EMS Update on EMS Update on H1N1 Influenza A H1N1 Influenza A

and Pan Fluand Pan FluKathy RobinsonKathy Robinson

NASEMSO Program ManagerNASEMSO Program Manager

September 23, 2009

EMS & 9-1-1EMS & 9-1-1Critical Components of the Critical Components of the

National StrategyNational Strategy

9/23/2009 2

EMS and 9-1-1 documents are available for download at www.ems.gov

We All Know…We All Know…

9/23/2009 3

Public Interest in ContextPublic Interest in Context

  Results Results 11 - - 1010 of about of about 38,400,00038,400,000 for for Swine FluSwine Flu [ [definition]. (]. (0.210.21 seconds)  seconds) 

Results Results 11 - - 1010 of about of about 49,000,00049,000,000 for for H1N1H1N1. (. (0.050.05 seconds)  seconds)  

  Results Results 11 - - 1010 of about of about 186,000,000186,000,000 for for Michael Jackson. (. (0.080.08 seconds)    seconds)   

9/23/2009 4

CDC—September 15, CDC—September 15, 20092009

““It never went away.”It never went away.” The virus has not changed to become The virus has not changed to become

more deadly.  more deadly.  Drug-resistant strands emerging.Drug-resistant strands emerging. Child deaths--had at least one severe Child deaths--had at least one severe

underlying illness or underlying underlying illness or underlying disability, actually, rather than illness, disability, actually, rather than illness, in most of the cases -- cerebral palsy, in most of the cases -- cerebral palsy, muscular dystrophy, long-standing muscular dystrophy, long-standing respiratory or cardiac problems. respiratory or cardiac problems. 

9/23/2009 5

CDC-September 15, 2009CDC-September 15, 2009

Child deaths--had at least one Child deaths--had at least one severe underlying illness or severe underlying illness or disability-- cerebral palsy, disability-- cerebral palsy, muscular dystrophy, long-standing muscular dystrophy, long-standing respiratory or cardiac problems. respiratory or cardiac problems. 

Children who didn't have an Children who didn't have an underlying condition and who did underlying condition and who did become severely ill, and they become severely ill, and they were generally infected also by were generally infected also by bacteria. bacteria. 9/23/2009 6

CDC-September 15, 2009CDC-September 15, 2009

Most people recover from infection Most people recover from infection without the need for hospitalization without the need for hospitalization or medical care. or medical care.

Causes more serious lung disease Causes more serious lung disease than seasonal flu strains and sheds than seasonal flu strains and sheds from the lung and throat tissue from the lung and throat tissue where it reproduces at higher where it reproduces at higher rates.**rates.**

High fever post viral infection?? High fever post viral infection?? Suspect bacterial pneumonia. Suspect bacterial pneumonia. 9/23/2009 7

Current StatusCurrent Status

Twenty-one states are reporting Twenty-one states are reporting widespread influenza activity at widespread influenza activity at this time. this time.

Reports of widespread influenza Reports of widespread influenza activity in September are very activity in September are very unusual. unusual.

Almost all of the influenza Almost all of the influenza viruses identified so far are 2009 viruses identified so far are 2009 H1N1 influenza A viruses. H1N1 influenza A viruses.

9/23/2009 8

INFLUENZA IN SCHOOLSINFLUENZA IN SCHOOLS

6/12/2009 National Association of State EMS Officials

9

Population Density and Mitigation

Population Density and Mitigation

9/23/2009 10

H1N1 in SchoolsH1N1 in Schools

Some schools in Florida Some schools in Florida and Canada have and Canada have banned hand sanitizers banned hand sanitizers because of the high because of the high concentration of concentration of alcohol.alcohol.

Officials worried about Officials worried about flammability and flammability and potential misuse as an potential misuse as an intoxicant.intoxicant.

Must store larger pump Must store larger pump containers and extra containers and extra bottles in fireproof bottles in fireproof cabinets or outdoor cabinets or outdoor sheds.sheds.

9/23/2009 11

New Thinking on School New Thinking on School ClosuresClosures

“ “The potential benefits of The potential benefits of preemptively dismissing students preemptively dismissing students from school are often outweighed by from school are often outweighed by negative consequences, including negative consequences, including students being left home alone, students being left home alone, health workers missing shifts when health workers missing shifts when they must stay home with their they must stay home with their children, students missing meals, and children, students missing meals, and interruption of students’ education.” interruption of students’ education.”

