ࡱ> '` ^bjbj{P{P .::V$$$$$$$8@"@"@"@"L"L8?"x#x#x#x#S$Z$$ ? ? ? ? ? ? ?$A@hBl0?$6S$S$660?$$x#x#E? = = =6:$x#$x# ? =6 ? = =$$ =x#" 0@":> =>[?0? =CZ<C =C$ =$*F =/l2[$$$0?0?= $$$?6666888D|!888|!888$$$$$$ H1N1 Flu Event November 3, 2009 Hosted by Healthy Delawareans with Disabilities Part 1- Introduction Hello and welcome everybody. I am very excited that you all are here at the Center for Disabilities Studies to learn a little bit more about H1N1 and individuals with disabilities. My name is Ilka Riddle and Im the director of the Healthy Delawareans with Disabilities project. Its a project here funded by the Centers for Disease Control and Prevention and actually the CDC is doing a lot of work around H1N1 and has been over the past couple of months. For them it was important that organizations or projects like ours actually get the information out to individuals and communities. So that is what we are doing today we will talk a little about H1N1 and how it affects people with disabilities and how you can plan and prepare for the flu season. We also have Craig Koska here, hes from the Division of Public Health and he will talk more towards wheat a pandemic is, talk a little specific about H1N1 and what to do towards emergency preparedness. Then Craig will also be the one that can give more information about the H1N1 and seasonal flu vaccine and then hopefully answer some of your questions you may have. What we are planning today is I will talk a little about why we focus on individuals with disabilities and then Craig will talk a little bit about the things we just mentioned. Then I will go into some more specific like how people with disabilities can plan and prepare for the seasonal and H1N1 flu this winter season. Then we will open it up to answer questions that you guys have. So we will take approximately two hours this afternoon, if you could hold your questions until the end that would be great. We have a few logistical things; we have some informational materials on the table and feel free to check it out and take some extras for some people you know that may be beneficial for them. It will be very important for you to fill out the evaluation forms that are on your seats and give us general feedback on how we did this afternoon, any further questions you may have etc. Background on People with Disabilities and Emergencies I would like to take a moment now to talk to you about why it is important to focus on people with disabilities when we are talking about H1N1 and the seasonal flu. For one, we know very little about the impact of influenza pandemics on individuals with disabilities. We have had pandemics before but no one has collected any data. We have no information about how they were affected, what happened to them, did it affect them differently, if more individuals have died or had complications from the flu. We have very little knowledge now so its important for us to focus on how individuals with disabilities are impacted by things like H1N1 and seasonal flu so we can plan appropriately and include individuals with disabilities to plan a response to a pandemic like H1N1. Also, we really dont include individuals with disabilities that well with emergency preparedness activities so far. So a lot of times, we saw that after Hurricane Katrina we did not plan very well to help individuals with disabilities in crisis situations, how to help them prepare for a crisis, how to help them in a crisis, so we really need to learn more and do better so its important for us to make sure individuals with disabilities get information but also to collect information from in with disabilities about what they need and what they think is important. Im sure you are all aware that people with disabilities face some barriers when they try to receive information or services specific to them. Theres lack of services, many times there is information not available in alternate formats, sign language interpreters might not be available if you go to a health care provider or large text information is not available. We want to make sure our project can provide that to you. Our website is  HYPERLINK "http://www.gohdwd.org" www.gohdwd.org, we have on our website a button that says flu update and if you click that button you will get information on H1N1 and the seasonal flu and you will also be able to access accessible material, large print, text versions so screen readers can read it, we also have some information links to videos that have close captioning so individuals who are hard of hearing can access them as well. So we are trying to give you this information through our website. Also what we have learned since the spring individuals with neurological, neuromuscular, or metabolic disorders are at greater risk for complications from the flu. So some individuals fall into that category of being at higher risk for H1N1 or the general seasonal flu. So if someone has multiple sclerosis, cerebral palsy, we have seen that the death rate was higher for those people and the complications were more severe for them. If somebody has neurological disorders such as seizure disorders or metabolic disorders such as diabetes we also saw there was an increase in complications from the flu and even death. Some individuals with disabilities are also at greater risk for secondary conditions such as asthma or arthritis and again having these conditions put you at higher risk for complications for H1N1 or the seasonal flu which is again why we want to make sure individuals with disabilities have this information to prepare themselves for this flu season. Some individuals with disabilities live in group home settings and even institutional settings and living in these settings puts you at greater risk for transmission of flu because you live in close quarters together so you are at higher risk of catching it if someone else has it at your group home or institutional setting. Finally for all of the individuals with disabilities that live in the community and depend on care from family members or paid professionals, they are greater risk for disrupted care or support if their caregiver or support person gets sick. So individuals with disabilities somewhat need to plan differently because they have to think of no only themselves but also the people who actually provide some care and assistance for them. They have to plan what to do if the caregiver cant come in or gets sick. Those are some of the things that we are going to address today and this is really just a very quick overview of why we think its important to talk about this topic this afternoon. I will now give it over to Craig and he will talk more about the pandemic in general. Part 2 Overview of Presentation, Craig Koska Since 2004 Ive done an awful lot of presentations on pandemic influenza. Most of them would not apply at this point because we were talking about pandemic influenza because we were afraid that the H5N1 if you remember the bird flu, we were afraid that was showing some signs that that could potentially become the next pandemic, as it turns out that didnt happen. So now were talking about the 2009 H1N1 influenza. You may well know this by another name and I should address that with you right up front. We were asked by the Department of Agriculture to refer to this novel virus in the way that it actually exists, its the 2009 H1N1 novel influenza as opposed to swine flue because so far there has been over a billion dollars in lost sales in the pork industry because people keep thinking well if its swine flu then you cant eat bacon, you cant eat any pork materials because youll catch the pig flu or the swine flu which is absolutely not the case. As a matter of fact if you go under the microscope and look at this particular virus it ahs components of human influenza, avian influenza and swine influenza so thats why we back off and do not call it the swine flu because it really refers to something that is not true. Let me do just a little bit of what were going to talk about today and an overview. I want to give you a chronology to show you whats been happening to get us where we are. Well do a little bit of definition of influenza and seasonal influenza and well do a little bit of comparison between the seasonal and pandemic flu. Well talk about our main concerns with this novel H1N1 influenza virus. Well talk about preparing for a pandemic, well cover some Frequently Asked Questions and Ill give you some resources you can use later. Chronology of Influenza Lets start with the chronology. March 18, 2009, the World Health Organization reported and outbreak of influenza like illness in Mexico. The laboratory analysis of the virus confirmed that a novel, a novel just means a new variation, of the H1N1 virus had emerged. Now when we have a novel virus emerge our concern is that thats a perfect situation for a pandemic because with a new or novel virus we do not have any immunity built up against it. On April 24, 2009, the World Health Organization reported influenza like illness in Mexico and just very early started moving into the U.S. As you can see at that time Mexico had 854 cases that have resulted in 59 deaths. At that point it was just very early for the U.S. we only had 7 cases and no deaths but what we were seeing even coming out of Mexico was a cause for concern because this novel influenza was striking young healthy adults. Well talk about it a little more when we talk about seasonal influenza but from the public health aspect that was a very significant point. Usually with influenza, the folks that we see that get most sick or die are its almost a standard U-curve the very very young then it drops off to you get some folks who may have a compromised immunity that could die from it but then we move out into the category of the elderly and the elderly are usually 90 percent of the cases that die every year from the seasonal flu. So we usually dont see it in the young health population and thats what makes this one unusual and scary for us. Now on the 28th of April, as a matter of fact on the morning of the 28th of April public health had different plans. They put together an exercise that we were going to be doing for medication dispensing from an anthrax attack so we had all our public health nurses ready and everybody was all ready to get up early that morning and go off to do our exercise. Instead they all got up early and went to the University of Delaware to set up what we call a neighborhood emergency help center because of w hat was happening there. Essentially we had an outbreak of this novel H1N1, the first outbreak the CDC says in college community in the U.S. They sent a team in from CDC to some research, they sent a team of epidemiologists to get some numbers and their