ࡱ> {}xyz'` )bjbj .b)$$B26666"3G B B B B B B B$Ch"F-B{{{-B66BBӰӰӰ{V66BӰ{BӰӰ $LE,6 Ɨ"ѬY'ZBXB0B'GGE,E,GC?SӰSSS-B-Bɰ SSSB{{{{$$$MUD$$$U$$$ AUGUST 20, 2009 Background Information for Dr. Mills PowerPoint presentation at Plenary Session Maine H1N1 Summit Note: Some information in this background document will change and likely be outdated very soon; it is important to check websites and other resources for updated information. GOALS FOR ADDRESSING H1N1: to limit the burden of disease to minimize social disruption H1N1 INFLUENZA VIRUS What is the influenza virus? The influenza virus, a member of the family Orthomyxoviridae (Greek myxa, means "mucus"), is one of the worlds most important and dangerous respiratory pathogens. Each year, it causes illness and death in millions of people globally, including an average of 36,000 deaths and 250,000 hospitalizations in the US. The genetic information of influenza virus is encoded as single stranded RNA. Like all viruses, influenza must invade a host cell and hijack its machinery to manufacture more viruses. What is the novel H1N1 influenza virus, or swine flu virus? This virus was originally referred to as swine flu because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs (swine) in North America. But further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and bird (avian) genes and human genes. Scientists call this a "quadruple re-assortment" virus. There are also H1N1 strains that are normal seasonal flu viruses What are the types of influenza viruses? Types of Influenza: A, B, C Most common human seasonal influenza types: A and B Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses and seals. Has 8 RNA segments Subtypes of Influenza A: denoted by H and N proteins Most common recent seasonal Influenza A subtypes: H3N2 and H1N1 (not the same as novel H1N1 or swine flu) Strains of Influenza A: further broken down, usually named by place first detected (A/California/04/2009) Influenza B viruses circulate widely only among humans. Has 8 RNA segments. Yearly influenza vaccine include strains of Influenza A (H1N1), Influenza A (H3N2), and Influenza B What is the meaning of the H and the N in the name of Influenza A viruses? Influenza A viruses are divided into subtypes based on two proteins on the surface of the virus: the hemagglutinin (H) and the neuraminidase (N). There are 16 different hemagglutinin subtypes and 9 different neuraminidase subtypes, all of which have been found among influenza A viruses in wild birds. Hemagglutinin has a role in attachment of the virus to cells in the respiratory system. Neuraminidase is involved in the release of new virus particles from host cells What other animals are commonly infected by influenza viruses? Wild birds are the primary natural reservoir for all subtypes of influenza A viruses and are thought to be the source of influenza A viruses in all other animals. Most influenza viruses cause asymptomatic or mild infection in birds; however, the range of symptoms in birds varies greatly depending on the strain of virus. Infection with certain avian influenza A viruses (for example, some strains of H5 and H7 viruses) can cause widespread disease and death among some species of wild and especially domestic birds such as chickens and turkeys. Pigs can be infected with both human and avian influenza viruses in addition to swine influenza viruses. Infected pigs get symptoms similar to humans, such as cough, fever and runny nose. Can dogs and cats become infected with influenza viruses? Not a lot is known about influenza in cats and dogs, though avian influenza has been detected in some cats, especially associated with cats eating birds in Asian countries affected by H5N1 avian influenza. H3N8 influenza virus, previously known to infect horses, is now known to infect dogs. There has not been any evidence of spread to humans. How do influenza viruses change over time? The influenza virus continuously changes to evade its host's acquired immunity. It does so via two main mechanisms: antigenic drift and antigenic shift. Antigenic drift is defined as the random accumulation of mutations in all the virus genes, including those that code for the surface proteins. Many of these of mutations occur as a random change in a single nucleotide. These changes, called point mutations, are common in RNA viruses, such as influenza. Point mutations that involve coding for the surface proteins H and N can change the proteins enough that they no longer are recognized by the immune system. Therefore, influenza vaccines must be reformulated continuously to keep pace with the constant mutations of the flu virus. Unlike antigenic drift, antigenic shift occurs at unpredictable intervals, when an existing influenza virus disappears and is replaced by a new subtype with new surface proteins.1 Antigenic shift happens as a result of mixing of the genome pieces from several different viruses that infected the same host cell. Antibodies made by the host immune system in response to the previous subtypes will not recognize the new subtype Antigenic shift was responsible for the emergence of the "Hong Kong" flu in 1968, which was caused by subtype H3N2. This subtype arose from reassortment of the human H2N2 subtype with genes from viruses with the H3 subtype that primarily infected birds. SURVEILLANCE What is disease surveillance as it applies to influenza? Surveillance is the tracking of the spread of the virus to: determine when and where flu activity is occurring track flu-related illness determine what flu viruses are circulating detect changes in flu viruses measure the impact of flu on hospitalizations and deaths In Maine we are increasingly focus on monitoring H1N1 in settings, ie outbreaks, such as schools, correctional facilities, shelters, health care settings, day care facilities, etc. as well as some high-risk populations such as pregnant women and health care workers. What is surveillance NOT? Surveillance is NOT: trying to identify every person with the disease not used for influenza to shut borders or quarantine Challenges: When we identified the numbers of cases in general locations (counties) the impression is that we were using the information in these ways. Challenges from: identifying numbers of cases; and confidentiality issues pressures to provide more information and law that dictates the minimum amount of info possible to be disclosed that is necessary to control the outbreak. What data sources does influenza surveillance rely on: Monitoring the virus The percentage of specimens tested for influenza that are positive for influenza; The types and subtypes of influenza viruses circulating; Resistance to influenza antiviral medications, and The emergence of new strains Sentinel physician surveillance for influenza-like illness (ILI), which monitors the percentage of doctor visits for symptoms that could be the flu. Hospitalization surveillance, which tracks numbers of hospitalizations with laboratory-confirmed flu infections among adults and children. Deaths from several cities that report the total number of deaths and the percentage of those that are coded as