Outline. Seasonal Influenza & Pneumonia National & State Statistics Novel Influenza A H1N1

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1 Outline Seasonal Influenza & Pneumonia National & State Statistics Novel Influenza A H1N1 National & State Statistics Lessons from Past Pandemics Vaccination & Treatment Strategies

2 Influenza Virus Influenza A virus Infect birds and some mammals including humans Antigenic drift and occasionally shift Categorized according to hemagglutinin and neuraminidase 16 different H antigens and 9 different N antigens Influenza B virus Only known to infect humans Antigenic drift, but not shift Influenza C virus Infects humans and pigs Rare compared to A & B Seasonal influenza vaccine contains 2 type A and 1 type B Number of Deaths in the U.S. for Leading Causes Final Data for 2005* Heart disease: 652,091 Cancer: 559,312 Stroke (cerebrovascular diseases): 143,579 Chronic lower respiratory diseases: 130,933 Accidents (unintentional injuries): 117,809 Diabetes: 75,119 Alzheimer's disease: 71,599 Influenza/Pneumonia: 63,001 Nephritis, nephrotic syndrome, and nephrosis: 43,901 Septicemia: 34,136 *Source: Deaths: Final Data for 2005, Tables C, 7, 30 PDF Available at

3 Number of Deaths in Maine for Leading Causes Final Data for 2005* Cancer: 3,218 Heart Disease: 2,941 Chronic lower respiratory diseases: 830 Stroke (cerebrovascular diseases): 693 Accidents (unintentional injuries): 579 Alzheimer's disease: 476 Diabetes: 385 Influenza/Pneumonia: 352 Nephritis, nephrotic syndrome, and nephrosis: 250 Intentional Self harm (suicide) 175 *Source: Deaths, percent of total deaths, and death rates for the 15 leading causes of death: United States and each State, 2005 PDF Did you get a flu shot in the last 12 months? 1. Yes 2. No 50% 50% 1 2

4 Number of adults age 65+ who did not receive an influenza vaccination within the past year 6,000 10,000 Cumberland, York 4,000 6,000 Aroostook, Penobscot, Androscoggin 2,000 4,000 Somerset, Hancock, Lincoln, Oxford, Kennebec 500 2,000 Franklin, Knox, Piscataquis, Sagadahoc, Waldo, Washington STATE TOTAL: 53,400 CDC. Behavioral Risk Factor Surveillance System, Number of adults age 65+ who have never had a pneumonia vaccination 8,000 12,000 Cumberland, York 4,000 8,000 Kennebec, Penobscot, Androscoggin 2,000 4,000 Somerset, Hancock, Lincoln, Oxford, Knox, Washington 500 2,000 Franklin, Sagadahoc, Waldo No Data Available Piscataquis STATE TOTAL: 65,300 CDC. Behavioral Risk Factor Surveillance System,

5 Influenza A Antigenic Shifts Spanish Asian Hong Russian H1N1 Flu Kong Flu of 2009 Flu of of 1968 In the United States, seasonal influenza activity typically peaks from to. 1. Mid October to late December 2. Late December to early March 3. Mid April to early September 4. No peak in activity, remains constant yearlong 25% 25% 25% 25% Current formulations of seasonal influenza vaccine contain strains of how many influenza viruses? 1. Two, one type A and one type B 2. Two, the strain that was most prevalent the year before and one to protect against avian flu 3. Three, two type A and one type B 4. Three, one type A, one type B, and one type c 25% 25% 25% 25%

6 The Signature Features of Influenza Pandemics Mark A. Miller, M.D., Cecile Viboud, Ph.D., Marta Balinska, Ph.D., and Lone Simonsen, Ph.D. n engl j med 360;25 june 18, 2009 The Signature Features of Influenza Pandemics Mark A. Miller, M.D., Cecile Viboud, Ph.D., Marta Balinska, Ph.D., and Lone Simonsen, Ph.D. n engl j med 360;25 june 18, 2009

7 The Signature Features of Influenza Pandemics Mark A. Miller, M.D., Cecile Viboud, Ph.D., Marta Balinska, Ph.D., and Lone Simonsen, Ph.D. n engl j med 360;25 june 18, 2009 The shift in mortality toward younger age groups a pattern of multiple waves Increased transmissibility of influenza because of high susceptibility of the population Weekly Influenza Activity Estimates Reported by State

8 H1N1 in Maine 387 confirmed cases 233 Maine residents 154 out of state residents 19 Hospitalizations 1 Death How Dangerous is the New H1N1? As of October 3rd, more than three million people are believed to have contracted the new flu in the U.S. 50,768 confirmed cases in U.S. 12,384 have been hospitalized in the U.S. 522 have died in U.S. (1 in Maine). 147 pediatric deaths. 34% of pregnant women require hospitalization. 70% of those hospitalized and 80% of those who have died have had underlying conditions.