report came back and said potentially 2,315 students and 300 faculty and staff may have been infected with the novel H1N1 at that time. So we knew we had a significant outbreak. And again, so far in Delaware, well at least at that point 84 percent of the confirmed cases were under age 29 and thats very unusual for us. If we move into June of 2009, the World Health Organization reported that 74 counties were now reporting this novel H1N1 influenza virus. There were almost 29,000 cases and 144 deaths. By that point in June 13, 217 cases or 46 percent of the overall cases were here in the U.S. and weve seen 27 deaths, about 20 percent of the deaths that were happening globally happened here. At that point on June 11 the World Health Organization declared that this novel H1N1 virus was creating a global pandemic. Pandemic is a very very very scary world and when we were talking about potential pandemics from the bird flu there were a lot of things people were concerned with and its just a scary word because it infers that its going to be like in the movies. Oh my goodness its going to be the andronimous strain and were all going to die. So when you hear the word pandemic it makes you nervous. Actually, all that a pandemic is, is that we see an increases in cases above what we would expect. In other words it is an epidemic that starts moving globally covering a wide area. So its not completely gloom and doom its just that were seeing an epidemic that is moving globally and spreading through a very wide area. By August of 2009 the World Health Organization reported that globally we have already had over millions of cases and 1.000 deaths across the world. We watched the H1 as it spread through the southern hemisphere. Essentially we have to remember we have a flu season here in Delaware and then it goes away where we dont have a flu season anymore but then it comes back. But actually it doesnt stop, it literally goes away as the planet tilts and we move into summertime. The southern hemisphere moves into its winter time and the flu goes down there circulates it down there and we watch it to see whats going to happen for the fall and winter when it comes back. Usually what CDC does to determine exactly how were going to make the seasonal flu vaccine. We see which strains are predominately running so weve been watching the H1N1 as it moves through the southern hemisphere and our fear was that it was going to increase it mortality. Very very infectious type of influenza not particularly deadly and I dont mean to discount the deaths that have occurred, I just mean if you look at it from a statistical standpoint we watched it move through the southern hemisphere and what it did there it pretty much did here which was create an awful lot of cases but not an awful lot of deaths. We were worried it was going to pick up a higher mortality as it moved as a matter of fact we were very worried it was going to move through either the areas in Egypt or the areas in Indonesia where the H5N1 bird flu is considered endemic which is its just there and it hasnt gone away. Our fear was that it had to do with mortality rate, usual season influenza mortality rate is very very low. Well below one percent. What we were seeing on the mortality of the bird flu was almost 60 percent so our fear was that these two were going to combine and give us something as contagious as the normal flu but it was going to come back and be more deadly and the good news is we didnt see that. What weve seen as it retuned to the U.S. in the fall is that its very very active very early. Our new season began on the first of September and again were seeing a lot of cases and were seeing more and more cases build but were not seeing that mortality rate go significantly higher. Now if we move a little bit further into closer times, on the 23rd of October President Obama declared a national emergency due to this 2009 H1N1 virus and essentially the reason he did that was to allow first of all hospitals to change their operations if they need be. For example, I think it was 3 or 4 weeks ago I heard that three or four weeks ago A.I. Dupont hospital had over 200 children show up in one day and that really kinda over burdens their system with the relaxation and not elimination but relaxation of the federal rule they can start doing things in your emergency operations that legally you wouldnt have been able to do, in your normal day to day operations. For example if you wanted to set up an alternate emergency department just for those people who are having flu like symptoms you can do that now. You can set up a tent outside of your ED or whatever you can change your operations and you needed a change in the law in order to be able to do that you needed this declaration. And it also has caused some changes that are going to become available for Medicare, Medicaid and the State Childrens Health Insurance Program (SCHIP) and HIPPAA and that has to do with finances, are they going to let them pay for the flu shot? And in some cases with HIPPAA its really a matter of what kind of information can be collected because it becomes very important from an epidemiological standpoint to have a significantly clear case study. As of the 30th of October the World Health Organization has said weve got millions and millions and millions of cases of the influenza on this planet now. It has produced 6,000 deaths globally. In the U.S. we know the cases are widespread, weve seen over 20,000 hospitalizations and over 1,000 deaths and 10 percent of those deaths have been in children and pediatric cases. We know that an awful high number of pregnant women hospitalized, there were about 100 of them and 28 of them died as a result of their exposure to the flu and thats a really high number for us. Within Delaware itself we have seen three deaths to date. We had a 15 year old male who is definitely within that category that were expecting to see. We had a 35 year old female, kinda moving out of that target circle and then a couple weeks ago we had an 80 year old lady down in Sussex County and thats very unusual because traditionally this H1N1 is not hitting the older generationlike seasonal flu does. Implications of Influenza So what are we talking about when we talk about influenza? You probably already know this. Its a contagious respiratory illness caused by a virus. It can cause mild to severe illness and at times it can lead to death. A person infected with the flu virus can transmit it 1 to 2 days before they have symptoms and let me repeat that. It is possible for you to be exposed to the H1N1 for the H1N1 to grow and replicate inside of you and you can pass it on to someone else 1 to 2 days before you start to get that feeling like youre coming down sick. Thats one of our major major reasons for pushing vaccinations so hard is because I think people are reasonable and if you know you are sick you would stay away from people especially vulnerable populations but that possibility being able to shed that virus and spread that disease before you even knew you had it can be a real problem. And, a person infected with the flu virus can still transmit it 5 to 7 days after the symptoms have started. Now what were recommending and what were recommending through the school system is that the child, if they come down with influenza, and Ill just leave it at that, if they come down with influenza, all influenza like illness is assumed to be H1N1 because its replaced the seasonal influenza and were not really in our peak influenza season here anyway. So if someone shows up at an emergency department and theyre showing symptoms they will pretty much diagnose them as H1N1. And in most cases they say okay they have the flu, take them home, put them in bed, force fluids, get rest, give some meds for pain, standard flu treatment. Identification of Influenza Types We know that there are 3 different types of influenza viruses; theres an A type and a lot of people assumed that meant avian, actually its more animal of which avian falls into that category but its not just bird its various types of animals. The B type is human influenza that can cause epidemics and the C type is a human type influenza that can cause mild infection but we dont really track that one nearly as much. Where do these things get their name from? You know Ive already talked H5N1 and now Im talking H1N1. It really has to do with the surface proteins (see video) on the virus itself. Theres a way through colorimetric testing that you can identify it. The H factor is the hemaglutinin which there are 16 different types of. The N factor is neuraminidase and there are 9 different types. So you can see that we can have an H5N1 very much like we have an H1N1 right now. Again, there is a total of 144 possible combinations. And as I speak to you today there are other influenza viruses in America right now. Theres an H7N2 thats happening in the chicken populations. I mean zoologically we chase these viruses around especially the A type because of agriculture and agriculture is watching and sampling their animals. So we know different viruses are going around. For example the H7N2 that is breaking out in chickens has not ever crossed over to people. I just want to let you know there are several viruses going around all the time. So if you hear the numbers just know thats how they are identified. Probably the best part of the story comes with this slide here (see slide). This is a hemaglutinin, the purpose of that protein on the surface of the virus is to grab onto the cell it is going to infect and cause them to start to grab together. This is the neuraminidase, or the N factor. Now what the neuraminidase does is help the virus get into he cell through the hemaglutinin which is part of the problem the influenza virus will grab on the to the cell use it neuraminidase to get within the cell and then the immune system will not recognize it because its already within the cell. What cell is that? Thats usually an epithelial cell in the lining of the esophagus so we know pretty much what happens. But then once replication occurs it wants that neuraminidase to get out of the cell and viral replication is pretty significant it would start with one virus grabbing onto and entering the cell. At the point that the virus enters the cell the virus takes over the cell and everything that cell has within it now becomes a part of a virus producing factory. It starts producing different parts of the virus, theyre assembled and then using that neuraminidase to get out of the cell when theyre released. Why is that important? Why do I even tell you about neuraminidase? Because if youve heard about Tamiflu, the treatment that we have, Tamiflu is a neuraminidase inhibitor so what would