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Just-in-Time Lecture
Influenza A(H1N1) (Swine Flu) Pandemic
(Version 15, first JIT lecture issued April 26)
December 28, 2009 (4:00 PM EST)
Rashid A. Chotani, MD, MPH, DTM
Adjunct Assistant Professor
Uniformed Services University of the Health Sciences
(USUHS)
240-367-5370
[email protected]
CHOTANI © 2009.
Acknowledgement
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, USA
Dr. Eugene Shubnikov, Institute of Internal Medicine, Russia
Dr. Faina Linkov, University of Pittsburgh, USA
Dr. Mita Lovalekar, University of Pittsburgh, USA
Dr. Nicolás Padilla Raygoza, Universidad de Guanajuato, México
Dr. Ali Ardalan, Tehran University of Medical Sciences, Iran
Dr. Mehrdad Mohajery, Tehran University of Medical Sciences, Iran
Dr. Seyed Amir Ebrahimzadeh, Tehran University of Medical Sciences, Iran
Dr. Nasrin Rahimian, Tehran University of Medical Sciences, Iran
Dr. Mohd Hasni , University of Kebangsaan, Malaysia
Dr. Kawkab Shishani, The Hashemite University, Jordan
Dr. Nesrine Ezzat Abdlkarim, Beirut Arab University, Lebanon
Dr. Khowlah Almohaini, University of Pittsburgh, USA
Dr. Duc Nguyen, University of Texas, USA
Dr. Elisaveta Jasna Stikova, University “Ss. Cyril and Methodius”, Skopje, Macedonia
Dr. Michèle Cazaubon, Secrétaire Gle de la Société Française d' Angéiologie, France
Dr. Yang Yingyun , Peking Union Medical College, China
Dr. Jesse Huang, Peking Union Medical College, China
Shimon Weitzman, Ben Gurion University of the Negev , Israel
Dr. Nurka Pranjic, Medical School University of Tuzla, Bosnia and Herzegovina
Dr. Shakir Jawad, Uniformed Services University of the Health Sciences, USA
Dr. Hiroya Goto, Ministry of Defense, Japan
Dr. Osamu Usami, National Cancer Institute, USA
Afham A. Chotani, USA
Truly a global effort
http://www.pitt.edu/~super1/
CHOTANI © 2009.
OUTLINE
1.
2.
3.
4.
5.
6.
7.
8.
Influenza Virus
Definitions
Introduction
History in the US
Spread/Transmission
Timeline/Facts
Response
Status Update
•
•
•
•
•
9.
10.
Case-Definitions
Guidelines
•
•
•
11.
12.
13.
14.
15.
16.
CHOTANI © 2009.
US
Mexico
Canada
European Union
Globally
Clinicians
Laboratory Workers
General Population
Treatment
Other Protective Measures
Summary
Timeline of Emergence
Lessons Learned from Past Pandemics
Conclusion & Recommendations
Virus
• RNA, enveloped
• Viral family: Orthomyxoviridae
• Size:
80-200nm or .08 – 0.12 μm
(micron) in diameter
• Three types
• A, B, C
• Surface antigens
• H (haemaglutinin)
• N (neuraminidase)
CHOTANI © 2009.
Credit: L. Stammard, 1995
Haemagglutinin subtype
H1
H2
H3
H4
H5
H6
H7
H8
H9
H10
H11
H12
H13
H14
H15
H16
Neuraminidase subtype
N1
N2
N3
N4
N5
N6
N7
N8
N9
Definitions
General
• 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
CHOTANI © 2009.
Survival of Influenza Virus
Surfaces 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 <5 minutes only at high viral titers
• Potential for indirect contact transmission
*Humidity 35-40%, Temperature 28C (82F)
CHOTANI © 2009.
Source: Bean B, et al. JID 1982;146:47-51
Influenza
The Normal Burden of Disease
• Seasonal Influenza
• Globally: 250,000 to 500,000 deaths per year
• In the US (per year)
•
•
•
•
~35,000 deaths (mainly among people 65 years or older)
>200,000 Hospitalizations
$37.5 billion in economic cost (influenza & pneumonia)
>$10 billion in lost productivity
• Pandemic Influenza
• An ever present threat
CHOTANI © 2009.
Swine Influenza A(H1N1)
Introduction
• Swine Influenza (swine flu) is a respiratory
disease of pigs caused by type A influenza
that regularly cause outbreaks of influenza
among pigs
• Most commonly, human cases of swine flu
happen in people who are around pigs
• Swine flu viruses do not normally infect
humans, however, human infections with
swine flu do occur, and cases of human-tohuman spread of swine flu viruses have
been documented
CHOTANI © 2009.
Swine Influenza A(H1N1)
History in US
•
A swine flu outbreak in Fort Dix, New Jersey,
USA occurred in 1976 that caused more
than 200 cases with serious illness in several
people and one death
•
•
More than 40 million people were vaccinated
However, the program was stopped short
after over 500 cases of Guillain-Barre
syndrome, a severe paralyzing nerve disease,
were reported
• 30 people died as a direct result of the
vaccination
•
In September 1988, a previously healthy 32year-old pregnant woman in Wisconsin was
hospitalized for pneumonia after being
infected with swine flu and died 8 days later.
•
From December 2005 through February
2009, a total of 12 human infections with
swine influenza were reported from 10 states
in the United States
CHOTANI © 2009.
Swine Influenza A(H1N1)
Transmission to Humans
• Through contact with infected pigs or
environments contaminated with
swine flu viruses
• Through contact with a person with
swine flu
• Human-to-human spread of swine flu
has been documented also and is
thought to occur in the same way as
seasonal flu, through coughing or
sneezing of infected people
CHOTANI © 2009.
Swine Influenza A(H1N1)
Transmission Through Species
Human Virus
Avian Virus
Avian/Human
Reassorted Virus
Swine Virus
Reassortment in Pigs
CHOTANI © 2009.
