Thursday, November 12, 2009

Weekly Update on H1N1 in Maine 11/12/2009

Maine CDC/DHHS Update on 2009 H1N1 Influenza Virus
November 12, 2009
Highlights
As expected, H1N1 continues to expand and worsen – 65 school outbreaks, ER visits for flu accounting for 1 in 6 ER patients, 19 hospitalizations, and 2 deaths (for a total of 3 since August).
Antiviral medicines are under-utilized.
Vaccine efforts continue – about 95% of schools are expected to complete their vaccinations by the end of next week, for a total of about 400 schools in 4 weeks’ time.

Increased Flu Activity in Maine and the US

The 2009 H1N1 flu continues to be widespread in Maine. Statewide, schools are reporting increased absenteeism due to influenza-like illness (ILI), with rates ranging from 15% to almost 50%. Schools in two communities have closed, and this is an administrative decision based on operational challenges associated with absenteeism among students as well as staff.

There were 65 new outbreaks reported this week (up from 24 last week), all in school settings. Outbreaks in schools occurred in the following counties: Androscoggin (10), Aroostook (2), Cumberland (5), Hancock (3), Kennebec (7), Oxford (3), Penobscot (18), Piscataquis (1), Sagadahoc (1), Somerset (3), Waldo (3), and York (9).

A total of 19 people were hospitalized due to H1N1 (up from 10 last week). Of those hospitalized, 5 were children; 3 were young adults ages 18-24; 10 were adults younger than 65; and one was an adult 65 or older. Two of the adults were in intensive care. Hospitalizations occurred in Androscoggin, Cumberland, Kennebec, Oxford, Penobscot, Washington, and York counties.

There were two deaths – one in a young adult reported in a press release late last week, and another in an adult in the 50-64 age group. Both deaths were in Penobscot County and both people had severe underlying conditions.

There have been confirmed cases of H1N1 in every county in Maine. People should assume that they will be exposed to the flu at some point, and with only enough vaccine for 1 in 8 people in Maine right now, we should all take precautions to prevent serious illness:
Stay home if you are sick, until you are fever-free for a full 24 hours without taking fever-reducing medicine.
Cough and sneeze into your elbow, or into a tissue. Throw this tissue away.
Wash your hands frequently with soap and water, but especially after coughing and sneezing. Alcohol-based hand gels can also be used.
Avoid touching your nose, mouth, and eyes. Germs can spread this way.
Avoid contact with sick people. If you are at very high risk for complications, you may want to avoid large crowds.
When vaccine is available, get both the seasonal and H1N1 flu vaccines.
Contact your health care provider if there are flu-like symptoms in a household where anyone is younger than 2 years old, 65 years or older, pregnant, and/or has an underlying medical condition. There are prescription medicines (antivirals such as Tamiflu®) that may help. The state’s stockpile of these medicines is also available to those who do not have adequate insurance and cannot afford the costs.
Although most people can stay home to recover without seeing a health care provider, anyone with the flu should seek medical attention for:
Dehydration
Trouble breathing
Getting better, then suddenly getting a lot worse
Any major change in one’s condition

H1N1 Vaccine Supply and Prioritization

Another 41,800 doses of H1N1 vaccine were distributed in Maine this week, bringing the total vaccine in the state to 180,400 doses.

US CDC released a list of recommended priority groups to receive the initial doses of H1N1 vaccine last summer. These groups were chosen because they were at high risk for complications from H1N1 or because they could pass H1N1 on to someone at high risk for complications.

Currently, we have received enough vaccine for about 1 in 4 people in priority populations in Maine. For this reason, Maine CDC has had to prioritize within the priority groups, based on trends in infections, the type and amount of vaccine available, and readiness of partners to administer vaccine.

The first groups targeted were children and pregnant women, because they are most disproportionately affected by H1N1 infection and because the types of vaccine available were most appropriate for them. Certain health care workers – for example, those who work in hospital maternity wards, pediatric units, ICU, and emergency departments – were also prioritized initially.

