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Title: Preparing for Pandemic H1N1 in the Fall: Best Practices from Recent Campus Experiences


1
Preparing for Pandemic H1N1in the Fall Best
Practices from Recent Campus Experiences
  • Jane Horton, MD, Director of Student Health and
    Counseling
  • Dawn Watkins, Vice President of Student Affairs
    and Dean of Students
  • Jeff Hanna, Executive Director of Communications
    and Public Affairs

2
Pre-Pandemic Planning
  • A Pandemic Flu Preparedness and Response Plan was
    adopted in 2006 as a component of our
    institutional crisis management plan
  • Pandemic flu defined as an influenza outbreak
    identified as pandemic flu by WHO, CDC and/or
    state health agencies, or a local outbreak of
    severe flu illness with an attack rate of greater
    than 10, and/or mortality rate of greater than
    1
  • Key elements of the plan include
  • Department-specific guidelines for pandemic flu
    planning and response
  • Implementation of social distancing to reduce
    spread of infection
  • Implementation of isolation of those affected by
    illness
  • Public health education using effective
    communication strategies
  • Coordination with VDH and local public health
    officials, MOU to serve as POD for vaccines
    and/or medications for the University community

3
Pre-Pandemic Planning (contd)
  • A five level plan was developed to serve as a
    tool to support decision making in the event of a
    pandemic flu outbreak. This plan outlines both
    triggers and key responses at each level
  • Level 1 Planning, Communication, Surveillance
    for pandemic flu
  • Develop Pandemic Flu Preparedness and Response
    Plan
  • Communicate planning and general public health
    information to University community
  • Monitor WHO, CDC, state health agencies for
    information regarding influenza activity

4
Pre-Pandemic Planning (contd)
  • Level 2 Pandemic flu identified
  • Monitor WHO, CDC, state health agencies for
    information regarding influenza activity
  • Implement travel restrictions recommended by CDC
    and US Dept of State
  • Communicate specific University and public health
    information to University community
  • Increase stocks of supplies needed to provide
    care in the event of a local outbreak

5
Pre-Pandemic Planning (contd)
  • Level 3 Pandemic flu present in Virginia
  • Monitor WHO, CDC, state and local health agencies
    for information regarding influenza activity
  • Increase stocks of supplies needed to provide
    care in the event of a local outbreak
  • Monitor for flu activity and severity in the
    University community
  • Participate in state and local health agency
    efforts to distribute national stockpiles of
    influenza vaccine and antiviral medication for
    prophylaxis and treatment
  • Consider limitation and/or suspension of
    University operations
  • Communicate disease recognition and management,
    personal protection, social distancing,
    quarantine and isolation information to
    University community

6
Pre-Pandemic Planning (contd)
  • Level 4 Pandemic flu present at WL or in the
    local community
  • Monitor WHO, CDC, state and local health agencies
    for information regarding influenza activity
  • Monitor for flu activity and severity in the
    University community
  • Participate in state and local health agency
    efforts to distribute national stockpiles of
    influenza vaccine and antiviral medication for
    prophylaxis and treatment
  • Communicate disease recognition and management,
    personal protection, social distancing,
    quarantine and isolation information to
    University community
  • Limit or suspend University operations and
    communicate same
  • Implement quarantine and isolation measures for
    those exposed/ill with influenza
  • Provide health care and essential services for
    those who remain on campus

7
Pre-Pandemic Planning (contd)
  • Level 5 Recovery
  • Monitor WHO, CDC, state and local health agencies
    for information regarding influenza activity
  • Prepare for possible further waves of pandemic
    flu activity, and return to Level 2
  • Decide to (partially or fully) resume University
    operations at Level 2
  • Communicate specific University and public health
    information to University community

8
Monday April 20
  • Classes resume after Spring Break.
  • Several students have traveled to Mexico,
    California or Texas during the break.

