Influenza a(H1N1) (Swine Flu), A Global Outbreak
Transcript of Influenza a(H1N1) (Swine Flu), A Global Outbreak
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CHOTANI 2009.
Rashid A. Chotani, MD, MPH, DTMAdjunct Assistant ProfessorUniformed Services University of the Health Sciences(USUHS)[email protected]
Just-in-Time LectureInfluenza A(H1N1) (Swine Flu) Pandemic(Version 12, first JIT lecture issued April 26)
Tuesday, June 11, 2009 (11:30 PM EST)
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The Author acknowledges the efforts, hard work and diligence for hosting this lecture, web-management & translations and thanks the entire Supercourse Team, specially the following
Dr. Ronald E. LaPorte, University of Pittsburgh, USADr. Eugene Shubnikov, Institute of Internal medicine, Novosibirsk, Russia
Dr. Faina Linkov, University of Pittsburgh, USADr. Mita Lovalekar, University of Pittsburgh, USA
Dr. Nicols Padilla Raygoza, Universidad de Guanajuato, MxicoDr. Ali Ardalan, Tehran University of Medical Sciences, Iran
Dr. Mehrdad Mohajery, Tehran University of Medical Sciences, IranDr. Seyed Amir Ebrahimzadeh, Tehran University of Medical Sciences, Iran
Dr. Nasrin Rahimian, Tehran University of Medical Sciences, Iran
Dr. Mohd Hasni , University of Kebangsaan, MalaysiaDr. Kawkab Shishani, The Hashemite University, Jordan
Dr. Nesrine Ezzat Abdlkarim, Beirut Arab University, LebanonDr. Khowlah Almohaini, University of Pittsburgh, USA
Dr. Duc Nguyen, University of Texas, USADr. Elisaveta Jasna Stikova, University Ss. Cyril and Methodius, Skopje, MacedoniaDr. Michle Cazaubon, Secrtaire Gle de la Socit Franaise d' Angiologie, France
Dr. Yang Yingyun , Peking Union Medical College, ChinaDr. Jesse Huang, Peking Union Medical College, China
Shimon Weitzman, Ben Gurion University of the Negev , IsraelDr. Nurka Pranjic, Medical School University of Tuzla, Bosnia and HerzegovinaDr. Shakir Jawad, Uniformed Services University of the Health Sciences, USA
Dr. Hiroya Goto, Ministry of Defense, JapanDr. Osamu Usami, National Cancer Institute, USA
Afham A. Chotani, USA
Truly a global efforthttp://www.pitt.edu/~super1/
Acknowledgement
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1. Influenza Virus2. Definitions3. Introduction4. History in the US5. Spread/Transmission6. Timeline/Facts7. Response8. Status Update
Mexico
US Canada European Union Globally
9. Case-Definitions10. Guidelines
Clinicians Laboratory Workers General Population
11. Treatment12. Other Protective Measures13. Summary14. Timeline of Emergence15. Lessons Learned from Past Pandemics16. Conclusion & Recommendations
OUTLINE
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Credit: L. Stammard, 1995
RNA, enveloped
Viral family: Orthomyxoviridae
Size:80-200nm or .08 0.12 m(micron) in diameter
Three types A, B, C
Surface antigens
H (haemaglutinin) N (neuraminidase)
Virus
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H1 N1
H2 N2
H3 N3
H4 N4
H5 N5
H6 N6
H7 N7
H8 N8
H9 N9
H10H11
H12
H13
H14
H15H16
Haemagglutinin subtype Neuraminidase subtype
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Epidemic a located cluster of cases Pandemic worldwide epidemic
Antigenic drift Changes in proteins by genetic point mutation & selection
Ongoing and basis for change in vaccine each year Antigenic shift
Changes in proteins through genetic reassortment
Produces different viruses not covered by annual vaccine
DefinitionsGeneral
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Survival of Influenza VirusSurfaces and Affect of Humidity & Temperature*
Hard non-porous surfaces 24-48 hours Plastic, stainless steel
Recoverable for > 24 hours
Transferable to hands up to 24 hours
Cloth, paper & tissue Recoverable for 8-12 hours
Transferable to hands 15 minutes
Viable on hands
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InfluenzaThe Normal Burden of Disease
Seasonal Influenza
Globally: 250,000 to 500,000 deaths per year
In the US (per year)
~35,000 deaths
>200,000 Hospitalizations
$37.5 billion in economic cost (influenza &pneumonia)
>$10 billion in lost productivity
Pandemic Influenza
An ever present threat
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Swine Influenza A(H1N1)Introduction
Swine Influenza (swine flu) is a respiratory
disease of pigs caused by type A influenzathat regularly cause outbreaks of influenzaamong pigs
Most commonly, human cases of swine fluhappen in people who are around pigs
Swine flu viruses do not normally infecthumans, however, human infections withswine flu do occur, and cases of human-to-human spread of swine flu viruses havebeen documented
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Swine Influenza A(H1N1)History in US
A swine flu outbreak in Fort Dix, New Jersey,
USA occurred in 1976 that caused more than200 cases with serious illness in severalpeople and one death More than 40 million people were vaccinated However, the program was stopped short after
over 500 cases of Guillain-Barre syndrome, asevere paralyzing nerve disease, werereported
30 people died as a direct result of thevaccination
In September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin washospitalized for pneumonia after beinginfected with swine flu and died 8 days later.
