Lecture+Influenza+A+ H1 N1

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Influenza A (H1N1)

National Center for Disease Prevention and Control, DOH

ROMEO ALMAZAN BITUIN, MD, MHA

Medical Specialist III HEMS Coordinator Dr. Jose Fabella Memorial Hospital Department of Health

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Influenza A (H1N1)Is PANDEMIC Imminent?



Influenza is usually a respiratory infection

Transmission– Regular person-to-person transmission – Primarily through contact with respiratory

droplets – Transmission from objects (fomites) possible


For More Lectures www.medicalppt.blogspot.comTransmission of Influenza• Limited studies, varying interpretations• Contact, droplet, and droplet nuclei

(airborne) transmission all likely occur– Relative contribution of each

unclear• Droplet thought most important

– Coughing, sneezing, talking

– Most studies either• Animals or human experiments under

artificial conditions• Outbreak investigations

– Unclear of infection source



Key CharacteristicsCommunicability

– Viral shedding can begin 1 day before symptom onset

– Peak shedding first 3 days of illness

– Correlates with temperature– Subsides usually by 5-7th day in

adults– can be 10+ days in children– Infants, children and the

immuno-compromised may shed the virus longer



Incubation period– Time from exposure to onset of symptoms– 1 to 4 days (average = 2 days)

Seasonality– In temperate zones, sharp peaks in winter months

– In tropical zones, circulates year-round with

seasonal increases.



Clinical Illness, Seasonal Influenza• Abrupt onset• Fever and constitutional symptoms: body aches,

headaches, fatigue• Cough, rhinitis, sore throat• GI symptoms and myositis more common in young

children• Sepsis-like syndrome in infants• Complications: viral and bacterial pneumonia, febrile

seizures, cardiomyopathy, encephalopathy/encephalitis, worsening underlying chronic conditions



Individuals at Increased Risk for Hospitalizations and Death

• Elderly > 65 years• Children less than two years• Certain chronic diseases

– Heart or lung disease, including asthma– Metabolic disease, including diabetes– HIV/AIDs, other immuno-suppression – Conditions that can compromise respiratory function or the handling

of respiratory secretions• Pregnant women



Vaccination

• Influenza vaccine is the best prevention for seasonal influenza.

• Inactivated viruses in the vaccine developed from three circulating strains (generally 2 Type A and 1 Type B strain)– Therefore, seasonal “flu shot” only works for 3 influenza

subtypes and will not work on pandemic strains.

• Live, intranasal spray vaccine for healthy non-pregnant persons 5-49 years

• Inactivated, injectable vaccine for persons 6 months and older



Influenza Viruses

• Classified into types A, B, and C• Only Types A and B cause

significant disease• Types B and C limited to humans• Type A viruses

• More virulent• Affect many species

C Goldsmith, CDC



Influenza A Viruses• Influenza A viruses categorized by subtype

• Classified according to two surface proteins• Hemagglutinin (H) – 16 known

– Site of attachment to host cells– Antibody to HA is protective

• Neuraminidase (N) – 9 known– Helps release virions from cells– Antibody to NA can help modify disease severity

N

H



A / Sydney / 05 / 97 (H3N2)

Nomenclature

Virus type

Strain number

Virus subtype

Place virusisolated

Year isolated



Influenza A (H1N1) is a novel virus

• Unusual combination of genetic material from pigs, birds & humans which have re-assorted

• human-to-human transmission occurs through respiratory droplets generated from sneeze or cough

• Affects all age groups• Vaccines for human seasonal flu can not

protect humans against the novel virus



Swine Influenza Viruses

• RNA viruses• Pigs can be infected by avian influenza and

human influenza viruses as well as swine influenza viruses.

• Re-assort and new viruses that are a mix of swine, human and avian influenza viruses can EMERGE



SIV

Genetic Re-assortment



Signs & Symptoms of Influenza A (H1N1)

• Fever• Lethargy• Lack of appetite• Coughing• Runny Nose• Sore throat• Nausea / Vomiting• Diarrhea



Swine H1N1 vs. Human H1N1

• swine H1N1 flu virus NOT the same as human H1N1 virus

• antigenically very different from human H1N1 viruses

• vaccines for human seasonal flu can not protect humans from swine H1N1



Transmission: Food-Borne?

• NO• Influenza A (H1N1) viruses are not transmitted

through food • Safe to eat properly handled and cooked pork

and pork products• Cook pork at an internal temperature of 70°C

(160°F)



Diagnosis and Laboratory Confirmation

• Clinically diagnosed• Respiratory Specimen

• first 4 to 5 days of illness • can shed for 10 days or longer

• Specimens sent to US CDC • ONLY laboratory that can isolate and

identify swine influenza type A virus



Treatment

• Influenza A (H1N1) is sensitive to:– Oseltamivir (tamiflu)– Zanamivir

• Self medication is discouraged, may induce drug resistance

• Chemoprophylaxis– Oseltamivir



Vaccine

• No Influenza A (H1N1) vaccine yet• Process of production is underway, but may

take 5 – 6 months• Seasonal influenza vaccine provides

protection against the seasonal human influenza strains only



Influenza A (H1N1) is a Public Health Emergency of International Concern (PHEIC)

Serious Public Health ImpactUnusual or UnexpectedInternational disease spreadInterference with international travel or

trade**WHO Recommends intensifying and enhancing national surveillance systems for Influenza-like Illnesses and atypical pneumonia



Pandemic Alert Phase 5


Influenza A (H1N1) Preparedness Plan

• Goal:– To minimize the public health & socio-economic impact of

influenza pandemic in the Philippines• Objectives:

– To maintain a functional command & control structure during an influenza pandemic

– To adopt early warning system for pandemic influenza– To identify & monitor cases of pandemic influenza– To manage large numbers of ill & dying people– To maintain essential services during a pandemic– To prevent spread through public health interventions– To manage public anxiety & panic & ensure effective &

appropriate information, education & campaign



What has been done?

