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2009 H1N1 Pandemic Alaska's Experience

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2009 H1N1 Pandemic Alaska's Experience 2009 H1N1 Pandemic Alaska’s Experience Joe McLaughlin, MD, MPH State Epidemiologist and Chief, Alaska Section of Epidemiology Outline • EOC activation • Antiviral stockpile • H1N1 vaccine • Laboratory testing • Communications • Surveillance • Hospitalization study EOC Activated in April • DPH staff & partners • Located at the Alaska State Public Health Laboratory in Anchorage EOC Workgroups •Vaccine distribution •Vaccine administration •Antiviral distribution •Public information •Community outreach •Community containment Early Response • Prepositioned 24% of state antiviral stockpile to 38 locations around the state Use of Stockpile Antivirals • Limited to treat suspected and confirmed H1N1-infected patients if – Patients were uninsured or underinsured and could not afford the medications – Patients and providers were unable to obtain antivirals via the routine supply chain routes H1N1 Vaccine • Shipped from the distributor (McKesson Corp) to the Epidemiology Vaccine Depot • Repackaged • Distributed proportionally by population • First shipment arrived October 5 VacTrAK Alaska’s Immunization Registry • In order to receive H1N1 vaccine, providers required to – Register into VacTrAK – Record H1N1 vaccine doses given to patients • Justification – To keep track of vaccine inventory and needs state- wide – To facilitate administration of the second dose for children aged <10 years • This requirement increased HCP awareness and interest in VacTrAK Vaccine Monitoring Data • Vaccine Depot received 303,000 doses of H1N1 vaccine • 228,000 doses distributed to providers – 142,466 doses recorded in VacTrAK – 131,000 patients • Unused doses were shipped out-of-state for disposal through the National Disposal Program Laboratory Capacity • Both state public health labs were certified to test for H1N1 in early May – Combined capacity of running ~300 specimens per week • Peak submissions occurred in late June – Laboratory staff exhaustion – In early July providers were asked to limit specimen submissions Laboratory Testing Recommendations • Providers were asked to submit only if – Patient was hospitalized with ILI; – Patient died of an acute illness where influenza was suspected; – Patient was an outpatient with severe ILI and tested negative with a rapid assay; or – If a confirmatory diagnosis would inform clinical decision making, infection control, or management of close contacts 11 Alaska Public Health Laboratory Influenza Isolates 80 2008–09 2009–10 70 July Influenza A(H1) 60 Influenza May 23 50 A(H3N2) 40 Pandemic Number A(H1N1) 30 Influenza A(no subtype) 20 Influenza B 10 0 40 44 48 52 3 7 11 15 19 23 27 31 35 39 43 47 51 3 7 11 15 19 23 27 31 35 Week Communication is Key • Media campaign – Simplify complex information – Openly share what you don’t know – Balance the needs to share information and protect confidentiality • Pan flu hotline • Webpage – Constant upkeep – Avoid information overload • Weekly teleconferences – Community partners – Health care partners Survey of HCP Teleconference Participants • 105 health care partners responded • 50% attended >7 teleconference • 82% rated the calls 4 or 5 on a 5-point scale • 99% said they would participate again Survey Results • Participants found the following information helpful – Alaska situational updates: 88% – Vaccine updates: 81% – Guidelines for clinicians: 79% – Question and answer period: 70% – Antiviral updates: 67% – Laboratory testing updates: 52% – Latest research updates: 51% – National situation update: 46% Hospitalizations (n=1,057) for Pneumonia and Influenza by Age- Group from September 1, 2009 through April 3, 2010 Laboratory-Confirmed Clinically Diagnosed Total Hospitalization Rate 400 700 350 600 300 500 250 400 200 300 150 200 100 Number of hospitalizations 50 100 Hospitalization rate per 100,000 persons 100,000 per rate Hospitalization 0 0 0-4 5-18 19-24 25-49 50-64 65+ Age-group in years Laboratory-Confirmed Influenza Deaths (N=11) by Age-Group from Sept 1, 2009 through April 3, 2010 5 4 3 2 4 Number of of deaths Number 1 2 2 2 1 0 0 0-4 5-18 19-24 25-49 50-64 65+ Age-group in years Positive Rapid Tests (n=1,103) for Influenza by Subtype and by Age-Group from September 1, 2009 through April 6, 2010 A B A/B Rate for all subtypes 450 400 400 350 350 300 300 250 250 200 200 150 150 100 100 Number of tests positive 50 50 0 0 Rate of positive tests per 100,000 persons 100,000 per tests positive of Rate 0-4 5-18 19-24 25-49 50-64 65+ Unk Age-group in years ILI Surveillance through Sept 2009 • ILI defined as fever (>100˚F) + cough or sore throat in the absence of a known cause other than influenza • Sentinel providers: Anchorage, Fairbanks, Juneau, Kenai, Soldotna, Unalaska, Valdez/Cordova Wk 36=Sept 5 Wk 27=July 4 Wk 17=April 25 Wk 1=January 3 19 