William Schaffner, MD, FACPM Mark B. Johnson, MD, MPH, FACPM

William Schaffner, MD, FACPM
Mark B. JJohnson,, MD,, MPH,, FACPM
Hugh Tilson, MD, MPH, DrPH, FACPM – Moderator
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y, and p
Leader in the science,, p
policy,
practice of p
preventive
medicine
Mission to improve population health status through
evidence-based
id
b d di
disease prevention
ti and
d health
h lth
promotion research, policies, practices, and programs
2,400
,
members engaged
g g in p
preventive medicine
practice, teaching and research
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General preventive medicine, public health, occupational and
environmental medicine
medicine, and aerospace medicine
medicine.
To learn more about the College, visit www.acpm.org
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y successes and failures in the federal,, state and
Identify
local public health response to the 2009-2010 H1N1
influenza pandemic
D
Describe
ib potential
t ti l iimprovements
t tto public
bli h
health
lth
communications as they relate to response among
private medicine institutions with diagnosis, infection
control and use of antivirals
Discuss how to incorporate lessons learned from the
2009 2010 H1N1 influenza pandemic to be better
2009-2010
prepared for future influenza epidemics and/or
pandemics.
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This activity has been planned and implemented in accordance
with the Essential Areas and Policies of the Accreditation Council
for Continuing Medical Education (ACCME).
ACPM is accredited by the ACCME to provide continuing medical
education for physicians.
ACPM designates this educational activity for a maximum of
1.0 Category 1 credits toward the American Medical Association
(AMA) Physician's Recognition Award (PRA)TM. Physicians
should only claim credit commensurate with the extent of their
participation in the activity.
To ensure an activity free of commercial bias, ACPM was
responsible for decisions regarding content and allocation of funds.
This activity has been funded through an unrestricted
educational grant provided by Gilead Sciences, Inc.
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Indicate your primary professional role
as it relates to the H1N1 influenza.
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Clinical Practice – Inpatient
Clinical Practice – Outpatient
Public Health Practice – Federal
Public Health Practice – State
Public Health Practice – County/Local
Academic
Other
William Schaffner, MD, FACPM
Department of Preventive Medicine
V d bilt U
Vanderbilt
University
i
it S
School
h l off M
Medicine
di i
Highly transmissible
Conventionally virulent
Child /
Children/young
adults
d l (not
(
≥65!)
65!)
Complications: Usual risk factors
Pregnancy
Obesity
Some healthy
Virus: Stable
Susceptible to antivirals
1. Virus discovered in humans early
2. Mexico – bit of a slow start
then an aggressive response
3. Virus characterized; tests developed
shared findings in record speed
4 Quick
4.
Q kF
Federal
d l response
5. Vaccine manufacturers collaborated
6. Vaccine clinical trials conducted
7. State and local public health organized
8. CDC’s excellent communication
9 Many
9.
M
media
di reports
t - good
d
1. WHO “pandemic” designation
2. No good name for H1N1 (“swine”, “novel”, etc.)
3 Closing
3.
Cl i national
i
lb
borders
d
Slaughtering pigs in Egypt
4. Vaccine: Old manufacturing
gp
process
Foreign factories
Aversion to adjuvants
Mistrust of vaccine
5. Over-promising vaccine delivery
6 S
6.
Stretched
h d clinical
li i l resources
Tiny hospital surge capacity
7. Need for enhanced surveillance
8. Utility of social distancing, school closures,
masks and hand washing
9. Health care worker undervaccination
Clinical Utility
Who should be treated?
Who should receive prophylaxis?
p p y
Public health utility
Impact on transmission?
F l outbreak
Focal
b k control?
l?
Institutional use?
