H1N1 Pandemic H1N1 Pandemic Influenza Planning Influenza Planning VideoconferenceVideoconference

August 26, 2009August 26, 2009

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Pandemic FluPandemic FluH1N1H1N1

Terry L Dwelle MD MPHTM Terry L Dwelle MD MPHTM CPH FAAPCPH FAAP

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Pandemic Influenza – General Pandemic Influenza – General InformationInformation

Pandemic is a worldwide epidemicPandemic is a worldwide epidemicWe can expect several pandemics in We can expect several pandemics in

the 21the 21stst century century

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H1N1 (Swine Origin H1N1 (Swine Origin Influenza Virus)Influenza Virus)

33,902 cases in the US (estimate is that there have been 1 million 33,902 cases in the US (estimate is that there have been 1 million cases in the US) cases in the US)

3663 hospitalizations (10.8%, 0.36% of estimated cases in the US)3663 hospitalizations (10.8%, 0.36% of estimated cases in the US) 170 deaths (0.5% of identified cases and 4.6% of those hospitalized, 170 deaths (0.5% of identified cases and 4.6% of those hospitalized,

0.017% of estimated cases in the US)0.017% of estimated cases in the US) Genetically this H1N1 is linked to the 1918-19 strainGenetically this H1N1 is linked to the 1918-19 strain Currently we are seeing almost totally H1N1 circulatingCurrently we are seeing almost totally H1N1 circulating Majority of the cases are in children and young adultsMajority of the cases are in children and young adults Majority of hospitalized patients have underlying conditions (asthma Majority of hospitalized patients have underlying conditions (asthma

being the most common, others include chronic lung disease, DM, being the most common, others include chronic lung disease, DM, morbid obesity, neurocognitive problems in children and pregnancy).morbid obesity, neurocognitive problems in children and pregnancy).

There have been over 50 outbreaks in campsThere have been over 50 outbreaks in camps Southern hemisphere – currently seeing substantial disease from Southern hemisphere – currently seeing substantial disease from

H1N1 that is cocirculating with seasonal influenza. There has been H1N1 that is cocirculating with seasonal influenza. There has been some strain on the health systems in some situations.some strain on the health systems in some situations.

About 30% of infected individuals are asymptomatic (study from About 30% of infected individuals are asymptomatic (study from Peru)Peru)

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H1N1 in PregnancyH1N1 in PregnancyApril 15 to May 18, 2009 – 34 confirmed or April 15 to May 18, 2009 – 34 confirmed or

probable cases of H1N1 in pregnant probable cases of H1N1 in pregnant women reported to the CDCwomen reported to the CDC

11/34 (32%) were admitted to hospital11/34 (32%) were admitted to hospitalGeneral population hospitalization rate General population hospitalization rate

7.6%7.6%6 deaths – pneumonia and acute 6 deaths – pneumonia and acute

respiratory distress syndromerespiratory distress syndromePromptly treat pregnant women with H1N1 Promptly treat pregnant women with H1N1

infection with antiviralsinfection with antivirals

Lancet on line, July 29, 2009

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Pandemic Influenza - ImpactPandemic Influenza - ImpactA moderate pandemic may exceed A moderate pandemic may exceed

the capacity of hospitals to provide the capacity of hospitals to provide inpatient careinpatient care

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Estimates of the Impact of an Influenza

1957 and 1957 and 19681968

19181918

Illness 90 million - 30% (160,000)

90 million - 30% (160,000)

Outpatient medical care

45 million - 50% (80,000)

45 million - 50% (80,000)

Hospitalization 865,000 (1600) – 1%

9, 900,000 (19,200) – 12%

ICU care 128,750 (256) – 0.16%

1,485,000 (2880) – 1.8%

Mechanical ventilation

64,875 (128) – 0.08%

745,500 (1488) – 0.93%

Deaths 209,000 (416) – 0.26%

1,903,000 (3840) – 2.4%

ND estimates in parentheses

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Pandemic Influenza - Pandemic Influenza - EpidemiologyEpidemiology