Currently, Maine CDC priority groups for vaccination are:
All children 6 months – 18 years of age
Pregnant women
Caregivers and household members of infants younger than 6 months old
Adults 18 – 64 years of age with chronic medical conditions**
Health care personnel with frequent direct contact with infectious materials and inpatients who are at high risk (pregnant women, children, and high-risk adults older than 65)

**Chronic medical conditions that confer a higher risk for influenza-related complications include chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematologic, or metabolic disorders (including diabetes mellitus) or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus).

We are currently distributing vaccine for use in the following settings:
K-12 schools
Health care providers who care for children, pregnant women and/or very high-risk adults
Colleges and universities for their high-risk students
Some pre-school settings such as preschool programs for high-risk children and Head Starts

By the end of next week, we expect:
About 95% of all K-12 schools, which is all schools that signed up to provide H1N1 vaccines, will have administered their first doses to children. The second doses for children ages nine and younger we anticipate will begin to be distributed in the next several weeks, but not until sometime in December.
All health care providers that ordered H1N1 vaccine for pregnant women will have received sufficient supply for their pregnant patients.

Over the next several weeks, we expect that it will be easier for household members of infants younger than six months old, pre-school aged children, and people younger than 65 at high risk due to underlying medical conditions to access vaccine through several channels:
Vaccine has been shipped to pediatric health care providers that placed orders for H1N1 vaccine. Public Health Nurses are conducting vaccine clinics in preschool settings for high-risk children and will soon be conducting vaccine clinics in Head Start locations. Other organizations are also starting to organize clinics for preschool aged children.
The limited amount of vaccine formulation that is ideal for adults is being distributed to specialists serving those adults who are at the highest risk – pulmonologists, cardiologists, oncologists, neurologists, rheumatologists, infectious disease physicians, and dialysis centers. We hope in the next week to be able to distribute increasing amounts of vaccine to other adult practices, such as internal medicine physicians. In addition, clinics for high risk groups will be starting in the coming weeks, and will be posted on the flu clinic locator at http://www.maineflu.gov/.
We hope to provide more vaccine for health care workers by the end of this month as the vaccine formulations for adults become more available. Any health care worker who fits into another high-risk group (pregnant, household member of an infant younger than six months, younger than 65 with an underlying health condition) should try to access vaccine now.

Once all of the prioritized groups have been vaccinated, we anticipate that there will be enough vaccine for anyone who wants it. However, vaccine may not be available to those not included in the priority groups until early in 2010.

Reporting Vaccine Administration

Maine CDC asks that all H1N1 vaccine providers and/or administrators are submitting the vaccine administration data into the Maine CDC’s weekly vaccine reporting system.

The weekly vaccine reporting form can be found at: http://www.maine.gov/dhhs/boh/maineflu/h1n1/health-care-providers.shtml. The vaccine reporting periods on the form are the same timeframe as the dates for the vaccine clinics. This form is then compiled by us and submitted, as required, to US CDC.

We have many thousands fewer doses of vaccine being reported as being administered than we believe have actually been administered. This will start impacting the flow of vaccine, since the flow of vaccine is expected to slow to those states that are not showing evidence of using it.

Maine CDC’s Immunization Program is compiling a database that matches the vaccine distribution database with the vaccine administration database by provider so we can tell which providers are not reporting on vaccine administration (or not using their vaccine). We will then use this to guide our vaccine distribution decision-making.

H1N1 Vaccination Distribution as of November 12:

STATE

180,400 doses
14% of the state population

These numbers mean there is 1 dose for every 4 people in a high priority group, and 1 for every 8 people in the state.

Adverse Events

US CDC's Vaccine Adverse Event Reporting System (VAERS) for years has recorded any adverse events following vaccination. This week Maine CDC compiled the data from the first month of H1N1 vaccine being administered in Maine. We found a total of 5 adverse events reported, all of them minor with none requiring hospitalization or evidence of long term problems. The events included: congestion and a sore throat following a nasal spray vaccine, and tingling and numbness following an injectable vaccine that resolved.


