Preparedness E-newsletter Archive - 2008

2008 News Icons

 

Mental Health in Disasters and Emergencies

Published: November 2008
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness; Richard T. Boland, MBA, EMT-P;

 

Soldier assisting a civilian

Being aware of and ready to respond to mental health needs during or after a crisis is fundamentally important to effective community response. This is now increasingly described as “mental health surge capacity”, in parallel to medical surge capability. Although mental health is typically paired with physical health, this is too restrictive a perspective. Mental health is best perceived as an integral part of public health, and a comprehensive approach to preparedness, response, and recovery. In this article is a summary of a recent Federal Subcommittee as well as useful links and references for your own planning purposes.

The effects of the Anthrax letters in the fall of 2001 occurred at many levels – direct effects on those who were infected (in the dozens), direct effects on those who were exposed (in the thousands), and indirect effects on those who feared they might be exposed (in the millions) - as the postal system was recognized as the avenue of transmission. As we learned during that time, the "terror" in bioterrorism may be a much larger challenge than the "bio", as many people came to fear white powder in all of its many forms.

Due to the power and immediacy of the media, even distant disasters are viewed by large numbers of people, with significant effects on their feelings and mental status. The murder of JFK (1963), the Challenger explosion (1986), and Hurricane Katrina (2005) are obvious examples of tragedies that were seen either live or on tape. Hurricane Katrina was particularly heartrending because the distress of many victims could be perceived over days and weeks.

Besides immediate and distant effects, individual and communities may develop sustained mental health challenges that persist for weeks, months or years. The effects of Post-Traumatic Stress Disorder (PTSD) and long-term anxiety and depression have been well-documented. In the case of Hurricane Katrina, where large segments of an entire previously coherent population have been fractured and disseminated around the country, the long-term negative effects can only be guessed at. On the flip side, factors that increase resistance to mental health stresses and community resilience to disasters are also important factors that affect how a given individual or group responds and recovers.

Lastly, responders are at elevated risk themselves from short and long-term mental health effects due to the nature of their work. Any comprehensive disaster mental health plan needs to make sure that disaster response workers are assessed and treated as needed for these sequelae.

What follows is a brief summary of a just released report from the federal “Disaster Mental Health Subcommittee” which is worth reading. The federal recommendations will now need to be implemented (or not), and your input on what is important may be of critical importance.

Summary

One year ago, Homeland Security Presidential Directive 21 (HSPD-21) tasked the Department of Health & Human Services (HHS) with developing recommendations for “protecting, preserving, and restoring individual and community mental health in catastrophic health event settings, including pre-event, intra-event, and post-event education, messaging, and interventions.” To execute this directive, the Disaster Mental Health Subcommittee was established under the National Biodefense Science Board (NBSB), an established Federal Advisory Committee with both legal and discretionary authorities providing advice and guidance to the Secretary of Health and Human Services.

Three writing groups consisting of Disaster Mental Health Subcommittee members were formed to develop recommendations for three interrelated areas - Intervention, Education and Training, and Communication and Messaging - with final revision and approval by the full subcommittee. The three groups met multiple times via teleconference and the entire subcommittee came together for a face-to-face meeting on two occasions: once on June 19–20, 2008, and again on September 23, 2008, in preparation for making the recommendations.

The National Biodefense Science Board approved all recommendations unanimously to be submitted to Secretary Michael O. Leavitt on November 19, 2008. A full report on the NBSB recommendations is available online.

Main Recommendations:

      • Integrate mental and behavioral health into all public health and medical preparedness and response activities.
      • Enhance the research agenda for disaster mental and behavioral health.
      • Enhance assessment of mental and behavioral health needs during emergencies.
      • Enhance disaster mental and behavioral health training for professionals and paraprofessionals.
      • Promote the population’s psychological resilience.
      • Ensure that the needs of at-risk individuals and issues of cultural responsiveness are being addressed in all efforts of the National Biodefense Science Board.
      • Develop a disaster mental and behavioral communication strategy.
      • Develop an accessible Internet-based communication toolkit.

Following incorporation of NBSB feedback to develop a final, approved Recommendations Report, the Disaster Mental Health Subcommittee will create a two-year implementation plan for the approved recommendations. This plan will identify the priorities, specific action steps, responsibilities, and timelines for carrying out the recommendations within the Subcommittee’s purview.

Comments

As First Aid is used in almost every disaster, Psychological First Aid (PFA) should also be used. First Aid and CPR are trained almost universally throughout the response community however, there is very little if any, psychological first aid training provided. Psychological first aid refers to the psychological support that is used to improve one’s own resilience, and is provided by paraprofessionals to families, friends, neighbors, co-workers, or students.

PFA is a form of learning that focuses on education regarding traumatic stress and active listening. PFA can also incorporate more sophisticated support given by primary care providers to their patients. PFA should be adapted to the needs of the group or community that have shared or the same kinds of needs. One who employs PFA should pay particular attention to serving the community or group of people affected rather than trying to fit the group to a particular support modality. Responders will often have needs that differ from those of the victims.

PFA has not been extensively researched however; education and active listening have been thoroughly investigated as strategies used in crisis intervention. When using PFA, mental health professionals should serve as educators and consultants in adapting the model to various communities.

To quote from the NBSB report, “It is important to extend psychological support training beyond mental health (e.g., psychiatry, psychology, counseling, social work, and marriage and family therapy) and health care professionals (e.g., medicine, pediatrics, nursing, and epidemiology) to include the full range of emergency responders (e.g., law enforcement, fire service, emergency medical responders), coroners and morgue staff, disaster relief personnel (e.g., American Red Cross and National Voluntary Organizations Active in Disaster), faith-based professionals and leaders, disaster response leaders (e.g., incident commanders, emergency managers, and civil service and elected government leaders), and educators.”

Somewhat different from PFA, Disaster Mental Health (DMH) refers to crisis intervention, psychological support, consultation, and liaison for clients, communities, families, and individuals after disasters occur. These tasks must be performed by mental health professionals. DMH should include preparedness activities and long term recovery for individuals and communities.

In particular, recommendation #4 may have a great deal of impact on the ability of people (professionals and paraprofessionals) to assist with those impacted by disaster. Disaster responders and victims must deal with traumatic stress. Although it is natural to experience stress during disasters and it is thought to be a survival skill, many people do not recognize it as survival and will become distressed rather than strengthened by it.

Responders go to affected areas leaving families and others that make up their support networks. Responders may become casualties or could experience cognitive problems which could lead to mistakes. It is important to increase the resilience of our nation’s response community by providing the resources necessary to support their psychological needs and the needs of their families.

Many of those that respond are professionals in a variety of disciplines that require specialized training and/or licensure. Most of the leadership in these agencies are not trained in the psychological impacts of disasters, nor do they have the necessary training to recognize when psychological impact is becoming a problem. The leadership and decision should be required to have training in recognizing the psychological needs of their teams.

