Get the Facts About Novel H1N1 Influenza


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Get the Facts About
Novel H1N1 Influenza

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  • For the most current number of human cases visit the CDC H1N1flu website: . CDC, along with state and local health agencies, are working together to investigate this situation. Numbers are updated every at 11:00 AM EDT.
  • Influenza primarily infects the respiratory tract (nose, throat, and lungs). The disease can cause severe illness and lead to life-threatening complications, such as pneumonia, in many people.
  • It is thought that the main way influenza viruses are spread from person to person is through transmission of respiratory droplets during coughing and sneezing. Close contact (about 3 feet or less) usually is necessary for this type of spread. Influenza viruses also can spread by touching respiratory droplets on yourself, others, or an object, then touching mucus membranes, such as the mouth, nose, or eyes, without washing contaminated hands.
  • It is very important for anyone with symptoms to avoid contact with others, but seek emergency care if any of the symptoms listed in this slide are present.
  • This means that when H1N1 was first discovered, about 23 out of ever 100.000 0 to 4 year olds were infected, 26 of 100,000 5 to 24 year olds were infected. You can see that the incidence is highest in this group, and very low in the 65 and up age range
  • This slide shows that 0 to 4 year olds had the highest hospitalization rates, that is 4.5 out of every 100,000 children were hospitalized
  • Any soap is fine …bacterial soap is no better than other soap for influenza …influenza is a virus not a bacteria
  • AT HOME, someone who is home sick should not be at the mall or grocery store
  • these 5 target groups comprise about 159 million persons. If not enough for these groups, subset will include #s 1, 2, and 3, plus children 6 months to 4 years, and 5-18 year olds with chronic medical conditions , brings # down to 49 million
  • CDC is reporting confirmed cases on a daily basis. States may announce cases as they are confirmed and therefore the numbers of cases may vary.
  • Get the Facts About Novel H1N1 Influenza

    1. 1. Get the Facts About Novel H1N1 Influenza
    2. 2. Novel H1N1 Influenza <ul><li>Novel H1N1 (referred to as swine flu early on) is a new influenza virus that is spreading from person-to-person. </li></ul><ul><li>The United States government has declared a public health emergency in the U.S. in response to the H1N1 outbreak. </li></ul><ul><li>Our goals are to: </li></ul><ul><ul><ul><li>reduce transmission and illness severity </li></ul></ul></ul><ul><ul><ul><li>provide information to help you stay healthy </li></ul></ul></ul><ul><ul><ul><li>Help you to know what to do if you get the flu </li></ul></ul></ul>
    3. 3. Novel H1N1 Influenza <ul><li>The first cases of human infection with novel H1N1 influenza virus were detected in April 2009 in San Diego and Imperial County, California and in Guadalupe County, Texas. </li></ul><ul><li>The virus has spread rapidly. </li></ul><ul><li>The virus is widespread in the United States at this time and has been detected internationally as well. </li></ul><ul><li>29,153 cases confirmed to date in US </li></ul><ul><ul><li>7,511 hospitalized </li></ul></ul><ul><ul><li>477 deaths </li></ul></ul>
    4. 4. Novel H1N1 Influenza <ul><li>This virus was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs (swine) in North America. </li></ul><ul><li>Further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and bird (avian) genes and human genes. </li></ul><ul><li>Scientists call this a &quot;quadruple reassortant&quot; virus. </li></ul><ul><li>Really a Europian, Asian, Bird, Swine, Human Flu </li></ul>
