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Influenza, 2009

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Influenza, 2009 Danae Bixler, MD, MPH Division of Infectious Disease Epidemiology – PowerPoint PPT presentation

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Title: Influenza, 2009


1
Influenza, 2009
  • Danae Bixler, MD, MPH
  • Division of Infectious Disease Epidemiology

2
Objectives
  • Summarize 2009 respiratory outbreaks in West
    Virginia
  • Review recently released information on novel
    influenza A (H1N1)
  • Epidemiology
  • Outbreaks
  • Hospitalizations
  • Review an outbreak of Streptococcal pharyngitis

3
Respiratory Outbreaks, 2009(provisional)
  • 53 outbreaks reported by 31 (56) counties
  • 25 (47) 2009 influenza A (H1N1)
  • 9 (17) Influenza-like illness
  • 5 (9) Influenza A
  • 5 (9) Upper respiratory illness
  • 3 (6) Group A Streptococcus
  • 2 (4) Influenza B
  • 4 other

4
2009 Influenza A (H1N1)
  • April 24, 2009 MMWR
  • 2 human cases of swine-origin influenza in
    Southern California
  • No history of swine contact
  • ILI in family contacts
  • May 1, 2009 MMWR
  • Cases in California, Texas
  • Not linked to each other
  • Not linked to outbreak in Mexico

5
2009 Influenza A (H1N1)NEJM, 2009 361115
6
H1N1 Descriptive EpidemiologyEuro Surveill,
2009 14(22)pii19232
7
H1N1 Descriptive EpidemiologyEuro Surveill,
2009 14(22)pii19232
8
Pediatric Hospitalization, ArgentinaNEJM, 2010,
36245
9
Pediatric Hospitalization, ArgentinaNEJM, 2010,
36245
10
Household TransmissionNEJM, 2009, 3612628
  • May 28, 2009
  • 938 probable/confirmed H1N1 case reports
  • 533 (57) households had two to six members
  • 216 (41) households without missing information
  • 600 household contacts.
  • Acute respiratory illness 2 or more of
  • Fever
  • Cough
  • Sore throat or
  • Runny nose
  • Secondary cases occurred within 7 days.

11
Household TransmissionNEJM, 2009, 3612628
Transmission of Acute Respiratory Illness in
Households
  • Median age in households 26 years
  • Median age of secondary cases 16.5 years
  • AR 28 in households with 2 members
  • AR 9 in houssholds with 6 members

12
Household TransmissionNEJM, 2009, 3612628
Variable Estimated Odds Ratio (95 CI) P Value
Age of household contact Age of household contact Age of household contact
0-4 years 3.52 (1.55 7.97) 0.003
5-18 years 2.01 (1.11 3.63) 0.03
19-50 years 1.00
gt 51 years 0.41 (0.08 2.04) 0.28
Doubling of household size 0.27 (0.14 0.52) lt0.001
13
West Virginia Experience
  • 2009 Influenza A (H1N1)

14
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18
Approach to Influenza Outbreak Investigation
  • 1. Prepare for field work
  • 2. Establish the existence of an outbreak
  • 3. Verify the diagnosis
  • 4. Construct a working case definition
  • 5. Find cases systematically and record
    information
  • 6. Perform descriptive epidemiology
  • 7. Develop hypotheses
  • 8. Evaluate hypotheses epidemiologically
  • 9. As necessary, reconsider, refine, and
    re-evaluate hypotheses
  • 10. Compare and reconcile with laboratory and/or
    environmental studies
  • 11. Implement control and prevention measures
  • 12. Initiate or maintain surveillance
  • 13. Communicate findings

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General Measures for Congregate Settings with
Healthy Individuals(CDC)
  • Keep / send ill persons home
  • Encourage
  • Respiratory etiquette
  • Hand hygiene
  • Routine environmental cleaning
  • Leave policies
  • Dont require MD note
  • Dont reward perfect attendance
  • Educate persons with underlying conditions

27
Control of Influenza in Long Term Care
  • Pre-season immunization of patients and staff
  • Isolation of ill persons
  • Secure the diagnosis rapidly
  • 8-10 specimens from recently ill persons
  • Begin antiviral prophlaxis according to
    recommendations
  • Continued surveillance to assess impact of
    control measures

28
Outbreaks in the Current Literature
  • 2009 Influenza A (H1N1)

29
Outbreak in a New York City High SchoolNEJM,
2009 3612628
  • Thursday, April 23, 2009
  • 100 of 2686 high school students ill
  • Fever, headache, dizziness, sore throat,
    respiratory symptoms
  • Friday, April 24, 2009 health department team
    dispatched
  • NP and OP specimens
  • School event for April 24 cancelled
  • Sunday, April 26 CDC confirmed H1N1
  • April 25-May 3 School closed

30
MethodsNEJM, 2009 3612628
  • NP swabs for RT-PCR
  • On-line survey of students
  • Recruitment by mass e-mail
  • Phone contact for persons with worsening illness
  • Case fever cough or sore throat

31
  • 119 confirmed cases
  • 2 hospitalized with LOS 1 day

NEJM, 2009 3612628
32
  • 124 laboratory-confirmed cases
  • 105 (85) reported ILI
  • 5 (4) laboratory-confirmed cases without ILI

