ﻢﻴﺣﺮﻟا ﻦﻤﺣﺮﻟا ﷲا...

1

الرحمن الرحيم الرحمن الرحيم بسم اهللا بسم اهللا Emerging Emerging && Pandemic Pandemic

Influenza Influenza A(H1N1)A(H1N1)

Part 1: Principles & EtiologyPart 1: Principles & EtiologySchool of HealthSchool of Health

ShahidBeheshti ShahidBeheshti University of Medical SciencesUniversity of Medical Sciences

By: Hatami H. MD. MPHBy: Hatami H. MD. MPH20092009

http://www.elib.hbi.ir/persian/EMERGING_EBOOK/EMERGING_INDEX.htm

2

زاي زاي ننفلوآ فلوآ نن موارد آ موارد آ نناولياولي) ) 19971997((ن ن ساسانن در ا در انندگادگاننپرپر

زاي زاي ننفلوآ فلوآ نن موارد آ موارد آ نناولياولي))20092009((ن ن ساسانن در ا در ا خوكي خوكي

3

Definitions• Epidemic - is an increase in

disease above what you what would normally expect

• Pandemic - is a worldwide epidemic

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

4

Definition and public health importanceDefinition and public health importanceDefinition and public health importance

••Influenza is one of the known Influenza is one of the known viralviralinfectious diseases, infectious diseases,

••has has killedkilled millions of peoples during millions of peoples during pandemics, epidemics and sporadic pandemics, epidemics and sporadic forms.forms.

•• One of the most remarkable One of the most remarkable features of influenza virus is the features of influenza virus is the frequency of frequency of changes inchanges in antigenicityantigenicity..

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

5

Definition and public health importanceDefinition and public health importanceDefinition and public health importance

••Alteration of the antigenAlteration of the antigen structure of the structure of the virus leads to infection with variants to virus leads to infection with variants to which little or which little or no resistanceno resistance is present in is present in the population at risk.the population at risk.

•• The The strain currently circulatingstrain currently circulating is a is a novel Influenza A(H1N1)novel Influenza A(H1N1)••It is thought to be composed of It is thought to be composed of avian, human, and swine components avian, human, and swine components from various continentsfrom various continents ht

t p:/ /

ww

w.e

li b.h

bi.i r

/ pe r

s ian

/ EM

ER

GIN

G_E

BO

OK

/EM

ER

GIN

G_I

ND

EX

. htm

6

Etiologic agentEtiologic agentEtiologic agent•• New StrainNew Strain of Influenza Virusof Influenza Virus

•• First Detected in April 2009 in the U.S.First Detected in April 2009 in the U.S.•• Originally CalledOriginally Called “Swine Flu”“Swine Flu”

•• Initial Tests Showed Many Genes Similar to Initial Tests Showed Many Genes Similar to Influenza Virus Occurs in PigsInfluenza Virus Occurs in Pigs

•• Further StudiesFurther Studies -- New Virus is Very New Virus is Very Different from Viruses in North American Different from Viruses in North American PigsPigs

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

7

Influenza VirusInfluenza Virus

RNA virusRNA virus SurfaceSurface glycoproteinsglycoproteins::

H / HAH / HA-- haemagglutininhaemagglutinin

N / NA N / NA -- NeuraminidaseNeuraminidase

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

8

FamilyFamily:: OrthomyxoviridaeOrthomyxoviridae•• segmented (8), ssRNA genomesegmented (8), ssRNA genome•• lipidlipid envelopenvelop

GeneraGenera:: Influenzavirus Types A, B and CInfluenzavirus Types A, B and CSubtypesSubtypes:: Human Human -- HH11NN11, H, H22NN22, H, H33NN22, H, H55NN11,,

HH99NN22’’ HH11NN22, H, H77NN77

Animals Animals –– HH11 to Hto H1515, N, N11 to Nto N9 9

Etiologic agentEtiologic agentEtiologic agent

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

9

Influenza subInfluenza sub--groupsgroups•• Influenza AInfluenza A

–– highly infectivehighly infective–– infects many speciesinfects many species–– causes frequent widespread epidemics and pandemicscauses frequent widespread epidemics and pandemics

•• Influenza BInfluenza B–– only found in humansonly found in humans–– capable of producing severe diseasecapable of producing severe disease–– cause of regional epidemicscause of regional epidemics

•• Influenza CInfluenza C–– causes mild diseasecauses mild disease–– humans are natural hosts but isolates also found in pigshumans are natural hosts but isolates also found in pigs–– does not cause epidemicsdoes not cause epidemics

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

10

H1H1H2H2H3H3H4H4H5H5H6H6H7H7H8H8H9H9H10H10H11H11H12H12H13H13H14H14H15H15H16H16

N1N1N2N2N3N3N4N4N5N5N6N6N7N7N8N8N9N9

Influenza A HA and NA SubtypesInfluenza A HA and NA Subtypes

Other AnimalsOther Animals






htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

11

H5N1 ?? H1N1 ??

HxNy ??

http

://w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

12

Genetic origins of (H1N1) 2009Genetic origins of (H1N1) 2009

PB2PB2PB1PB1PAPAHAHANPNPNANAMPMPNSNS



Classical swine, N. American lineageClassical swine, N. American lineageAvian, N. American lineageAvian, N. American lineageHuman seasonal H3N2Human seasonal H3N2Eurasian swine lineageEurasian swine lineage

Eurasian Eurasian swine H1N1swine H1N1

N. American H1N1N. American H1N1(swine/avian/human)(swine/avian/human)

Pandemic (H1N1) Pandemic (H1N1) 2009, combining 2009, combining swine, avian and swine, avian and human viral human viral componentscomponents

avian, human, and swine components htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

13

•• The strain currently circulating is a The strain currently circulating is a novelnovelInfluenza A(H1N1)Influenza A(H1N1)

•• It is thought to be composed of It is thought to be composed of avianavian, , humanhuman, and , and swineswine components from components from various continents various continents

•• This strain is most likely This strain is most likely a new subtypea new subtypeof A/H1N1 not previously seen in swine of A/H1N1 not previously seen in swine or humansor humans

Novel A(H1N1)Novel A(H1N1)Novel A(H1N1)

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

14

ويژگي هاي مهم ويروس آنفلوآنزاي ويژگي هاي مهم ويروس آنفلوآنزاي A(H1N1) 2009A(H1N1) 2009

InfectivityInfectivityPathogenicityPathogenicityVirolenceVirolence AntigenicityAntigenicityImmunogenicityImmunogenicity

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

15

Case Definitions• Suspect Case: a person with acute febrile respiratory illness

with onset • within 7 days of close contact with a person who is a confirmed case of

S-OIV infection, or • within 7 days of travel to community where there are one or more

confirmed cases of S-OIV infection, or • resides in a community where there are one or more confirmed cases of

S-OIV infection. • Probable Case: a person with an acute febrile respiratory

illness who is positive for influenza A, but negative for H1 andH3 by influenza RT-PCR

• Confirmed Case: a person with an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests: • real-time RT-PCR • viral culture

htt p

:/ /w

ww

.eli b

.hbi

.i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X. h

tm

16

SwineSwine--HIN1HIN1

انتقال متقابل ويروس آنفلوآنزاي خوكي نوع حيواني

انتقال ويروس آنفلوآنزاي خوكي نوع انساني

Human Human A(A(HIN1)HIN1)

2009 قبل از سال

2009سال

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

17

Influenza Type A Viruses:Influenza Type A Viruses:Antigenic Shift 1889Antigenic Shift 1889--20092009

