Flu Prevention Could Include Mass Vaccinations at Schools

By Christine Kilgore

Public health officials are preparing for a full range of pandemic H1N1 scenarios—from outbreaks of generally mild severity to worst-case scenarios in which the novel H1N1 virus causes more severe illness.

In one of a series of town hall meetings on influenza, Fairfax County’s health director said that no one really knows how serious the pandemic may be this fall and winter.

It could could remain as it is now– more like seasonal influenza than H5N1 avian influenza or previous pandemics in terms of its severity–“or it could become more severe as it circulates through the community,” Dr. Gloria Addo-Ayensu told residents from Fairfax County and Falls Church City gathered at James Lee Community Center on Friday, Sept. 11. “We just don’t know.”

In any case, the Fairfax County Health Department, which serves Falls Church City as well as the county, anticipates “higher-than-normal illness and deaths” and “enormous demands on the health care system,” she said.

The health department is hoping that widespread distribution of the 2009 H1N1 vaccine, once it becomes available, can be achieved through physicians’ offices, pharmacies, and other traditional vaccine providers. Letters went out last week to providers urging them to sign agreements with the Virginia Department of Health to receive and administer novel H1N1 vaccine.

“If we look in a few weeks and see that many providers have signed the agreement . . . then we will serve as a safety net to provide vaccines to people without insurance,” she explained at the meeting. “But if we find that only a tiny fraction have signed up, we’ll go to the schools and hold mass vaccinations.”

Schools could be key to a “plan B” vaccination effort since teens and young adults have thus far been disproportionately affected by the pandemic H1N1 virus. The median age of people reported as having pandemic H1N1 influenza thus far is 14, Dr. Addo-Ayensu said.

Health department officials are talking with Falls Church City Public Schools officials about using George Mason High School as a mass dispensing location for H1N1 vaccine for FCCPS students if the need arises.

Dr. Lois Berlin, FCCPS superintendent, asked the health department to designate George Mason as a dispensing site after learning that the health department had already started planning for possible mass distribution at various Fairfax County high schools, Karen Acar, communications director for FCCPS, told the Falls Church Times.

In conjunction with the health department, FCCPS is now seeking volunteers among Falls Church City employees to attend a CRI training session later this month that will include how a medication distribution site should operate (see box).

In past influenza seasons, most local providers have been strongly committed to vaccination efforts, taking care of most residents who need the vaccine, Dr. Addo-Ayensu noted. “I believe we’ve only ordered 2,000-3,000 doses in our department (for previous seasonal influenza vaccinations), and that’s for about 1.5 million people,” she said.

The novel H1N1 influenza vaccination effort could be a bit “more complicated,” for vaccine providers, however, because the federal Centers for Disease Control and Prevention is requiring more information and effort from them in order to monitor safety and track adverse events, she noted.

Trials of the 2009 H1N1 vaccine that are currently underway are not being done to establish safety, but to determine dosage and other issues. (One recently-completed Australian study suggests that 1 vaccination—rather than 2, as had been anticipated—may be enough. Other trials are ongoing).   The safety profile should be similar to that of the seasonal flu vaccine, however, since both vaccines are manufactured in the same way, Dr. Addo-Ayensu emphasized.

The CDC has recommended that vaccination efforts focus on five key populations that have been most impacted by the current H1N1 influenza pandemic:

• Pregnant women
• People who live with or care for children younger than 6 months of age
• Health care and emergency medical services personnel
• Individuals aged 6 months-24 years
• People aged 25-64 who have chronic health disorders or compromised immune systems.

Vaccine availability and demand are unpredictable, however, making it quite possible that initially the vaccine will be limited (in addition to pregnant women, many health care workers, and people who care for infants) to children 6 months through 4 years of age, and to children 5-18 who have chronic medical conditions. “Right now, this is what we expect,” Dr. Addo-Ayensu said.  Once demand for the prioritized groups has been met at the local level, providers should begin vaccinating everyone aged 25-64, and after that, people aged 65 or older, the CDC has advised. (Current studies indicate that, unlike with seasonal flu, people 65 and older are at significantly less risk for infection than younger age groups.)

The county’s guidance for schools is based on what is known now about the severity of the outbreak during this past spring and summer, and will change if severity increases, Dr. Addo-Ayensu said.