 

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Rural Preparedness

Published: October 2008
Written by: J. David Piposzar, MPH, Adjunct Assistant Professor of Environmental and Occupational Public Health

Why Rural Preparedness Training?

Over the next five years, the United States will face a serious shortage of skilled public health personnel that will directly affect the ability of states and local governments to protect public health.  As many as 45 to 50 percent of public health employees will become eligible to retire in the next five years according to the Center for State and Local Government Excellence .  “State and local governments are already facing vacancy rates of up to 20 percent and turnover rates of 14 percent due to retirement, attrition, and expanded responsibilities. This loss of trained workers comes just when public health departments are assuming greater responsibility for threats such as pandemic influenza, bioterrorism, and drug resistant strains of common diseases.”

Our public health “workforce crisis” is exacerbated in rural communities where the ratio of public health workers to population is already extremely low. Pennsylvania is particularly vulnerable given that the existing 10 local (city and county) health departments serve less than half of the state's human population.

As a result, 61 of the 67 counties in Pennsylvania rely on the small numbers of staff in Community Health Centers, administered by the Pennsylvania Department of Health, to serve the largest rural population of any state in the United States. While the numbers of existing public health workers is always challenging to estimate, it remains a fact that Pennsylvania has one of if not the the lowest ratios of government public health workers per capita in the nation.

As a result, rural preparedness training is of particular importance and is desperately needed in small cities, towns, and villages across America if we expect them to respond to emergencies, prevent the spread of disease, and ensure that food and water supplies remain safe. Rural communities differ from their urban counterparts in many ways. As examples:

  • Rural communities are home to many potential targets, including nuclear facilities, agro-chemical plants, and refineries;
  • Rural areas are the home to agricultural production, with an estimated 2,000,000 vulnerable sites in the US alone;
  • Urban water supplies often originate in rural areas;
  • Infectious diseases can more easily be targeted towards smaller communities with the same effects of fear, morbidity and mortality;
  • Mass evacuations from urban areas into less populated areas will quickly consume resources and overwhelm available services; and
  • Low threat perception creates barriers to preparedness planning.

Presently, the 40 accredited schools of public health (two in Pennsylvania) lack the capacity to train large number of public health workers to meet these demands. In addition, most graduates of the accredited schools of public health do not initially take jobs in local government health agencies, owing to lack of competitive pay and benefits, budgetary constraints, and geographic solitude.

In response to this need, the Preparedness Center and the Center for Rural Health Practice (CRHP) created What All Rural Responders Should Know About Public Health Emergencies. This training course was developed through funding from CDC to train rural responders, who may be called upon to fulfill public health emergency functions in support of, or in lieu of, governmental public health workers. Classes are structured to enhance inter-agency communications and better integrate first responders and non-traditional secondary responders into Pennsylvania's existing emergency management framework (although the concepts covered are translatable to any state response network). Case studies (Flu Pandemic, Canadian SARS outbreak; Hepatitis A; Hanta and West Nile viruses; plague, smallpox, etc), are used to illustrate important disease control and prevention strategies useful in developing disaster plans for any organization or business. The map below shows the wide geographic utilization of these voluntary trainings over the past 3 years.

Joint efferts by the Preparedness Center and CRHP are unique by targeting the non-traditional, secondary responders comprised of faith based organizations, mental health providers, Community Emergency Response Teams (CERTs), Medical Reserve Corp volunteers, Red Cross and Salvation Army members, and other volunteers aiding in disasters (VOADs). Post-course evaluations reflect the fact that these entities rarely have the opportunity to meet with and understand how best to integrate their services with existing emergency management agencies. That finding is discouraging since critically needed resources and human services that determine how well a community responds and recovers from a major event are managed by these entities; but also points to the important role of their training. Past disasters have clearly shown the importance of church, school, civic, and business sectors in determining the readiness and resilience of a community. Existing community networks represent a critical social and economic infrastructure often overlooked, and no less important than, the losses to physical infrastructure depicted in news accounts following a disaster.

Rural preparedness training is also unique in providing a rare opportunity for the non-traditional secondary responder to meet face-to-face and train with their community’s first responders.  We know of no other class that brings such a diverse audience to the table to better understand others’ roles, responsibilities, and expectations. As an example, our audiences include public health and emergency medical personnel, law enforcement officers, firefighters, hazardous materials response teams, public works and engineering firms, hospital and healthcare providers, state and local government officials, school administrators and school nurses, elected representatives, agriculture and veterinary services, dispatchers and public safety communications specialists, and other community-level response partners. Upon completion of this course, all attendees are better able to:

  • Identify critical public health & mental health emergency functions and services;
  • Understand agency roles and responsibilities within an existing emergency management framework;
  • Identify key partners in community-based disease surveillance and early warning systems;
  • Communicate infection control practices and procedures to protect self, family, patients, and others;
  • Evaluate the role of local hospitals and laboratories in supporting disease prevention & control; and
  • Know where to turn for additional information and emergency planning guidance.

Contrary to general public perception, state and local government workers and volunteer organizations are not covered under the same safety standards as their counterparts in the private sector. Representatives from the U.S. Department of Labor-Occupational Safety and Health Administration participate in our training as part of a formal partnership agreement. By adding this component, we think our training helps assure that first and secondary responders do not themselves become victims because of poor safety practices, and/or a general lack of training in hazard recognition and personal protection measures.

Regional Task Forces and/or County Emergency Management Coordinators typically host these trainings. They often invite other state and local experts to contribute toward a customized program relevant to the needs of their specific county. That structure is crucial because in the final analysis, every community must develop its own plans and procedures unique to the hazards and threats each faces and making use of the resources which are at hand. Perhaps our greatest contribution is providing all attendees with a textbook to help guide their continuing efforts to enhance their community’s overall readiness.
 
Center for State and Local Government Excellence Fact Sheet: “The Impending Shortage in the State and Local Public Health Workforce

Center for State and Local Government Excellence Fact Sheet, Wake Up, America! The Future Public Health Workforce is at Risk

 

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CDC selects University of Pittsburgh as one of seven "Preparedness and Emergency Response Research Centers"

Published: September 2008
Article by: Centers for Disease Control and Prevention’s (CDC)

 

Parran Hall

Graduate School of Public Health - Parran Hall

"The Centers for Disease Control and Prevention’s (CDC) Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) has announced awards totaling $10.9 million in fiscal year 2008 for the Preparedness and Emergency Response Research Centers (PERRCs).

The PERRCs, located at seven accredited schools of public health, were established to investigate the structure, capabilities and performance of public health systems for preparedness and emergency response activities.  

Interested applicants were encouraged to follow four themes in proposing research activities including: 1) enhancing the usefulness of training; 2) improving communications in preparedness and response; 3) creating and maintaining sustainable preparedness and response systems; and 4) generating criteria and metrics applicable to an all-hazard approach to preparedness to measure effectiveness and efficiency.  

