Pandemic (H1N1) 2009CMOs Meeting in Brindisi

Dr. Esther Tan Medical Services Division

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WFP Video: Working in a Severe Pandemic

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Outline

• History and origin of the Pandemic 2009• Epidemiology of this pandemic• Clinical features and high-risk groups• Clinical management• What’s next, including pandemic vaccines• Public health measures• Administrative issues• Q&A• PPE Use• Photo-taking!!

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History of Influenza Pandemics

1900

1850

1950

2000

1847

1889

1918

19571968

42 yrs

29 yrs

39 yrs

11 yrs

Pandemic usually occur every 30 – 40 years

Last Pandemic was ≈ 40 yrs ago, in 1968....

Last Pandemic was ≈ 40 yrs ago, in 1968....

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2009

Origin of Pandemic (H1N1) Virus

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Pandemic (H1N1) 2009: Quadruple ressortment of 2 swine flu strains, 1 human and 1 avian flu

strain

History of Ressortment Events in Evolution of 2009 Pandemic Virus

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Earliest Confirmed Pandemic Case Mexico City, mid-March

WHO Pandemic Phase 6

As of 13 August:>182,166 lab-confirmed

1799 deathsSpread over 177 countries

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As of 21 August:7983 hospitalized cases

522 deathsSpread over 53 states

Transmission

• Similar to other influenza viruses– Spread for person to person through

large droplets that usually travel only a short distance (<6 feet)

– Contact with contaminated surfaces – Via droplet nuclei (“airborne” transmission)

• All respiratory secretions and bodily fluids (e.g. diarrheal stool) of cases should be considered potentially infectious

Incubation & Infectious Period

• Incubation period range from 1-7 days, more likely 1-4 days

• Duration of shedding of virus unknown• Infectious period of seasonal flu: shed virus

from day -1 until resolution of symptoms (usually about 7 days)

• Children, especially younger children, might be infectious for up to 10 days.

Demographics

Pandemic Flu Age Distribution

• Flu Pandemics: typically affects persons who are not at the extremes of age

• Seasonal Flu: Severe disease in infants/young children and elderly

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In Mexico, among 5-59 yrs

Seasonal Flu Pandemic Flu

% of Deaths 17% 87%

% of Severe Pneumonia

32% 71%

Pandemic Flu Epidemiology in US

• Disproportionately affect younger persons• 75% of hospitalizations are <49 years• 60% of deaths are <49 years• In NYC, median age of hospitalized cases: 21 yrs

• Infection rate highest in 5−24 yrs; Hospitalization rate highest in 0−4 year age group, followed by 5−24 year age group.

• Seasonal Flu: Highest rate of hospitalization among young children and elderly > 65 years; 90% of flu deaths among persons >65 years

• Adults, especially > 60 years, may have some degree of preexisting cross-reactive antibody to the novel H1N1 flu virus

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Clinical Presentation

Clinical Characteristics of Hospitalized Cases, US19 JUN 2009 (n=268)

83%

54%

40% 37% 36% 36%31% 31% 29%

24% 24%

93%

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In NYC, found that case definition covered 95% of

lab-confirmed cases:“Fever + Cough/Sore Throat”

Mild/Uncomplicated Presentation

• Similar to seasonal flu: Fever, cough, sore throat, fatigue, headache or body aches, chills, stuffy or running nose

• GI symptoms – diarrhea and/or vomiting, especially in children

• Seasonal flu stays mainly in nasal cavity

• Pandemic flu virus goes deeper into trachea, lung, intestinal tract

Severe/Hospitalized Cases: Characteristics

• Studies showed among confirmed cases, rate of hospitalization ranged 0.3% - 10%

• Median age: 15 to 42 yrs (>65 rare)

• M:F ratio is 1:1

• Most hospitalizations due to primary viral pneumonia (“viral pneumonitis”)

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Severe/Hospitalized Cases: Characteristics

• Secondary bacterial pneumonia infrequent

• Main pathological findings include diffuse alveolar damage, haemorrhagic interstitial pneumonitis with lymphocyte proliferation, few neutrophils and ARDS

• Cases of nosocomial VAP identified in prolonged hospital course

• Multiple pulmonary emboli have been observed

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Severe/Hospitalized Cases: Characteristics

• Viral pneumonia progresses rapidly

• Respiratory failure and ARDS unusually refractory to standard oxygenation strategies

• In these patients, for confirming diagnosis by PCR, deep tracheal aspirates far superior to nasopharyngeal samples

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Atypical Presentations

• GI symptoms– Reported in 50% of patients with mild/moderate

symptoms not hospitalized– Less frequent in hospitalized patients

• Pediatric cases– Sudden infantile death in one 23 month old– Flu-associated encephalopathy reported– Invasive bacterial infections reported (S. aureus,

Gp A strep, Strep. Pneum.)