Mark B. Johnson, MD, MPH, FACPM
President, American College of Preventive Medicine
E
Executive
ti Director,
Di t Jefferson
J ff
County
C
t Public
P bli Health,
H lth Golden,
G ld
C
Colorado
l d
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Trust is critical
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With public
With providers
p
With media
With elected officials
With intra-department divisions and programs
With State health department
Be flexible
B
fl ibl
Keep it simple
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Communication is key
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With private providers, both directions
With emergency
g
y management
g
system
y
With media
With elected officials
With minority communities
 Word of mouth is critical
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Communicate about uncertainties
 Carefully! Every word matters
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With logistics
g
and human resources staff
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Utilize your strengths
Know what you don’t know
Practice exercises, p
practice exercises, and more
practice exercises
Reaching school-aged children was fairly easy;
reaching children in daycare and preschool
was much harder
Pre-registering private providers
d
streamlined
l d
process and engaged interested providers early
on
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Getting some, even a minimal amount, of the
vaccine to all providers mitigated anxiety and
frustration
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Frequent small shipments helped keep them
vaccinating even when they could not have a mass
vaccination clinic
Restrictions on vaccinating caused pushback
from upset and confused older adults
Tremendous demand from pregnant women
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Problems due to distribution and vaccine
formulation
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Weekly communication with local agencies and
hotline phone for providers with questions
very helpful in some states
Communicate with
h videoconferencing
d
f
when
h
possible – overcrowded telephone conferences
are a mess
One size does NOT fit all – local health
departments have different needs & strengths
Differentiation of H1N1 and seasonal influenza
vaccine caused confusion
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Expanding the vaccination program from
“high-risk” groups to general population was
often not coordinated well, leading to anger,
confusion and unexpected jump in demand for
some providers
Using a provider survey was an effective
method in some states to assess when to
expand vaccination to other groups
Antiviral agents were available in adequate
quantities
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Preplanned vaccine distribution had to be
changed due to available vaccine formulation
Planning
g efforts for H5N1 p
pandemic influenza
were very helpful in the H1N1 influenza
pandemic
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The H1N1 pandemic did not conform to prior
planning assumptions
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Began
g in Mexico, not Asia
Not as lethal as predicted
Season of origin was spring, not late fall
Cohort at risk for disease and death were children
and young adults, not infants and the elderly
Global influenza surveillance has improved
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CDC still unable to give real-time number of
p
and deaths
influenza cases,, hospitalizations
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Active animal surveillance may have detected
this H1N1 strain much earlier
Pandemic p
preplanning
p
g increased the capacity
p
y
to produce influenza vaccine, but the process
needs to be updated and streamlined
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Cell-based manufacturing should provide process
that is scalable and faster
Still problems with cultivation and quality control
H1N1 was already widespread when it was
finally recognized
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We don
don’tt have an adequate understanding in
regard to why vaccines are refused, or how to
overcome such refusals
There was a major breakdown in the
distribution of vaccines nationwide
Viral testing methodologies are woefully
inadequate, but this was quickly identified
More effective influenza education needs to
aimed at both the general public and health
care workers
k
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Antiviral agents are less effective in special
populations
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Higher
g
doses of oseltamivir (Tamiflu) are required in
obese patients
Legal issues regarding mandatory vaccination
policies
li i ((e.g., h
health
l h care workers)
k ) need
d to b
be
resolved
Th United
The
U it d States
St t is
i exceptionally
ti
ll dependent
d
d t
on vaccine production in other countries
The vaccine was protective
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CDC risk communication assessment
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Calls for accurate information; consistent, unified
message; and candor about what is known and not
known
In spring outbreak
 Struck good balance describing disease that was
contagious but not highly virulent
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In fall outbreak
 Problems with timeframe for vaccine delivery and
convincing public and health care workers on safety of
the new H1N1 vaccine
Moderated by
Hugh Tilson, MD, MPH, DrPH, FACPM
Adjunct
j
Professor, University
y of North Carolina, Gillings
g School of
Global Public Health, Chapel Hill, North Carolina
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How would you rate your national professional
society in keeping you apprised of medical
issues related to H1N1 (clinical management,
vaccine priorities, antiviral use, etc.)?
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Excellent
E
ll t
Very Good
Good
F i
Fair
Poor
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How would you rate the alignment of federal
state and local public health agencies in their
communications about H1N1?
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Excellent
Very Good
Good
Fair
Poor
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