Funded PERRCs include:

  • Emory University
    Grant Title: Emory Preparedness and Emergency Response Center
    Research Priority: Create and Maintain Sustainable Preparedness and Response Systems 
  • Harvard University
    Grant Title: Linking Assessment and Measurement to Performance in Public Health Emergency Preparedness Systems (LAMPS)
    Research Priority: Generate Criteria and Metrics to Measure Effectiveness and Efficiency
  • Johns Hopkins University
    Grant Title: Mental and Behavioral Public Health Systems Preparedness Research
    Research Priority: Preparedness to address the risks of vulnerable populations
  • University of Minnesota
    Grant Title: University of Minnesota: Simulations and Exercises for Educational Effectiveness
    Research Priority: Enhance the Usefulness of Training 
  • University of North Carolina Chapel Hill
    Grant Title: North Carolina Public Health Preparedness Systems Research Center
    Research Priority: Create and Maintain Sustainable Preparedness and Response Systems 
  • University of Pittsburgh
    Grant Title: University of Pittsburgh Preparedness and Emergency Response Research Center
    Research Priority: Create and Maintain Sustainable Preparedness and Response Systems and Generate Criteria and Metrics to Measure Effectiveness and Efficiency
  • University of Washington
    Grant Title: Northwest Preparedness and Response Research Center
    Research Priority: Improve Communications in Preparedness and Response  

The research center awards are for a five-year project period that begins September 30, 2008 and ends September 29, 2013. 

CDC received more than 20 applications which underwent the NIH/CDC process for a rigorous peer view to evaluate the scientific and technical merit of proposed activities and secondary review for determining relevance to COTPER funding priorities. These priorities were, in part, based upon research priorities recommended in the letter report prepared by the Institute of Medicine (IOM), Research Priorities in Emergency Preparedness and Response for Public Health Systems. (Click here to view the report)."

 

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Graduate Certificate Program Turns Five

Published: August 2008

Five Year Anniversary | Program History | Curriculum | Career Paths | Quotes from Graduates

5 Year Anniversary

Five Year Anniversary

The Graduate Certificate Program in Public Health Preparedness and Disaster Response is celebrating its fifth anniversary this fall. This innovative program was one of the first in the nation with a focus on preparedness and remains the only one to offer a foundation in public health combined with an all-hazards approach.

Since its inception, 28 students – including physicians, Masters-degree and Doctoral students, and non-degree professionals from the community – have completed the 15-credit program. An additional 24 students are currently enrolled, with more expected this fall as new students arrive.

Graduates have used their training to obtain important preparedness and response positions at city, county and state health departments, within medical systems, at universities, at the CDC and in the military. One of the graduates was accepted into CDC’s prestigious Epidemic Intelligence Service (EIS) and another directs radiation preparedness activities for the eastern United States and Europe for the Navy.

Gail Cairns, Behavioral and Community Health Sciences professor and founder of the program, said, “the program and its fifth anniversary are a bigger success than we’d ever anticipated!"

Letter from the Director - Dr. Schwerha

Program History

Figure 1

The Graduate School of Public Health and the University of Pittsburgh Center for Public Health Preparedness launched the Certificate Program in 2003.

It is co-sponsored by the Departments of Behavioral and Community Health Sciences and Environmental and Occupational Health, and was founded through the creative work of Professors Gail Cairns and Joseph Schwerha and Associate Dean Sandra Quinn, with key leadership provided by Associate Dean Margaret Potter and the Dean (at that time) of GSPH Bernie Goldstein.

The program is funded in large part by the Centers for Disease Control and Prevention, with additional contributions from GSPH. In addition, each year up to 5 students receive “Fellowships” to help defray the costs of the program and 3 – 4 students work in the Preparedness Center as funded interns.

 The most recent innovation was development of a “Summer Institute” last month. Using an innovative course format requiring only one week of in-person activity, students were offered two 2-credit courses in  Emerging Infectious Diseases and Emergency Preparedness Law and Ethics, as well as an integrated one-day leadership seminar.

Curriculum

The Certificate Program provides students and professionals with a practical academic foundation in order to further strengthen the public health workforce and infrastructure. 

Students may be full-time, part-time, or non-degree status, and preparedness and response professionals are encouraged to participate. Students must complete 15 credits, of which 10 are required and 5 are elective. The required courses include detailed education and training taught by educators with practical, hands-on experience in public health preparedness and response. Content areas include: 1) Surveillance and Epidemiology; 2) Risk Communication; 3) Psychosocial Effects of disasters and emergencies; 4) Disaster Management, including NIMS, ICS, and other federal guidelines and methodologies; 5) Public Health Law; 6) Environmental Health and Safety; 7) Program Planning; and 8) Evaluation of outcomes, exercises, and drills.

Career Paths

The Program gives graduates the advantage in the job market. Graduates have moved on to become a(n):

  • Public Health Program Coordinator - Mascoma Valley Health Initiative
  • Project Coordinator/Intern - Pitt Center for Public Health Preparedness
  • Prevention Specialist - Centers for Disease Control and Prevention
  • Assistant Professor of Medicine, Associate Medical Director, STATMedEvac UPMC, Presbyterian
  • Public Health Preparedness Planning - Bucks County Department of Health
  • Epidemic Intelligence Service (EIS) - Centers for Disease Control & Prevention
  • Project Coordinator - University of Pittsburgh, Graduate School of Public Health, Center for Public Health Practice
  • Vector Control Specialist - Allegheny County Health Department, West Nile Virus Control Program
  • Biostatistician - University of Pittsburgh Cancer Institute
  • Program Manager - UPMC
  • Director, EMS and Critical Care Transport - University Hospitals Case Medical Center
  • Senior Assistant Counsel - Commonwealth of Pennsylvania
  • Research Associate Sr. - UPMC
  • Emergency Preparedness Coordinator - Pennsylvania Department of Health
  • Research Analyst (also PhD student in Epidemiology at GSPH) - University of Pittsburgh, Center for Injury Research and Control

Graduate Students

Duquesne Project and Emilie

Emilie Delestienne stands in front of her
poster she made for the Duquesne Project.

Quotes from Graduates

Emilie Delestienne - The core certificate courses not only introduced important concepts in public health preparedness but also challenged me to think about public health preparedness on multiple levels…the knowledge and skills I have developed from participating in the Certificate in Public Health Preparedness and Disaster Response are invaluable to my education and professional development in public health.

Sherrianne Gleason - The program gave me the opportunity to develop a unique set of knowledge and skills for the job market.  I now have a basic science background, as well as a background in emergency preparedness.

