Approaching Flu Season - Putting Planning Assumptions into Action

By Neil Twitchell

As this article is being written in early September, the traditional flu season in the Southern Hemisphere is coming to close and international public health experts are closely tracking circulation of the H1N1 (swine) flu virus. Three key findings from these activities were included in an August 28, 2009 situation report published by the U.S. Centers for Disease Control and Prevention (CDC):

The 2009 H1N1 influenza virus is the predominant influenza virus in circulation worldwide.

The epidemiology of the disease caused by the 2009 H1N1 influenza virus in the Southern Hemisphere is very similar to that described in the United States this past spring.

There have been no significant changes detected in the 2009 H1N1 influenza virus isolated from persons in the Southern Hemisphere as compared to viruses isolated from persons in the Northern Hemisphere.

Tracking Flu Activity in New Hampshire

New Hampshire officials, led by the Department of Health and Human Services (DHHS), Division of Public Health Service (DPHS), have similarly been tracking flu activity since the first cases were reported in May. Trends detected in New Hampshire follow national patterns, with more influenza cases reported than normal, generally mild disease being seen in healthy people, and hospitalizations and the sole death reported thus far linked to individuals with underlying chronic health conditions.

Based on this information, New Hampshire officials are basing their efforts on several planning assumptions:

The current novel H1N1 flu pandemic will affect 30 percent of the population over a six-month period, with less than a 1 percent mortality rate.

Most cases will be mild, with most people cared for at home for up to a week.

Higher rates of hospitalizations and deaths will be seen among high risk individuals from target populations.

Novel H1N1 vaccine will begin to be available to target populations beginning in September.

Increasing the number of residents getting vaccinated for seasonal flu will reduce the burden on the healthcare system and employers.

Specific interventions should be determined through a collaboative decision-making process with key stakeholders represented.

Based on these planning assumptions, what are the important elements for government agencies to address as we approach the traditional flu season in New Hampshire and the rest of the Northern Hemisphere?

Acknowledge and Help Control the Spread of H1N1 and Seasonal Flu

During several late August conference calls with municipal and school officials, DPHS Director Dr. Jose Montero reminded participants that “H1N1 flu didn’t go away over the summer. It’s here. It stayed here, and we are still experiencing cases."

The current expectation is that most cases of flu this fall and winter will likely be due to H1N1. While investigating and counting individual cases is an important tool during the early stages of a pandemic, after a certain level has been reached, counting cases is no longer a public health need. At this point, public health agencies like DPHS and CDC are monitoring the impact of H1N1 using systems that provide population-based data. In New Hampshire, this includes a number of physician offices that report flu symptoms among their patients, data from hospital emergency room visits and pharmacy sales of common medications. Therefore, a key understanding is to acknowledge that H1N1 is present in communities across the state rather than focusing on any specific number or location of cases. Thus, now is the time to implement supportive workplace policies and increase public education efforts.

Dr. Montero also stressed that a second key element to understand about H1N1 is that “it’s as bad as a regular flu, and that’s an important concept—because the regular flu causes about 36,000 deaths a year in the U.S. So, people should not think ‘oh, it’s just the flu.’ Every year, flu is a severe illness that causes severe complications, and some people end up in the hospital or die." These facts point to a need for local officials to help increase the public’s understanding that seasonal flu is more serious than many people think and, thus far, H1N1 is causing a level of illness and complications similar to seasonal flu. Municipal officials should make extra efforts to have all employees who are recommended to be vaccinated against seasonal flu do so now; implement policies that support employees to stay home when they or a family member are sick; and maintain routine cleaning of workplaces.

At present, the DPHS recommends that anyone who has respiratory symptoms with a fever should not attend work or school and should return only after being free of fever for 24 hours. Employers are encouraged to adapt personnel policies as needed to support staff adhering to this recommendation in order to reduce transmission to others in the workplace.

Perhaps the most important effort each of us can take is to promote good respiratory etiquette and hand hygiene at work, school and home. This means covering your nose and mouth when coughing or sneezing into your elbow or sleeve, not your hands, and by using (and discarding) a tissue. Frequent hand washing is essential, using soap and water or alcohol based hand cleaners. Employers should download and use posters and facts sheets about these practices in every worksite.

Participate in Regional Mass Vaccination Planning and Delivery

We are all familiar with how residents typically get a flu shot when they want one, either through their medical provider or community-based clinics offered by homecare (for example, visiting nurse) agencies or by for-profit providers in grocery stores, pharmacies and similar locations.

