Public Intelligence

Response to H1N1
•Strategic National Stockpile
•Distributed 25% pro rata supply
•Enhanced Surveillance Initiated
•PCR panH1N1 kits for testing
•Development at CDC, EUA at FDA, manufacture at ATCC, and ready to ship in ~ 2.5 weeks

1. Current stocks of disposable N-95 respirators will not be sufficient to meet demands within the health care community.

a. Increased number of sick individuals;

b. Decreased stores and available stock-on-hand;

c. Limited production with dependence on international production facilities;

d. Production and delivery may be impacted by staff and employee absenteeism;

e. The pandemic may result in the prolonged requirement for respiratory protection.

A DEADLY plague could sweep across Europe, doctors fear, after an outbreak of a virus in Ukraine plunged the country and its neighbours into a state of panic. A cocktail of three flu viruses are reported to have mutated into a single pneumonic plague, which it is believed may be far more dangerous than swine flu. The death toll has reached 189 and more than 1 million people have been infected, most of them in the nine regions of Western Ukraine. President of Ukraine Viktor Yushchenko has called in the World Health Organisation and a team of nine specialists are carrying out tests in Kiev and Lviv to identify the virus. Samples have been sent to London for analysis.

The number of those estimated to perish during another pandemic influenza (PI) event in the United States (US) may be between 5%- 7% of the infected population (infected population est. to be 25%) or 3,612,500 – 5,057,500 respectively1. Governmental authorities, primarily the medical examiner/coroner (ME/C), law enforcement, public health, and associated death care professionals, will not only need to manage these fatalities but also the 2.4 million deaths that occur annually.

Ukraine is in the midst of what some might call swine-flu hysteria. The country is in virtual lockdown mode, with the government closing schools, universities and movie theaters and banning all public gatherings until the end of November. Pharmacies have run out of protective masks; those who missed the rush are improvising with scarves or homemade facsimiles. And rumors are running rampant, much as they did during Soviet times when the authorities tried to cover up disasters like the Chernobyl nuclear-plant meltdown.

• As of 16 October, the number of Influenza-Like Illness (ILI) deaths in the U.S. was 537 this week compared to 405 deaths reported last week. (Source: HHS/CDC)
• As of 16 October, the most significant impacts of A(H1N1) remain increased ILI outpatient visits and influenza associated pediatric deaths. (Source: HHS/CDC)
• CDC provided updated interim guidance on the use of face masks and N95 respirators for decreasing exposure to A(H1N1). (Source: HHS/CDC)

2009 H1N1 Influenza

As of October 2, 2009:
–World Health Organization (WHO) regions have reported over 343,298 laboratory-confirmed cases
–At least 4,108 deaths
–The laboratory-confirmed cases represent a substantial underestimation of total cases

So far this year, there have been nine deaths related to H1N1 influenza in the state. The other H1N1-related deaths are as follows: A 45-year-old female from Sierra County with end stage liver disease, a 52-year-old female from Bernalillo County with chronic pulmonary disease, a 48-year-old female from McKinley County with asthma and diabetes, a 21-year-old female from Los Alamos County without chronic medical conditions, a 58-year-old male from Bernalillo County with chronic conditions that put him at risk for serious complications from the flu, a 28-year-old male from Lea County died Sept. 23 after being hospitalized in El Paso, Texas.

This exercise is designed to create an opportunity for the participants to experience a series of possible pandemic influenza environments. These scenarios are not necessarily predictive, nor do they represent the official viewpoint of any organization, group, or entity. The exercise is intended to allow the participants and their organizations to explore possible situations and to consider their options for responses and mitigation approaches. The sponsors understand that no scenario can present all aspects of a possible situation, and that there is no way to know definitively the actual circumstances that might be present during a pandemic.

The Los Angeles County Department of Public Health (LACPDH) encourages schools, residents, community organizations and businesses to develop plans and policies in the event of a public health emergency, such as a pandemic or other large-scale disease outbreak. Preparedness is one of the best prevention techniques available. Many of the planning procedures and precautionary measures suggested are important to practice in everyday life—not only in the event of a public health emergency.

Influenza A (H1N1) 2009 Monovalent Vaccine Live, Intranasal is not approved for use in children <24 months of age. In a clinical trial with FluMist, among children 6-23 months of age, wheezing requiring bronchodilator therapy or with significant respiratory symptoms occurred in 5.9% of FluMist recipients compared to 3.8% of active control (injectable influenza vaccine made by Sanofi Pasteur Inc.) recipients (Relative Risk 1.5, 95% CI: 1.2, 2.1). Wheezing was not increased in children ≥24 months of age. Hypersensitivity, including anaphylactic reaction, has been reported during post-marketing experience with FluMist.