Erin K. Sauber-Schatz - The Graduate Certificate Program in Public Health Preparedness and Disaster Response has benefited me professionally because I have formal training and education in a field of public health that not many others have had.  This makes me a unique candidate for public health jobs and/or fellowships.  The Certificate helped me to develop skills and a way of thinking that is beyond traditional public health education.  The certificate program has made me a better epidemiologist and public health professional.  The certificate program opened my eyes to the fact that public health professionals can and often are first responders in emergency or disaster situations.  If an emergency or disaster strikes I believe that I am capable and ready to help.  I have many more options for where I would like to work and what I would like to do with my education thanks to the Graduate Certificate in Public Health Preparedness and Disaster Response.

Leah Applying Pesticide

Leah Lamonte applies pesticide
to a problem area.

Leah Lamonte - The certificate program has been very beneficial to me in my current job…the certificate classes gave me tools to be effective in public health at the ground level.  Particularly useful to me today, I learned about the role of government agencies in public health and the importance of good communication and relationships between agencies.  I also learned how to portray a public health message to the public and media which is an important part of my job.  The certificate program gave me the opportunity to do an internship at Allegheny Co. Health Dept where I was able to network with local public health employees and actually see how public health is done at the county level.  All in all, I believe that the certificate program gives students a realistic view of working in the public health field which is extremely valuable when entering the workforce.

Jennifer Lucado - I think that knowing about preparedness has opened a new class of job opportunities to me.  Instead of just applying for epidemiology positions, I feel confident in applying for positions in emergency planning and bioterrorism response.

Sonja Jacobs Likumahuwa - Because of my participation in the certificate program, I got involved with the American Red Cross as a volunteer with disaster services.  My current job as the coordinator for a liver cancer study involves communicating with people who are experiencing a traumatic event (cancer), and I think the certificate program and my experience with the Red Cross has prepared me to handle that.

Julie Giombetti Moss - The classes I took for the certificate program were the most interesting and enjoyable that I took during my time as a student in GSPH.  I am glad I had the opportunity to participate in the program.

 

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Emerging Infectious Diseases (EID)

Published: July 2008
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

 

Outbreak Map

Ever wonder just what exactly an “emerging infectious disease” is? Does HIV qualify - or XDR Tuberculosis, SARS, or West Nile Virus? And do you have at your fingertips all the websites and resources you need to keep track of the latest microbiological health threats from around the world? This Global Disease Alert Map is one example of an essential information resource; read on to find out more!

Emerging Infectious Diseases (or EIDs) are typically defined as microorganisms (including viruses, bacteria, fungi, protozoa, and prions) that fall into one of three categories:

eid
  • “New” to a species – human examples include HIV and SARS and E. coli 0157
  • “New” to a geographic region – examples include West Nile Virus and Monkeypox in North America
  • “Newly” pathogenic (due to either drug resistance or increased pathogensis) – examples include community-acquired MRSA and chloroquine-resistant malaria and XDR TB

Most EIDs are zoonoses, meaning they have jumped from animals to people at some time in the recent past. Examples include H5N1 influenza (from birds starting in 1997), HIV/AIDS (HIV 1 came from Chimpanzees in the mid-twentieth century), and SARS (from civet cats in 2002).

Viruses are the most common type of EIDs, although of the 4 most widespread and dangerous EIDs in the world today, 2 are viruses (HIV/AIDS and Dengue), 1 is a bacterium (Tuberculosis), and 1 is a protozoan (Malaria).

In addition, some EIDs are carried by vectors, such as mosquitoes or ticks; others are transmitted through contaminated food or water, and a number of others are strictly “person to person”. Given that there are hundreds of EIDs to keep track of these days, with more coming on line all the time, you may find it useful to access one or more of the many information sources listed below to help answer your questions.

Several last things: first, sites are selected based purely on their content and usefulness as judged by the Center for Public Health Preparedness at the University of Pittsburgh; second, many thanks are due to Sherrianne Gleason at GSPH for her contributions to this resource list; and third, if you know of other really useful information sources, please let me know. Thank you!

Sites with really useful e-mail alerts

Center for Infectious Disease Research & Policy

CIDRAP has superb daily updates and a special focus on food safety, influenza, bioterrorism, and biosecurity.

International Society for Infectious Diseases

ProMed-mail - the Program for Monitoring Emerging Diseases, is an Internet-based reporting system dedicated to rapid global dissemination of information on outbreaks of infectious diseases and acute exposures to toxins that affect human health, including those in animals, and in plants grown for food or animal feed.

Centers for Disease Control and Prevention (CDC)

E-mail alerts and updates - includes a choice of a multitude of topics; you pick which ones and how frequently you want to be alerted.
Emerging Infectious Diseases is CDC’s Journal for EID topics and also includes updates and podcasts.
Morbidity and Mortality Weekly Report is CDC’s weekly report with alerts, breaking news, data on specific diseases as reported by state and territorial health departments, as well as reports on topics of international interest, and notices of events of interest to the public health community.
Terrorism and Emergency Response for Clinicians - includes updates and training opportunities.

U.S. Food and Drug Administration (FDA)

E-mail updates on several different topics, including Recalls and Safety Alerts

World Health Organization

Updates and Alerts on WHO news, disease outbreaks, avian influenza, and other information.

Sites with important EID surveillance information

All Diseases

Global Outbreak Alert & Response Network

Global Public Health Intelligence Network

Global Disease Alert Map

Global Atlas of Infectious Diseases

Influenza Sites

CDC Flu Site

Flu Wiki

Flu Trackers

World Health Organization Flu Site

Food and Animal Health and Safety

Surveillance and Testing Information

Foodnet - Foodborne Diseases Active Surveillance Network.
PulseNet is a national network of public health and food regulatory agency laboratories coordinated by the Centers for Disease Control and Prevention (CDC).     
NARMS - National Antimicrobial Resistance Monitoring System: Enteric Bacteria.

Other Useful Sites

Center for Science in the Public Interest (CSPI) Food Safety

Fixing Food Safety: Protecting America’s Food Supply

Institute for Food Laws and Regulations

United States Department of Agriculture

Animal Health from the Animal and Plant Health Inspection Service (APHIS); provides a wide variety of information on animal diseases and veterinary topics.
Foodborne Illness Cost Calculator provides information on the assumptions behind foodborne illness cost estimates—and gives you a chance to make your own assumptions and calculate your own cost estimates.
Food Safety and Inspection Service (FSIS)
Current Food Recalls – meat products regulated by USDA.

Food and Drug Administration

Recalls, Market Withdrawals and Safety Alerts – includes non-meat products such as seafood and produce.

Food Agriculture Organization of the United Nations (FAO)

Main Site

Food Security Statistics (FAO)

Information on Vaccines and Vaccine-Preventable Diseases

Immunization Action Coalition

Vaccine Information for the Public and Health Professionals

CDC’s main vaccination and immunization website

Adolescent & adult vaccine quiz

Infant and young child vaccination guide

Really Good Site for Data and Statistics

Centers for Disease Control and Prevention – Data and Statistics

 

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Number of Salmonella cases in outbreak reaches 31,000

Published: June 2008
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

 

International Sanitation 2008

Yes, 31,000. Or possibly more. This number is calculated by multiplying the number of confirmed genetically-linked cases (810 as of June 26) by a multiplier of 38.6. This multiplier is taken directly from CDC’s own estimate of the ratio of unreported/reported cases of non-typhoidal salmonella. 1 Thus, this outbreak may be the largest in US history.