Swine Influenza A(H1N1) March 2009
Timeline
•
In March and early April 2009, Mexico experienced
outbreaks of respiratory illness and increased
reports of patients with influenza-like illness (ILI) in
several areas of the country
•
April 12, the General Directorate of Epidemiology
(DGE) reported an outbreak of ILI in a small
community in the state of Veracruz to the Pan
American Health Organization (PAHO) in
accordance with International Health Regulations
•
April 17, a case of atypical pneumonia in Oaxaca
State prompted enhanced surveillance throughout
Mexico
•
April 23, several cases of severe respiratory illness
laboratory confirmed as influenza A(H1N1) virus
infection were communicated to the PAHO
•
Sequence analysis revealed that the patients were
infected with the same strain detected in 2 children
residing in California
•
CHOTANI © 2009.
Samples from the Mexico outbreak match swine
influenza isolates from patients in the United States
Source: CDC
Swine Influenza A(H1N1) March 2009
Facts
•
Virus described as a new subtype of
A/H1N1 not previously detected in
swine or humans
•
CDC determines that this virus is
contagious and is spreading from
human to human
•
The virus contains gene segments from
4 different influenza types:
•
•
•
•
CHOTANI © 2009.
North American swine
North American avian
North American human and
Eurasian swine
Swine Influenza A(H1N1)
US Response
•
The Strategic National Stockpile (SNS) is
releasing one-quarter of its
•
•
•
Anti-viral drugs
Personal protective equipment and
Reparatory protection devices
•
President Obama today asked Congress for
an additional $1.5 billion to fight the swine flu
•
On April 27, 2009, the CDC issued a travel
advisory that recommends against all nonessential travel to Mexico
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Global Response
•
The WHO raises the alert level to Phase 6
•
•
•
•
•
CHOTANI © 2009.
WHO’s 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
Swine Influenza A(H1N1)
Status Update
•
US: March – December 28
•
Estimates
•
•
•
•
•
•
•
Laboratory confirmed cases: 68,123
Deaths: 823
Activity: On decline
CANADA: As of December 23
•
•
•
Death among children since August 2009: 221
Sub-type: 99% Influenza A (H1N1)
Activity: On decline
MEXICO: March 01 – December 23
•
•
•
•
Symptomatic: ~ 55 million
Hospitalized: ~300,000
Deaths: ~ 13,000
Deaths: 401
Activity: On decline
EUROPEAN UNION & EFTA COUNTRIES: April 27December 28
•
•
•
•
•
•
CHOTANI © 2009.
Deaths: 1,832
All 27 EU and 4 EFTA countries reporting cases
471 confirmed cases reported on September 24
~10,000 Hospitalized
~2,200 admitted to intensive care
Vast majority of cases reported between 20-49 years of age
Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO
Swine Influenza A(H1N1)
Status Update
GLOBALLY: March 1-December 23
• At least 11,516 Deaths
•
•
•
•
•
•
Africa Region (AFRO):
Americas Region (AMRO):
Eastern Mediterranean Region (EMRO):
Europe Region (EURO) :
South-East Asia Region (SEARO):
Western Pacific Region (WPRO) :
109
6,670
663
2,045
990
1,039
ECDC reported a total of 12,776 deaths –
December 28, 2009
CHOTANI © 2009.
Source: WHO
Swine Influenza A(H1N1)
CDC Estimates from April-November 14, 2009, By Age Group
2009 H1N1
Cases
0-17 years
18-64 years
65 years and older
Cases Total
Hospitalizations
0-17 years
18-64 years
65 years and older
Hospitalizations Total
Deaths
0-17 years
18-64 years
65 years and older
Deaths Total
CHOTANI © 2009.
Mid-Level Range*
Estimated Range *
~16 million
~27 million
~4 million
~47 million
~12 million to ~23 million
~19 million to ~38 million
~3 million to ~6 million
~34 million to ~67 million
~71,000
~121,000
~21,000
~213,000
~51,000 to ~101,000
~87,000 to ~172,000
~15,000 to ~29,000
~154,000 to ~303,000
~1,090
~7,450
~1,280
~9,820
~790 to ~1,550
~5,360 to ~10,570
~920 to ~1,810
~7,070 to ~13,930
Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm
Swine Influenza A(H1N1)
Symptoms Reported in US Hospitalized Patients
Symptoms
CHOTANI © 2009.
Number (n=268)
%
Fever
249
93%
Cough
223
83%
Shortness of breath
145
54%
Fatigue/Weakness
180
40%
Chills
99
37%
Myalgias
96
36%
Rhinorrhea
96
36%
Sore throat
84
31%
Headache
83
31%
Vomiting
78
29%
Wheezing
64
24%
Diarrhea
64
24%
Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm
Swine Influenza A(H1N1)
Lab-Confirmed Cases in the US as of July 24, 2009 (n=43,771)
Percent Represents proportion of Total Cases
25000
22080
50%
Cases
20000
15000
10000
5000
7434
17%
4816
11%
0
0-4
6741
5-24
25-49
15%
2187
1%
5%
513
50-64
>=65
UK
Age Grougs
CHOTANI © 2009.
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
Swine Influenza A(H1N1)
Lab-Confirmed Cases in the US as of July 24, 2009 (n=37,030*)
Rate Per 100,000 Population by Age Group
30
26.7
25
Cases
20
22.9
n=22080
n=4816
15
10
6.97
n=7434
5
3.92
n=2187
1.3
n=513
0
0-4
5-24
25-49
50-64
>=65
Age Grougs
*Excludes 6,741 Cases with missing data
Rate/100,000 by Single Year Age Groups: Denominator Source: 2008 Census Estimated, US Census Bureau
CHOTANI © 2009.
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
Swine Influenza A(H1N1)
Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011)
Percent Represents proportion of Total Hospitalizations
2000
Hospitalizations
1718
34%
1500
1184
1000
24%
953
19%
658
13%
500
225
4%
273
5%
0
0-4
5-24
25-49
50-64
>=65
UK
Age Grougs
CHOTANI © 2009.
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
Swine Influenza A(H1N1)
Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011)
Rate Per 100,000 Population by Age Group
5
Hospitalizations
4.5
4
4.5
N=953
3.5
3
2.5
2.1
2
1.7
N=1718
1.5
1.1
1
13%
N=1184
1.2
n=225
N=658
0.5
0
0-4
5-24
25-49
50-64
>=65
Age Grougs
CHOTANI © 2009.
