chotani © 2009. rashid a. chotani, md, mph, dtm adjunct assistant professor uniformed services...
TRANSCRIPT
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 15, first JIT lecture issued April 26)
December 28, 2009 (4:00 PM EST)
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, 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, MacedoniaDr. 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 , 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
CHOTANI © 2009.
1. Influenza Virus2. Definitions3. Introduction4. History in the US5. Spread/Transmission 6. Timeline/Facts7. Response 8. Status Update
• US • Mexico• 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
CHOTANI © 2009.
Credit: L. Stammard, 1995
• 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)
Virus
H1 N1H2 N2H3 N3H4 N4H5 N5H6 N6H7 N7H8 N8H9 N9
H10H11H12H13H14H15H16
Haemagglutinin subtype Neuraminidase subtype
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
Definitions General
CHOTANI © 2009. Source: Bean B, et al. JID 1982;146:47-51
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.
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-to-human 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 32-year-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
Avian Virus
Human Virus
Swine Virus
Avian/HumanReassorted Virus
Reassortment in Pigs
CHOTANI © 2009.
Swine Influenza A(H1N1) March 2009Timeline
• 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• Samples from the Mexico outbreak match swine
influenza isolates from patients in the United States
Source: CDC
CHOTANI © 2009.
Swine Influenza A(H1N1) March 2009Facts
• 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: • North American swine• North American avian• North American human and • Eurasian swine
CHOTANI © 2009.
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 non-essential travel to Mexico
Source: CDC
CHOTANI © 2009.
Swine Influenza A(H1N1) Global Response
• The WHO raises the alert level to Phase 6• 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
CHOTANI © 2009.
Swine Influenza A(H1N1)Status Update
• US: March – December 28 • Estimates
• Symptomatic: ~ 55 million• Hospitalized: ~300,000• Deaths: ~ 13,000
• Death among children since August 2009: 221• Sub-type: 99% Influenza A (H1N1)• Activity: On decline
• MEXICO: March 01 – December 23• Laboratory confirmed cases: 68,123• Deaths: 823• Activity: On decline
• CANADA: As of December 23• Deaths: 401• Activity: On decline
• EUROPEAN UNION & EFTA COUNTRIES: April 27- December 28• 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
CHOTANI © 2009.
GLOBALLY: March 1-December 23 • At least 11,516 Deaths
• Africa Region (AFRO): 109• Americas Region (AMRO): 6,670 • Eastern Mediterranean Region (EMRO):
663• Europe Region (EURO) : 2,045• South-East Asia Region (SEARO): 990 • Western Pacific Region (WPRO) : 1,039
Source: WHO
Swine Influenza A(H1N1)Status Update
ECDC reported a total of 12,776 deaths – December 28, 2009
CHOTANI © 2009.
Swine Influenza A(H1N1) CDC Estimates from April-November 14, 2009, By Age Group
Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm
2009 H1N1 Mid-Level Range* Estimated Range *Cases 0-17 years ~16 million ~12 million to ~23 million18-64 years ~27 million ~19 million to ~38 million65 years and older ~4 million ~3 million to ~6 million
Cases Total ~47 million ~34 million to ~67 millionHospitalizations 0-17 years ~71,000 ~51,000 to ~101,00018-64 years ~121,000 ~87,000 to ~172,00065 years and older ~21,000 ~15,000 to ~29,000
Hospitalizations Total ~213,000 ~154,000 to ~303,000Deaths 0-17 years ~1,090 ~790 to ~1,55018-64 years ~7,450 ~5,360 to ~10,57065 years and older ~1,280 ~920 to ~1,810
Deaths Total ~9,820 ~7,070 to ~13,930
CHOTANI © 2009.
Swine Influenza A(H1N1) Symptoms Reported in US Hospitalized Patients
Symptoms 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
CHOTANI © 2009.
4816
22080
7434
2187513
6741
0
5000
10000
15000
20000
25000
0-4 5-24 25-49 50-64 >=65 UK
Age Grougs
Cas
es
Swine Influenza A(H1N1) Lab-Confirmed Cases in the US as of July 24, 2009 (n=43,771)
11%
50%
17%
5%
1%15%
Percent Represents proportion of Total Cases
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
CHOTANI © 2009.
