INFLUENZA A (H1N1)INFLUENZA A (H1N1) SWINE FLU : SWINE FLU :

EVOLUTION OF EVOLUTION OF THE PROBLEMTHE PROBLEM

BYBY

DR ESSAM EL-GAMALDR ESSAM EL-GAMALProfessor of Chest DiseasesProfessor of Chest Diseases

Mansoura Faculty of MedicineMansoura Faculty of MedicineTuesday May, 5, 2009Tuesday May, 5, 2009

IntroductionIntroduction

Swine Influenza Swine Influenza (swine flu) is a (swine flu) is a respiratory disease of respiratory disease of pigs caused by type pigs caused by type A influenza that A influenza that regularly cause regularly cause outbreaks among outbreaks among pigs.pigs.

IntroductionIntroduction

Swine flu viruses do not normally Swine flu viruses do not normally infect humans, infect humans,

However, human infections with However, human infections with swine flu do occur affecting people swine flu do occur affecting people who are around pigs.who are around pigs.

it’s possible for swine flu viruses to it’s possible for swine flu viruses to spread from person to person also.spread from person to person also.

Influenza Pandemics of theInfluenza Pandemics of thepast 100 yearspast 100 years

Year of OriginYear of Origin Sub-Type in CirculationSub-Type in Circulation

1890 H2N81890 H2N8

1900 H3N81900 H3N8

1918 H1N1 (Spanish Flu)1918 H1N1 (Spanish Flu)

1957 H2N2 (Asian Flu)1957 H2N2 (Asian Flu)

19681968 H3N2 (Hong Kong Flu) H3N2 (Hong Kong Flu)

19771977 HIN1 (Russian Flu) HIN1 (Russian Flu)

Spread in less than 30 daysSpread in less than 30 days!!

Source: PBS, WGBH American Experience :Influenza 1918 www.pbs.org/wgbh/amex/influenza/maps

Hospital ResponseHospital Response

Shifts are extended.Shifts are extended. Least ill are discharged.Least ill are discharged. Urgent patients only are Urgent patients only are

admitted.admitted. Severe shortages of Severe shortages of

linens, bedpans, gowns, linens, bedpans, gowns, mattresses.mattresses.

Offices, gymnasiums, Offices, gymnasiums, warehouses, tent cities warehouses, tent cities used to isolate and care used to isolate and care for the sick.for the sick. Emergency Hospital During Influenza Epidemic,

Source: National Museum of Health and Medicine

An Emergency Hospital for An Emergency Hospital for Influenza Patients 1918Influenza Patients 1918

Mass BurialsMass Burials

Source: Crosby, Alfred W. Jr., Epidemic and Peace 1918,

Why The Current Swine Flu is Why The Current Swine Flu is Terrible ???Terrible ???

The 1918 flu pandemic (Spanish flu) The 1918 flu pandemic (Spanish flu) that spread to every part of the world, that spread to every part of the world, was caused by a virulent and deadly was caused by a virulent and deadly Influenza A virus of the same strain Influenza A virus of the same strain (H1N1).(H1N1).

It lasted from March 1918 to June 1920 It lasted from March 1918 to June 1920 and affected up to one billion people and affected up to one billion people

( > ( > ½ ½ world's population at that time). world's population at that time).

Why The Current Swine Flu is Why The Current Swine Flu is Terrible ???Terrible ???

It is cosidered to be the most It is cosidered to be the most devastating epidemic in recorded world devastating epidemic in recorded world history.history.

Around 70 - 100 million people were Around 70 - 100 million people were

killed worldwide (equivalent of ⅓ of killed worldwide (equivalent of ⅓ of population of Europe) and > double the population of Europe) and > double the No killed in World War I.No killed in World War I.

Swine Flu Outbreaks in USASwine Flu Outbreaks in USA An outbreak ccurred in New An outbreak ccurred in New

Jersey, 1976 and caused > 200 Jersey, 1976 and caused > 200 cases with serious illness and cases with serious illness and one death.one death. > 40 million were vaccinated > 40 million were vaccinated

and 30 died as a direct result and 30 died as a direct result of vaccination.of vaccination.

The program was stopped after The program was stopped after over 500 cases of GPS, were over 500 cases of GPS, were reported.reported.

12 human infections with swine flu were reported (from 10 US states)

between Dec 2005 - Feb 2009.