Among the other issues discussed at last week’s town hall meeting:

Pandemic trends: Pandemic influenza tends to occur in two or three waves — with each “wave,” or period of high infectivity, lasting 2-3 months — over a year or more. In previous pandemics — particularly the 1918 “Spanish” influenza pandemic — most of the deaths occurred in the second wave. This does not mean the second wave of the 2009 pandemic will be severe, but it does emphasize the importance of prevention efforts. There have been three pandemics in the 20^th century: the 1918 pandemic (a different H1N1 strain) as well as pandemics in 1957 (H2N2) and 1968 (H3N2).

H1N1 v. seasonal flu: The spectrum of symptoms is similar with both, and it is possible only with testing to tell if someone who is sick with influenza-like illness has novel H1N1 flu or seasonal flu. The public health focus is now on testing people with severe illness only — those in the hospital. (Cases out of the hospital will be treated based on symptoms.)

“Public health has moved away from counting cases (of H1N1 infection),” Dr. Addo-Ayensu noted. Numbers of laboratory-confirmed cases therefore represent an under-estimation of total cases.

Dr. Gordon Theisz, a Falls Church resident and family physician who was at the meeting, said afterward that the traditional nose swabs seen in physicians’ offices are not able to differentiate between H1N1 and seasonal flu, and have been found to be less effective in identifying the H1N1 virus.

People should expect an upsurge of both H1N1 and seasonal influenza, Dr. Addo-Ayensu said. (Pandemic influenza viruses have been observed to replace whatever seasonal influenza virus is in circulation at the time, however, and thus far this summer, H1N1 has out-competed all other influenza subtypes. According to the CDC weekly flu report for the week ending on September 5, the vast majority — 97% — of all influenza A viruses that were sub-typed and reported to the CDC were H1N1 viruses.)

Common symptoms: Influenza is characterized by a fever (over 100 degrees Fahrenheit) plus cough and or sore throat, Dr. Addo-Ayensu said. Other symptoms include headache, muscle aches,  extreme weakness, tiredness, diarrhea, and vomiting. Influenza viruses are much less likely to cause watery eyes and a runny nose.

Cold viruses, on the other hand, are more likely to cause a runny or stuffy nose and milder symptoms overall. Colds rarely cause fever. “For many of us, fever will be the distinguishing feature of influenza,” she said.  Influenza symptoms appear 1-4 days after being infected.

Infectivity: The H1N1 virus appears to be more contagious than seasonal influenza. People can be contagious starting from the day the first symptoms develop until 3-5 days afterward (during which time they often have fever). Infected children, as well as adults with weakened immune systems, can spread the virus for more than a week.

Influenza viruses can live up to 7-8 hours on solid surfaces, she said.

High-risk groups: Women who are pregnant and people with chronic illnesses such as asthma, diabetes, chronic obstructive pulmonary disease, morbid obesity, and various neurocognitive and neuromuscular diseases are more likely to have more serious illness and complications and should seek treatment early.

Precautions: Washing hands frequently and thoroughly for 20 seconds offers by far the best protection. Alcohol-based hand-sanitizers are also effective in killing the influenza virus, but hand washing is preferable after using the toilet and whenever feasible.

Coughing and sneezing into your elbow or upper sleeve, staying home when sick, and staying at least 6 feet away from someone who has influenza-like symptoms are also important. (School advisories urge staff and students to stay home for at least 24 hours after fever goes away without the use of fever-reducing medications.)

Respiratory masks used by health care workers and designated as N95 have been shown to be more effective than regular surgical masks in protecting the wearer, but they must be specially fitted and specially ordered to be most effective.

Dr. Theisz told the Falls Church Times that standard surgical masks can help reduce the spread of disease from infected people, but the best advice for anyone who suspects they have influenza is to stay home.

The Fairfax County Health Department recently expanded its public meeting schedule to include an informational program on H1N1 influenza that will be broadcast live on FCC-TV (Cox 12, RCN 2, Verizon 35) on October 5 at 7 p.m. The program will be rebroadcast at various times throughout the fall.

For more information on H1N1 influenza , including a self-care guide, see www.fairfaxcounty.gov/hd/flu/swineflu.htm.  The county regularly updates this website.

Christine Kilgore, a resident of Falls Church City, writes about medicine and health issues for a number of publications.