(August/2009) The NC OEMS has released 2 new protocols related to the H1N1 influenza.

Copies of both protocols are attached. They also can be found at http://www.ncems.org/nccepprotocols.html

This toolkit provides guidance to planners for identifying, engaging, communicating with and providing services to at-risk populations during public health emergencies such as pandemic influenza.

Who should use this toolkit?
While the toolkit was primarily designed for planners at local health departments, planners at other emergency response agencies and organizations may find these materials useful.

What topics are addressed by the toolkit?
The toolkit covers 5 areas of preparedness for at-risk populations developed by the Association of State and Territorial Health Officials (ASTHO). These areas are: 1) collaboration with and engagement of at-risk populations; 2) identifying at-risk populations; 3) communication with and education of at-risk populations; 4) provision of services (clinical and non-clinical); and 5) how to test, exercise, measure, and improve preparedness of at-risk populations.

What is included for each topic?
The toolkit contains 10 examples of local initiatives that have strengthened disaster preparedness and response for at-risk populations. For each local initiative, an audio clip with key contacts is provided to describe the activity and ways in which it was implemented.

Additional sections in each of the 5 main topic areas include “Tips and Suggested Planning Activities” and a “Topic Spotlight,” which provide practical guidelines for local planners interested in at-risk population planning.

The toolkit also includes ready-to-use PowerPoint templates that may be customized for presentations to at-risk groups or partner organizations in the community to obtain support for planning activities.

Who developed this toolkit?
This toolkit was developed in the spring of 2009 by the North Carolina Center for Public Health Preparedness (NCCPHP) at the UNC Gillings School of Global Public Health in partnership with the Office of Public Health Preparedness and Response at the North Carolina Division of Public Health. If you have questions or comments about this project, please contact NCCPHP at 919-843-5561 or nccphp@unc.edu.

How was the toolkit developed?
NCCPHP conducted 5 focus groups with local planners at sites around the state of North Carolina from December 2008 through February 2009 to obtain key information about existing gaps in resources and perceived barriers to planning. One key theme from the focus groups was the lack of information on promising practices for at-risk population planning at local health departments in North Carolina. In response to this expressed need, NCCPHP solicited North Carolina local health departments and emergency management agencies for planning tools and success stories to include in the toolkit.

Dynasty: Influenza Virus in 1918 and Today

The influenza virus that wreaked worldwide havoc in 1918-1919 founded a viral dynasty that persists to this day, according to scientists from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

In an article published online on June 29 by the New England Journal of Medicine, authors Anthony S. Fauci, M.D., Jeffery K. Taubenberger, M.D., Ph.D., and David M. Morens, M.D., argue that we have lived in an influenza pandemic era since 1918, and they describe how the novel 2009 H1N1 virus now circling the globe is yet another manifestation of this enduring viral family.

“The 1918-1919 influenza pandemic was a defining event in the history of public health,” says NIAID Director Dr. Fauci. “The legacy of that pandemic lives on in many ways, including the fact that the descendents of the 1918 virus have continued to circulate for nine decades.”

Influenza viruses have eight genes, two of which code for virus surface proteins — hemagglutinin (H) and neuraminidase (N) — that allow the virus to enter a host cell and spread from cell to cell. There are 16 H subtypes and 9 N subtypes, and, therefore, 144 possible HN combinations. However, only three (H1N1, H2N2 and H3N2) have ever been found in influenza viruses that are fully adapted to infect humans.

Other combinations, such as avian influenza H5N1, occasionally infect people, but they are bird viruses, not human viruses.
“The eight influenza genes can be thought of as players on a team: certain combinations of players may arise through chance and endow the virus with new abilities, such as the ability to infect a new type of host,” says Dr. Morens, Senior Advisor to the NIAID Director. That is likely what happened to spark the 1918 pandemic, he adds. Scientists have shown that the founding virus was an avian-like virus. The virus had a novel set of eight genes and — through still-unknown mechanisms — gained the ability to infect people and spread readily from person to person.