Food Safety

Food safety (or lack thereof) is a hot topic these days. From last year’s contaminated pet food to the current national salmonella outbreak in tomatoes, food safety remains a public health challenge that needs attention – NOW.

Food is an essential part of human existence, not just as an energy source, but as an integral part of celebrations, family gatherings, travel to new and exciting places, and much more. Now more than ever, food is what links people around the world. Almost anywhere in the US you can visit restaurants serving dishes that originated in China, Mexico, India, South America, Italy, Thailand, France, and Japan, to name just a few.

Not only are recipes international, but the food is as well. An estimated 15% of the nation’s overall food supply is imported – but this jumps to 60% of fresh fruits and vegetables and 75% of seafood. 2 The vast majority of these imports go straight to our plates, with only 1% (or less) actually inspected by FDA. 3 Given that approximately ½ of the world’s population has limited or no access to sanitary facilities, the risk of source contamination is very real. And this problem is worsening as more and more food is imported and FDA’s budget and ability to inspect and weed out suspect items diminishes.

However, this is not to imply that only imported food can be risky. The food inspection and monitoring system within the 50 states and territories is outdated, understaffed, underfunded, and often ineffective. This sad fact is documented in a growing number of places and documents, including recent reports from the National Academy of Sciences, Institute of Medicine, US Government Accountability Office, Trust for America’s Health, and Congress.

Despite this evidence, the situation is clearly becoming more rather than less hazardous. 2007 Data from FoodNet shows that rates of infections with major pathogens – Salmonella, Campylobacter, Listeria, Shigella, E. coli O157, Vibrio and Yersinia – remain high and have not decreased over the last 3 years after previous gains. In 2007 an unprecedented number of cryptosporidiosis cases were reported to CDC, nearly doubling from the previous year. Norovirus outbreaks tripled in 2006, frequently occurring in hospitals, long-term care facilities, cruise ships and other settings where older or higher-risk individuals are especially endangered. 4

CDC is also behind the times. The standard estimate of food-related illness and death in the United States is based on an MMWR report from 1999 which uses data from as far back as 1992. Even though the data is illuminative – an estimated 76 million illnesses, 325,000 hospitalizations, and 5000 deaths – it is dramatically out of date and doesn’t provide the kind of information that governmental agencies like FDA and USDA, public health practitioners, and the general public can use.

US Map

The current Salmonella outbreak is illustrative of the outmoded and ineffective system that exists in this country. Since April, more than 810 people in ¾ of the states have been sickened, and up to 100 or more hospitalized by Salmonella “Saintpaul”. The ongoing epidemiologic investigation has indicated that tomatoes and products containing these tomatoes are the culprit, and that they may have originated in Florida or Mexico.

This is not the really bad part (unless you or someone you know has been affected). The bad part is that this exact scenario has been repeated multiple times over the last several years. Tomatoes, and in particular tomatoes from certain regions – especially Florida – have been the probable source of repeated salmonella infections. 13 multistate infections of Salmonella are linked to tomatoes since 1990, infecting as many as 79,000 people. Recent MMWRs include:

  • September 7, 2007: “Multistate Outbreaks of Salmonella Infections Associated with Raw Tomatoes Eaten in Restaurants – United States 2005-2006” 5; and
  • April 8, 2005: “Outbreaks of Salmonella Infections Associated with Eating Roma Tomatoes – United States and Canada, 2004” 6.

The Challenge

The issues needing to be acknowledged and addressed are diverse and complex – but not unsolvable with adequate funding, staffing, creativity, and political support. A very brief summary of the main challenges are delineated below.

Graph of Imports of U.S. Food

  1. Emerging Infectious Diseases
    The microbiological contaminants in food and water are changing and adapting. It is likely that the increase in Cryptosporidium infections and outbreaks is due to a shift in the predominant subtype from C. parvum to C. hominis, making person-to-person transmission more likely. 7 The surge in Norovirus infections in recent years is secondary to the appearance of two novel co-circulating GII.4 strains. E. coli 0157:H7 was first recognized as a cause of outbreaks in 1982 and was estimated to cause over 73,000 cases in 1999. 8,9

  2. Increasing imports
    As of 2007, an estimated 189,000 registered foreign facilities manufacture, process, pack, or hold food consumed by Americans (compared to only 136,000 registered domestic facilities). 10 Previously, the bulk of imported foods consisted of unprocessed food ingredients. Today, foods that are inherently more likely to pose risks, such as ready-to-eat food products, fresh produce and sea food, account for an increasing proportion of imported foods. FDA’s 2007 report notes that “FDA often has very limited information regarding conditions under which most food is produced in foreign countries. While many foreign countries have well-developed regulatory systems…others may not be able to ensure food safety to the same degree.”11

  3. Discoordinated oversight, surveillance and tracking
    FDA, USDA, CDC, and EPA all have roles in protecting Americans from food-related pathogens and contaminants, along with a bewildering array of state-level agencies, and over 3000 local health departments and retail inspection agencies. As previously noted in this article, CDC’s summary data is woefully out of date, and EPA’s ability to monitor for pesticides and toxic chemicals appears vanishingly small, especially regarding imported food. USDA Food Safety and Inspection Service (FSIS) “spends most of its resources inspecting every beef and pork carcass from practices used 100 years ago” 12 and faces other challenges regarding updating of outdated practices. But the bulk of criticism seems to fall on FDA; the NY Times notes a striking unanimity about the agency’s weaknesses, from “Congressional Democrats and Republicans, industry and consumer groups, and authoritative independent analysts”. 13

One challenge is that FDA’s mandate is generally reactive, rather than protective and proactive, and the agency is in need of Congressional action to update functions, legal tools, funding, and scientific energy. An example of this reactive process can be seen in the current Salmonella outbreak; only AFTER this has spread throughout most of the country is Congress willing to provide more resources. Not until June – 2 months after the onset of the outbreak – did Congress authorize an additional $275 million for FDA ($125 million specifically for food safety). Senator Arlen Specter noted that administration delays in seeking money for food protection efforts at the food and drug agency amounted to "criminal negligence....The failure to have these inspections is subjecting people to bodily injury and death," 14 said Mr. Specter, who sent a letter to Mr. Leavitt insisting that the additional money for the FDA should be included in a supplemental request this year, not in next year's budget.