Current Situation in the USCurrent Situation in the US Now : since March Now : since March

2009, 160 of confirmed 2009, 160 of confirmed cases with one death from cases with one death from 21 States are reported. 21 States are reported.

Virus is described as a new Virus is described as a new subtype of A/H1N1 not subtype of A/H1N1 not previously detected in previously detected in swine or humans.swine or humans.

Samples from Mexico Samples from Mexico outbreak match swine outbreak match swine influenza isolates from influenza isolates from patients in USA.patients in USA.

Source: CDC

Current Situation in the USCurrent Situation in the US

CDC has determined CDC has determined that this virus is that this virus is contagious and is contagious and is spreading from human spreading from human to human.to human.

April 27, 2009 : CDC April 27, 2009 : CDC recommends against recommends against all non-essential travels all non-essential travels to Mexico. to Mexico.

Source: CDC

April 23-24April 23-24, in NYC : 222 high school , in NYC : 222 high school students visited the nursing office and students visited the nursing office and left school because of illness.left school because of illness.

April 24 (Friday)April 24 (Friday)

Nasopharyngeal swabs were collected Nasopharyngeal swabs were collected from 9 newly symptomatic studentsfrom 9 newly symptomatic students

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

MMRW Report, April 30, 2009

April 26April 26, 2009 :, 2009 : 7 of 9 specimens collected 7 of 9 specimens collected were positive for the new were positive for the new strain of influenza.strain of influenza.

April 27April 27, School closed, School closed..

MMRW Report, April 30, 2009MMRW Report, April 30, 2009

April 26-28, 2009 :April 26-28, 2009 : 37 (88%) of 42 specimens collected tested 37 (88%) of 42 specimens collected tested

positive, bringing the total number of positive, bringing the total number of confirmed cases to 44 of which :confirmed cases to 44 of which : Median age was 15 years (range: 14-21 ys)Median age was 15 years (range: 14-21 ys) Thirty-one (70%) were females.Thirty-one (70%) were females.

5 May 2009 -- As of 06:00 GMT5 May 2009 -- As of 06:00 GMT ::USA has reported 286 lab USA has reported 286 lab

confirmed human cases, confirmed human cases, including one death.including one death.

• 5 patients reported travel outside NYC 5 patients reported travel outside NYC within US states in the week before within US states in the week before symptom onset.symptom onset.

•None of the 44 patients reported recent None of the 44 patients reported recent travel to California, Texas, or Mexico.travel to California, Texas, or Mexico.

Current Situation in MexicoCurrent Situation in Mexico A total of ~ 2,498 suspected A total of ~ 2,498 suspected

cases,165 deaths and 1311 cases,165 deaths and 1311 hospitalizations hospitalizations (for (for pneumonia) pneumonia) have been have been reported in 31 of 32 Mexico reported in 31 of 32 Mexico States (Ministry of Health).States (Ministry of Health).443 Lab confirmed443 Lab confirmed

11stst case discovered in Oaxaca, case discovered in Oaxaca, April 13, 2009, a woman died of April 13, 2009, a woman died of pneumonia. pneumonia.

Source: Mexican Ministry of Health, WHO, CDC, PAHO & ProMED

Current Situation in MexicoCurrent Situation in Mexico

The illness outbreak in Mexico City The illness outbreak in Mexico City prompted the country's health minister prompted the country's health minister to : to :

-- cancel classes in Mexico City.cancel classes in Mexico City.

- advise students and adults to avoid - advise students and adults to avoid crowded public places.crowded public places.

Current Situation in MexicoCurrent Situation in Mexico

CDC's lab analyzed 14 samples CDC's lab analyzed 14 samples from severely ill Mexican pts :from severely ill Mexican pts :

7 of them had the same swine 7 of them had the same swine flu mix as the virus that flu mix as the virus that infected the US patient.infected the US patient.

Canada's national lab has Canada's national lab has confirmed swine flu A/H1N1 in confirmed swine flu A/H1N1 in 18 isolates from Mexican pts : 18 isolates from Mexican pts : 12 of which were identical to 12 of which were identical to the swine flu viruses from the swine flu viruses from California.California.

Source: WHO, CDC & ProMED

Current Situation in MexicoCurrent Situation in Mexico

The virus in Mexico differs from The virus in Mexico differs from seasonal influenza in that it affects seasonal influenza in that it affects otherwise healthy young adults, (20- 50 otherwise healthy young adults, (20- 50 years) however, seasonal influenza years) however, seasonal influenza typically affects the very young and typically affects the very young and very old (Ministry of Health).very old (Ministry of Health).