22.9
26.7
6.97
3.92
1.3
0
5
10
15
20
25
30
0-4 5-24 25-49 50-64 >=65
Age Grougs
Cas
es
Swine Influenza A(H1N1) Lab-Confirmed Cases in the US as of July 24, 2009 (n=37,030*)
n=4816
n=22080
n=7434
n=2187n=513
Rate Per 100,000 Population by Age Group
*Excludes 6,741 Cases with missing dataRate/100,000 by Single Year Age Groups: Denominator Source: 2008 Census Estimated, US Census Bureau
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
CHOTANI © 2009.
953
1718
1184
658
225 273
0
500
1000
1500
2000
0-4 5-24 25-49 50-64 >=65 UK
Age Grougs
Ho
spit
aliz
atio
ns
Swine Influenza A(H1N1) Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011)
19%
34%
24%
13%
4%5%
Percent Represents proportion of Total Hospitalizations
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
CHOTANI © 2009.
4.5
2.1
1.1 1.2
1.7
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
0-4 5-24 25-49 50-64 >=65
Age Grougs
Ho
spit
aliz
atio
ns
Swine Influenza A(H1N1) Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011)
N=953
N=1718
N=1184
13%
N=658
n=225
Rate Per 100,000 Population by Age Group
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
CHOTANI © 2009.
7
48
124
71
26 26
0
50
100
150
0-4 5-24 25-49 50-64 >=65 UK
Age Grougs
Nu
mb
er o
f D
eath
s
Swine Influenza A(H1N1) Deaths Among Lab-Confirmed Cases in the US as of July 24, 2009 (n=302)
2%
16%
41%
24%
9% 9%
Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC
CHOTANI © 2009.
Swine Influenza A(H1N1) Mexico Epidemic Curve Confirmed, by Day
0
200
400
600
800
1000
1200
3/1/
2009
4/1/
2009
5/1/
2009
6/1/
2009
7/1/
2009
8/1/
2009
9/1/
2009
10/1
/200
9
11/1
/200
9
12/1
/200
9
Day
No
. o
f C
on
firm
ed C
ases
Source: Secretaria de Salud, Mexico
Total Number of Confirmed Cases = 66,415*
As of December 09, 2009
*NOTE: Numbers can change
Epidemiological Alert
4/13/09
School Closure4/24/09
Suspension of Non-essential Activities5/1/09
School Open5/12/09
CHOTANI © 2009.
7,467
10,509
19,781
12,980
7,2855,079
3,0941,287 640
0
3,000
6,000
9,000
12,000
15,000
18,000
21,000
0-4 5-9 10-19 20-29 30-39 40-49 50-59 60+ NA
No
. Co
nfi
rme
d C
as
es
Age Group
Swine Influenza A(H1N1) Mexico Confirmed Case Distribution, by Age
Total Number of Confirmed Cases = 68,123
As of December 23, 2009
Source: Secretaria de Salud, Mexico
CHOTANI © 2009.
Swine Influenza A(H1N1) Mexico Confirmed Death, by Age Groups
2.34.6 4.4 3.3 2.9
811.1 8.5
13.79.2 9.6 9.6 7.3
2.7 1 0.90
25
50
75
100
<1
1-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
>75
Age Group
No
. of
De
ath
s
0
25
50
75
100
Ca
se
-Fa
talit
y (
%)
Deaths %
Deaths = 823
As of December 23, 2009
Source: Secretaria de Salud, Mexico
Male: 50.7%
Female: 49.3%
69.7% Deaths
CHOTANI © 2009.
1.3
2.1
2.9
4.5
10.7
12.8
12.9
37.1
0 5 10 15 20 25 30 35 40
Autoimmune
Neoplasm
Infectious
Respiratory
Other
Cardiovascular
Smoker
Metabolic
Percent
Swine Influenza A(H1N1) Mexico Death, by Underlying Condition
N=823
As of December 23, 2009
Source: Secretaria de Salud, Mexico
CHOTANI © 2009.
Swine Influenza A(H1N1) Mexico Deaths, by Symptoms
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
As of December 23, 2009
N=823
CHOTANI © 2009.