YearYear SubtypeSubtype Common NameCommon Name SourceSource18891889 H2N2H2N2 ??19001900 H3N8H3N8 ??19181918 H1N1H1N1 Spanish fluSpanish flu AvianAvian19571957 H2N2H2N2 Asian fluAsian flu AvianAvian11

19681968 H3N2H3N2 Hong Kong fluHong Kong flu AvianAvian11

19771977 H1N1H1N1 Russian flu 1978 ?Russian flu 1978 ?2009 H1N1 2009 H1N1 Swin Swin flu flu 33 ViVi11Reassortant with avian virusReassortant with avian virus http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

18

منتظر منتظر 13881388اين همان پاندمي بعدي است كه تا اوايل سال اين همان پاندمي بعدي است كه تا اوايل سال ؟ ولي آخرين جهانگيري آنفلوآنزا نخواهد بود ؟ ولي آخرين جهانگيري آنفلوآنزا نخواهد بود !!آن بوديم آن بوديم

1976 1976 –– H1N1 H1N1 Swine fluSwine flu1986 1986 –– H1N1 H1N1 Swine virusSwine virus

1988 1988 –– H1N1 H1N1 Swine virusSwine virus1993 1993 ––SwineSwine/avian recombinant/avian recombinant

1995 1995 –– H7N7 Duck virusH7N7 Duck virus1997 1997 –– H5N1 Avian virusH5N1 Avian virus

1999 1999 –– H9N2 Quail virusH9N2 Quail virus20032003–– H5N1 Avian virusH5N1 Avian virus2003 2003 –– H7N7 Avian virusH7N7 Avian virus

2004 2004 –– H5N1 Avian virusH5N1 Avian virus

Timeline of human infection with novel influenza virusesTimeline of human infection with novel influenza viruses(1968(1968--2009) 2009)

2004 2004 –– H7N3 Avian virusH7N3 Avian virus2004 2004 –– H7N1 Avian virusH7N1 Avian virus

2009 2009 -- Swine virusSwine virus

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

19

HumanHumanvirusvirus

ReassortantReassortantvirusvirus

NonNon--humanhumanvirusvirus

15 HAs15 HAs9 NAs9 NAs

DIRECTDIRECT

Mechanism of antigenic shift

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

20

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

21

Genetic origins of (H1N1) 2009Genetic origins of (H1N1) 2009




Classical swine, N. American lineageClassical swine, N. American lineageAvian, N. American lineageAvian, N. American lineageHuman seasonal H3N2Human seasonal H3N2Eurasian swine lineageEurasian swine lineage

Pandemic (H1N1) Pandemic (H1N1) 2009, combining 2009, combining swine, avian and swine, avian and human viral human viral componentscomponents

avian, human, and swine components http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

22



Part 2: Clinical EpidemiologyPart 2: Clinical Epidemiology

School of HealthSchool of HealthShahidBeheshti ShahidBeheshti University of Medical SciencesUniversity of Medical Sciences



23

1)1) Incubation periodIncubation period2)2) Natural course Natural course 3)3) Geographical distributionGeographical distribution4)4) Timeline trendTimeline trend5)5) Age, Gender, Occupation, Social situationAge, Gender, Occupation, Social situation6)6) Predisposing factorsPredisposing factors7)7) Susceptibility & ResistanceSusceptibility & Resistance8)8) Secondary attack rateSecondary attack rate9)9) Modes of transmission, period of communicabilityModes of transmission, period of communicability

Definition and public health importanceDefinition and public health importanceEtiologic agents Etiologic agents

Clinical Epidemiology of Clinical Epidemiology of H1N1 fluH1N1 flu

Prevention : primary, secondary, tertiaryPrevention : primary, secondary, tertiary

OC

CU

RR

EN

CE

OC

CU

RR

EN

CE

24

OCCURRENCEOCCURRENCEOCCURRENCE1)1) Incubation periodIncubation period2)2) Natural course Natural course 3)3) Geographical distributionGeographical distribution4)4) Timeline trendTimeline trend5)5) Age, Gender, Occupation, Social situationAge, Gender, Occupation, Social situation6)6) Predisposing factorsPredisposing factors7)7) Susceptibility & ResistanceSusceptibility & Resistance8)8) Secondary attack rateSecondary attack rate9)9) Modes of transmission, period of communicabilityModes of transmission, period of communicability

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

25

1-Incubation period11--Incubation periodIncubation period

• The estimated incubation period is unknown

• could range from 1-7 days,

• more likely 1-4 days.

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

26

2-Natural course22--Natural courseNatural course• Fever, chills, headache,

• Upper respiratory tract symptoms (cough, sore throat, rhinorrhea, shortness of breath),

• Myalgias, arthralgias, fatigue,

• Vomiting, or diarrhea. • In New York City, 95% of patients with novel influenza A (H1N1) met the case definition for influenza-like illness (subjective fever plus cough and/or sore throat)

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

27

•have ranged from mild respiratory illness, to

•lower respiratory tract illness,

•dehydration, or

•pneumonia.

•Deaths caused by previous variants of swine influenza viruses have occasionally occurred.

Natural courseNatural courseNatural course

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

28

New H1N1: clinical descriptionNew H1N1: clinical description(preliminary findings)(preliminary findings)

•• FeverFever 94%94%•• CoughCough 92%92%•• Sore throatSore throat 66%66%•• Vomiting Vomiting 25%*25%*•• DiarrheaDiarrhea 25%*25%*•• V and/or DV and/or D 38%*38%*

* Unlike seasonal influenza* Unlike seasonal influenza

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

29

Revised European planning assumptions for the Revised European planning assumptions for the pandemic pandemic –– first wave, pandemic (H1N1) 2009first wave, pandemic (H1N1) 2009

12% of workforce12% of workforcePeak absence ratePeak absence rate

0.1% to 0.2% (cannot exclude up to 0.35%) of 0.1% to 0.2% (cannot exclude up to 0.35%) of clinical casesclinical casesCase fatality rateCase fatality rate

2% of clinical cases2% of clinical casesHospitalisation rateHospitalisation rate

15% of clinical cases15% of clinical casesComplication rateComplication rate

6.5% (local planning assumptions 4.5% to 6.5% (local planning assumptions 4.5% to 8%) per week8%) per weekPeak clinical attack ratePeak clinical attack rate

30%30%Clinical attack rateClinical attack rate

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

30

با مداخله با مداخله

تاثير مداخله بر سير طبيعي همه گيري تاثير مداخله بر سير طبيعي همه گيري آنفلوآنزا آنفلوآنزا

تاخير در پيك همه گيري و عريض شدن آنتاخير در پيك همه گيري و عريض شدن آن••كاهش بار ناگهاني سيستم بهداشتي ـ درماني كاهش بار ناگهاني سيستم بهداشتي ـ درماني ••كاهش تعداد كلي موارد كاهش تعداد كلي موارد ••صرف وقت كمترصرف وقت كمتر••

موارد موارد روزانهروزانه

روزهاي پس از وقوع اولين مورد روزهاي پس از وقوع اولين مورد

بدون مداخله بدون مداخله

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

31

3-Geographical distribution33--Geographical distributionGeographical distribution

• The first cases of human infection with novel H1N1 influenza virus were detected in April2009 in San Diego and Imperial County, California and in Guadalupe County, Texas.

• The virus has spread rapidly.