influenza or pneumonia. The number of laboratory-confirmed deaths from influenza among children What is Endemic vs Epidemic vs Pandemic? Endemic describes levels of an infection which do not exhibit wide fluctuations through time Epidemic describes an unexpected increase in the incidence of a disease If a new virus that is the result of antigenic shift causes illness in people and can be transmitted easily from person to person, an influenza pandemic can occur. These outbreaks are called pandemics, because they occur over very wide geographic areas and affect an exceptionally high proportion of the population. Influenza outbreaks usually occur from November through April. Most annual epidemics are relatively mild. However, occasionally deadly worldwide epidemics arise. Influenza causes 36,000 approximately deaths annually in the United States and leads to the hospitalization of about 200,000 persons each year. What has novel H1N1 surveillance shown us? Highly Transmissible: Influenza Infection: Spread Aerosolized droplets from coughing or sneezing up to a 6 foot radius Hand to face contact (nose, eyes, or mouth) after touching infected areas Virus infectious only up to 2-8 hrs on surfaces Incubation period 1 to 7 days (avg H1N1 3-4 days) Symptom duration 3 to 7 days but up to 14 days (avg H1N1 3-5 days) Contagious 1 day before symptoms to 10 days after symptoms peak period while febrile Influenza Like Illness (ILI) Criteria Symptoms to meet criteria for ILI: Fever plus sore throat or cough Other common symptoms Headache Muscle & joint aches Nausea, vomiting, or diarrhea Fatigue Pneumonia Shortness of breath Nation US Data as of 8/13/09 Hospitalizations = 7,511 Deaths = 477 Officials estimate that more than 1 million Americans have been infected. Worldwide March/April, 2009 first detected in Mexico and southern US August, 2009 detected in over 200 countries. Predictions for this fall/winter: Southern Hemisphere that are now experiencing their winter flu season. H1N1 has been the predominant influenza virus in almost all areas except South Africa. Many countries have experienced strains on their health care system with full ICUs (especially pediatric), school closures. They are now starting to report decreases in the numbers of ill people. A few seasonal influenza viruses have been detected in the US in mid-August, including an H3N2 in Maine Who has been affected by Novel H1N1 in the U.S.? Median age for cases 12 years old For hospitalizations 20 For deaths 37 Compared with seasonal flu: Average age of seasonal flu - 2/3 of hospitalizations occur in those over 65 Over 90% of deaths and about 60 percent of hospitalization occur in people older than 65 Illness with the new H1N1 virus has ranged from mild to severe. While most people who have been sick have recovered without needing medical treatment, hospitalizations and deaths from infection with this virus have occurred. In seasonal flu, certain people are at high risk of serious complications. This includes people 65 years and older, children younger than five years old, pregnant women, and people of any age with certain chronic medical conditions. About 70 percent of people who have been hospitalized with this novel H1N1 virus have had one or more medical conditions previously recognized as placing people at high risk of serious seasonal flu-related complications. This includes pregnancy, diabetes, heart disease, asthma and kidney disease. One thing that appears to be different from seasonal influenza is that adults older than 64 years do not yet appear to be at increased risk of novel H1N1-related complications thus far. CDC laboratory studies have shown that no children and very few adults younger than 60 years old have existing antibody to novel H1N1 flu virus; however, about one-third of adults older than 60 may have antibodies against this virus. It is unknown how much, if any, protection may be afforded against novel H1N1 flu by any existing antibody. It appears that H1N1 flu has caused greater disease burden in people younger than 25 years of age than older people. At this time, there are few cases and few deaths reported in people older than 64 years old, which is unusual when compared with seasonal flu. However, pregnancy and other previously recognized high risk medical conditions from seasonal influenza appear to be associated with increased risk of complications from this novel H1N1. These underlying conditions include asthma, diabetes, suppressed immune systems, heart disease, kidney disease, neurocognitive and neuromuscular disorders and pregnancy. What are the major underlying conditions that appear to put people at highest risk for complications due to H1N1? Respiratory illnesses (e.g. Asthma, COPD) Cardiovascular Disease Diabetes Pregnancy Immunocompromised individuals Neuromuscular diseases Pregnancy is a particular concern.  HYPERLINK "http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61304-0/abstract" http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61304-0/abstract This article and other data indicate they are at high-risk for serious illness, including hospitalization and death from H1N1. Preliminary data indicate a hospitalization rate for pregnant women that is 4 times that in the general population. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs. What is the situation in Maine? See latest Wednesday update at  HYPERLINK "http://www.maineflu.gov" www.maineflu.gov As of August 19, 354 confirmed cases; 200 in Maine residents; 154 in out of state residents; 19 hospitalizations (incl 4 needing a ventilator) 1 death What can you do to help with surveillance? Check Maine CDCs weekly Wednesday Report If you have more questions on surveillance, the H1N1 In-Depth and the Community Response breakouts will have more information on this. Health care providers sign up to be a sentinel provider Local Health Officers find out how you can help more info in the community response breakout Schools report to Maine CDC if an increase in absentee rates or 15% absent Emergency management be aware from the Wednesday report if there is community H1N1 in your area MITIGATION Sneeze Facts: Sneezes are an automatic reflex that cant be stopped once sneezing starts. Sneezes can travel at a speed of 100 miles per hour and the wet spray can radiate five feet. Influenza germs spread from person to person by way of coughing, sneezing or simply talking. That's because droplets from an infected person get into the air and are inhaled by people nearby. Anyone within three to five feet can easily be infected. Influenza germs also are spread when a person touches something that is contaminated with germs and then touches their eyes, nose or mouth. Influenza germs can live for hours on surfaces like doorknobs, desks and tables. Too bad they don't glow green, so we could see them and avoid coming in contact with them! But be aware they're there. Fortunately, there are ways to avoid them. PREVENTION: How long can influenza virus remain viable on objects (such as books and doorknobs)? Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on the surface. What kills influenza virus? Influenza virus is destroyed by heat (167-212F [75-100C]). In addition, several chemical germicides, including chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols are effective against human influenza viruses if used in proper concentration for a sufficient length of time. For example, wipes or gels with alcohol in them can be used to clean hands. The gels should be rubbed into hands until they are dry. What surfaces are most likely to be sources of contamination? Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk, for example, and then touches their own eyes, mouth or nose before washing their hands. What are some prevention steps we can use at work, home, and at school? Teach respiratory hygiene and shared responsibility to adhere to it. Examples include: teaching hygienic sneezing and coughing techniques; assuring hand sanitizer and tissues are easily available; and displaying posters with reminders about good hand-washing, sneezing and coughing etiquette, and staying isolated if ill. Some materials such as videos (Why Dont We Do It In Our Sleeves) and posters can be found on Maine CDCs website at:  HYPERLINK "http://www.maine.gov/dhhs/boh/swine-flu-2009.shtml" http://www.maine.gov/dhhs/boh/swine-flu-2009.shtml. Stock up on prevention tools. Examples include hand sanitizer, tissues, and posters. . Consider implementing some social distancing measures such as rearranging furniture to increase space between people and especially between workers and the public (6 feet is between people is best). Respiratory Hygiene: Cover your mouth and nose with a tissue when you cough or sneeze. If you don't have a tissue, cough or sneeze into your upper arm, not your hands. Put your used tissues in a wastebasket. Wash your hands with soap and water or alcohol-based hand rub (also called a hand sanitizer.) Stay home while ill, but if you must go out in public (for instance, to seek medical care), wear a surgical or procedure mask. Keep Your Hands Clean Your hands may look clean, but they have germs on them that could make you or someone else sick. Avoid touching your eyes, nose or mouth. Wash your hands often with soap for 20 seconds or use alcohol-based hand rub to protect yourself from germs and avoid spreading them to others. After wiping or blowing your nose or coughing or sneezing; After using the bathroom; After being in contact with or being near someone who is ill; After touching handrails, doorknobs, telephones or other things handled by many people; Before and after eating or drinking; Before handling food, especially ready-to-eat foods like salads and sandwiches; and After handling garbage or trash. How to Use Alcohol-Based Hand Rub: Dispense alcohol-based hand rub into palm of hand. Rub hands together working the gel between your fingers, under nails and back of hands. Continue rubbing hands until they are dry. Do not rinse hands or dry hands with a paper towel. Why should I cover my mouth and nose with a tissue when I cough or sneeze? Germs such as influenza, cold viruses, and even whooping cough are spread by coughing or sneezing. When you cough or sneeze on your hands, your hands carry and spread these germs. When you touch an object such as a door handle, telephone or computer keyboard with unclean hands, you are spreading germs. The next person who touches these objects may pick up germs and get sick if they do not clean their hands before touching their eyes, nose or mouth. TISSUE, PLEASE If you cough Or if you sneeze Cover your mouth With a tissue, please If no tissue is in site Use your sleeve It is polite More Resources:  HYPERLINK "http://www.coughsafe.com/" http://www.coughsafe.com/ Maines own Dr. Ben Lounsburys EARLY DETECTION: What are some early detection strategies we can implement in our community? For residential facilities or institutions: Consider purchasing extra thermometers and personal protective equipment such as masks, respirators, and gloves. Consider active surveillance by daily prompting of newly new residents or those exposed to someone with H1N1 to report any fevers or other symptoms. Report a possible outbreak and/or obtain guidance on testing and management from Maine CDCs clinical consultation toll free 24-hour phone line at 1-800-821-5821. Active (prompting or testing) vs Passive (reminders) Options should take in account context of community disease prevalence, risk profile of constituents in question, and setting (residential vs commuter, etc) ISOLATION: The difference between quarantine and isolation can be summed up like this: Isolation applies to persons who are known to be ill with a contagious disease and is also used as a term to describe anyone who is asked to avoid contact with others. Quarantine applies to those who have been exposed to a contagious disease but who may or may not become ill. It also can refer to a building or physical location that is isolated from other places. What are the new CDC recommendations for Isolation? In most community settings in which most people are not at increased risk for complications: People with ILI stay home at least 24 hours after free of fever without any fever-reducing medications. For most this will require an exclusion period of 3 5 days. In health care settings and settings with large proportion of people at high-risk (eg child care facilities for young children), exclusion should continue for 7 days from symptom onset or until 24 hours symptom-free, whichever is longer. Some Details of New Isolation Period: CDC recommends that people with influenza-like illness remain at home until at least 24 hours after they are free of fever (100 F [37.8C]), or signs of a fever without the use of fever-reducing medications. This is a change from the previous recommendation that ill persons stay home for 7 days after illness onset or until 24 hours after the resolution of symptoms, whichever was longer. The new recommendation applies to camps, schools, businesses, mass gatherings, and other community settings where the majority of people are not at increased risk for influenza complications. This guidance does not apply to health care settings where the exclusion period should be continued for 7 days from symptom onset or until the resolution of symptoms, whichever is longer; see  HYPERLINK "http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm" http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm for updates about the health care setting. This revision for the community setting is based on epidemiologic data about the overall risk of severe illness and death and attempts to balance the risks of severe illness from influenza and the potential benefits of decreasing transmission through the exclusion of ill persons with the goal of minimizing social disruption. Decisions about extending the exclusion period should be made at the community level, in conjunction with local and state health officials. More stringent guidelines and longer periods of exclusion for example, until complete resolution of all symptoms may be considered for people returning to a setting where high numbers of high-risk people may be exposed, such as a camp for children with