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Just-in-Time Lecture Influenza A(H1N1) (Swine Flu) Pandemic (Version 15, first JIT lecture issued April 26) December 28, 2009 (4:00 PM EST) Rashid A. Chotani, MD, MPH, DTM Adjunct Assistant Professor Uniformed Services University of the Health Sciences (USUHS) 240-367-5370 [email protected] CHOTANI © 2009. Acknowledgement The Author acknowledges the efforts, hard work and diligence for hosting this lecture, web-management & translations and thanks the entire Supercourse Team, specially the following Dr. Ronald E. LaPorte, University of Pittsburgh, USA Dr. Eugene Shubnikov, Institute of Internal Medicine, Russia Dr. Faina Linkov, University of Pittsburgh, USA Dr. Mita Lovalekar, University of Pittsburgh, USA Dr. Nicolás Padilla Raygoza, Universidad de Guanajuato, México Dr. Ali Ardalan, Tehran University of Medical Sciences, Iran Dr. Mehrdad Mohajery, Tehran University of Medical Sciences, Iran Dr. Seyed Amir Ebrahimzadeh, Tehran University of Medical Sciences, Iran Dr. Nasrin Rahimian, Tehran University of Medical Sciences, Iran Dr. Mohd Hasni , University of Kebangsaan, Malaysia Dr. Kawkab Shishani, The Hashemite University, Jordan Dr. Nesrine Ezzat Abdlkarim, Beirut Arab University, Lebanon Dr. Khowlah Almohaini, University of Pittsburgh, USA Dr. Duc Nguyen, University of Texas, USA Dr. Elisaveta Jasna Stikova, University “Ss. Cyril and Methodius”, Skopje, Macedonia Dr. Michèle Cazaubon, Secrétaire Gle de la Société Française d' Angéiologie, France Dr. Yang Yingyun , Peking Union Medical College, China Dr. Jesse Huang, Peking Union Medical College, China Shimon Weitzman, Ben Gurion University of the Negev , Israel Dr. Nurka Pranjic, Medical School University of Tuzla, Bosnia and Herzegovina Dr. Shakir Jawad, Uniformed Services University of the Health Sciences, USA Dr. Hiroya Goto, Ministry of Defense, Japan Dr. Osamu Usami, National Cancer Institute, USA Afham A. Chotani, USA Truly a global effort http://www.pitt.edu/~super1/ CHOTANI © 2009. OUTLINE 1. 2. 3. 4. 5. 6. 7. 8. Influenza Virus Definitions Introduction History in the US Spread/Transmission Timeline/Facts Response Status Update • • • • • 9. 10. Case-Definitions Guidelines • • • 11. 12. 13. 14. 15. 16. CHOTANI © 2009. US Mexico Canada European Union Globally Clinicians Laboratory Workers General Population Treatment Other Protective Measures Summary Timeline of Emergence Lessons Learned from Past Pandemics Conclusion & Recommendations Virus • RNA, enveloped • Viral family: Orthomyxoviridae • Size: 80-200nm or .08 – 0.12 μm (micron) in diameter • Three types • A, B, C • Surface antigens • H (haemaglutinin) • N (neuraminidase) CHOTANI © 2009. Credit: L. Stammard, 1995 Haemagglutinin subtype H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 H11 H12 H13 H14 H15 H16 Neuraminidase subtype N1 N2 N3 N4 N5 N6 N7 N8 N9 Definitions General • Epidemic – a located cluster of cases • Pandemic – worldwide epidemic • Antigenic drift • Changes in proteins by genetic point mutation & selection • Ongoing and basis for change in vaccine each year • Antigenic shift • Changes in proteins through genetic reassortment • Produces different viruses not covered by annual vaccine CHOTANI © 2009. Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature* • Hard non-porous surfaces 24-48 hours • Plastic, stainless steel • Recoverable for > 24 hours • Transferable to hands up to 24 hours • Cloth, paper & tissue • Recoverable for 8-12 hours • Transferable to hands 15 minutes • Viable on hands <5 minutes only at high viral titers • Potential for indirect contact transmission *Humidity 35-40%, Temperature 28C (82F) CHOTANI © 2009. Source: Bean B, et al. JID 1982;146:47-51 Influenza The Normal Burden of Disease • Seasonal Influenza • Globally: 250,000 to 500,000 deaths per year • In the US (per year) • • • • ~35,000 deaths (mainly among people 65 years or older) >200,000 Hospitalizations $37.5 billion in economic cost (influenza & pneumonia) >$10 billion in lost productivity • Pandemic Influenza • An ever present threat CHOTANI © 2009. Swine Influenza A(H1N1) Introduction • Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs • Most commonly, human cases of swine flu happen in people who are around pigs • Swine flu viruses do not normally infect humans, however, human infections with swine flu do occur, and cases of human-tohuman spread of swine flu viruses have been documented CHOTANI © 2009. Swine Influenza A(H1N1) History in US • A swine flu outbreak in Fort Dix, New Jersey, USA occurred in 1976 that caused more than 200 cases with serious illness in several people and one death • • More than 40 