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

32

Geographical distributionGeographical distributionGeographical distribution

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

33


EMRO19 September 2009

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

34


IRAN1388 مهرماه 1

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

35

1/7/1388توزيع جنسي بيماران ايراني تا 13881388//77//11توزيع جنسي بيماران ايراني تا توزيع جنسي بيماران ايراني تا

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

36

1/7/1388توزيع بيماران ايراني برحسب مبداء تا 13881388//77//11توزيع بيماران ايراني برحسب مبداء تا توزيع بيماران ايراني برحسب مبداء تا

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

37

1/7/1388توزيع سني بيماران ايراني تا 13881388//77//11توزيع سني بيماران ايراني تا توزيع سني بيماران ايراني تا

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

38

4-Timeline trend44--Timeline trendTimeline trend

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

39

H7H7H5H5H9H9**

19801980

19971997

Recorded new avian influenzasRecorded new avian influenzas

19961996 20022002

19991999

20032003

19551955 19651965 19751975 19851985 19951995 20052005

H1N1H1N1H2N2H2N2

18891889RussianRussianinfluenzainfluenza

H2N2H2N2

H2N2H2N2

19571957AsianAsian

influenzainfluenzaH2N2H2N2

H3N2H3N2

19681968Hong KongHong Konginfluenzainfluenza

H3N2H3N2

H3N8H3N8

19001900Old Hong Old Hong

Kong influenzaKong influenzaH3N8H3N8

19181918SpanishSpanishinfluenzainfluenza

H1N1H1N1

19151915 19251925 19551955 19651965 19751975 19851985 19951995 2005200518951895 19051905 20102010 20152015

20092009PandemicPandemicinfluenzainfluenza

H1N1H1N1

Recorded human pandemic influenzaRecorded human pandemic influenza(early sub(early sub--types inferred)types inferred)

H1N1H1N1PandemicPandemic

H1N1H1N1

Pandemic history of influenzaPandemic history of influenzaPandemic history of influenza

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

40

19001900

18501850

19501950

20002000

18471847

18891889

19181918

1957195719681968

4242 yrsyrs

2929 yrsyrs

3939 yrsyrs

1111 yrsyrs

3030 –– 4040 yearsyears cyclecycle

No Pandemic for > 40 yearsNo Pandemic for > 40 yearsNo Pandemic for > 40 years

20082008

Pandemic history of influenzaPandemic history of influenzaPandemic history of influenza

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

41

5-Age, Gender, Occupation, Social situation55--Age, Gender, Occupation, Social situationAge, Gender, Occupation, Social situation

• Highest incidence of lab confirmed infections in school age children

• Highest hospitalization rates among 0-4 year olds

• Fewest cases but highest case-fatality ratioin older adults

• Distribution of cases by age group is markedly different compared to seasonal influenza

http

://w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

42

Age, Gender, Occupation, Social situationAge, Gender, Occupation, Social situationAge, Gender, Occupation, Social situation

•Higher proportion of hospitalized cases in children and young adults

• Few cases in older adults

• No reports of outbreaks among residents in long term care facilities

• 70% of hospitalized cases have an underlying medical condition that confers higher risk for complications

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

43

Age distribution of laboratory-confirmed novel influenza A(H1N1), USA, 2009 (n=37,030*)

بيشترين موارد بيماري

بيشترين موارد بيماري

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

44

Hospitalization rate per 100,000 population by age group of laboratory-confirmed novel influenza A(H1N1), 24 JUL 2009 (n=4,738*)

بيشترين موارد بستري در بيمارستان

بيشترين موارد بستري در بيمارستان

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

45

Deaths by age group of laboratory-confirmed novel influenza A(H1N1), 24 JUL 2009 (n=302)

بيشترين موارد مرگ ناشي از بيماري

بيشترين موارد مرگ ناشي از بيماري

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

46

) مورد5337(وضعيت بيماري در گروه هاي سني مختلف در مكزيك

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

47

0%

10%

20%

30%

40%

50%

60%

0 20 40 60 80

Age (midpoint of age class)

% w

ith c

linic

al d

isea

se

1918 New York State

1918 Manchester1918 Leicester1918 Warrington & Wigan

1957 SE London1957 S Wales1957 Kansas City

1968 Kansas City

Age-specific clinical attack rate in previous pandemics

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

48

6-Predisposing factors66--Predisposing factorsPredisposing factorsThe following groups are considered more at risk of The following groups are considered more at risk of experiencing experiencing severe diseasesevere disease than the general population should than the general population should they become infected with the pandemic A(H1N1) virus 2009: they become infected with the pandemic A(H1N1) virus 2009:

•• People with chronic conditions People with chronic conditions in the following categoriesin the following categories: : •• chronic chronic respiratoryrespiratory diseases; diseases; •• chronic chronic cardiovascularcardiovascular diseases (though not isolated mild hypertension); diseases (though not isolated mild hypertension); •• chronic chronic metabolicmetabolic disorders (notably diabetes); disorders (notably diabetes); •• chronic chronic renal and hepaticrenal and hepatic diseases; diseases; •• persons with persons with deficient immunitydeficient immunity (congenital or acquired); (congenital or acquired); •• chronic chronic neurologicalneurological or or neuromuscularneuromuscular conditions; andconditions; and•• any other condition that impairs a personany other condition that impairs a person’’s immunity or prejudices their respiratory (breathing) s immunity or prejudices their respiratory (breathing)

function, including severe or morbid obesity. function, including severe or morbid obesity.

•• Pregnant women.Pregnant women.•• Young children (especially those under two years)Young children (especially those under two years)

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

49

7-Susceptibility & Resistance77--Susceptibility & ResistanceSusceptibility & Resistance

•• The age groups affected by the pandemic are The age groups affected by the pandemic are generally youngergenerally younger. .

•• This is true for those most frequently infected, and This is true for those most frequently infected, and especially so for those experiencing severe or fatal especially so for those experiencing severe or fatal illnessillness

•• To date, most severe cases and deaths have To date, most severe cases and deaths have occurred in adults under the age of 50 years, occurred in adults under the age of 50 years,

•• Deaths in the elderly comparatively rareDeaths in the elderly comparatively rare

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

50

8-Secondary attack rate88--Secondary attack rateSecondary attack rate

•• The overall attack rate was highest The overall attack rate was highest among children aged 5among children aged 5----14 years 14 years

•• 147 per 100,000 population, 147 per 100,000 population,

•• 14 times higher than for adults aged ≥60 14 times higher than for adults aged ≥60 years.years.

••Secondary attack rate Secondary attack rate 55--15%15%

http

://w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

51

9-Modes of transmission 99--Modes of transmission Modes of transmission •• Primary Exposure RoutePrimary Exposure Route –– Person to Person to

PersonPerson•• Inhalation of Airborne Droplets from Infected Inhalation of Airborne Droplets from Infected

Person Coughing or SneezingPerson Coughing or Sneezing

•• Secondary Route of ExposureSecondary Route of Exposure --Viruses Viruses on Surfaceson Surfaces•• Can Live on Surfaces for 2 Hours or MoreCan Live on Surfaces for 2 Hours or More•• Person Touching Contaminated Tables, Person Touching Contaminated Tables,

Doorknobs, Desks, Then Touching Face, Doorknobs, Desks, Then Touching Face, Eyes, Nose, or MouthEyes, Nose, or Mouth

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

52

Modes of transmission Modes of transmission Modes of transmission

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

53

• shedding virus from one day prior to illness onset until resolution of symptoms.

• from one day before to 7 days followingillness onset.

• Children, especially younger children, might be infectious for up to 10 days.

• Immuno-suppressed more than others.