9
Thursday April 23
  • CDC announces human cases of swine influenza A
    (H1N1) virus infection identified in California
    and Texas, in addition to cases in Mexico

10
Friday April 24
  • CDC sends investigators into the field in
    Mexico, California and Texas
  • VDH releases swine influenza virus infection
    testing recommendations to clinicians
  • Clinicians should consider the possibility of
    swine influenza virus infection in patients
    presenting with febrile respiratory illness
    (fever gt100 F plus a cough and/or sore throat, in
    the absence of another known cause) who
  • Live in or have traveled to San Diego and/or
    Imperial County, California or Guadalupe County,
    Texas or
  • Have been in contact with ill persons from these
    areas in the 7 days prior to their illness onset.

11
April 19-25
  • WL CLINICAL EXPERIENCE FOR THE WEEK
  • 24 students seen with respiratory illnesses and
    2 with ILI.

12
Sunday April 26
  • Public health emergency declared in U.S.
  • CDC announces additional cases in CA, TX, KS, OH
    and NYC. Testing shows virus is susceptible to
    oseltamivir and zanamavir. Interim guidance
    released on how to care for people who are sick
    and the use of face masks in a community setting
    where spread of swine flu has been detected.
  • Internal communications begin at WL about
    assessing risk on campus and communicating with
    the University community.

13
Monday April 27
  • CDC activates Emergency Operations Center and
    issues travel warning to avoid non-essential
    travel to Mexico
  • VDH declares public health emergency in Virginia
    and activates Incident Command Center.
  • CDC and VDH recommendations are used to develop
    communications to WL community regarding swine
    flu outbreak.

14
Monday April 27
  • Current case definition any patient with ILI
    who lived, traveled, or had contact with an ill
    person from any area with confirmed swine
    influenza cases.
  • SHC staff updated on swine flu outbreak, case
    definition for ILI and swine flu, respiratory
    precautions, management of ILI, etc. Signs,
    masks, tissues and hand sanitizer placed at
    patient check-in location. Swine flu information
    from CDC placed in waiting room for patient
    education.

15
Monday April 27
  • Case 1 presents to SHC with ILI past 48 hours,
    no known contact with ill person or personal
    travel to any area with confirmed swine flu
    cases. Admitted to infirmary, private room,
    respiratory isolation. Rapid influenza A test
    positive, second swab obtained for swine flu
    testing, oseltamivir treatment initiated, health
    department notified.
  • Two other students with ILI have negative rapid
    influenza tests.

16
Tuesday April 28
Dean Watkins message appears in Campus Notices
17
Tuesday April 28
  • Dr. Horton notifies Dean Watkins of Case 1
    student with ILI and positive influenza A test,
    possible swine flu. VDH agrees to do swine flu
    testing on our student even though case
    definition was not met.
  • Dean Watkins alerts WL President Ruscio to the
    potential of swine flu in a student.
  • Dean Watkins message is sent to the campus as a
    broadcast email.
  • Emergency Management team receives an email
    updating members on the situation.
  • CDC Swine Flu widget is added to the Student
    Health and Counseling Web site.

18
Tuesday April 28
  • Case 2 presents to SHC with ILI past 24 hours,
    no known contact with ill person or personal
    travel to any area with confirmed swine flu
    cases.
  • Three other students with ILI have negative
    rapid influenza tests.
  • First positive swine flu case in a college
    reported by Notre Dame.
  • WHO raises worldwide pandemic alert to Phase 4
    (confirmed person to person spread of a new
    influenza virus able to cause community-level
    outbreaks)

19
Wednesday April 29
  • Case 2 influenza A test positive, respiratory
    isolation and oseltamivir treatment initiated,
    VDH and administration notified. Dr. Horton
    notifies Dean Watkins of a second possible swine
    flu case. Dean Watkins notifies President Ruscio
    and Public Affairs Director Hanna of situation.
  • Two other students with ILI have negative rapid
    influenza tests.
  • Initial internal email exchanges regarding
    Alumni Reunions, which are scheduled to begin the
    following day.
  • CDC posters distributed around the campus.
  • General notice about swine flu is posted on the
    alumni site and on the alumni reunion site.
  • Work begins on developing a special light
    swine flu Web site.