asthma or a child care facility for children younger than 5 years old. Epidemiologic data collected during spring 2009 found that most people with the 2009 H1N1 influenza virus who were not hospitalized had a fever that lasted 2 to 4 days; this would require an exclusion period of 3 to 5 days in most cases. Those with more severe illness are likely to have a fever for longer periods of time. Although fever is a component of the case definition of influenza-like illness, the epidemiologic data collected during spring 2009 found that a minority of patients infected with the 2009 H1N1 influenza virus with respiratory symptoms did not have a fever. Sick individuals should stay at home until the end of the exclusion period, to the extent possible, except when necessary to seek required medical care. Sick individuals should avoid contact with others. Keeping people with a fever at home may reduce the number of people who get infected, since elevated temperature is associated with increased shedding of influenza virus. CDC recommends this exclusion period regardless of whether or not antiviral medications are used. People on antiviral treatment may shed influenza viruses that are resistant to antiviral medications. Many people with influenza illness will continue shedding influenza virus 24 hours after their fevers go away, but at lower levels than during their fever. Shedding of influenza virus, as detected by RT-PCR, can be detected for 10 days or more in some cases. Therefore, when people who have had influenza-like illness return to work, school, or other community settings they should continue to practice good respiratory etiquette and hand hygiene and avoid close contact with people they know to be at increased risk of influenza-related complications. Because some people may shed influenza virus before they feel ill, and because some people with influenza will not have a fever, it is important that all people cover their cough and wash hands often. To lessen the chance of spreading influenza viruses that are resistant to antiviral medications, adherence to good respiratory etiquette and hand hygiene is as important for people taking antiviral medications as it is for others. Fever-reducing medications, that is, medications containing acetaminophen or ibuprofen, are appropriate for use in individuals with influenza-like illness. Aspirin (acetylsalicylic acid) should not be given to children or teenagers who have influenza; this can cause a rare but serious illness called Reyes syndrome. The determination of readiness to return to school, businesses, or other community settings should be made when at least 24 hours have passed since the ill persons temperature first remained normal without the use of these medications. When should I consider wearing masks?  HYPERLINK "http://www.cdc.gov/h1n1flu/masks.htm" http://www.cdc.gov/h1n1flu/masks.htm In areas with confirmed human cases of novel influenza A (H1N1) virus infection, the risk for infection can be reduced through a combination of actions. No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These recommended actions include: respiratory hygiene; isolation of those with ILI; and others avoiding contact within 6 feet of those with ILI. For health care settings, see CDC guidance and OSHA standards. If you are someone at risk for complications from influenza: consider wearing a mask in an unavoidable crowded setting where there is H1N1 transmission in the geographical area/community or when having to care for a household members with ILI. If you are ill with ILI, consider a face mask if you need to be around others (within 6 feet) such as breastfeeding or going to a doctors appointment. SCHOOL MITIGATION: Summary: If H1N1 severity is same as Spring, 2009: Stay home when sick. Quickly separate ill staff and students Emphasize respiratory hygiene Routine cleaning Early treatment of high-risk who are ill Consider selective school dismissal If H1N1 severity increases: Active screening for fever High-risk students and staff stay home Those with ill household member stay home Increased social distancing Extend isolation period to >7 days Consider school dismissal reactive vs preemptive Details: Recommended school responses for the 2009-2010 school year Under conditions with similar severity as in spring 2009  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "stayhome" Stay home when sick: Those with flu-like illness should stay home for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines. They should stay home even if they are using antiviral drugs. (For more information, visit  HYPERLINK "http://www.cdc.gov/h1n1flu/guidance/exclusion.htm" http://www.cdc.gov/h1n1flu/guidance/exclusion.htm.)  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "sepill" Separate ill students and staff: Students and staff who appear to have flu-like illness should be sent to a room separate from others until they can be sent home. CDC recommends that they wear a surgical mask, if possible, and that those who care for ill students and staff wear protective gear such as a mask.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "hand" Hand hygiene and respiratory etiquette: The new recommendations emphasize the importance of the basic foundations of influenza prevention: stay home when sick, wash hands frequently with soap and water when possible, and cover noses and mouths with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available).  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "routine" Routine cleaning: School staff should routinely clean areas that students and staff touch often with the cleaners they typically use. Special cleaning with bleach and other non-detergent-based cleaners is not necessary.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "early" Early treatment of high-risk students and staff: People at high risk for influenza complications who become ill with influenza-like illness should speak with their health care provider as soon as possible. Early treatment with antiviral medications is very important for people at high risk because it can prevent hospitalizations and deaths. People at high risk include those who are pregnant, have asthma or diabetes, have compromised immune systems, or have neuromuscular diseases.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "seldismiss" Consideration of selective school dismissal: Although there are not many schools where all or most students are at high risk (for example, schools for medically fragile children or for pregnant students) a community might decide to dismiss such a school to better protect these high-risk students. Under conditions of increased severity compared with spring 2009  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "screen" Active screening: Schools should check students and staff for fever and other symptoms of flu when they get to school in the morning, separate those who are ill, and send them home as soon as possible. Throughout the day, staff should be vigilant in identifying students and other staff who appear ill.