Period of communicabilityPeriod of communicabilityPeriod of communicability

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

54

1 Day before & up to 3 – 5 days after the onset of symptoms.

Longer in children, 7 days or more

Period of communicabilityPeriod of communicabilityPeriod of communicability

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

55

Prevention:• primary,• secondary,• tertiary

Prevention:Prevention:•• primary,primary,•• secondary,secondary,•• tertiarytertiary

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

56

• Cough/Sneeze - Cover Nose/Mouth with Tissue or Sneeze into the Sleeve• Dispose Used Tissues in the Trash

• Wash Hand with Soap & Water (At Least 20 Seconds) or Use Alcohol-Based Hand Sanitizers

• Avoid Touching Eyes, Nose, or Mouth• Avoid Contact with Sick People

• If Sick, Stay at Home Away from Work or School and Limit Contact with Others

Primary preventionPrimary preventionPrimary prevention

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

57

VaccinationVaccination•• There is currently NO vaccine available for swine There is currently NO vaccine available for swine

influenza but it is anticipated that one will be influenza but it is anticipated that one will be developed in the next few monthsdeveloped in the next few months

Primary preventionPrimary preventionPrimary prevention

ChemoprophylaxisChemoprophylaxis

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

58

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

59

محدود به : بعد از تماس كموپروفيالكسي مواردي است كه تماس يافتگان نزديك، جزو

و يا كاركنان خدمات بهداشتي ـ پرخطرگروه . درماني باشند

محدود به : قبل از تماس كموپروفيالكسي مواردي است كه گروه هاي پرخطر و از جمله كاركنان بهداشتي ـ درماني، اجبارا با مبتاليان

) 40( به اين بيماري در تماس خواهند بود

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

60

Primary preventionPrimary preventionPrimary prevention• Best Precautions

• Stay Healthy & Get Plenty of Rest• Wash Your Hands Frequently• Avoid Contact with Persons Who Are Sick

• If Sick, Stay at Home, Away from Work/School

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

61

Emergency Warning Symptoms• Adults

• Difficulty breathing or shortness of breath

• Pain or pressure in chest or abdomen

• Sudden dizziness • Confusion • Severe or

persistent vomiting

• Children• Fast breathing or trouble

breathing • Bluish skin color • Not drinking enough fluids • Not waking up or not interacting • Being so irritable that child does

not want to be held • Flu-like symptoms improve but

then return with fever and worse cough

• Fever with a rash

Secondary preventionSecondary preventionSecondary prevention

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

62

Treatment of S-OIV• The CDC recommends Oseltamivir (Tamiflu) and

Zanamivir (Relenza) for treatment• Oseltamivir is approved to treat and prevent infection in

people at least 1 year old• Zanamivir is approved to treat infection in people at least 7

years old, and to prevent infection in people at least 5 years old

• Antiviral drugs are most effective within 2 days of symptom onset

• There is currently NO vaccine available for swine influenza but it is anticipated that one will be developed in the next few months

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

63

Tertiary preventionTertiary preventionTertiary prevention

معموال عارضه پايداري ايجاد نمي كند

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

64



Part 3: Pandemic Part 3: Pandemic CaractristicsCaractristicsSchool of HealthSchool of Health

ShahidBeheshti ShahidBeheshti University of Medical SciencesUniversity of Medical Sciences



65

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

66

Declared globally by the World Health OrganizationDeclared globally by the World Health OrganizationDeclared nationally by the Department of Health and Human ServicDeclared nationally by the Department of Health and Human Serviceses

InterpandemicInterpandemic Pandemic AlertPandemic Alert PandemicPandemic

Phase IPhase I Phase 2Phase 2 Phase 3Phase 3 Phase 4Phase 4 Phase 5Phase 5 Phase 6Phase 6

Phases of a PandemicPhases of a PandemicWorld Health OrganizationWorld Health Organization

PreparednessPreparedness ResponseResponse

جايگاه فعلي پاندمي جايگاه فعلي پاندمي PeriodsPeriods = = ها ها دوره دوره

PhasesPhases= = مراحل مراحل

67

Phase 1: No infections in humans are being caused by viruses circulating in animals.

••Phase 1Phase 1 ––No new virus No new virus subtypes in subtypes in humanshumans

68

Phase 2: Animal flu virus causes infection in humans, and is a potential pandemic threat.

••Phase 2Phase 2 ––Animal Animal subtypesubtype poses poses a risk of a risk of human human diseasedisease

69

Phase 3: Flu causes sporadic cases in people, but no significant human-to-human transmission.

••Phase 3Phase 3 ––Human infectionHuman infection, , no human to no human to human spreadhuman spread

70

Phase 4: Human-to-human transmission and community-level outbreaks.

Phase 4Phase 4 ––

Small localizedSmall localizedclusters of human clusters of human to human spreadto human spread

71

Phase 5: Human-to-human transmission in at least two countries. Strong signal pandemic imminent.

Phase 5Phase 5 ––

Larger clustersLarger clusters, , still localized, still localized, virus adapting to virus adapting to humanshumans

72

Phase 6: Virus spreads to another country in a different region. Global pandemic under way.

Phase 6Phase 6 ––Increased and Increased and sustained sustained transmissiontransmission in in the general the general populationpopulation. . Waves of 8Waves of 8--12 12 weeksweeks

73

Post-peak: Pandemic activity appears to be decreasing though second wave possible.

Post-pandemic: activity returns to normal, seasonal flu levels.

74

دميدمين ن اثرات مخرب پا اثرات مخرب پا

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

75

• Medical care• Hospitals• Nursing homes• Day care • Transportation• Communications• Schools

• Banks• Stores• Restaurants• Utilities• Police• Fire and EMS• Agriculture

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

76

دميدمين ن اثرات مخرب پا اثرات مخرب پا نميزا ل به ن كاهش پرس

در كل سيستم % 30تقريبي

مديريت چه اموري قائم به فرد مديريت چه اموري قائم به فرد مي باشد؟؟ مي باشد؟؟

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

77

Estimated numbers of Illness, Hospitalization, and Deaths Moderate and Severe Pandemic Scenarios - US and King County

مربيديتي و مرتاليتيتخمين ميزان Severe Severe

(1918 (1918 –– like)like)ModerateModerate

(1957(1957––like)like)CharacteristicCharacteristic

11,50011,5001,2501,250DeathsDeaths

59,40059,4005,1905,190HospitalizatioHospitalizationn

270,000270,000270,000270,000Outpatient Outpatient CareCare

540,000540,000540,000540,000IllnessIllness

Total PopulationTotal Populationيك ميليون و هشتصد هزار نفر يك ميليون و هشتصد هزار نفر

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

78

دميدمين ن اثرات مخرب پا اثرات مخرب پا در كل سيستم % 30 تقريبي ن ميزا ل به ن كاهش پرس

ين درما مراكز خدمات بهداشتي ـ نتوا كاهش امدادي يروهاي ن نتوا كاهش يتي ن يروهاي ام ن كاهش

اتن امكا و ابع نمحدوديت م

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

79

دميدمين ن اثرات مخرب پا اثرات مخرب پا :اتنامكا و ابع ن محدوديت م

قل ن اختالل در امر حمل و اختالل در امر ارتباطات

مشكل برق مشكل آب

مشكل سوخت . . . ht

tp: //

ww

w. e

li b.h

bi. i r

/ pe r

s ian

/ EM

ER

GIN

G_E

BO

OK

/EM

ER

GIN

G_I

ND

EX

.ht m

80

ها ندا ن زن گشوده شد ي اجتماعي ناامن

. . .


