Influenza, Vaccinations and the Community

1. Influenza, Vaccinations and the Community Gaurov Dayal, M.D. Chief Medical Officer Adventist HealthCare

2. About Adventist HealthCare • Faith-based, non-profit network of healthcare providers: hospitals, home health services, skilled nursing centers, and other healthcare facilities and services. • Based in Rockville, Maryland. • More than 7,200 employees. • Provides health care and services to more than 450,000 men, women and children in our community annually.

3. Adventist HealthCare Entities Acute Care • Washington Adventist Hospital • Shady Grove Adventist Hospital • Shady Grove Adventist Emergency Center (Germantown) • Clarksburg Community Hospital (Proposed) • Hackettstown Regional Medical Center (NJ) Specialty Care • Adventist Rehabilitation Hospital of Maryland • Adventist Behavioral Health Rockville • Adventist Behavioral Health Anne Arundel • Adventist Behavioral Health Eastern Shore • The Ridge School of Montgomery County • The Ridge School of Anne Arundel County • The Ridge School of the Eastern Shore • Behavioral Health at Washington Adventist Hospital • The Reginald S. Lourie Center for Infants and Young Children Senior Living Services • Kingshire Manor Assisted Living • Bradford Oaks Nursing and Rehabilitation Center • Fairland Nursing and Rehabilitation Center • Glade Valley Nursing and Rehabilitation Center • Heritage House Hackettstown Senior Housing • Shady Grove Nursing and Rehabilitation Center • Sligo Creek Nursing and Rehabilitation Center • Springbrook Nursing and Rehabilitation Center Home Health Care • Adventist Choice Nursing • Adventist Home Assistance • Adventist Home Health • Adventist Preferred Nursing Cytology & Histology Services of MD

4. What is flu? • An illness caused by influenza virus. • Seasonal flu • A contagious infection of the nose, throat and lungs that is caused by the influenza virus • Slightly different forms each year • Officially identified in Maryland in late 2009 • H1N1 flu(or “swine flu”) • A new form of the flu virus first detected in people in the U.S. in April 2009 • New combination of four genetic elements • 90 percent of current circulating flu estimated to be H1N1

5. Different Types of Flu • Type A– moderate to severe illness • All age groups • Humans and other animals • Type B– milder epidemics • Humans only • Primarily affects children • Type C– rarely reported in humans • No epidemics

6. The Influenza Virus Fig.1 Electron micrograph • Hemagglutinin protein • Allows virus to stick to cells of some animals and not others • Neuraminidase protein • Helps release new virus from cells • Genes (RNP) divided into 8 parts • Allows 2 or more viruses to mix and match genes Fig.2 Schematic of influenza virus

7. The “H” and the “N” in Flu • Stand for different hemagglutinins (“H”) and neuraminidases (“N”) • Used to subtype influenza A strains • 16 different H’s • 9 different N’s • Current human subtypes • A(H1N1) and A(H3N2) primarily • Antibodies against H’s and N’s made by our immune system protect us • H and N subtypes are basis for flu vaccines

8. How does flu spread? • Seasonal flu and H1N1 flu spread the same way. • Spreads through respiratory droplets: • Coughing • Sneezing • Touching droplets (nose, mouth, eyes) then touching another person or surface without washing hands

9. Symptoms of Flu • Similar for H1N1 and Seasonal flu • Common Symptoms: • Fever • Sore throat • Runny/stuffy nose • Body aches • Chills • Headache • Fatigue • With H1N1, may experience vomiting or diarrhea.

10. High-Risk Groups • Seasonal flu • People over 50 • Children between six months and two years • Pregnant women • People with chronic heart, lung or kidney conditions, diabetes or a weakened immune system. • H1N1 flu • Pregnant women • Healthcare and emergency medical services personnel • People between the ages of 6 months and 24 years old • People between the ages of 25 through 64 years with chronic health disorders or compromised immune systems

11. Signs of Medical Emergency from Flu • Emergency warning signs for adults (need urgent medical attention): • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then return with fever and worse cough

12. Signs of Medical Emergency from Flu • Emergency warning signs in children (need urgent medical attention): • Fast breathing or trouble breathing • Bluish or gray skin color • Not drinking enough fluids • Severe or persistent vomiting • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with fever and worse cough

13. Epidemic vs Pandemic • Epidemic • Occur every year • Result from minor changes in influenza A viruses that circulate • Pandemic • Happen occasionally • Driven by an antigenic shift in the virus • Result from completely new influenza A virus circulating

14. Antigenic Shift: How it Happens

15. Credit: US National Museum of Health and Medicine Previous Pandemics • 1957 Asian Flu • 1-4 million deaths • 70,000 U.S. deaths • 1968 Hong Kong Flu • 1-4 million deaths • 34,000 U.S. deaths • 1918 Spanish Flu • 20-40 million deaths • 675,000 U.S. deaths

16. WHO Pandemic Alert Phases

17. Seasonal Flu Epidemic Stats- U.S. • 25-50 million cases of influenza each year • Seasonal flu: 200,000 hospitalizations and 36,000 deaths annually • Flu cost U.S. approx. $71 -167 billion annually • Adults can lose an average of: • 2.4 days incapacitated or confined to a bed • 2.8 work days being sick with influenza • 1.3 work days caring for a child 7 or under with influenza • Up to 111 million adult workdays - costing $7 billion - are lost every year to influenza in sick days and lost productivity.