Not only did the 1918 H1N1 virus set off an explosive pandemic in which tens of millions died, during the pandemic the virus was transmitted from humans to pigs, where — as it does in people — it continues to evolve to this day. “Ever since 1918, this tenacious virus has drawn on a bag of evolutionary tricks to survive in one form or another…and to spawn a host of novel progeny viruses with novel gene constellations, through the periodic importation or exportation of viral genes,” write the NIAID authors.

“All human-adapted influenza A viruses of today — both seasonal variations and those that caused more dramatic pandemics — are descendents, direct or indirect, of that founding virus,” notes Dr. Taubenberger, Senior Investigator in NIAID’s Laboratory of Infectious Diseases. “Thus we can be said to be living in a pandemic era that began in 1918.”

How exactly do new influenza gene teams make the leap from aquatic birds to a new host, such as people or other mammals? What factors determine whether infection in a new host yields a dead-end infection or sustained, human-to-human transmission, as happened in 1918? Research on such topics is intense, but at this time definitive answers remain elusive, notes Dr. Morens.

It is known that the human immune system mounts a defense against the influenza virus’s H and N proteins, primarily in the form of antibodies. But as population-wide immunity to any new variant of flu arises, the virus reacts by changing in large and small ways that make it more difficult for antibodies to recognize it. For nearly a century, then, the immune system has been engaged in a complicated pas de deux with the 1918 influenza virus and its progeny, say the NIAID authors. The partners in this dance are linked in an endless effort to take the lead from the other.

While the dynasty founded by the virus of 1918 shows little evidence of being overthrown, the NIAID authors note that there may be some cause for optimism. When viewed through a long lens of many decades, it does appear that successive pandemics and outbreaks caused by later generations of the 1918 influenza dynasty are decreasing in severity, notes Dr. Morens. This is due in part to advances in medicine and public health measures, he says, but this trend also may reflect viral evolutionary pathways that favor increases in the virus’s ability to spread from host to host, combined with decreases in its tendency to kill those hosts.

“Although we must be prepared to deal with the possibility of a new and clinically severe influenza pandemic caused by an entirely new virus, we must also understand in greater depth, and continue to explore, the determinants and dynamics of the pandemic era in which we live,” conclude the authors.

(See a diagram of the genetic relationships among human and swine influenza viruses at http://www3.niaid.nih.gov/news/newsreleases/2009/flu_genetic_lineage.htm.)

For more information on influenza visit http://www.PandemicFlu.gov for one-stop access to U.S. Government information on avian and pandemic flu. Also, see NIAID’s flu portal (http://www3.niaid.nih.gov/topics/Flu/default.htm) and the CDC’s Seasonal Flu page at http://www.cdc.gov/flu/.
The National Institutes of Health (NIH) — The Nation’s Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov Reference: DM Morens et al. The persistent legacy of the 1918 influenza virus. New England Journal of Medicine. DOI: 10.1056/NEJMp0904819 (2009)

AAA Letter to Membership

CDC Confirmed Cases of H1N1 swine origin influenza in the U.S.
As of 1100 on May 7, 2009
Confirmed Cases= 896
Deaths= 2

MEMBER ADVISORY: RESPIRATORY PROTECTION H1N1 FLU

Recently, confusion has emerged from the labor sector regarding the use of N95 masks versus P100 filtering face pieces in the context of the currently H1N1 flu outbreak. In response, OSHA has published a clarification. In short, N95 masks remain the recommended level of respiratory protection for pandemic influenza.

N 95 versus P 100 filtering face pieces for EMS personnel
A concern has been raised that Emergency Medical Service (EMS) personnel should be wearing P100 filtering face piece respirators (FFR) instead of N95 filtering face piece respirators as the minimum respiratory protection required during a pandemic influenza crisis. The filter efficiency of a P100 FFR is greater than that of an N95 only when the great majority of the particulates it encounters are concentrated at the most penetrating particle size of 0.3 microns.

That is where filter efficiency would have a significant impact on penetration into the respirator. Once the particle size of infectious particles and droplets encountered increase in size slightly, the efficiency of an N95 filter rapidly approaches that of the P100 filter. The distribution of particles from coughs and sneezes of pandemic flu infected individuals is not predominately in the most penetrating particle size range, and particles are readily captured by either an N95 or P100 filter.

