Seasonal Influenza Prevention and Control: Strategies for Head Start and Child Care Programs The National Center on Health and Healthy Child Care America Henry (Hank) Bernstein, DO, MHCM, FAAP Timothy R. Shope, MD, MPH, FAAP August 22, 2013 1

Webinar Objectives 1. Discuss why influenza (the flu) can be serious in children. 2. Describe flu recommendations and clarify why it’s important to aim for universal immunization of children and caregivers who spend time in Head Start and other early education and child settings. 3. Identify strategies that can be used in child care settings to prevent or control the spread of influenza.

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Why Are Young Children at Risk for Infectious Diseases? • • • • •

Exposure to germs for the first time Young immune systems Tend to touch everything and put hands/objects in mouth Spread germs easily by playing and eating close together Caregivers (and children) don’t always: • Wash hands • Cover their cough • Get vaccinated • Stay home when ill

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Estimated Vaccine-Preventable Disease Incidence and Deaths in the US Disease

Annual Cases

Annual Deaths

Influenzaa,b

61,000,000c (‘09)

3,349–48,614 (‘76– ‘07)

Pneumococcal disease, invasive (bacteremia & meningitis)d

42,000 (‘07)

4,500 (‘07)

HPVe (cervical cancer)

10,520 (‘04)

3,900 (‘04)

Hepatitis Bf

4,519 (‘07)

719 (‘07)

Meningococcal diseasef

1,077 (‘07)

87 (‘07)

Hepatitis Af

2,979 (‘07)

34 (‘07)

Varicellaf (chickenpox)

40,146 (‘07)

14 (‘07)

Pertussisf

10,454 (‘07)

9 (‘07)

a CDC.

Updated CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations, and Deaths in the US. April 2009 – April 10, 2010. Available at cdc.gov/h1n1flu/estimates)2009_h1n1.htm. MMWR. 2010: 59 (22): 1057-62. C Data based on CDC estimates of 2009 H1N1 cases using statistical modeling. d CDC. ABCs Report: Streptococcus pneumoniae, 2007 Available at http://www.cdc.gov/abcs/reports-findings/survreports/spneu04.html. e American Cancer Society. Cancer Facts and Figures 2004. Available at cancer.org/downloads/STT/CAFF_finalPWSecured.pdf. f CDC. Pink Book. 12th ed. Available at http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. b

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Influenza (Flu) – What is it? •Viral infection of breathing system (nose, throat and lungs) •Spread easily from person to person •Signs or symptoms include: oSudden fever oHeadache oBody aches oChills oSore throat oStuffy, runny nose

oDry, hacking cough oLess energy than usual oBelly pain oNausea/vomiting oDiarrhea oPinkeye

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Influenza – How Does it Spread?

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“Don’t Worry…I’m not Contagious!” Did you know… • Adults and children spread infection when: o infected but not showing signs of illness o developing an illness (incubation) o recovering from illness (viral shedding) • This makes it challenging to control the spread of germs

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“Don’t Worry…I’m not Contagious!” •Incubation period o 1 - 4 days •Contagious period o Begins the day before symptoms appear o Lasts 7+ days after onset •Viral shedding

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Cold

Flu

Yes

Yes

Symptoms

Mild (runny/stuffy nose)

More intense (fever, body aches, and more)

Can lead to hospitalization or death?

No

Yes

Vaccine Available?

No

Yes

Can identify with a test?

No

Yes

Respiratory Virus?