NEJM, 2009 3612628
33
EpidemiologyNEJM, 2009 3612628
  • Incubation Period
  • Duration of Illness
  • 50 recovered by 6 days
  • 75 recovered by 9 days
  • Summary recovery takes as much as 1-2 weeks
  • 5 developed symptoms by 0.9 days
  • 50 by 1.4 days
  • 95 by 2.2 days
  • Summary incubation period 1-2 days

34
NYC Schools Influenza Outbreak Investigation
  • 1. Prepare for field work
  • 2. Establish the existence of an outbreak
  • 3. Verify the diagnosis
  • 4. Construct a working case definition
  • 5. Find cases systematically and record
    information
  • 6. Perform descriptive epidemiology
  • 7. Develop hypotheses
  • 8. Evaluate hypotheses epidemiologically
  • 9. As necessary, reconsider, refine, and
    re-evaluate hypotheses
  • 10. Compare and reconcile with laboratory and/or
    environmental studies
  • 11. Implement control and prevention measures
  • 12. Initiate or maintain surveillance
  • 13. Communicate findings

35
Influenza A 2009 (H1N1) in Nursing HomesMMWR,
2010 5974-77.
  • 3 nursing home outbreaks
  • ILI attack rates
  • Residents 6 - 28
  • Staff 5 - 40
  • Control
  • Oseltamivir prophylaxis
  • Droplet precautions
  • Hand hygiene and cough etiquette
  • Restrict new admissions and visitors

36
Influenza Prevention and Control Guidelines for
Nursing Homes MMWR, 2010 5974-77.
  • Vaccinate health-care personnel against seasonal
    influenza and 2009 pandemic influenza A (H1N1).
    Vaccinate residents of long-term--care facilities
    for seasonal influenza and offer 2009 H1N1 as
    this vaccine becomes widely available.
  • Instruct all residents and staff members to use
    respiratory hygiene and cough etiquette.
  • Restrict ill visitors and ill health-care
    personnel from the facility.
  • Continue active surveillance and use influenza
    testing for new cases of acute respiratory
    illness and influenza-like illness.
  • To the extent possible, segregate ill residents
    from unaffected residents and maintain
    appropriate levels of isolation.
  • When influenza is detected in the facility,
    administer influenza antiviral treatment to ill
    residents and influenza antiviral prophylaxis to
    unaffected residents. Unaffected health-care
    personnel should be offered influenza antiviral
    prophylaxis.
  • SOURCES CDC. Interim guidance on infection
    control measures for 2009 H1N1 influenza in
    healthcare settings, including protection of
    healthcare personnel October 14, 2009. Available
    at http//www.cdc.gov/h1n1flu/guidelines_infection
    _control.htm. Carman WF, Elder AG, Wallace LA, et
    al. Effects of influenza vaccination of
    health-care workers on mortality of elderly
    people in long-term care a randomised controlled
    trial. Lancet 200035593--7.

37
Group A Streptococcal Pharyngitis
  • Langiappe

38
GAS Pharyngitis
  • Acute pharyngotonsillitis
  • Fever
  • Sore throat
  • Complications
  • Scarlet fever
  • Rheumatic fever
  • Acute glomerulonephritis
  • Purulent complications otitis media, sinusitis,
    peritonsillar and retropharyngeal abcesses,
    suppurative cervical adenitis

39
GAS Pharyngitis
  • Transmission
  • Person-to-person
  • Foodborne
  • No fomite or zoonotic transmission
  • Colonization
  • 15 of asymptomatic children
  • Persist for months
  • Transmission is minimal

40
GAS pharyngitis diagnosis
  • Who should be tested?
  • Acute onset
  • Fever
  • Clinical signs and symptoms or exposure
  • Pharyngeal exudate
  • Pain on swallowing
  • Enlarged tender anterior cervical nodes
  • Do not test children with viral syndrome
  • Coryza, conjunctivitis, hoarseness, cough, etc.

41
Line List
Grade Fever Sore Throat Rapid Positive Culture Positive Student/Staff Diagnosis Date
K y y y y Student 5/1/2009
K y y y Student 5/1/2009
1 y y y Student 5/1/2009
K y y y y Student 5/3/2009
K y y y Student 5/3/2009
3 y y y Student 5/4/2009
3 y y y y Student 5/4/2009
K y y y Student 5/4/2009
1 y y y Student 5/4/2009
y y y Staff 5/4/2009
y y y Staff 5/4/2009
42
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43
GAS Pharyngitis Outbreak Investigation
  • 1. Prepare for field work
  • 2. Establish the existence of an outbreak
  • 3. Verify the diagnosis
  • 4. Construct a working case definition
  • 5. Find cases systematically and record
    information
  • 6. Perform descriptive epidemiology
  • 7. Develop hypotheses
  • 8. Evaluate hypotheses epidemiologically
  • 9. As necessary, reconsider, refine, and
    re-evaluate hypotheses
  • 10. Compare and reconcile with laboratory and/or
    environmental studies
  • 11. Implement control and prevention measures
  • 12. Initiate or maintain surveillance
  • 13. Communicate findings

44
Conclusions
  • We survived (the 1st wave).
  • Experience with seasonal influenza surveillance /
    outbreak investigation was an excellent model for
    pandemic response
  • Outbreak investigation is good practice for the
    next public health emergency

45
For most basic outbreaks
  • 2. Establish the existence of an outbreak
  • 3. Verify the diagnosis
  • 11. Implement control and prevention measures
  • 12. Initiate or maintain surveillance
  • 13. Communicate findings
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