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High-Risk Groups

Experience of the US and Canada

• US: >70% of hospitalized patients & 80% of fatal cases have underlying conditions

• Canada: Only 37% of hospitalized patients have at least 1 co-morbidity

• Mexico: Among fatal cases, only 46% had underlying condition

• Good percentage of severe cases found in previously healthy individuals

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US: Underlying Conditions of Hospitalized Cases19 JUN 2009 (n=268)

*Excludes hypertension

Categories of High-Risk Persons

• Infants and children < 5 years• The elderly (>65 years) • Pregnant women• Patients with chronic co‐morbid conditions

such as cardiovascular, respiratory or liver disease, diabetes, and those with immunosuppression related to malignancy, HIV infection or other diseases

• Persons under 18 years of age who are receiving long-term aspirin therapy

Pregnancy as a Risk Factor

• Pregnant women constituted 6% of H1N1 deaths in US

• Are at increased risk of hospitalizations and deaths, even more so than in seasonal flu

• Intrauterine fetal deaths or spontaneous abortions

• Need for prompt treatment– Delays in treatment often lead to fatality

Morbid Obesity as a Risk Factor

• Anecdotal support by clinicians

• Michigan: 9/10 ventilated ICU patients had BMI>30, 7/10 had BMI>40

• California: 60% of fatal cases had BMI>30, 37% of these had no other risk factors

• Need further study

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Clinical Management

Mild Cases

• Supportive treatment (Paracetamol, fluids) based on symptoms

• Salicylates should not be used in <19 yrs due to Reye syndrome

• Early administration of antivirals in at-risk patients

• Virus susceptible to oseltamivir & zanamivir, resistant to amantadine & rimantadine

• Adequate infection control precautions at home (cough etiquette, hand hygiene, ventilation)

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Reporting Cases to UNMS: Current Case Definition

Case Report Form at www.un.org/staff/pandemic

Under “For UN Health Care Providers”

Severe/Complicated Cases

• Administer antiviral treatment ASAP on hospital admission, should not delay

• Among 27 fatal cases in Mexico, median time from symptom onset to txmt: 8 days

• Don’t wait for confirmatory H1N1 lab tests

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Severe/Complicated Cases

• Oxygen therapy important– Monitor O2 saturation by pulse oximetry– Provide supplemental O2 or mechanical ventilation to

correct hypoxaemia– Maintain O2 sats >90% (>95% during pregnancy and other

clinical situations)– Severe hypoxaemia: High flow oxygen (10 L/min) by face

mask– Note patients who experience difficulties with compliance

e.g children– Use a low-volume, low-pressure strategy to protect lungs

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Severe/Complicated Cases

• Antibiotics: No need chemoprophylaxis; if pneumonia, treat as for community-acquired pneumonia

• Routine use of corticosteroids should be avoided, especially moderate to high dose– No benefit in treatment – Higher doses associated with

serious side effects and evidence of increased viral replication in SARS

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Infection Control

• Standard plus Droplet Precautions

• If performing high-risk aerosol-generating procedures (e.g. bronchoscopy, any aspiration of the respiratory tract), use respirator (e.g. N95), eye protection, gowns and gloves

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Standard Precautions

• Previously called Universal Precautions

• Assumes blood and body fluid of ANY patient could be infectious

• Recommends PPE and other infection control practices to prevent transmission in any healthcare setting

• Decisions about PPE use determined by type of clinical interaction with patient

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PPE for Standard Precautions

• Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin

• Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated

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PPE for Standard Precautions

• Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions

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Droplet Precautions

• Droplet Precautions – Surgical masks within 3 feet of patient

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Hand Hygiene

• Required for Standard and Expanded Precautions

• Perform…– Immediately after removing PPE

– Between patient contacts

• Wash hands thoroughly with soap and water or use alcohol-based hand rub

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Diagnosis

• Reverse transcriptase polymerase chain reaction (RT-PCR) and viral culture

• Currently no validated rapid bedside diagnostic test available

• Lab samples: From deep nasal passages (nasal swab), nasopharynx (naso-pharyngeal swab), or bronchial/tracheal aspirate

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WHO Reference on Antivirals

Recommendations For Antiviral Use

• Priority: Hospitalized Patients with suspected or confirmed pandemic H1N1 virus infection– Treatment recommended with Oseltamivir or

Zanamivir– Treat patients as soon as possible (duration: 5 days)

• Outpatients with uncomplicated illness but who are at high risk of severe disease– Treatment recommended with Oseltamivir or

Zanamivir– Treat patients as soon as possible (duration: 5 days)

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Extension of Tamiflu Shelf-Life