happen in this case is the virus would get into the cell, go through the replication, but the newly produced viruses would not be able to get out of the cell. They would then die with the cell and the disease would stop. Weve seen that, weve tracked Tamiflu with the H5N1 and were seeing the same thing with the H1N1. If you can get the Tamiflu into the individual within probably the first 48 hours, youre chances of success are real high. We watched that in Indonesia and folks that were coming in with a high fever but had been having that fever for 3-5 days before coming into the hospital, the Tamiflu didnt help as much. By getting it in there in the first 48 hours it really helps the process. Spreading Influenza How do we spread influenza? By sneezing, coughing, touching things recently contaminated by someone with the flu virus and yes this year is the please sneeze into your elbow and cover your coughs and be very very careful with what you touch and I think hand sanitizer works really well. So how do we transmit this? Its usually through droplets by coughing or sneezing or directly touching a contaminated surface. We know that the virus can persist 2 to up to 8 hours on the surface. A lot of that is dependent on how much sunlight it is exposed to. Ultraviolet rays just destroy the virus, so its always good to remember that sunshine kills the influenza virus. Thats something that you can always use. And just incase youre wondering if you get into a game of trivial pursuit the material that is ejected from an individual is ejected at approximately 600 miles an hour. Symptoms of Influenza What do we see as symptoms of influenza? Nothing here should be surprising. Fever over 100 degrees, cough (usually non productive), headache, body ache, severe fatigue, runny nose, sore throat, may have diarrhea, nausea, or vomiting. As a matter of fact the results that came back from the University of Delaware showed that the diarrhea, nausea and vomiting occurred in the older populations that were exposed to it. Unfortunately these symptoms can look like many many other things. Treating Influenza So how do we treat it? With the flu you let it run its course, plenty of rest, plenty of fluids, Tylenol for pain and fever and if it gets bad enough you can give anti-viral medications. When we came up to the University of Delaware in April, we actually gave out Tamiflu as a preventative. You can take 1 pill a day for 10 days and it can prevent the flu taking over you if you have been exposed. Weve backed off of that because of the limited amount of Tamiflu and now Tamilfu is only being used for treatment which is essentially the same packet; 2 pills a day for 5 days, is that neuraminidase inhibition were trying to get it to do. Now when we talk about seasonal flu, everybody thinks well seasonal flu, it comes and goes and its not significant you know theres not really any reason to worry about it. But if you look at it its very very serious. You know it usually peaks in Delaware between December and March , and every year on average we see 5 to 20 (15-16 million people) percent of the U.S. population come down with the flu and what do you do? You come home, take fluids. We wind up with about 200,000 hospitalized and usually between 32-36 thousand deaths each year. Like we talked about before; very young, the elderly folks and folks with compromised immune systems. Most people recover within 1-2 weeks without any medical treatment whatsoever. Globally it travels around pretty much like it does here in the U.S. We see between a half and a quarter million deaths each year from global seasonal influenza. Thats an amazing number to think but when you start looking at hard numbers it is a very serious killer. And in order to fight that killer what we do every year and again because of the tilt of the planet we look to the southern hemisphere to see whats circulating and fight this killer. The seasonal flu this year does have an H1N1 component and it did last year but what has happened si that virus has changed and mutated. The H1 component is the seasonal vaccine will not protect you from the novel H1N1 virus. Weve got an H3N2, another type of virus that has crossed over into humans. Seasonal Flu vs. Pandemic Flu Seasonal flu is pretty predictable, weve see it before, we know how it works. The one thing they say that is predictable about pandemic influenza is that its not predictable. It does not necessarily run the same course as seasonal flu. Pandemic flu is caused by a novel virus strain with no resistance or antibodies built up. It affects large amounts of people, different age groups globally. It can cause serious illness and like weve already talked about death. Weve seen pandemic influenza before. The thing thats scares us is the 1918 Spanish flu. Now why they called it the Spanish flu, it had nothing to do with Spain, it was during the war and Spain had not locked down its press. So when the Spanish reported that the King had been taken to bed with a Spanish lady meaning he had caught influenza and everyone keyed in, Oh well call it the Spanish flu. It actually probably broke out in Kansas in America as opposed to Spain but it was called the Spanish flu. It was also an H1N1 so its like the great great grandfather of what were looking at. The Spanish flu caused 20-40 million deaths, 675,00 of them being in the U.S. How bad did it get? If we just go up the road an hour to the city of Philadelphia, during 1918 the population of Philadelphia was actually higher than it is today which is kind of unusual but you have to think of it. It was wartime, there was shipbuilding going on, the population really came into the city to help build the ships. But they were living in absolutely terrible conditions. How bad did it get? The second week of October in 1918 when it really struck and we saw most of the deaths; the city of Philadelphia had to figure out what they were going to do with 6,500 bodies per day for that two week period. So they had to open up mass graves and bury people that way. Thats why were scared of influenza, we fear that we will see something like this happen again. In 1957 we saw an Asian flu which was an H2N2 where we saw 1-4 million deaths in which 70,000 were in the U.S. In 1968 we saw the Hong Kong Flu which was an H3N2 again cause 1-4 million deaths, about 34,000 in the U.S. We know that a pandemic when it comes through an area in multiple waves because we know influenza does that. You start to watch your case rate it will start to climb, then very rapidly peak and then very rapidly drop off and youll think good were past the flu were done with it. Actually thats just a wave and it will come back through and catch those who didnt get it before. It usually lasts 6-8 weeks and the time between pandemic waves varies and its not very predictable but once you start to see it grow youre going to see that pattern. You are going to see some growth then a spike and almost on equal side of the spike you are going to see it drop off very quickly. So what are our concerns with this novel H1N1 virus? The global expansion of cases, were still getting reports from the southern hemisphere very much like our own flu season you know last year we came out of flu season we were in April we were not supposed to have any more flu and then this novel H1N1 just kept boiling and boiling and we saw cases still occur in the southern hemisphere. Its not done and gone from there. As a matter of fact globally this new H1N1 is replacing the seasonal flu. Were not seeing very much seasonal flu at all on the globe. Thats the scary part, not that its not there but were just seeing more of the H1N1 which means its still there so we still need to get our seasonal flu vaccine as well as an H1N1 vaccine. We were worried initially because we were going to have a tool to fight it, Tamiflu or Relenza were they still going to work? The good news is yes they do. Weve seen a few isolated cases in individuals, I think because the Tamiflu may have been a little too late. We havent really seen massive resistance develop with the Tamiflu so were lucky in that respect. Then the availability and accuracy of the vaccine, when we first started out and a new novel virus had developed, we needed to develop a new vaccine to fight it. Vaccine manufacturing usually takes between 6 and 9 months. Then there is testing and trials, so we know where theres a new influenza virus, we are going to be playing catch up. We thought gosh we arent going to have enough of the vaccine until the beginning of November. Then the manufacturer said we think we will be up and running in October, theyve since had problems in production and whats happening now is that initially the virus was not growing as fast as they expected or predicted it to grow. Its the exact same process weve used in the development of this vaccine that weve used for the seasonal influenza. Its grown in chicken eggs just like the seasonal flu. It is no more dangerous than seasonal influenza, you grow the virus in chicken eggs and then you draw it off. The good news is that H1N1 would grow in chicken eggs because we found out very early on, the scary part about the H5N1, the bird flu completely devastated the egg and you couldnt grow a vaccine in chicken eggs and wed have to develop a whole new technology for that. Talking about availability, one of the other problems was we didnt have anybody that wanted to manufacture vaccines. Vaccine manufacturing was not a very good business, your liability is huge, your profit margin was tiny and there was a problem with vaccine manufacturing. The federal government has indemnified the manufacturer from being sued which now allows people to go into the vaccine manufacturing business without carrying that huge threat of lawsuits and we have people stepping up and manufacturing vaccines again. There was a period of time where we thought we werent going to have enough even seasonal flu vaccine because we didnt have any manufacturers. If you remember three years ago we had a problem with the Chailon corporation, I think theyre out of England. They were having some problems with their quality control. If you remember the year the word came out that we didnt have enough seasonal influenza vaccine to go around. This was interesting because the year prior to that we had plenty of vaccine and would up destroying it because no one wanted it. But let the word get out that there was a shortage of it and the following year everybody wanted it so I think thats just human nature. So responding to a pandemic what can we do? Probably one of the most important things happened back in July. President Obama said first of all we know we have something coming thats scary and we know its a pandemic but what we