Swine Influenza A(H1N1) Canada Confirmed Cases & Deaths, by Province or Territory
0 0 01
859
330
3636
2259
1348
831
42 5
382 405
1444 38181201
1114
26687
488
0
500
1000
1500
2000
2500
3000
3500
4000
Britis
hC
olu
mb
ia
Alb
erta
Sa
ska
tch
ew
an
Ma
nito
ba
On
tario
Qu
eb
ec
Ne
wB
run
sw
ick
No
va
Sc
otia
Prin
ce
Ew
ard
Isla
nd
Ne
wfo
un
dla
nd
Yu
ko
n
No
rthw
es
tT
errito
ries
Nu
na
vu
t
Province or Territory
No
. of
Co
nfi
rme
d C
as
es
& D
ea
ths
Confirmed cases Hospitalized
As of July 15, 2009
Total Number of Confirmed Cases 10,156 = ; Death = 45; Cases reported from 13 of 13 Provinces
Source: Public Health Agency of Canada
1
3
3 6
15
0 00
0
17
00
0
Deaths
Since July 15 only deaths have been reported – now totaling 397
CHOTANI © 2009.
Swine Influenza A(H1N1) Canada Total Confirmed Deaths, by Province or Territory
7 70
16
3 1 1
106118
65
10
52
15
0
20
40
60
80
100
120
Britis
hC
olu
mb
ia
Alb
erta
Sa
sk
atc
he
wa
n
Ma
nito
ba
On
tario
Qu
eb
ec
Ne
wB
run
sw
ick
No
va
Sc
otia
Prin
ce
Ew
ard
Isla
nd
Ne
wfo
un
dla
nd
Yu
ko
n
No
rthw
es
tT
errito
ries
Nu
na
vu
t
Province or Territory
No
. of
Co
nfi
rme
d C
as
es
& D
ea
ths
As of December 23, 2009
Total Number of Confirmed Death = 401; Deaths reported from 12 of 13 Provinces
Source: Public Health Agency of Canada
CHOTANI © 2009.
361 126 70 297 293 63668 297
1125
19538
2149
206 200885
2470
30 5 51 280 29814731336
164
2983
334 133 244
153812741176
13471
0
4000
8000
12000
16000
20000
Au
stria
Be
lgiu
m
Bu
lga
ria
Cyp
rus
Cze
ch R
ep
.
De
nm
ark
Esto
nia
Fin
lan
d
Fra
nce
Ge
rma
ny
Gre
ece
Hu
ng
ry
Icela
nd
Irela
nd
Italy
La
tvia
Lie
chte
nstie
n
Lith
uan
ia
Lu
xemb
ou
rg
Ma
lta
Ne
the
rlan
ds
No
rwa
y
Po
lan
d
Po
rtuga
l
Ro
ma
nia
Slo
vakia
Slo
ven
ia
Sp
ain
Sw
ed
en
Sw
itzerla
nd
Un
ited
Country
No
. of
Co
nfi
rme
d C
ase
s &
De
ath
s
Confirmed cases
Swine Influenza A(H1N1) EU & EFTA Confirmed Cases & Deaths
Total Number of Confirmed Cases = 53,513; 163 Death; 31 Countries; CFR 0.3%
April 27 – September 24, 2009
Source: ECDC
329 31
2
3
1
4 3
1
32 2
78
1
Deaths
Currently only deaths are being reported – now totaling 1,371
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)
Co
nfi
rme
d C
as
es
27 April to 8 May 2009n=46
Source: ECDC
Swine Influenza A(H1N1) EU & EFTA Countries Confirmed Case Distribution, by Age
CHOTANI © 2009.
3
3548
3645
2 3
49
13
256
229
303
25
3
59
228
27
3
30
57
116
53
2916
0
188
132
223
17
0
50
100
150
200
250
300
350
Au
stria
Be
lgiu
m
Bu
lga
ria
Cyp
rus
Cze
ch R
ep
.
De
nm
ark
Esto
nia
Fin
lan
d
Fra
nce
Ge
rma
ny
Gre
ece
Hu
ng
ry
Icela
nd
Irela
nd
Italy
La
tvia
Lie
chte
nstie
n
Lith
ua
nia
Lu
xem
bo
urg
Ma
lta
Ne
the
rlan
ds
No
rwa
y
Po
lan
d
Po
rtug
al
Ro
ma
nia
Slo
vakia
Slo
ven
ia
Sp
ain
Sw
ed
en
Sw
itzerla
nd
Un
ited
Kin
gd
om
Country
No
. of
Co
nfi
rme
d C
as
es
& D
ea
ths
Swine Influenza A(H1N1) EU & EFTA Deaths
Total Number of Deaths among Confirmed Cases = 1,832April 27 – December 28, 2009
Source: ECDC
CHOTANI © 2009.