From December 2005 through February2009, a total of 12 human infections withswine influenza were reported from 10 statesin the United States
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Swine Influenza A(H1N1)Transmission to Humans
Through contact with infected pigs orenvironments contaminated withswine flu viruses
Through contact with a person with
swine flu
Human-to-human spread of swine fluhas been documented also and isthought to occur in the same way asseasonal flu, through coughing orsneezing of infected people
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Swine Influenza A(H1N1)Transmission Through Species
Avian Virus
Human Virus
Swine Virus
Avian/HumanReassorted Virus
Reassortment in Pigs
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Swine Influenza A(H1N1) March 2009Timeline
In March and early April 2009, Mexico experiencedoutbreaks of respiratory illness and increased
reports of patients with influenza-like illness (ILI) inseveral areas of the country
April 12, the General Directorate of Epidemiology(DGE) reported an outbreak of ILI in a smallcommunity in the state of Veracruz to the PanAmerican Health Organization (PAHO) inaccordance with International Health Regulations
April 17, a case of atypical pneumonia in OaxacaState prompted enhanced surveillance throughoutMexico
April 23, several cases of severe respiratory illnesslaboratory confirmed as influenza A(H1N1) virusinfection were communicated to the PAHO
Sequence analysis revealed that the patients wereinfected with the same strain detected in 2 childrenresiding in California Samples from the Mexico outbreak match swine
influenza isolates from patients in the United States
Source: CDC
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Swine Influenza A(H1N1) March 2009Facts
Virus described as a new subtype ofA/H1N1 not previously detected in
swine or humans
CDC determines that this virus iscontagious and is spreading fromhuman to human
The virus contains gene segments from
4 different influenza types: North American swine North American avian North American human and Eurasian swine
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Swine Influenza A(H1N1)US Response
The Strategic National Stockpile (SNS) isreleasing one-quarter of its Anti-viral drugs Personal protective equipment and Reparatory protection devices
President Obama today asked Congress for anadditional $1.5 billion to fight the swine flu
On April 27, 2009, the CDC issued a traveladvisory that recommends against all non-essential travel to Mexico
Source: CDC
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Swine Influenza A(H1N1)Global Response
The WHO raises the alert level to Phase 6 WHOs alert system was revised after Avian influenza began to spread in 2004 Alert Level raised to Phase 3
In Late April 2009 WHO announced the emergence of a novel influenza A virus April 27, 2009: Alert Level raised to Phase 4 April 29, 2009: Alert Level raised to Phase 5 June 11, 2008: Alert Level raised to Phase 6
Source: WHO
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Swine Influenza A(H1N1) May 25, 2009Status Update
MEXICO: March 01-June 09, a total of
6,241 Laboratory confirmed cases 108 deaths reported All 32 States
UNITED STATES: March 28-June 09, a totalof 13,217 Laboratory confirmed cases,
27 deaths All Sates plus District of Columbia and Puerto
Rico Vast majority of cases mild
CANADA: As of June 10, a total of 2,978 Laboratory confirmed cases,
4 deaths 12 of 13 States 533 new Laboratory confirmed cases June 8 Vast majority of cases mild
Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO
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Swine Influenza A(H1N1) May 25, 2009Status Update
EUROPEAN UNION & EFTA COUNTRIES:
April 27- May 25, a total of 1,565 Laboratory confirmed cases no deaths 26 countries 126 confirmed cases reported on June 09 567 in-country transmissions Vast majority of cases reported between 20-49
years of age
GLOBALLY: March 1-May 25, a total of 27,737 Laboratory confirmed cases, from 74
countries 144 Deaths among laboratory confirmed cases
from 7 countries
Mexico: 108 deaths US: 27 deaths Canada: 04 death Chile: 02 deaths Costa Rica: 01 death Columbia: 01 death Dominican Rep.: 01 death
Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO
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Swine Influenza A(H1N1)Mexico Epidemic Curve Confirmed, by Day
4
5961
75
128127
148
126
112
90
168
224
217
214
201
176
199
221
270
290
400
385
309
262
15
310
76
3122
14 1014
4138427
6500 234210 3322111211017 3
8
122
186
77
158
92
6965
85
7176
59
5052
4136 31
3729
33
2025
816
0
50
100
150
200
250
300
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400
3/11/09
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6/9/09
6/10/09
Day
No.ofConfirmedCases
Source: Secretaria de Salud, Mexico
Total Number of Confirmed Cases = 6,241*
As of June 09, 2009
*NOTE: 54 confirmed cases not included
Epidemiological Alert
School Closure
Suspension of Non-essential Activities
School Open
S f ( 1 1)
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1776 1720
1191
638
476
273
12740
0
200
400
600
800
1000
1200
1400
1600
1800
2000
0-9 10-19 20-29 30-39 40-49 50-59 60+ NA
Age Group
No.