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Influenza Disease Burden in the US in an Average Year Deathsa 3,349–48,614

Hospitalizationsb 117,000–816,000

Physician visits ~25 million Infections and illnesses 50–60 million a

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MMWR. 2010: 59(22):1057–1062. hospitalization and mortality associated with influenza virus infection. Thompson WW, et al. JAMA. 2003;289:179; Thompson WW, et al. JAMA. 2004;292:1333; Couch RB. Ann Intern Med. 2000;133:992; Patriarca PA. JAMA. 1999;282:75;ACIP. MMWR. 2004;53(RR06):1. B All-cause

2012-13 US Influenza Season (compared with 2011-2012)

• • • •

Influenza A (H3N2) most common strain ↑ outpatient visits for influenza-like illness (ILI) ↑ rates of hospitalizations ↑ deaths from pneumonia and influenza

MMWR. 2012: 62(23);473-479

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Selected underlying medical conditions in patients hospitalized w/ influenza, 2012-2013

45% of hospitalized children were HEALTHY

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Influenza is Unpredictable! Outbreak • Sudden rise in the cases of a disease (eg, bronchiolitis, hand-foot-and-mouth disease, influenza) Epidemic • More cases of disease than would be expected in a community/region during a given period • Cannot be explained by expected seasonal increases Pandemic • Epidemic that spreads through populations world-wide

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The ABC’s of Influenza

Seasonal flu

Swine flu

• A (H1N1; H3N2) • B (2 types)

• H1N1 • H3N2v

Avian flu • H5N1 • H7N9

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Quiz There are ___ new strains in the seasonal influenza vaccine for 2013-2014. A. B. C. D.

0 1 2 3

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2013-2014 Seasonal Influenza Vaccine Strains Trivalent • A/California/7/2009 (H1N1)pdm09-like virus • A/Texas/50/2012 (H3N2)-like virus* • B/Massachusetts/2/2012 virus (from last year’s B/Yamagata lineage of viruses)*

Quadrivalent •Adds B/Brisbane/60/2008-like virus (B/Victoria lineage)*

*2-3 strains different from last season 17

Types of Influenza Vaccine • Shot: Inactivated Influenza Vaccine (IIV) o In the muscle (intramuscular) o Under the skin (intradermal) • Nasal Spray: Live-Attenuated Influenza Vaccine (LAIV4)

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Quiz For whom is influenza vaccine NOT recommended? A. B. C. D. E. F. G.

Pregnant women, regardless of trimester Women who are breastfeeding Infants under 6 months of age Health care personnel Household contacts of healthy children < 5 years of age Household contacts of children with high risk conditions Children and adults with egg allergy

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All people 6 months of age and older should get flu vaccine every year

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Special Populations to Reach

Children

Household Contacts of High Risk Children and All Children $10 billion/year • Adults spread disease to children

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Cocooning Makes Sense Vaccination strategy which aims to protect children from disease by immunizing caregivers:

Vaccinate Caregiver

Less Infections in Caregiver

Decreased Children’s Exposure to Disease

Decreased Infection in Children

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Influenza Vaccination Rates for Adults Early 2012-13 Season

26%

59% Adults ≥ 65 yearsa

Adults 18-64 yearsa

47% Pregnant Womenb A NIS

67% Health Care Personnelc

and NFS, Nov 2012. http://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2012.htm. CDC Internet Panel Surveys. http://www.cdc.gov/flu/fluvaxview/pregnant-women-2012.htm. c CDC Internet Panel Surveys: http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm. b

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• 67% of HCP were vaccinated • 21% of HCP reported a hospital requirement for vaccination • Flu vaccine rates for HCP when o Vaccine is required: 95% o No vaccine is required: 68% • Higher coverage when vaccine offered: o On-site o Free of charge o On more than 1 day 29

Antiviral Medications Expected 2013–2014 Viruses

Adamantanes

Oseltamivir

Zanamivir

(Amantadine/Rimantadine)

(Tamiflu)

(Relenza)

Resistant

Susceptible

Susceptible

Seasonal influenza A (H3N2) virus

Resistant

Susceptible

Susceptible

Seasonal influenza B virus (either lineage)

Resistant

Susceptible

Susceptible

Seasonal influenza A (H1N1) virus (derived from 2009 pandemic)

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New Horizons for Influenza Vaccinology

H3N2v

Vaccine Effectiveness •High Dose •Adjuvant

Age-specific Vaccine Preference

H7N9

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What is unique about young children in early education settings and influenza? • Younger children at higher risk of influenza complications – death, hospitalization, school absence, doctor visits, ear infections • Less “social distancing” and hygiene • Influenza is spread by coughing, sneezing, and touching things • Children bring influenza home to families and spread it into communities

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How can we control influenza in HS/EHS and child care settings?