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "highrisk" High-risk students and staff members stay home: People at high-risk of flu complications should talk to their doctor about staying home from school when a lot of flu is circulating in the community. Schools should plan now for ways to continue educating students who stay home through instructional phone calls, homework packets, internet lessons, and other approaches.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "illhouse" Students with ill household members stay home: Students who have an ill household member should stay home for five days from the day the first household member got sick. This is the time period they are most likely to get sick themselves.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "distance" Increase distance between people at schools: CDC encourages schools to try innovative ways of separating students. These can be as simple as moving desks farther apart or canceling classes that bring together children from different classrooms.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "exclude" Extend the period for ill persons to stay home: If influenza severity increases, people with flu-like illness should stay home for at least 7 days, even if they have no more symptoms. If people are still sick, they should stay home until 24 hours after they have no symptoms.  HYPERLINK "http://www.flu.gov/plan/school/k12techreport.html" \l "dismiss" School dismissals: School and health officials should work closely to balance the risks of flu in their community with the disruption dismissals will cause in both education and the wider community. The length of time schools should be dismissed will vary depending on the type of dismissal as well as the severity and extent of illness. Schools that dismiss students should do so for five to seven calendar days and should reassess whether or not to resume classes after that period. Schools that dismiss students should remain open to teachers and staff so they can continue to provide instruction through other means. Reactivedismissals might be appropriate when schools are not able to maintain normal functioning for example, when a significant number and proportion of students have documented fever while at school despite recommendations to keep ill children home. Preemptive dismissals can be used proactively to decrease the spread of flu. CDC may recommend preemptive school dismissals if the flu starts to cause severe disease in a significantly larger proportion of those affected. TREATMENT: What should I do if I get sick? If you live in areas where people have been identified with novel H1N1 flu and become ill with influenza-like symptoms, including fever, body aches, runny or stuffy nose, sore throat, nausea, or vomiting or diarrhea, you should stay home and avoid contact with other people. HYPERLINK "http://www.cdc.gov/h1n1flu/guidance/exclusion.htm"  CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.) Stay away from others as much as possible to keep from making others sick. Staying at home means that you should not leave your home except to seek medical care. This means avoiding normal activities, including work, school, travel, shopping, social events, and public gatherings. If you have severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed. If you become ill and experience any of the following warning signs, seek emergency medical care. In children, emergency warning signs that need urgent medical attention include: Fast breathing or trouble breathing Bluish or gray skin color Not drinking enough fluids Severe or persistent vomiting Not waking up or not interacting Being so irritable that the child does not want to be held Flu-like symptoms improve but then return with fever and worse cough In adult, emergency warning signs that need urgent medical attention include: Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting Flu-like symptoms improve but then return with fever and worse cough If someone in my household has novel H1N1 flu, should I go to work? Employees who are well but who have an ill family member at home with novel H1N1 flu can go to work as usual. These employees should monitor their health every day, and take everyday precautions including washing their hands often with soap and water, especially after they cough or sneeze. Alcohol-based hand cleaners are also effective.* If they become ill, they should notify their supervisor and stay home. Employees who have an underlying medical condition or who are pregnant should call their health care provider for advice, because they might need to receive influenza antiviral drugs to prevent illness. For more information please see  HYPERLINK "http://www.cdc.gov/h1n1flu/guidance/workplace.htm" General Business and Workplace Guidance for the Prevention of Novel Influenza A (H1N1) Flu in Workers. Are there medicines to treat novel H1N1 infection? Yes. CDC recommends the use of oseltamivir (Tamiflu) or zanamivir (Relenza) for the treatment and/or prevention of infection with novel H1N1 flu virus. Antiviral drugs are prescription medicines (pills, liquid or an inhaled powder) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. During the current pandemic, the priority use for  HYPERLINK "http://www.cdc.gov/h1n1flu/recommendations.htm" influenza antiviral drugs during is to treat severe influenza illness (for example hospitalized patients) and people who are sick who have a condition that places them at high risk for serious flu-related complications. VACCINATION Seasonal flu vaccine Expected in September Will begin prior to H1N1 vaccination program Usual recommendations for who should get it H1N1 flu vaccine Initial supply expected in fall Human trials currently underway Likely two shots, one month apart Given to priority groups first SEASONAL VACCINE: What is in the seasonal influenza vaccine? The flu shot vaccine contains inactivated strains of influenza viruses from three groups - one A (H3N2) virus, one A (H1N1) virus, and one B virus. Ongoing genetic changes in influenza viruses must be reflected in the composition of the influenza vaccine for each year. The World Health Organization's (WHO) Global Influenza Surveillance Network, a partnership of 112 National Influenza Centers in 83 countries, continually monitors viral strains found circulating in humans. Each year, WHO recommends a vaccine recipe that targets the three most active virulent strains worldwide. What are the recommendations for seasonal flu vaccine this year? CDC recommends that people will start to go out and get vaccinated against seasonal influenza as soon possible as vaccines become available at their doctors offices and in their communities (this may be as early as August for some). The seasonal flu vaccine is unlikely to provide protection against novel H1N1 influenza. Who should get vaccinated this season? In general, anyone who wants to reduce their chances of getting the flu can get vaccinated. However, it is recommended by CDC and the Advisory Committee on Immunization Practices (ACIP) that certain people should get vaccinated each year. Most of these people are recommended for vaccination because they are at high risk of