Confirm
edCases
Swine Influenza A(H1N1)Mexico Confirmed Case Distribution, by Age
Total Number of Confirmed Cases = 6,241*
As of June 09, 2009
Source: Secretaria de Salud, Mexico
*NOTE: 54 confirmed cases not included
S i I fl A(H1N1)
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Swine Influenza A(H1N1)Mexico Confirmed Cases & Death, by Age Groups
1.90.91.9
5.68.38.37.4
13.99.312
12
0.9
3.76.5
3.72.8
0
2
4
6
8
10
12
14
16
75
Age Group
No.ofDeaths
0
10
20
30
40
50
6070
80
90
100
Case-Fatality(
%)
Deaths %
Total Number of Confirmed Cases = 6,241*
Deaths = 108
As of June 09, 2009
Source: Secretaria de Salud, Mexico
Male:
48.1%
Female:
51.9%
*NOTE: 43 confirmed cases not included
71.3% Deaths
S i I fl A(H1N1)
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2
3
3
4
5
5
8
13
15
22
0 5 10 15 20 25
Retired
Unemployed
Pubic Sector Worker
Professional
Minor
Tradesmen
Student
Private Sector Worker
Independent Worker
House Bound
Deaths
Swine Influenza A(H1N1)Mexico Death, by Occupation
N=80
S i I fl A(H1N1)
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Swine Influenza A(H1N1)US Confirmed Cases & Deaths, by State
25 16
2217
577
9104
461
1670
60468294 9
973
75
395
142
247 11516 92 17
787547
33
1357
173
92 1343 96 89
298
40 15
128
64
148
108 30
299
9323 18 60 10
167
858
35 55 24
1
1
4
5
1
8
2
1
3
1
0
500
1000
1500
2000
2500
Alab
ama
Alaska
Arka
nsas
Arizo
na
Calif
ornia
Colo
rado
Conn
ectic
ut
Delaw
are
Florid
a
Georgia
Hawaii
Idaho
Illinois
India
naIo
wa
Kans
as
Kentucky
Louis
iana
Maine
Marylan
d
Massachu
setts
Michig
an
Minn
esota
Mississ
ippi
Miss
ouri
Montan
a
Nebr
aska
Neva
da
NewHa
mpshire
NewJersey
NewMe
xico
NewYo
rk
North
Carolina
North
DakotaOh
io
Oklah
oma
Oreg
on
Penn
sylva
nia
Rhod
eIsla
nd
SouthC
arolin
a
SouthD
akota
Tenn
essee
TexasUt
ah
Verm
ont
Virgin
ia
Washin
gton
Washin
gton,
D.C.
West
Virgini
a
Wiscon
sin
Wyom
ing
Puerto
Rico
US States
No.ofConfirmed
Cases
Source: CDC
Total Number of Confirmed Cases = 13,217; 27 Death; 50 States + District of Columbia + Puetro Rico
As of June 11, 2009 (12:30 PM ET)
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Swine Influenza A(H1N1)MMRW Report, April 28
MMWR, April 28, 2009 / 58(Dispatch);1-3 47 patients reported to CDC with known ages (out of 64)
the median age was 16 years (range: 3-81 years) 38 (81%) were aged
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MMWR, April 30, 2009 / 58(Dispatch);1-3 NYC school (high school A)
2,686 students and 228 staff members
April 23-24, 222 students visited the school nursing office and left school because ofillness
DOHMH collect nasopharyngeal swabs from any symptomatic students April 24 (Friday), DOHMH collected nasopharyngeal swabs from five newly symptomatic
students identified by the school nurse and four newly symptomatic students identified ata nearby physician's office
April 27, School closed DOHMH also provided nasopharyngeal test kits to selected physicians' offices in the
vicinity of high school A April 26, 7 of 9 specimens collected on April 24 were positive for the new strain of
influenza April 26-28, 37 (88%) of 42 specimens collected tested positive, bringing the total
number of confirmed cases to 44
April 27 DOHMH conducted telephone interviews with the 44 patients Median age was 15 years (range: 14-21 years) All were students, with the exception of one student teacher aged 21 years Thirty-one (70%) of the 44 were female Thirty (68%) were non-Hispanic white; seven (16%) were Hispanic; two (5%) were non-
Hispanic black; and five (11%) were other races Four patients reported travel outside NYC within the United States in the week before symptom
onset, and an additional patient traveled to Aruba in the 7 days before symptom onset. None of
the 44 patients reported recent travel to California, Texas, or Mexico
Swine Influenza A(H1N1)MMRW Report, April 30
Source: CDC. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm
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Swine Influenza A(H1N1)MMRW Report, April 30
MMWR, April 30, 2009 / 58(Dispatch);1-3 Illness onset dates ranged from April 20 to
April 24 10 (23%) of the patients had illness onset on
April 22, and 28 (64%) had illness onset onApril 23 (Figure).