    5. 5. Pandemic H1N1 Influenza Virus in PA Pandemic H1N1 Influenza Virus in PA • First laboratory-confirmed case: April 29, 2009. • As of August 11, 2009: 2,018 probable and confirmed cases. • 51 counties - confirmed cases. • 59% of probable and confirmed cases between the ages of 5 to 19 years old. • 51% Female and 49% Male. • 9 confirmed deaths. • 15 school closures. • 21 summer camp outbreaks. • 4 correctional facility outbreaks. • Number (%) of confirmed cases: – hospitalized: 57 (2.8%) – health care workers: 7 (0.4%) – pregnant women: 11 (0.5%) Confirmed Cases Probable Cases Deaths 8/11/2009 Novel 2009 Influenza A/H1N1 <ul><li>• First laboratory-confirmed case: April 29, 2009. </li></ul><ul><li>• As of August 11, 2009: 2,018 probable and confirmed cases. </li></ul><ul><li>• 51 counties - confirmed cases. </li></ul><ul><li>59% of probable and confirmed cases between the ages of 5 to 19 • 51% Female and 49% Male. </li></ul><ul><li>• 9 confirmed deaths. • 15 school closures. </li></ul><ul><li>• 21 summer camp outbreaks. • 4 correctional facility outbreaks. </li></ul><ul><li>• Number (%) of confirmed cases: hospitalized: 57 (2.8%)– health care workers: 7 (0.4%) pregnant women: 11 (0.5%) </li></ul>
    6. 6. Novel H1N1 Influenza <ul><li>CDC expects that more cases, more hospitalizations, and more deaths from this outbreak will occur over the coming days and months as we enter the new Flu season. </li></ul><ul><li>Influenza is always serious – each year in the United States, seasonal influenza results, on average, in an estimated 36,000 deaths and more than 200,000 hospitalizations from flu-related causes. </li></ul><ul><li>This outbreak certainly poses the potential to be at least as serious as seasonal flu, if not more so, especially given the fact that there currently is no vaccine against this virus. </li></ul><ul><li>Because this is a new virus, most people will not have immunity to it, and illness may be more severe and widespread as a result. </li></ul>
    7. 7. Novel H1N1 Influenza <ul><li>In seasonal flu, certain people are at “high risk” of serious complications. </li></ul><ul><ul><li>people 65 years and older </li></ul></ul><ul><ul><li>children younger than five years old </li></ul></ul><ul><ul><li>pregnant women </li></ul></ul><ul><ul><li>people of any age with certain chronic medical conditions. </li></ul></ul><ul><ul><li>medical conditions previously recognized as placing people at “high risk” of serious seasonal flu-related complications. This includes pregnancy, diabetes, heart disease, asthma and kidney disease. </li></ul></ul>
    8. 8. Novel H1N1 Influenza <ul><li>One thing that appears to be different from seasonal influenza is that adults older than 64 years do not yet appear to be at increased risk of novel H1N1-related complications thus far. </li></ul><ul><li>CDC laboratory studies have shown that no children and very few adults younger than 60 years old have existing antibody to novel H1N1 flu virus. </li></ul><ul><li>About one-third of adults older than 60 may have antibodies against this virus. It is unknown how much, if any, protection may be afforded against novel H1N1 flu by any existing antibody. </li></ul>
    9. 9. Signs and symptoms <ul><li>Symptoms of novel H1N1 flu in people are similar to those associated with seasonal flu. </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Sore throat </li></ul></ul><ul><ul><li>Runny or stuffy nose </li></ul></ul><ul><ul><li>Body aches </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>In addition, vomiting (25%) and diarrhea (25%) have been reported. (Higher rate than for seasonal flu.) </li></ul></ul>
    10. 10. How does novel H1N1 Influenza spread? <ul><li>This virus is thought to spread the same way seasonal flu spreads </li></ul><ul><li>Primarily through respiratory droplets </li></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Sneezing </li></ul></ul><ul><ul><li>Touching respiratory droplets on yourself, another person, or an object, then touching mucus membranes (e.g., mouth, nose, eyes) without washing hands </li></ul></ul>
    11. 11. How does novel H1N1 Influenza spread? <ul><li>Eating Pork </li></ul><ul><ul><li>No. The novel H1N1 influenza virus (formerly referred to as swine flu) virus is not spread by food. </li></ul></ul><ul><li>Public swimming pools </li></ul><ul><ul><li>No. Chlorination/other chemicals kill Flu virus. </li></ul></ul>
    12. 12. What can you do to protect yourself from getting sick? <ul><li>There is no vaccine right now to protect against this new H1N1 virus. </li></ul><ul><li>However, everyday actions can help prevent spread of germs that cause respiratory illnesses like influenza. </li></ul>