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
Swine Influenza A(H1N1)
Deaths Among Lab-Confirmed Cases in the US as of July 24, 2009 (n=302)
150
Number of Deaths
124
41%
100
71
24%
48
50
16%
7
0
26
26
9%
9%
>=65
UK
2%
0-4
5-24
25-49
50-64
Age Grougs
CHOTANI © 2009.
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
Swine Influenza A(H1N1)
Mexico Epidemic Curve Confirmed, by Day
As of December 09, 2009
Total Number of Confirmed Cases = 66,415*
School Closure
4/24/09
Suspension of Non-essential Activities
5/1/09
No. of Confirmed Cases
1200
Epidemiological
Alert
4/13/09
1000
800
600
School Open
5/12/09
400
200
12/1/2009
11/1/2009
10/1/2009
9/1/2009
8/1/2009
7/1/2009
6/1/2009
5/1/2009
4/1/2009
3/1/2009
0
Day
*NOTE: Numbers can change
CHOTANI © 2009.
Source: Secretaria de Salud, Mexico
Swine Influenza A(H1N1)
Mexico Confirmed Case Distribution, by Age
As of December 23, 2009
Total Number of Confirmed Cases = 68,123
19,781
No. Confirmed Cases
21,000
18,000
15,000
12,980
12,000
9,000
10,509
7,467
7,285
5,079
6,000
3,094
3,000
1,287
640
60+
NA
0
0-4
5-9
10-19 20-29 30-39 40-49 50-59
Age Group
CHOTANI © 2009.
Source: Secretaria de Salud, Mexico
Swine Influenza A(H1N1)
Mexico Confirmed Death, by Age Groups
As of December 23, 2009
Deaths = 823
Fem ale:
49.3%
Deaths
Male:
50.7%
%
100
100
75
75
50
50
25
8
2.3
3.3
8.5
25
13.7
9.2
9.6
9.6
7.3
2.9
2.7
1
0.9
>75
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
1-4
<1
0
4.6
4.4
11.1
Case-Fatality (%)
No. of Deaths
69.7% Deaths
0
Age Group
CHOTANI © 2009.
Source: Secretaria de Salud, Mexico
Swine Influenza A(H1N1)
Mexico Death, by Underlying Condition
As of December 23, 2009
Metabolic
37.1
Smoker
12.9
Cardiovascular
12.8
Other
10.7
N=823
Respiratory
4.5
Infectious
2.9
Neoplasm
2.1
Autoimmune
1.3
0
5
10
15
20
25
30
35
40
Percent
CHOTANI © 2009.
Source: Secretaria de Salud, Mexico
Swine Influenza A(H1N1)
Mexico Deaths, by Symptoms
As of December 23, 2009
N=823
CHOTANI © 2009.
Selected Symptoms
%
Fever
88.3%
Cough
84.9%
Shortness of breath
51.9%
Headache
35.7%
Rhinorrhea
29.6%
Myalgias
21.6 %
Vomiting
10.2%
Diarrhea
8.6%
Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm
Swine Influenza A(H1N1)
Canada Confirmed Cases & Deaths, by Province or Territory
Confirmed cases
Hospitalized
15
4000
3636
3500
Deaths
3000
17
2500
2259
2000
3
1500
1348
1000
87
14
831
201
0
0
266
488
0
0
0
330
42 1
11
0
8
51
44
0
0
1 0
14 0
405
38
Nunavut
Newfoundland
Prince Eward
Island
Nova Scotia
New
Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
0
Northwest
Territories
382
6
Yukon
500
3
859
1
British
Columbia
No. of Confirmed Cases & Deaths
As of July 15, 2009
Total Number of Confirmed Cases 10,156 = ; Death = 45; Cases reported from 13 of 13 Provinces
Province or Territory
Since July 15 only deaths have been reported – now totaling 397
CHOTANI © 2009.
Source: Public Health Agency of Canada
Swine Influenza A(H1N1)
Canada Total Confirmed Deaths, by Province or Territory
118
120
106
100
80
60
65
52
40
15
20
16
10
3
1
1
Northwest
Territories
Nunavut
7
Yukon
7
0
0
Newfoundland
Prince Eward
Island
Nova Scotia
New
Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British
Columbia
No. of Confirmed Cases & Deaths
As of December 23, 2009
Total Number of Confirmed Death = 401; Deaths reported from 12 of 13 Provinces
Province or Territory
CHOTANI © 2009.
Source: Public Health Agency of Canada
Swine Influenza A(H1N1)
EU & EFTA Confirmed Cases & Deaths
April 27 – September 24, 2009
Total Number of Confirmed Cases = 53,513; 163 Death; 31 Countries; CFR 0.3%
No. of Confirmed Cases & Deaths
Confirmed cases
19538
20000
78
16000
13471
12000
Deaths
8000
4000
29
1
361 126 70 297 293 636 68 297
1125
2149
1
3
3
1
206 200
2 2470
1
885
30
5
3
51 280 298
4
3
32
2983
2
153812741176
14731336
164
334 133 244
0
United
Switzerland
Sweden
Spain
Slovenia
Slovakia
Romania
Portugal
Poland
Norway
Netherlands
Malta
Luxembourg
Lithuania
Liechtenstien
Latvia
Italy
Ireland
Iceland
Hungry
Greece
Germany
France
Finland
Estonia
Denmark
Czech Rep.
Cyprus
Bulgaria
Belgium
Austria
Country
Currently only deaths are being reported – now totaling 1,371
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
EU & EFTA Countries Confirmed Case Distribution, by Age
27 April to 8 May 2009
n=46
25
23
Confirmed Cases
20
15
10
7
6
5
5
3
2
0
0-9
10-19
20-29
30-39
40-49
50-59
Age Group (Years)
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
EU & EFTA Deaths
April 27 – December 28, 2009
Total Number of Deaths among Confirmed Cases = 1,832
No. of Confirmed Cases & Deaths
350
303
300
256
250
223
200
188
150
132
116
100
59
48
50
35
3
17
25
27
22
16
2
8
3
57 49
53
45
36
0
0
30
29
13
3 3
22
9
United Kingdom
Switzerland
Sweden
Spain
Slovenia
Slovakia
Romania
Portugal
Poland
Norway
Netherlands
Malta
Luxembourg
Lithuania
Liechtenstien
Latvia
Italy
Ireland
Iceland
Hungry
Greece
Germany
France
Finland
Estonia
Denmark
Czech Rep.