20
Wednesday April 29
  • WHO raises worldwide pandemic alert to Phase 5
    (strong signal that pandemic is imminentthe time
    to finalize organization, communication, and
    implementation of planned mitigation measures is
    short)

21
Thursday April 30
  • Notified by VDH that case 1 now considered
    probable swine flu since the influenza A strain
    could not be typed by the state lab. Specimen
    from case 1 sent to CDC for further testing.
  • Specimen from case 2 sent to VDH for further
    testing.
  • First two cases of swine flu in Virginia are
    confirmed neither is a WL case.
  • Dean Watkins issues an update to Emergency
    Management team including general updates,
    talking points and reminder to review Pandemic
    Flu Plan and carry emergency USB at all times.
  • Draft of campus-wide communication re one
    probable swine flu case is prepared and sent to
    Central Shenandoah Health District Director Dr.
    Douglas Larsen.

22
Thursday April 30
  • First conference call held with VDH officials to
    discuss WL cases and response.
  • Decision is made to follow the states
    established policy of not announcing probable
    cases.
  • As part of conference call, VDH decides to
    develop a special advisory on swine flu to
    colleges and universities.
  • Report received from Council of Independent
    Colleges of Virginia (CICV) Pandemic Advisory
    Task Force 4/29/09 conference call, that included
    Dr. Diane Woolard from VDH, recommending close
    monitoring but no move to suspending classes or
    canceling events on campuses.

23
Friday May 1
  • A special flyer is developed for alumni reunions
    and is posted at registration desks, reminding
    visitors of recommended personal respiratory
    hygiene precautions and self-isolation for ILI.
  • CDC releases swine flu infections alert for
    institutions of higher education.
  • Letter from Dr. Karen Remley, VDH State Health
    Commissioner, to Virginia College and University
    students.
  • Case 3 presents to SHC.
  • Two other students with ILI have negative rapid
    influenza tests.

24
Friday May 1
  • 630 p.m. Dr. Larsen informs that the two WL
    cases are now probable swine flu swine flu
    since the influenza A strain could not be typed
    by the state lab. VDH intends to release
    information to news media.
  • 830 p.m. VDH distributes news release
    announcing two probable cases among Washington
    and Lee students
  • 9 p.m. Blast email is sent to WL community.
    Students are asked to forward the information to
    parents.
  • 9 p.m. go.wlu.edu/health Web site goes live
    with memo and other information. Home page now
    features an alert box in red directing people to
    the special page.
  • Dean Watkins and Dr. Horton begin receiving
    emails of concern from faculty about students who
    may have been in class with symptoms.

25
Friday May 1
26
Friday May 1
27
Saturday May 2
  • President Ruscio announces probable swine flu
    cases at breakfast meeting of alumni reunions.
  • Four area TV stations arrive mid-morning to
    report on situation.
  • Local and area print media call for information
    and are directed to the swine flu Web page.
  • Message is sent to WL families from Dean
    Watkins.
  • VDH makes announcement the first probable case
    at WL has now been confirmed as swine flu,
    making it the third case in Virginia.
  • Strategy meeting with Dr. Larsen and by phone
    with VDH.
  • CDC releases interim guidance on school
    closures.

28
Saturday May 2
  • Contact list developed for Case 2, who went to
    class with fever and cough before diagnosis
    faculty and students notified by email about
    possible exposure, appropriate actions if
    symptoms develop, and availability of anti-viral
    prophylaxis for high-risk individuals.
  • One student with ILI has negative rapid
    influenza test.