6 3
207
2314 10 10
25
519
50
202
0
50
100
150
200
250
Alb
ania
Arm
enia
Belaru
s
Bo
snia &
Herzeg
ovin
ia
Cro
atia
Maced
on
ia
Geo
rgia
Ko
sovo
Mo
ldo
va
Mo
nten
egro
Ru
ssia
Serb
ia
Ukrain
e
Countries
Co
nfi
rme
d D
ea
ths
Swine Influenza A(H1N1) Other European Countries & Central Asia Confirmed Deaths
n=397
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
42
7
109
147
4071
16 275 1
5023 30
8
97110
15
415
627
0
50
100
150
200
250
300
350
400
450
Alg
eria
Bah
rain
Eg
ypt
Islamic R
epu
blic o
f Iran
Iraq
Israel
Jord
an
Ku
wait
Leb
ano
n
Lib
ya
Mo
racco
Occu
pied
Palestin
ian T
erritory
Om
an
Qatar
Sau
di A
rabia
Syrian
Arab
Rep
ub
lic
Tu
nisia
Tu
rkey
Un
ited A
rab E
mirates
Yem
en
Countries
Co
nfi
rme
d D
ea
ths
Swine Influenza A(H1N1) Mediterranean & Middle East Confirmed Deaths
n=1,246
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
1 38
2 1 2
93
51
0
10
20
30
40
50
60
70
80
90
100
Gh
ana
Mad
agscar
Mau
ritius
Mo
zamb
iqu
e
Nam
ibia
Sao
To
me &
Prin
cipe
So
uth
Africa
Su
dan
Tan
zania
Countries
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) Africa Confirmed Deaths
n=116
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
401
823
2160
0
500
1000
1500
2000
2500
Can
ada
Mexico
US
A
Countries
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) North America Confirmed Deaths
n=3,384
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
4 31
47
41
23
31
1816
6
11 11
2 1 25
0
10
20
30
40
50
Bah
am
Barb
ado
s
Caym
an Islan
d
Co
sta Rica
Cu
ba
Do
min
icanR
epu
blic
El S
alvado
r
Gu
atemala
Ho
nd
uras
Jamaica
Nicarag
ua
Pan
ama
Sain
t Kitts &
Nevis
Sain
t Lu
cia
Su
rinam
Trin
idad
-T
ob
ago
Countries
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) Central America & Caribbean Confirmed Deaths
n=222
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
617
58
1632
150 19396 52
205
33121
0
500
1000
1500
2000
Arg
entin
a
Bo
livia
Brazil
Ch
ile
Co
lom
bia
Ecu
do
r
Parag
uay
Peru
Urig
uay
Ven
ezuela
Countries
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) South America Confirmed Deaths
n=3,157
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
17 6
509
51
880
107
2 126 2 1
148
35 35
0
200
400
600
800
1000
Afg
han
istan
Ban
glad
esh
Ch
ina
(Min
land
)
Ho
ng
Ko
ng
SA
R C
hin
a
Ind
ia
Japan
Macao
SA
RC
hin
a
Mald
ives
Mo
ng
olia
Nep
al
Pakistan
So
uth
Ko
rea
Sri L
anka
Taiw
an
Countries
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) North-East & South Asia Confirmed Deaths
n=1,820
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
16 10
1
77
3019
191
53
0
50
100
150
200
Bru
nei
Baru
ssalam
Cam
bo
dia
Ind
on
esia
Lo
as PD
R
Malaysia
Ph
illipp
ines
Sin
gap
ore
Th
iland
Vietn
am
Countries
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) South-East Asia Confirmed Deaths
n=388
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
191
1 1
20
2 1 10
50
100
150
200
Au
stralia
Co
ok Islan
d
Marsh
all Island
New
Zealan
d
Sam
oa
So
lom
on
Island
To
ng
a
Countries
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) Australia & Pacific Confirmed Deaths
n=217
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
1 1 212 17
2 5 317 23 21 17 15 22 16 15 12
24
49 43
84100
169188
208
267
319
151
0
50
100
150
200
250
300
350
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
No
of
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) EU & EFTA Countries Confirmed Deaths, by Week
n=1,803
Source: ECDC
As of December 28, 2009
CHOTANI © 2009.
19 7 5 6 1 23
170
85 110146
207 212261
436396
461422 405
235
485
190 212181
129
1046
303330
566 581
936
1231
1066
1177
642
0
200
400
600
800
1000
1200
1400
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
No
of
Co
nfi
rmed
Dea
ths
Swine Influenza A(H1N1) Global Confirmed Deaths, by Week
n=12,682
Source: ECDC
* 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
As of December 28, 2009
CHOTANI © 2009.