Pandemics occur in waves Pandemics occur in waves The order in which communities will be affected The order in which communities will be affected

will likely be erraticwill likely be erratic Some individuals will be asymptomatically Some individuals will be asymptomatically

infectedinfected A person is most infectious just prior to A person is most infectious just prior to

symptom onsetsymptom onset Influenza is likely spread most efficiently by Influenza is likely spread most efficiently by

cough or sneeze droplets from an infected cough or sneeze droplets from an infected person to others within a 3 foot circumferenceperson to others within a 3 foot circumference

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Secondary Effects on Secondary Effects on Individuals and CommunitiesIndividuals and Communities

Individuals and FamiliesIndividuals and Families Income / job security due to absenteeismIncome / job security due to absenteeism Protecting children from exposure to influenzaProtecting children from exposure to influenza Continuity of educationContinuity of education Fear, worry, stigmaFear, worry, stigma Access to essential goods and services (eg food, medication, Access to essential goods and services (eg food, medication,

etc.)etc.) Home-based healthcareHome-based healthcare

CommunitiesCommunities Maintaining business continuityMaintaining business continuity Sustaining critical infrastructuresSustaining critical infrastructures Availability of essential goods and services (supply chains)Availability of essential goods and services (supply chains) Supporting vulnerable populationsSupporting vulnerable populations

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Pandemic Influenza - Pandemic Influenza - ResponseResponse

We don’t look at pandemic flu as a We don’t look at pandemic flu as a separate disease to be dealt with in a separate disease to be dealt with in a different way from regular seasonal different way from regular seasonal influenzainfluenza

Influenza response toolboxInfluenza response toolboxSocial distancing and infection control measureSocial distancing and infection control measureVaccineVaccineAntiviral medicationsAntiviral medications

The most effective way to prevent The most effective way to prevent mortality is by social distancingmortality is by social distancing

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Proxemics of Influenza Proxemics of Influenza TransmissionTransmission

Elementary Schools

Hospitals

Offices

Residences

3.9 ft

7.8 ft11.7 ft

16.2 ft

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Goals of Influenza PlanningGoals of Influenza Planning

-20

0

20

40

60

80

100

5 10 15 20 25 30 35 40 45 50 55 60

No InterventionWith Intervention

Cases

Day

Goals•Delay outbreak peak•Decompress peak burden on hospitals and infrastructure•Diminish overall cases and health impacts

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IsolationIsolation From From

www.cdc.gov/h1n1flu/guidance_homecare.htm Data from 2009Data from 2009

Most fevers lasted 2-4 daysMost fevers lasted 2-4 days90% of household transmissions occurred within 5 90% of household transmissions occurred within 5

days of onset of symptoms in the 1days of onset of symptoms in the 1stst case caseRequires 3-5 days of isolation (different from the 7 Requires 3-5 days of isolation (different from the 7

days previously used for influenza). The rule here is days previously used for influenza). The rule here is isolation for 24 hours after resolution of the fever isolation for 24 hours after resolution of the fever without the use of fever-reducing medications.without the use of fever-reducing medications.

Consider closing a school or business for a minimum Consider closing a school or business for a minimum of 5 days which should move the infected into the of 5 days which should move the infected into the area of much lower nasal shedding and contagion. area of much lower nasal shedding and contagion.

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Unstressed Hospital and Clinic Unstressed Hospital and Clinic Surge - North DakotaSurge - North Dakota

8.36

4.18

2.792.09

1.67

0123456789

10 20 30 40 50

100% CapHosp / ILI

Regional ILI rate

Clinic Caution 16.5

Clinic Crisis 21 X

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EMS Response RolesEMS Response RolesStephen P. Pickard MDStephen P. Pickard MD

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EMS Response Roles

Current EMS rolesCurrent EMS rolesTransport Transport Vaccination (paramedics)Vaccination (paramedics)

Potential additional roles in a surge Potential additional roles in a surge Altered transport rules if surge occursAltered transport rules if surge occurs Supplementation of acute care (ER, Supplementation of acute care (ER,

inpatient)inpatient) MCF directorMCF director

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Pan Flu AntiviralsPan Flu AntiviralsTerry L Dwelle MD MPTHM Terry L Dwelle MD MPTHM