http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

81

ب ن جوا تاثير بر كليه دگين ز ات نشئو و

اجتماعي


http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

82

•••

83

دهي اثرات دهي اثرات ننساماسامادمي دمي ننمخرب پا مخرب پا

، حفظ و نمسئول تامي ارتقاء سالمتي جسمي،

ي، اجتماعي ؟؟؟؟؟ ن روا

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

84

وزارت بهداشت ت سالمت نمعاو

محور اصلي

وزارت بهداشت وزارت بهداشت ت سالمت ت سالمت ننمعاو معاو

محور اصلي محور اصلي

نيروهاي مردمي نيروهاي مردمي هاي دولتي هاي دولتي ننارگاارگا

NGONGOهاها

ستاد بحران ستاد بحران

وزارت كشوروزارت كشورها ها استانداري استانداري

بسيج جامعه پزشكيبسيج جامعه پزشكي

85

دهي دهي ننساماساما كلي كلي امهامهننبر بر بيماري و مرگ و مير نميزا ـ كاهش 1 پاشيدگي ازهم ندن ـ به حداقل رسا2

اجتماعي هاي اجتماعي نزيا ندن ـ به حداقل رسا3 حكومتينكيا ـ حفظ 4

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

86

ين درما مراكز خدمات بهداشتي ـ نتوا كاهش امدادي يروهاي ن نتوا كاهش

اتن امكا و ابع نمحدوديت م

ي و پيشگيري ي و پيشگيري ن ن پيش بي پيش بي

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

87

ي و پيشگيري ي و پيشگيري ن ن پيش بي پيش بي :اتنامكا و ابع ن محدوديت م

قل ن اختالل در امر حمل و اختالل در امر ارتباطات

مشكل برق مشكل آب

مشكل سوخت ور مشترك ور مشترك ن ن به اجراي ما به اجراي ما يازيازنن . . . ht

tp: //

ww

w. e

li b.h

bi. i r

/ pe r

s ian

/ EM

ER

GIN

G_E

BO

OK

/EM

ER

GIN

G_I

ND

EX

.ht m

88

:اتنامكا و ابع ن محدوديت م قل ن اختالل در امر حمل و

دارو، غالت، مواد (حمل زودرس برخي از كاالها قل زودرس مواد اوليه، نحمل و . . . )سوختي


http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

89

:اتنامكا و ابع ن محدوديت م اختالل در امر ارتباطات

. . . تهيه راديوهاي كوچك


http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

90

:اتنامكا و ابع ن محدوديت م مشكل برق

برق در نل ذخيره، تهيه يخچال هاي بدو ن آموزش پرس مراكز بهداشتي


ور مشترك ور مشترك ن ن به اجراي ما به اجراي ما يازيازنن http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

91

:اتنامكا و ابع ن محدوديت م مشكل آب

. . . حفر چاه هاي اضطراري،


http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

92

آمادگي پاسخ دهي به وقوع جهانگيري Antiviral drugsVaccine, etcMedical care, PPEMedical

interventional

Non- Medical Interventions

Personal hygieneTravel restrictionQuarantine Social distancingRisk communication

SecurityFood & water supplyPower supplyTransportationTelecommunicationOther essential services

Social Services(keep a society running)

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

93

Organizational Response –3 main committees

Public Health Response

Medical Response

Laboratory Response

Risk Communication

Social Response

Strategies

http

://w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

94

آمادگي هاي فردي و خانوادگي در صورت

وقوع همه گيري آمادگي هاي فردي و آمادگي هاي فردي و خانوادگي در صورت خانوادگي در صورت

وقوع همه گيري وقوع همه گيري

http

: //w

ww

. eli b

.hbi

. ir/ p

ers i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

95

آمادگي هاي فردي و اجتماعي به هنگام وقوع همه گيري آنفلوآنزا

ـ آيا در صورتي كه يكي از اعضاء خانواده دچار 1آنفلوآنزا شود آمادگي الزم جهت مراقبت از وي وجود

دارد؟ ـ در صورتي كه فرزند شما كه به كودكستان يا 2

مدرسه ميرود بيمار شود آمادگي الزم براي مراقبت در منزل وجود دارد؟ مثال اگر شما و همسرتان هر دو

كارمند هستيد و كس ديگري با شما در يك منزل، زندگي نمي كند چگونه برنامه ريزي خواهيد كرد؟

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

96

آمادگي هاي فردي و اجتماعي به هنگام وقوع همه گيري آنفلوآنزا

ـ در صورتي كه وقوع مواردي از بيماري در مهد 3كودك يا مدرسه منجر به تعطيلي شده و فرزند شما

مجبور باشد در منزل بماند آمادگي الزم وجود دارد؟ ـ آيا در صورتي كه مسئوليت اداري، صنعتي يا 4

اجتماعي خاصي داريد فرد يا افرادي هستند كه در غياب شما وظايف شما را انجام داده و مانع تعطيلي

شوند؟ ht . . . ـ 5

tp: //

ww

w. e

li b.h

bi. i r

/ pe r

s ian

/ EM

ER

GIN

G_E

BO

OK

/EM

ER

GIN

G_I

ND

EX

.ht m

97

مايحتاج الزم در منزل در زمان اوج گيري همه گيري و تعطيلي احتمالي ادارات و مراكز

ـ هدف اصلي، قطع ارتباط فيزيكي با خارج منزل و 1يا به حداقل رساندن آن است

6-8 ـ هرچند ممكن است موج همه گيري به مدت 2هفته به طول انجامد ولي حداقل بايد بتوانيد براي دو

هفته برنامه ريزي نماييد ليتر آب به ازاي هريك از اعضاء 4 حدول ـ روزانه 3

خانواده ht ـ مواد غذايي كنسرو شده يا خشك، به مقدار 4

tp: //

ww

w. e

li b.h

bi. i r

/ pe r

s ian

/ EM

ER

GIN

G_E

BO

OK

/EM

ER

GIN

G_I

ND

EX

.ht m

98


ـ داروهايي كه بعضي از اعضاء خانواده بايستي 5مصرف كنند

آسپيريني ـ داروهاي مسكن غير 6)ترمومتر( ـ درجه تب 7 ـ وسايل و لوازم كمك هاي اوليه 8 ـ مواد شوينده خانگي 9

ht ـ راديو ترانزيستوري 10tp

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

99


ـ باطري هاي مناسب 11 ـ چراغ قوه 12 ـ ليست اسامي و شماره تماس پزشك يا 13

پزشكاني كه اعضاء خانواده تحت نظر آنها هستند ـ شماره تماسهاي اضطراري 14 ـ شماره تماس همسايگان 15. . . ـ 16 ht

tp: //

ww

w. e

li b.h

bi. i r

/ pe r

s ian

/ EM

ER

GIN

G_E

BO

OK

/EM

ER

GIN

G_I

ND

EX

.ht m

100


Influenza Influenza A(H1N1)A(H1N1)Part 4: Part 4: Clinical, Diagnosis, ManagementClinical, Diagnosis, Management

School of HealthSchool of HealthShahidBeheshti ShahidBeheshti University of Medical SciencesUniversity of Medical Sciences



101

Signs and symptomsSymptoms of novel H1N1 flu in people are similar to those

associated with seasonal flu.• Fever • Cough • Sore throat• Runny or stuffy nose • Body aches • Headache• Chills • Fatigue• In addition, vomiting (25%) and diarrhea (25%) have been

reported. (Higher rate than for seasonal flu.)

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

102

How does novel H1N1 Influenza How does novel H1N1 Influenza spread?spread?

•• This virus is thought to spread This virus is thought to spread the same way seasonal flu the same way seasonal flu spreadsspreads

•• Primarily through respiratory Primarily through respiratory droplets droplets •• CoughingCoughing•• SneezingSneezing•• Touching respiratory droplets on Touching respiratory droplets on

yourself, another person, or an object, yourself, another person, or an object, then touching mucus membranes (e.g., then touching mucus membranes (e.g., mouth, nose, eyes) without washing mouth, nose, eyes) without washing handshands

103

Watch for emergency warning signs

Most people should be able to recover at home, but watch for emergency warning signs that mean you should seek immediate medical care.