Among 35 patients who reported a maximumtemperature, the mean was 102.2F (39.0C)(range: 99.0-104.0F [37.2--40.0C])
In total, 42 (95%) patients reported subjective
fever plus cough and/or sore throat, meeting theCDC definition for influenza-like illness (ILI) At the time of interview on April 27, 37 patients
(84%) reported that their symptoms were stableor improving, three (7%) reported worseningsymptoms (two of whom later reportedimprovement), and four (9%) reported completeresolution of symptoms
Only one reported having been hospitalized for
syncope and released after overnightobservation
Symptoms Number (n=44)
%
Cough 43 98%
Fever 42 96%
Fatigue 39 89%
Headache 36 82%
Sore throat 36 82%
Runny nose 36 82%
Chills 35 80%
Muscle aches 35 80%
Nausea 24 55%
Stomach ache 22 50%
Diarrhea 21 48%
Shortness of breath 21 48%
Joint pain 20 46%
Source: CDC. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm
S i I fl A(H1N1)
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Swine Influenza A(H1N1)Canada Confirmed Cases & Death, by Province or Territory
296151
3256
195
611
1562
78
221
1
1
2
1
0
600
1200
1800
B
ritish
Co
lumbia
Alberta
Sa
skatchewan
Ma
nitoba
On
tario
Qu
ebec
New
Brunswick
No
vaScotia
PrinceEward
Island
Ne
wfoundland
Yu
kon
No
rthwest
Te
rritories
Nu
navut
Province or Territory
No.ofConfirmed
Cases&Deaths
As of June 11, 2009 1500 (EDT)
Total Number of Confirmed Cases 2,978 = ; Death = 4; 12 of 13 Provinces
Source: Public Health Agency of Canada
S ine Infl en a A(H1N1)
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7 14 2 1 4 10 4 4
71 90
7 4 3 1256
123 13 7 2 11 3
357
19 18
822
1 4 821
4 4 1 16
127
4
380
12 12
0
300
600
900
A
ustria
B
elgium
B
ulgaria
C
yprus
C
zechRep.
D
enmark
E
stonia
F
inland
F
rance
G
ermany
G
reece
H
ungry
Iceland
Ireland
Italy
L
uxembourg
N
etherlands
N
orway
P
oland
P
ortugal
R
omania
S
lovakia
S
pain
S
weden
S
witzerland
U
nitedKingdom
Country
No.ofConfirmedCases&In-Country
Transmission
Confirmed cases In-Country Transmission
Swine Influenza A(H1N1)EU & EFTA Confirmed Cases & In-Country Transmission
Total Number of Confirmed Cases = 1,565; 0 Death; 26 Countries;
567 In-Country Transmissions
April 27 - June 11, 2009 (1700 CEST)
Source: ECDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)EU & EFTA Countries Epidemic Curve Confirmed, by Day
April 27 June 11, 2009 (1700 CEST)N=1,565
Number of Confirmed Cases
DaysSource: ECDC
Swine Influenza A(H1N1)
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3
6
23
7
5
2
0
5
10
15
20
25
0-9 10-19 20-29 30-39 40-49 50-59
Age Group (Years)
ConfirmedC
ases
27 April to 8 May 2009N=46
Source: ECDC
Swine Influenza A(H1N1)EU & EFTA Countries Confirmed Case Distribution, by Age
L b t C fi d C f N I fl
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Laboratory-Confirmed Cases of New InfluenzaA(H1N1) by Countries, June 11, 2009
0
5000
10000
15000
Argen
tina
Austra
lia
Austri
a
Baham
as
Bahrain
Barbados
Belgiu
m
Bolivia
Brazil
Bulgaria
Canad
a
CaymanIslands,UKOT
Chile
China
Colom
bia
Costa
Rica
Cuba
Cypru
s
Czech
Republic
Denmark
Domin
ica
Domin
icanRepublic
Ecuad
or
Egypt
ElSalv
ador
Estonia
Finlan
d
France
Germa
ny
Greece
Guate
mala
Hondu
ras
Hunga
ry
Iceland
India
Ireland
Israel
Italy
Jamaica
Japan
Korea,Republicof
Kuwait
Leban
on
Luxem
bourg
Malaysia
Mexico
Netherlands
New
Z
ealand
Nicara
gua
Norwa
y
Panam
a
Paraguay
Peru
Philippines
Poland
Portug
al
Romania
Russia
Saudi
Arabia
Singapore
Slovak
ia
Spain
Swede
n
Switze
rland
Thaila
nd
TrinidadandTobago
Turkey
Ukrain
e
United
ArabEmirates
United
Kingdom
United
Statesof
Urugu
ay
Venez
uela
VietNam
Countries
No.