    13. 13. “Swine Flu Parties” <ul><li>&quot;Swine flu parties&quot; are gatherings during which people have close contact with a person who has novel H1N1 flu in order to become infected with the virus. The intent of these parties is for a person to become infected with what for many people has been a mild disease, in the hope of having natural immunity novel H1N1 flu virus that might circulate later and cause more severe disease. </li></ul>
    14. 14. Take these everyday steps to protect your health <ul><li>Wash your hands often with </li></ul><ul><li>soap and warm water, </li></ul><ul><li>especially after you cough </li></ul><ul><li>or sneeze. Wash for 15 – 20 </li></ul><ul><li>seconds. </li></ul><ul><li>Alcohol-based hand </li></ul><ul><li>wipes or gel sanitizers are also </li></ul><ul><li>effective. </li></ul>
    15. 15. Take these everyday steps to protect your health <ul><li>Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it. </li></ul><ul><li>Avoid touching your eyes, nose or mouth. </li></ul><ul><li>Germs spread this way. </li></ul><ul><li>Avoid contact with sick people. </li></ul>
    16. 16. If you get sick… <ul><li>Stay home if you’re sick </li></ul><ul><li>for 7 days after your symptoms </li></ul><ul><li>begin or until you’ve been </li></ul><ul><li>symptom-free for 24 hours, </li></ul><ul><li>whichever is longer. </li></ul><ul><li>If you are sick, limit your contact </li></ul><ul><li>with other people as much as possible. </li></ul>
    17. 17. Steps to Lessen the Spread of Flu in the Home <ul><li>Keep the sick person away from other people as much as possible especially others who are at high risk for complications from influenza </li></ul><ul><li>Remind the sick person to cover their coughs, and clean their hands with soap and water or an alcohol-based hand rub often, especially after coughing and/or sneezing </li></ul><ul><li>Have everyone in the household clean their hands often, using soap and water or an alcohol-based hand rub. </li></ul><ul><li>Ask your Doctor if household contacts of the sick person—particularly those contacts who may be pregnant or have chronic health conditions—should take antiviral medications such as oseltamivir (Tamiflu®) or zanamivir (Relenza®) to prevent the flu </li></ul><ul><li>If you are in a high risk group for complications from influenza , you should attempt to avoid close contact (within 6 feet) with household members who are sick with influenza. If close contact with a sick individual is unavoidable, consider wearing a facemask or respirator, if available and tolerable.  Infants should not be cared for by sick family members.  </li></ul>
    18. 18. Placement of the sick person <ul><li>Keep the sick person in a room separate from the common areas of the house. (For example, a spare bedroom with its own bathroom, if that’s possible.) Keep the sickroom door closed. </li></ul><ul><li>Unless necessary for medical care or other necessities, people who are sick with an influenza-like-illness should stay home and keep away from others as much as possible, including avoiding travel, for at least 24 hours after fever is gone except to get medical care or for other necessities. </li></ul><ul><li>If persons with the flu need to leave the home (for example, for medical care), they should wear a facemask, if available and tolerable , and cover their nose and mouth when coughing or sneezing </li></ul><ul><li>Have the sick person wear a facemask – if available and tolerable – if they need to be in a common area of the house near other persons. </li></ul><ul><li>If possible, sick persons should use a separate bathroom. This bathroom should be cleaned daily with household disinfectant. </li></ul>
    19. 19. Household Cleaning, Laundry, and Waste Disposal <ul><li>Throw away tissues and other disposable items used by the sick person in the trash. </li></ul><ul><li>Wash your hands after touching used tissues and similar waste. </li></ul><ul><li>Keep surfaces (especially bedside tables, surfaces in the bathroom, and toys for children) clean by wiping them down with a household disinfectant according to directions on the product label. </li></ul><ul><li>Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first. </li></ul><ul><li>Wash linens (such as bed sheets and towels) by using household laundry soap and tumble dry on a hot setting. Avoid “hugging” laundry prior to washing it to prevent contaminating yourself. Clean your hands with soap and water or alcohol-based hand rub right after handling dirty laundry. </li></ul><ul><li>Eating utensils should be washed either in a dishwasher or by hand with water and soap. </li></ul>