Antiviral Treatment


Anyone who is in a high risk category for flu complications – those younger than 2 years old, 65 years or older, pregnant, and/or those with an underlying medical condition – should be started on prescription antiviral medicines such as Tamiflu® if they have flu symptoms (or if anyone in their household has symptoms). These medicines can significantly reduce severity (including hospitalization and death) as well as duration of illness.

State Stockpile:
Maine CDC encourages physicians to prescribe antiviral medications as appropriate. In an effort to minimize financial barriers, Maine CDC has mobilized a significant portion of the state-purchased stockpile of antiviral medications for use by patients who do not have adequate insurance coverage (no insurance, high deductibles, high co-pays). Read the full Health Alert issued on this topic here: http://www.maine.gov/tools/whatsnew/index.php?topic=DHHS-HAN&id=84066&v=alert

Pediatric Suspension:
The FDA has issued guidance on compounding an oral suspension of Tamiflu® to provide multiple prescriptions: http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm188629.htm/ohttp:/www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm188629.htmblocked::http:/www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm188629.htm

MaineCare is promulgating emergency rules increasing the reimbursement for compounding pediatric suspension from $4.35 to $10. The full stockpile of pre-prepared pediatric suspension in the stockpile has been fully deployed to hospitals, health centers, and Hannaford’s pharmacies and other willing pharmacies.

Additional Federal Guidance on Antivirals:
US CDC has posted information about the safety of antivirals: http://www.cdc.gov/H1N1flu/antivirals/safety_info.htm
US CDC Health Alert: Key Issues for Clinicians Concerning Antiviral Treatments for 2009 H1N1: The 2009 H1N1 virus continues to be the dominant influenza virus in circulation in the United States. The benefit of antiviral treatment is greatest when it is initiated as early as possible in the clinical course. http://www.cdc.gov/H1N1flu/HAN/110609.htm


Clinical Testing, Reporting, and Management of H1N1

Health care providers and other public health partners are asked to report to Maine CDC influenza infection among patients who:
· Are hospitalized;
· Have died; and/or
· Are associated with a suspected outbreak.
Health care providers with questions on influenza can contact the Maine CDC at 1-800-821-5821 24 hours a day, 7 days a week.

Testing:
§ Submit a specimen for influenza testing for patients with ILI who are hospitalized, who have died, or for whom a diagnosis of influenza would affect clinical care, infection control, or management of contacts.
§ When testing is indicated, rapid diagnostic tests that are negative should be followed by PCR testing.
§ For outbreaks in institutional settings, submit 3-4 specimens to confirm the cause of the outbreak. Once infection has been confirmed as influenza, further testing is not usually indicated.
§ Information on testing at the Health and Environmental Testing Laboratory is available at: http://www.maine.gov/dhhs/etl/micro/submitting_samples.htm

Algorithm for Testing and Management of H1N1 can be found at: http://www.maine.gov/tools/whatsnew/attach.php?id=82597&an=1
Additional Information for Health Care Providers on testing, reporting and management of H1N1, including patient handouts can be found at:
http://www.maine.gov/dhhs/boh/maineflu/h1n1/health-care-providers.shtml and
http://www.maineflu.gov/


Guidance for Schools and Day Cares
In light of recent school outbreaks, we expect that most schools in the state will eventually have some cases of the flu. Schools and day cares do not need to notify parents of each individual case of the flu. However, parental notification may be helpful in some situations.

If you have cases of flu in your school and are unsure whether you should notify parents, you may contact Maine CDC for guidance. There are specific reporting guidelines and forms related to increased absenteeism, available at: http://www.maine.gov/dhhs/boh/maineflu/h1n1/educators.shtml#forms

If you are a school or day care administrator and have questions about reporting increased absenteeism, precautions to take, or the ways in which to notify parents, please contact our Clinical Consultation line at 1-800-821-5821 or e-mail disease.reporting@maine.gov.