ConfirmedCases
4
27
Chinese Taipei has reported 36 confirmed cases of influenza A (H1N1) with 0 deaths. Cases from Chinese Taipei are included in the cumulativetotals provided in the table above.
Cumulative and new figures are subject to revision
28,774 Cases & 144 Deaths
74 Countries
108
2
1
1
1
Source: WHO
Global Distribution of Reported Cumulative Laboratory
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Global Distribution of Reported Cumulative LaboratoryConfirmed Cases of Swine Influenza A(H1N1) by
Countries, June 11, 2009 (14:00 GMT)
Source: WHO
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)USCase Definitions
A confirmed case of swine influenza A (H1N1) virus infection isdefined as a person with an acute febrile respiratory illness withlaboratory confirmed swine influenza A (H1N1) virus infection at CDCby one or more of the following tests: real-time RT-PCR
viral culture
Aprobable case of swine influenza A (H1N1) virus infection isdefined as a person with an acute febrile respiratory illness who is: positive for influenza A, but negative for H1 and H3 by influenza RT-PCR, or positive for influenza A by an influenza rapid test or an influenza
immunofluorescence assay (IFA) plus meets criteria for a suspected case
A suspected case of swine influenza A (H1N1) virus infection isdefined as a person with acute febrile respiratory illness with onset within 7 days of close contact with a person who is a confirmed case of
swine influenza A (H1N1) virus infection, or within 7 days of travel to community either within the United States or
internationally where there are one or more confirmed swine influenzaA(H1N1) cases, or
resides in a community where there are one or more confirmed swineinfluenza cases.
Source: CDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)USCase Definitions
Infectious periodfor a confirmed case of swine influenza A(H1N1)
virus infection is defined as 1 day prior to the cases illness onset to 7days after onset
Close contactis defined as: within about 6 feet of an ill person who isa confirmed or suspected case of swine influenza A(H1N1) virusinfection during the cases infectious period
Acute respiratory illness is defined as recent onset of at least two ofthe following: rhinorrhea or nasal congestion, sore throat, cough (withor without fever or feverishness)
High-risk groups: A person who is at high-risk for complications ofswine influenza A(H1N1) virus infection is defined as the same forseasonal influenza (see Reference)
Source: CDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Guidelines for Clinicians
Clinicians should consider the possibility of swine
influenza virus infections in patients presenting withfebrile respiratory illness who live in areas where human cases of swine influenza A(H1N1)
have been identified or have traveled to an area where human cases of swine influenza
A(H1N1) has been identified or have been in contact with ill persons from these areas in the 7
days prior to their illness onset
If swine flu is suspected, clinicians should obtain arespiratory swab for swine influenza testing and place it
in a refrigerator (not a freezer) once collected, the clinician should contact their state or local
health department to facilitate transport and timely diagnosis ata state public health laboratory
Source: CDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Guidelines for Clinicians
Signs and Symptoms Influenza-like-illness (ILI)
Fever, cough, sore throat, runny nose, headache, muscle aches. Insome cases vomiting and diarrhea. (These cases had illness onsetduring late March to mid-April 2009)
Cases of severe respiratory disease, requiring hospitalization
including fatal outcomes, have been reported in Mexico The potential for exacerbation of underlying chronic medical
conditions or invasive bacterial infection with swine influenza virusinfection should be considered
Non-hospitalized ill persons who are a confirmed or
suspected case of swine influenza A (H1N1) virusinfection are recommended to stay at home (voluntaryisolation) for at least the first 7 days after illness onsetexcept to seek medical care
Source: CDC
Swine Influenza A(H1N1)
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FDA Issues Authorizations for Emergency Use (EUAs) of Antivirals
On April 27, 2009, the U.S. Food and Drug Administration (FDA) issuedEUAs in response to requests by the Centers for Disease Control andPrevention (CDC) for the swine flu outbreak
One of the reasons the EUAs could be issued was because the U.S.Department of Health and Human Services (HHS) declared a public healthemergency on April 26, 2009
The swine influenza EUAs aid in the current response: Tamiflu: Allow for Tamiflu to be used to treat and prevent influenza in children
under 1 year of age, and to provide alternate dosing recommendations forchildren older than 1 year. Tamiflu is currently approved by the FDA for thetreatment and prevention of influenza in patients 1 year and older.
