Thursday, September 3, 2009

Weekly Update on H1N1 in Maine 9/2/09

Tracking Updates

On Friday, Aug. 28, US CDC reported 8,843 hospitalizations and 556 deaths nationwide from H1N1. As of Aug. 23, the World Health Organization reported 2,185 deaths from H1N1 and reports of H1N1 from over 200 countries.

Maine has identified 360 cases of H1N1, which include 19 individuals requiring hospitalization and one individual who has died. Of Maine residents with H1N1, 60 percent have been under 25 years of age. The number of cases is only a barometer of community transmission, not of actual case counts, because not all people with infection are tested.

Vaccination

Maine CDC vaccine planning with communities and schools is well underway. There are several areas we are focused on right now:
1. Maine CDC is working with Maine Department of Education (DOE) to assure that all Maine children are offered seasonal (regular) and H1N1 vaccine in local schools. As of Monday August 31st, our toll free H1N1 number (1-888-257-0990) is staffed 9 am – 5 pm with professionals from Maine CDC and DOE to assist schools and partnering health care providers in this effort. We will refer a District Vaccine Coordinator to those schools and/or health care providers who need more direct assistance in this effort.

2. Maine CDC is working with the Regional Resource Centers at Eastern Maine Medical Center, Central Maine Medical Center, and Maine Medical Center, to assure that all health care providers and Emergency Medical Services personnel (EMS) are offered H1N1 vaccine during the first few weeks of its arrival.

3. Maine CDC is working with clinicians who provide health care for pregnant women to assure they have H1N1 vaccine for their patients and themselves as soon as it arrives in Maine.

4. Maine CDC will also be working with residential schools, employers, and health care providers to assure all others in the high-risk groups for H1N1 are offered vaccine.

Governor’s Declaration:
Governor John E. Baldacci on September 1, 2009 signed a Proclamation of Civil Emergency Due to a Highly Infectious Agent to allow the State to better respond to the potential dangers of H1N1 flu and to facilitate a statewide vaccination campaign.

Many school districts reported that a concern about potential liability was putting at risk their ability to participate in vaccination clinics. The proclamation protects school districts and other vaccination clinic participants from liability. The proclamation also will provide immunity from tort liability for approved health care workers who administer the flu vaccines. The Maine CDC, DOE, and MEMA will coordinate and facilitate the implementation of school supported vaccine clinics for both the seasonal flu and H1N1.
The press release and the declaration itself can be found at:
http://www.maine.gov/tools/whatsnew/index.php?topic=Portal+News&id=78666&v=article-2008

Maine CDC Conference Calls:
School-Located Seasonal and H1N1 Vaccine Initiative for school personnel and health care providers working on this initiative - Monday September 14th 12 noon – 1 pm

Clinicians Who Care for Pregnant Women: Thursday September 17th, 12 noon – 1 pm

Phone Number for Both Calls: 1-800-914-3396 and passcode 473623

Vaccine Coordinators – An Update
Vaccine Coordinators have been appointed for each Public Health District in Maine. Vaccine Coordinators will be one component of district leadership teams, which also include staff from the three Regional Resource Centers for Public Health Emergency Preparedness, and Emergency Management Agencies. These Vaccine Coordinators will be following up on discussions had at the Summit to plan for local vaccine distribution, and ensuring that people in the groups prioritized by US CDC (see below) are offered vaccine.

An Updated Contact List of Vaccine Coordinators:

District 1 – York: Sharon Leahy-Lind, 490-4625

District 2 – Cumberland: Meredith Tipton, 592-5631

District 3 – Western Maine: MaryAnn Amrich, 753-9103
(Franklin, Oxford, and Androscoggin counties)

District 4 – Mid Coast: Jen Gunderman-King, 596-4278
(Waldo, Knox, Lincoln, and Sagadahoc counties)

District 5 – Central Maine: Sue Lee, 592-5634
(Somerset and Kennebec counties)

District 6 – Penquis: Jessica Fogg starting September 8 (and Debra Roy in the interim) 592-5633 (phone for either)
(Penobscot and Piscataquis counties)

District 7 – Downeast: Al May starting September 8, 263-4975 (and Mary Jude in the interim, 287-5182)
(Washington and Hancock counties)

District 8 – Aroostook: Sharon Ramey (Interim until September 21), 592-5632

Tribal Vaccine Coordinator: Jerolyn Ireland, 532-2240, Ext. 15

Many resources for vaccination clinics have been posted on our Summit web site (http://www.maine.gov/dhhs/boh/maineflu/h1n1-summit.shtml) under the morning breakout for Organizers of Large-Scale Vaccine Clinics.