Global Distribution of Reported Laboratory Confirmed Cases & Deaths of Swine Influenza A(H1N1), December 23, 2009
Source: WHO
CHOTANI © 2009.
Geographic Spread of Influenza ActivityBased Upon Country Reporting, Week 50, 2009 (07-23 December)
Source: WHO
CHOTANI © 2009.
Impact on Healthcare Services Based Upon Degree of Disruption,
As a Result of Acute Respiratory DiseasesWeek 50, 2009 (07-13 December)
Source: WHO
CHOTANI © 2009.
Number of Specimens Positive for Influenza Sub-Type
Source: CDC
CHOTANI © 2009.
Laboratory-Confirmed Cases & Deaths of New Influenza A(H1N1) by WHO Regions, September 20, 2009
8264
130448
11621
53000
30293
85299
41 2948 72 154 340 3620
20000
40000
60000
80000
100000
120000
140000
Africa R
egio
n(A
FR
O)
Am
ericasR
egio
n (A
MR
O)
Eastern
Med
iterranean
Reg
ion
(EM
RO
)
Eu
rop
e Reg
ion
(EU
RO
)
So
uth
-East A
siaR
egio
n(S
EA
RO
)
Western
Pacific
Reg
ion
(WP
RO
)
WHO Region
No
. Co
nfi
rme
d C
as
es
& D
ea
ths
*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.
At least 318,925 Cases & Over 3917 DeathsOverall Case-Fatality Rate (CFR) in Confirmed ~ 1.2%
Source: WHO
CFR = 0.5%
CFR = 2.5%
CFR = 0.6%
CFR = 1.1%
CFR = 0.3%
CFR = 0.4%
CHOTANI © 2009.
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: • real-time RT-PCR • viral culture
• A probable case of swine influenza A (H1N1) virus infection is defined 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 is defined 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 influenza A(H1N1) cases, or
• resides in a community where there are one or more confirmed swine influenza cases.
Source: CDC
CHOTANI © 2009.
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)
Source: CDC
CHOTANI © 2009.
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
Source: CDC
CHOTANI © 2009.
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
Source: CDC
CHOTANI © 2009.
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:• 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.
Swine Influenza A(H1N1) Guidelines for Clinicians
Source: FDA
CHOTANI © 2009.
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• all waste disposal procedures should be followed as outlined
in your facility standard laboratory operating procedures
Source: CDC
CHOTANI © 2009.
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
Source: CDC
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 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:• 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.
Swine Influenza A(H1N1) Biosafety Guidelines for Laboratory Workers
Source: CDC
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-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 Availability TypicalProcessing Time2
Sensitivity3 for2009 H1N1influenza
Distinguishes 2009 H1N1 influenza from other influenza A
viruses?
Rapid influenza diagnostic tests (RIDT)4
Antigen detection
Wide 0.5 hour 10 – 70% No
Direct and indirectImmunofluorescence
assays (DFA and IFA)5
Antigen detection
Wide 2 – 4 hours 47–93% No
Viral isolation in tissue cellculture
Virus isolation
Limited 2 -10 days - Yes 6
Nucleic acid amplification tests
(including rRT-PCR) 7
RNA detection
Limited8 48 – 96 hours [6-8 hours toperform test]
86 – 100% Yes
Source: CDC
CHOTANI © 2009.
• 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: • 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
Swine Influenza A(H1N1) Antiviral Protection
Source: CDC
CHOTANI © 2009.
• 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.
• Pre-exposure: Antivirals should only be used in limited circumstances, and in consultation with local medical or public health authorities.
• Antiviral Use for Control of Novel H1N1 Influenza Outbreaks• 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• 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.
Swine Influenza A(H1N1) Antiviral Protection
Source: CDC
CHOTANI © 2009. Source: CDC
Oseltamivir (Tamiflu) Zanamivir (Relenza)
Treatment Prophylaxis 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
Swine Influenza A(H1N1) Antiviral Protection
CHOTANI © 2009.
• 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)
• 4.5 million doses recalled due to decreased potency in the US
Swine Influenza A(H1N1) Vaccine Protection
CHOTANI © 2009.