Tamiflu and Relenza: Allow for both antivirals to be distributed to large segments
of the population without complying with federal label requirements that wouldotherwise apply to dispensed drugs and to be accompanied by writteninformation about the emergency use of the medicines.
Swine Influenza A(H1N1)Guidelines for Clinicians
Source: FDA
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Biosafety Guidelines for Laboratory Workers
Diagnostic work on clinical samples from patients who are suspectedcases of swine influenza A (H1N1) virus infection should be conducted in
a BSL-2 laboratory All sample manipulations should be done inside a biosafety cabinet (BSC)
Viral isolation on clinical specimens from patients who are suspectedcases of swine influenza A (H1N1) virus infection should be performed ina BSL-2 laboratory with BSL-3 practices (enhanced BSL-2 conditions)
Additional precautions include: recommended personal protective equipment (based on site specific risk
assessment) respiratory protection - fit-tested N95 respirator or higher level of protection shoe covers closed-front gown double gloves
eye protection (goggles or face shields)
Waste all waste disposal procedures should be followed as outlined
in your facility standard laboratory operating procedures
Source: CDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Biosafety Guidelines for Laboratory Workers
Appropriate disinfectants 70 per cent ethanol 5 per cent Lysol 10 per cent bleach
All personnel should self monitor for fever and anysymptoms. Symptoms of swine influenza infectioninclude diarrhea, headache, runny nose, and muscle
aches
Any illness should be reported to your supervisorimmediately
For personnel who had unprotected exposure or aknown breach in personal protective equipment toclinical material or live virus from a confirmed case ofswine influenza A (H1N1), antiviral chemoprophylaxiswith zanamivir or oseltamivir for 7 days after exposurecan be considered
Source: CDC
Swine Influenza A(H1N1)
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FDA Issues Authorizations for Emergency Use (EUAs) of Diagnostic
Tests On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued
EUAs in response to requests by the Centers for Disease Control andPrevention (CDC) for the swine flu outbreak
One of the reasons the EUAs could be issued was because the U.S.Department of Health and Human Services (HHS) declared a public healthemergency on April 26, 2009
The swine influenza EUAs aid in the current response: Diagnostic Test: Allow CDC to distribute the rRT-PCR Swine Flu Panel
diagnostic test to public health and other qualified laboratories that have theequipment and personnel to perform and interpret the results.
Swine Influenza A(H1N1)Biosafety Guidelines for Laboratory Workers
Source: CDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Guidelines for General Population
Covering nose and mouth with a
tissue when coughing or sneezing Dispose the tissue in the trash after
use.
Handwashing with soap and water Especially after coughing or sneezing.
Cleaning hands with alcohol-basedhand cleaners Avoiding close contact with sick
people Avoiding touching eyes, nose or
mouth with unwashed hands If sick with influenza, staying home
from work or school and limitcontact with others to keep frominfecting them
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Treatment
No vaccine available
Antivirals for the treatment and/or prevention of infection: Oseltamivir (Tamiflu) or Zanamivir (Relenza)
Use of anti-virals can make illness milder and recovery faster
They may also prevent serious flu complications
For treatment, antiviral drugs work best if started soon after gettingsick (within 2 days of symptoms)
Warning! Do NOTgive aspirin (acetylsalicylic acid) or aspirin-containing products (e.g. bismuth subsalicylate Pepto Bismol) tochildren or teenagers (up to 18 years old) who are confirmed orsuspected ill case of swine influenza A (H1N1) virus infection; thiscan cause a rare but serious illness called Reyes syndrome. Forrelief of fever, other anti-pyretic medicationsare recommended suchas acetaminophen or non steroidal anti-inflammatory drugs.
Source: CDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Treatment
Source: CDC
Oseltamivir (Tamiflu) Zanamivir (Relenza)
Treatment Prophylaxis Treatment Prophylaxis
Adults 75 mg capsule twiceper day for 5 days
75 mg capsule onceper day
Two 5 mg inhalations(10 mg total) twice perday
Two 5 mg inhalations(10 mg total) once perday
Children 15 kg or less: 60 mgper day divided into 2doses
30 mg once per day Two 5 mg inhalations(10 mg total) twice perday (age, 7 years or
older)
Two 5 mg inhalations(10 mg total) once perday (age, 5 years or
older)1523 kg: 90 mg perday divided into 2doses
45 mg once per day
2440 kg: 120 mg perday divided into 2doses
60 mg once per day
>40 kg: 150 mg perday divided into 2doses
75 mg once per day
Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatmentdose for 5 days.