CPH FAAPCPH FAAP

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Intervention - AntiviralsIntervention - Antivirals Antivirals (Tamiflu and Relenza) will be used Antivirals (Tamiflu and Relenza) will be used

primarily for treatment not prophylaxisprimarily for treatment not prophylaxisND will have approximately 160,000 treatment ND will have approximately 160,000 treatment

courses available for a pandemic (25% of the courses available for a pandemic (25% of the population)population)

Distribution flowDistribution flowNormalNormalNormal + Supplementation (from the state cache, Normal + Supplementation (from the state cache,

some prepositioned with LPHU’s) some prepositioned with LPHU’s) Points of DistributionPoints of Distribution

Resistance is a major concernResistance is a major concern

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Antiviral Treatment – H1N1Antiviral Treatment – H1N1Sensitive to anitvirals - zanamivir Sensitive to anitvirals - zanamivir

(Relenza) and oseltamivir (Tamilflu) (Relenza) and oseltamivir (Tamilflu) Uncomplicated febrile illness due to Uncomplicated febrile illness due to

H1N1 does not require treatmentH1N1 does not require treatmentTreatment is recommended forTreatment is recommended for

All hospitalized patients with confirmed, All hospitalized patients with confirmed, probable or suspected H1N1probable or suspected H1N1

High risk patients for complicationsHigh risk patients for complications

www.cdc.gov/h1n1flu/recommendations.htm

High risk groups for High risk groups for complicationscomplications

< 5yo (highest risk is < 2yo)< 5yo (highest risk is < 2yo) Adults Adults >> 65yo 65yo Persons with the following conditionsPersons with the following conditions

AsthmaAsthmaOther chronic pulmonary diseasesOther chronic pulmonary diseasesCardiovascular disease (except hypertension)Cardiovascular disease (except hypertension)Kidney, liver, blood disorders (including sickle cell disease), Kidney, liver, blood disorders (including sickle cell disease),

neurologic, neuromuscular, metabolic (including diabetes neurologic, neuromuscular, metabolic (including diabetes mellitus)mellitus)

Immunosuppression including that caused by medication or by Immunosuppression including that caused by medication or by HIVHIV

Pregnant womenPregnant women< 19yo receiving long-term aspirin therapy< 19yo receiving long-term aspirin therapyResidents of nursing homes and other chronic care facilitiesResidents of nursing homes and other chronic care facilities

www.cdc.gov/h1n1flu/recommendations.htm

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Treatment guidanceTreatment guidanceStart treatment as soon as possible Start treatment as soon as possible

after onset of symptoms after onset of symptoms Best if started before 48 hours from Sx Best if started before 48 hours from Sx

onsetonsetStill may be some benefit in Rx after 48 Still may be some benefit in Rx after 48

hourshoursDuration – 5 daysDuration – 5 days

www.cdc.gov/h1n1flu/recommendations.htm

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ProphylaxisProphylaxisClose contact of cases (confirmed, Close contact of cases (confirmed,

probable or suspected) who are at probable or suspected) who are at high-risk for complicationshigh-risk for complications

Health care personnel, public health Health care personnel, public health workers, or first responders who have workers, or first responders who have unprotected close contact to a case unprotected close contact to a case (confirmed, probable or suspect) during (confirmed, probable or suspect) during the infectious period (24 hours before the infectious period (24 hours before to 24 hours after becoming afebrile)to 24 hours after becoming afebrile)

www.cdc.gov/h1n1flu/recommendations.htm

Vaccination StrategyVaccination StrategyMolly Sander, MPHMolly Sander, MPH

Immunization Program Immunization Program ManagerManager

ND House Bill 1215Certified or licensed emergency medical

technicians-intermediate and paramedics, who are employed by a hospital and who are working in a non-emergency setting, may provide patient care within a scope of practice established by the department and may administer influenza vaccinations.EMS personnel may NOT administer vaccine

to anyone under the age of 18.

VaccineVaccine Separate novel H1N1 influenza vaccine

from seasonal trivalent vaccine. 45 million doses in mid-October

Followed be 20 million doses per week there after.

Five manufacturers: same age indications as seasonal vaccine.Both injectable and intranasal vaccine will

be available. Assume 2 doses required for everyone,

separated by 3 to 4 weeks.