Cyprus
Bulgaria
Belgium
Austria
Country
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
Other European Countries & Central Asia Confirmed Deaths
As of December 28, 2009
n=397
250
202
Confirmed Deaths
200
150
100
50
50
23
20
Albania
Armenia
7
10
10
Kosovo
3
Georgia
6
25
14
19
5
0
Ukraine
Serbia
Russia
Montenegro
Moldova
Macedonia
Croatia
Bosnia &
Herzegovinia
Belarus
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
Mediterranean & Middle East Confirmed Deaths
As of December 28, 2009
n=1,246
415
400
350
300
250
200
147
150
109
97
100
27
5
23
30
Oman
7
16
Occupied Palestinian Territory
50
40
Kuwait
50
71
42
Jordan
Confirmed Deaths
450
110
15
8
1
6
27
0
Yemen
United Arab Emirates
Turkey
Tunisia
Syrian Arab Republic
Saudi Arabia
Qatar
Moracco
Libya
Lebanon
Israel
Iraq
Islamic Republic of Iran
Egypt
Bahrain
Algeria
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
Africa Confirmed Deaths
As of December 28, 2009
n=116
100
93
Confirmed Deaths
90
80
70
60
50
40
30
20
8
1
2
Sao Tome &
Principe
Madagscar
2
Namibia
1
3
Ghana
10
5
1
0
Tanzania
Sudan
South Africa
Mozambique
Mauritius
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
North America Confirmed Deaths
As of December 28, 2009
n=3,384
2500
Confirmed Deaths
2160
2000
1500
1000
500
823
401
0
USA
Mexico
Canada
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
Central America & Caribbean Confirmed Deaths
As of December 28, 2009
n=222
Confirmed Deaths
50
47
41
40
31
30
23
18
20
16
11
10
6
5
1
2
Surinam
1
2
Saint Lucia
3
Saint Kitts &
Nevis
4
11
0
TrinidadTobago
Panama
Nicaragua
Jamaica
Honduras
Guatemala
El Salvador
Dominican
Republic
Cuba
Costa Rica
Cayman Island
Barbados
Baham
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
South America Confirmed Deaths
As of December 28, 2009
n=3,157
2000
Confirmed Deaths
1632
1500
1000
617
500
150
205
193
96
58
52
121
33
0
Venezuela
Uriguay
Peru
Paraguay
Ecudor
Colombia
Chile
Brazil
Bolivia
Argentina
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
North-East & South Asia Confirmed Deaths
As of December 28, 2009
n=1,820
1000
Confirmed Deaths
880
800
600
509
400
200
148
107
2
1
Pakistan
26
Nepal
1
Maldives
Bangladesh
2
Macao SAR
China
6
Afghanistan
51
17
35
35
0
Taiwan
Sri Lanka
South Korea
Mongolia
Japan
India
Hong Kong
SAR China
China
(Minland)
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
South-East Asia Confirmed Deaths
As of December 28, 2009
n=388
Confirmed Deaths
200
191
150
100
77
53
50
30
19
10
Cambodia
Indonesia
1
6
1
0
Vietnam
Thiland
Singapore
Phillippines
Malaysia
Loas PDR
Brunei
Barussalam
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
Australia & Pacific Confirmed Deaths
As of December 28, 2009
n=217
Confirmed Deaths
200
191
150
100
50
20
Marshall Island
1
1
Tonga
Cook Island
2
Solomon
Island
1
Samoa
1
0
New Zealand
Australia
Countries
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
EU & EFTA Countries Confirmed Deaths, by Week
As of December 28, 2009
n=1,803
No of Confirmed Deaths
350
319
300
267
250
208
188
169
200
151
150
100
100
84
49 43
50
1
1
2
12 17
2
5
3
17 23 21 17 15 22 16 15 12 24
0
25 26 27 28 29 30 32 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Week-2009
CHOTANI © 2009.
Source: ECDC
Swine Influenza A(H1N1)
Global Confirmed Deaths, by Week
As of December 28, 2009
n=12,682
1400
No of Confirmed Deaths
1231
1177
1200
1066
1046
1000
936
800
642
566 581
600
436
461
396
485
422 405
400
303
261
207 212
170
200
85
19
7
5
6
1
110
235
190
146
212
330
181
129
23
0
18 19 20 21 22 23 25 26 27 28 29 30 32 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Week-2009
* Increase in number of deaths in week 43 due to aggregate reporting of fatal cases from Brazil (week 37-40) &
due to batch report of US fatal cases since August 1, 2009
CHOTANI © 2009.
Source: ECDC
Global Distribution of Reported Laboratory Confirmed Cases
& Deaths of Swine Influenza A(H1N1), December 23, 2009
CHOTANI © 2009.
Source: WHO
Geographic Spread of Influenza Activity
Based Upon Country Reporting,
Week 50, 2009 (07-23 December)
CHOTANI © 2009.
Source: WHO
Impact on Healthcare Services Based Upon Degree of Disruption,
As a Result of Acute Respiratory Diseases
Week 50, 2009 (07-13 December)
CHOTANI © 2009.
Source: WHO
Number of Specimens Positive for
Influenza Sub-Type
CHOTANI © 2009.
Source: CDC
Laboratory-Confirmed Cases & Deaths of New Influenza
A(H1N1) by WHO Regions, September 20, 2009
At least 318,925 Cases & Over 3917 Deaths
Overall Case-Fatality Rate (CFR) in Confirmed ~ 1.2%
CFR = 2.5%
No. Confirmed Cases & Deaths
140000
130448
120000
CFR = 0.4%
100000
85299
80000
CFR = 0.3%
53000
60000
40000
CFR = 0.5%
20000
CFR = 1.1%
30293
CFR = 0.6%
11621
8264
340
362
Western Pacific
Region (WPRO)
154
South-East Asia
Region
(SEARO)
Americas
Region (AMRO)
Africa Region
(AFRO)
72
Europe Region
(EURO)
2948
Eastern
Mediterranean
Region (EMRO)
41
0
WHO Region
*Given that countries are no longer required to test and report individual cases, the number of cases reported
actually understates the real number of cases.
CHOTANI © 2009.