A related problem is that the division of responsibilities between FDA and USDA makes no sense in the modern world. FDA has a bizarre set of unrelated responsibilities including food, animal and veterinary practices, drugs and medial devices, cosmetics, and radiation emitting products. The food-related responsibilities overlap with USDA in peculiar ways – for example, FDA regulates frozen pizza. However, if the pizza is topped with 2 percent or more of cooked meat or poultry, then USDA’s FSIS is the regulatory agency. Consequently, inspections at pizza production facilities follow 2 sets of guidelines, one from FDA and one from USDA. 15 Consolidation, integration and modernization of federal agencies combined with a consistent focus on domestic and imported food safety is essential. These federal activities will have the added bonus of making it easier for state and local agencies to follow suit and help ensure a safe and healthy product for all for all of us.

International Year of Sanitation

Lastly, did you know that 2008 is the “International Year of Sanitation”? Given the increasingly international basis of food imports – not just for the United States but for most countries around the world – improved safety of food and food production processes is a worthy goal. One of the main aspects of this safety is improved sanitation worldwide, and the World Health Organization has declared this year as, in fact, “International Year of Sanitation.” This is a more complex topic than we can possibly cover in this edition of the newsletter, but more information can be obtained at the following sites:


  1. Voetsch et al. FoodNet Estimate of the Burden of Illness Caused by Nontyphoidal Salmonella Infections in the United States. CID 2004:38 (Suppl 3).
    http://www.cdc.gov/enterics/publications/280-voetscha1.pdf.
  2. http://www.fda.gov/oc/initiatives/advance/food/plan.pdf
  3. Trust for America’s Health. Fixing Food Safety: Protecting America’s Food Supply from
    Farm-to-Fork. www.healthyamericans.org. April 2008.
  4. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5633a2.htm
  5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a3.htm
  6. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5413a1.htm
  7. FOODNET NEWS Spring 2008. www.cdc.gov/foodnet.
  8. CDC. http://www.cdc.gov/ecoli/qa_ecoli_sickness.htm.
  9. CDC. http://www.cdc.gov/ecoli/outbreaks.html.
  10. FDA. http://www.fda.gov/oc/initiatives/advance/food/plan.html.
  11. FDA. http://www.fda.gov/oc/initiatives/advance/food/plan.html.
  12. Trust for America’s Health. Fixing Food Safety: Protecting America’s Food Supply from Farm-to-Fork. www.healthyamericans.org. April 2008.
  13. NY Times. http://www.nytimes.com/2008/02/03/opinion/03sun1.html.
  14. http://specter.senate.gov/public/index.cfm?FuseAction=
    NewsRoom.Articles&ContentRecord_id=83447b17-92f9-1042-ee93-10493a477014
    .
  15. Trust for America’s Health. Fixing Food Safety: Protecting America’s Food Supply from
    Farm-to-Fork. www.healthyamericans.org. April 2008.

 

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Education and Training at the Public Health Institute

Published: May 2008
Written by: Molly Eggleston, MPH, CHES, Associate Director for Service and Outreach, Center for Public Health Preparedness

2008 Spring Public Health Institute

Spring Training 08

Each spring and fall the Pennsylvania Department of Health hosts the Public Health Institute. The foremost objective of the Institute is to provide educational and training opportunities for the Public Health workforce on the broad areas of public health and public health/emergency preparedness. The University of Pittsburgh Center for Public Health Preparedness presented four training sessions at the Spring 2008 session in State College, Pennsylvania, providing a total of 585 continuing education accredited hours for learners. All of the Center’s sessions generated requests for repeat training in learners’ respective geographic areas. The date for the 2008 Fall Public Health Institute should be announced soon. Stay tuned.

Courses:

  • The Pennsylvania Preparedness Leadership Institute (Advanced Program)
  • PODS: From Activation through Termination
  • Incident Command and Management for Schools
  • What All Rural Responders Must Know About Public Health Emergencies

 

Leadership

PPLI Logo

The two and a half day Pennsylvania Preparedness Leadership Institute (PPLI) Advanced Program was held by invitation only for graduates of the Regional PPLI Program. The purpose of the Advanced Program is to facilitate development, delivery, and evaluation of leadership education and training programs for the public health and emergency preparedness workforce, i.e., professionals in the disciplines of public and mental health, emergency medical services, emergency management, hospitals and healthcare delivery, public safety, and state and local officials.

 

PODS

The Center offered participants a unique perspective on Points of Dispensing (POD) – an insider’s view. Activities included orientation to the common characteristics of POD design and function and then simulation of a POD set up using a “POD in a box” kit. Given a Job Action Sheet, just-in-time training, and a yellow vest, “Workers” disseminated simulated medications to clients who had impairments in their ability to speak, move, and understand. Clients who were sick or symptomatic were diverted to a first aid/behavioral health station for diagnosis and transfer to medical care. Co-trainer Tim Nilson from Seven Mountains Emergency Medical Services Council trained screeners and security staff to assure that only well people were allowed to proceed through the POD. The debriefing yielded regional differences in POD organization and the universal need to recruit volunteers to staff PODS through SERVPA or local medical reserve corps.

 

Schools

School Bus

“Incident Command and Management for Schools” provided an opportunity for school personnel, emergency management officials, firefighters, law enforcement, and public health professionals to complete two standard FEMA courses on NIMS and ICS for schools. The session oriented school personnel to the ICS principles so that schools can more effectively interact with first responders during an incident involving the school community. Co-trainer Steven P. Michael, Emergency Management Specialist (EMS) for the Pennsylvania Emergency Management Agency (PEMA) Central Area Office, distilled the essential ICS information for school personnel, and peppered his presentation with experiences and examples from his career in the military and in service to the Commonwealth. Co-trainer Joe Roberge, PA State NIMS Coordinator, PEMA, provided context for the schools to understand their roles and responsibilities in NIMS. He encouraged PA’s K-12 school districts to secure a copy of their county's NIMS ordinances or resolutions and upon review and consent, include them in their school’s Emergency Operations Plan.

 

Rural

Rural Road
Center for Rural Health Practice Logo

"What All Rural Responders Must Know about Public Health Emergencies" promoted a model of pandemic influenza as a worst case scenario for all-hazards emergency planning. Trainers stressed the importance of existing social networks of non-traditional responders (including VOADS, faith-based organizations, mental health providers, civic organizations and CBOs) in rural preparedness and response. Traditional responders, including EMS, emergency management, law enforcement, fire service, Hazmat teams, medical and veterinary personnel, and voluntary service organizations will be called upon to fulfill public health emergency functions in support of, or in lieu of, governmental public health workers during a public health emergency in rural PA.

These sessions reinforce the need for all responders to be highly connected with those in their community who will make a difference during times of crisis.

 

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Global Climate Change

Published: April 2008
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

Is Global Climate Change(GCC) real?

The Intergovernmental Panel on Climate Change (IPCC) released its 4th report in November 2007. In this synthesis of data from thousands of sources, it is clear that climate change is both real and worsening. The most important greenhouse gases – carbon dioxide, methane, and nitrogen dioxide – have all dramatically increased since the onset of the industrial revolution.

