Dr. Lang Answers Questions from H1N1 Pandemic Planning Webinar
The following webinar originally took place on 09.16.09 with Dr. William Lang (click to view Pandemic Planning webinar recap).
IMPORTANT NOTE: Some of these questions are fairly specific. General commentary on H1N1-2009 cannot substitute for individual medical advice! Also, the findings and recommendations for dealing with H1N1 are changing frequently, so people should monitor a trusted information source, and (especially those at high risk) should ask their physician for guidance if unsure.
Q1: Should people have 2 vaccinations: regular flu shot as well as the 2009 H1N1 when available? Will doctors clinics do that or just want to give you the regular flu shot? Will the seasonal vaccine counteract the H1N1 flu (make the vaccine for H1N1 less effective)? This was suggested in findings online.
A1: Most people should receive both vaccinations. The "regular" or seasonal flu shot is available now and people should get that as soon as possible. The H1N1-2009 vaccination will be available beginning next month on a rolling schedule with priority set by each state. By the way, there is no cost for the vaccine (the US Government has purchased all of it), but providers may charge for administration. There is theoretically some risk of decreased effectiveness of live virus vaccinations (the intranasal spray versions) if they are administered too closely together, but this should not apply to the more common injectable vaccination.
Q2: Is the "regular" flu shot still recommended? Our office supplies seasonal flu shots each year. Should these still be offered? And should we inquire about adding the H1N1 to that plan?
A2: Yes, the "regular" flu shot is most definitely recommended. For H1N1, your office should check with your occupational health provider to see if they have signed up with your state to be an authorized vaccine "site." There are 90,000 providers in the country who have signed up to be vaccinators, but the details are being handled on a state-by-state basis, as is the distribution of vaccine. Also, remember that this vaccine has a prioritization to it. The Advisory Committee on Immunization Practices (ACIP) recommended that the following groups receive the vaccine before others: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children 5 through 18 years of age who have chronic medical conditions. Because of this, it will likely be late fall before vaccinations are generally available.
Q3: Once you have a seasonal flu shot, how long is it good for? Once you have a H1N1 flu shot, how long will it last? Can you contract the Flu by getting the vaccine?
A3: Immunity from a flu shot lasts for different lengths of time in different people, but in most cases, the highest immunity lasts 6 to 9 months, although there is usually some immunity that lasts indefinitely. Also, remember that the flu vaccine changes every year to try to match the currently circulating flu virus, which is constantly changing. This means that even if the immunity created by a flu vaccine is prolonged, it might not be applicable to the next year's circulating virus. This information applies to any flu vaccination, but the new H1N1 has not been around long enough to have confirmatory studies on how long immunity lasts. You can't get the flu from a flu shot (people who have immune system difficulties or live with others with immune system difficulties should not typically receive the nasal spray vaccine, but that is a different issue).
Q4: Should people who aren't in the "high risk" categories still get the vaccine?
A4: Expect that more guidance will come out over the next month or so, but the guidance currently is that once high-risk populations are vaccinated, everyone should consider vaccination. That has benefit not only to the person receiving the vaccine, but it also will help stop the community circulation of the virus, thus helping the pandemic to "burn-out." Remember, for most people, the H1N1-2009 illness is not severe, but in a small, but unpredictable, subset of the population, the virus can cause severe disease. While all vaccinations have a small risk of adverse effects, the current public health thinking is that the risk of severe disease in an unvaccinated person is higher than the risk of significant side effects from the vaccine.
Q5: Can a person get H1N1 more than once?
A5: H1N1 is only one subtype of flu virus, but there are many strains of H1N1. Someone may (in fact, most people probably have) been infected with some type of H1N1 flu virus at some point in their life, but not with this H1N1-2009 strain. In most cases, you cannot become ill with the same strain of H1N1 (or any other flu virus) a second time (and even if you do become infected, the illness would likely be very minimal).
Q6: Can you be a carrier of the virus without displaying symptoms?
A6: It appears that people can be infected (and then infectious) and have little or no symptoms. There does not, however, appear to be a prolonged "carrier" state. Some people just have a very minimal infection.
Q7: I have heard of cases where doctors are telling people they have H1N1, but they don't test for it. How is this monitored--relative to accurate surveillance?
A7: Currently, ongoing surveillance has demonstrated that over 97% of all circulating flu in this country is H1N1-2009. Consequently, if someone has an "Influenza-like illness" the overwhelming likelihood is that they have H1N1-2009. Since we know that, and since the treatment (if any) does not depend on the type of flu, there is no need to confirm flu type in each person. Surveillance (essentially spot-checking) in certain clinics continues so that we do continue to have an idea of how the outbreak is changing over time (see Answer A13).