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Swine Influenza A(H1N1)Other Protective Measures
Defining Quarantine vs. Isolation vs. Social-Distancing Isolation: Refers only to the sequestration ofsymptomatic
patents either in the home or hospital so that they will not infectothers
Quarantine: Defined as the separation from circulation in thecommunity ofasymptomaticpersons that may have beenexposed to infection
Social-Distancing: Has been used to refer to a range of non-quarantine measures that might serve to reduce contactbetween persons, such as, closing of schools or prohibiting largegatherings
Source: CDC
Swine Influenza A(H1N1)
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Swine Influenza A(H1N1)Other Protective Measures
Personnel Engaged in Aerosol Generating Activities CDC Interim recommendations: Personnel engaged in aerosol generating activities (e.g., collection of
clinical specimens, endotracheal intubation, nebulizer treatment,bronchoscopy, and resuscitation involving emergency intubation orcardiac pulmonary resuscitation) for suspected or confirmed swineinfluenza A (H1N1) cases should wear a fit-tested disposable N95respirator
Pending clarification of transmission patterns for this virus, personnelproviding direct patient care for suspected or confirmed swine influenzaA (H1N1) cases should wear a fit-tested disposable N95 respirator when
entering the patient room
Respirator use should be in the context of a complete respiratoryprotection program in accordance with Occupational Safety and HealthAdministration (OSHA) regulations.
Source: CDC
Swine Influenza A(H1N1)
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Infection Control of Ill Persons in a Healthcare Setting
Patients with suspected or confirmed case-status should be placedin a single-patient room with the door kept closed. If available, anairborne infection isolation room (AIIR) with negative pressure airhandling with 6 to 12 air changes per hour can be used. Air can beexhausted directly outside or be recirculated after filtration by a high
efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy,or intubation, use a procedure room with negative pressure airhandling.
The ill person should wear a surgical mask when outside of thepatient room, and should be encouraged to wash hands frequentlyand follow respiratory hygiene practices. Cups and other utensils
used by the ill person should be washed with soap and water beforeuse by other persons. Routine cleaning and disinfection strategiesused during influenza seasons can be applied to the environmentalmanagement of swine influenza.
Swine Influenza A(H1N1)Other Protective Measures
Source: CDC
Swine Influenza A(H1N1)
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Infection Control of Ill Persons in a Healthcare Setting
Standard, Droplet and Contact precautions should be usedfor allpatient care activities, and maintained for 7 days after illness onsetor until symptoms have resolved. Maintain adherence to handhygiene by washing with soap and water or using hand sanitizerimmediately after removing gloves and other equipment and afterany contact with respiratory secretions.
Personnel providing care to or collecting clinical specimens fromsuspected or confirmed cases should wear disposable non-sterilegloves, gowns, and eye protection (e.g., goggles) to preventconjunctival exposure.
Swine Influenza A(H1N1)Other Protective Measures
Source: CDC
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Surgical masks Easily available and commonly used for routine surgical and examination
procedures High-filtration respiratory mask
Special microstructure filter disc to flush out particles bigger than 0.3 micron.These masks are further classified: oil proof oil resistant not resistant to oil
The more a mask is resistant to oil, the better it is The masks have numbers beside them that indicate their filtration efficiency.
For example, a N95 mask has 95% efficiency in filtering out particles greaterthan 0.3 micron under normal rate of respiration.
The next generation of masks use Nano-technologywhich are capable ofblocking particles as small as 0.027 micron.
Types of Protective Masks
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CHOTANI 2009.
Summary
WHO raised the alert level to Phase 6 on June 11, 2009
There is a disparity between the % case-fatality-rate between Mexico (1.73%), USA
(0.20%) and Canada (0.13%) The overall global case-fatality (28,774 cases and 144 deaths) is 0.50%
~ 1,500 cases worldwide (reported) needed hospitalization Majority in Mexico
Epidemiological Data US
Median Age 16 years (range: 1-81 years) Over 80% of the cases in
-
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gInfluenza A Viruses in Humans
1918 1957 1968 1977 1997
1998/9
2003
H1
H1
H3H2
H7
H5H5
H9
SpanishInfluenza
H1N1
AsianInfluenza
H2N2
RussianInfluenza
AvianInfluenza
HongKong
InfluenzaH3N2
2009
H1
Reassorted Influenzavirus (Swine Flu)
1976 Swine FluOutbreak, Ft.
Dix
Lessons Learned form
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Past Pandemics
First outbreaks March 1918 in Europe, USA Highly contagious, but not deadly Virus traveled between Europe/USA on troop
ships Land, sea travel to Africa, Asia Warning signal was missed
August, 1918 simultaneous explosiveoutbreaks in in France, Sierra Leone, USA 10-fold increase in death rate Highest death rate ages 15-35 years
Cytokine Storm?