CDC has issued a vaccination campaign planning checklist: http://www.cdc.gov/H1N1flu/vaccination/statelocal/planning_checklist.htm


Seasonal Flu Vaccine:

H1N1 has been the focus of attention since the spring, but it is important that we do not forget the risks of seasonal flu. US CDC recommends that people at risk for the seasonal flu get vaccinated as soon as it is available. The protection you get from the vaccine will not wear off before the flu season is over.

The following groups are prioritized for seasonal flu vaccination:
Children ages 6 months to 18 years
Pregnant women
People 50 years of age and older
People of any age with certain chronic medical conditions
People who live in nursing homes and other long-term care facilities
People who live with or care for those at high risk for complications from flu, including:
Health care workers
Household contacts of persons at high risk for complications from the flu
Household contacts and out of home caregivers of children younger than 6 months old

The seasonal flu vaccine is not expected to specifically protect against H1N1. However, with H1N1 and seasonal flu viruses both expected to be circulating, getting a seasonal flu vaccine early will help a person’s overall protection against the flu. We anticipate that season flu and H1N1 vaccines may be administered on the same day. However, we expect seasonal flu vaccine to be available sooner than H1N1 vaccine, which we expect to arrive in the state in mid-October at the earliest. CDC recommends that people get vaccinated against seasonal flu as early as possible.

H1N1 Vaccine:

US CDC updated its Q&A on H1N1 vaccine to include guidance for those who were vaccinated against swine flu in 1976. The 1976 swine flu virus and the current H1N1 virus are different enough that it’s unlikely that a person vaccinated in 1976 will have full protection against H1N1, and therefore should still be given the H1N1 vaccine. (http://www.cdc.gov/h1n1flu/vaccination/public/vaccination_qa_pub.htm)

This US CDC podcast discusses H1N1 flu vaccine and how to protect your family: http://www2a.cdc.gov/podcasts/player.asp?f=13958.

For most people, two doses of the H1N1 vaccine may be necessary for full protection against the virus. The exact timing between doses will not be known until further clinical trial data are available; however, US CDC anticipates that 21-28 days will be needed between the first and second doses.

The H1N1 vaccine is not intended to replace the seasonal flu vaccine – it is intended to be used in addition to seasonal flu vaccine to protect people. At this point in time, there is no evidence that vaccinations will be mandatory. US CDC recommends (http://www.cdc.gov/mmwr/pdf/rr/rr58e0821.pdf) that the following groups should be considered the highest priority to be offered the first available doses of vaccine:
Pregnant women, because they are at higher risk of complications – especially in the second and third trimesters – and can potentially provide protection to infants who cannot be vaccinated;
Household members and caregivers for children under 6 months old, because younger infants are at higher risk of complications and cannot be vaccinated;
Health care and emergency medical services personnel, because infections among health care workers have been reported and this can be a potential source of infection for patients;
All people ages 6 months through 24 years of age:
Children ages 6 months to 18 years, because there have been many cases of H1N1 in children and they are in close contact with each other in school and day care settings, which increases the chances of spreading disease;
Young adults ages 19 through 24, because there have been many cases of H1N1 in healthy young adults, and they often live, work, and study in close proximity, and they are a frequently mobile population;
People ages 25 through 64 who have health conditions associated with a higher risk of medical complications from the flu, including those with asthma, COPD, diabetes, chronic cardiovascular disease, and people with compromised immune systems.

CDC also issued a Q&A on H1N1 vaccine distribution: http://www.cdc.gov/H1N1flu/vaccination/statelocal/centralized_distribution_qa.htm


Good Health Habits Can Help Stop Germs

Prevention of H1N1 is most important, especially now that the virus is widespread in many parts of Maine. Covering coughs and sneezes with a tissue or sleeve, washing hands frequently, and staying home if ill with a fever are shared responsibilities of everyone in Maine, especially to protect people who are at higher risk for complications from H1N1 (http://www.cdc.gov/h1n1flu/vaccination/acip.htm).

Important Differences Between H1N1 and Seasonal Flu

The age groups affected by H1N1 are generally younger than those affected by the regular seasonal flu. This is true for those most frequently infected, and especially for those experiencing severe or fatal illness.

To date, most severe cases and deaths have occurred in adults younger than 50, with deaths in the elderly comparatively rare. In seasonal flu, around 90% of severe and fatal cases occur in people age 65 years or older.

Perhaps most significantly, clinicians from around the world are reporting a very severe form of disease, also in young and otherwise healthy people, which is rarely seen in seasonal flu infections. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays.