• Activation of the DOH Management Committee on Prevention and Control of Re-Emerging Infectious Diseases (DOHMC-PCREID) with the Secretary of Health as the Chairperson of the DOH Central Command

• Enhanced health surveillance in hospitals, seaports, and airports which include thermal scanning of arriving passengers from affected countries– emergency procurement of 4 additional thermal

scanners



What has been done?

• Health Declaration Checklist to screen for potential signs & symptoms & possible exposure to the virus

• Health Alert Notice (HAN) distributed to all arriving travelers who are strongly advised to monitor body temperature daily up to 10 days from date of arrival & to contact health authorities A.S.A.P. if they become ill during this period



What has been done?

• Issuance of travel advisory to the public– No travel ban but travelers are asked to reconsider

their plans to travel to affected countries unless extremely necessary

– The World Health Organization does not recommend any travel restrictions or closure of borders at this time

• Activation of DOH HOTLINE (+632-7111001 / +632-7111002) for immediate reporting of suspected Influenza A (H1N1), flu-like illness and atypical pneumonia by DOH regional Offices, LGUs, hospitals, and the public


For More Lectures www.medicalppt.blogspot.comInfluenza A (H1N1) Surveillance Reporting Flow

Bureau of Quarantine Referral Hospitals

Influenza-like Illness Surveillance

Event-based Surveillance

NEC/HOTLINESurveillance Team

Response needed?

Yes

Daily zero reporting

No

WHO

Inform other offices, agencies, etc. involved

in the response

EXECOM

Central Command

Media

End

Cases under investigation

Probable/Confirmed

Probable/Confirmed



What has been done?

• Firmed up national stockpile of Personal Protective Equipment (PPE) & the antiviral drug (Oseltamivir) and other logistics– Priority will be high-risk exposure groups consisting of

frontline health workers and surveillance teams – Interim Guidelines on Clinical Management of

Influenza A (H1N1) Virus Infection and the Use of Antivirals

– Interim Guidelines on the Use of Personal Protective Equipments and Infection Control During Influenza A (H1N1) Outbreaks



Interim Guidelines on Clinical Management of Influenza A (H1N1) Virus Infection and the Use of Antivirals

• Case definitions for infections with Influenza A (H1N1)• Clinical Management of Influenza A (H1N1) Virus

Infection• Use of Antiviral Agents

– Priority groups to receive antiviral agents for prophylaxis• Health workers• First responders• Workers providing essential services

– For treatment, priority will be the patients considered at high risk of severe disease

• Discharge guidelines



Interim Guidelines on the Use of Personal Protective Equipments & Infection Control During Influenza A (H1N1) Outbreaks

• Rational use of personal protective equipments

• Guidelines on the use of masks• Public health measures• Personal hygiene• Guidelines on infection control in health care

setting



What has been done?

• National Referral Centers for EID readied in the event of suspected or confirmed swine flu cases– Research Institute of Tropical Medicine (RITM)– Lung Center of the Philippines– San Lazaro Hospital– Vicente Sotto Memorial Medical Center– Davao Medical Center

• Organized the DOH Central Command for A (H1N1) that will oversee the operations of the different components of the A(H1N1) Task Force– Planning, Operations, Financing, Logistics



Health Emergency Management Structure



What has been done?

• Convened a meeting of all Metro Manila DOH Hospitals to orient them on the situation & come up with a response plan for hospitals

• Secretary Francisco T. Duque IIII called for a DOH Command Conference to check the readiness plans & command & control systems of all regions nationwide

• Secretary Francisco T. Duque III is made de facto Crisis Manager of the national Disaster Coordinating Council (NDCC) to coordinate government efforts in responding to the threat of Influenza A/H1N1



What has been done?

• Request of Php 93.5 M calamity fund for the preparedness phase of a possible pandemic

• Meeting with Metro Manila private hospitals and DOH retained hospitals on referral procedures to DOH-Designated Hospitals for the Isolation & Treatment of suspected Influenza A (H1N1) cases; as well as contingency plans for a worse case scenario



DOH – Medical City Joint Forum (May 4, 2009)

• Guidance on– Surveillance

• Case definitions, case reporting forms– Infection control

• Will the private hospitals be allowed to admit cases? As of now, only the referral hospitals will be allowed to admit cases

– Use of oseltamivir• Prophylaxis, treatment

• Societal approach rather than health sectors only• Updates to be provided on a regular basis



Public Health Advisory

• Cover nose and mouth with a tissue when coughing or sneezing.

• Wash hands regularly with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective

• Avoid close contact with sick people.• If sick, self-monitor and stay home from work or

school and limit contact with others.• Consult your doctor immediately should signs

and symptoms of flu persist.



Risk Communications Challenges

• How to communicate with stakeholders minimizing fear and panic

• Informing or instructing widely

divergent audiences

• Minimizing / overcoming

misinformation, rumors and myths

• Encouraging the adoption of

appropriate protective actions

• Building trust



What’s next?

• Coordination with other concerned agencies regarding national response in the event of a pandemic– OP, DA, DILG, DFA, NDCC



Thank you for listening


and God Bless Us All !

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