Both the N95 FFR and the P100 FFR have the same Assigned Protection Factor (APF) of 10. The actions that most impact the level of protection that EMS personnel receive against pandemic influenza are obtaining a proper face piece fit consistently, and performing fit testing to make sure that the best fitting respirator has been selected.

It is the quality of the face piece fit that can most greatly impact the protection provided by any respirator. A P100 FFR can increase breathing resistance for the wearer and could result in increased leakage past the face seal for an improperly fitting respirator. The N95 and P100 filters have both been shown to be effective in controlling exposures to bacterial and viral particles in the atmosphere.

Therefore, OSHA has recommended the fit tested N95 filtering face piece respirator used within the context of a respiratory protection program as the minimum level of respiratory protection for pandemic flu.

Office of Emergency Management
Directorate of Technical Support and Emergency Management
US Department of Labor/OSHA
200 Constitution Are NW RM N3655
Washington, DC 20210

North Carolina Public Health Officials announced Sunday a confirmed case of H1N1 flu within the State.
New case definitions from the CDC have dropped travel to an endemic area and are now
based on fever plus additional symptoms. Follow the link to the new protocol.

CDC continues to take aggressive action to respond to an expanding outbreak caused by novel H1N1 flu.

CDC’s response goals are to:

1. Reduce transmission and illness severity, and
2. Provide information to help health care providers, public health officials and the public address the challenges posed by this emergency.

CDC continues to issue and update interim guidance daily in response to the rapidly evolving situation. CDC will issue updated interim guidance for clinicians on how to identify and care for people who are sick with novel H1N1 flu illness. This guidance will provide priorities for testing and treatment for novel H1N1 flu infection. The priority use for influenza antiviral drugs during this outbreak will be to treat people with severe flu illness.

CDC has completed deployment of 25 percent of the supplies in the Strategic National Stockpile (SNS) to all states in the continental United States. These supplies and medicines will help states and U.S. territories respond to the outbreak. In addition, the Federal Government and manufacturers have begun the process of developing a vaccine against the novel H1N1 flu virus.

Response actions are aggressive, but they may vary across states and communities depending on local circumstances. Communities, businesses, places of worship, schools and individuals can all take action to slow the spread of this outbreak. People who are sick are urged to stay home from work or school and to avoid contact with others, except to seek medical care. This action can avoid spreading illness further.

H1N1 Flu (Swine Flu)
Last updated May 2, 2009, 1:30 pm ET

CDC continues to take aggressive action to respond to an expanding outbreak caused by H1N1 (swine flu).
CDC’s response goals are to:

1. Reduce transmission and illness severity, and
2. Provide information to help health care providers, public health officials and the public address the challenges posed by this emergency.

CDC continues to issue and update interim guidance daily in response to the rapidly evolving situation. This includes guidance on when to close schools and how to care for someone who is sick at home. Supplies from CDC’s Division of the Strategic National Stockpile (SNS) are being sent to all 50 states and U.S. territories to help them respond to the outbreak. In addition, the Federal Government and manufacturers have begun the process of developing a vaccine against this new virus.
Response actions are aggressive, but they may vary across states and communities depending on local circumstances. Communities, businesses, places of worship, schools and individuals can all take action to slow the spread of this outbreak. People who are sick are urged to stay home from work or school and to avoid contact with others, except to seek medical care. This action can avoid spreading illness further.

Tags: Alerts, Emergency Medical Services, Swine Flu

The North Carolina Office of EMS released a suspected influenza protocol. EMS agencies may use the protocol for screening and protective actions.

Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Confirmed or Suspected Swine-Origin Influenza A (H1N1) Infection

Page last updated April 29, 9:15 PM ET

Interim Recommendations
Coordination among PSAPs, the EMS system, healthcare facilities (e.g. emergency departments), and the public health system is important for a coordinated response to swine-origin influenza A (H1N1). Each 9-1-1 and EMS system should seek the involvement of an EMS medical director to provide appropriate medical oversight. Given the uncertainty of the disease, its treatment, and its progression, the ongoing role of EMS medical directors is critically important. The guidance provided in this document is based on current knowledge of swine-origin influenza A (H1N1).

