSITIES With Residential Living Test a sample of the population

Verify presence of 2009 H1N1 fluDetermine extent of disease spread

Self-isolation for residential studentsReturn home if possibleStay in private room; “flu buddy” to helpFor close contact, ill student wears a maskConsider temporary housing

STUDENT HEALTH CENTERS

Education regarding who needs medical evaluation and treatmentSevere illnessHigh risk for complications

Education re symptoms of complications Encourage students to clean frequently

Additional steps if flu outbreak becomes severe People at high risk for complications may

consider staying at home Distance learning Increase distances between people -ideally 6

feet Consider whether to suspend or modify campus

events Extend the period of self-isolation Class suspension – consult public health

Department of Public Instruction Recommendations for Schools during 2009 H1N1 Flu

Rachel Gallagher, RN, MS, CPNP School Nurse Consultant

WI Department of Public Instruction

09/29/09

Management guidelines

Exclusion Criteria

Surveillance

Masks

Cleaning

Stay home if sick.

Teach and model cough etiquette and frequent handwashing.

Early treatment of high risk groups

Routine cleaning.

Consider selective school dismissal

Obtain the vaccine when available.

Health officer closes a school – days of instruction are waived, however hours of instructions are not

Voluntary closure – apply for waiver

Hours of instruction – Continuation of Instruction

Exclusion criteria 24° after fever is gone without fever reducing

medicationSchool nurse and healthcare providers providing

services to high risk student populationso Chronic illnesso Pregnant womeno <5 years of age

Well family members of sick students

Tale of two school districts

Wisconsin Statute Chapter 252.21(10(6)o Notify Health Officero Medical provider directiveso Confidentiality

Disease activity vs. testing

Data for decision-making

Justification for possible waiver

YES Process

Identification of students with “flu-like symptoms” Mask as soon as possible Isolate Exclude

Caregivers providing care within 6 feet of student with “flu-like symptoms”

Routine cleaning

Special attention to commonly usedsurfaces in the schoolsetting

Limited benefit

Factors to consider:

Disease activity of your community

Disease activity of the fieldtrip destination

Interaction with local community

Anticipated vaccine availability – October

Target populations vs. Priority Groupso children- 6 months to 24 yearso people with chronic illnesso pregnant womeno caregivers for children under the age of 6 months o health care worker and medical personnel

School may be vaccination sites –

Seasonal and H1N1 Vaccination

Active screening.

Increase social distancing.

Increase the time for sick people to stay home.

High-risk individual should stay home.

Students will ill family members should stay home.

2009 H1N1 Disease Prevention & Control

Nancy Healy-Haney, Psy.D, MPH, BSN, Manager

Waukesha County Public Health Division

09/29/09

Disease Prevention

2009 H1N1 Vaccine

Influenza vaccination is the most effective method for preventing influenza and influenza-related complications

2009 H1N1 Vaccine - Is It Safe? 2009 H1N1 Vaccine is made exactly as the

seasonal influenza vaccine is made which is very safe.

2009 H1N1 Vaccine and the seasonal vaccine are made by injecting a small amount of the influenza virus protein into embryonic chicken eggs; the fluid is harvested days later, it is purified into vaccine.

2009 H1N1 Vaccine has proven very safe in the clinical trials

Adults will need 1 dose. Children under 10 years will need 2 doses

2009 H1N1 Vaccine is now licensed by the Food and Drug Administration

Is It Safe? (cont’d)

2009 H1N1 Vaccine - Is It Effective?

The National Institute of Health vaccine trials are determining the vaccine efficacy. Early results = Antibodies present in

15 mcg to 30 mcg doses Final results = what minimum dose is necessary for effective immunity

2009 H1N1 has no additives (adjuvant) and is not the same 1976 Swine Flu vaccine

2009 H1N1 Vaccine Products

Products are:

Live Attenuated Intranasal Vaccine:

- Ages 2 years – 49 years

Inactivated Injectible Vaccine:

- Ages 6 months & older

Can I get Seasonal Flu Vaccine and the 2009 H1N1 Vaccine?

Answer = Yes

2009 H1N1 Vaccine -Five Initial Target Groups

Centers for Disease Control and Prevention 2009 H1N1 Influenza Vaccine target groups include:

• Pregnant women because they are at higher risk of complications;

• Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated;

Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients;

All people from 6 months through 24 years of age Children from 6 months through 18 years of age because

an unusually high number cases have been seen in this age group

Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in this healthy young adult population, as they live, work and study in close proximity.

Target Groups: (cont’d)

Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

As Vaccine Becomes Available

All Age Groups Are Recommended to be vaccinated.

40 – 50 million doses by mid October10 – 20 million doses per week there after

Target Groups: (cont’d)

Where can I get the 2009 H1N1 Vaccine?

From:

The Waukesha County Public Health Division

Private physicians

2009 H1N1 Disease Prevention

Prevention: Mass Immunization Campaign2009 H1N1 Vaccine Mass Immunization Campaign Late October / November 2009 Provided by Waukesha County Public Health Division

PHASE I First Responder Vaccination Mass Clinic: Expo Forum – Waukesha Healthcare workers and EMS personnel

2009 H1N1 Disease Prevention

PHASE II Target PopulationsA. Mass Clinic: Expo Forum – Waukesha

- Pregnant women- Household contacts to children 6 months

and under, - People 6 months through 24 years

B. Waukesha County Quadrant PODS(Points of Distribution):

Menomonee Falls, Oconomowoc, New Berlin, Mukwonago

PHASE III All Age Groups Mass Clinic: Expo Forum – Waukesha Open to general population

2009 H1N1 Disease Prevention

Control

2009 H1N1 case investigation follow-up and isolation is conducted by the Waukesha County Public Health Division

Currently the Waukesha County Public Health Division will NOT be: Routinely following up on individual cases of H1N1, Notifying schools of individual H1N1 cases, Quarantining exposed persons Closing schools unless the disease is out of control

2009 H1N1 Disease Control

Resources Websites

http://pandemic.wisconsin.gov/ http://www.waukeshacounty.gov/pandemicflu http://dpi.wi.gov/sspw/pandemicflu.html

Call 211 from a landline Public Health Contacts

Call Waukesha County Public Health at 262-896-8430 Kim Babel, RN is school resource Cindy Barfknecht, RN is for other settings

Questions?