will not do is promote panic, we will promote vigilance, we will promote preparation but we will not promote panic about this. He went on to say that the federal government is not going to take full control of this. The federal government will step up to the plate financially because the H1N1 vaccine there is not charge, the federal government has already paid for all of the vaccine. However the federal government said what we are going to do is let the states deal with the distribution and how were going to get things set up. Why because the states do this year in and year out with the seasonal and his was a point of trust. There was no need for the federal government because they knew the states could handle it well. So what the federal government was going to do was support the states and it was mostly through financial support. Prevention So how do we prevent it, how do we prevent spreading the flu onto each other? Clean hands frequently, avoid touching hands and mouth, avoid people that you know are already sick and ultimately get our vaccinations. This year we are telling people you need two vaccines. You need your seasonal flu shot because the seasonal flu has not be eradicated by the H1N1 just were seeing more of the H1N1 and you need the H1N1 shot as well because even the seasonal flu vaccine has the H1N1 component in it, thats the old virus and it has already mutated in it so your seasonal shot will not protect you against H1N1. These are our priorities, what were doing in the state of Delaware. Our first concern is pregnant women. We got our first batches of flu vaccine and we couldnt use them on pregnant women because they were the flu mist version, the live attenuated virus. So we had to wait for the injectable to come out. Pregnant women are our first priority, then people who live or work with children under six months because you cannot vaccinate a child under six months old, that means they are wide open for that infection. We promised we would give it out to health care infrastructure and EMS because theyre the folks who are going to be responding. Then we branch out into the community with the 25-64 year olds with chronic health disorders or compromised immunity. When all of that is done we move into our non high risk groups. This is the attack Delaware is taking. Essentially what weve done so far is the first thing we did was crank up a registry. Who is going to want H1N1 vaccine? What doctors offices? If the doctors office or health center has ordered over a 100 doses, that will be shipped directly to them from the manufacturer. If they ordered less than 100 doses that will be shipped and it has been shipped to the state of Delaware and our folks in public health preparedness have been out running vaccine, less than a 100 doses to all the doctors offices that wanted them. Again what weve seen mostly is the flu mist to date but were starting to get the shot vaccine in so if youre having a little trouble getting someone in to get vaccinated or your doctor or health care provider doesnt have it yet, its coming! Its just not here yet and thats where the race is. The flu is spreading and were trying to play catch up with the vaccine. In general the U.S. has ordered 250 million doses and doses was a relatively generic term because we werent sure what doses was going to mean. As a matter of fact there are two different kinds of doses right now. If you are under 10 years old and youre using the flu mist, you need two. Yesterday I was lucky enough to be at the Booker T. Washington elementary school in Dover helping the little guys get their flu mist and I thought they did really well, they did really well. Its a little scary for them because most of the time when they were getting a flu shot they would see a syringe and at the end of that syringe would be a needle that was going to cause them pain. There were a few kids that were concerned that the syringe was going to be near their nose and we had to continually show them that there was no needle. We had a few criers but not nearly as many as we usually see. Every year in public health we try to do some flu clinics, some north and some south. Weve been able to vaccinate 2,500 people in a single day. Its usually the kids who are the ones you have to watch out for. We did a drive thru one time and the nurses really liked the drive thru. You pull up to me, the child is in a car seat already strapped down, he isnt going anywhere. The nurses are like we like this we like this, no chasing the little guys around. All you need to do is for the younger brother to see the older brother get that shot then its all over. Theyre amazingly quick for little people and they have a tendency to get under things we cant. So weve got five manufacturers making this vaccine, theres only one of them in the U.S. the rest are over seas. Right now the reason we dont have enough vaccine or we predicted or wanted is because of the production lag. The virus is growing slower in the eggs than they thought it would. Theyve been able to change that somewhat and increase that though were coming back with things looking much much better and more vaccines are being shipped. Talk about current information. I just pulled this information up this morning. Delaware is going to be allocated a total of 520,000 doses, to date weve only received 46,000. So we dont have enough vaccine yet but its coming. Additionally for this week, the week of November 2-6 we are expecting and starting to receive 26,000 doses of injectable and another 2,500 doses of the nasal spray. You probably wont see the nasal spray out there in the general public because were using that for the school campaign. Were using the nasal spray for grades K-5 and then five and above will get the injectable. Public health nurses are dong the elementary schools and were working with a national contractor to help us give the vaccines for the colleges and universities and everyone else. So you might see public health staff, you might see a contractor. In the schools if the child is below grade five it will be public health. If they are above grade five it will be a private contractor, theyll be doing the injectable. I stole this picture (see slide) straight from the News Journals front page because this is Clatyon and hes absolutely adorable with his reaction to the shot. Boy did I see a lot of that yesterday. Mind you, thirty seconds later after they adapt, the came over to me and told them to throw their tissue away and put on a I got a flu shot sticker you should have seen them, Aw, that didnt hurt. That didnt bother me. I could have taken it right in the arm with a needle, Im tought. This other picture over here (on right), you know how tough it is to find someone getting a normal flu shot that doesnt look pleasant. Usually its like Oh gosh this doesnt hurt. I wanted this picture to show the young lady was upset by it because we know particularly in that 12-14 year old age group for young females sometimes they get so emotionally wrought that they get an injection and they pass out. It doesnt have anything to do with the vaccine other than theyre so nervous, so I remind myself that way that sometimes this is not particular pleasant. Shes not screaming or trying to get up and run away. We saw more people in our flu clinics who would just stand up and quietly cry. Its the little guys that run on ya. Preparation for Flu So what do we do to prepare at home or prepare to take care of some of the folks you take care of? You really need to think about ok, what do I need to do here? What am I gunna do if someone Im taking care of or one of my loved ones comes down ill with the flu? So you need to determine what supplies you are going to need to supply that care at home, how are you going to plan for isolation of sick family members at home? Im the father of six so I just isolate myself, it seems to work in my house. Build some sort of kit and information together. You know when youre dealing with folks with disabilities youve gotta have that packet ready to go at all times. How many times have you done that this year including with anybody, especially at the hospital, prescriptions and over the counter cold remedies and water and food. You know there was a point where we were saying hey folks back in the days of H5N1, we were saying you might want to store away enough food and water to keep yourself in your house for a week or two if you had to. It doesnt look like H1N1 is doing that unless it goes through a significant mutation and becomes much deadlier we will probably continue to see throughout our entire flu season what we are seeing now. An important point to remember is that 99% of the time this is just like seasonal flu. You feel it coming on and you all know what parts of your bodies tells you its coming on. Usually for me its my lower back. I get that feeling in my lower back and Im like Ut-oh, I think Im getting the flu. Usually because its Friday so its on my time, or there is a wedding or something really important that you have to be at. Alcohol based hand rubs, very popular with the UD students until we explained to them no, this is rubbing alcohol. Some of them were saying they do a lot of decontamination on the weekends. Weve been talking about preparing people at work. Employees should be encouraged to follow public health guidelines and know about school closings and avoiding crowds. We havent really got to that point. As a matter of fact school closings sounds like a very easy thing from the public health perspective, just close the schools, why? Because then theyll stay away from each other and everythings great. Well, first of all they dont stay away from each other. They dont go to school, they all go to the mall and hangout or they go to each others houses and they hang out. So that whole idea of staying away from each other didnt quite work out. We also found out in Delaware we have a significant population of kids who if they dont go to school today, they dont eat today because of some of the programs they have at the schools. So we are very reluctant to close to schools because unless you do it very early and break it, its not really effective and were past that point. Weve been talking to a lot of businesses, provide guidance to your employees who get sick and need to stay home or to provide care for a sick family member. Right now with the economy we know that there are people who are going to go to work sick because they need the money. We know statistically people have done that. What were trying to do is work with the employers. Some of the employers are starting to get smart and say you know what it might actually be cheaper for me to allow my sick staff members to stay home and not bring that disease in and spread