million people were vaccinated However, the program was stopped short after over 500 cases of Guillain-Barre syndrome, a severe paralyzing nerve disease, were reported • 30 people died as a direct result of the vaccination • In September 1988, a previously healthy 32year-old pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu and died 8 days later. • From December 2005 through February 2009, a total of 12 human infections with swine influenza were reported from 10 states in the United States CHOTANI © 2009. Swine Influenza A(H1N1) Transmission to Humans • Through contact with infected pigs or environments contaminated with swine flu viruses • Through contact with a person with swine flu • Human-to-human spread of swine flu has been documented also and is thought to occur in the same way as seasonal flu, through coughing or sneezing of infected people CHOTANI © 2009. Swine Influenza A(H1N1) Transmission Through Species Human Virus Avian Virus Avian/Human Reassorted Virus Swine Virus Reassortment in Pigs CHOTANI © 2009. Swine Influenza A(H1N1) March 2009 Timeline • In March and early April 2009, Mexico experienced outbreaks of respiratory illness and increased reports of patients with influenza-like illness (ILI) in several areas of the country • April 12, the General Directorate of Epidemiology (DGE) reported an outbreak of ILI in a small community in the state of Veracruz to the Pan American Health Organization (PAHO) in accordance with International Health Regulations • April 17, a case of atypical pneumonia in Oaxaca State prompted enhanced surveillance throughout Mexico • April 23, several cases of severe respiratory illness laboratory confirmed as influenza A(H1N1) virus infection were communicated to the PAHO • Sequence analysis revealed that the patients were infected with the same strain detected in 2 children residing in California • CHOTANI © 2009. Samples from the Mexico outbreak match swine influenza isolates from patients in the United States Source: CDC Swine Influenza A(H1N1) March 2009 Facts • Virus described as a new subtype of A/H1N1 not previously detected in swine or humans • CDC determines that this virus is contagious and is spreading from human to human • The virus contains gene segments from 4 different influenza types: • • • • CHOTANI © 2009. North American swine North American avian North American human and Eurasian swine Swine Influenza A(H1N1) US Response • The Strategic National Stockpile (SNS) is releasing one-quarter of its • • • Anti-viral drugs Personal protective equipment and Reparatory protection devices • President Obama today asked Congress for an additional $1.5 billion to fight the swine flu • On April 27, 2009, the CDC issued a travel advisory that recommends against all nonessential travel to Mexico CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Global Response • The WHO raises the alert level to Phase 6 • • • • • CHOTANI © 2009. WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3 In Late April 2009 WHO announced the emergence of a novel influenza A virus April 27, 2009: Alert Level raised to Phase 4 April 29, 2009: Alert Level raised to Phase 5 June 11, 2008: Alert Level raised to Phase 6 Source: WHO Swine Influenza A(H1N1) Status Update • US: March – December 28 • Estimates • • • • • • • Laboratory confirmed cases: 68,123 Deaths: 823 Activity: On decline CANADA: As of December 23 • • • Death among children since August 2009: 221 Sub-type: 99% Influenza A (H1N1) Activity: On decline MEXICO: March 01 – December 23 • • • • Symptomatic: ~ 55 million Hospitalized: ~300,000 Deaths: ~ 13,000 Deaths: 401 Activity: On decline EUROPEAN UNION & EFTA COUNTRIES: April 27December 28 • • • • • • CHOTANI © 2009. Deaths: 1,832 All 27 EU and 4 EFTA countries reporting cases 471 confirmed cases reported on September 24 ~10,000 Hospitalized ~2,200 admitted to intensive care Vast majority of cases reported between 20-49 years of age Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO Swine Influenza A(H1N1) Status Update GLOBALLY: March 1-December 23 • At least 11,516 Deaths • • • • • • Africa Region (AFRO): Americas Region (AMRO): Eastern Mediterranean Region (EMRO): Europe Region (EURO) : South-East Asia Region (SEARO): Western Pacific Region (WPRO) : 109 6,670 663 2,045 990 1,039 ECDC reported a total of 12,776 deaths – December 28, 2009 CHOTANI © 2009. Source: WHO Swine Influenza A(H1N1) CDC Estimates from April-November 14, 2009, By Age Group 2009 H1N1 Cases 0-17 years 18-64 years 65 years and older Cases Total Hospitalizations 0-17 years 18-64 years 65 years and older Hospitalizations Total Deaths 0-17 years 18-64 years 65 years and older Deaths