ACIP RecommendationsACIP Recommendations 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;

ACIP RecommendationsACIP RecommendationsHealthcare 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; Include public health personnel

ACIP RecommendationsACIP RecommendationsAll people from 6 months through 24

years of age Children from 6 months through 18 years

of age because many cases of novel H1N1 influenza are 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 many cases of novel H1N1 influenza are in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,

ACIP RecommendationsACIP RecommendationsPersons aged 25 through 64 years who

have health conditions associated with higher risk of medical complications from influenza. Chronic pulmonary disease, including asthmaCardiovascular diseaseRenal, hepatic, neurological/neuromuscular, or

hematologic disordersImmunosuppressionMetabolic disorders, including diabetes mellitus

ACIP RecommendationsACIP Recommendations 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. 

ACIP RecommendationsACIP Recommendations If demand exceeds supply (not expected):

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.

DistributionDistributionH1N1 vaccine purchased from

manufacturers by the federal government.

Vaccine is allocated to states based on population.North Dakota will receive 0.208%

H1N1 vaccine will be distributed through a third party distributor (McKesson)Will also ship ancillary supplies.

• Alcohol pads, syringes, needles, sharps containers

EnrollmentEnrollmentProviders are required to sign an

enrollment form in order to receive H1N1 vaccine.CDC is creating a standardized form. It is

currently unavailable.Enrollment requirements unknown,

but most likely include:Proper storage and handling: 35 ° – 46° FFollowing of ACIP recommendationsReporting of doses administered?

Administration FeeAdministration FeeThe federal government will set a

maximum administration fee.Most likely at the Medicare rate:

$18.45/dose in North Dakota. (Different than Medicaid fee cap for VFC:$13.90)

Cannot charge for the cost of the vaccine, as it is free from the federal government.

Administration fee may be billed to patient, Medicaid, Medicare, private insurance, etc.

Local public health units cannot refuse to vaccinate based on inability to pay.Private providers will probably be able to

refuse vaccination if patient is unable to pay.

NDIISThe North Dakota Immunization

Information System (NDIIS) is a confidential, population-based, computerized information system that attempts to collect vaccination data about all North Dakotans.

Healthcare providers, local public health units, schools, and childcares may have access to the NDIIS.

NDIISNDIISThe NDIIS will be used to track doses

administered.Similar data entry to other vaccines, but

includes high-risk groups for vaccination.Doses administered must be reported to

CDC by the state on a weekly basis.Report each Tuesday for the previous week.

Contact the NDDoH at 701.328.3386 or toll-free at 800.472.2180 if interested in obtaining access.

Strategies for VaccinationStrategies for VaccinationCheck with local public health unit

to determine local strategies.Mass Immunization ClinicsSchool Clinics:

• Recommended by CDC• Good way to capture children

Vaccination similar to seasonal influenza vaccination. (private and public mix)

Seasonal Influenza Seasonal Influenza VaccinationVaccination

May be started when vaccine is available.Immunity lasts for at least one year according to

CDC. ACIP recommendations published and available

at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5808a1.htm?s_cid=rr5808a1_e. All children, 6 months – 18 years of ageAll persons 50 years of age or olderResidents of long-term care facilitiesPregnant women (during any trimester)Persons 6 months and older with a chronic illnessHealthcare personnel, including home careEmployees of long-term care facilitiesHousehold contacts of high-risk persons

Vaccine TypesTrivalent Inactivated Vaccine (TIV):

InjectableAdults need 0.5 mL dose IMAvailable in syringes and multi-dose vialsDifferent brands have different age

indicationsLive Attenuated Intranasal Vaccine

(LAIV):Licensed for people ages 2 – 49 yearsHalf of the sprayer in each nostril

Contraindications and PrecautionsTIV

Persons with a severe allergic reaction (anaphylaxis) to a vaccine component or following a prior dose of TIV should not receive TIV.• Includes anaphylactic allergy to eggs

Moderate or severe acute illness—vaccinate after symptoms have decreased

Contraindications and Precautions LAIV

Persons who should NOT receive LAIV:• Children <2 years of age• 50 years of age or older• Persons with chronic medical conditions• Children or adolescents receiving long-term aspirin

therapy• Pregnant women• Immunosuppressed persons• Persons with a history of a severe allergy to egg or

any other vaccine component• Persons with a history of Guillain-Barré syndrome

Defer vaccine for persons with moderate or severe acute illness until symptoms improve

Vaccine Information Statements

A VIS must be given with each dose.