it out and then I have everyone else out sick. So some of the employers have been really good at saying you are not going to be charged annually, youre not going to lose money to say home from work. Some have changed and some havent. We are working really hard on that. Because they realize they need to keep their business running and the more disease that comes into the business, the less the business can function. So theyre talking about sick leave, benefits, working from home which is (Im the father of six so work from home is the scariest thing Ive ever heard of). Work from home no, no no, no. As a matter of fact Ive talked to public health and they said when I retire I can still come back and hang out in my office every day until I get the kids through college. So, again were working with employers, preparing at schools, ask whats going on and say hey when are you guys giving the vaccine. Were out there now, we started yesterday and well be out there this week. Were going to be continuing until we have no more vaccine. I dont mean until we run out, I mean until there is no more vaccine manufactured. Were going to keep rolling and keep rolling and pointing it to different groups. Initially were trying to get as much vaccine as we can out to take care of the pregnant women so thats going out to the doctors offices and OBGYNs and clinics because were really afraid of that. Our next major push is going after the school kids, kindergarten all the way up through college. Then more vaccine will become available and well start spreading it out to doctors offices. So right now if you were trying to get a hold of your doctor to get an H1N1 vaccine, youre not going to see it yet. Now that the vaccine manufacturing is back up and the numbers are back up were looking forward to it. Between you me and the fence post, I wasnt particularly saddened when I heard vaccine productivity wasnt as high as wed like because as soon as you say we dont have any vaccine all of those people who said they werent getting a vaccine come to you demanding they want a vaccine. So maybe its a good thing to grab peoples attention and say hey this valuable, this is worth tracking, this is worth doing. Again to prepare for school based immunizations down at Booker T Washington Elementary school just one school in Dover. I asked the school nurse, How do your numbers look? She said, 30 percent of the students who are eligible to get the vaccine did not bring back their permission slips. So there is about 30 percent of the kids at Booker T. Elementary who could potentially be exposed to H1N1 without a vaccine because they didnt do the permission slips. Ive heard some scary numbers; Ive heard that parents in New York City, about 60 percent of them said they will not get their child vaccinated. Across the country theres as high as 40 percent of the people who say I will not get my child vaccinated because theyre afraid of the vaccine and that is so incredibly scary because it is the same exact process used to make the seasonal flu vaccine. Theres nothing scary, theres nothing particularly going wrong with this H1N1 that folks have to worry about, although the lunatic fringe has really been having a field day with trying to scare people about the vaccine. This is a safe and effective vaccine. Do some people have problems taking a vaccine? Yeah there are some people who find out the first time they have egg allergies because it is grown in chicken eggs. There have been cases where people, and there will continue to be cases, where individual cases have a bad reaction to the vaccine. But overall this is a very very safe, very effective vaccine. There is really no logical reason to A. not get it yourself and B give it to your family members. So what do we expect? Well unlike other disasters a pandemic doesnt destroy homes, buildings and houses however if we get up to that point of 30-40 percent of people being sick at one times things can be disruptive. The guy that drives the truck that brings the bread and milk to your local grocery store, if hes out sick you are not going to get your milk and bread. Is that important? All you have to do is think back to last winter, when they say on the radios were getting a half inch of snow and go ahead and try finding milk and bread on your way home because everyone runs to the shelf. And again, theres a possibility if this thing starts to get uglier then you will be asked to take personal action to stop the spread of the disease. There may be a point when we recommend that people dont gather in large groups which probably would not have been a good idea to put out there in Philadelphia with the football and baseball games. But thats okay and I will say nothing about the Phillies or the Yankees. So one of the more frequently asked questions and this is one of the ones Ive been getting is Will the seasonal flu vaccine protect me from the novel H1N1 virus? And the answer is very simply no it will not! So does that mean dont bother to get your seasonal flu vaccine? Absolutely not, nothing has changed about the seasonal flu other then at this point we are seeing more H1N1 but we dont usually see very high seasonal flu. We dont really see it until it starts to get cold and nasty. Where and when can I get my seasonal flu shot? Were not doing a lot of clinics through public health this year. Weve done some but the best thing to do is if you want to get your seasonal flu shot to hit up Happy Harrys or another pharmacy. There is a little bit of a problem with the seasonal flu vaccine. You know what that problem is? The seasonal flu vaccine is made by the same companies who make the H1N1. So initially, they made some batches of seasonal and they switched over and theyre making some batches of the H1N1. Theyre continuing to make seasonal but theyve kind of backed off of that. Well see seasonal influenza shots again after the H1N1 vaccine numbers come up. Will I really need 1, 2 or 3 shots? Well yeah, if youre a young person you probably will because below age 10 if you have taken the mist you need two doses of that. They recommend 28 days apart but theyre saying if it is compressed three weeks apart looks like it works pretty well. So theyll need a second shot of the H1N1and theyll need their seasonal as well. So for some folks it may be three for others maybe one H1N1 vaccine and one seasonal flu vaccine. Now one of the things I wanted to share with you is some of our websites and things where you can find information. If you want to know whats going on within Delaware, across the board,  HYPERLINK "http://www.flu.delaware.gov" www.flu.delaware.gov which is our public health website and I check it daily because I know Im going to go out and talk to folks. The information is updated as soon as new information comes in. So we check that daily, thats a good one. Another,  HYPERLINK "http://www.pandemicflu.gov" www.pandemicflu.gov if you want to look at things from the National level.  HYPERLINK "http://www.cdc.gov" www.cdc.gov, CDC is our living, talking bible. We follow their guidance and theyre doing a pretty good job of staying on top of everything. If you want to get down, one of the things I was a little nervous about today in coming to talk to this group is that I may not be able to answer intricate questions that come up about this disability, that disability. Just go to the CDCs website, theyve got it all listed or if youve got questions. Probably the best thing to do is call your doc especially if youre helping care for someone else. Call the doctor and say look this is the situation, what do you think? If you want to look at it globally, the World Health Organization does a real good job. If youve got some questions you want to ask the state, this is our epidemiological department (1-888-295-5156) 24 hours a day. Our immunization departments number is 302-744-1060. Dr. Riddle, that means Im done. Dr. Ilka Riddle I know that Craig already talked about talking to the health care provider so we talk about something we call the flu plan that you should talk with your primary care provider about and that is taking care of someone who has a disability or if you have a disability. What you want to do is talk with your health care provider about what to do to protect yourself from the flu. Just call them up, you can talk to a nurse and ask them to give you some tips and they will know you. They will know your disability; they will know the disability of the person you take care of. So they might be able to give you more specifics that are specific to your situation or specific to your disability. So go call them up, they will give you some information like what you can do or what specific steps you have to take. Also talk with them about if the person with a disability has another health condition, they might be able to talk to you about that too. Are there some interactions or are there some additional things you have to think about? In terms of your medication, if you are using specific kinds of medications they will be able to tell you if you have to adjust them and if you have to watch them. For example, if youre a diabetic on insulin, getting sick with the flu there might be some implications about how you have to take your medicine, what you have to do in terms of eating, how you have to adjust to having the flu. So thats why its important for you if you have a chronic condition or if you have a disability to really make sure that you and your health care provider have talked beforehand so youre prepared in the event you get the flu. Then you should always talk to your health care provider about when its a good time to call them for you or for the person you are taking care of. Is it just when the person has a fever or a cough or if there are other issues going on regarding their disability when you think the flu might impact other conditions they may have. So its really important to have that plan in place before something happens. Preparation here is really the key. The next thing is to really develop a flu plan with family members. Again we want to really make sure that all family members that have contact with you if you have a disability know about the condition you have, the disability you have and the positional risk for complications. So again if you have a neurological disorder, if you have a neuromuscular disorder you are in a high risk group so you want to make sure your family members know what your condition is and that you are at higher risk for complications. Make a plan of who to contact in case of an emergency. Either if you get sick or the person who takes care of you or provides services to you gets sick where you then get someone in to help you out. If you have a disability or have a family member with a