Total CHOTANI © 2009. Mid-Level Range* Estimated Range * ~16 million ~27 million ~4 million ~47 million ~12 million to ~23 million ~19 million to ~38 million ~3 million to ~6 million ~34 million to ~67 million ~71,000 ~121,000 ~21,000 ~213,000 ~51,000 to ~101,000 ~87,000 to ~172,000 ~15,000 to ~29,000 ~154,000 to ~303,000 ~1,090 ~7,450 ~1,280 ~9,820 ~790 to ~1,550 ~5,360 to ~10,570 ~920 to ~1,810 ~7,070 to ~13,930 Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm Swine Influenza A(H1N1) Symptoms Reported in US Hospitalized Patients Symptoms CHOTANI © 2009. Number (n=268) % Fever 249 93% Cough 223 83% Shortness of breath 145 54% Fatigue/Weakness 180 40% Chills 99 37% Myalgias 96 36% Rhinorrhea 96 36% Sore throat 84 31% Headache 83 31% Vomiting 78 29% Wheezing 64 24% Diarrhea 64 24% Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm Swine Influenza A(H1N1) Lab-Confirmed Cases in the US as of July 24, 2009 (n=43,771) Percent Represents proportion of Total Cases 25000 22080 50% Cases 20000 15000 10000 5000 7434 17% 4816 11% 0 0-4 6741 5-24 25-49 15% 2187 1% 5% 513 50-64 >=65 UK Age Grougs CHOTANI © 2009. Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC Swine Influenza A(H1N1) Lab-Confirmed Cases in the US as of July 24, 2009 (n=37,030*) Rate Per 100,000 Population by Age Group 30 26.7 25 Cases 20 22.9 n=22080 n=4816 15 10 6.97 n=7434 5 3.92 n=2187 1.3 n=513 0 0-4 5-24 25-49 50-64 >=65 Age Grougs *Excludes 6,741 Cases with missing data Rate/100,000 by Single Year Age Groups: Denominator Source: 2008 Census Estimated, US Census Bureau CHOTANI © 2009. Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC Swine Influenza A(H1N1) Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011) Percent Represents proportion of Total Hospitalizations 2000 Hospitalizations 1718 34% 1500 1184 1000 24% 953 19% 658 13% 500 225 4% 273 5% 0 0-4 5-24 25-49 50-64 >=65 UK Age Grougs CHOTANI © 2009. Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC Swine Influenza A(H1N1) Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011) Rate Per 100,000 Population by Age Group 5 Hospitalizations 4.5 4 4.5 N=953 3.5 3 2.5 2.1 2 1.7 N=1718 1.5 1.1 1 13% N=1184 1.2 n=225 N=658 0.5 0 0-4 5-24 25-49 50-64 >=65 Age Grougs CHOTANI © 2009. Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC Swine Influenza A(H1N1) Deaths Among Lab-Confirmed Cases in the US as of July 24, 2009 (n=302) 150 Number of Deaths 124 41% 100 71 24% 48 50 16% 7 0 26 26 9% 9% >=65 UK 2% 0-4 5-24 25-49 50-64 Age Grougs CHOTANI © 2009. Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC Swine Influenza A(H1N1) Mexico Epidemic Curve Confirmed, by Day As of December 09, 2009 Total Number of Confirmed Cases = 66,415* School Closure 4/24/09 Suspension of Non-essential Activities 5/1/09 No. of Confirmed Cases 1200 Epidemiological Alert 4/13/09 1000 800 600 School Open 5/12/09 400 200 12/1/2009 11/1/2009 10/1/2009 9/1/2009 8/1/2009 7/1/2009 6/1/2009 5/1/2009 4/1/2009 3/1/2009 0 Day *NOTE: Numbers can change CHOTANI © 2009. Source: Secretaria de Salud, Mexico Swine Influenza A(H1N1) Mexico Confirmed Case Distribution, by Age As of December 23, 2009 Total Number of Confirmed Cases = 68,123 19,781 No. Confirmed Cases 21,000 18,000 15,000 12,980 12,000 9,000 10,509 7,467 7,285 5,079 6,000 3,094 3,000 1,287 640 60+ NA 0 0-4 5-9 10-19 20-29 30-39 40-49 50-59 Age Group CHOTANI © 2009. Source: Secretaria de Salud, Mexico Swine Influenza A(H1N1) Mexico Confirmed Death, by Age Groups As of December 23, 2009 Deaths = 823 Fem ale: 49.3% Deaths Male: 50.7% % 100 100 75 75 50 50 25 8 2.3 3.3 8.5 25 13.7 9.2 9.6 9.6 7.3 2.9 2.7 1 0.9 >75 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 1-4 <1 0 4.6 4.4 11.1 Case-Fatality (%) No. of Deaths 69.7% Deaths 0 Age Group CHOTANI © 2009. Source: Secretaria de Salud, Mexico Swine Influenza A(H1N1) Mexico Death, by Underlying Condition As of December 23, 2009 Metabolic 37.1 Smoker 12.9 Cardiovascular 12.8 Other 10.7 N=823 Respiratory 4.5 Infectious 2.9 Neoplasm 2.1 Autoimmune 1.3 0 5 10 15 20 25 30 35 40 Percent CHOTANI © 2009. Source: Secretaria de Salud, Mexico Swine Influenza A(H1N1) Mexico Deaths, by Symptoms As of December 23, 2009 N=823 CHOTANI © 2009. Selected Symptoms % Fever 88.3% Cough 84.9% Shortness of breath 51.9% Headache 35.7% Rhinorrhea 29.6% Myalgias 21.6 % Vomiting 10.2% Diarrhea 8.6% Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm Swine Influenza A(H1N1) Canada Confirmed Cases & Deaths, by Province or Territory Confirmed cases Hospitalized 15 4000 3636 3500 Deaths 3000 17 2500 2259 2000 3 1500 1348 1000 87 14 831 201 0 0 266 488 0 0 0 330 42 1 11 0 8 51 44 0 0 1 0 14 0 405 38 Nunavut Newfoundland