    20. 20. Treatment <ul><li>Fluids </li></ul><ul><li>Rest </li></ul><ul><li>Tylenol </li></ul><ul><li>Special Considerations for Children Aspirin or aspirin-containing products (e.g. bismuth subsalicylate – Pepto Bismol) should not be administered to any confirmed or suspected ill case of novel influenza H1N1 virus infection aged 18 years old and younger due to the risk of Reye syndrome. For relief of fever, other anti-pyretic medications such as acetaminophen are recommended. </li></ul><ul><li>Children younger than 4 years of age should not be given over-the-counter cold medications without first speaking with a healthcare provider. </li></ul>
    21. 21. Watch for emergency warning signs <ul><li>Most people should be able to recover at home, but watch for emergency warning signs that mean you should seek immediate medical care. </li></ul><ul><li>In adults: </li></ul><ul><ul><ul><ul><li>Difficulty breathing or shortness of breath </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pain or pressure in the chest or abdomen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sudden dizziness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Confusion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Severe or persistent vomiting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flu-like symptoms improve but then return with </li></ul></ul></ul></ul><ul><ul><ul><ul><li>fever and worse cough </li></ul></ul></ul></ul>
    22. 22. Medications <ul><li>Treatment is recommended for: </li></ul><ul><ul><li>All hospitalized patients with confirmed, probable or suspected novel influenza (H1N1). </li></ul></ul><ul><ul><li>Patients who are at higher risk for seasonal influenza </li></ul></ul><ul><li>Benefits from antiviral treatment in studies of seasonal influenza is strongest when treatment is started within 48 hours of illness onset </li></ul><ul><li>Two medications </li></ul><ul><ul><li>Zanamivir ( Relenza) </li></ul></ul><ul><ul><li>Oseltamivir (Tamiflu) </li></ul></ul><ul><ul><li>Others such as Amantidine and Ramantidine have been shown not to work </li></ul></ul>
    23. 23. Chemoprophylaxis <ul><li>Post exposure antiviral chemoprophylaxis with either oseltamivir or zanamivir can be considered for the following: </li></ul><ul><ul><li>Close contacts of cases (confirmed, probable, or suspected) who are at high-risk for complications of influenza </li></ul></ul><ul><ul><li>Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with novel (H1N1) influenza virus infection (confirmed, probable, or suspected) during that person’s infectious period. </li></ul></ul><ul><li>Pre-exposure antiviral chemoprophylaxis should only be used in limited circumstances, and in consultation with local medical or public health authorities. </li></ul>
    24. 24. Vaccination <ul><li>Vaccine to be available October/November </li></ul><ul><li>Vaccination program will be VOLUNTARY. </li></ul><ul><li>Encourage both seasonal and pandemic vaccine. </li></ul><ul><li>Pandemic vaccine - two dose – Seasonal – one dose </li></ul><ul><li>Public Health Flu Vaccination Response </li></ul><ul><ul><ul><li>Mass Immunization </li></ul></ul></ul><ul><li>Blended Pandemic Vaccination Model - private providers </li></ul><ul><ul><ul><li>and public mass vaccination clinics. </li></ul></ul></ul><ul><li>Private providers – through website utilizing the Statewide </li></ul><ul><ul><ul><li>Immunization Information System (SIIS). </li></ul></ul></ul><ul><li>Pre-registration required. </li></ul><ul><li>Vaccine will be drop-shipped. </li></ul><ul><li>All vaccine administration is entered in SIIS </li></ul>
    26. 26. Symptoms of Swine Flu in Children <ul><li>Classically children have a sudden onset of high fever, chills and respiratory symptoms along with mild nasal congestion and cough </li></ul><ul><li>Older children may complain of scratchy throats and muscle aches </li></ul><ul><li>Infants and children may also have vomiting and diarrhea </li></ul>