World Health Organization, September 2009 World Health Organization, September 2009

9/23/2009 12

RESPIRATORY RESPIRATORY PROTECTION FOR HEALTH PROTECTION FOR HEALTH CARE WORKERSCARE WORKERS

9/23/2009 13

Masks and RespiratorsMasks and Respirators

Estimated NeedEstimated Need More than 30 billion More than 30 billion

masks needed in a masks needed in a pandemicpandemic 27B surgical masks27B surgical masks 5 billion N-95 5 billion N-95

US StockpileUS Stockpile SNS contains 119 SNS contains 119

million masksmillion masks 39 million surgical39 million surgical 80 million N-95’s80 million N-95’s

9/23/2009 14

RealityReality

One anecdotal report— One anecdotal report— 7000 7000 masks masks in caring for in caring for ONEONE H1N1 H1N1 Influenza A Influenza A patient patient in one ICUin one ICU

9/23/2009 15

N-95 vs Surgical Mask?N-95 vs Surgical Mask?

CDC – “We want to ensure that CDC – “We want to ensure that health care workers are safe.”health care workers are safe.”

Revised guidance expected this Revised guidance expected this weekweek

9/23/2009 16

IOM Advisory Committee-IOM Advisory Committee-N95N95

The committee was The committee was not charged with not charged with considering considering implementation implementation issues, which include issues, which include cost, availability of cost, availability of equipment, and equipment, and other considerations other considerations (such as effective (such as effective vaccines) in the vaccines) in the implementation of implementation of such guidance.such guidance.

9/23/2009 17

IOM Advisory Committee- IOM Advisory Committee- N95N95

An emphasis is needed on An emphasis is needed on implementing a range of implementing a range of strategies across all levels.strategies across all levels.

Studies on influenza transmission Studies on influenza transmission show that airborne transmission show that airborne transmission is one of the potential routes of is one of the potential routes of transmission.transmission.

9/23/2009 18

IOM Advisory Committee-IOM Advisory Committee-N95N95

The committee endorses the current The committee endorses the current CDC guidelines and recommends that CDC guidelines and recommends that these guidelines should be continued these guidelines should be continued until or unless further evidence can be until or unless further evidence can be provided to the effect that other forms provided to the effect that other forms of protection or other guidelines are of protection or other guidelines are equally or more effective.equally or more effective.

Employers should ensure that the use Employers should ensure that the use and fit testing of N95 respirators be and fit testing of N95 respirators be conducted in accordance with OSHA conducted in accordance with OSHA regulations…regulations…

9/23/2009 19

Key Points-IOMKey Points-IOM

The use of respirators should be The use of respirators should be for those in initial contact with for those in initial contact with individuals presenting with individuals presenting with unidentified febrile respiratory unidentified febrile respiratory illnesses and those healthcare illnesses and those healthcare workers in close contact with workers in close contact with individuals with confirmed or individuals with confirmed or suspected H1N1.suspected H1N1.

9/23/2009 20

Key Points-IOMKey Points-IOM

PPE needs to be viewed asPPE needs to be viewed as one one part part of a continuum of controlsof a continuum of controls to to ensure worker and patient safety ensure worker and patient safety that range from engineering that range from engineering controls and administrative controls and administrative approaches to pharmaceutical approaches to pharmaceutical measures.measures.

9/23/2009 21

Key Points-IOMKey Points-IOM

Emergency medical respondersEmergency medical responders Fit-tested disposable N-95 Fit-tested disposable N-95

respirator if in close contactrespirator if in close contact Aerosol generating activitiesAerosol generating activities Interfacility transfersInterfacility transfers

9/23/2009 22

This Just In…This Just In…

Last week, American Society for Last week, American Society for Microbiology Meeting describes first Microbiology Meeting describes first randomized controlled trial comparing N95 randomized controlled trial comparing N95 to facemasksto facemasks

MacIntyre Study found that surgical masks MacIntyre Study found that surgical masks had no protective effect. In contrast, the had no protective effect. In contrast, the N95s, compared with the controls, were N95s, compared with the controls, were linked withlinked with 60% reduction in risk for any respiratory illness60% reduction in risk for any respiratory illness 75% reduction in flu-like illness75% reduction in flu-like illness 56% decrease in lab-confirmed respiratory illness56% decrease in lab-confirmed respiratory illness 75% reduction in confirmed flu75% reduction in confirmed flu

9/23/2009 23

Really???Really???

The researchers found that fit-The researchers found that fit-testing of the made no difference in testing of the made no difference in protection. protection.