having serious flu complications or they live with or care for people at high risk for serious complications. People recommended for seasonal influenza vaccination during the 2009-10 season remain the same as the previous season: Children aged 6 months up to their 19th birthday Pregnant women People 50 years of age and older People of any age with certain chronic medical conditions People who live in nursing homes and other long-term care facilities People who live with or care for those at high risk for complications from flu, including: Health care workers Household contacts of persons at high risk for complications from the flu Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated) H1N1 VACCINE:  HYPERLINK "http://www.cdc.gov/h1n1flu/vaccination/statelocal/qa.htm" http://www.cdc.gov/h1n1flu/vaccination/statelocal/qa.htm What about the recommendations for the expected H1N1 vaccine? However a novel H1N1 vaccine is currently in production and may be ready for the public in the fall. The novel H1N1 vaccine is not intended to replace the seasonal flu vaccine. CDCs Advisory Committee on Immunization Practices (ACIP), a panel made up of medical and public health experts, met July 29, 2009, to make recommendations on who should receive the new H1N1 vaccine when it becomes available. While some issues are still unknown, such as how severe the virus will be during the fall and winter months, the ACIP considered several factors, including current disease patterns, populations most at-risk for severe illness based on current trends in illness, hospitalizations and deaths, how much vaccine is expected to be available, and the timing of vaccine availability. The groups recommended to receive the novel H1N1 influenza vaccine include: Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated; Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by cocooning them from the virus; Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity; All people from 6 months through 24 years of age Children from 6 months through 18 years of age because we have seen many cases of novel H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and, Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza. Some prioritization can be done within these groups if needed: 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. Once the demand for vaccine for the prioritized groups has been met at the local level, programs and providers should also begin vaccinating everyone from the ages of 25 through 64 years. Current studies indicate that the risk for infection among persons age 65 or older is less than the risk for younger age groups. However, once vaccine demand among younger age groups has been met, programs and providers should offer vaccination to people 65 or older. Im in a high priority group and I dont want the vaccine; or Im not in the high priority group and I do want the vaccine. This is similar to if one has a household with 6 family members: policeman; his wife who is a nurse; his elderly mother; their pregnant daughter and her partner; and toddler child (grandchild of the policeman and nurse). There is only vaccine for 3 people in the household at this time, though sufficient supplies for everyone are eventually expected. Knowing that pregnant women and children are being disproportionately affected by H1N1 and knowing that nurses are contracting it from patients and can transmit it to vulnerable patients, it seems logical that the vaccine first go to the pregnant daughter, toddler grandchild, and nurse. In most circumstances the policeman, grandmother, and daughters partner are going to understand. This story is then played out across the state and across the country where vaccine supplies are expected to be sufficient eventually for everyone, but with the first few shipments, it makes sense to provide it to those who are being disproportionately affected or can transmit it to those who are. Will this vaccine be mandatory? At this point in time there does not appear to be a reason to mandate it for the general public. Current Maine law requires health care facilities such as nursing homes and hospitals to adopt policies that offer influenza vaccine to direct care staff on an annual basis. It is unclear if this applies to H1N1 vaccine, but certainly it is our desire for all health care staff to be at least offered the vaccine. Currently, there are 4 vaccines required for K-12 schools. Influenza is not one of them. How will I know to where to obtain one? We expect to have a media campaign to announce this. You can also find out from our website and most likely local health care providers. May I get the seasonal vaccine at the same time as the H1N1 vaccine? Clinical trials are exploring this question. It is anticipated that seasonal vaccine and novel H1N1 vaccines may be administered together. Will it have thimerosal? There will be some thimerosal-free vaccine for young children and pregnant women. Most of the vaccine will be in mulit-dose vials, and will have some thimerosal. What about the clinical trials? They are happening now, and will be used to determine if the dosage can be stretched out. The H1N1 vaccine is being manufactured very similarly as seasonal flu vaccine, which does not go through clinical trials every year. The trials are designed to help answer the following: How large a vaccine dose, and how many doses of vaccine, are needed to induce an immune response that is predictive of protection? Can 2009 H1N1 influenza vaccine be safely administered at the same time or sequentially with the seasonal flu vaccine, and will both vaccines induce protective immune response. Are these vaccines safe in healthy people of various ages? Q&A on Clinical Trials on H1N1 Vaccine:  HYPERLINK "http://www3.niaid.nih.gov/news/QA/vteuH1N1qa.htm" http://www3.niaid.nih.gov/news/QA/vteuH1N1qa.htm Will it have an adjuvant? It is unlikely H1N1 vaccine will be adjuvanted. Definitive information will be available once clinical trial data are available. If it has an adjuvant, formulation will vary by provider. For Novartis, vaccine may be preformulated with adjuvant. For CSL, GSK and Sanofi Pasteur, mixing of vaccine and adjuvant at the site of administration will be necessary. Specific information on storage requirements and procedures for mixing vaccine and adjuvant will be provided by CDC. Medimmune vaccine will not be adjuvanted. Will the vaccine be administered under EUA (Emergency Use Authorization)? EUA will not be used for unadjuvanted vaccine if FDA licenses the vaccine under the current BLA (Biologics License Application) as a strain change. What about the 1976 swine flu and vaccine safety concerns? Background on 1976 swine flu: In early 1976, the novel A/New Jersey/76 (Hsw1N1) influenza virus caused severe respiratory illness in 13 soldiers with 1 death at Fort Dix, New Jersey. Since A/New Jersey (H1N1) was similar to the 19181919 pandemic virus (also a H1N1 strain), rapid outbreak assessment and enhanced surveillance were initiated. Up to 230 soldiers were infected with the A/New Jersey virus. Cases of swine flu strain of H1N1 were found only among the Fort Dix Army personnel and in January and early February of 1976. No other evidence of transmission was found. GBS: Guillain-Barr Syndrome is a disorder in which the body's immune system attacks part of the peripheral nervous system, causing (primarily) temporary weakness and paralysis. The epidemiology of Guillain-Barr syndrome (GBS) indicates that the crude annual incidence rate of GBS is about 1 per 100,000 people. In general, incidence rates are higher with advancing age until about 75 years. 