Source: WHO
Swine Influenza A(H1N1)
US Case Definitions
•
A confirmed case of swine influenza A (H1N1) virus infection is defined as a
person with an acute febrile respiratory illness with laboratory confirmed swine
influenza A (H1N1) virus infection at CDC by one or more of the following tests:
•
•
•
A probable case of swine influenza A (H1N1) virus infection is defined as a
person with an acute febrile respiratory illness who is:
•
•
•
real-time RT-PCR
viral culture
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 is defined as a
person with acute febrile respiratory illness with onset
•
•
•
CHOTANI © 2009.
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 influenza A(H1N1) cases, or
resides in a community where there are one or more confirmed swine influenza
cases.
Source: CDC
Swine Influenza A(H1N1)
US Case Definitions
• Infectious period for a confirmed case of swine influenza A(H1N1)
virus infection is defined as 1 day prior to the case’s illness onset to 7
days after onset
• Close contact is defined as: within about 6 feet of an ill person who is
a confirmed or suspected case of swine influenza A(H1N1) virus
infection during the case’s infectious period
• Acute respiratory illness is defined as recent onset of at least two of
the following: rhinorrhea or nasal congestion, sore throat, cough (with
or without fever or feverishness)
• High-risk groups: A person who is at high-risk for complications of
swine influenza A(H1N1) virus infection is defined as the same for
seasonal influenza (see Reference)
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Guidelines for Clinicians
• Clinicians should consider the possibility of swine
influenza virus infections in patients presenting with
febrile 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 a
respiratory 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 at
a state public health laboratory
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Guidelines for Clinicians
• Signs and Symptoms
• Influenza-like-illness (ILI)
• Fever, cough, sore throat, runny nose, headache, muscle aches. In
some cases vomiting and diarrhea. (These cases had illness onset
during 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 virus
infection should be considered
• Non-hospitalized ill persons who are a confirmed or
suspected case of swine influenza A (H1N1) virus
infection are recommended to stay at home (voluntary
isolation) for at least the first 7 days after illness onset
except to seek medical care
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Guidelines for Clinicians
FDA Issues Authorizations for Emergency Use (EUAs) of Antivirals
•
On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued
EUAs in response to requests by the Centers for Disease Control and
Prevention (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 health
emergency on April 26, 2009
•
The swine influenza EUAs aid in the current response:
CHOTANI © 2009.
•
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 for
children older than 1 year. Tamiflu is currently approved by the FDA for the
treatment 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 would
otherwise apply to dispensed drugs and to be accompanied by written
information about the emergency use of the medicines.
Source: FDA
Swine Influenza A(H1N1)
Biosafety Guidelines for Laboratory Workers
•
Diagnostic work on clinical samples from patients who are suspected
cases 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 suspected
cases of swine influenza A (H1N1) virus infection should be performed in
a 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
•
CHOTANI © 2009.
all waste disposal procedures should be followed as outlined
in your facility standard laboratory operating procedures
Source: CDC
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 any
symptoms. Symptoms of swine influenza infection
include diarrhea, headache, runny nose, and muscle
aches
• Any illness should be reported to your supervisor
immediately
• For personnel who had unprotected exposure or a
known breach in personal protective equipment to
clinical material or live virus from a confirmed case of
swine influenza A (H1N1), antiviral chemoprophylaxis
with zanamivir or oseltamivir for 7 days after exposure
can be considered
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Biosafety Guidelines for Laboratory Workers
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 and
Prevention (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 health
emergency on April 26, 2009
•
The swine influenza EUAs aid in the current response:
•
CHOTANI © 2009.
Diagnostic Test: Allow CDC to distribute the rRT-PCR Swine Flu Panel
diagnostic test to public health and other qualified laboratories that have the
equipment and personnel to perform and interpret the results.
Source: CDC
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-based
hand 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 limit
contact with others to keep from
infecting them
CHOTANI © 2009.
Comparison of Available Influenza
Diagnostic Tests1
Influenza Diagnostic
Tests
Method
3
Availability
Typical
2
Processing Time
Sensitivity for
2009 H1N1
influenza
Distinguishes 2009 H1N1 influenza
from other influenza A
viruses?
Rapid influenza diagnostic
4
tests (RIDT)
Antigen
dete
ction
Wide
0.5 hour
10 – 70%
No
Direct and indirect
Immunofluorescence
5
assays (DFA and IFA)
Antigen
dete
ction
Wide
2 – 4 hours
47–93%
No
Viral isolation in tissue cell
culture
Virus
isola
tion
Limited
2 -10 days
-
Nucleic acid amplification
tests
7
(including rRT-PCR)
RNA
dete
ction
Limited
48 – 96 hours
[6-8 hours to
perform test]
86 – 100%
CHOTANI © 2009.
8
Yes
6
Yes
Source: CDC
Swine Influenza A(H1N1)
Antiviral Protection
•
There are two flu antiviral drugs recommended
•
Oseltamivir or Zanamivir
•
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 getting sick (within
2 days of symptoms)
•
Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing
products (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers
(up to 18 years old) who are confirmed or suspected ill case of swine
influenza A (H1N1) virus infection; this can cause a rare but serious illness
called Reye’s syndrome. For relief of fever, other anti-pyretic medications are
recommended such as acetaminophen or non steroidal anti-inflammatory
drugs.
•
Treatment is recommended for:
•
•
•
CHOTANI © 2009.
All hospitalized patients with confirmed, probable or suspected novel influenza
(H1N1).
Patients who are at higher risk for seasonal influenza complications
If patient is not in a high-risk group or is not hospitalized, healthcare providers
should use clinical judgment to guide treatment decisions
Source: CDC
Swine Influenza A(H1N1)
Antiviral Protection
•
Antiviral Chemoprophylaxis for Treatment:
•
Post-exposure: Duration chemoprophylaxis is 10 days after the last known
exposure to novel (H1N1) influenza and may be considered in the following:
• Close contacts of cases (confirmed, probable, or suspected)
• Health care personnel, public health workers, or first responders who have had a
recognized, unprotected close contact exposure to a person (confirmed, probable, or
suspected) during that person’s infectious period.
•
•
Antiviral Use for Control of Novel H1N1 Influenza Outbreaks
•
•
•
Pre-exposure: Antivirals should only be used in limited circumstances, and in
consultation with local medical or public health authorities.