Published at: Published at: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/sephttp://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/sep1709respir-jw.html 1709respir-jw.html

9/23/2009 24

Fraudulent ProductsFraudulent Products

136 entries so 136 entries so farfar

Topics on this PageTopics on this Page

        Air System ProductsAir System Products    Body Wash Products    Body Wash Products    Device Products    Device Products    Gel Products    Gel Products    Gloves Products    Gloves Products    Hand Sanitizer Products    Hand Sanitizer Products    Herbal Extract Products    Herbal Extract Products    Inhaler Products    Inhaler Products    Kit Products    Kit Products    Mask Products    Mask Products    Shampoo Products    Shampoo Products    Spray Products    Spray Products    Supplement Products    Supplement Products    Tea Products    Tea Products    Test Products    Test Products

9/23/2009 25

http://www.accessdata.fda.gov/scripts/h1n1flu/

9/23/2009 26

MEDICAL MEDICAL COUNTERMEASURESCOUNTERMEASURES

6/12/2009 National Association of State EMS Officials

27

CDC Media Briefing –CDC Media Briefing –September 18September 18

FDA has licensed H1N1 vaccine FDA has licensed H1N1 vaccine (4 of 5 manufacturers, so far)(4 of 5 manufacturers, so far)

Good antibody responseGood antibody response 90,000 distribution sites90,000 distribution sites Live, attenuated virus (easiest and quickest to Live, attenuated virus (easiest and quickest to

make)make) Triggers immune response, can’t infect Triggers immune response, can’t infect

individualsindividuals 3.4 million (inhalable) doses ready by 13.4 million (inhalable) doses ready by 1stst

week of Octoberweek of October 195 million doses available by the end of the year195 million doses available by the end of the year

Should be available to anyone who wants it Should be available to anyone who wants it 9/23/2009 28

CDC Media Briefing –CDC Media Briefing –September 18September 18

FluMist is approved for healthy FluMist is approved for healthy individuals between 2 and 49individuals between 2 and 49 No kids under 2No kids under 2 No pregnant womenNo pregnant women No immuno-compromisedNo immuno-compromised

Expect inactivated vaccines to Expect inactivated vaccines to become available early to mid-become available early to mid-OctoberOctober

9/23/2009 29

Vaccine Priority GroupsVaccine Priority Groups

Pregnant women Pregnant women Health care workers and emergency Health care workers and emergency

medical responders medical responders People caring for infants under 6 People caring for infants under 6

months of age months of age Children and young adults from 6 Children and young adults from 6

months to 24 years months to 24 years People aged 25 to 64 years with People aged 25 to 64 years with

underlying medical conditions (e.g. underlying medical conditions (e.g. asthma, diabetes)asthma, diabetes)

9/23/2009 30

CDC Media Briefing –CDC Media Briefing –September 18September 18

Could be minor variations from Could be minor variations from the federal list in the statesthe federal list in the states

Feds won’t intervene to Feds won’t intervene to supersede State priorities supersede State priorities

9/23/2009 31

VaccineVaccine

NEJM Preliminary ReportNEJM Preliminary Report Swiss firm Novartis and the Swiss firm Novartis and the

Australian firm CSL report that Australian firm CSL report that nearly 300 adults given nearly 300 adults given experimental pandemic vaccines experimental pandemic vaccines "unexpectedly" developed "unexpectedly" developed protective antibodies after just one protective antibodies after just one dosedose

Published at www.nejm.org September 10, 2009 Published at www.nejm.org September 10, 2009 (10.1056/NEJMoa0907413) (10.1056/NEJMoa0907413)

9/23/2009 32

Influenza and GBSInfluenza and GBS

Influenza virus infection has also Influenza virus infection has also been associated with GBS. been associated with GBS. 

Baseline rates of GBS and Baseline rates of GBS and miscarriages (1 per 100,000 pop.) miscarriages (1 per 100,000 pop.)

In 1976, there was a small risk of In 1976, there was a small risk of GBS following influenza (swine flu) GBS following influenza (swine flu) vaccination (approximately 1 per vaccination (approximately 1 per 100,000 persons vaccinated).  100,000 persons vaccinated).  

9/23/2009 33

Influenza and GBSInfluenza and GBS

Numerous studies have been done Numerous studies have been done to evaluate if other flu vaccines to evaluate if other flu vaccines were associated with GBS.  In were associated with GBS.  In most studies, no association was most studies, no association was found.found.