In addition, global average surface temperature and sea level are rising, and northern hemisphere snow cover, both in terms of glaciers and the north polar ice cap, is shrinking. Eleven of the twelve years between 1995 – 2006 are among the 12 warmest years on record.

 

What is the IPCC?

The IPCC is a scientific intergovernmental body set up by the World Meteorological Organization (WMO) and by the United Nations Environment Programme (UNEP) in 1988. The group released summary reports on climate change in 1990, 1995, 2001, and most recently in 2007. Each report has been more definitive than the previous with regards to the reality of climate change. The IPCC was awarded the Nobel Peace Prize in 2007.

 

Does the United States government agree with the IPCC’s analysis?

Yes. At the United Nations Climate Change Conference in Bali in December 2007, the US delegation acknowledged the reality of climate change and pledged to work with international partners on remediation activities.

 

Will temperature increase and effects be distributed equally around the globe?

No. Although average global temperature is on the rise and projected to increase for at least the next 100 years, the increase in temperature will be largest at farthest north latitudes (see chart). Effects on permafrost, tundra, and the northern polar ice cap are likely to be severe.

 

Geographical pattern of surface warming

How will weather change?

Because of the complexity of weather systems and the ecosphere, it is challenging to make predictions with a high degree of confidence. The IPCC reports that:

  • Warming will be greatest over land and at most high northern latitudes and least over Southern Ocean and parts of the North Atlantic Ocean, continuing recent observed trends.
  • Contraction will be seen in snow cover area, with increases in thaw depth over most permafrost regions and decrease in sea ice extent; in some projections using, Arctic late-summer sea ice disappears almost entirely by the latter part of the 21st century.
  • There will very likely be an increase in frequency of hot extremes, heat waves and heavy precipitation, along with a likely increase in tropical cyclone intensity.
  • There will be a poleward shift of extra-tropical storm tracks with consequent changes in wind, precipitation and temperature patterns.
  • It is very likely that there will be precipitation increases in high latitudes and likely decreases in most subtropical land regions, continuing observed recent trends; in other words, wet areas will get wetter and dry areas will get drier.

 

What other factors are important?

There are several other trends that, combined with increases in temperature and sea level, will make GCC worse than it might otherwise be. It is important to note that the trends described below are most common in underdeveloped countries, which are also the regions that have the least ability to adapt to changes brought about by GCC.

  • World population is expected to increase by at least 3 billion by 2100 – further straining food supply, especially in regions where droughts may become more common and more severe.
  • World population is increasingly living in cities, and this trend is most rapid in more populous, less developed parts of the world. This is important for a variety of reasons, one of which is that cities tend to be hotter than surrounding areas. “ Heat islands” form as vegetation is replaced by asphalt and concrete for roads, buildings, and other structures necessary to accommodate growing populations. These surfaces absorb - rather than reflect - the sun's heat, causing surface temperatures and overall ambient temperatures to rise. Urban and suburban temperatures are 2 to 10°F (1 to 6°C) hotter than nearby rural areas (from EPA). During heat waves, this increase may be the difference between “hot” and “fatally hot”, especially for vulnerable populations. The Chicago heat wave in 1995 may be an example of such a phenomenon.
  • Deforestation is the second largest contributor to carbon emissions after the burning of fossil fuels, due mostly to release of carbon-based products from burning of forests or rotting of cut trees which are removed to make way for agricultural or animal farms. Additional problems include the loss of those forests for the sequestration of carbon (from absorption of carbon dioxide), loss of habitats and biodiversity, and loss of ground cover, to name a few.

Who will be hit the hardest?

World chart

The 3 billion-plus people who live in poverty around the world will be hardest hit by changes in climate. In many countries, the poor are more dependent on natural resources and have less ability to adapt to a changing climate, and governments with fewer resources have less capacity for planning and adjustment to changing conditions. In addition, as seen in Hurricane Katrina and a host of other weather-related disasters, people with fewer resources are more likely to live in higher-risk areas and have less ability to get out of harm’s way. In addition, low-lying coastal communities, because of proximity to and vulnerability from rising sea levels and severe weather systems, will be at high risk.

What will the predicted health effects of Global Climate Change?

The IPCC’s 2007 developed the tables listed below. The first looks at a variety of effects which are predictable in coming years. The second is specific to human health conditions and includes estimates as to magnitude and likelihood of the listed risks.

 

Global mean annual temperature change relative to 1980-1999

 

Impact chart

Although these challenges both appear and are difficult and challenging, there is still time to act. The expression, “think globally, act locally” has never been more apt. And in the words of John Gardner from his book On Leadership, “Don’t pray for the day when we finally solve our problems. Pray that we have the freedom to continue working on the problems that the future will never cease to throw at us.”

 

References and Links

All graphs are from the Intergovernmental Panel on Climate Change, 4th Assessment Report, November 2007 (http://www.ipcc.ch/), except the Urban Heat Island image and some text, which is from the US Environmental Protection Agency (http://www.epa.gov/hiri/).

 

There are a huge number of links and references which may be of interest to the reader. A very few are included below:

 

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Influenza Update II

Published: February 2008
Written by: Ramakrishna Prasad, MD, MPH, Visiting Assistant Professor, Center for Public Health Preparedness; Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

The 2007-08 Influenza Season

Figure 1

FluView

 

Figure 2

Comparison of nedss influenza cases in current season to previous season

Comparison of NEDSS influenza cases in
current season to previous season.

 

Figure 3

Total number of influenza cases in NEDSS

Total number of influenza cases in NEDSS,
by week and region (RSV not included)

 

Figure 4

Number of cases

 

 

vaccination
CDC/James Gathany

CDC’s Advisory Committee Recommends Influenza Vaccination for Children 6 months through 18 years of age

There are two big stories this week. First, CDC’s Advisory Committee on Immunization Practices has just recommended annual influenza vaccination for ALL children age 6 months through 18 years of age. These recommendations become official recommendations of CDC once they are accepted by the director of CDC and the Secretary of Health and Human Services and are published in the Morbidity and Mortality Weekly Report. This change will likely have a significant impact on vaccine demand and usage, and has the potential to significantly reduce influenza carriage and transmission in both pediatric and adult age groups.

The second big story is this year’s flu season, which is the most active in many years. Details are included in the following sections.

Epidemiology

The current season started slowly. In fact, as of the first week of January, none of the 50 states had reported widespread flu activity. In January, the first state to report widespread flu was Colorado. As seen in Figure 1, this situation has undergone a near total metamorphosis in the last 6 weeks or so. Nationwide, following a rapid surge in flu cases, the only state not to report widespread flu activity now is Florida. This week is the 7th consecutive week that the pneumonia and influenza mortality has exceeded the epidemic threshold.

The State is witnessing one of the busiest flu seasons in many years as shown on the graph of the state’s NEDSS reports (Figures 2 and 3). The weekly frequency of reported cases far exceeds that seen in any of the previous five flu seasons. For the 5th consecutive week, a steep rise in flu cases across the state can be seen. All counties in the state have reported flu activity. The largest number of early cases of influenza were reported from the SW and NW regions; and it appears that the flu season has peaked in both these areas and may be starting to trend downwards. In the Central and Eastern parts of the state, flu cases are still increasing.

