2009 H1N1 PandemicAlaska’s Experience

Joe McLaughlin, MD, MPHState Epidemiologist and Chief,Alaska Section of Epidemiology

Outline• EOC activation• Antiviral stockpile• H1N1 vaccine • Laboratory testing• Communications• Surveillance• Hospitalization study

EOC Activated in April

• DPH staff & partners• Located at the Alaska State Public Health

Laboratory in Anchorage

•Vaccine distribution•Vaccine administration•Antiviral distribution•Public information•Community outreach•Community containment

EOC Workgroups

Early Response

• Prepositioned 24% of state antiviral stockpile to 38 locations around the state

Use of Stockpile Antivirals

• Limited to treat suspected and confirmed H1N1-infected patients if– Patients were uninsured or underinsured

and could not afford the medications– Patients and providers were unable to obtain

antivirals via the routine supply chain routes

H1N1 Vaccine• Shipped from the distributor (McKesson

Corp) to the Epidemiology Vaccine Depot• Repackaged• Distributed proportionally by population• First shipment arrived October 5

VacTrAKAlaska’s Immunization Registry

• In order to receive H1N1 vaccine, providers required to – Register into VacTrAK – Record H1N1 vaccine doses given to patients

• Justification– To keep track of vaccine inventory and needs state-

wide– To facilitate administration of the second dose for

children aged <10 years• This requirement increased HCP awareness and

interest in VacTrAK

Vaccine Monitoring Data

• Vaccine Depot received 303,000 doses of H1N1 vaccine

• 228,000 doses distributed to providers– 142,466 doses recorded in VacTrAK

– 131,000 patients

• Unused doses were shipped out-of-state for disposal through the National Disposal Program

• Both state public health labs were certified to test for H1N1 in early May– Combined capacity of running ~300

specimens per week • Peak submissions occurred in late June

– Laboratory staff exhaustion– In early July providers were asked to limit

specimen submissions

Laboratory Capacity

Laboratory Testing Recommendations

• Providers were asked to submit only if– Patient was hospitalized with ILI;– Patient died of an acute illness where influenza was

suspected;– Patient was an outpatient with severe ILI and tested

negative with a rapid assay; or– If a confirmatory diagnosis would inform clinical

decision making, infection control, or management of close contacts

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40 44 48 52 3 7 11 15 19 23 27 31 35 39 43 47 51 3 7 11 15 19 23 27 31 35

Num

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Week

Influenza A(H1)

Influenza A(H3N2)

Pandemic A(H1N1)

Influenza A(no subtype)

Influenza B

2008–09 2009–10July

May 23

Alaska Public Health Laboratory Influenza Isolates

Communication is Key• Media campaign

– Simplify complex information– Openly share what you don’t know– Balance the needs to share information and

protect confidentiality• Pan flu hotline• Webpage

– Constant upkeep– Avoid information overload

• Weekly teleconferences– Community partners– Health care partners

Survey of HCP Teleconference Participants

• 105 health care partners responded• 50% attended >7 teleconference• 82% rated the calls 4 or 5 on a 5-point

scale• 99% said they would participate again

Survey Results• Participants found the following

information helpful– Alaska situational updates: 88%– Vaccine updates: 81% – Guidelines for clinicians: 79%– Question and answer period: 70%– Antiviral updates: 67%– Laboratory testing updates: 52%– Latest research updates: 51%– National situation update: 46%

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Age-group in years

Hospitalizations (n=1,057) for Pneumonia and Influenza by Age-Group from September 1, 2009 through April 3, 2010

Laboratory-Confirmed Clinically Diagnosed Total Hospitalization Rate

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Age-group in years

Laboratory-Confirmed Influenza Deaths (N=11) by Age-Group from Sept 1, 2009 through April 3, 2010

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Age-group in years

Positive Rapid Tests (n=1,103) for Influenza by Subtype and by Age-Group from September 1, 2009 through April

6, 2010

A B A/B Rate for all subtypes

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ILI Surveillance through Sept 2009• ILI defined as fever (>100˚F) + cough or sore throat in the

absence of a known cause other than influenza

• Sentinel providers: Anchorage, Fairbanks, Juneau, Kenai, Soldotna, Unalaska, Valdez/Cordova

19

Wk 1=January 3

Wk 36=Sept 5

Wk 27=July 4

Wk 17=April 25

ILI Surveillance Since October 2009

20

Wk 1= January 1

Wk 40= Oct 3

Hospitalization Study

• CDC Arctic Investigations Program and Section of Epidemiology

• Chart review of lab-confirmed patients who were Anchorage residents hospitalized– Sept 1 through October 21