2/3 of GBS occur several days to weeks after an infectious event, most commonly a viral diarrheal or upper respiratory infection. Important trigger agents of GBS include nonspecific respiratory and gastrointestinal infections and cytomegalovirus infection. Influenza like illness (ILI) is also associated with GBS, and reported at a higher rate than influenza vaccine. GBS and Influenza Vaccine: Influenza vaccine is not felt to be a major trigger for GBS, but a major exception to this is the occurrence of just under 1 excess case of GBS per 100,000 A/New Jersey influenza vaccinations administered in the United States, 1976-1977. Subsequent studies of GBS and influenza vaccine have not shown statistically significant and consistent excess cases of GBS with influenza vaccine, though an analysis of the 1992-1992, 1993-1994 influenza seasons (after reports of possible increased GBS) indicated a possible excess of 1 case of GBS per million vaccine. A 2004 JAMA review of VAERS (vaccine adverse events reporting system) shows reports of GBS associated with influenza vaccine have decreased since 1990. GBS in general has decreased, along with one of its strongest associated infections, campylobacter, which has seen reductions thought to be the result of improved food safety, especially in the poultry industry. H1N1 Vaccine and GBS Monitoring: VAERS and enhanced active surveillance are being used this fall to determine any excess GBS associated with H1N1 vaccine We must constantly weigh risks and benefits of vaccine with the risks of the disease. At this point, about 500 people in the U.S., mostly young people, have died of H1N1 disease, and there is ongoing transmission across most of the globe. Guillain-Barre Syndrome Fact Sheet  HYPERLINK "http://www.ninds.nih.gov/disorders/gbs/gbs.htm" http://www.ninds.nih.gov/disorders/gbs/gbs.htm Swine Influenza A Outbreak, Fort Dix, NJ 1976; January, 2006  HYPERLINK "http://www.cdc.gov/ncidod/EID/vol12no01/05-0965.htm" http://www.cdc.gov/ncidod/EID/vol12no01/05-0965.htm Reflections of the 1976 Swine Flu Vaccination Program by former directors of US CDC and National Influenza Immunization Program, January, 2006  HYPERLINK "http://www.cdc.gov/ncidod/eid/vol12no01/05-1007.htm#1" http://www.cdc.gov/ncidod/eid/vol12no01/05-1007.htm#1 GBS Epidemiology with Influenza Vaccine  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/7224614?dopt=Abstract" http://www.ncbi.nlm.nih.gov/pubmed/7224614?dopt=Abstract GBS Following Influenza Vaccine 2004 JAMA  HYPERLINK "http://jama.ama-assn.org/cgi/content/full/292/20/2478" http://jama.ama-assn.org/cgi/content/full/292/20/2478 American Journal of Epidemiology 2008 article on GBS and ILI and influenza vaccine  HYPERLINK "http://aje.oxfordjournals.org/cgi/content/abstract/169/3/382" http://aje.oxfordjournals.org/cgi/content/abstract/169/3/382 Emerging Infectious Disease article on association between Influenza A and other infections with GBS, 2006  HYPERLINK "http://www.cdc.gov/ncidod/EId/vol12no12/05-1032.htm" http://www.cdc.gov/ncidod/EId/vol12no12/05-1032.htm Journal of Infectious Disease, 2008 article on GBS and Influenza Vaccine  HYPERLINK "http://www.journals.uchicago.edu/doi/abs/10.1086/589624" http://www.journals.uchicago.edu/doi/abs/10.1086/589624 What will the vaccine cost? The vaccine and supplies are being distributed as a free federal resource. It is being determined how much a vaccine can charge for administering the vaccine. Will health care providers get reimbursed? It is expected that providers will be reimbursed by MaineCare, Medicare, and insurers who normally reimburse for vaccine administration, but this is all being worked on. Our Insurance Superintendent has done a great job working with insurers, and they have also stepped up to the plate. So far, Anthem, Cigna, Aetna, and Harvard Pilgrim say they will be covering the H1N1 vaccine. What about those who cannot pay? Maine CDC is working with partners to identify free sites of vaccine administration such as public vaccine clinics and sites of free health care. What about vaccine supplies? Needles, syringes, sharps containers, and alcohol swabs are planned to be shipped with vaccine. How much vaccine is expected to be shipped? At this point in time, it appears ~180,000 doses may be first shipped in mid-October to Maine, followed by ~80,000 doses per week. How will it be distributed? Maine CDC is working with many health care partners to determine the details of this. Maine CDC already distributes several million doses of vaccine every year, so is likely to use commonly used channels as well as others. Who will administer it? To be determined, and afternoon tabletop exercises to help determine. What settings will it be administered? To be determined, and afternoon tabletop exercises to help determine. What about active military and tribal members? DOD will vaccinate active military State and local need to plan with Tribes What data will be collected by US CDC? Minimum data requirements include age group, 1st or 2nd dose, date of vaccination, and state. PRIORITY POPULATIONS FOR H1N1 VACCINE 8,500 1% Pregnant women 18,500 3% Caregivers of infants <6 months old 390,000 64% 6 months to 25 years of age 155,000 25% 25 to 65 year olds with chronic conditions 37,000 6% Health care workers 6,000 1% EMS 615,000 TOTAL LICENSE ALLOWS TO VACCINATE 3,800 15% Physicians (MDs and DOs) 19,000 74% Nurses 500 2% Physician Assistants 200 1% Pharmacists (1,100 total, but new law 9/12/09) 2,000 8% EMS 25,500 TOTAL (plus 660 dentists who can give injections) Common Settings: Health care settings Schools Employment settings Retail Day care, WIC, preschools Large scale clinics Homes Other Highest priorities: pregnant women, caregivers for young infants, HCWs/EMS with direct patient contact, young children (<5 yo), and children 5 18 with chronic conditions Ballpark Figures Assumptions likely to change 2 doses of vaccine x 615,000 priority population x 70% = 861,000 shots 861,000 divided by 2,500 likely willing and able vaccinators = 350 shots per vaccinator for high-risk population 2 doses of vaccine x 1.3 million total population x 85% = 2.21 million shots 2.21 million shots divided y 2,500 likely willing and able vaccinators = 884 shots per vaccinator for most Mainers Maine Bureau of Insurance: health emergency preparedness August 16, 2009 The Bureau of Insurance has taken steps to ensure that all insurers in Maine are adequately prepared to deal with public emergencies. Bulletin 358: In June 2009 the Bureau issued Bulletin 358 to all insurance companies reminding them that they are required to have business continuity plans to ensure that there is no disruption in service to their customers during and after a disaster, including a public health emergency.  