A cornerstone for the control of seasonal influenza outbreaks in nursing homes and
other long term care facilities.
If outbreaks were to occur, it is recommended that ill patients be treated with
oseltamivir or zanamivir and that chemoprophylaxis with either oseltamivir or
zanamivir be started as early as possible to reduce the spread of the virus as is
recommended for seasonal influenza outbreaks in such settings.
Children Under 1 Year of Age
•
CHOTANI © 2009.
Oseltamivir is not licensed for use in children less than 1 year of age. Because
infants experience high rates of morbidity and mortality from influenza, infants with
novel (H1N1) influenza virus infections may benefit from treatment using
oseltamivir.
Source: CDC
Swine Influenza A(H1N1)
Antiviral Protection
Oseltamivir (Tamiflu)
Treatment
Prophylaxis
Zanamivir (Relenza)
Treatment
Prophylaxis
Adults
75 mg capsule twice
per day for 5 days
75 mg capsule once
per day
Two 5 mg inhalations
(10 mg total) twice per
day
Two 5 mg inhalations
(10 mg total) once per
day
Children
15 kg or less: 60 mg
per day divided into 2
doses
30 mg once per day
Two 5 mg inhalations
(10 mg total) twice per
day (age, 7 years or
older)
Two 5 mg inhalations
(10 mg total) once per
day (age, 5 years or
older)
15–23 kg: 90 mg per
day divided into 2
doses
45 mg once per day
24–40 kg: 120 mg per
day divided into 2
doses
60 mg once per day
>40 kg: 150 mg per
day divided into 2
doses
75 mg once per day
Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatment
dose for 5 days. <3 months: 12 mg twice daily; 3-5 months: 20 mg twice daily; 6-11 months: 25 mg twice daily
Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. Recommended
prophylaxis dose for 10 days. <3 months: Not recommended unless situation judged critical due to limited data on use in this
age group; 3-5 months: 20 mg once daily; 6-11 months: 25 mg once daily
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Vaccine Protection
• Novel H1N1 vaccine available for since Mid-September
• Seventh Harvard Pandemic Survey
•
•
•
38% of Children in the US immunized
50% Adults do not intend to be immunized
35% of parents do not intend to get their children immunized
• Novel H1N1 vaccine is not intended to replace the
seasonal flu vaccine – it is intended to be used along-side
seasonal flu vaccine
• Vaccines:
• Inactivated influenza virus vaccines
• CSL Ltd. of Australia
• Novartis Vaccines of Switzerland
• Sanofi Pasteur of France
•
800,000 pre-filled syringes were recalled are for young children, ages 6 months
to 3 years in the US
• GlaxoSmithKline (GSK) of UK
• Sinovac Biotech of China
• Live-attenuated virus vaccine
• MedImmune LLC of US (nasal-spray)
•
CHOTANI © 2009.
4.5 million doses recalled due to decreased potency in the US
Adverse events reported after receipt of influenza A (H1N1) 2009 monovalent vaccines and
seasonal influenza vaccines
Vaccine Adverse Event Reporting System (VAERS), United States, July 1- November 24, 2009
Serious adverse events†
Influenza vaccine received
All reports
of adverse
events*
Total
Fatal
Nonserious
events†
Nonfatal
No.
(%)
No.
(%)
No.
(%)
No.
(%)
H1N1 total
3,783
204
5.4
13
0.3
191
5
3,579
94.6
Live, attenuated monovalent vaccine
1,115
52
4.7
3
0.3
49
4.4
1,063
95.3
Monovalent inactivated, split-virus or subunit
2,439
135
5.5
9
0.4
126
5.2
2,304
94.5
229
17
7.4
1
0.4
16
7
212
92.6
4,672
283
6.1
16
0.3
267
5.7
4,389
93.9
480
35
7.3
0
---
35
7.3
445
92.7
4,028
232
5.8
15
0.4
217
5.4
3,796
94.2
164
16
9.8
1
0.6
15
9.1
148
90.2
Unknown
Seasonal total
Live, attenuated influenza vaccine
Trivalent inactivated
Unknown
* An adverse event reported to VAERS might occur by chance after vaccination or might be related causally to vaccine; VAERS generally does not
determine whether a vaccine caused an adverse event. Excluding 62 reported with insufficient information, of which two were serious adverse events:
one allergic and one local reaction (i.e., cellulitis at the injection site).
†
Serious adverse events are defined as those resulting in death, life-threatening illness, hospitalization, prolongation of hospitalization, persistent or
significant disability, or congenital anomaly. All other events are categorized as nonserious. Food and Drug Administration. 21 CFR Part 600.80.
Postmarketing reporting of adverse experiences. Federal Register 1997;62:52252--3.
SOURCE: Safety of Influenza A (H1N1) 2009 Monovalent Vaccines --- United States, October 1--November 24, 2009, MMWR. December 11, 2009 / 58(48);1351-1356
CHOTANI © 2009.
Patient age, sex, and clinical characteristics regarding the 13 reported deaths after
receipt of influenza A (H1N1) 2009 monovalent vaccines
Vaccine Adverse Event Reporting System, United States, 2009*
Age
(yrs)
Sex
H1N1
vaccine
type
Vaccination
to onset
(days)
1
Male
MIV†
1
Febrile seizures (one after measles, mumps, rubella
vaccination)
Sudden death, no evidence of trauma
2
Female
MIV
0
Encephalopathy, central apnea, traumatic brain damage,
seizures
Sudden cardiopulmonary arrest
9
Female
LAMV§
6
Trisomy 21, leukemia (in remission), cardiac disease
(neutropenia on vaccination day)
Pneumococcal pneumonia/H1N1 influenza
18
Male
LAMV
0
No significant history, dental care for gingivitis 2 weeks before
H1N1 vaccination; enlarged heart on chest radiograph
Massive aspiration/ Sudden cardiopulmonary
arrest
19
Female
MIV
9
Rett syndrome, severe muscle wasting/physical disability
Bilateral pneumonia, respiratory failure
35
Female
LAMV
3
Hereditary spherocytosis, splenectomy
Pneumoccocal sepsis
38
Male
MIV
19
Immunocompromised
Respiratory failure/Under review
46
Female
MIV
2
Hypertension, hyperlipidemia, pulmonary embolism, deep vein
thrombosis
Pulmonary embolus/Negative for H1N1 in lung
tissue
49
Female
MIV
3
Type 2 diabetes, stroke, chronic obstructive pulmonary
disease, emphysema, substance abuse
Suspected cardiovascular event
53
Female
MIV
5
End-stage renal disease and atrial fibrillation
Under review
56
Female
MIV
0
Driver involved in motor vehicle crash leaving clinic after H1N1
vaccination
Trauma
61
Male
MIV
13
Hypertension, diabetes, peripheral vascular disease, end stage
renal disease
Cardiac/Respiratory arrest, gram- negative
sepsis
77
Male
MIV
2
Lung cancer atrial fibrillation, recurrent deep venous
thrombosis hypertension, hyperlipidemia
Suspected myocardial infarction
Medical history
Preliminary diagnosis/Autopsy results
* As of November 24, 2009. † Monovalent inactivated, split-virus or subunit vaccines. § Live, attenuated monovalent vaccine.