Advice from the World Health Organization

WHO has monitored outbreaks of H1N1 from different parts of the world to get a sense of how the flu pandemic will evolve in the next several months. WHO advises us to be prepared for a second wave of flu. (http://www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html)

H1N1 has quickly become the dominant type of flu in most parts of the world. Close monitoring by WHO has shown no signs that the virus has mutated, and the overwhelming majority of people with H1N1 continue to experience mild illness.

While these trends are encouraging, large numbers of people are still susceptible to infection.

Larger numbers of severely ill patients requiring intensive care are likely to be a burden on health services, possibly disrupting care for other diseases.

Only a handful of H1N1 viruses have been resistant to Tamiflu® worldwide, despite the administration of many millions of treatments with this drug. Intense monitoring of treatment-resistant flu continues.

H1N1 and Pregnant Women

An increased risk during pregnancy – especially in the second and third trimesters – has been consistently well-documented across countries. Pregnant women are prioritized for H1N1 vaccine because of this risk, and because they can potentially provide protection to infants who cannot be vaccinated.

H1N1 Vaccine Q&A for Pregnant Women (source: US CDC):

Q: Why does CDC recommend that pregnant women receive the 2009 H1N1 influenza vaccine?
A. It is important for a pregnant woman to receive the 2009 H1N1 influenza vaccine as well as a seasonal influenza vaccine. A pregnant woman who gets any type of flu is at risk for serious complications and hospitalization. Pregnant women who are otherwise healthy have been severely impacted by the 2009 H1N1 influenza virus (formerly called “novel H1N1 flu” or “swine flu”). In comparison to the general population, a greater proportion of pregnant women infected with the 2009 H1N1 influenza virus have been hospitalized. In addition, severe illness and death has occurred in pregnant women. Six percent of confirmed fatal 2009 H1N1 flu cases thus far have been in pregnant women while only about 1% of the general population is pregnant. While hand washing, staying away from ill people, and other steps can help to protect pregnant women from influenza, vaccination is the single best way to protect against the flu.

Q: Is there a particular kind of flu vaccine that pregnant women should get? Are there flu vaccines that pregnant women should not get?
A. There are two type of flu vaccine. Pregnant women should get the "flu shot"— an inactivated vaccine (containing fragments of killed influenza virus) that is given with a needle, usually in the arm. The flu shot is approved for use in pregnant women.
The other type of flu vaccine — nasal-spray flu vaccine (sometimes called LAIV for “live attenuated influenza vaccine)—is not currently approved for use in pregnant women. This vaccine is made with live, weakened flu viruses that do not cause the flu). LAIV (FluMist®) is approved for use in healthy* people 2-49 years of age who are not pregnant.

Q. Will the seasonal flu vaccine also protect against the 2009 H1N1 flu?
A. The seasonal flu vaccine is not expected to protect against the 2009 H1N1 flu. Similarly, the 2009 H1N1 influenza vaccine will not protect against seasonal influenza.

Q. Can the seasonal influenza vaccine and the 2009 H1N1 influenza vaccine be given at the same time?
A. It is anticipated that seasonal flu and 2009 H1N1 vaccines may be administered on the same day but given at different sites (e.g. one shot in the left arm and the other shot in the right arm). However, we expect the seasonal vaccine to be available earlier than the 2009 H1N1 influenza vaccine. The usual seasonal influenza viruses are still expected to cause illness this fall and winter. Pregnant women and others at increased risk of complications of influenza are encouraged to get their seasonal flu vaccine as soon as it is available.

Q: Is the 2009 H1N1 influenza vaccine safe for pregnant women?
A: Influenza vaccines have not been shown to cause harm to a pregnant women or her baby. The seasonal flu shot (injection) is proven as safe and already recommended for pregnant women. The 2009 H1N1 influenza vaccine will be made using the same processes and facilities that are used to make seasonal influenza vaccines.

Q: What safety studies have been done on the 2009 H1N1 influenza vaccine and have any been done in pregnant women?
A: A number of clinical trials which test 2009 H1N1 influenza vaccine in healthy children and adults are underway. These studies are being conducted by the National Institutes of Allergies and Infectious Diseases (NIAID). Studies of 2009 H1N1 influenza vaccine in pregnant women are expected to begin in September.

Q: Does the 2009 H1N1 influenza vaccine have preservative in it?
A: There is no evidence that thimerosal (used as a preservative in vaccine packaged in multi-dose vials) is harmful to a pregnant woman or a fetus. However, because some women are concerned about exposure to preservatives during pregnancy, manufacturers will produce preservative-free seasonal and 2009 H1N1 influenza vaccines in single dose syringes for pregnant women and small children. CDC recommends that pregnant women may receive influenza vaccine with or without thimerosal.