Two studies suggested that Two studies suggested that approximately 1 person out of 1 approximately 1 person out of 1 million vaccinated persons may be million vaccinated persons may be at risk of GBS associated with at risk of GBS associated with seasonal influenza vaccine.   seasonal influenza vaccine.   9/23/2009 34

AntiviralsAntivirals

H1N1 has high H1N1 has high level of level of susceptibility to susceptibility to antiviralsantivirals

Best outcomes Best outcomes associated in associated in treatment within treatment within 48 hours48 hours

9/23/2009 35

Resuming ActivitiesResuming Activities

CDC Guidance – can resume CDC Guidance – can resume activities 24 hours after fever activities 24 hours after fever subsidessubsides

Two small studies—Canada and Two small studies—Canada and Singapore—H1N1 patients may Singapore—H1N1 patients may be infectious 10+ days be infectious 10+ days

9/23/2009 36

EMTALA ENFORCEMENT EMTALA ENFORCEMENT DURING EXTRAORDINARY DURING EXTRAORDINARY SURGESSURGES

6/12/2009 National Association of State EMS Officials

37

EMTALA and Pan FluEMTALA and Pan Flu

CMS Memorandum to State CMS Memorandum to State Agencies August Agencies August 2009-”Extraordinary surges”2009-”Extraordinary surges”

Hospitals can establish alternative Hospitals can establish alternative screening sites ON CAMPUS to screening sites ON CAMPUS to perform MSE’s for persons perform MSE’s for persons presenting to the ED with ILI. presenting to the ED with ILI.

Can be redirected after qualified Can be redirected after qualified person determines there is no person determines there is no obvious EMC.obvious EMC.

9/23/2009 38

EMTALA and Pan FluEMTALA and Pan Flu

Off-site ILI screening centersOff-site ILI screening centers Can’t refer patients there from Can’t refer patients there from

ED.ED. Can’t be used to screen patients Can’t be used to screen patients

for other urgent, unscheduled for other urgent, unscheduled illnesses or conditions. illnesses or conditions.

9/23/2009 39

Drive-through TriageDrive-through Triage

9/23/2009 40

Influenza in ContextInfluenza in Context

Seasonal influenza results in Seasonal influenza results in 200,000 hospitalizations annually 200,000 hospitalizations annually in the United States.in the United States.

Seasonal influenza causes 36,000 Seasonal influenza causes 36,000 thousand deaths each year in the thousand deaths each year in the US, ranking it among the nation’s US, ranking it among the nation’s top 10 causes of death.top 10 causes of death.

Influenza related deaths are usually Influenza related deaths are usually due to secondary pneumonias, due to secondary pneumonias, exacerbated cardiopulmonary exacerbated cardiopulmonary conditions, or other chronic conditions, or other chronic diseases.diseases.

9/23/2009 41

Critical StrategiesCritical Strategies

Respiratory Respiratory HygieneHygiene Cover your mouth Cover your mouth

when you sneeze or when you sneeze or coughcough

WASH YOUR HANDS WASH YOUR HANDS FREQUENTLYFREQUENTLY

Avoid touching your Avoid touching your face, eyes, nose, face, eyes, nose, mouthmouth

If you are sick, STAY If you are sick, STAY HOMEHOME

Immediately discard Immediately discard used tissues and then used tissues and then WASH YOUR HANDS!WASH YOUR HANDS!9/23/2009 42

Current RecommendationCurrent Recommendation

Stay home if you are sick for Stay home if you are sick for 7 days after your symptoms 7 days after your symptoms begin or until you have been begin or until you have been symptom-free for 24 hours, symptom-free for 24 hours, whichever is longer.whichever is longer.

9/23/2009 43

Fall 2009 so far…Fall 2009 so far…

The epidemiology of the The epidemiology of the disease caused by the 2009 disease caused by the 2009 H1N1 influenza virus in the H1N1 influenza virus in the Southern Hemisphere is Southern Hemisphere is very similar to that very similar to that described in the United described in the United States this past spring. States this past spring.

There have been no There have been no significant changes significant changes detected in the 2009 H1N1 detected in the 2009 H1N1 influenza virus isolated influenza virus isolated from persons in the from persons in the Southern Hemisphere as Southern Hemisphere as compared to viruses compared to viruses isolated from persons in isolated from persons in the Northern Hemisphere.  the Northern Hemisphere. 

9/23/2009 44

9/23/2009 45

201 Park Washington CourtFalls Church, VA 22046Phone: 703.538.1799

Email: info@nasemso.org