JEFFREY S.

BROWN, MPH, MSW

Health and Human Services Agency Nevada County KAREN MILMAN, MD, MPH
Public Health Officer/Director
Director Health and Human Services
Agency
500 CROWN POINT CIRCLE, STE 110 10075 LEVON AVE STE 207
10075 LEVON AVE STE 20796161
GRASS VALLEY, CA 95945
Public Health Department TRUCKEE,
TRUCKEE,
TELEPHONE
CALIFORNIA
CALIFORNIA 96161
(530) 582-7814
TELEPHONE (530) 265-1450 TELEPHONE
FAX (530)
(530) 582-7814
582-7732
FAX (530) 582-7732
(888) 303-1450

FAX (530) 271-0837

Update on “Pandemic H1N1 Influenza A” to Providers and other Partners

November 23, 2009
Please address Provider questions this week to Patti Carter at 530-265-7174.

This update contains new and updated information regarding the surveillance, diagnosis
and treatment of persons with Pandemic H1N1 Influenza A and Influenza Like Illness (ILI).
The information provided is from several sources including the Centers for Disease Control
(CDC) and the California Department of Public Health, Division of Communicable Disease
(CDPH).

NEVADA COUNTY NUMBERS

• There have been no reported hospitalizations in Nevada County residents
this past week due to the H1N1 virus.
• There have been no fatalities of Nevada County residents due to the H1N1
virus.

CALIFORNIA NUMBERS
• There continue to be an average of 500 new hospitalizations and 20 fatalities from
H1N1 in the State of California each week.
• To date, in California, there have been 6069 hospitalizations and 318 fatalities. Of
these fatalities, 39 were children less than 18 years of age and 11 were pregnant
women.

NEW INFORMATION:
• H1N1 manufacturing and distribution remains significantly behind the initial
projected schedules and California has only received approximately 55% of what was
initially expected to arrive by the end of October.
• There continues to be a limited supply of H1N1 vaccine in the County. School based
clinics continued this week with a clinic at Nevada Union for medically fragile
students. Additional clinics for high school aged students only continue next week in
Truckee with NUHS and BRHS clinics the first week of December.

GUIDELINES/RECOMMENDATIONS:
• Nevada County Public Health recommends that clinicians strongly consider H1N1 as
the initiating cause of pneumonia in all hospitalized patients and thus swab the
patient for H1N1 and the sample sent off to the State laboratory. A reminder: Rapid
Influenza A testing is not a valid indicator for the presence of the H1N1 virus.
• There is a new California Department of Public Health reporting
requirement: Any patient hospitalized with a confirmed influenza
diagnosis, whether H1N1, seasonal influenza A, or seasonal influenza B
MUST now be reported to the local health department as a mandated
reportable illness.
• In addition, all patients hospitalized with a diagnosis that starts with influenza
symptoms must be reported to the Public Health Department within 24 hours of the
patient being hospitalized. A possible or probable diagnosis involving H1N1 is a
mandated reportable illness.
• Attached are two new short alerts from the California Department of Public Health for
your review:
○ Information regarding Tamiflu
○ Expanded recommendations for who should receive the Pneumovax Vaccine.
 State of California—Health and Human Services Agency
California Department of Public Health
MARK B HORTON, MD, MSPH ARNOLD SCHWARZENEGGER
Director Governor
October 15, 2009
TO: California Physicians
FROM: Mark B. Horton, MD, MSPH
Director

SUBJECT: H1N1 Vaccine and Thimerosal Exemption

SUMMARY
Since 2006, California law [Health and Safety Code Section 124172 subdivision (a)] has
stated that vaccines containing specific levels of mercury cannot be administered to
pregnant women and young children, except under certain circumstances. The
Secretary of the California Health and Human Services Agency has granted an
exemption to this restriction for Influenza A (H1N1) 2009 Monovalent Vaccine in children
younger than 3 years of age and pregnant women from October 12, 2009 – November
30, 2009. The exception is being granted because of the present dangers posed by
pandemic (H1N1) influenza and because there are insufficient supplies of thimerosal-
free influenza A (H1N1) 2009 monovalent influenza vaccine to comply with the law. The
need for an extension of the exemption will be assessed over this period.