disability what do you do if you get sick and cannot take care of that person with a disability? Who can come in and help out? This is why you want to have this plan in place beforehand. Where will you stay if you get? Will you have to go to somebody elses house? Who will run errands for you? Those questions should really be talked about beforehand. Again, make sure that youre prepared and you dont have to scramble around when you already feel really sick or are running a fever. Then if you have a disability or are taking care of someone who has a disability make a flu plan with your childs school, day care or day program that your loved one is going to. Again, I think Craig already talked about that check out the guidelines that these organizations have and how they are enforced. Are schools, day cares and day programs doing what they are supposed to be doing? What are they doing? For example my daughter is in a daycare and I made sure to talk to the daycare about what they are doing in terms of the teachers. Are you asking them to get a flu shot? What if my child gets sick? So that you know whats going on in your childs day care or in the schools or the day program for adults with disabilities who may go during the day. Make sure the staff knows about the condition you have or that your loved one has and that they know about the potential risks for complications. Again you may want to make sure that they have the emergency contact information for you or the family. Who is going to pick your child up if they get sick or who is going to pick up and adult with a disability that goes to a day program? Who can come during the day to pick them up should they get sick? Then I think its really important that communication between the schools, day cares and day programs and the families is really going well. So make sure that you talk with them and that people know whats going on. Sometimes you forget about that communication and then we think about it when we are sick so we want to make sure we have that in place and that we know everyone who needs the information has it to make sure the person gets the appropriate treatment and can be taken care of really well. Also, I think earlier Craig mentioned something about medical health sheets so you want to make sure you have put together a sheet that talks about the health care provider and has information about the provider, where somebody goes to, list the condition somebody has, list all the medications and medical devices somebody uses or supplies needed for a treatment plan that somebody needs. So again, if you are a caregiver, you provide the care and then you get sick, somebody else could take care of the person with a disability. They could have the information they need to provide appropriate care. In general for individuals, who have chronic health conditions again talk to health providers, continue to take the medicine you were prescribed if you get sick until you talk to your health care provider. Your healthcare provider is really the one who can determine if need to change your medication. Again the message is get vaccinated, it really helps you to prevent getting the flu. You should always ask if the nasal mist or the flu shot is the right option for you. You might have a condition that prevents you from getting that nasal mist and you should really get a shot. So you should always ask what is the right option for you? Make sure that you have a supply of the immediate medications in case you cannot get out of the house and then again if you are out in public and you have a chronic condition take extra precautions. It might be worth thinking about wearing a mask. Those masks b y the way arent full proof, they dont completely protect you, they can help you be protected but theyre not completely protecting you. So if you wear a mask be aware that it might still be helpful for you to stay away from other people, avoid crowded space if you have a chronic condition you want to make sure you dont get sick. Just some information for individuals with Diabetes, it has been recommended for people with Diabetes to get H1N1 as well as the seasonal flu vaccinations. You have to be six months or older to get those. You should continue to take your Diabetes medicine until you talk to your health care provider even if youre sick or have diarrhea or are vomiting and youre not even sure if the medication gets into your system. But make sure you talk to your health care provider as soon as possible. You should test your blood glucose levels to see where you are, drink some extra fluids, try to eat as normally as possible again its all until you talk to your health care provider, they are the ones that can give you advice and tell you what to do. Make sure that youre not losing weight and here are some tips for when you should talk to your health care provider immediately. When you really cannot keep anything down, if you have severe diarrhea, again this is a list and Im sure a lot Diabetics will know already that they have to call their doctor if any of these things are happening to them. But they are at a pretty high risk for complications of H1N1 that they can get sick pretty quickly because of their disability if they have H1N1. Finally what Craig earlier mentioned, where can you get the seasonal flu in Delaware? At your health care provider, federally qualified health centers offer some vaccines however there are some restrictions that apply to them. When you go to  HYPERLINK "http://www.delaware.flu.gov" www.delaware.flu.gov you will get a list of what and where you qualify for, state service centers- again there are also restrictions that apply your general pharmacy. We heard earlier that there is currently a shortage however they should get them back in so you can get them there. Then theres the flu shot locator  HYPERLINK "http://www.flucliniclocator.org" www.flucliniclocator.org and you can type in where you live, where you can get a flu shot within in five or ten miles of the area in which you live and they will let you know which pharmacies have the flu shot available and again thats only for the seasonal flu not the H1N1. However the H1N1 flu vaccine again there is some guidelines on the  HYPERLINK "http://www.delaware.flu.gov" www.delaware.flu.gov website. Health care providers are really like the first bet for H1N1. So if youve talked to your healthcare provider already and you have been frustrated because youve called and theyve said they dont have it, we still dont know when were going to get it in. Be persistent, thats really the message we are sending out currently, keep calling they are going to get it eventually. Then you want to make sure you know. Call your health care provider thats really the one provider who can get you the H1N1 vaccine. Again some of the federally qualified health centers will offer the H1N1 vaccines, public schools or private schools. We have just heard from Craig the campaign has started and schools have already started and kids have got their flu shots and this will continue over the next couple of weeks. Colleges and universities will give out H1N1 vaccines to high risk students. There was some debate about pharmacies, I dont know if youve heard anything Craig in terms of H1N1 for pharmacies to also give it out. Craig: I think that is going to happen when we get plenty of vaccines. Some of the state service centers will offer H1N1 in the future. Some additional resources, I think Craig already mentioned, like flu.gov has a lot of great information or the CDC on H1N1. There is also the 1-800 CDC-INFO number. It was actually really great, I tried it out to see how it goes and a nice person will answer and ask what your question is and then they will either have the answer right away which is great but if they dont you know they will check with their colleagues or search the database and then they will either find it for you right away or they will actually call you back if it takes a little longer to get the information for you. So if you know somebody who is not totally computer literate or would actually like to talk to a person, you can call there and they will try to find the answer for you. Also in your handouts you have some of the websites listed so that you have the information right and hand and also our website  HYPERLINK "http://www.gohdwd.org" www.gohdwd.org we actually have the flu update button as I said earlier and you will find most of the information there and some great links and also, the telephone numbers. So thats the information I had to add to what Craig already said and we would like to open it up now to questions anyone might have for us. Ive got several questions for Craig. Part 4- Question and Answer Q- Dr. Oz said we couldnt get people to get vaccines but now that there is a shortage we have found a way to get then to get vaccines, which is sad but true. I just heard that there have been some pigs that have been found with the swine flu. I know you said we need not worry about pork but what about these that definitely have swine flu? What would happen if we consumed that meant? A: If you consumed it raw, there would be a problem but once you cook the meat its very much like chicken and bird flu. Once the meat is cooked you will be safe. Q: Okay, I have some friends who are getting ready to fly out this Thursday and you hear about how they recycle the air on an airplane? What do you suggest, my understanding is that whoever sits in front of you or next to you can spew this flu. A: My recommendation would be, first we know the airlines are screening passengers to try and keep the sick passengers off the flights and offering different accommodations, thats working already. If youre considered probably the best thing to do is carry your own respirator. Q: Okay, well I suggested a make and airborne. A: Well thats what I mean, I say respirator only because an N95 mask is technically a respirator rather than just a surgical mask Q: The other thing I had heard is that there are negative readings. In fact, my daughter is a nurse in Wilkes-Barre and she had all of the symptoms, was definitely ill, had a very sore throat, high fever, ears hurt, it felt like someone was pressing down on her chest, a rapid heart beat all of the symptoms and the result came back negative. A: It depends on what they tested her for, theres a kit out there that lets you know if its an A type virus and thats all it will tell you. So if it came back negative it probably wasnt an A type but maybe it could have been the B, human type virus or it could have been the seasonal flu which would not have shown up or it could be one of the many other viruses we are not currently looking for right now. Q: The last thing I am questioning is supposedly now