SOURCE: Safety of Influenza A (H1N1) 2009 Monovalent Vaccines --- United States, October 1--November 24, 2009, MMWR. December 11, 2009 / 58(48);1351-1356
CHOTANI © 2009.
Swine Influenza A(H1N1)
Vaccine Protection
•
CDC’s Advisory Committee on Immunization Practices (ACIP) recommends the
following groups to receive the novel H1N1 influenza vaccine:
•
Pregnant women because they are at higher risk of complications and can potentially provide
protection to infants who cannot be vaccinated;
•
Household contacts and caregivers for children younger than 6 months of age because younger
infants are at higher risk of influenza-related complications and cannot be vaccinated.
Vaccination of those in close contact with infants less than 6 months old might help protect
infants by “cocooning” them from the virus;
•
Healthcare and emergency medical services personnel because infections among healthcare
workers have been reported and this can be a potential source of infection for vulnerable
patients. Also, increased absenteeism in this population could reduce healthcare system
capacity;
•
All people from 6 months through 24 years of age
•
Children from 6 months through 18 years of age because we have seen many cases of novel
H1N1 influenza in children and they are in close contact with each other in school and day care
settings, which increases the likelihood of disease spread, and
•
Young adults 19 through 24 years of age because we have seen many cases of novel H1N1
influenza in these healthy young adults and they often live, work, and study in close proximity,
and they are a frequently mobile population; and,
•
Persons aged 25 through 64 years who have health conditions associated with higher risk of
medical complications from influenza.
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Face Mask and Respirator Protection
Setting
Persons not at increased risk of severe
illness from influenza
(Non-high risk persons)
Persons at increased risk of severe illness from
influenza
(High-Risk Persons)
Community
No 2009 H1N1 in community
Facemask/respirator not recommended
Facemask/respirator not recommended
2009 H1N1 in community: not crowded setting
Facemask/respirator not recommended
Facemask/respirator not recommended
2009 H1N1 in community: crowded setting
Facemask/respirator not recommended
Avoid setting. If unavoidable, consider
facemask or respirator
Caregiver to person with influenza-like illness
Facemask/respirator not recommended
Avoid being caregiver. If unavoidable, use
facemask or respirator
Other household members in home
Facemask/respirator not recommended
Facemask/respirator not recommended
No 2009 H1N1 in community
Facemask/respirator not recommended
Facemask/respirator not recommended
2009 H1N1 in community
Facemask/respirator not recommended
but could be considered under certain
circumstances
Facemask/respirator not recommended but
could be considered under certain
circumstances
Respirator
Consider temporary reassignment. Respirator
Home
Occupational (non-health care)
Occupational (health care)
Caring for persons with known, probable or
suspected 2009 H1N1 or influenza-like illness
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Other Protective Measures
Defining Quarantine vs. Isolation vs. Social-Distancing
• Isolation: Refers only to the sequestration of symptomatic
patents either in the home or hospital so that they will not infect
others
• Quarantine: Defined as the separation from circulation in the
community of asymptomatic persons that may have been
exposed to infection
• Social-Distancing: Has been used to refer to a range of nonquarantine measures that might serve to reduce contact between
persons, such as, closing of schools or prohibiting large
gatherings
CHOTANI © 2009.
Source: CDC
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 or
cardiac pulmonary resuscitation) for suspected or confirmed swine
influenza A (H1N1) cases should wear a fit-tested disposable N95
respirator
• Pending clarification of transmission patterns for this virus, personnel
providing direct patient care for suspected or confirmed swine influenza
A (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 respiratory
protection program in accordance with Occupational Safety and Health
Administration (OSHA) regulations.
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Other Protective Measures
Infection Control of Ill Persons in a Healthcare Setting
• Patients with suspected or confirmed case-status should be placed
in a single-patient room with the door kept closed. If available, an
airborne infection isolation room (AIIR) with negative pressure air
handling with 6 to 12 air changes per hour can be used. Air can be
exhausted 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 air
handling.
• The ill person should wear a surgical mask when outside of the
patient room, and should be encouraged to wash hands frequently
and follow respiratory hygiene practices. Cups and other utensils
used by the ill person should be washed with soap and water before
use by other persons. Routine cleaning and disinfection strategies
used during influenza seasons can be applied to the environmental
management of swine influenza.
CHOTANI © 2009.
Source: CDC
Swine Influenza A(H1N1)
Other Protective Measures
Infection Control of Ill Persons in a Healthcare Setting
• Standard, Droplet and Contact precautions should be used for all
patient care activities, and maintained for 7 days after illness onset
or until symptoms have resolved. Maintain adherence to hand
hygiene by washing with soap and water or using hand sanitizer
immediately after removing gloves and other equipment and after
any contact with respiratory secretions.
• Personnel providing care to or collecting clinical specimens from
suspected or confirmed cases should wear disposable non-sterile
gloves, gowns, and eye protection (e.g., goggles) to prevent
conjunctival exposure.
CHOTANI © 2009.
Source: CDC
Summary
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WHO raised the alert level to Phase 6 on June 11, 2009
As of December 28, 2009, worldwide more than 208 countries and overseas territories or
communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including
at least 13,000 deaths
Northern Hemisphere: Overall disease activity has recently peaked.