29
April 26May 2
  • WL CLINICAL EXPERIENCE FOR THE WEEK
  • 86 students seen with respiratory illnesses and
    15 with ILI, including cases 1-3.
  •  

30
Sunday May 3
  • Letter from Dr. Remley to health care providers
    with updated case definitions (no longer requires
    travel or exposure history), testing, isolation,
    treatment, post-exposure prophylaxis for those in
    high-risk groups.
  • Cases 4 and 5 present to SHC.
  • Frequently Asked Questions are added to Web page.

31
Monday May 4
  • Cases 6-10 present to SHC.
  • Council of Independent Colleges of Virginia
    (CICV) hold follow up conference call on
    pandemic.
  • Special communication is distributed to WL
    students studying abroad.
  • An email update to the community adds a specific
    warning to students about sharing cups.
  • Information is shared with faculty at the
    regularly scheduled faculty meeting.
  • An additional update is given to the Emergency
    Management Team

32
Tuesday May 5
  • Dean Watkins meets with individual classes and
    groups, including education studies which has
    student teachers in area schools.
  • Emergency Management Team meets to discuss
    current status of the outbreak on campus.
  • New guidance forthcoming from CDC for colleges
    and universities discussed during VDH conference
    call, removes recommendation for school closings.
  • Dr. Horton consults with Athletic Department and
    mens lacrosse team about a team member with
    swine flu, as well as the upcoming NCAA mens
    lacrosse and womens tennis tournaments scheduled
    to be held on campus.
  • Athletic Director Jan Hathorn consults with NCAA
    and with competing teams

33
Wednesday May 6
  • Cases 11-13 present to SHC.
  • Four cases are moved from SHC infirmary to
    on-campus apartment to complete 7 day isolation.

34
Wednesday May 6
  • Cases 11-13 present to SHC.
  • Four cases are moved from SHC infirmary to
    on-campus apartment to complete 7 day isolation.
  • Dean Watkins contacts local public school
    superintendents.
  • Dean Watkins and Dr. Horton begin to develop a
    campus-wide questionnaire with VDH.
  • VDH announces that there are seven confirmed
    cases at WL.
  • Dean Watkins and Communications Director Hanna
    hold news conference with local and area media.
  • WL mens lacrosse team hosts NCAA tournament
    game without top player who is being treated for
    H1N1.

35
Thursday May 7
  • New communication to WL parents from Dean
    Watkins.
  • Two cases are moved from SHC infirmary to
    on-campus apartment to complete 7 day isolation.

36
Friday May 8
37
May 3-9
  • WL CLINICAL EXPERIENCE FOR THE WEEK
  • 71 students seen with respiratory illnesses, and
    20 with ILI, including cases 4-13.

38
Monday May 11
  • CDC releases interim guidelines for IHE, which
    do not recommend that colleges or universities
    cancel classes or other large gatherings.

39
Tuesday May 12
  • Dr. Horton meets with Facilities Management
    staff for QA.

40
Thursday May 14
  • Case 14 presents to SHC.

41
May 10-16
  • WL CLINICAL EXPERIENCE FOR THE WEEK
  • 70 students seen with respiratory illnesses, and
    2 with ILI, including case 14.

42
May 17-23
  • CLINICAL EXPERIENCE FOR THE WEEK
  • 59 students seen with respiratory illnesses, and
    2 with ILI.

43
May 24-30
  • CLINICAL EXPERIENCE FOR THE WEEK
  • 50 students seen with respiratory illnesses, and
    0 with ILI.

44
Thursday June 4
  • Undergraduate Commencement at Washington and Lee

45
Thursday June 11
  • WHO raises worldwide pandemic alert to Phase 6
    (global pandemic is underway).

46
Lessons Learned / Considerationsfor Fall -
Winter 2009
  • Things can change and develop quickly. We moved
    from Level 1 to Level 4 of our pandemic flu plan
    within 4 days of the first notice from CDC of
    swine flu cases in the US and Mexico , within 1
    day of a public health emergency being declared
    in US. There may not be much time to revise or
    finalize plans, increase stock of supplies, etc.
    Communications must be constant, both within the
    emergency management team and across the
    community.
  • Most of our cases did not have exposure to known
    cases of novel H1N1 influenza or clear
    environmental connections. Many were first year
    students living in residence halls or sophomores
    living in Greek houses. Many reported extensive
    social contacts that included sharing cups at
    parties.
  • We presume that our students who traveled over
    spring break in mid-April brought this virus back
    to campus, and that those index cases were either
    not severe enough for the students to seek
    medical attention or were not recognized as
    influenza.