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
Influenza vaccine receivedAll reports of adverse
events*
Serious adverse events†
Total Fatal NonfatalNonserious
events†
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
Unknown 229 17 7.4 1 0.4 16 7 212 92.6
Seasonal total 4,672 283 6.1 16 0.3 267 5.7 4,389 93.9
Live, attenuated influenza vaccine 480 35 7.3 0 --- 35 7.3 445 92.7
Trivalent inactivated 4,028 232 5.8 15 0.4 217 5.4 3,796 94.2
Unknown 164 16 9.8 1 0.6 15 9.1 148 90.2
* 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)
SexH1N1
vaccine type
Vaccination to onset (days)
Medical history Preliminary diagnosis/Autopsy results
1 Male MIV† 1Febrile seizures (one after measles, mumps, rubella vaccination) Sudden death, no evidence of trauma
2 Female MIV 0Encephalopathy, central apnea, traumatic brain damage, seizures Sudden cardiopulmonary arrest
9 Female LAMV§ 6Trisomy 21, leukemia (in remission), cardiac disease (neutropenia on vaccination day) Pneumococcal pneumonia/H1N1 influenza
18 Male LAMV 0No 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 2Hypertension, hyperlipidemia, pulmonary embolism, deep vein thrombosis
Pulmonary embolus/Negative for H1N1 in lung tissue
49 Female MIV 3Type 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 0Driver involved in motor vehicle crash leaving clinic after H1N1 vaccination Trauma
61 Male MIV 13Hypertension, diabetes, peripheral vascular disease, end stage renal disease
Cardiac/Respiratory arrest, gram- negative sepsis
77 Male MIV 2Lung cancer atrial fibrillation, recurrent deep venous thrombosis hypertension, hyperlipidemia Suspected myocardial infarction
* 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.
• 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.
Swine Influenza A(H1N1) Vaccine Protection
Source: CDC
CHOTANI © 2009.
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
Home
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
Occupational (non-health care)
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
Occupational (health care)
Caring for persons with known, probable or suspected 2009 H1N1 or influenza-like illness
Respirator Consider temporary reassignment. Respirator
Source: CDC
CHOTANI © 2009.
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 non-quarantine measures that might serve to reduce contact between persons, such as, closing of schools or prohibiting large gatherings
Source: CDC
CHOTANI © 2009.
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.
Source: CDC
CHOTANI © 2009.
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.
Swine Influenza A(H1N1) Other Protective Measures
Source: CDC
CHOTANI © 2009.
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.
Swine Influenza A(H1N1) Other Protective Measures
Source: CDC
CHOTANI © 2009.
Summary• 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 • Approximately 53% of hospitalized cases in Canada had an underlying medical condition
• Europe: Widespread and active transmission continued to be observed throughout the continent• 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
• In the US • 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
• In Mexico• 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• Majority of the cases reported in health young adults (20-29 years)
• Globally• Number of deaths being reported is rising
• Vaccine • Total Adverse Events: 5.4% (0.3% fatal)• Sanofi Pasteur & MedImmune vaccine recalled due to potency issues
• Anti-virals (oseltamivir and zanamivir)• Oseltamivir resistance reported recently in immunocompromised patents
CHOTANI © 2009.
Timeline of EmergenceInfluenza A Viruses in Humans
1918 1957 1968 1977 1997
1998/9
2003
H1
H1
H3H2
H7
H5H5H9
SpanishInfluenza
H1N1
AsianInfluenza
H2N2
RussianInfluenza
AvianInfluenza
Hong Kong
InfluenzaH3N2
2009
H1
Reassorted Influenza virus (Swine Flu)
1976 Swine Flu Outbreak,
Ft. Dix
CHOTANI © 2009.
Lessons Learned formPast 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 explosive outbreaks 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, secondary
bacterial 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
CHOTANI © 2009.
• Pandemics are unpredictable• 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• 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 stop pandemic 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 high mortality
• Delaying spread is desirable• Fewer people ill at one time improve capacity to cope with
sharp increase in need for medical care
Lessons Learned formPast Pandemics
CHOTANI © 2009.
Conclusion/Recommendations
1. Past experience with pandemics have taught us that the second wave is 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 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. • 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• 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
CHOTANI © 2009.
Conclusion/Recommendations
3. Each locality/jurisdiction needs to • 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
4. 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
• 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
CHOTANI © 2009.
Conclusion/Recommendations
5. School Closures:• 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
6. Burden of Disease & Mortality• 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
7. 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 • There is better surveillance, communication, understanding of infection
control, vaccines, anti-virals, antibiotics and advancement in science and resources to produce countermeasures quickly