9 This September and October, 99% of all subtyped influenza A viruses being reported to CDC are which strain? 25% 25% 25% 25% 1. Novel H1N1 2. Seasonal H3N2 3. Seasonal H1N1 4. Influenza B The number of influenza associated pediatric deaths has risen sharply in the past few weeks. 1. True 2. False 50% 50% 1 2

10 Priority Groups for the Seasonal Influenza Vaccine Children aged 6 months up to their 19th birthday 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 less than 6 months of age (these children are too young to be vaccinated) Source: Influenza trivalent vaccines Live Attenuated versus Inactivated Influenza Vaccine in Infants and Young Children N Engl J Med 2007;356: Children 6 to 59 months of age, without a recent episode of wheezing illness or severe asthma. Randomized, double blind study with either trivalent live attenuated influenza vaccine or trivalent inactivated vaccine children completed the study and were monitored with culture throughout the influenza season.

11 Live Attenuated versus Inactivated Influenza Vaccine in Infants and Young Children N Engl J Med 2007;356: Priority Groups for the new H1N1 vaccine. Pregnant women Infants' caregivers and contacts Children ages 6 months through 24 years old People up to 65 years old with medical conditions Health care workers Emergency medical services workers Source: Influenza A (H1N1) 2009 Monovalent Vaccines MMWR Morb Mortal Wkly Rep Oct 9;58(39):

12 Response after One Dose of a Monovalent Influenza A (H1N1) 2009 Vaccine Preliminary Report N Engl J Med 2009;361. Same Day Vaccine Administration Inactivated Seasonal + Inactivated 2009 H1N1 Inactivated Seasonal + Live Attenuated 2009 H1N1 Live Attenuated Seasonal + Inactivated 2009 H1N1 Live Attenuated Seasonal + Live Attenuated 2009 H1N1 Antiviral Resistance Olseltamivir Zanamivir Amantidine Seasonal A H1N1 Resistance Susceptible Susceptible Seasonal A H3N2 Susceptible Susceptible Resistance Seasonal B Susceptible Susceptible Resistance 2009 A H1N1 Susceptible Susceptible Resistance Antivirals ought to be started within 48 hours of symptom onset.

13 A 42 year old man with a history of diabetes requests both the seasonal and the swine flu shot. His wife is currently pregnant in her 2 nd trimester. Select the true statement. 1. The live intranasal vaccine is contraindicated for him. 2. She is a priority group for the seasonal flu shot, but not the 2009 H1N1 shot. 3. He may receive both inactivated vaccines on the same day. 4. He may receive both live attenuated vaccines on the same day. 25% 25% 25% 25% A 21 year old woman is experiencing influenza like illness (fever, cough, muscle aches). The new H1N1 strain is known to be very prevalent in the community at this time. Select the true statement. 1. If within 48 hours of 25% 25% 25% 25% onset, prescribe treatment doses of amantadine. 2. If within 48 hours of onset, prescribe treatment doses of Relenza or Tamiflu. 3. Administer an inactivated 2009 H1N1 flu shot today. 4. Administer a live 2009 H1N1 flu shot today A mother wants her 4 year old son to receive both the seasonal and swine flu vaccine. She strongly objects to any vaccines with mercury content. Select the vaccine that her son should NOT receive. 1. Live, seasonal Flumist 2. Live, 2009 H1N1 Flumist 3. Inactivated, seasonal Fluzone shot from a prefilled syringe 4. Inactivated, seasonal Fluzone shot from a multidose vial 25% 25% 25% 25%

14 Stay tuned!... CDC Influenza Website Flu in Maine: Maine Department of Health and Human Services