Prince Eward Island Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta 0 Northwest Territories 382 6 Yukon 500 3 859 1 British Columbia No. of Confirmed Cases & Deaths As of July 15, 2009 Total Number of Confirmed Cases 10,156 = ; Death = 45; Cases reported from 13 of 13 Provinces Province or Territory Since July 15 only deaths have been reported – now totaling 397 CHOTANI © 2009. Source: Public Health Agency of Canada Swine Influenza A(H1N1) Canada Total Confirmed Deaths, by Province or Territory 118 120 106 100 80 60 65 52 40 15 20 16 10 3 1 1 Northwest Territories Nunavut 7 Yukon 7 0 0 Newfoundland Prince Eward Island Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta British Columbia No. of Confirmed Cases & Deaths As of December 23, 2009 Total Number of Confirmed Death = 401; Deaths reported from 12 of 13 Provinces Province or Territory CHOTANI © 2009. Source: Public Health Agency of Canada Swine Influenza A(H1N1) EU & EFTA Confirmed Cases & Deaths April 27 – September 24, 2009 Total Number of Confirmed Cases = 53,513; 163 Death; 31 Countries; CFR 0.3% No. of Confirmed Cases & Deaths Confirmed cases 19538 20000 78 16000 13471 12000 Deaths 8000 4000 29 1 361 126 70 297 293 636 68 297 1125 2149 1 3 3 1 206 200 2 2470 1 885 30 5 3 51 280 298 4 3 32 2983 2 153812741176 14731336 164 334 133 244 0 United Switzerland Sweden Spain Slovenia Slovakia Romania Portugal Poland Norway Netherlands Malta Luxembourg Lithuania Liechtenstien Latvia Italy Ireland Iceland Hungry Greece Germany France Finland Estonia Denmark Czech Rep. Cyprus Bulgaria Belgium Austria Country Currently only deaths are being reported – now totaling 1,371 CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) EU & EFTA Countries Confirmed Case Distribution, by Age 27 April to 8 May 2009 n=46 25 23 Confirmed Cases 20 15 10 7 6 5 5 3 2 0 0-9 10-19 20-29 30-39 40-49 50-59 Age Group (Years) CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) EU & EFTA Deaths April 27 – December 28, 2009 Total Number of Deaths among Confirmed Cases = 1,832 No. of Confirmed Cases & Deaths 350 303 300 256 250 223 200 188 150 132 116 100 59 48 50 35 3 17 25 27 22 16 2 8 3 57 49 53 45 36 0 0 30 29 13 3 3 22 9 United Kingdom Switzerland Sweden Spain Slovenia Slovakia Romania Portugal Poland Norway Netherlands Malta Luxembourg Lithuania Liechtenstien Latvia Italy Ireland Iceland Hungry Greece Germany France Finland Estonia Denmark Czech Rep. Cyprus Bulgaria Belgium Austria Country CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) Other European Countries & Central Asia Confirmed Deaths As of December 28, 2009 n=397 250 202 Confirmed Deaths 200 150 100 50 50 23 20 Albania Armenia 7 10 10 Kosovo 3 Georgia 6 25 14 19 5 0 Ukraine Serbia Russia Montenegro Moldova Macedonia Croatia Bosnia & Herzegovinia Belarus Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) Mediterranean & Middle East Confirmed Deaths As of December 28, 2009 n=1,246 415 400 350 300 250 200 147 150 109 97 100 27 5 23 30 Oman 7 16 Occupied Palestinian Territory 50 40 Kuwait 50 71 42 Jordan Confirmed Deaths 450 110 15 8 1 6 27 0 Yemen United Arab Emirates Turkey Tunisia Syrian Arab Republic Saudi Arabia Qatar Moracco Libya Lebanon Israel Iraq Islamic Republic of Iran Egypt Bahrain Algeria Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) Africa Confirmed Deaths As of December 28, 2009 n=116 100 93 Confirmed Deaths 90 80 70 60 50 40 30 20 8 1 2 Sao Tome & Principe Madagscar 2 Namibia 1 3 Ghana 10 5 1 0 Tanzania Sudan South Africa Mozambique Mauritius Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) North America Confirmed Deaths As of December 28, 2009 n=3,384 2500 Confirmed Deaths 2160 2000 1500 1000 500 823 401 0 USA Mexico Canada Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) Central America & Caribbean Confirmed Deaths As of December 28, 2009 n=222 Confirmed Deaths 50 47 41 40 31 30 23 18 20 16 11 10 6 5 1 2 Surinam 1 2 Saint Lucia 3 Saint Kitts & Nevis 4 11 0 TrinidadTobago Panama Nicaragua Jamaica Honduras Guatemala El Salvador Dominican Republic Cuba Costa Rica Cayman Island Barbados Baham Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) South America Confirmed Deaths As of December 28, 2009 n=3,157 2000 Confirmed Deaths 1632 1500 1000 617 500 150 205 193 96 58 52 121 33 0 Venezuela Uriguay Peru Paraguay Ecudor Colombia Chile Brazil Bolivia Argentina Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) North-East & South Asia Confirmed Deaths As of December 28, 2009 n=1,820 1000 Confirmed Deaths 880 800 600 509 400 200 148 107 2 1 Pakistan 26 Nepal 1 Maldives Bangladesh 2 Macao SAR China 6 Afghanistan 51 17 35 35 0 Taiwan Sri Lanka