• UNMS Influenza Pandemic Guidelines:”the expiry date of UN held stockpiles of oseltamivir may..be extended for 2 years, provided that the storage conditions of the stockpile are known to have met the manufacturer’s recommendations”

• Applies only to Roche products and capsule form only

• Tamiflu should be stored in a dry place out of direct sunlight, at <25oC

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Oseltamivir-Resistant Viruses

• 12 oseltamivir-resistant viruses detected• 8 associated with oseltamivir post-exposure prophylaxis• 1 associated with treatment of uncomplicated illness• 2 from immunocompromised patients receiving oseltamivir

treatment• All sensitive to Zanamivir

• Arisen from different part of the world• 4 Japan, 2 USA, 2 Hong Kong, China, 1 each Denmark,

Canada, Singapore, China

• No epi links• No sign of onward transmission

No change in recommendations for treatment or prophylaxis of persons with influenza

-- BREAK --

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What’s Next?

• Activity in S. Hemisphere decreasing, with epidemiology across countries there similar to moderate Spring wave in US

• Pandemic virus is the predominant influenza virus circulating worldwide

Past Influenza Pandemics:Second Waves Can Be Worse!

Large Second Wave in UK’s 1918 Pandemic

What will be the severity of Pandemic

(H1N1) 2009?

Get Prepared for Lots of Flu Activity!

Phases of a Vaccination Program

1. Vaccine development• Develop reference strain• Prepare master seed strain• Manufacture clinical investigational lot• Conduct clinical studies

2. Commercial scale manufacturing

3. Distribution and administration

4. Post-launch effectiveness, safety and utilization monitoring

We’re here!

Vaccine Manufacturing Process & Timeline

SAGE Recommendations, 7 July

• Priority groups for pandemic vaccination – recommendation to countries:– Health care workers are first priority– Followed by, in no particular priority order

• Pregnant women• >6 months with underlying chronic medical

conditions including asthma and morbid obesity• Healthy young adults (between 15-49 years)• Healthy children• Healthy adults >49 yrs and <65 yrs• Healthy adults >65 yrs 70

US Target Groups for Vaccination

• Pregnant women• People who live with or care for children < 6

months of age• Health care and emergency medical services

personnel • Persons between 6 months - 24 years of age• People from 25 - 64 years who are at higher risk

for novel H1N1 because of chronic health disorders or compromised immune systems.

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Highest Priority if Limited Availability

• Pregnant women

• People who live with or care for children < 6 mths

• Health care and emergency medical services personnel with direct patient contact

• Children 6 mths - 4 yrs

• Children 5 - 18 yrs with chronic medical conditions

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Public Health Measures

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Key Messages to Staff

6. FluVaccination

5. StockpileSupplies

4. Self CareKnowledge

3. Heed Travel Advice

2. SocialDistancing

1. PersonalHygiene

CORE STRATEGIES

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Practice Personal Hygiene

Wash hands often Cover coughs and sneezes

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Stress Hand Hygiene

Unwashed hand

Washed hand

Practice Social Distancing

Avoid close contact will ill persons

Ill staff should stay home until 24 hrs after

fever resolves

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Travel Advisories

• No travel restrictions from WHO– Know where to seek

medical care if you feel sick during travel

– After return from travel, monitor your health for 7 days

• Practice personal hygiene

• Wash hands and cover coughs and sneezes

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Staff Should Have Self Care Knowledge

Know how to care for themselves and family at home

Know the symptoms of mild and

severe influenza

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Comprehensive Pandemic Booklet

http://www.un.org/staff/pandemic/

• Anyone who:– Has difficulty breathing or chest pain– Has purple or blue discoloration of the lips– Is vomiting and unable to keep liquids down– Has seizures (uncontrolled fits)– Is less responsive than normal or becomes

confused– Has signs of dehydration:

• dizziness when standing, absence of urination, or in infants a lack of tears when crying

When To Seek Emergency Care?

• Search for and contact a local health care provider near where you live:

• Use network of participating physicians under your health insurance plan to identify your doctor (http://www.un.org/Depts/oppba/accounts/insurance/healthPlans.htm ).

• Staff with no health insurance can look up the New York City Health and Hospitals Corporation (HHC) directory  (http://www.nyc.gov/html/hhc/html/facilities/directory.shtml

Getting Prepared: Choosing A Local Health Care Provider

Stockpile 6 Weeks of Supplies

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Vaccinate Against The Flu

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Administrative Issues

• Plan for increased absences due to illness among staff and family members

• Plan how to continue essential functions of the medical services and the organization, with fewer staff

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Contact Tracing and Quarantine

• Consider carefully local health authorities recommendations

• Depending on country strategy, may consider identifying close contacts (<1m) to provide those with underlying conditions antiviral prophylaxis

• Close contacts should monitor themselves for flu symptoms for 7 days after last exposure

• Usually no need to quarantine close contacts who are well

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WHO: Antiviral Chemoprophylaxis

• WHO in general does not recommend antiviral chemoprophylaxis because of the “opportunity cost and utilization of antiviral drugs that may be needed for treatment is not warranted”

• No pre-exposure chemoprophylaxis recommended

• If considered due to specific scenarios, post-exposure chemoprophylaxis with Oseltamivir or Zanamivir should be limited to close contacts of lab-confirmed cases who are at high risk of complications– Duration: 7-10 days after last known exposure

Surgical Mask Use in Community Setting

When To Use A Surgical Mask?