Q: Can the 2009 H1N1 influenza vaccine be given at any time during pregnancy?
A: Yes.

Q: How many 2009 H1N1 influenza vaccine shots will be needed?
A: Some people, including pregnant women, may need two doses. We will know more about the number of doses once data from the clinical trials are available.

Q. What will be the recommended interval between the first and second dose if two doses are needed?
A. This will not be known until clinical trial data are available. We anticipate that 21-28 days will be needed between the first and second doses.

Q: Should the 2009 H1N1 influenza vaccine be given to someone who has had an influenza- like illness since between April and now? Do I need a test to know if I need the vaccine or not?
A. There is no test that can show whether a person had 2009 H1N1 influenza in the past. Many different infections, including influenza, can cause influenza-like symptoms such as cough, sore throat and fever. In addition, infection with one strain of influenza virus will not provide protection against other strains. People for whom influenza vaccine is recommended should receive the 2009 H1N1 vaccine, even if they had an influenza-like illness previously. It is not necessary to test a person who previously had an influenza-like illness. People for whom the 2009 H1N1 influenza vaccine is recommended should receive it, even if they have had an influenza-like illness previously, unless they can be certain they had 2009 H1N1 influenza based on a laboratory test that can specifically detect 2009 H1N1 viruses. CDC recommends that persons who were tested for 2009 H1N1 influenza discuss this issue with a healthcare provider to see if the test they had was either an RT-PCR or a viral culture that showed 2009 H1N1 influenza. There is no harm in being vaccinated if you had 2009 H1N1 influenza in the past.

Q: What are the possible side effects of the 2009 H1N1 influenza vaccine?
A. The side effects from 2009 H1N1 influenza vaccine are expected to be similar to those from seasonal flu vaccines. The most common side effects following vaccination are expected to be mild, such as soreness, redness, tenderness or swelling where the shot was given. Some people might experience headache, muscle aches, fever, nausea and fainting. If these problems occur, they usually begin soon after the shot and may last as long as 1-2 days. Like any medicines, vaccines can cause serious problems like severe allergic reactions. However life-threatening allergic reactions to vaccines are very rare. In 1976, an earlier type of swine flu vaccine was associated with cases of a severe paralytic illness called Guillain-Barre Syndrome (GBS) at a rate of approximately 1 case of GBS per 100,000 persons vaccinated. Some studies done since 1976 have shown a small risk of GBS in persons who received the seasonal influenza vaccine. This risk is estimated to be no more than 1 case of GBS per 1 million persons vaccinated. Since then, flu vaccines have not been clearly linked to GBS. GBS has a number of different causes, and GBS can occur in a person who has never received an influenza vaccine. The potential benefits of influenza vaccination in preventing serious illness, hospitalization, and death substantially outweigh these estimates of risk for vaccine-associated GBS.

Anyone who has a severe (life-threatening) allergy to eggs or to any other substance in the vaccine should not get the vaccine. People should always inform their immunization provider if they have any severe allergies, if they’ve ever had a severe allergic reaction following flu vaccination, or if they have ever had GBS.

Q. Can the family members of a pregnant woman receive the nasal spray vaccine?
A. Pregnant women should not receive the live nasal spray influenza vaccine but family and household members and other close contacts of pregnant women (including healthcare personnel) who are 2 through 49 years old, healthy* and not pregnant may receive live nasal spray vaccine.

Q. Can a pregnant healthcare worker administer the live nasal influenza vaccine?
A. Yes. No special precautions are (such as gloves) are necessary. Hands should be washed or cleaned with waterless hand sanitizer before and after administering the vaccine or having any direct contact with patients in a health care setting.

H1N1 Vaccine Q&A for Health Care Providers Who Treat Pregnant Women:

Q. Where can healthcare providers obtain 2009 H1N1 influenza vaccine?
A. Please visit our H1N1 vaccination web site for more information: http://www.maine.gov/dhhs/boh/maineflu/h1n1-vaccine.shtml

Q. How will healthcare providers obtain other supplies necessary for vaccination?
A. The vaccine will be distributed with a kit which will contain needles, syringes, sharps containers and alcohol swabs.

Q. How much does the vaccine cost?
A. The vaccine will be provided free; however, healthcare providers may bill for vaccine administration.