people are not doing the testing to see if you have the virus because there are assuming everything now is swine. A: Essentially now what is happening with doctors offices and hospitals is that we are seeing so much H1N1 that if you show up with influenza like illness it is just assumed that it is H1N1 and you proceed on from there because it wouldnt really change your treatment routine anyway depending on which one it was. Youll go home and go to bed. There is a pretty safe assumption, the only thing that would really be out there is the seasonal flu and if they are doing the A type testing, if they are doing A and B screening and that comes back negative then you dont A or B influenza but you may have C or you have a different virus working all together. Q: One other thing that I did forget, I have a lot of questions. My husband is a heart patient and he is 67 and I am just shuttering at the thought of him getting this. What do I need to be concerned about? Respiration problems? Trach problems? A: Essentially what the doctors are telling people, you know because a lot of people are coming into hospitals and the doctors are sending them home. Why? Oh, because they have the flu. The thing they are saying look out for, always look out for is they start having difficulty breathing, if they start turning blue, Thats the time you need to not take them to the doctor but take them to the ER. The respiratory distress is the factor we are most concerned about. Response: Thank you very much; this has been very informative today. Person 2 Q; I have a six year old with Cerebral Palsy and twin two year old girls who are healthy and my husband is also kind of immune challenged because he doesnt have a spleen. I know with the younger kids they are already giving them the mist. I told the school that he disability and that I have already arranged for him to get a shot but if my girls get the mist then cant that shed and get my husband sick before he gets it or my son sick and obviously me but like you said your wife and I and all of the other moms out there are not allowed to get sick. A: I think the point that the media always misses on this is when were talking about the flu mist, it is a live virus but it has been attenuated. That virus really cant produce diseases anymore. My recommendation would still be when your younger children get the flu mist maybe avoid contact for the evening but this particular vaccine although it is a live virus its already been attenuated and studied so that it will not produce the disease but it will produce the antigens that will produce the antibodies that will protect you. By design, the live attenuated virus will not give you the disease. I would still be careful and if I still had any further questions I would sit down and talk with my doctor. Q: My other question is, is there a thymeresol free injectable? A: Yes and there always has been. The only place that you see any thymeresol at all is in the multi dose vials. It is in the multi dose vials; there are traces of it because you have syringes going in and out and in and out. The single dose vials have no thymeresol. Q: Who has multi-dose and who has single dose and who would use a multi-dose vial? A: They can order it either way but if youve got the concerns about the thymeresol then make sure you get the single. Q: So if its a person with neurological problems, you suggest staying away from thymeresol just in case? A: Yes. When you are talking to your doctor make it clear that you want the single dose of the vaccine and not the multi-dose. Thats not to say that the multi-dose is not safe but again thymersesol is used to prevent bacteria and things from growing in the mutli-dose so you should be okay with it but I would say talk to your doctor and use get the single dose. A: Great, thank you! Person 3 Q: Im a school nurse down in Dover and I work at a school of children with special needs. I kinda have a comment or concern. Basically in my school we have three to five year olds and I am really disappointed because I feel like this population has been missed with what the public health is doing that theyre immunizing children K-12. So my population not even that the three to five year olds are missed but also the other ones who are in school who have chronic illness and its kinda disappointing because I would think that that would be the part of the population that should be targeted. Now all of these students have to wait until their doctors get the immunization. So I just feel like we were really missed. A: Ok, I dont know that theyre planning not to go below that age group. Again, its really been an issue of priority. Pregnant women first and then that age group and as the vaccine comes in perhaps well be back around to hit your age group but were not there yet. Again, a lot of this is based on vaccine availability. We plan to have plenty of vaccine available for anybody in the state of Delaware who wants it. Its just really a matter of where the decisions have been made to prioritize these first doses that came in. A: Just one other comment about that, I dont know how much public health I guess referred to the school nurses association to get some insight into how to handle this program and I suggest thats an important piece. A: Okay, I know weve been working, but I dont know if that particular question has been asked because it didnt occur to me that, Im not going to say left off, just not move up to the front of the priority list. Person 4: Q: Just as a follow up to that, my son goes to Leeds which is an all special needs school and of course the guidelines were kindergarten to fifth grade and 95 percent of their population was missed because they have neurological disorders so when they called up the county and the school nurses and if thats all theyre giving us for that population they are pretty much leaving out the whole school. A: Ilka speaking, actually I have a comment to that. We got very upset parents calling us and saying the same thing so we have talked with Linda Wolfe who works for the Department of Education and is the liaison to DPH and she got back to us and said unfortunately the problem right now is that we only have the flu mist available and for that population it doesnt work. It does not mean that the children with special needs were left out, unfortunately we have to wait until we have the injectables available but theyre not supposed to be left off the list on actually getting it. A: So will they send out different paper work because basically what theyve told us is that anyone from K-5 could receive only the flu mist. Q: And that information Id really say call Linda Wolfe and ask her directly. There might be some children who will not be getting it through their schools because of the situation where they cannot get the flu mist. So they have to go to their health care provider and that might be in case. Again I am not positive about that but you can go back to the department of education and ask them that question. I think thats an excellent question. Person 5: Q: I have two questions about the shedding of the virus. I have parents calling and sending emails because theyre concerned about them not wanting their child to be administered the vaccine but because they know that it is a live virus and theyre worried that when they are done getting the vaccine those kids are going to sneeze on their kids or its going to be spread on surfaces and then their child would get the virus. A: I do understand and as I said people are doing a very good job on picking up on the fact that the particular vaccine is a live virus but theyre not doing a good job on picking up that the live virus has been attenuated so that it cannot produce a disease so theyre not dangerous and they will not provide a threat to your family if they got flu mist today. I would be a little more concerned if they had just got their flu mist like we saw yesterday, kids breathing it in and out and its running down their faces. Youve got to wipe it with a tissue and get them hand sanitized and send them back to their classrooms and theyre okay. Its an attenuated virus not to produce disease only to produce the antigens to produce antibodies to fight the disease. It is specifically designed not to cause the flu. Q: Is there a way to explain this to the parents? That their child will be safe if their children are not getting the vaccine. Actually, I dont have a whole lot of kids who have permission to get the vaccine. Some of them are being turned away because they have asthma and that brings me to another question. A lot of the parents are calling offices, pediatrician offices and asking them about the H1N1 vaccine. The physicians are then telling them oh go ahead and get it at the school when the physician is aware that they have asthma. Why are they telling them to go ahead and get it at the school and then Im telling them they cant have it here, you have to get it done at the physicians office. A: The only answer I can give you as to why someone would make that kind of mistake is potentially the physicians dont realize that we are using the flu mist in grades K-5. They may think youve got the injectable and the mist so go ahead and get it there. So perhaps they dont realize this. Its not going to be forever, its just all we have so far. When the injectable becomes more available it will be an option as well. Q: I was just wondering who told the physicians about the whole project? A: There is communication at the medical society of Delaware for example, they work very closely with DPH and they do send out information to physicians to get updates. I dont know how well that communication is at all times. Q: Well thats what I was assuming, that the Department of Public Health communicates with the physicians. I would just think they would pick up on what they wanted to pick up on. I understand the busyness, trust me I do. A: However, the fact that you told me that. When I go back there is a method for me to channel questions and channel concerns up to the senior executive team and say hey I was up at the University of Delaware and I heard that doctors are telling folks this or folks are still afraid of the attenuated virus and we need to get the word out to the doctors a little more clearer because it hasnt hit them all yet. Q: Please, because I have parents fighting with me, telling me this is what the doctor said, and I am just repeating myself over and over again. A: Public health is making multiple phone calls direct towards categories of physicians because of our awareness of things like what has been mentioned. Were having group conversations and we are aware that the medical society is joined by I dont know what percent of doctors but not all of them. We