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Possible Answers • Immunize • Infection control • Exclusion (denying admission of an ill child or staff member to a facility or asking them to leave if they are already present)

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Quiz Which is the most effective method for preventing influenza in child care settings? A. Immunization B. Infection control C. Exclusion

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Answer: Immunization! Efficacy in Reducing Influenza 90 80 70 60 50

?

40 30 20 10 0 Immunization

Infection Control

Exclusion 36

Influenza Immunization • Influenza immunization • Intranasal vaccine (LAIV – only for children 2 yrs and older) more effective in young children ~86-96% • Shot (Inactivated) ~70% • Chances of getting influenza without immunization • Children who get sick from flu yearly ~10-40% • Children in child care who get infected in a flu season > 50%

Weycher, Vaccine 2005; DiazGranados, Vaccine 2012; Hurwitz, JID, 2000; Redbook, 2012

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Infection Control How does influenza spread?

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Answer • Influenza spreads by droplets projected into the air from coughing and sneezing • To a lesser extent, it is also spread by those droplets falling onto surfaces and being touched by others

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Infection Control • • • •

Hand hygiene Surface cleaning, sanitizing and disinfecting Cough, sneeze etiquette Recommendations covered extensively in Caring for Our Children, 3rd Edition at: http://cfoc.nrckids.org/StandardView/3.3 (FYI: New CFOC searchable database!) 40

How Good is Infection Control in Reducing Respiratory Illness? • Pretty good for school age children (>50%) • Not very good for 0-5 year olds • 35% reduction in influenza-like illness with hourly hand sanitizer use. Every two hours insufficient. Hand sanitizer for children the only change. No effect on absence. (Pandejpong, 2012) • 17% reduction in respiratory illness only in children < 2yrs (Roberts, 2000) • Other studies show only ~10% decrease in absence (Uhari 1999; Lennell 2008) 41

Infection Control to Prevent Influenza? • Still should do it all the time • Regimen should not change for influenza season • Helps to preventing other infections • More effective at reducing diarrhea viruses • More frequent alcohol-based hand sanitizer or hand washing may help a little • But airborne spread limits protection against influenza 42

Exclusion • Should not exclude solely for prevention of spread

• Can’t tell who has influenza versus common cold viruses • Influenza virus may be shed (child is still infectious) up to two weeks • Lots of children are infected and are infectious with influenza but don’t show symptoms

• Should exclude if the child

• Is unable to participate in normal activities • Requires too much care for staff to be able to care for the ill child and attend to the needs of others • Meets other exclusion criteria as described in Managing Infectious Diseases, 3rd ed.

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How do we increase immunization rates in child care settings? • Staff (adults) • Children

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Importance of Staff (Adult) Influenza Immunizations • Duty to protect children staff care for, especially those < 6 months • Not solely an individual decision (cocooning) • Some health care systems require influenza vaccine as a condition of employment • Prevent illness and lost work • Prevent spread into community

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Increasing Staff Flu Immunization Rates Top Reasons Adults Don’t Get Influenza Immunizations: • Belief that healthy people don’t need it • Lack of physician recommendation • Fear of vaccine side effects • Infrequent physician visits • Afraid of needles • Cost or inconvenience

Nowalk, AJPM, 2010

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Increasing Staff Immunization Rates Top Methods to Improve Influenza Immunizations: • Improve access to immunizations • Eliminate costs and/or provide incentives

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Recommended Strategy for Increasing Influenza Vaccine Among Adults • Inform staff about influenza vaccine recommendations • Arrange for and advertise on-site influenza vaccination • Try to reduce barriers such as fear of side effects, cost and inconvenience • Help establish the habit of yearly flu vaccine

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Education • Use Centers for Disease Control materials www.cdc.gov/flu/freeresources • Try to address barriers/health beliefs • I don’t ever get the flu (10-20% chance each year) • The flu vaccine causes me to get sick • I don’t trust the flu vaccine (the government)