MMWR, April 30, 2009MMWR, April 30, 2009

March 2009 :March 2009 :

Mexico Mexico experiencedexperienced outbreaks of influenza-like outbreaks of influenza-like illness (ILI).illness (ILI).

April 12, 2009 :April 12, 2009 :

the General Directorate of Epidemiology (DGE) the General Directorate of Epidemiology (DGE) reportedreported an outbreak of ILI in a small community in an outbreak of ILI in a small community in the state of Veracruz to the Pan American Health the state of Veracruz to the Pan American Health Organization (PAHO)Organization (PAHO)

April 17, 2009 :April 17, 2009 :

a case of atypical pneumoniaa case of atypical pneumonia in Oaxaca State in Oaxaca State aroused enhanced surveillance throughout Mexicoaroused enhanced surveillance throughout Mexico

Source: CDC

MMWR, April 30, 2009MMWR, April 30, 2009

April 23, 2009 :April 23, 2009 : several cases of severe respiratory illness, lab several cases of severe respiratory illness, lab

confirmed as influenza A(H1N1) virus infection were confirmed as influenza A(H1N1) virus infection were communicated to the PAHO. communicated to the PAHO.

Sequence analysis revealed that the patients were Sequence analysis revealed that the patients were infected with the same strain detected in 2 children infected with the same strain detected in 2 children living in California.living in California.

April 30, 2009 :April 30, 2009 : a total of 1,918 suspected cases were reported, a total of 1,918 suspected cases were reported,

including 286 probable and 97 confirmed cases including 286 probable and 97 confirmed cases including 7 persons who had diedincluding 7 persons who had died

MMWR, April 30, 2009MMWR, April 30, 2009

Of the 24 patients for whom demographic Of the 24 patients for whom demographic and clinical information was available, and clinical information was available, 20 (83%) were hospitalized, 3 were examined 20 (83%) were hospitalized, 3 were examined

in outpatient settings, and 1 had illness that in outpatient settings, and 1 had illness that was not medically attended.was not medically attended.

79% of patients aged 5 - 59 years.79% of patients aged 5 - 59 years. 62 % (15 patients) were females.62 % (15 patients) were females.

Source: CDC

Last News : 5 May 2009 -- As Last News : 5 May 2009 -- As of 06:00 GMTof 06:00 GMT

21 countries have officially reported 1124 cases 21 countries have officially reported 1124 cases of influenza A (H1N1) infection.of influenza A (H1N1) infection.

Mexico has reported 590 laboratory confirmed Mexico has reported 590 laboratory confirmed human cases of infection, including 25 deaths. human cases of infection, including 25 deaths.

The United States has reported 286 laboratory The United States has reported 286 laboratory confirmed human cases, including one death.confirmed human cases, including one death.

Canada: 140 confirmed cases, Spain: 54 Canada: 140 confirmed cases, Spain: 54 confirmed cases, UK: 18 confirmed cases.confirmed cases, UK: 18 confirmed cases.

Situation in EGYPT:Situation in EGYPT:

Egypt started a mass slaughter of Egypt started a mass slaughter of thousands of pigs in an effort to thousands of pigs in an effort to prevent swine flu spreading, prevent swine flu spreading, although flu cannot be caught although flu cannot be caught from eating pig meat, and there is from eating pig meat, and there is no scientific rationale for no scientific rationale for slaughtering pig.slaughtering pig.

Situation in EGYPT:Situation in EGYPT:

The authorities have increased The authorities have increased numbers of medical staff at Cairo numbers of medical staff at Cairo airport to check passengers arriving airport to check passengers arriving from Mexico and will monitor them from Mexico and will monitor them during their stay.during their stay.

Up till now, no cases of swine flu in Up till now, no cases of swine flu in Egypt. However, neighbouring Israel Egypt. However, neighbouring Israel has 2 confirmed cases in humans. has 2 confirmed cases in humans.

DOHMH : New York City Department of DOHMH : New York City Department of Health and Mental Hygiene.Health and Mental Hygiene.

CDC : center of disease control and CDC : center of disease control and prevention.prevention.

MMWR : Morbidity and mortality weekly MMWR : Morbidity and mortality weekly report.report.