Anaphylaxis has been reported after administration of FLUVIRIN. Although FLUVIRIN and Influenza A (H1N1) 2009 Monovalent Vaccine contain only a limited quantity of egg protein, this protein can induce immediate hypersensitivity reactions among persons who have severe egg allergy. Allergic reactions include hives, angioedema, allergic asthma, and systemic anaphylaxis. The 1976 swine influenza vaccine was associated with an increased frequency of Guillain-Barré syndrome (GBS). Evidence for a causal relation of GBS with subsequent vaccines prepared from other influenza viruses is unclear. If influenza vaccine does pose a risk, it is probably slightly more than 1 additional case/1 million persons vaccinated.

Anaphylaxis has been reported after administration of influenza vaccines. Although Influenza A (H1N1) 2009 Monovalent Vaccine contains only a limited quantity of egg protein, this protein can induce immediate hypersensitivity reactions among persons who have severe egg allergy. Allergic reactions include hives, angioedema, allergic asthma, and systemic anaphylaxis. The 1976 swine influenza vaccine was associated with an increased frequency of Guillain-Barré syndrome (GBS). Evidence for a causal relation of GBS with subsequent vaccines prepared from other influenza viruses is unclear. If influenza vaccine does pose a risk, it is probably slightly more than 1 additional case/1 million persons vaccinated. Neurological disorders temporally associated with influenza vaccination such as encephalopathy, optic neuritis/neuropathy, partial facial paralysis, and brachial plexus neuropathy have been reported.

Because postmarketing reporting of adverse reactions is voluntary and from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to vaccine exposure. The adverse reactions described have been included in this section because they: 1) represent reactions that are known to occur following immunizations generally or influenza immunizations specifically; 2) are potentially serious; or 3) have been reported frequently.

* Disease likely persists through summer in US, possible surge in late August when school returns
* Monitor closely for genetic and antigenic virus changes
* Expected higher attack rate (20-30%) than in spring (6-15%), notably affecting younger individuals
* Vaccine availability possibly mid October, Federal funds for distribution and administration are available
* Healthcare facility support in part from HPP grants
* SNS Antiviral stocks likely to be distributed
* Drifted H3N2 may co-circulate with novel H1N1

As health officials brace for a new onslaught of illness from the novel H1N1 virus, they remain perplexed by one of the most unusual and unsettling patterns to emerge from this pandemic — the tendency of the so-called swine flu to strike younger, healthier people.

Gold Coast

• Media are reporting concerns about the imminent arrival of almost 1,000 organ recipients on the Gold Coast for the World Transplant Games. The Local Organising Committee Chairman is said to be negotiating with a health provider to set up a flu clinic at the Games. [couriermail.com.au, 4/8/09]

• Queensland Health has had extensive correspondence with the United Kingdom Organising Committee for the Transplant Games regarding the event. The Organising Committee concluded it would continue with the Games as planned.

Townsville HSD reported a youth at Cleveland Detention Centre was displaying influenza like symptoms. The inmate was swabbed, isolated and commenced on Tamiflu, with ten further courses of Tamiflu supplied to the Centre’s nurse. Two further suspected cases have been swabbed, administered Tamiflu and isolated. On Tnesday, 04 Angnst 2009, Townsville HSD reported two positive cases of Pandemic (HlNl) 2009 at the facility.

This report is based on the most recent and accurate available information at the time of preparation. Given the rapidly changing nature of the incident, readers should be aware of the potential requirement for later confirmation or clarification.

In a contest that pits human against virus, the U.S. government is evaluating the safety and effectiveness of swine flu vaccine in hopes of having millions of doses ready for use before the next wave of the pandemic H1N1 sweeps across the nation. This week the virus struck first, infecting a handful of students at the University of Wisconsin-Madison; an additional 25 to 30 are awaiting results of a swine flu test.

* WHO: Pandemic Phase 6 (11 JUN 2009 1600 EDT)
* Outbreaks in at least one country in > two WHO regions
* USG: Public Health Emergency declared (26 Apr 2009)
* Renewed by HHS Secretary Kathleen Sebelius
* HHS: Downgraded to Phase 1 – Awareness (9 May 2009)

One of the main battlegrounds in the fight against an expected resurgence of swine flu this fall will be the schoolyard, a place where the disease could, well, go viral. People between 6 months and 24 years old appear to be particularly vulnerable to the swine flu virus, known as H1N1.

– Antigenic characteristics
– Transmission characteristics
– Severity of disease
– Antiviral resistance
– Intensity (surge) in US cases

Global Situation. Influenza is an acute viral disease of the respiratory tract caused by influenza viruses A, B or C. These A, B and C viruses are antigenically distinct and there is no cross immunity between them. While all three influenza viruses may affect humans, in lower animals and birds, influenza A viruses are of primary concern.

The Commonwealth of Virginia’s Pandemic Influenza Plan addresses the Commonwealth’s response to and recovery from a pandemic influenza in a comprehensive and coordinated manner to ensure essential services across all sectors of state government can be maintained throughout the event period, which may last as long as 18-24 months. The Virginia Department of Health (VDH) developed an Influenza Pandemic Plan (Health Component) in 2002, which was subsequently updated in 2006 and 2007.