Isolates and subtypes

So far, the flu season this year has gone through four phases:

  • The low activity phase from September through December
  • The H1N1 predominant phase from late December through mid-January
  • The H3N2 predominant phase from mid-January onwards
  • The influenza type B surge phase starting in early February.

Nationwide, influenza type A has accounted for 84% of cases (Figure 4). The remaining 16% of cases have been due to influenza type B. Both influenza A (H1N1) and A (H3N2) are circulating. Although influenza A (H1) viruses predominated through mid-January, an increasing proportion of subtyped influenza A viruses are influenza A (H3) viruses. Influenza A (H3) viruses were reported more frequently than influenza A (H1) viruses during January 20–February 9. During week 6, influenza A (H3) became the predominant virus for the season overall.

Vaccine mismatch

The predominant H3 strain being isolated this year is the A/Brisbane/10/2007-like strain which does not match this season’s vaccine. It is a recent antigenic “drifted” variant from the strain used in this year’s vaccine in the US.

Once influenza A (H3N2) took over from H1N1 in late January, it has gone on to become the principal subtype of this season. A possible explanation for this may be due to mismatches between the vaccine and the predominant strains circulating in the United States. According to the CDC, only 11% of the H3 isolates matched the vaccine strain, and only 5% of the B isolates matched the vaccine. In contrast, H1 isolates show a 96% match. Nonetheless, some protection is certainly better than no protection at all and vaccination remains the most effective means to prevent influenza.

Because of these mismatches, the 2008-09 influenza vaccine for the United States will include three new strains: an A/Brisbane/10/2007 (H3N2)-like virus, a B/Florida/4/2006-like virus and A/Brisbane/59/2007 (H1N1)-like virus strain. The H3N2 and B virus vaccine components in the U.S. vaccine are included in the 2008 vaccine for the Southern Hemisphere. Influenza vaccine manufacturers produced as many as 130 million doses of influenza vaccine for the 2007-08 influenza season and have discussed expanding current production capacity in the coming years.

CDC is also reporting a number of pediatric deaths due to influenza, but not an atypically high number at this time. More information is available at http://www.cdc.gov/flu/weekly/index.htm.

Resistance

Tamiflu

Thus far, and for the first time, a significant number of isolates are resistant to the neuraminidase inhibitor, Tamiflu (Oseltamivir). All the resistant isolates belong to the A (H1N1) subtype. Nearly 8% of H1 isolates are resistant to Tamiflu. In Europe these rates are even higher. It is of concern that last year only 0.7 % of H1 isolates showed resistance to this drug. This represents a more than 10 fold rise in the circulation of drug resistant strains this year. Furthermore, the antiviral drug class, Adamantanes, is no longer recommended either for the prevention or treatment of influenza as more than 99% of H3N2 isolates are found resistant to this class.

Non-pharmaceutical interventions

Though no resistance has been seen in H3 and type B isolates, it may be only a matter of time given the dramatic changes in H1 resistance patterns. Given the issues associated with less than optimal vaccine fit and resistance to antiviral medications, the importance of non-pharmaceutical approaches cannot be overstated. Measures to prevent both the acquisition of illness and its transmission are critical to combat flu. These include:

  • Effective hand hygiene
  • Keeping your hands away from your nose, eyes and mouth
  • Wearing a mask (if taking care of patients who may be ill with influenza)
  • Covering your cough
  • Staying home if you are not feeling well

In conclusion, the flu season this year continues to gain further momentum both nationally and in the state. Though it appears to have just gone through its peak and may start trending downwards in south-western Pennsylvania, this will become clear only over the next couple of weeks or so. Also, since the flu season typically lasts up to 12 weeks or more, it may still not be too late to get a flu shot for you or for patients.

 

Note: The authors wish to thank the Pennsylvania Department of Health for sharing the non-CDC graphs in this article.

 

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Influenza Update

Published: January 2008
Written by: Sam Stebbins, MD, MPH, Director, Center for Public Health Preparedness

 

Flu Season is here!

Number of Cases chart

U.S. WHO/NREVSS Collaborating Laboratories

Cases of influenza have been confirmed in 60 counties in Pennsylvania and flu season appears to be taking off. Data from the Pennsylvania Department of Health flu website through January 26th (week 4) shows that flu season is much more active than last year.

Flu isolates are predominantly type A in the state, consistent with nationwide trends where so far 85% of cases are caused by influenza type A and 15% by influenza type B. Both H1 and H3 are circulating, and there is a trend towards more H3 in recent weeks. One of the reasons this year may be more active than we would like is due to mismatches between the vaccine and the predominant strains circulating in the United States. According to CDC’s report from last Friday, only 11% of the H3 isolates matched the vaccine strain, and only 5% of the B isolates matched the vaccine. In contrast, H1 isolates show a 96% match.

The predominant H3 strain being isolated this year is “A/Brisbane/10/2007”, a recent antigenic variant from the strain used in this year’s vaccine in the US. Because they are closely related, a flu shot may still provide significant protection. However the predominant B isolates belong to a lineage distinct from that in the vaccine, and thus the vaccine is less likely to be effective.

This means that activities to prevent both acquiring illness and passing it on to others are more important than ever. These include:

  • Effective hand hygiene
  • Keeping your hands away from your nose, eyes and mouth
  • Wearing a mask (if taking care of patients who may be ill with influenza)
  • Covering your cough
  • Staying home if you are not feeling well

Flu season typically lasts up to 12 weeks or more, so it is not too late to get a flu shot for you or for patients.

Pittsburgh Influenza Prevention Project fighting flu in new way

Pittsburgh Influenza Prevention Project

Flu season is firmly under way in the 10 Pittsburgh K-5 Schools which are part of The Pittsburgh Influenza Prevention Project (PIPP), a project of the Center for Public Health Practice.  Under the direction of Dean Donald Burke, Principal Investigator, and Co-PI Samuel Stebbins, PIPP is monitoring absent students in these schools for flu, and testing children who have flu-like symptoms.  PIPP field staff conducts home visits to test the children.  PIPP is also testing various non-pharmaceutical interventions (no shots or medicines) in the schools to see if flu is prevented and absenteeism is reduced. 

PIPP is innovative on many levels. It seeks to understand how flu is transmitted in schools, and between families and schools. It operates in a broad partnership with the Pittsburgh Board of Education, multiple organizations within the University, UPMC and local, state and federal Public Health agencies. PIPP is one of 8 studies being conducted in cooperation with the US Centers for Disease Control and Prevention. Findings from this research will have application in pandemic flu response and the discussion of school closure as a preventive measure. It will also impact preventive health policies in schools that reduce absenteeism due to flu and related diseases.

 

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