Q8: We had an employee that was tested for the 2009 H1N1 two weeks ago and hasn't heard the results. What is the time frame for the patient to hear back from their doctor on these tests?
A8: There are many different types of tests. A non-specific office-based test can tell if you have influenza (with fairly high accuracy, although not perfect) right away, but confirmatory typing can take several days, especially given the volume of specimens being submitted. But see Answer 7: it doesn't really matter to most individual cases. The purpose for confirmatory typing is to help health officials manage the epidemic. Unless someone requires hospitalization, then confirming the specific type of flu is less important to managing an individual patient.
Q9: CDC is not recommending antivirals be given on preventative basis. How are companies using/distributing them given this new guidance?
A9: There are really three reasons to give an individual antiviral medications: For treatment, for prophylaxis (i.e., taking after a fairly certain close exposure in order to prevent development of illness), and to have on-hand for immediate use if symptoms develop. In order to be sure that there is an adequate supply of antivirals to treat those at high-risk or who are developing more severe symptoms, CDC is discouraging use for treatment in low-risk people, for prophylaxis (except those at high risk with confirmed exposure), and for "pre-need" distribution. Some companies, however, have pre-arranged for availability of antivirals for their staff so they can ensure access to medications without regard to what is happening to supply issues in the community. As long as there is a provider-based system for distributing and educating employees on appropriate use of antivirals, this is very good. Pre-distribution without education and provider involvement increases the risk that antivirals may be used inappropriately, thus decreasing their availability when needed. One important consideration that CDC does not address is that some companies (working with their providers) may choose to give a "stand-by" course of antivirals to employees who are traveling frequently (especially internationally), so that they have a sure supply should they begin to develop illness while on the road (ideally they also have a means to talk to a provider before they actually start taking). This is a good strategy.
Q10: Can you comment on any additional risk around children with epilepsy and H1N1?
A10: That issue is probably best discussed with a pediatrician and/or neurologist as there are so many individualized considerations.
Q11: What about people with asthma and diabetes, how should they handle the possibility of H1N1?
A11: Chronic medical conditions such as those do put the person at higher risk, so vaccination is important (NOT the intranasal vaccine in anyone with asthma!). It is also important to seek care early if the person develops any signs of H1N1 infection as this person would be someone who should start antivirals as soon as possible. Some providers are prescribing "stand-by" courses of antivirals for these people to keep at home so they can start taking treatment at the earliest signs of illness (after contacting their provider). This is an "off-label" use of antivirals, however.
Q12: What are your thoughts about the 5 year old boy in Tennessee who died from flu? He had no known pre-existing conditions.
A12: There are a number of troubling cases like this around the world where otherwise healthy individuals have developed severe infections. Scientists do not know why this happens, but it does. It is important to note that this also happens with seasonal flu, but it's not national news when it does, and it does seem to happen somewhat more frequently with this flu than regular seasonal flu (or it may just be that the high number of cases in the population because of the lack of immunity makes it appear that this happens at a higher rate). In any event, these unpredictable severe courses means that anyone developing worrisome symptoms (especially respiratory problems) should contact a physician ASAP. It also provides the best reason to get vaccinated when available.
Q13: Will they resume testing once the regular season flu hits as well, so they can differentiate between the two?
A13: That type of testing is ongoing for exactly that reason (See http://www.cdc.gov/flu/weekly)
Q14: With all the media hype, do you think that it has helped decrease the number of deaths?
A14: Public awareness has made people more aware that preventive measures (hand hygiene, respiratory hygiene, social distancing, avoiding those who appear ill, not coming to work/school ill, etc.) can be effective, so the spread of the outbreak has probably been blunted somewhat. Because of that, it probably has helped decrease deaths (although see the answer to Q15). There is a fine line, however, between education/awareness and "hype" but that is a long discussion!
Q15: Have the new cases shown an increase in deaths as well?
A15: Interestingly, there has not been an increase in the number of "pneumonia and influenza" related deaths over this summer, despite a significant increase in flu cases (there is a graph on the CDC FluView website (see A13 that addresses this directly).
Q16: At this point it has not mutated correct?
A16: As far as virologists can tell, there have been no significant circulating mutations. There have been 21 cases of anti-viral resistance, but these appear to be isolated mutations that have not propagated (spread).
Q17: If fever is gone but still coughing should we insist on employees staying home until symptoms are fully gone?