In adults: • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then return with

fever and worse cough

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

104

Emergency warning signs in children

If a child gets sick and experiences any of these warning signs, seek emergency medical care.

In children: • Fast breathing or trouble breathing • Bluish or gray skin color • Not drinking enough fluids • Severe or persistent vomiting • Not waking up or not interacting • Irritable, the child does not want to be held • Flu-like symptoms improve but then return

with fever and worse cough

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

105

. . موارد موارد ) ) ManagementManagement( ( مديريت مديريت اول اول عبارت است از مرحله عبارت است از مرحله ترياژترياژاست كه باعث تسهيل طبقه است كه باعث تسهيل طبقه ) ) سيستماتيكسيستماتيك ( (منديمندي، روند نظام ، روند نظام ترياژترياژ

بندي بيماران براساس تظاهرات باليني و فوريت خدمات مورد نياز بندي بيماران براساس تظاهرات باليني و فوريت خدمات مورد نياز آنان و ازجمله تعيين برنامه درماني مناسب براي آنان ميگردد و آنان و ازجمله تعيين برنامه درماني مناسب براي آنان ميگردد و

:: عبارت است از عبارت است از ترياژترياژبنابراين اهداف بنابراين اهداف جداسازي طبقه بندي شده بيماران به منظور كاهش خطر جداسازي طبقه بندي شده بيماران به منظور كاهش خطر ··

انتقال يا سرايت بيماري انتقال يا سرايت بيماري تعيين نوع و شدت بيماري و تشخيص افتراقي به منظور تعيين نوع و شدت بيماري و تشخيص افتراقي به منظور ··

اهداف درماني به موقع اهداف درماني به موقع

بيماران در شرايط اضطراري مندطبقه بندي نظام )ترياژ ( همه گيري

بيماران در شرايط اضطراري بيماران در شرايط اضطراري مندمندطبقه بندي نظام طبقه بندي نظام ))ترياژ ترياژ ( ( همه گيري همه گيري

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

106

اولويت بندي خدمات مورد نياز بيماران و تعيين مراحل خدماتي اولويت بندي خدمات مورد نياز بيماران و تعيين مراحل خدماتي ··بعدي مثال؛ ايزوالسيون در منزل يا اقدامات سرپايي بعدي مثال؛ ايزوالسيون در منزل يا اقدامات سرپايي

ارجاع بيماران به مراكز مورد نياز بر حسب شدت و وخامت ارجاع بيماران به مراكز مورد نياز بر حسب شدت و وخامت ··بيماري، اجتناب از تحميل بار غيرضروري به تسهيالت موجود و بيماري، اجتناب از تحميل بار غيرضروري به تسهيالت موجود و خودداري از استفاده نادرست از نيروي هاي انساني و منابع و خودداري از استفاده نادرست از نيروي هاي انساني و منابع و

تجهيزاتتجهيزات

بيماران در شرايط اضطراري مندطبقه بندي نظام )ترياژ ( همه گيري

بيماران در شرايط اضطراري بيماران در شرايط اضطراري مندمندطبقه بندي نظام طبقه بندي نظام ))ترياژ ترياژ ( ( همه گيري همه گيري

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

108

الف ـ خدمات سرپايي و آسپيرين از تجويز (مسكّن/ داروهاي ضد تب ·

)تركيبات آن بخصوص در اطفال خودداري شود تجويز مايعات فراوان ·استراحت و ايزوالسيون در منزل ·اقدامات مرتبط با كنترل عفونت ·پيگيري سير باليني توسط گروه خدمات اوليه ·

پزشكي يا از طريق تلفن

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

109

ب ـ خدمات بستري در بيمارستان مسكّنداروهاي تب بر و ·درمان با اكسيژن ·تجويز مايعات از راه دهان يا داخل وريدي ·پايش سير بيماري ·درمان براساس برنامه هاي درماني متكي بر طبقه بندي وضعيت بيماري ·اقدامات مرتبط با كنترل عفونت ·پيگيري سير باليني توسط گروه خدمات اوليه پزشكي يا از طريق تلفن و ·

بررسي عالئم هشداردهنده، ترخيص از بيمارستان به محض تحمل كافي آب و غذا از راه دهان، قطع تب

. %85عدم وجود تنگ نفس و درجه اشباع اكسيژن بيش از

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

110

ج ـ خدمات پزشكي در منزل كسب اطمينان از وجود محل مناسبي به منظور ايزوالسيون و ·

برقراري امنيت بهداشتي و وجود وسايل و تجهيزات الزم كسب اطمينان از اينكه گروه هاي خدمات اوليه پزشكي از ·

آمادگي و تجهيزات كافي برخوردار باشند برقراري ارتباط مداوم و پويا بين گروه هاي خدمات اوليه ·

پزشكي و بيماران و خانواده آنها در صورت امكان، جداسازي فرد بيمار از ساير اعضاء خانواده در يك اطاق جداگانه، تا زمان بهبود عالئم، استفاده مداوم بيمار از ماسك جراحي، تاكيد بر اهميت بهداشتي شستشوي مرتب دستها بوسيله بيماران و بويژه بعد از عطسه و سرفه و امثال اينها، شستن مرتب ليوان و ساير ظروفي كه توسط بيماران، مورد استفاده قرار گرفته

است http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

111

د ـ توصيه هاي ويژه به هنگام جابجا كردن بيماران

توسط ) Rigid( استفاده از ماسك سخت جراحي ·بيماران

استفاده كاركنان از ماسك سخت جراحي و دستكش · مصرف به هنگام حمل بيماران غيراستريل يكبار

پرسنل بايستي به طور دقيق دستهاي خود را با آب و صابون بشويند و يا با ماده ضدعفوني كننده حاوي الكل، ضد عفوني

نمايند

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

112

ه ـ نحوه مالقات و مصاحبه با بيمار متري با بيماران در صورتي 8/1رعايت فاصله حداقل ·

مناسبي ) protection barriers( حفاظتي سدهايكه وجود نداشته باشد

استفاده از ماسك جراحي ·دفع بهداشتي ماسك در كيسه هاي پالستيكي ·

مخصوص دفع زباله هاي بيولوژيكي عفوني شستشوي دقيق دستها با آب و صابون يا مواد ضدعفوني

كننده حاوي الكل

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

113

منصوبين و ـ توصيه هاي بهداشتي به استفاده از ماسك جراحي · خودداري از دست دادن، بوسيدن و در آغوش گرفتن ·

بيماران متقاعد كردن بيماران به خودداري از حاضر شدن در ·

و در صورتيكه عدم حضور آنها به داليلي پرازدحام اماكن باشد، توصيه به استفاده از ماسك جراحي ناپذير اجتناب

مصرف جلو يكبار نظارت بر امر قراردادن دستمال · دهان و بيني به هنگام سرفه و عطسه كردن و دفع سريع

توسط بيماران سربسته دستمال در يك ظرف

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

114

منصوبين و ـ توصيه هاي بهداشتي به نظارت بر امر استفاده از ماسك سخت تا زمان · ·

.بهبودي عالئم عفونت حاد تنفسي توسط بيماران دفع صحيح ماسك مورد استفاده قبل از خيس شدن ·

.با بخار دهان و بيني، پاره شدن يا كثيف شدن آن شستن دقيق دستها با آب و صابون يا محلول حاوي الكل