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On-site Immunizations • Health Department • Passport Heath, Inc • If can’t arrange on-site then make it convenient for staff to get it • Find information about local sites • Give scheduled time off

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Cost Issues • Almost all studies show influenza immunization is cost effective for a business • Some businesses pay for the vaccine (free for employee) • One study showed the two most important predictors of vaccination for those already receiving it free and on-site were: • $5 gift card • Being able to choose shot versus nasal vaccine

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What Strategy Should You Adopt in Child Care Settings? • As a teacher/caregiver, get the vaccine! • As a director or administrator, do as many of the recommendations as possible • Keep in mind current immunization rates: – 12-22% of child care center employees – 37% of adults in corporations – 42% of health care workers De Perio, J Community Health, 2012; Nowalk Am J Prev Med 2010

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Increasing Influenza Immunization Rates for Children in Child Care • Challenging • Limited a little by parent and medical site intermediaries • Model should be the same as for other vaccines which are just as “required”

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Influenza Immunization Lower in Minority Children Immunization Rates % 50 45 40 35 30 25 20 15 10 5 0 White

Black

Hispanic

2011 National Flu Survey in Uwemedino, J Community Health, 2012

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Determinants of Lower Immunizations in Minority and Lower Income Children • Limited English proficiency • Younger parents • Less interaction with medical home (regular doctor or health care team) • Lack of a reminder system from medical home Uwemedino, J Community Health, 2012

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A Role for Education of Parents about Influenza Vaccine in Young Children • Inform them of “new” requirements • Information at Centers for Disease Control: http://www.cdc.gov/flu/freeresources/print-family.htm • Higher risk for younger children • Use multiple methods of communication – verbal, written, translated – sent home and posted in centers (could even try social media or texting!) • Likelihood of infection in a given year • Possibility of death or hospitalization, ie a number of healthy children died last year from the flu – even one is too many (fear tactics) 56

Appeal to the Pocketbook • Days missed from care leads to lost work, lost income for hourly workers, possibly lost job for those coming off welfare • Review exclusion criteria

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Duty to Society Vaccinating children • Reduces infection rates in household contacts – 42% reduction in flu-like illness in all household contacts – 80% reduction in school-age contacts • Is more effective at reducing flu spread than vaccinating adults – Vaccinating 20% of school children more effective than vaccinating 90% of adults in reducing mortality of ≥ 64 year olds Hurwitz, JAMA, 2000 Longini, Pediatrics, 2012 58

Mandates! • Influenza vaccine is “required” just as much as the other immunizations we give, it’s just a newer requirement • Not yet in all state child care policies, or codes • You can develop your own rules for your programs • Require regular health visits (increases odds of influenza vaccine)

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Reward Techniques • Try to arrange on-site vaccination programs • Consider a voucher toward reduced fees for immunized children

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What Have YOU Done to Increase Vaccination in Your Program?

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Take Home Points • Influenza is the most common cause of vaccine-preventable deaths in children • Children spread influenza into families and community • Immunization is by far the best influenza prevention tactic • Infection control is also important but not as effective as immunization • Exclusion should be used when needed but not as a method to reduce spread • Child care programs have an important role and opportunity to improve immunization rates

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Healthy Child Care America Contact Information Toll-Free: 888-227-5409 Email: [email protected] Website: http://www.healthychildcare.org/

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National Center on Health Contact Information Toll-Free: 888-227-5125 Email: [email protected] Website: http://eclkc.ohs.acf.hhs.gov/hslc/ttasystem/health/center

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Acknowledgements This presentation/webinar was supported by: • Cooperative agreement number 5U58DD000587-4 from the Centers for Disease Control and Prevention • Grant #90HC0005 for the U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start • Grant #U46MC04436 from the US Department of Health and Human Services, the Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB) and the Administration for Children and Families, Office of Child Care Its contents are solely the responsibility of the authors/presenters and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the U.S. Department of Health and Human Services.

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