South Korea Mongolia Japan India Hong Kong SAR China China (Minland) Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) South-East Asia Confirmed Deaths As of December 28, 2009 n=388 Confirmed Deaths 200 191 150 100 77 53 50 30 19 10 Cambodia Indonesia 1 6 1 0 Vietnam Thiland Singapore Phillippines Malaysia Loas PDR Brunei Barussalam Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) Australia & Pacific Confirmed Deaths As of December 28, 2009 n=217 Confirmed Deaths 200 191 150 100 50 20 Marshall Island 1 1 Tonga Cook Island 2 Solomon Island 1 Samoa 1 0 New Zealand Australia Countries CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) EU & EFTA Countries Confirmed Deaths, by Week As of December 28, 2009 n=1,803 No of Confirmed Deaths 350 319 300 267 250 208 188 169 200 151 150 100 100 84 49 43 50 1 1 2 12 17 2 5 3 17 23 21 17 15 22 16 15 12 24 0 25 26 27 28 29 30 32 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Week-2009 CHOTANI © 2009. Source: ECDC Swine Influenza A(H1N1) Global Confirmed Deaths, by Week As of December 28, 2009 n=12,682 1400 No of Confirmed Deaths 1231 1177 1200 1066 1046 1000 936 800 642 566 581 600 436 461 396 485 422 405 400 303 261 207 212 170 200 85 19 7 5 6 1 110 235 190 146 212 330 181 129 23 0 18 19 20 21 22 23 25 26 27 28 29 30 32 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Week-2009 * Increase in number of deaths in week 43 due to aggregate reporting of fatal cases from Brazil (week 37-40) & due to batch report of US fatal cases since August 1, 2009 CHOTANI © 2009. Source: ECDC Global Distribution of Reported Laboratory Confirmed Cases & Deaths of Swine Influenza A(H1N1), December 23, 2009 CHOTANI © 2009. Source: WHO Geographic Spread of Influenza Activity Based Upon Country Reporting, Week 50, 2009 (07-23 December) CHOTANI © 2009. Source: WHO Impact on Healthcare Services Based Upon Degree of Disruption, As a Result of Acute Respiratory Diseases Week 50, 2009 (07-13 December) CHOTANI © 2009. Source: WHO Number of Specimens Positive for Influenza Sub-Type CHOTANI © 2009. Source: CDC Laboratory-Confirmed Cases & Deaths of New Influenza A(H1N1) by WHO Regions, September 20, 2009 At least 318,925 Cases & Over 3917 Deaths Overall Case-Fatality Rate (CFR) in Confirmed ~ 1.2% CFR = 2.5% No. Confirmed Cases & Deaths 140000 130448 120000 CFR = 0.4% 100000 85299 80000 CFR = 0.3% 53000 60000 40000 CFR = 0.5% 20000 CFR = 1.1% 30293 CFR = 0.6% 11621 8264 340 362 Western Pacific Region (WPRO) 154 South-East Asia Region (SEARO) Americas Region (AMRO) Africa Region (AFRO) 72 Europe Region (EURO) 2948 Eastern Mediterranean Region (EMRO) 41 0 WHO Region *Given that countries are no longer required to test and report individual cases, the number of cases reported actually understates the real number of cases. CHOTANI © 2009. Source: WHO Swine Influenza A(H1N1) US Case Definitions • A confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests: • • • A probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness who is: • • • real-time RT-PCR viral culture positive for influenza A, but negative for H1 and H3 by influenza RT-PCR, or positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case A suspected case of swine influenza A (H1N1) virus infection is defined as a person with acute febrile respiratory illness with onset • • • CHOTANI © 2009. within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection, or within 7 days of travel to community either within the United States or internationally where there are one or more confirmed swine influenza A(H1N1) cases, or resides in a community where there are one or more confirmed swine influenza cases. Source: CDC Swine Influenza A(H1N1) US Case Definitions • Infectious period for a confirmed case of swine influenza A(H1N1) virus infection is defined as 1 day prior to the case’s illness onset to 7 days after onset • Close contact is defined as: within about 6 feet of an ill person who is a confirmed or suspected case of swine influenza A(H1N1) virus infection during the case’s infectious period • Acute respiratory illness is defined as recent onset of at least two of the following: rhinorrhea or nasal congestion, sore throat, cough (with or without fever or feverishness) • High-risk groups: A person who is at high-risk for complications of swine influenza A(H1N1) virus infection is defined as the same for seasonal influenza (see Reference) CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Guidelines for Clinicians • Clinicians should consider the possibility of swine influenza virus infections in patients presenting with febrile respiratory illness who • live in areas where human cases of swine