بالفاصله بعد از هر تماس با بيماران

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

115

ز ـ تجويز داروهاي ضد ويروس توصيه شده است اين داروها صرفا به منظور اهداف درماني و براساس

. وند برنامه هاي كشوري متكي بر امكانات و توانمندي هاي هر كشوري تجويز ش : هاي تجويز داروهاي ضد ويروسي عبارتند از انديكاسيون

سير سريع بيماري · بيماران بستري در بخش مراقبت هاي ويژه ·د بيماران مبتال به پنوموني كه نياز به بستري شدن در بيمارستان دارن · يا بيماريهاي ريوي قبلي كه نياز به بستري COPD بيماران مبتال به ·

شدن داشته اند بيماريهاي قلبي مادرزادي پيچيده اي كه نياز به بستري شدن دارند · نارسايي مزمن كليوي كه نياز به بستري شدن داشته باشد ·

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

116

ز ـ تجويز داروهاي ضد ويروس د و كاركنان خدمات بهداشتي ـ درماني كه دچار عالئم شبه آنفلوآنزا هستن ·

در تماس با موارد محتمل يا قطعي آنفلوآنزا قرار گرفته اند حاملگي به سر ميبرند سوم يا دوم خانم هاي بارداري كه در سه ماهه · مشكالت قلبي يا بيماريهاي قلبي كه قبال نياز به بستري شدن در ·

بيمارستان داشته است د بيماران تحت درمان با داروهاي سركوبگر ايمني، دريافت كنندگان پيون ·

HIV/AIDSعضو يا

خامت ساير بيماران مبتال به بيماريهاي زمينه اي مزمني كه نشانه اي از و ·بيماري را نشان ميدهند

اطرافيان بيماراني كه بيماري آنها به داليل اجتماعي، شخصي يا خانوادگي براي . آنها مخاطره آميز ميباشد

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

117

ز ـ تجويز داروهاي ضد ويروس اول ساعت 48تحت چنين شرايطي درمان بايد طي ·

شروع بيماري در اول ساعت 36شروع عالئم و ترجيحا ساعت پس 24-48 سال، شروع شود و تا 12كودكان زير

البته . روز ادامه يابد 5-7از بهبودي عالئم، حداكثر به مدت در بيماران بستري در بخش مراقبت هاي ويژه مدت درمان

.)37، 26(بستگي به وضعيت آنان دارد قبل يا بعد از تماس، كموپروفيالكسي موارد لزوم ·

بسيار محدود ميباشد

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

118

ز ـ تجويز داروهاي ضد ويروس خانم هاي بارداري كه جزو موارد مشكوك، محتمل يا ·

روز 5 جديد طبقه بندي ميشوند به مدت آنفلوآنراي قطعي و ترجيحا درمان با ضدويروس تحت درمان با داروهاي

Oseltamivir قرار گيرند .. شروع عالئم، تجويز شود اول ساعت 48اين دارو بايد در

ضمنا توصيه شده است در صورتي كه خانم هاي باردار در تماس با مورد مشكوك، محتمل يا قطعي آنفلوآنزاي جديد

روز تحت پوشش پيشگيري دارويي با 10باشند به مدت Oseltamivir يا Zanamivir 45. 37، 26( قرار گيرند(

http

: //w

ww

. eli b

.hbi

. i r/ p

e rs i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

119

REFERENCES• Interim Guidance for Clinicians on Identifying and Caring for

Patients with Swine-origin Influenza A (H1N1) Virus Infection, 2009.

•• H1N1 Influenza virus, UCOP May 2009 Safety MeetingH1N1 Influenza virus, UCOP May 2009 Safety Meeting

• Anthony Fiore, Novel influenza A (H1N1) Epidemiology Update, CDC 2009

• Evolution of the H1N1 pandemic, European Centre for Disease Prevention and Control 31 July 2009.

• Preparing for pandemic flu, MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES, 2009.

• Preparing Workplaces for an Influenza Pandemic,

• Rosemawati Ariffin, Infectious Disease Surveillance Section Disease Control Division Ministry of Health Malaysia, 2009.

• http://PandemicFlu.gov

• Michael Cooperstock, New influenza A(H1N1), University of Missouri Health Care System, 2009.

http

: //w

ww

. eli b

.hbi

. ir/ p

ers i

an/ E

ME

RG

ING

_EB

OO

K/E

ME

RG

ING

_IN

DE

X.h

t m

120

1) MMWR, Swine Influenza A (H1N1) Infection in Two Children --- Southern California, March--April 2009, CDC, Internet site. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5815a5.htm

2) WHO, Influenza-like illness in the United States and Mexico, Internet site, The first Update, World Health Organization, http://www.who.int/csr/don/2009_04_24/en/index.html .

3) Jonathan S. Nguyen-Van-Tam , Alan W. Hampson, The epidemiology and clinical

impact of pandemic influenza, Vaccine 21 (2003) 1762–1768 .http://www.elsevier.com/locate/vaccine

4) World now at the start of 2009 influenza pandemic, Dr Margaret Chan Director-General of the World Health Organization . . . 11 June 200911 June 2009

http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/.

5) Swine Flu, World Health Organization,Weekly Epidemiological Record, No. 18, 2009, 84, 149–160.

6) Spread of a Novel Influenza A (H1N1) Virus via Global Airline Transportation, n engl j med 361;2nejm.org july 9, 2009, pp. 212-14. http://content.nejm.org/cgi/reprint/361/2/212.pdf

7) WHO, Influenza A(H1N1) - update 43, World Health Organization, Internet Site

http://www.who.int/csr/don/2009_06_03/en/index.html وزارت فنĤوري سينا ـ معاونت تحقيقات و ابن نياكان ـ كتاب الكترونيك قانون در طب پژوهشي پزشكي بسترهاي : ، حسينحاتمي ـ 8

. 521، صفحه 1387بهداشت، سال

http://www.elib.hbi.ir/persian/TRADITIONAL-MEDICINE/CANON-WEB/CANON-02/CANON0-FAR-02%20162.pdf

ساير منابع


121

9) Raphael Dolin, Influenza, in : Fauce, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo, Harrison’s Principles of Internal medicine, McGraw-Hill medical publishing division, New York, 17th ed. 2008, pp 1127-32.

10) Key Facts About Swine Influenza May 2, 2009, Center for Diseases Control and Prevention, Internet Site. http://www.cdc.gov/h1n1flu/key_facts.htm.

11) Kendall P. Myers W. Olsen, Gregory C. Gray, Cases of Swine Influenza in Humans: A Review of the Literature, CID, 2007:44, PP. 1084-88.

12) Shanta M. Zimmer, and Donald S. Burke, Historical Perspective — Emergence of Influenza A (H1N1) Viruses, n engl j med 361;3 nejm.org july 16, 2009 279.

13) David M. Morens, Jeffery K. Taubenberger, Anthony S. Fauci,. The Persistent Legacy of the 1918 Influenza Virus, The NEW ENGLAND JOURNAL of MEDICINE, n engl j med 361;3 nejm.org july 16, 2009 225.

14) WHO global influenza, preparedness plan Department of Communicable Disease Surveillance and Response Global Influenza Programme, WHO/CDS/CSR/GIP/2005.5.

http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_5.pdf

15) Influenza H5N1, Hong Kong Special Administrative Region of China, WEEKLY EPIDEMIOLOGICAL RECORD, No. 50, 12 DECEMBER 1997 380. http://www.who.int/docstore/wer/pdf/1997/wer7250.pdf .