18. H1N1 Pandemic Estimates from April – November 14, 2009 (CDC) • Approx. 47 million cases of 2009 H1N1 • 16 million 17 years and younger • 27 million 17-64 years • Approx. 213,000 2009 H1N1-related hospitalizations • 9,820 2009 H1N1-related deaths

19. Global Impact of H1N1 • On June 11, 2009, the World Health Organization declared that a global pandemic of H1N1 flu is underway by raising the worldwide pandemic alert level to Phase 6. • This action was reflection of the spread of H1N1 flu, not the severity of illness caused by the virus. • More than 200 countries have reported cases of H1N1 • The United States continues to report the largest number of H1N1 flu cases of any country worldwide, however, most people who have become ill have recovered without requiring medical treatment.

20. Current Situation • Influenza has decreased in recent weeks • Seasonal influenza is present in Maryland (in addition to H1N1) • Vaccinations for seasonal and H1N1 recommended and available to everyone

21. Preventing Flu • Vaccination is best way to prevent flu. • Everyday actions can keep you healthy. • Wash hands often or use an alcohol-based hand cleaner. • Cover your nose and mouth with a tissue when you cough or sneeze. Through tissue in the trash and wash your hands. • Cough or sneeze into the crease of your elbow if no tissue is available. • Avoid touching your eyes, nose or mouth. Germs spread that way. • Social distancing: stay home if you get sick. • CDC: Stay home from work or school and limit contact with others for at least 24 hours after your fever is gone except to get medical care or for other necessities

22. Treating Flu • Antivirals (tamiflu and relenza) can lessen duration and severity of illness • Must be given within 48 hours of start of symptoms

23. Production of Flu Vaccine • Takes five to six months to make flu vaccine. • Vaccines produced in chicken eggs. • Time consuming • Scientists in the public and private sector worked with CDC to isolate and modify the new H1N1 flu virus so that it could be used to make vaccine. • In September, the U.S. FDA approved four manufacturers to produce vaccines against the 2009 H1N1 flu virus.

24. Flu Vaccine • Flu vaccination is the best defense against seasonal flu and H1N1 flu. • Seasonal flu vaccine was already developed when H1N1 hit in spring 2009 • Public needs two vaccinations in 2009/2010 • H1N1 and Seasonal • Young children need two doses, four week apart (of each form) when receiving first dose of vaccine • 7-14 days before vaccine is fully protective

25. Flu Vaccine • 2009/2010 Vaccine • Seasonal vaccine contains three viruses • One A (H3N2) • One regular seasonal A (H1N1) virus unrelated to swine flu • One B virus • H1N1 vaccine contains one novel H1N1 virus Seasonal and H1N1 vaccine can be given at same time to anyone over 10 years • Two shots • One shot, one nasal spray • Vaccine not recommended for those with colds or those allergic to eggs

26. Common Flu Vaccine Myths • H1N1 vaccine is unsafe • H1N1 vaccine manufactured the same way as regular vaccine • Technology used for 60 years with excellent safety record • H1N1 vaccine is untested • Vaccine given to thousands of volunteers before FDA approved • H1N1 vaccine contains dangerous “adjuvant” • Adjuvants are added to enhance immune response in some vaccines to allow smaller quantities • H1N1 vaccine in U.S. has no adjuvant • H1N1 vaccine has a dangerous preservative (Thimerosal) • Thimerosol– used since 1930’s to prevent in advertent bacterial and fungal contamination in multi-dose vials • In 1999, USPHS and AAP asked to remove thimerosal from single-dose vials of vaccine. Subsequent research has found that infants can have 8X as much mercury as is in H1N1 vaccine. • H1N1 vaccine in multi-dose vials has 25 micrograms per dose

27. Adventist HealthCare and Flu • Adventist HealthCare is largest provider of flu vaccinations in Montgomery County. • Provides more than 10,000 seasonal flu shots annually through Health and Wellness • Businesses • Churches • Community Centers • General clinics • Annual seasonal flu vaccination and education campaign

28. Community Response to H1N1 • Implementation of pandemic plans (previous emergency planning) • Fall 2009 flu vaccination campaign • Focus on seasonal flu and H1N1 • Seasonal and H1N1 vaccine – some free vaccine • Promote seasonal vaccinations (prior to wide availability of H1N1 vaccine) • Web site (www.helpstoptheflu.com) • Fact sheets, clinic dates, ask the expert, media updates • Earned media, social media, vaccination clinics • Educate community on flu prevention • Hand washing, social distancing, etc.

29. Adventist HealthCare Flu Stats • October and November 2009 (Shady Grove Adventist Hospital and Washington Adventist Hospital) • 5,389 patients in Emergency Departments • In October, Shady Grove’s main ED averaged 60 ILI patients/day • 124 inpatients

30. Looking to the Future: Flu • Continue to promote vaccinations for community - likely less resistance to vaccinations (combined vaccine will help) • Assess flu and vaccination situation for 2010/2011 vaccination campaign • Partner with local health departments, government and other organizations to promote flu prevention and health • Other health threats for community

31. Questions?