influenza A(H1N1) have been identified or • have traveled to an area where human cases of swine influenza A(H1N1) has been identified or • have been in contact with ill persons from these areas in the 7 days prior to their illness onset • If swine flu is suspected, clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer) • once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Guidelines for Clinicians • Signs and Symptoms • Influenza-like-illness (ILI) • Fever, cough, sore throat, runny nose, headache, muscle aches. In some cases vomiting and diarrhea. (These cases had illness onset during late March to mid-April 2009) • Cases of severe respiratory disease, requiring hospitalization including fatal outcomes, have been reported in Mexico • The potential for exacerbation of underlying chronic medical conditions or invasive bacterial infection with swine influenza virus infection should be considered • Non-hospitalized ill persons who are a confirmed or suspected case of swine influenza A (H1N1) virus infection are recommended to stay at home (voluntary isolation) for at least the first 7 days after illness onset except to seek medical care CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Guidelines for Clinicians FDA Issues Authorizations for Emergency Use (EUAs) of Antivirals • On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued EUAs in response to requests by the Centers for Disease Control and Prevention (CDC) for the swine flu outbreak • One of the reasons the EUAs could be issued was because the U.S. Department of Health and Human Services (HHS) declared a public health emergency on April 26, 2009 • The swine influenza EUAs aid in the current response: CHOTANI © 2009. • Tamiflu: Allow for Tamiflu to be used to treat and prevent influenza in children under 1 year of age, and to provide alternate dosing recommendations for children older than 1 year. Tamiflu is currently approved by the FDA for the treatment and prevention of influenza in patients 1 year and older. • Tamiflu and Relenza: Allow for both antivirals to be distributed to large segments of the population without complying with federal label requirements that would otherwise apply to dispensed drugs and to be accompanied by written information about the emergency use of the medicines. Source: FDA Swine Influenza A(H1N1) Biosafety Guidelines for Laboratory Workers • Diagnostic work on clinical samples from patients who are suspected cases of swine influenza A (H1N1) virus infection should be conducted in a BSL-2 laboratory • All sample manipulations should be done inside a biosafety cabinet (BSC) • Viral isolation on clinical specimens from patients who are suspected cases of swine influenza A (H1N1) virus infection should be performed in a BSL-2 laboratory with BSL-3 practices (enhanced BSL-2 conditions) • Additional precautions include: • • • • • • • recommended personal protective equipment (based on site specific risk assessment) respiratory protection - fit-tested N95 respirator or higher level of protection shoe covers closed-front gown double gloves eye protection (goggles or face shields) Waste • CHOTANI © 2009. all waste disposal procedures should be followed as outlined in your facility standard laboratory operating procedures Source: CDC Swine Influenza A(H1N1) Biosafety Guidelines for Laboratory Workers • Appropriate disinfectants • 70 per cent ethanol • 5 per cent Lysol • 10 per cent bleach • All personnel should self monitor for fever and any symptoms. Symptoms of swine influenza infection include diarrhea, headache, runny nose, and muscle aches • Any illness should be reported to your supervisor immediately • For personnel who had unprotected exposure or a known breach in personal protective equipment to clinical material or live virus from a confirmed case of swine influenza A (H1N1), antiviral chemoprophylaxis with zanamivir or oseltamivir for 7 days after exposure can be considered CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Biosafety Guidelines for Laboratory Workers FDA Issues Authorizations for Emergency Use (EUAs) of Diagnostic Tests • On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued EUAs in response to requests by the Centers for Disease Control and Prevention (CDC) for the swine flu outbreak • One of the reasons the EUAs could be issued was because the U.S. Department of Health and Human Services (HHS) declared a public health emergency on April 26, 2009 • The swine influenza EUAs aid in the current response: • CHOTANI © 2009. Diagnostic Test: Allow CDC to distribute the rRT-PCR Swine Flu Panel diagnostic test to public health and other qualified laboratories that