19 ILI Surveillance Since October 2009 Wk 40= Oct 3 Wk 1= January 1 20 Hospitalization Study • CDC Arctic Investigations Program and Section of Epidemiology • Chart review of lab-confirmed patients who were Anchorage residents hospitalized – Sept 1 through October 21 – Four acute care hospitals in Anchorage Rates and Characteristics of Influenza Hospitalizations by Race Race Number Underlying In vaccine (rate) disease (%) priority group (%) White 24 (11) 63 67 AI/AN 15 (50)* 73 73 A/PI 9 (40)* 89 78 Black 11 (21) 100 100 *Statistically significant compared to whites Hospitalization Study Results • 44% of adult patients were obese (BMI >30) – AK BRFSS: 28% of adult Alaskans are obese • 5% were pregnant • 88% of AN and A/PI met the criteria for empiric antiviral therapy prior to hospitalization • 78% received antivirals while hospitalized Hospitalization Study Conclusions • Hospitalization rates were significantly higher for AN and A/PI • Most cases occurred in persons with pre- existing medical conditions • A higher proportion of adult patients were obese compared to the general population • The data did not support a need to modify existing vaccine priority groups or empiric treatment recommendations for Alaska 2010–11 Flu Season Update • ASVL has reported 10 PCR-confirmed flu A since May – 9 were H3; 1 was inconclusive – 3 of the last 4 H3s were negative by rapid testing • Trivalent vaccine virus strains – A/California/7/2009(H1N1)-like – A/Perth/16/2009 (H3N2)-like – B/Brisbane/60/2008-like • State-supplied vaccine – 89,940 doses ordered; ~75% already received and shipped out – Pediatric vaccine goes to public and private clinics – Adult vaccine goes to PH Centers, AN clinics, and LTC facilities 2010–11 Flu Vaccine Age Number of State-supplied Doses Flu Vaccine Licensed for: State-approved: Ordered Sanofi Fluzone – 6–35 mos 6–35 mos 11,000 Prefilled Syringe (1/2 dose) Sanofi Fluzone – >6 mos >6 mos–18 yrs 32,510 Multidose vial MedImmune 2–49 yrs 2–18 yrs 17,600 FluMist nasal spray GSK FluLaval – >18 yrs >18 yrs 28,830 Multidose vial TOTAL 89,940 Fluzone High-dose Vaccine • FDA-approved for people aged >65 yrs – Single dose, prefilled syringe – Not State-supplied • Contains 4 times more antigen to create a stronger immune response – Increased immune response supported by clinical trials – Studies are ongoing to determine if an increased immune response leads to greater protection • Similar safety profile as regular flu vaccine • Neither CDC nor ACIP is expressing preference of Fluzone over regular flu vaccine "My vaccine protects you, your vaccine protects me." Thank you! Hospitalizations (n=1,057) for Pneumonia and Influenza by Week’s End from September 1, 2009 through April 3, 2010 Laboratory-Confirmed Clinically Diagnosed Percent of hospitals reporting 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 Number of hospitalizations 20 20 Percent of of reporting hospitals Percent 10 10 0 0 Sep Sep Oct Oct Oct Nov Nov Dec Dec Jan Jan Feb Feb Mar Mar Apr 5 19 3 17 31 14 28 12 26 9 23 6 20 6 20 3 By week ending ILI Surveillance Alaska 2009 Provider Vaccine delivered to Pre-Registration H1N1 Vaccine Distribution Depot from McKesson VacTrAK staff enter Provider Depot enters vaccine mnfr & registered provider Registration lot # into VacTrAK into VacTrAK For each community, EOC reviews: EOC: - population data - determines vaccine allotments - #/type of providers registered - submits order spreadsheet to Depot - VacTrAK inventory & usage reports for next day’s shipments Depot: Provider documents - assesses vaccine inventory vaccine usage in VacTrAK - reviews EOC order spreadsheet (direct or paper submission) - enters orders into VacTrAK Packing staff: Provider - fill order administers - determine appropriate shipping/delivery route vaccine Provider receives & Provider within Anchorage/MatSu Provider outside Anchorage/MatSu appropriately stores - vaccine prepared for distribution - approriate shipping mechanism arranged vaccine by delivery driver - fax sent to provider re: ETA Strengthened Relationships with Partner Agencies • CDC Arctic Investigations Program • Alaska Division of Homeland Security & Emergency Management • Deptartment of Education and Early Development • Alaska Native Tribal Health Consortium • Joint Task Force Alaska (DOD) • Municipality of Anchorage DHHS • Private industry • Many others… EOC Response Activities • Receipt of resources from federal SNS • Shipment of stockpile supplies to communities and providers • SNS antiviral usage • Receipt of H1N1 vaccine • Public information/public education Alaska Pandemic Flu Website Laboratory-Confirmed Influenza Deaths (N=11) by Week's End from Sept 1, 2009 through April 3, 2010 3 2 1 Number of of deaths Number 0 Sep Sep Oct Oct Oct Nov Nov Dec Dec Jan Jan Feb Feb Mar Mar Apr 5 19 3 17 31 14 28 12 26 9 23 6 20 6 20 3 By week ending State of Alaska Surveillance VacTrAK Webpage.
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