Central and Eastern Europe, and in parts of West, Central, and South Asia: Continued increases in
influenza activity
United States and Canada: Influenza activity continues to be geographically widespread but overall
levels of influenza-like-illness has declined substantially
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Europe: Widespread and active transmission continued to be observed throughout the continent
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Approximately 53% of hospitalized cases in Canada had an underlying medical condition
Overall pandemic influenza activity appears to have recently peaked across a majority of countries
Western and Central Asia: Virus circulation remains active throughout the region, however disease
trends remain variable
East Asia: Influenza transmission remains active but appears to be declining overall
Central and South America and the Caribbean: influenza transmission remains geographically
widespread but overall disease activity has been declining or remains unchanged in most parts,
except for in Barbados and Ecuador, were recent increases in respiratory diseases activity have
been reported
Southern Hemisphere: Sporadic cases of pandemic influenza continued to be reported without
evidence of sustained community transmission.
CHOTANI © 2009.
Summary
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In the US
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In Mexico
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Number of deaths being reported is rising
Vaccine
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Majority of the cases reported in health young adults (20-29 years)
Globally
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Majority of the cases reported in health young adults
70% of the deaths were reported in healthy young adults, 20-54 years
Individuals 60+ seem to be protected as the number of cases and have a lower case-fatality
compared to the rest of the population
In EU
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Highest incidence of lab-confirmed cases reported among 5-24 years old
Highest hospitalization rate among 0-4 years old
Underlying health conditions confers high risk of complications and deaths
Total Adverse Events: 5.4% (0.3% fatal)
Sanofi Pasteur & MedImmune vaccine recalled due to potency issues
Anti-virals (oseltamivir and zanamivir)
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CHOTANI © 2009.
Oseltamivir resistance reported recently in immunocompromised patents
Timeline of Emergence
Influenza A Viruses in Humans
Reassorted Influenza
virus (Swine Flu)
1976 Swine
Flu Outbreak,
Ft. Dix
H1
Avian
Influenza
H9 H7
H5 H5
H1
H3
H2
H1
1918
1957
Spanish
Influenza
H1N1
Asian
Influenza
H2N2
CHOTANI © 2009.
1968
1977
Hong
Russian
Kong
Influenza
Influenza
H3N2
1997
2003
1998/9
2009
Lessons Learned form
Past Pandemics
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First outbreaks March 1918 in Europe, USA
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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 explosive
outbreaks in in France, Sierra Leone, USA
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10-fold increase in death rate
Highest death rate ages 15-35 years
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Deaths from primary viral pneumonia, secondary
bacterial pneumonia
Deaths within 48 hours of illness
Coincident severe disease in pigs
20-40 million killed in less than 1 year
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Cytokine Storm?
World War I –8.3 million military deaths over 4
years
25-35% of the world infected
CHOTANI © 2009.
Lessons Learned form
Past Pandemics
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Pandemics are unpredictable
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Mortality, severity of illness, pattern of spread
A sudden, sharp increase in the need for medical care
will always occur
Capacity to cause severe disease in nontraditional
groups is a major determinant of pandemic impact
Epidemiology reveals waves of infection
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Ages/areas not initially infected likely vulnerable in future
waves
Subsequent waves may be more severe
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1918- virus mutated into more virulent form
1957 schoolchildren spread initial wave, elderly died in
second wave
Public health interventions delay, but do not stop
pandemic spread
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Quarantine, travel restriction show little effect
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Temporary banning of public gatherings, closing schools
potentially effective in case of severe disease and high
mortality
Delaying spread is desirable
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CHOTANI © 2009.
Does not change population susceptibility
Delay spread in Australia— later milder strain causes
infection there
Fewer people ill at one time improve capacity to cope with
sharp increase in need for medical care
Conclusion/Recommendations
1. Past experience with pandemics have taught us that the second wave
is worse than the first causing more deaths due to:
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Primary viral pneumonia, Acute Respiratory Distress Syndrome (ARDS),
& Secondary bacterial infections, particularly pneumonia
Fortunately compared to the past now we have vaccines, anti-virals and
antibiotics (to treat secondary bacterial infections) & rT-PCR based rapid
diagnostic devices
This pandemic is milder than previously predicted with a case-fatality less
than 1%
2. At present most of the deaths due to the novel H1N1 strain has been
reported from the Americas.
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Disease seems to be affecting the healthy strata of the population based
upon epidemiological data
Anecdotal data suggests that the number of deaths among the pediatric
population has risen recently due to infection with the novel H1N1
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CHOTANI © 2009.
Most of these deaths however have been reported in cases with underlying
medical conditions
60 years and above age group seems to show some protection against
this strain suggesting past exposure and some immunity
Conclusion/Recommendations
3.
Each locality/jurisdiction needs to
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4.
Have enhanced disease and virological surveillance capabilities
Develop a plan to house large number of severely sick and provide care
if needed to deal with mildly sick at home (voluntary quarantine)
Healthcare facilities/hospitals need to focus on increasing surge capacity
and stringent infection prevention/control
General population needs to follow basic precautions
In the Northern Hemisphere influenza viral transmission traditionally
stops by the beginning of May but in pandemic years (1957) sporadic
outbreaks occurred during summer among young adults
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CHOTANI © 2009.
This novel H1N1 strain has survived high humidity or temperature and
continued to spread during the summer months and will continue to
spread and cause infection
Conclusion/Recommendations
5.
School Closures:
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6.
Preemptive school closures merely delay the spread of disease
Once schools reopen the disease transmits and spreads
Puts unbearable pressure on single-working parents and would be
devastating to the economy
Closure after identification of a large cluster would be appropriate as
absenteeism rate among students and teachers would be high enough to
justify this action
Burden of Disease & Mortality
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Actual burden of the disease will be higher than the regular seasonal flu
despite the availability of vaccine, antivirals and excellent public
knowledge
With the variation in reporting it is very difficult to appreciate the total
number of deaths
It is imperative to appreciate that “times-have-changed”
7.
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CHOTANI © 2009.
Though this strain has spread very quickly across the globe and seems
to be highly infectious, today we are much better prepared than 1918
There is better surveillance, communication, understanding of infection
control, vaccines, anti-virals, antibiotics and advancement in science and
resources to produce countermeasures quickly