Q. If a pregnant woman delivers before receiving her second dose of vaccine, should she still receive the second dose?
A. Yes. In addition to protecting her from infection, infants less than 6 months old will not be able to be vaccinated so it is recommended that everyone who lives with or provides care for infants less than 6 months of age receive both the seasonal influenza vaccine and 2009 H1N1 influenza monovalent vaccine to provide protection for the infant. One recent study conducted in Bangladesh, assessed the effectiveness of influenza immunization for mothers and their young infants. Inactivated influenza vaccine reduced proven influenza illness by 63% in infants up to 6 months of age. This study confirmed that maternal influenza immunization is a strategy with substantial benefits for both mothers and infants.

Q. Where can healthcare providers get more information about the 2009 H1N1 influenza vaccine?
A. Information is continually updated at http://www.cdc.gov/h1n1flu/vaccination/

Vulnerable Groups

Data continue to show that certain medical conditions increase the risk of severe and fatal illness (http://www.cdc.gov/h1n1flu/vaccination/acip.htm). These include respiratory disease, notably asthma, cardiovascular disease, diabetes and immunosuppression.

Several early studies show a higher risk of hospitalization and death among certain subgroups, including minority groups and indigenous populations. In some studies, the risk in these groups is four to five times higher than in the general population. (http://www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html)

Early data from two countries suggest that people co-infected with H1N1 and HIV are not at increased risk of severe or fatal illness, provided these patients are receiving antiretroviral therapy. In most of these patients, illness caused by H1N1 has been mild, with full recovery. (http://www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html)


Other New or Recently Updated H1N1 Guidance or News

This MMWR report (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5833a1.htm) summarizes laboratory-confirmed cases of H1N1 identified between April and July in Chicago, Illinois, and provides clinical and epidemiologic data for a subset of those cases. The study found that the attack rate was highest among children ages 5-14, and 14 times higher than for adults 60 and older. The highest hospitalization rates were among children up to age 4, followed by children 5- to 14-years-old.

This MMWR report (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5833a2.htm) describes a study of seasonal flu and H1N1 in New Zealand, which determined that H1N1 quickly took over the number of cases identified as seasonal flu. Similarly, early results from a study of flu in ferrets (http://www.nih.gov/news/health/aug2009/niaid-31.htm) indicates that H1N1 probably will dominate over seasonal flu in the coming flu season, and that H1N1 caused more severe disease.

Community Flu 1.0 software to calculate the cost, in terms of workdays lost, of influenza and the associated interventions: http://www.cdc.gov/flu/tools/communityflu/

FluLabSurge1.0 software to assist lab directors forecast the demand for testing: http://www.cdc.gov/flu/tools/flulabsurge/

US CDC listed its public health emergency response projects related to H1N1: http://www.cdc.gov/h1n1flu/responseprojects.htm.

The US Department of Health and Human Services, Department of Homeland Security, Department of Education, and Sesame Workshop have launched a new advertising campaign designed to encourage children and families to practice healthy habits and to take steps to prevent the spread of the 2009 H1N1 flu virus. The PSAs featured in this campaign can be viewed on http://www.flu.gov/.

How to Stay Updated

Weekly Updates: Check the Wednesday late afternoon updates on H1N1 in Maine on Maine CDC’s H1N1 website. Now available as an RSS feed (midway down the center of the homepage): http://www.maineflu.gov/

Health Alert Network: Sign up to receive urgent updates from Maine CDC’s Health Alert Network (HAN). The easiest and quickest way is to sign up is through the HAN Alert RSS feed at http://www.mainepublichealth.gov/ (midway down the center of the homepage).

Follow Maine CDC’s Updates:
Facebook (search for “Maine CDC”)
Twitter (http://twitter.com/MEPublicHealth)
MySpace (www.myspace.com/mainepublichealth)
Maine CDC’s Blog (http://mainepublichealth.blogspot.com/)

H1N1 Conference Calls: September 14th for schools and health care providers involved with the school-located seasonal and H1N1 vaccine efforts and September 17th for clinicians who care for pregnant women. Calls are 12 noon – 1 pm. Phone Number for Both Calls: 1-800-914-3396 and passcode 473623.

Consider Calling or Emailing Us:
For clinical consultation, outbreak management guidance, and reporting of an outbreak of H1N1 call Maine CDC’s toll free 24-hour phone line at: 1-800-821-5821.
General Public Call-in Number for Questions: 1-888-257-0990NextTalk (deaf/hard of hearing) - (207) 629-5751Monday - Friday 9 a.m. – 5 p.m.
Email your questions to: Sue.Dowdy@maine.gov

U.S. CDC H1N1 Recommendations and Guidance:
http://www.cdc.gov/h1n1flu/ and http://www.flu.gov/

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