Pandemic Influenza (H1N1) Disease and Vaccine in Young Children

In April 2009 a novel pandemic influenza A (H1N1) virus was determined to be the
cause of influenza illness in Southern California and the cause of outbreaks of
respiratory illness in Mexico. On June 11, 2009, the World Health Organization (WHO)
declared a worldwide pandemic, indicating uncontained community-level transmission
of the pandemic influenza A (H1N1) virus in multiple areas of the world. Worldwide
transmission of the pandemic influenza A (H1N1) virus has continued since June in
both the Northern and Southern Hemispheres and is expected to increase in California
during the autumn or winter.

Young children and pregnant women are amongst the groups that have been at higher
risk of pandemic (H1N1) influenza. The incidence of hospitalization from pandemic
influenza in the United States and in California has been highest among children
younger than 4 years. Medical risk factors for severe infection, including pregnancy,
are similar to those identified for seasonal influenza. At least four pregnant women in
California have died from pandemic influenza A (H1N1) to date, and the incidence of
hospitalization associated with pandemic influenza in pregnant women has been at
least four times higher than that of the general population.

Influenza vaccination can prevent influenza and influenza-related complications. The

federal Advisory Committee on Immunization Practices (ACIP) has recently
recommended that certain groups at highest risk for infection or influenza-related
complications, including children and
 Immunization Branch/Division of Communicable Disease Control 850 Marina Bay Parkway, Building P, 2nd Floor, Richmond,
CA 94804 (510) 620-3737 Internet Address: www.cdph.ca.gov

H1N1 Vaccine and Thimerosal Exemption Page 2 October 15, 2009

pregnant women, should be the initial targets for pandemic influenza A (H1N1) vaccination
programs. Therefore, the national and California immunization campaigns are attempting to
immunize pregnant women and young children promptly to protect them against pandemic (H1N1)
influenza disease.

Exemption to California Mercury Free Vaccine Act

California Health and Safety Code Section 124172 subdivision (c) permits the Secretary of the Health
and Human Services Agency to exempt the use of a vaccine from section 124172 subdivision (a) “if the
secretary finds, and the Governor concurs, that…shortage of supply of a vaccine that would prevent
children under three years of age and knowingly pregnant receiving the needed vaccine,” making
“necessary the administration of a vaccine containing more mercury than the maximum level set forth
in subdivision (a)…”

Because of the dangers posed by influenza posed by pandemic (H1N1) influenza, and because there is
currently insufficient supplies of influenza A (H1N1) 2009 monovalent influenza vaccine that have levels
of mercury below the state legal limits, an exemption has been granted from California Health and Safety
Code Section 124172 subdivision (a) for influenza A (H1N1) 2009 monovalent influenza vaccine
administered to children younger than 3 years old and pregnant women for the period of October 12,
2009 – November 30, 2009. Vaccine supplies and distribution will continue to be assessed to determine
whether an extension of the exemption will be needed to protect Californians against pandemic (H1N1)
influenza.

In accordance with the intent of the law, during this exemption period physicians should prioritize
supplies of thimerosal-free vaccine to young children and pregnant women as long as prioritization
does not prevent the immunization of others.

As with other routine vaccines, providers should continue to provide patients and parents or guardians
with the specific Vaccine Information Statement (VIS) that lists risks and benefits before immunization.
Providers should also discuss the availability of thimerosal-free influenza A (H1N1) 2009 monovalent
influenza vaccine with patients, parents and guardians prior to immunization. During this discussion,
please consider
• Children younger than 3 years old are among those recommended to receive 2 doses of vaccine
for full protection
• Pandemic (H1N1) influenza virus is currently circulating in California
• Whether your patients of any age will have additional opportunities to return for immunization in
time to be protected against infection

For additional information about these topics, please contact the California Department of Public
Health’s Immunization Branch at (510) 620-3737 or www.getimmunizedca.org.

cc: CDPH Immunization Branch Field Representatives Local Health Officers Local Health
Department Immunization Coordinators