– Four acute care hospitals in Anchorage

Rates and Characteristics of Influenza Hospitalizations by Race

Race Number(rate)

Underlying disease (%)

In vaccine priority group

(%)

White 24 (11) 63 67

AI/AN 15 (50)* 73 73

A/PI 9 (40)* 89 78

Black 11 (21) 100 100

*Statistically significant compared to whites

Hospitalization Study Results

• 44% of adult patients were obese (BMI >30)– AK BRFSS: 28% of adult Alaskans are obese

• 5% were pregnant

• 88% of AN and A/PI met the criteria for empiric antiviral therapy prior to hospitalization

• 78% received antivirals while hospitalized

Hospitalization Study Conclusions

• Hospitalization rates were significantly higher for AN and A/PI

• Most cases occurred in persons with pre-existing medical conditions

• A higher proportion of adult patients were obese compared to the general population

• The data did not support a need to modify existing vaccine priority groups or empiric treatment recommendations for Alaska

2010–11 Flu Season Update

• ASVL has reported 10 PCR-confirmed flu A since May– 9 were H3; 1 was inconclusive

– 3 of the last 4 H3s were negative by rapid testing

• Trivalent vaccine virus strains – A/California/7/2009(H1N1)-like

– A/Perth/16/2009 (H3N2)-like

– B/Brisbane/60/2008-like

• State-supplied vaccine– 89,940 doses ordered; ~75% already received and shipped out

– Pediatric vaccine goes to public and private clinics

– Adult vaccine goes to PH Centers, AN clinics, and LTC facilities

2010–11 Flu Vaccine

State-supplied Flu Vaccine

AgeNumber of

DosesOrderedLicensed for: State-approved:

Sanofi Fluzone –Prefilled Syringe (1/2 dose)

6–35 mos 6–35 mos 11,000

Sanofi Fluzone –Multidose vial

>6 mos >6 mos–18 yrs 32,510

MedImmuneFluMist nasal spray

2–49 yrs 2–18 yrs 17,600

GSK FluLaval –Multidose vial

>18 yrs >18 yrs 28,830

TOTAL 89,940

Fluzone High-dose Vaccine

• FDA-approved for people aged >65 yrs– Single dose, prefilled syringe

– Not State-supplied

• Contains 4 times more antigen to create a stronger immune response– Increased immune response supported by clinical trials

– Studies are ongoing to determine if an increased immune response leads to greater protection

• Similar safety profile as regular flu vaccine

• Neither CDC nor ACIP is expressing preference of Fluzone over regular flu vaccine

"My vaccine protects you, your vaccine protects me."

Thank you!

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By week ending

Hospitalizations (n=1,057) for Pneumonia and Influenza by Week’s End from September 1, 2009 through April 3, 2010

Laboratory-Confirmed Clinically Diagnosed Percent of hospitals reporting

ILI Surveillance

ProviderPre-Registration

Provider Registration

Vaccine delivered toDepot from McKesson

VacTrAK staff enter registered provider

into VacTrAK

Depot enters vaccine mnfr & lot # into VacTrAK

For each community, EOC reviews:- population data- #/type of providers registered- VacTrAK inventory & usage reports

EOC:- determines vaccine allotments - submits order spreadsheet to Depot

for next day’s shipments

Depot: - assesses vaccine inventory- reviews EOC order spreadsheet- enters orders into VacTrAK

Packing staff:- fill order- determine appropriate shipping/delivery route

Provider outside Anchorage/MatSu- approriate shipping mechanism arranged- fax sent to provider re: ETA

Provider within Anchorage/MatSu- vaccine prepared for distribution

by delivery driver

Provider receives &appropriately stores

vaccine

Provider administers

vaccine

Provider documents vaccine usage in VacTrAK

(direct or paper submission)

Alaska 2009H1N1 Vaccine Distribution

Strengthened Relationships with Partner Agencies

• CDC Arctic Investigations Program• Alaska Division of Homeland Security & Emergency

Management• Deptartment of Education and Early Development• Alaska Native Tribal Health Consortium• Joint Task Force Alaska (DOD)• Municipality of Anchorage DHHS• Private industry• Many others…

EOC Response Activities• Receipt of resources from

federal SNS • Shipment of stockpile

supplies to communities and providers

• SNS antiviral usage• Receipt of H1N1 vaccine• Public information/public

education

Alaska Pandemic Flu Website

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Sep 19

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By week ending

Laboratory-Confirmed Influenza Deaths (N=11) by Week's End from Sept 1, 2009 through April 3, 2010

State of Alaska Surveillance

VacTrAK Webpage