have the equipment and personnel to perform and interpret the results. Source: CDC Swine Influenza A(H1N1) Guidelines for General Population • Covering nose and mouth with a tissue when coughing or sneezing • Dispose the tissue in the trash after use. • Handwashing with soap and water • Especially after coughing or sneezing. • Cleaning hands with alcohol-based hand cleaners • Avoiding close contact with sick people • Avoiding touching eyes, nose or mouth with unwashed hands • If sick with influenza, staying home from work or school and limit contact with others to keep from infecting them CHOTANI © 2009. Comparison of Available Influenza Diagnostic Tests1 Influenza Diagnostic Tests Method 3 Availability Typical 2 Processing Time Sensitivity for 2009 H1N1 influenza Distinguishes 2009 H1N1 influenza from other influenza A viruses? Rapid influenza diagnostic 4 tests (RIDT) Antigen dete ction Wide 0.5 hour 10 – 70% No Direct and indirect Immunofluorescence 5 assays (DFA and IFA) Antigen dete ction Wide 2 – 4 hours 47–93% No Viral isolation in tissue cell culture Virus isola tion Limited 2 -10 days - Nucleic acid amplification tests 7 (including rRT-PCR) RNA dete ction Limited 48 – 96 hours [6-8 hours to perform test] 86 – 100% CHOTANI © 2009. 8 Yes 6 Yes Source: CDC Swine Influenza A(H1N1) Antiviral Protection • There are two flu antiviral drugs recommended • Oseltamivir or Zanamivir • Use of anti-virals can make illness milder and recovery faster • They may also prevent serious flu complications • For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms) • Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing products (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers (up to 18 years old) who are confirmed or suspected ill case of swine influenza A (H1N1) virus infection; this can cause a rare but serious illness called Reye’s syndrome. For relief of fever, other anti-pyretic medications are recommended such as acetaminophen or non steroidal anti-inflammatory drugs. • Treatment is recommended for: • • • CHOTANI © 2009. All hospitalized patients with confirmed, probable or suspected novel influenza (H1N1). Patients who are at higher risk for seasonal influenza complications If patient is not in a high-risk group or is not hospitalized, healthcare providers should use clinical judgment to guide treatment decisions Source: CDC Swine Influenza A(H1N1) Antiviral Protection • Antiviral Chemoprophylaxis for Treatment: • Post-exposure: Duration chemoprophylaxis is 10 days after the last known exposure to novel (H1N1) influenza and may be considered in the following: • Close contacts of cases (confirmed, probable, or suspected) • Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person (confirmed, probable, or suspected) during that person’s infectious period. • • Antiviral Use for Control of Novel H1N1 Influenza Outbreaks • • • Pre-exposure: Antivirals should only be used in limited circumstances, and in consultation with local medical or public health authorities. A cornerstone for the control of seasonal influenza outbreaks in nursing homes and other long term care facilities. If outbreaks were to occur, it is recommended that ill patients be treated with oseltamivir or zanamivir and that chemoprophylaxis with either oseltamivir or zanamivir be started as early as possible to reduce the spread of the virus as is recommended for seasonal influenza outbreaks in such settings. Children Under 1 Year of Age • CHOTANI © 2009. Oseltamivir is not licensed for use in children less than 1 year of age. Because infants experience high rates of morbidity and mortality from influenza, infants with novel (H1N1) influenza virus infections may benefit from treatment using oseltamivir. Source: CDC Swine Influenza A(H1N1) Antiviral Protection Oseltamivir (Tamiflu) Treatment Prophylaxis Zanamivir (Relenza) Treatment Prophylaxis Adults 75 mg capsule twice per day for 5 days 75 mg capsule once per day Two 5 mg inhalations (10 mg total) twice per day Two 5 mg inhalations (10 mg total) once per day Children 15 kg or less: 60 mg per day divided into 2 doses 30 mg once per day Two 5 mg inhalations (10 mg total) twice per day (age, 7 years or older) Two 5 mg inhalations (10 mg total) once per day (age, 5 years or older) 15–23 kg: 90 mg per day divided into 2 doses 45 mg once per day 24–40 kg: 120 mg per day divided into 2 doses 60 mg once per day >40 kg: 150 mg per day divided into 2 doses 75 mg once per day Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatment dose for 5 days. <3 months: 12 mg twice daily; 3-5 months: 20 mg twice daily; 6-11 months: 25 mg twice daily Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. Recommended