Deaths from primary viral pneumonia, secondarybacterial pneumonia
Deaths within 48 hours of illness Coincident severe disease in pigs
20-40 million killed in less than 1 year World War I 8.3 million military deaths over 4
years
25-35% of the world infected
Lessons Learned form
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Pandemics are unpredictable Mortality, severity of illness, pattern of spread
A sudden, sharp increase in the need for medical carewill always occur
Capacity to cause severe disease in nontraditionalgroups is a major determinant of pandemic impact
Epidemiology reveals waves of infection Ages/areas not initially infected likely vulnerable in future
waves
Subsequent waves may be more severe 1918- virus mutated into more virulent form 1957 schoolchildren spread initial wave, elderly died in
second wave
Public health interventions delay, but do not stoppandemic spread Quarantine, travel restriction show little effect
Does not change population susceptibility Delay spread in Australia later milder strain causes
infection there Temporary banning of public gatherings, closing schools
potentially effective in case of severe disease and highmortality
Delaying spread is desirable Fewer people ill at one time improve capacity to cope with
sharp increase in need for medical care
Past Pandemics
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Conclusion/Recommendations
1. Past experience with pandemics have taught us that the second waveis worse than the first causing more deaths due to: Primary viral pneumonia, Acute Respiratory Distress Syndrome (ARDS), &
Secondary bacterial infections, particularly pneumonia
Fortunately compared to the past now we have anti-virals and antibiotics(to treat secondary bacterial infections)
Though difficult, there is likelihood that there will be a vaccine for this
strain by the emergence of the second wave In the US each year ~35,000 deaths are attributed to influenza resulting in
>200,000 hospitalizations, costing $37.5 billion in economic cost (influenza& pneumonia) and >$10 billion in lost productivity
Based upon past experience and the way the current H1N1 pandemic isacting (current wave is contagious, spreading rapidly and in
Mexico/Canada based upon preliminary data affecting the healthy), thereis a likelihood that come fall there might be a second wave which could bemore virulent
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Conclusion/Recommendations
At present most of the deaths due to H1N1 strain has been reportedfrom Mexico.
The disease, though spreading rapidly across the globe, is of a mild form(exception Mexico)
Most people do not have immunity to this virus and, as it continues tospread. More cases, more hospitalizations and some more deaths areexpected in the coming days and weeks
Disease seems to be affecting the healthy strata of the population basedupon epidemiological data from Mexico and EU
60 years and above age group seems to show some protection againstthis strain suggesting past exposure and some immunity
Of concern is the disease spread in Australia
Each locality/jurisdiction needs to Have enhanced disease and virological surveillance capabilities
Develop a plan to house large number of severely sick and provide careif needed to deal with mildly sick at home (voluntary quarantine)
Healthcare facilities/hospitals need to focus on increasing surge capacityand stringent infection prevention/control
General population needs to follow basic precautions
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Conclusion/Recommendations
1. In the Northern Hemisphere influenza viral transmission traditionallystops by the beginning of May but in pandemic years (1957) sporadic
outbreaks occurred during summer among young adults Likelihood that
This wave will fade in North America by the end of June or will cause diseasein a few cases (influenza virus cannot survive high humidity or temperature)
Will reappear in autumn in North America with the likelihood of being a highlypathogenic second wave
Will continue to circulate and cause disease in the Southern Hemisphere
2. Border Closure and Travel Restrictions: The disease has already crossed all borders and continents, thus, border
closure or travel restrictions will not change the course of the spread ofdisease Most recently, the 2003 experience with SARS demonstrated the
ineffectiveness of such measures In China, 14 million people were screened for fever at the airport, train
stations, and roadside checkpoints, but only 12 were found to have probableSARS
Singapore reported that after screening nearly 500,000 air passengers, nonewere found to have SARS
Passive surveillance methods (in which symptomatic individuals report illness)can be important tools
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Conclusion/Recommendations
1. School Closures:
Preemptive school closures will merely delay the spread of disease Once schools reopen (as they cannot be closed indefinitely), the disease
will be transmitted and spread Furthermore, this would put unbearable pressure on single-working
parents and would be devastating to the economy (as children cannot beleft alone)
Closure after identification of a large cluster would be appropriate as
absenteeism rate among students and teachers would be high enough tojustify this action
High priority should be given to develop and include the presentNorth American (swine) influenza A(H1N1) virus in next yearsvaccine. A critical look at manufacturing capacity is called for
It is imperative to appreciate that times-have-changed Though this strain has spread very quickly across the globe and seems to
be highly infectious, today we are much better prepared than 1918. Thereis better surveillance, communication, understanding of infection control,anti-virals, antibiotics and advancement in science and resources toproduce an affective vaccine
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