    27. 27. H1N1 Impact on different age groups April 15, 2009 – July 24, 2009 Graph A: Novel H1N1 Confirmed and Probable Case Rate in the United States, By Age Group                                                                                                                                                                       
    28. 28. H1N1 Hospitalization Rates by Age Group                                                                   
    29. 29. Higher Risk Populations (Pediatric) <ul><li>Children under age 2, especially infants under age 6 months </li></ul><ul><li>Children with chronic medical conditions- </li></ul><ul><ul><li>Immunosuppressed children (such as HIV) </li></ul></ul><ul><ul><li>Asthma and other chronic lung conditions </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Sickle cell Disease </li></ul></ul><ul><ul><li>Seizure disorder (epilepsy) or other neurologic problems </li></ul></ul><ul><ul><li>Heart Disease </li></ul></ul><ul><ul><li>Developmental disabilities such as CP (cerebral palsy) </li></ul></ul>
    30. 30. What to do if Your Child has Flu-Like Symptoms <ul><li>Mild illness: Stay home from school or child care. </li></ul><ul><li>Younger than 3 months with a fever: see a doctor </li></ul><ul><li>Older than 3 months with a fever: the degree of fever is not as important as how he or she feels and acts. </li></ul><ul><li>Any child with a chronic medical condition (as mentioned above), who has even mild flu symptoms should see a doctor. </li></ul>
    31. 31. Signs that Warrant a Visit to the Doctor <ul><li>lethargy </li></ul><ul><li>irritability </li></ul><ul><li>fast breathing </li></ul><ul><li>vomiting </li></ul><ul><li>inattention to the environment </li></ul><ul><li>poor feeding </li></ul>
    32. 32. Caring for a Child with a Flu-Like Illness <ul><li>WASH YOUR HANDS OFTEN!! </li></ul><ul><ul><li>soap and water (Sing the happy birthday song twice!) </li></ul></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>use an alcohol-based hand gel if soap is not available. </li></ul></ul>
    33. 33. Caring for a Child with a Flu-Like Illness <ul><li>Keep surfaces (including toys, bedside table, doorknobs) clean – wipe them down with a household disinfectant. </li></ul><ul><li>Wash bed sheets and towels with laundry detergent in hot water. Avoid “hugging” the dirty laundry on the way to the washing machine, and wash your hands right after handling dirty laundry </li></ul>
    34. 34. What to do if your Child has Flu-Like Symptoms <ul><li>You can give medicine such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) for fever. Do not give aspirin-containing products. </li></ul><ul><li>If they are not eating well, encourage them to drink liquids. </li></ul><ul><li>Cough and cold medications do not help, and should not be used, especially in young children under 4 years of age. </li></ul><ul><li>Call your doctor for advice. Your doctor can help you decide whether your child needs to be seen or if they may need to be tested and/or treated for swine influenza. </li></ul>
    35. 35. Caring for a Child with a Flu-Like Illness <ul><li>Keep your child at home. Don’t let him go to school or child care until he has been fever-free for 24 hours. </li></ul><ul><li>Keep a sick child away from other people as much as possible. </li></ul><ul><li>When holding a small child who is sick, place the child’s chin on your shoulder so that he or she will not cough in your face. </li></ul>
    36. 36. Warning Signs that Your Child’s Illness is Getting Worse <ul><li>Trouble breathing or fast breathing </li></ul><ul><li>Not drinking well </li></ul><ul><li>Not urinating as much as usual </li></ul><ul><li>Bluish or gray skin color </li></ul><ul><li>Being irritable even after their fever goes down </li></ul><ul><li>Not waking up normally or interacting normally </li></ul><ul><li>Rash </li></ul><ul><li>The fever goes down and flu symptoms get better, but then get worse again a day or two later </li></ul>
    37. 37. Antiviral Medications <ul><li>Antiviral medications like Tamiflu and Relenza, which are in adequate supply, work against the H1N1 swine influenza virus. </li></ul><ul><li>Treatment may not be indicated for everyone </li></ul><ul><li>Relenza is not for young children. </li></ul><ul><li>Your doctor can advise you about whether either of these medications are right for your child. </li></ul>