47
Lessons Learned / Considerationsfor Fall -
Winter 2009
  • Colleges and universities will be on the front
    line for influenza outbreaks this fall and winter
    as students return to our campuses from all over
    the world. Both seasonal and novel H1N1
    influenza virus will likely be circulating.
  • Social distancing and personal protection
    guidelines will need to be adopted early and
    followed consistently by a significant proportion
    of the University community to slow spread of the
    virus. Effective education of all students,
    faculty and staff will be a key to success.
  • Seasonal and novel H1N1 influenza virus
    immunization programs for students, faculty and
    staff will be important in trying to slow or
    minimize the impact of influenza on the
    operations of IHE for 2009-2010. Planning for
    these immunization programs (in conjunction with
    VDH) should begin now.

48
Lessons Learned / Considerationsfor Fall -
Winter 2009
  • Isolation of infected students for 7 days after
    onset of illness will be a challengeconsider
    plans for providing medical care, housing,
    bathrooms, meals and appropriate education and
    supplies to minimize spread of infection to
    others. Stock up on masks, gloves, hand
    sanitizer, tissues, etc.
  • Mandatory isolation strategies may keep students
    from seeking appropriate medical care for ILI,
    and most IHE do not have the facilities/services
    available to cohort infected students
    effectively.
  • Voluntary isolation in place will be more
    effective in reducing spread for students living
    off campus than for those living in residence
    halls and/or taking their meals in congregate
    settings.
  • Effective education of students, faculty and
    staff will be a key to success of social
    distancing and isolation strategies.

49
Lessons Learned / Considerationsfor Fall -
Winter 2009
  • Most people who have become ill with the novel
    H1N1 influenza virus have recovered without
    requiring medical treatment. Many may not
    recognize they have the flu and therefore may not
    follow isolation guidelines.
  • Treatment and post-exposure prophylaxis with
    antiviral medication is recommended only for
    those hospitalized with illness and those in
    high-risk groups for flu complications. This
    includes pregnant women, those with
    immunosuppression and chronic pulmonary
    (including asthma), cardiovascular (except
    hypertension), renal, hepatic, hematological
    (including sickle cell disease), neurologic,
    neuromuscular, or metabolic disorders (including
    diabetes mellitus).
  • Yet everyone will likely want antiviral
    medication for treatment and/or post-exposure
    prophylaxis. This will drain resources and may
    increase the risk of the virus developing
    resistance to current antiviral medications.

50
Lessons Learned / Considerationsfor Fall -
Winter 2009
  • This novel H1N1 influenza virus is capable of
    causing widespread campus and community
    outbreaks. It may be difficult to continue
    operations for health services and other
    university functions (including classes) in the
    face of significant student, faculty and staff
    absenteeism, which may be as high as 20-40.
  • Consider triggers for an institutional decision
    to suspend/resume classes. Develop a business
    continuity plan for the institution and
    individual departments and operations if there is
    a flu outbreak with a high prevalence of
    influenza illness and associated disruption of
    operations.

51
Contact Information
  • Jane T. Horton, MD
  • Director, Student Health and Counseling
  • jhorton_at_wlu.edu
  • 540-458-8401
  • Dawn Watkins, PhD
  • Vice President of Student Affairs and Dean of
    Students
  • dwatkins_at_wlu.edu
  • 540-458-8751
  • Jeff Hanna
  • Executive Director of Communications and Public
    Affairs
  • jhanna_at_wlu.edu
  • 540-458-8459
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