are aware that people dont read their incoming mail immediately and so were trying to provide every means that we can. (By the way this is Dr. Krisman she is with public health) Person 6 Q: I am also a nurse in a school for children with special needs and my children are age 2-21 so my question was kinda along the lines, I have this group of children, the younger group who are not able to get the shots and well say well call the physicians offices and when they do theyll say (several in Dover) that were not even ordering them. Were not going to have it, were not planning on having it so go to generalized clinic that the public health is going to put up. My concern is now that you have the highest risk children with special needs who cannot take the flu mist are essentially being shoved to the back of the crowd who can potentially suffer the worst consequences. Theyre the group thats getting missed and any time I have directed questions its basically cut off, sorry thats the way it is K-5 and thats it. The doctors offices are overwhelmed from people calling the doctors offices; well is it safe? Well no one has died from it. Thats not very helpful and its frightening the parents. So I guess my biggest question is now what about the set of children who cant get it anywhere who are probably at the greatest risk for potential complications. A: Well what I would do when I get back is make sure that this information flows up to the senior executive team which I am sure they are already aware of and its a problem we can fix but its only a problem we can fix if we are aware of it. Weve got to get more of the injectable in and when that comes in we can address those who cannot take the flu mist. Q: Right now do the pediatricians offices currently have the H1N1 vaccine available to them? I have had one child who has received a shot from their pediatrician. A: Probably not nearly as much as wed like there to be. Weve really got that flu mist version to dispense it out at the schools. Q: Is it an option for the pediatricians offices to simply say we are not doing it because thats what Im getting from the parents. I have not spoken to the offices directly. I know Nemours will have a batch and dispense it and then theyve utilized it all. I mean there are some doctors offices that sound like they have never ordered it and they dont seem like they plan to leave my children out there dangling with no resources to go to. A: I am a member of the immunization coalition of Delaware and that question was asked and my understanding is that doctors had to sign up in order to be providers of the H1N1 vaccine so they had to order it through DPH so there are physicians who have not ordered it and are not planning on giving it. That is my understanding. So what you have said sounds correct to me, that there are some providers who are not going to provide H1N1 in their offices at all. Q: So I guess they will be bounced back to a public health clinic if they cant get it. A: I dont anticipate it being a problem. The only problem we are having is getting the injectable vaccine. Person 7 Q: I want to shift to the college population at the University of Delaware. Obviously the University of Delaware has an H1N1 response team in place and are looking at how to respond since the occurrences of last April. I work with the students who have chronic illness and disabilities and immune system issues and my concern is, is there something concerning strategies considering were dealing with the college population, were dealing with classrooms and close quarters, residence halls. Is there a point where someone who is at risk may need to decide to leave the campus prior to having symptoms? Right now the Universities response is if you have symptoms you remove yourself you kind of stay in your residence hall room, dont go to the dining hall, dont do this and so if those cases become extremely high and students are encouraged to make their own decisions. Ive basically told students to work with their doctors and if their doctors say get off campus, we would apply those same rules for excused absences even though they have no symptoms. But is there any type of criteria I can give them from the CDC or any source. My students are going to talk to their doctors and are finding out well were not dealing with H1N1. So what else can we be telling the students? A: Well we know that the contractor we are going to be using for fifth grade and up is going to be coming to the University of Delaware and we are going to be working with the center here at the University to make sure they get enough vaccine. Again I think this situation brings us back to people are paying attention, theyre asking the right questions but unfortunately theyre showing the right frustration as well as we all are but as the injectable vaccines becomes more available we should be able to solve the problems of the manufacturing of the vaccine. But youre giving them the right advice and it should be a doctors based decision. My guess is that we are going to get more vaccine out there son enough to preclude that problem. Thats my hope, thats the plan thats what were seeing. When we say the vaccine manufacturing or production is lower than we thought, we started of this year thinking we werent going to have any vaccine until the beginning of November and then we began to see things earlier in October. So that gave everyone the feeling of okay were really on top of it its not going to be a problem. Well then as the manufacturing slowed down were back in this lull. Theyve corrected the problems, its going better, I think its just going to be days. Can we get the vaccine out there in order for it to really be effective and I think we will. But your advice for your students is to talk to your doctors and the doctors say well my advice is for you to get off of that campus for a while then that you know. At no point will public health really disagree with what is said by a physician and their patients. Could be good advice, hopefully it wont get to that. The vaccine will really kick in and hopefully well have enough to deal with those populations. I think the problem is actually the slowness of the vaccine production now. If we had the vaccine it wouldnt be a problem. Person 8: Q: A significant number of the population who has died to date have not had previous medical conditions. At death they are found at complete organ failure and or double pneumonia. What is being done to address that and why is that provision so limited in being put out to the public? A: Those are excellent questions that I am no where near prepared to answer these questions but if we can get together when were done here and I can write down your questions and put them through my system I will be able to answer but right now I cant answer your question, Im sorry. Q: Can you tell me whats happening in the Ukraine right now? A: I just read about that this morning from the World Health Organization. Cases really seem to be exploding there and I didnt really get a feel from reading the report as to why other than it really just seems to be exploding and there is some real problems going on there. Q: I think this is information that we really keep it under cover and when things start popping the trust level of the community wonders if this real information or not. People really wonder if this stuff is really going on. We need this information so we make healthy decisions. A: I dont mean to dodge that bullet referring back to what we already know but youre talking about what was going on when we were tracking the H5N1 the bird flu. The reason that people were dying from the bird flu is because they were healthy because it creates such a cytokine storm that its your own immune system that actually kills you not the virus itself. Its your bodys reaction. So to say that with an H1N1 we had very healthy people with very healthy immune systems that died with multiple organ failure would be the same thing we saw with the H5N1. It was the healthy people that were dying not the sick people. Person 9: There are three things I want to say, I dont know which one of you said it but you were talking about permission in the schools for the shot. I know for most parents that are deaf and have kids, I was wondering f the parents that are deaf, do they understand the language that you are printing and putting out for them? I know sometimes it depends n their reading level if they are even able to understand what is being put out to the public. You know sometimes they have a first or second grade level of reading and I know some of the words they use its really difficult for them to understand the words that are being used. Another concern I have when you made an announcement about the emergency warning people about the H1N1, I was wondering if the doctors offices in the area, should they be more willing to get interpreters especially when the parents are contacting these doctors. Theyre calling relay services and they go into the doctors offices and this information that is going out also the CDC the web you have there, is it possible to have an interpreter on there so when the information is given out that when the deaf person gets on the website they would understand the information that is being said because their level of reading and understanding is so weak. Maybe someone that can interpret in ASL so the information can get put out for them. I havent heard anything from the community yet about closed caption or any way for deaf people to get the information that is being put out. I know there is another web called deafmd, I know they sign on there like when there is information that hasnt been put out there are signers right on the website that it can get out to the community even if the comment is positive or negative. That information is put out and they get that information because there is someone there that can sign. Not someone thats signing crazy giving all kinds of information but just basic information that they would understand. My concern is the language limitations that some people may have same as with hospitals. I know the hospital has a policy that they have interpreters when deaf people come in there. But a doctors office, a lot of doctors offices around here, they dont provide an interpreter so when a deaf person goes in there and this information is given out, maybe it would be good if they could just get an interpreter for these kind of situations. I have an example from last year, its not related to the H1N1 but one of the deaf people went to a doctor and the doctor said oh you dont need an interpreter your kid can interpret. The doctor actually wanted the kid to interpret for the parent. 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