Again, it’s always important to get vaccinated against seasonal flu, and employers should take steps to increase the number of employees who get vaccinated.

Since the strain of H1N1 that is circulating now is a novel virus, perhaps the most ambitious component of the public health response will be to provide vaccinations. In late August, the CDC identified the following five target populations for early vaccination once clincial trials are completed:

Pregnant women
Caregivers and household members of children under 6 months of age
Children and young adults ages 6 months to 24 years
Healthcare workers, including emergency medical services
Adults ages 24 to 65 with chronic medical conditions who are at risk for influenza complications

While several of these groups will be vaccinated by their regular medical provider or through occupational health programs, planning is underway to also open regional mass vaccination clinics for uninsured or under-insured individuals in these target populations and the public as larger quantities of vaccine are available. As discussed in related articles previously published in New Hampshire Town and City, these clinics are being planned and operated by All Health Hazard Region (AHHR) planning teams that include a broad range of stakeholders like local first responders, health officers, administrators and elected officials. Clinic sites, commonly referred to as Points of Dispensing or PODs, will be able to serve large numbers of residents in a region using schools, community centers and other buildings that offer convenient access.

In August and September, the CDC released supplemental funds to states to plan and implement a mass vaccination campaign. In New Hampshire, the state has provided funding to AHHRs to support additional planning staff and purchase needed supplies to strengthen their response capability. The AHHR teams are developing detailed plans to offer clinics throughout their regions. These federal funds are also expected to cover a significant share of the costs associated with mass vaccination clinics, with further details available in upcoming guidance from the CDC.

“The unique characteristics of public health emergencies like pandemic necessitate a regional approach," according to Dr. Montero. “This approach maximizes utilization of available staff and resources, which are typically overtaxed due to the impact of a pandemic. For example, the capacity of health care providers—who are essential to POD operations—will be best used in larger, regional clinics. Common sense tells us that there are efficiencies inherent in regional clinics, especially in light of the workforce pressures we will all be experiencing."

Municipalities should also assess how they can provide some staffing support to regional clinics that are serving residents of their community. For example, when first responders from a host community are supporting a regional POD, neighboring towns may provide “backfill" through mutual aid agreements. Office staff could be assigned to help register patients and provide other administrative support. Department heads, such as the health officer or emergency management director, are strong candidates to take on-site leadership roles during POD operations.

In addition to these public clinics, it is expected that many schools will offer clinics for their students, since all children are recommended to have both seasonal and H1N1 vaccinations. This will call for close coordination between municipal, school and AHHR partners.

Assure Decision-Making is Based on Accurate Information and Collaboration

The amount of information available about H1N1 influenza is overwhelming. As in any emergency, perhaps the most critical role for government officials is to help deliver key facts and recommendations to the public. This can be done proactively by putting links to public health and safety agencies on municipal websites. Similarly, municipal officials should regularly check these sites for new postings, such as policy guidance, clinic schedules, and situation reports from state and federal agencies. “It is inevitable that not all states will implement their response in exactly the same way," notes Dr. Montero. “The key to good local decision-making is to be knowledgeable about how New Hampshire is responding as a state."

It is also incumbent for local officials to coordinate with school officials, AHHR planning teams and state agencies such as the DPHS, HSEM and the Department of Education. For example, based on the situation in early September, there are no recommendations for closure of schools or cancellation of sports events or other large gatherings. However, this may need to be considered in specific situations, such as when staff absenteeism rates are high enough that safe operations cannot be maintained. Employers, and especially schools, should look to their own experience to assess what trigger points may have required them to consider closures in the past. Certainly the impact of any closure would be better managed after discussions with municipal and state officials so that all entities have a same knowledge and their actions are coordinated.

While the H1N1 virus has resulted in the first influenza pandemic since the 1970s and represents a significant worldwide challenge, much has changed during the last three decades with respect to emergency preparedness that allows us, as a state and nation, to meet that challenge. As a state, New Hampshire has a higher percent of residents with health insurance than the national average, universal access to childhood vaccines and skilled leaders at the local and state levels. Decision-making that is based on the best facts available—at any time and after consultations with key stakeholders—will help us leverage these assets to mitigate the impact on state residents by preventing the spread of H1N1 and people from becoming ill as well as treating those who are ill.

Neil Twitchell is administrator of the Community Public Health Development Section of the New Hampshire Department of Health and Human Services, Division of Public Health Services.

Flu-Related Web Resources

New Hampshire Department of Health and Human Services

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services