HYPERLINK "http://www.maine.gov/pfr/insurance/bulletins/358.htm" http://www.maine.gov/pfr/insurance/bulletins/358.htm Emergency Rule 765 Health Insurance Emergency Planning and Procedures: After an assessment of the health insurance companies readiness to operate during a public health disaster and in consultation with the Maine CDC, on June 16, 2009 the Bureau issued Emergency Rule 765. It is in effect for 90 days.  HYPERLINK "http://www.maine.gov/pfr/insurance/rules/765.htm" http://www.maine.gov/pfr/insurance/rules/765.htm The emergency rule requires health insurers to remove barriers for their members who need to access medical care and services should a large-scale public health problem occur. In the event the Governor declares a public health emergency, and the Superintendent of Insurance then issues the direction, each health insurer must be able to: Suspend plan rules for prior medical authorization, pre-certification, and utilization review; Suspend plan rules for accessing prescription drugs, including prior approval requirements, refill limitations, and co-payments; Suspend incentives or requirements for enrollees to obtain health services from contracted network providers; Waive rate increases, extend grace periods, extend coverage for employees losing group coverage, and ease enrollment requirements; Waive cost barriers for accessing needed services, including co-payments, co-insurance, and deductibles; and Waive time limits for filing claims. In addition, health insurers must submit specific information to the Bureau, including how the carrier will increase coordination with public agencies should a health emergency develop, and provide assurance that each health insurer is ready to address the emergency. Proposed permanent rule has been filed with the Secretary of State. The Bureau held a public hearing on August 5, 2009, and will continue collecting written comments from stakeholders until August 17, 2009. The Bureau intends to implement the permanent rule by the time Rule 765 expires in mid-September. NAIC: The Bureau is working with insurance regulators in other states through the National Association of Insurance Commissioners (NAIC) to encourage a more coordinated effort from insurance regulators around the nation. COMMUNICATION What do we know? What do we not know? What are we doing about it. What you can do. Who is your audience: young people, pregnant women, immigrants, those without access to health care, those with disabilities, etc Think of whom you are not reaching and who are most vulnerable STAY INFORMED! Maine State Govt  HYPERLINK "http://www.maineflu.gov" www.maineflu.gov Wednesday Updates Subscribe to Health Advisories Maine CDC Facebook, Twitter, My Space, Blog Maine CDC Conference Calls Call or Email Maine CDC US CDC  HYPERLINK "http://www.cdc.gov/h1n1flu/" \o "http://www.cdc.gov/h1n1flu/" http://www.cdc.gov/h1n1flu/ Federal H1N1 HYPERLINK "http://www.flu.gov/" http://www.flu.gov/ 1918 Pandemic (H1N1) 5,000 deaths in Maine 500,000 deaths in US 40 million worldwide 5 10% of the worlds young people More deaths in soldiers in a 6 week period due to influenza in WWI than several years of combat 1957 Pandemic (H2N2) 70,000 deaths in US 1 2 million worldwide 1968 Pandemic (H3N2) 34,000 deaths in US 700,000 worldwide Maine Estimates Severe Pandemic (1918 like): 390,000 ill 40,000 hospitalized 9,100 deaths Moderate Pandemic (1957/1968 like): 390,000 ill 5,000 hospitalized 1,100 deaths   stu|% & ' B O ` a  xlaTaTahwIheD0JCJaJhwIheDCJaJhwIheD5CJaJhwIhJt5>*CJaJhwIhh5>*CJaJhwIh5>*CJaJ hwIhy3 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hZdcBi>iW#jx,k%nkS6ZPLyk~{<45k$G#j)l7+W}lP'Lanm:=o~{<?QolEto-vdoc?ZdplEjpU{*zP#p#A=CCp1hhwqu`!pr&Xt?Y.Rt0#tm^uXu?0ffffffgu%NIvT2-v=_LoSHwx eby~{<rfzjdOZdU{*z9+d5z#c`vqAz#j{'zP',{)_9'Qo{)2})o{w%Z={{'X{wXF/} &a~ _oqS%?QA16h]J9331G y3JHR9hk_QZ??gM!+":#7^$ %u&?]&a(7)w*(8./3Q3@4f5b95~:;nD={Q@ZDeDE 5GjPJIP)P7QGTooU9}ZMG]_3_u_`oak}a1cjyc,i+jfktn/tFurvsovz#zQNzw|w|+>}`~X~ct5bgIrYD#"^,9LV |2CZHY3r<!I-KdVi3au1CKWLmJt_TwI 7TB5.F_{~Nn^lJB<6U/b~@aa; aa)P@UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New;Wingdings"qh{fئt!rt!r!24d 2qHX-?=2Still, the authors urge that the 2009 H1N1 virus continue to be closely tracked and studied as the usual influenza season in the Northern Hemisphere draws nearOITState of Maine*                           ! " # $ % & ' ( ) Oh+'0 @LXdp    Still, the authors urge that the 2009 H1N1 virus continue to be closely tracked and studied as the usual influenza season in the Northern Hemisphere draws nearOIT Normal.dotState of Maine6Microsoft Office Word@Ik@jA!@"t!՜.+,D՜.+, hp  $Office of Information Technologyr' Still, the authors urge that the 2009 H1N1 virus continue to be closely tracked and studied as the usual influenza season in the Northern Hemisphere draws near Title 8@ _PID_HLINKSA@})lhttp://www.flu.gov/ 6/ihttp://www.cdc.gov/h1n1flu/ ]Hfhttp://www.maineflu.gov/ Pc1http://www.maine.gov/pfr/insurance/rules/765.htm  E`5http://www.maine.gov/pfr/insurance/bulletins/358.htm 64]8http://www.journals.uchicago.edu/doi/abs/10.1086/589624 :xZ4http://www.cdc.gov/ncidod/EId/vol12no12/05-1032.htm  W=http://aje.oxfordjournals.org/cgi/content/abstract/169/3/382 JGT6http://jama.ama-assn.org/cgi/content/full/292/20/2478 Q9http://www.ncbi.nlm.nih.gov/pubmed/7224614?dopt=Abstract  zN4http://www.cdc.gov/ncidod/eid/vol12no01/05-1007.htm17}K4http://www.cdc.gov/ncidod/EID/vol12no01/05-0965.htm >9H/http://www.ninds.nih.gov/disorders/gbs/gbs.htm XE1http://www3.niaid.nih.gov/news/QA/vteuH1N1qa.htm  B9http://www.cdc.gov/h1n1flu/vaccination/statelocal/qa.htm ,??/http://www.cdc.gov/h1n1flu/recommendations.htm ]<2http://www.cdc.gov/h1n1flu/guidance/workplace.htm ^92http://www.cdc.gov/h1n1flu/guidance/exclusion.htm y/62http://www.flu.gov/plan/school/k12techreport.htmldismisst(32http://www.flu.gov/plan/school/k12techreport.htmlexcludeN02http://www.flu.gov/plan/school/k12techreport.html distanceL-2http://www.flu.gov/plan/school/k12techreport.html illhouse [*2http://www.flu.gov/plan/school/k12techreport.html highriskc0'2http://www.flu.gov/plan/school/k12techreport.htmlscreeno0$2http://www.flu.gov/plan/school/k12techreport.html seldismissU!2http://www.flu.gov/plan/school/k12techreport.htmlearlyi-2http://www.flu.gov/plan/school/k12techreport.htmlroutine]2http://www.flu.gov/plan/school/k12techreport.htmlhandh82http://www.flu.gov/plan/school/k12techreport.htmlsepill^2http://www.cdc.gov/h1n1flu/guidance/exclusion.htm _2http://www.flu.gov/plan/school/k12techreport.html stayhomeIG%http://www.cdc.gov/h1n1flu/masks.htm iv <http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm  _ http://www.coughsafe.com/ e/3http://www.maine.gov/dhhs/boh/swine-flu-2009.shtml ]Hhttp://www.maineflu.gov/ #=Shttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61304-0/abstract   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abdefghijlmnopqrstuvw|Root Entry FƗ"~Data 1Table`HWordDocument.bSummaryInformation(cDocumentSummaryInformation8ktCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q