Influenza a(H1N1) (Swine Flu), A Global Outbreak

8/14/2019 Influenza a(H1N1) (Swine Flu), A Global Outbreak

1/56

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)
http://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gif


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CHOTANI 2009.

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


3/56

CHOTANI 2009.

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
http://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gifhttp://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gif


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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


5/56

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


6/56

CHOTANI 2009.

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


7/56CHOTANI 2009. Source: Bean B, et al. JID 1982;146:47-51

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


8/56CHOTANI 2009.

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


9/56CHOTANI 2009.

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


10/56CHOTANI 2009.

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


11/56CHOTANI 2009.

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


12/56CHOTANI 2009.

Swine Influenza A(H1N1)Transmission Through Species

Avian Virus

Human Virus

Swine Virus

Avian/HumanReassorted Virus

Reassortment in Pigs


13/56CHOTANI 2009.

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


14/56CHOTANI 2009.

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


15/56CHOTANI 2009.

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


16/56CHOTANI 2009.

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


17/56CHOTANI 2009.

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


18/56CHOTANI 2009.

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


19/56CHOTANI 2009.

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

350

400

3/11/09

3/12/09

3/13/09

3/14/09

3/15/09

3/16/09

3/17/09

3/18/09

3/19/09

3/20/09

3/21/09

3/22/09

3/23/09

3/24/09

3/25/09

3/26/09

3/27/09

3/28/09

3/29/09

3/30/09

3/31/09

4/1/09

4/2/09

4/3/09

4/4/09

4/5/09

4/6/09

4/7/09

4/8/09

4/9/09

4/10/09

4/11/09

4/12/09

4/13/09

4/14/09

4/15/09

4/16/09

4/17/09

4/18/09

4/19/09

4/20/09

4/21/09

4/22/09

4/23/09

4/24/09

4/25/09

4/26/09

4/27/09

4/28/09

4/29/09

4/30/09

5/1/09

5/2/09

5/3/09

5/4/09

5/5/09

5/6/09

5/7/09

5/8/09

5/9/09

5/10/09

5/11/09

5/12/09

5/13/09

5/14/09

5/15/09

5/16/09

5/17/09

5/18/09

5/19/09

5/20/09

5/21/09

5/22/09

5/23/09

5/24/09

5/25/09

5/26/09

5/27/09

5/28/09

5/29/09

5/30/09

5/31/09

6/1/09

6/2/09

6/3/09

6/4/09

6/5/09

6/6/09

6/7/09

6/8/09

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)


20/56CHOTANI 2009.

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


As of June 09, 2009



S i I fl A(H1N1)


21/56CHOTANI 2009.

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 %


Deaths = 108

As of June 09, 2009


Male:

48.1%

Female:

51.9%


71.3% Deaths

S i I fl A(H1N1)


22/56CHOTANI 2009.

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)


23/56

CHOTANI 2009.

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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CHOTANI 2009.

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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CHOTANI 2009.

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


Source: CDC. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm


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CHOTANI 2009.


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)


27/56

CHOTANI 2009.

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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CHOTANI 2009.

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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CHOTANI 2009.

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



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CHOTANI 2009.

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


31/56

CHOTANI 2009.

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
http://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gifhttp://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gifhttp://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gif


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CHOTANI 2009.

Global Distribution of Reported Cumulative LaboratoryConfirmed Cases of Swine Influenza A(H1N1) by

Countries, June 11, 2009 (14:00 GMT)

Source: WHO

http://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gifhttp://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gifhttp://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gif


33/56

CHOTANI 2009.

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



34/56

CHOTANI 2009.

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



35/56

CHOTANI 2009.

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



36/56

CHOTANI 2009.


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



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CHOTANI 2009.

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.


Source: FDA



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CHOTANI 2009.

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



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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



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CHOTANI 2009.

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.


Source: CDC



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CHOTANI 2009.

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



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CHOTANI 2009.

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



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CHOTANI 2009.

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



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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



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CHOTANI 2009.

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.


Source: CDC



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CHOTANI 2009.

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.


Source: CDC


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CHOTANI 2009.

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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CHOTANI 2009.

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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CHOTANI 2009.

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
http://www.history.navy.mil/photos/images/h41000/h41730.jpghttp://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gifhttp://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gif


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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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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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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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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

Influenza a(H1N1) (Swine Flu), A Global Outbreak

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