October 1, 2009
H1N1 OUTBREAK 2009: Since September 1, 2009, we have identified over 300 children (both on -site and from the community) with a positive diagnostic test for influenza A, presumed H1N1. Over half of these children presented within the past five days. I believe we are now on the upside of a typical bell-shaped curve that defines a classic influenza epidemic. We can expect to see increasing disease activity for the next three to four weeks, a three to four week peak of activity, then a six week decrease in activity. This has affected our emergency department (ED numbers have exceeded 200 for four straight days), inpatient units (a handful of inpatients, primarily with asthma exacerbations) and our clinics (especially Children’s Health Clinic and Pulmonary). I want to provide some very succinct comments:
• H1N1 is now prevalent in our community and likely to produce increasing numbers of children and young adults with disease over the next 12 weeks.
• This virus is comparable to seasonal influenza in terms of its transmissibility and its virulence. One notable exception is that the attack rate for H1N1 has been reported to be 1.3/100,000 people aged 65 and older, versus 26.7/100,000 for patients 5 to 24 years of age. Usually the elderly have more disease.
• Hopefully by now, most of you and your staff have received seasonal influenza vaccine.
• Health care workers who are infected with H1N1 will be required to remain off duty for at least seven days from onset of infection (CDC recommendation).
• This virus is sensitive to Tamiflu. Tamiflu availability is limited. The CDC recommends routine treatment for all hospitalized patients and for those individuals at risk of complications (children less than 5 years of age, pregnant women, individuals with metabolic diseases, etc). See the CDC guidelines on the use of antiviral agents in treating and preventing infections due to H1N1. Quoting: Persons who are not at higher risk for complications or do not have severe influenza requiring hospitalization generally do not require antiviral medications for treatment or prophylaxis. This is very important because supplies of Tamiflu are limited. Widespread use of Tamiflu for children with uncomplicated influenza is likely to exhaust current supplies of medication very quickly.
• Our off-site testing facilities will process samples for influenza testing, including collection of samples from patients. Samples are then sent to Dayton Children’s for analysis.
• Internally, we are following the CDC guidelines regarding the use of N-95 respirators by staff that is caring for children with influenza. OSHA requires us to “fit-test” our staff before allowing the use of the N-95 respirators. Until the testing phase is completed (it requires 20 to 30 minutes of time per staff member), we are placing all admissions with influenza (proven or suspected), on 3 West or in the PICU. We will expand placement to the AHU once the staff are trained. Thus, keep in mind that if you try to place a patient in the AHU with suspect or proven influenza, our staff will move them to 3 West for the next few days.
• Vaccines: To date nearly 1,300 of our staff have been immunized with the trivalent vaccine aimed at protecting against seasonal influenza. As of today, there is no vaccine available for H1N1. Once available, we are prepared to immunize health care workers based upon their risk and vaccine availability. It is likely that we will see very little vaccine in the first delivery, projected to be in the next two weeks.
• We realize that you and your staff are already seeing increased numbers of influenza like illnesses in your offices. We deeply appreciate your willingness to see as many patients as you can. This allows our ED to focus on the 175 to 200 children a day who are being seen for the usual ED problems. We will open an ancillary facility to handle the overflow from the ED. We will staff that facility with volunteers from our professional staff, including APNs, who will be adding this task to their daily activities. If you can help staff our ancillary site evenings or weekends, please let me know. Based upon experiences elsewhere, it is possible that as many as 200 children a day could present for evaluation and treatment. Even if we only see an added 100 children a day, the need for physicians and APNs will be substantial.
Questions? Please contact Sherman Alter, MD, at 937-641-3329 option #2 or Thomas Murphy, MD, at 937-641-5871.
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