US CDC has issued guidance for schools (http://www.cdc.gov/h1n1flu/schools/schoolguidance.htm) and child care programs (http://www.cdc.gov/h1n1flu/childcare/guidance.htm) designed to decrease exposure to the flu while limiting the disruption of day-to-day activities and learning.

Maine CDC is not issuing directives to close schools or day cares at this time. These are administrative decisions, largely based on staffing capacity.

New Videos, posters, and related materials from US CDC
Influenza Round Table: Warning Signs Video
Don't Get, Don't Spread Video
H1N1 Flu Vaccine -- Why the Delay? Watch a new CDC video to find out how flu vaccines are made: http://is.gd/4OVFq
"Seasonal and 2009 H1N1 Flu: For Parents Who Have Children or Adolescents with High-Risk Medical Conditions" brochure. New brochure for parents of high-risk children. http://www.cdc.gov/h1n1flu/childcare/toolkit/pdf/H1N1Seasonal_HiRiskChildren_Final.pdf
Updated: H1N1 Flu and You Brochure
Update: Poster-Disposable Respirators: General Donning InstructionsThese posters describe general procedures for properly putting on and taking off a disposable respirator. http://www.cdc.gov/h1n1flu/eua/pdf/n95instructions.pdf

Other Updates from Federal Partners
The World Organization for Animal Health issues this report that the recent identification of H1N1 in a house cat in Iowa is no additional cause for alarm (http://www.oie.int/eng/press/en_091104.htm) and CDC updated this Q&A about H1N1 in pets (http://www.cdc.gov/h1n1flu/qa.htm).

The commissioner of the US Food and Drug Administration (FDA) sent a letter to America’s healthcare professionals thanking them for their efforts during the 2009 H1N1 influenza outbreak and providing information on the safety of the 2009 H1N1 vaccines. The letter can be viewed at http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm189691.htm


Maine CDC H1N1 Activities This Past Week

Calls received by the phone bank: 708
Questions coming into flu.questions@maine.gov: 227
Hits on the webpages associated with http://www.maineflu.gov/: 71,425
Lab tests we (HETL at Maine CDC) conducted: 451
Lab tests we (HETL) conducted total since April: 6,134
Calls coming into the clinical consultation line: 202
Maine CDC employees whose jobs do not normally involve anything related to H1N1 who have volunteered with the phone bank and other related efforts: 124
Maine CDC employees who have been redeployed from other activities to focus on H1N1: 97

Many Maine CDC posters and magnets are now available for order online: http://www.maine.gov/dhhs/boh/flu-poster-orders.shtml

How to Stay Updated

· Flu News: View current Maine CDC press releases, Thursday morning weekly updates, and urgent updates from our Health Alert Network (HAN) by visiting: http://www.maine.gov/dhhs/boh/maineflu/flu-news.shtml. RSS feeds are available for the weekly updates and HAN. Starting this week, Maine CDC is posting the top Q&A from Maine at the beginning of each week, which can be accessed the same way as these Weekly Updates.
· Follow Maine CDC’s Social Media Updates:
o Facebook (search for “Maine CDC”)
o Twitter (http://twitter.com/MEPublicHealth)
o MySpace (www.myspace.com/mainepublichealth)
o Maine CDC’s Blog (http://mainepublichealth.blogspot.com/)
· H1N1 Conference Calls: Maine CDC will be holding conference calls to provide updates and take questions on H1N1. The next call will be held Monday, November 16, from noon to 1 pm. To participate, call 1-800-914-3396 and enter pass code 473623#. During calls, please press *6 to mute your line and #6 to un-mute when you are actively participating.

Call or Email 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: 1-888-257-0990
Deaf and Hard of Hearing phone number: 1-800-606-0215
Phone lines are open Monday - Friday 9 a.m. – 5 p.m.
· Email your questions to: flu.questions@maine.gov

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