2009-2010 seasonal VIS are available at www.cdc.gov/vaccines/pubs/vis/default.htm.

H1N1 VIS not yet available.

VAERSRemember to report

vaccine adverse events for both seasonal and H1N1.

http://vaers.hhs.gov/VAERS module will

be available in NDIIS.Same fields as VAERS

form.Pre-populated with

demographic and vaccine information from NDIIS.

Contact InformationContact Information Molly Sander, MPH, Program Manager 328-

4556 Abbi Pierce, MPH, Surveillance Coordinator

328-3324 Keith LoMurray,

IIS Sentinel Site Coordinator 328-2404

Tatia Hardy, VFC Coordinator 328-2035

Kim Weis, MPH, AFIX Coordinator 328-2385

Community Community Mitigation and Mitigation and

Infection ControlInfection ControlKirby Kruger, DirectorKirby Kruger, Director

Division of Disease ControlDivision of Disease Control

Community MitigationCommunity MitigationSchoolsSchoolsChildcare settingsChildcare settingsHealthcare settingsHealthcare settingsBusinessesBusinessesGeneral PublicGeneral PublicHome careHome care

Community MitigationCommunity MitigationIsolation or exclusionIsolation or exclusion

Voluntary and passiveVoluntary and passive24 hours after fever subsides and not using fever 24 hours after fever subsides and not using fever

reducing medicationreducing medication

Hand hygieneHand hygieneRespiratory etiquetteRespiratory etiquette

Exclusion Period - time ill people Exclusion Period - time ill people should be away from othersshould be away from others

Applies to settings in which the Applies to settings in which the majority of the people are not at majority of the people are not at increased risk for complicationsincreased risk for complications

For the general publicFor the general publicDoes Does NOTNOT apply to health care settings apply to health care settings

StaffStaffVisitorsVisitors

Antivirals not considered with exclusionAntivirals not considered with exclusion

Infection ControlInfection ControlHealthcare FacilitiesHealthcare Facilities

CDC still recommending airborne CDC still recommending airborne precautionsprecautions (N95) with all (N95) with all encounters with patients with ILIencounters with patients with ILI

HICPACHICPACHas endorsed standard precautions plus Has endorsed standard precautions plus

droplet precautionsdroplet precautionsWHO – same as HICPACWHO – same as HICPACNDDoH Similar to HICPAC and WHONDDoH Similar to HICPAC and WHO

Infection Control for EMSInfection Control for EMS Infectious Period for Novel H1N1Infectious Period for Novel H1N1

One day before to 7 days following One day before to 7 days following onset or after symptoms subside – onset or after symptoms subside – whichever is longerwhichever is longer

PSAPsPSAPsPSAPs should determine if anyone at PSAPs should determine if anyone at

the incident has influenza-like illnessthe incident has influenza-like illnessFebrile respiratory illnessFebrile respiratory illness

This should be communicated with This should be communicated with EMSEMS

Potential for Febrile Potential for Febrile Respiratory Illness at the Respiratory Illness at the

SceneScenePSAP advises potential febrile PSAP advises potential febrile

respiratory illnessrespiratory illnessAssess scene safetyAssess scene safetyEMS should don appropriate PPE prior to EMS should don appropriate PPE prior to

entering the sceneentering the scene

PSAP Does not Advise Potential for PSAP Does not Advise Potential for Febril Respiratory IllnessFebril Respiratory Illness

Maintain a distance of 6 feet Maintain a distance of 6 feet between yourself and others at the between yourself and others at the scenescene

Assess patients for fever and Assess patients for fever and respiratory symptomsrespiratory symptomsIf no symptoms – provide standard care If no symptoms – provide standard care If symptoms use appropriate PPEIf symptoms use appropriate PPE