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• WHO: No evidence that wearing masks in community setting is effective

• Currently recommended only for ill persons and in health care settings and medical staff caring for suspected patients

• Nevertheless, individuals may wish to wear it – but must remember it should be combined with other public health measures

WFP Video: Using a Surgical Mask

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If Pandemic Increases in Severity..

• Consider active screening of staff who report to work

• Consider alternative work environments for high-risk staff

• Consider increasing social distancing in the workplace

• Consider canceling non-essential travel and advise staff of possible disruptions while travelling

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UNMS Checklist of Activities

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UNMS Checklist of Activities

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UNMS Checklist of Activities

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UNMS Checklist of Activities

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UN Doctor’s FAQs

1. Clinical Description

2. Clinical Management

3. Infection Control

4. Surveillance & Lab Tests

5. Tamiflu

6. Travel

7. Vaccine

Available at www.un.org/staff/pandemic97

WFP Video: Donning On and Off PPE

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Use of PPE in Healthcare Settings

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Types of PPE Used in Healthcare Settings

• Gloves – protect hands

• Gowns/aprons – protect skin and/or clothing

• Masks and respirators– protect mouth/nose • Respirators – protect respiratory tract from

airborne infectious agents

• Goggles – protect eyes

• Face shields – protect face, mouth, nose, and eyes

Key Points About PPE

• Don before contact with the patient, generally before entering the room

• Use carefully – don’t spread contamination

• Remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room

• Immediately perform hand hygiene101

How to Don On PPE

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Sequence for Donning PPE

1. Gown first

2. Mask or respirator

3. Goggles or face shield

4. Gloves

• *Combination of PPE will affect sequence – be practical

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How to Don a Gown

• Select appropriate type and size

• Opening is in the back

• Secure at neck and waist

• If gown is too small, use two gowns– Gown #1 ties in front

– Gown #2 ties in back

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How to Don a Mask

• Place over nose, mouth and chin

• Fit flexible nose piece over nose bridge

• Secure on head with ties or elastic

• Adjust to fit

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How to Don a Particulate Respirator (e.g. N95 Mask)

• Select a fit tested respirator• Place over nose, mouth and chin• Fit flexible nose piece over nose bridge• Secure on head with elastic• Adjust to fit• Perform a fit check –

– Inhale: respirator should collapse– Exhale: check for leakage around face

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How to Don Eye and Face Protection

• Position goggles over eyes and secure to the head using the ear pieces or headband

• Position face shield over face and secure on brow with headband

• Adjust to fit comfortably

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How to Don Gloves

• Don gloves last

• Select correct type and size

• Insert hands into gloves

• Extend gloves over isolation gown cuffs

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How to Safely Use PPE

• Keep gloved hands away from face

• Avoid touching or adjusting other PPE

• Remove gloves if they become torn; perform hand hygiene before donning new gloves

• Limit touching of surfaces and items

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How to Remove PPE

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“Contaminated” and “Clean”Areas of PPE

• Contaminated – outside front• Areas of PPE that have or are likely to have

been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside

• Clean – inside, outside back, ties on head and back

• Areas of PPE that are not likely to have been in contact with the infectious organism

Sequence for Removing PPE

1. Gloves and gown together

2. Perform hand hygiene

3. Face shield or goggles

4. Mask or respirator

5. Perform hand hygiene

PPE Use in Healthcare Settings

Where to Remove PPE

• At doorway, before leaving patient room or in anteroom*

• Remove respirator outside room, after door has been closed*

* Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub

How to Remove Gloves and Gown

• Unfasten ties

• Peel gown away from neck and shoulder with gloves

• Roll inside out – turn contamined outside toward the inside and roll into a bundle

• Perform hand hygiene

Remove Goggles or Face Shield

• Grasp ear or head pieces with ungloved hands

• Lift away from face

• Place in designated receptacle for reprocessing or disposal

PPE Use in Healthcare Settings

Removing a Surgical Mask

• Remove from face by handling only the ties/bands

• Discard

• Perform hand hygiene

Removing a Particulate Respirator

• Lift the bottom elastic over your head first

• Then lift off the top elastic

• Discard

• Perform hand hygiene

Thank you

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