    38. 38. What about medication to treat H1N1? <ul><li>Oseltamivir (“Tamiflu”) </li></ul><ul><ul><li>used to treat some types of influenza infection ('flu') in adults and children (older than 1 year of age) who have had symptoms of the flu for no longer than 2 days </li></ul></ul><ul><ul><li>also used to prevent some types of flu in adults and children (older than 1 year of age) when they have spent time with someone who has the flu or when there is a flu outbreak. </li></ul></ul><ul><ul><li>Not officially approved for children under age 1, but limited trials show a good safety profile </li></ul></ul>
    39. 39. What about medications to treat H1N1? <ul><li>Zanamivir (“Relenza”) </li></ul><ul><ul><li>Zanamivir is taken by inhalation </li></ul></ul><ul><ul><li>is not recommended for those with asthma or other respiratory diseases. </li></ul></ul><ul><ul><li>not approved for treating influenza in children under 7. </li></ul></ul>
    40. 40. What About a Vaccine? <ul><li>Routine vaccination against influenza not likely to protect against H1N1 </li></ul><ul><li>Specific vaccines against the novel influenza A (H1N1) virus are being manufactured </li></ul><ul><li>Licensed vaccine is expected to be available in the United States by mid-October 2009 </li></ul><ul><li>Initial supply of these vaccines might not be enough to meet the demand for vaccine, so high risk groups will probably be immunized first </li></ul>
    41. 41. What about a Vaccine? <ul><li>Five initial target groups </li></ul><ul><ul><li>Pregnant women </li></ul></ul><ul><ul><li>persons who live with or provide care for infants aged <6 months </li></ul></ul><ul><ul><li>health-care and emergency medical services personnel </li></ul></ul><ul><ul><li>children and young adults aged 6 months--24 years, </li></ul></ul><ul><ul><li>persons aged 25--64 years who have medical conditions that put them at higher risk for influenza-related complications </li></ul></ul><ul><li>Vaccination programs will begin as soon as supply becomes available 50 Million to start and 20 million per week up to 190 million </li></ul>
    42. 42. What about a Vaccine? <ul><li>Vaccine recommendations will most likely expand to include all persons 6 months to 64 years if supply allows </li></ul><ul><li>Vaccine availability is expected to expand over time </li></ul><ul><li>All persons currently recommended for seasonal influenza vaccine, including those aged ≥65 years, should receive the seasonal vaccine as soon as it is available. </li></ul>
    43. 43. How can we prevent the spread of H1N1? <ul><li>Cover your mouth/nose when sneezing/coughing </li></ul><ul><ul><li>Tissue </li></ul></ul><ul><ul><li>Sneeze/cough into your elbow/upper sleeve </li></ul></ul><ul><li>Throw away dirty tissues in trash </li></ul><ul><li>Wash your hands immediately after coughing/sneezing </li></ul><ul><ul><li>soap and water for 20 seconds </li></ul></ul><ul><ul><li>alcohol-based hand sanitizer </li></ul></ul>
    44. 44. How can we prevent the spread of H1N1? <ul><li>Avoid touching your eyes, nose and mouth </li></ul><ul><li>If you get sick, stay home from work or school until you are free of fever (without the use of acetominophen or ibuprofen) for 24 hours </li></ul>
    45. 45. Summary <ul><li>CDC anticipates that there will be more cases, more hospitalizations and more deaths associated with this new virus in the coming days and weeks because the population has little to no immunity against it. </li></ul><ul><li>We must all work together to limit and control the transmission of novel H1N1 influenza. </li></ul>
    46. 46. Summary <ul><li>For the most current information on the H1N1 influenza outbreak, visit </li></ul><ul><li>CDC, WHO, and public health officials worldwide are carefully monitoring the situation. </li></ul><ul><li>Follow all recommendations for preventing the spread of influenza. </li></ul><ul><li>For local guidance, contact your state, local, or county health officials. </li></ul>
    47. 47. Resources <ul><li> </li></ul><ul><li> </li></ul><ul><li>1-800-CDC-INFO (1-800-232-4636) </li></ul><ul><li>FACEBOOK—St. Joseph Medical Center </li></ul><ul><li>TWITTER--sjberksswineflu </li></ul>