A17: The guidance is back and forth on when employees can come back to work. It is important to note that a "post viral cough" can last several weeks after a respiratory virus infection and it is NOT evidence of continued infection, so the presence or absence of a cough is not a good determinant. Follow local public health guidance and check for CDC updates, but in the absence of more specific guidance, a good rule of thumb (for adults, at least) is that once the fever has subsided (WITHOUT the use of anti-fever meds, such as acetaminophen or ibuprofen) for at least 24 hours, and other major symptoms such as sore throat and body aches/pains have cleared, then a person is probably no longer infectious. Fatigue and mild non-productive cough may continue for a few days (or longer for the cough), but those are not indicative of continued infection.
Q18: How do you suggest combating pandemic fatigue?
A18: Education. People need to have a good source of non-hyped information ("just the facts, ma'am") on the current status as well as what they can do to prevent spread. Remind people that if everyone takes the appropriate, reasonable, preventive measures as discussed, we can help keep this outbreak from spreading. If we're successful, then we can potentially make this a non-event. The difficulty is that if we all do the right, reasonable, things and there is no big outbreak, we'll never know if that is because of our good efforts or because the virus smoldered out on its' own. Doing the simple things are so "low-cost" however, that it's not worth risking the outbreak!
Q19: How do you get buy-in from upper management in a business that is reluctant to have a high profile pandemic preparedness plan?
A19: The most important thing is education. Doing the "right thing" to educate the employees, to take basic preventive measures, and to have an "all-hazards" contingency operations plan that can be adapted to the current situation is just good business with minimal costs. For companies that are big enough to have Sarbanes-Oxley apply, some legal experts have suggested that failing to take appropriate measures for a reasonably foreseeable event, such as an ongoing outbreak, could have Sarbanes-Oxley related consequences (but I'm not a lawyer so before using that with senior management, check with corporate counsel!).
Q20: Aside from staffing issues, what other significant Human Resource issues have you seen? For example how do you handle employees with no sick time and are told to stay home?
A20: One of the biggest HR related issues is how to deal with contractors. Typically, contractors are incentivized to come to work no matter what. That would be counter-productive in this environment. Another major issue is how to deal with the situation where schools are closed because of an outbreak. If employees have to put their children in day-care type settings, instead of school, the kids are probably at even higher risk of spreading the illness and getting the employees infected when they come home. Shift-work and telework have been found to be effective strategies for dealing with these situations. If there are employees with no sick-time who are ill with influenza-like symptoms, they have the potential to significantly impair overall productivity if they come to work and cause others to become infected, so some strategy to allow them to remain out of work is important. To the greatest extent possible, it is not good to require employees to have a doctors' note to stay out of work or to return to work. The medical system has the potential to be overloaded and this would significantly contribute to that as well as putting employees in the epicenter of infection (if they have to go to a hospital/clinic to get the note).
Q21: If there is a reported case of H1N1 how do you balance the notifying a response team (cleaning crew etc) while balancing the employees privacy (HIPPA)?
A21: One strategy that some organizations have used is to assume that any employee who is out of work for unscheduled reasons may have been infectious. The cleaning that is required is just good basic cleaning and does not require extensive precautions on the part of cleaning crews. Wiping touch surfaces with basic office cleaners is the most important component of H1N1 preventive housekeeping (the EPA has a list of cleaners effective against flu virus) Also, if an employee becomes obviously ill at work, it is reasonable to tell cleaning crews that said person left work unexpectedly (without going in to reasons) and to pay special attention to cleaning their workspaces. Specifically in regards to schools, the CDC website says: "CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required." This same guidance should apply to workplaces.
Q22: Is 2009 H1N1 covered by FMLA?
A22: I'm not an FMLA expert, but my understanding is that H1N1-2009 is like any other disease as far as FMLA is concerned.
Q23: What trusted sources should we use to monitor?
A23: The CDC website is very good and their weekly briefings, including the Q&A sessions, are excellent. The weekly briefings are buried in the website, however. Once on the H1N1 flu page, go to "Audio and Video" then "Press Briefings." They are, however, addressing everything from a purely public health point-of-view and cannot tailor their recommendations to businesses / large organizations effectively. The best "trusted source" would be a local occupational health or infectious disease consultant who can synthesize the public health recommendations with the local specifics.
(WARNING...this last section is not unbiased information, but since the question was asked!) The company I work for, Shoreland, Inc. is an internationally-known provider of multi-source, integrated, medical analysis and recommendations on health issues for organizations. We address issues ranging from H1N1 to Avian flu to travel health and provide ongoing "push" brief updates/analysis via email as key health-related issues develop or change. This increases productivity as your staff does not have to use their time each day to see what new health related developments have occurred in the world.