PPEPPEUse standard precautions plus Use standard precautions plus

droplet precautions for patients with droplet precautions for patients with respiratory illnessrespiratory illnessWear a gownWear a gownDroplet precautions – use of a surgical or procedure Droplet precautions – use of a surgical or procedure

maskmaskUse an N-95 or N-100 if performing respiratory Use an N-95 or N-100 if performing respiratory

procedures that may aerosolize respiratory secretionsprocedures that may aerosolize respiratory secretionsUse eye and/or face protection if warrantedUse eye and/or face protection if warrantedFollow good hand hygiene proceduresFollow good hand hygiene procedures

Aerosol Generating Activities Aerosol Generating Activities Endotracheal intubationEndotracheal intubationNebulizer treatmentsNebulizer treatmentsCPRCPRResuscitation involving emergency Resuscitation involving emergency

intubationintubation

FinallyFinallyHave the patient wear a surgical Have the patient wear a surgical

mask, if he or she can tolerate itmask, if he or she can tolerate itRoutine cleaning with an EPA Routine cleaning with an EPA

registered productregistered productNotify receiving facility regarding the Notify receiving facility regarding the

febrile respiratory illnessfebrile respiratory illness

Infection Control in the HomeInfection Control in the HomeCaring for an Ill Person at Caring for an Ill Person at

HomeHome Place ill person in a private room try to designate one Place ill person in a private room try to designate one

bathroom for ill personbathroom for ill person Have ill person wear a surgical maskHave ill person wear a surgical mask No visitorsNo visitors One non-pregnant person should provide careOne non-pregnant person should provide care Caregiver should consider wearing maskCaregiver should consider wearing mask Caregiver should consider N95 if assisting with Caregiver should consider N95 if assisting with

respiratory treatmentrespiratory treatment Hand hygiene and respiratory etiquette for householdHand hygiene and respiratory etiquette for household Use paper towels to dry handsUse paper towels to dry hands

Surveillance, Testing Surveillance, Testing and Reportingand Reporting

Kirby Kruger, State Kirby Kruger, State Epidemiologist, Division Epidemiologist, Division

DirectorDirectorof Disease Controlof Disease Control

What have we seen in ND?What have we seen in ND?

 

Laboratory SurveillanceLaboratory SurveillanceSentinel PhysiciansSentinel PhysiciansSyndromic SurveillanceSyndromic SurveillanceFollow-up of random sample of Follow-up of random sample of

children under the age of 18children under the age of 18School absenteeism reportsSchool absenteeism reportsOutbreak SupportOutbreak Support

SurveillanceSurveillance

HospitalizationsHospitalizationsWork with Infection Control NursesWork with Infection Control NursesParticipate in the Emerging Infections ProgramParticipate in the Emerging Infections ProgramUse of RedBat to gather Hospitalization dataUse of RedBat to gather Hospitalization dataUse of HC StandardUse of HC Standard

School absenteeism ratesSchool absenteeism ratesIncrease the number of schools that reportIncrease the number of schools that reportMonitor school closuresMonitor school closures

SurveillanceSurveillance

Outbreak SupportOutbreak SupportIncrease the number of facilities that Increase the number of facilities that

can report outbreaks and receive free can report outbreaks and receive free testingtesting

SurveillanceSurveillance

TestingTesting Limited testing in all areas of North Dakota Limited testing in all areas of North Dakota

where novel H1N1 has not been where novel H1N1 has not been demonstrateddemonstratedTesting will be stopped once ongoing transmission is Testing will be stopped once ongoing transmission is

likely (2-5 positive tests)likely (2-5 positive tests)Current restriction on testing Current restriction on testing

• Ward, Cass and Burleigh CountiesWard, Cass and Burleigh Counties All areas can continue to test for novel All areas can continue to test for novel

H1N1 in hospitalized patients in which H1N1 in hospitalized patients in which H1N1 infection has not been ruled outH1N1 infection has not been ruled out

ResourcesResourcesNDDoH flu web-page (updated every

Wednesday)http://www.ndflu.com/

CDC flu web-pagehttp://www.cdc.gov/flu/http://www.cdc.gov/flu/

Questions and Questions and AnswersAnswers