16) Cumulative number of confirmed human cases of avian influenza A / (H5N1), reported to WHO, 1 July 2009.( به قوت خود باقي بود و با گزارش جديدي جايگزين نشد 1388 مردادماه 21اين گزارش در سايت مربوطه تا )

(http://www.who.int/csr/disease/avian_influenza/country/cases_table_2009_08_11/en/index.html)

17) WHO, New influenza A (H1N1) virus: global epidemiological situation, June 2009, Weekly Epidemiological Record, No. 25, 2009, 84, 249–26019.

18) Anna R Thorner, MD, Epidemiology, clinical manifestations, and diagnosis of swine H1N1 influenza A, July 9, 2009.

122

19) Laboratory-confirmed cases of pandemic (H1N1) 2009 as officially reported to WHO by States Parties to the International Health Regulations, Pandemic (H1N1) 2009 - update 58, 6 July 2009 09:00 GMT. http://www.who.int/csr/don/2009_07_06/en/index.html .

20) Fredrich G Hayden, Influenza, In: Wingarden, Smith, Bennett, Cecil Textbook of Medicine, 23rd ed. W. B. Saunders Company, Philadelphia, 2008, pp. 2464-2470.

21) John J. Treanor, Influenza Virus, In : Mandell, Douglas, Bennett’s Principles and Practice of Infectious Diseases, 6th ed., 2005, pp. 2060-85.

بيماريها و بازپديدي و نوپديدي انساني، در كتاب آنفلوآنزاي و مروري بر ) A(H5N1 آنفلوآنزاي پرندگان نوپديدي : ـ حاتمي، حسين22. 817-921، صفحات 1384، جلد سوم، سال پزشكيسالمت حرفه هاي

23) Interim Guidance for Clinicians on Identifying and Caring for Patients with Swine-origin Influenza A (H1N1) Virus Infection, May 4, 2009 4:45 PM ET.

، صفحات ضميمه 1387، در كتاب جامع بهداشت عمومي، ويراست دوم، چاپ دوم، سال آنفلوآنزا و كنترل اپيدميولوژي : ، حسينحاتميـ 24.اولجلد

25) Flowchart of Novel Influenza (A/H1N1) Diagnosis at Medical Institutes (24 May, 2009, http://www.mhlw.go.jp/english/topics/influenza_a/090524.html .

26) General Recommendations for Clinical Management of Influenza A(H1N1) Cases, Technical Document 2, Pan American Health Organisation , Office of the Assistant Director , Health Systems and Services Area, 2009.

http://new.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=1529&Itemid=

27) Viruses resistant to Oseltamivir (Tamiflu) identified, Weekly Epidemiological Record, 17 july 2009, No. 29, 2009, 84, 289–300.

28) Influenza A (H1N1), Latest situation in the EMRO, Last update: 7 September 2009.

http://www.emro.who.int/csr/h1n1/ به خاطر ارسال اين گويا، با تشكر از برادرم جناب آقاي دآتر 1388 جديد در ايران، مركز مديريت بيماريها، سال آنفلوآنزاي ـ موارد قطعي 29تاريخآمار .26/5/1388تا

123

30) Novel Influenza A (H1N1) Virus Infection --- Mexico, March--May, 2009, MMWR, June 5, 2009 / 58(21);585-589. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5821a2.htm .

31)Baby delivered prematurely from swine flu patient dies.

_latestcnn.com/2009/HEALTH/07/20/swine.flu.baby.death/index.html?section=cnnhttp://www.

32) WHO recommendations on pandemic (H1N1) 2009 vaccines,

http://www.who.int/csr/disease/swineflu/notes/h1n1_vaccine_20090713/en/ .

33) WHO, Weekly Epidemiological Record, 3 JULY 2009, 84th YEAR / 3 JUILLET, No. 27, 2009, 84, 269–280.

34) WHO recommendations on pandemic (H1N1) 2009 vaccines, Pandemic 2009 briefing note 2.

http://www.who.int/csr/disease/swineflu/notes/h1n1_vaccine_20090713/en/index.html .

35) Recommended composition of influenza virus vaccines for use in the 2009-2010, northern hemisphere influenza season, World Health Organization, Internet Site.

http://www.who.int/csr/disease/influenza/recommendations2009_10north/en/index.html. اسماعيل ذوقي، پرفسور استيل، ترجمه . اچپروفسور جيمز خوك، در كتاب بيماريهاي قابل انتقال بين انسان و حيوان، تاليف آنفلوآنزاي ـ 36

با كسب اجازه از محضر . (345-54، صفحات 1376 ويروسي، جلد دوم، موسسه تحقيقات واكسن و سرم سازي رازي، سال زئونوزهاي ). استاد ذوقي

37) Robert W Derlet, Influenza, eMedicine Specialties > Infectious Diseases > Viral Infections, Jun 11, 2009 http://emedicine.medscape.com/article/219557-overview .

38) Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts, May 6, 2009.http://www.cdc.gov/h1n1flu/recommendations.htm .

39) Strategic Advisory Group of Experts on Immunization, Report of the extraordinary meeting on theinfluenza A (H1N1) 2009 pandemic, 7 July 2009, WORLD HEALTH ORGANIZATION, No. 30, 2009, 84, 301–308.

124

40) INTERIM CASE MANAGEMENT OF INFLUENZA A H1N1 FOR WHO AFRO May 19, 2009.

http://www.afro.who.int/ddc/influenzaa/document/interim_case_management_of_influenza.pdf .

41) Rapid-Test Sensitivity for Novel Swine-Origin Influenza A (H1N1) Virus in Humans, Th e new englandjournal o f medicine, Copyright © 2009 Massachusetts Medical Society, n engl j med 10.1056/nejmc0904264. 2009, PP. 1-2. http://content.nejm.org/cgi/content/full/NEJMc0904264 .

42) Laboratory-confirmed cases of pandemic (H1N1) 2009 as officially reported to WHO by States Parties to the IHR (2005), Pandemic (H1N1) 2009 - update 64.

http://www.who.int/csr/don/2009_09_04/en/index.html

43) Walter R. Dowdle, Influenza Pandemic Periodicity, Virus Recycling, and the Art of Risk Assessment, Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 1, January 2006. http://www.cdc.gov/ncidod/EID/vol12no01/pdfs/05-1013.pdf.

44) Thomas R. Frieden, Tanja Popovic, …Prevention and Control of Seasonal Influenza With Vaccines, Recommendations of the Advisory Committee on Immunization Practices, 2009, Mortality and Morbidity Weekly Report, july 31, 2009 / Vol. 58 / No. RR-8, PP. 1-65.

45) Pregnant Women and Novel Influenza A (H1N1), Virus: Considerations for Clinicians, June 30, 2009. http://www.cdc.gov/h1n1flu/clinician_pregnant.htm .

46) Pandemic influenza in pregnant women, Pandemic (H1N1) 2009 briefing note 5, WHO, http://www.who.int/csr/disease/swineflu/notes/h1n1_pregnancy_20090731/en/index.html .

، دانشگاه علوم پزشكي آرمانشاه و معاونت سالمت وزارت بيوتروريسماپيدميولوژي و آنترل بيماريهاي مرتبط با : ـ حاتمي، حسين47. 112-144، صفحات 1382بهداشت، انتشارات صدا، سال http://www.elib.hbi.ir/persian/library.htm .

، سايت اينترنتي وزارت بهداشت؛ 1388نياكان، سال ـ حاتمي، حسين، كاربردهاي باليني اپيدميولوژي در طب رايج و پزشكي 48

http://www.elib.hbi.ir/persian/CLINICAL-EPIDEMIOLOGY/INDEX.htm


ﻢﻴﺣﺮﻟا ﻦﻤﺣﺮﻟا ﷲا...

Documents