The U.S. Department of Transportation’s EMS Pandemic Influenza Guidelines for Statewide Adoption and Preparing for Pandemic Influenza: Recommendations for Protocol Development and 9-1-1 Personnel and Public Safety Answering Points (PSAPs) are available online at www.ems.gov External Web Site Policy. (Click on Pandemic News). State and local EMS agencies should review these documents for additional information. For instance, Guideline 6.1 addresses protection of the EMS and 9-1-1 workers and their families while Guideline 6.2 addresses vaccines and antiviral medications for EMS personnel. Also, EMS Agencies should work with their occupational health programs and/or local public health/public safety agencies to make sure that long term personal protective equipment (PPE) needs and antiviral medication needs are addressed. (Follow Link for More Information)

Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been Detected

April 27, 2009 011:00AM ET

This document provides interim guidance and will be updated as needed.

Detailed background information and recommendations regarding the use of masks and respirators in non-occupational community settings can be found on PandemicFlu.gov in the document Interim Public Health Guidance for the Use of Facemasks and Respirators in Non-Occupational Community Settings during an Influenza PandemicExternal Web Site Policy..

Information on the effectiveness of facemasks1 and respirators2 for the control of influenza in community settings is extremely limited. Thus, it is difficult to assess their potential effectiveness in controlling swine influenza A (H1N1) virus transmission in these settings. In the absence of clear scientific data, the interim recommendations below have been developed on the basis of public health judgment and the historical use of facemasks and respirators in other settings.

In areas with confirmed human cases of swine influenza A (H1N1) virus infection, the risk for infection can be reduced through a combination of actions. No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household.Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings.

When it is absolutely necessary to enter a crowded setting or to have close contact3 with persons who might be ill, the time spent in that setting should be as short as possible. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. A respirator that fits snugly on your face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through a respirator for long periods of time. More information on facemasks and respirators can be found at www.cdc.gov/swineflu.

When crowded settings or close contact with others cannot be avoided, the use of facemasks1 or respirators2 in areas where transmission of swine influenza A (H1N1) virus has been confirmed should be considered as follows:

1. Whenever possible, rather than relying on the use of facemasks or respirators, close contact with people who might be ill and being in crowded settings should be avoided.
2. Facemasks1 should be considered for use by individuals who enter crowded settings, both to protect their nose and mouth from other people’s coughs and to reduce the wearers’ likelihood of coughing on others; the time spent in crowded settings should be as short as possible.
3. Respirators2 should be considered for use by individuals for whom close contact with an infectious person is unavoidable. This can include selected individuals who must care for a sick person (e.g., family member with a respiratory infection) at home.

These interim recommendations will be revised as new information about the use of facemasks and respirators in the current setting becomes available.

For more information about human infection with swine influenza virus, visit the CDC Swine Flu website.

1 Unless otherwise specified, the term “facemasks” refers to disposable masks cleared by the U.S. Food and Drug Administration (FDA) for use as medical devices. This includes facemasks labeled as surgical, dental, medical procedure, isolation, or laser masks. Such facemasks have several designs. One type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the nose bridge, and may be flat/pleated or duck-billed in shape. Another type of facemask is pre-molded, adheres to the head with a single elastic band, and has a flexible adjustment for the nose bridge. A third type is flat/pleated and affixes to the head with ear loops. Facemasks cleared by the FDA for use as medical devices have been determined to have specific levels of protection from penetration of blood and body fluids.

2 Unless otherwise specified, “respirator” refers to an N95 or higher filtering facepiece respirator certified by the U.S. National Institute for Occupational Safety and Health (NIOSH).

3 Three feet has often been used by infection control professionals to define close contact and is based on studies of respiratory infections; however, for practical purposes, this distance may range up to 6 feet. The World Health Organization uses “approximately 1 meter”; the U.S. Occupational Safety and Health Administration uses “within 6 feet.” For consistency with these estimates, this document defines close contact as a distance of up to 6 feet.