prophylaxis dose for 10 days. <3 months: Not recommended unless situation judged critical due to limited data on use in this age group; 3-5 months: 20 mg once daily; 6-11 months: 25 mg once daily CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Vaccine Protection • Novel H1N1 vaccine available for since Mid-September • Seventh Harvard Pandemic Survey • • • 38% of Children in the US immunized 50% Adults do not intend to be immunized 35% of parents do not intend to get their children immunized • Novel H1N1 vaccine is not intended to replace the seasonal flu vaccine – it is intended to be used along-side seasonal flu vaccine • Vaccines: • Inactivated influenza virus vaccines • CSL Ltd. of Australia • Novartis Vaccines of Switzerland • Sanofi Pasteur of France • 800,000 pre-filled syringes were recalled are for young children, ages 6 months to 3 years in the US • GlaxoSmithKline (GSK) of UK • Sinovac Biotech of China • Live-attenuated virus vaccine • MedImmune LLC of US (nasal-spray) • CHOTANI © 2009. 4.5 million doses recalled due to decreased potency in the US Adverse events reported after receipt of influenza A (H1N1) 2009 monovalent vaccines and seasonal influenza vaccines Vaccine Adverse Event Reporting System (VAERS), United States, July 1- November 24, 2009 Serious adverse events† Influenza vaccine received All reports of adverse events* Total Fatal Nonserious events† Nonfatal No. (%) No. (%) No. (%) No. (%) H1N1 total 3,783 204 5.4 13 0.3 191 5 3,579 94.6 Live, attenuated monovalent vaccine 1,115 52 4.7 3 0.3 49 4.4 1,063 95.3 Monovalent inactivated, split-virus or subunit 2,439 135 5.5 9 0.4 126 5.2 2,304 94.5 229 17 7.4 1 0.4 16 7 212 92.6 4,672 283 6.1 16 0.3 267 5.7 4,389 93.9 480 35 7.3 0 --- 35 7.3 445 92.7 4,028 232 5.8 15 0.4 217 5.4 3,796 94.2 164 16 9.8 1 0.6 15 9.1 148 90.2 Unknown Seasonal total Live, attenuated influenza vaccine Trivalent inactivated Unknown * An adverse event reported to VAERS might occur by chance after vaccination or might be related causally to vaccine; VAERS generally does not determine whether a vaccine caused an adverse event. Excluding 62 reported with insufficient information, of which two were serious adverse events: one allergic and one local reaction (i.e., cellulitis at the injection site). † Serious adverse events are defined as those resulting in death, life-threatening illness, hospitalization, prolongation of hospitalization, persistent or significant disability, or congenital anomaly. All other events are categorized as nonserious. Food and Drug Administration. 21 CFR Part 600.80. Postmarketing reporting of adverse experiences. Federal Register 1997;62:52252--3. SOURCE: Safety of Influenza A (H1N1) 2009 Monovalent Vaccines --- United States, October 1--November 24, 2009, MMWR. December 11, 2009 / 58(48);1351-1356 CHOTANI © 2009. Patient age, sex, and clinical characteristics regarding the 13 reported deaths after receipt of influenza A (H1N1) 2009 monovalent vaccines Vaccine Adverse Event Reporting System, United States, 2009* Age (yrs) Sex H1N1 vaccine type Vaccination to onset (days) 1 Male MIV† 1 Febrile seizures (one after measles, mumps, rubella vaccination) Sudden death, no evidence of trauma 2 Female MIV 0 Encephalopathy, central apnea, traumatic brain damage, seizures Sudden cardiopulmonary arrest 9 Female LAMV§ 6 Trisomy 21, leukemia (in remission), cardiac disease (neutropenia on vaccination day) Pneumococcal pneumonia/H1N1 influenza 18 Male LAMV 0 No significant history, dental care for gingivitis 2 weeks before H1N1 vaccination; enlarged heart on chest radiograph Massive aspiration/ Sudden cardiopulmonary arrest 19 Female MIV 9 Rett syndrome, severe muscle wasting/physical disability Bilateral pneumonia, respiratory failure 35 Female LAMV 3 Hereditary spherocytosis, splenectomy Pneumoccocal sepsis 38 Male MIV 19 Immunocompromised Respiratory failure/Under review 46 Female MIV 2 Hypertension, hyperlipidemia, pulmonary embolism, deep vein thrombosis Pulmonary embolus/Negative for H1N1 in lung tissue 49 Female MIV 3 Type 2 diabetes, stroke, chronic obstructive pulmonary disease, emphysema, substance abuse Suspected cardiovascular event 53 Female MIV 5 End-stage renal disease and atrial fibrillation Under review 56 Female MIV 0 Driver involved in motor vehicle crash leaving clinic after H1N1 vaccination Trauma 61 Male MIV 13 Hypertension, diabetes, peripheral vascular disease, end stage renal disease Cardiac/Respiratory arrest, gram- negative sepsis 77 Male MIV 2 Lung cancer atrial fibrillation, recurrent deep venous thrombosis hypertension, hyperlipidemia Suspected myocardial infarction Medical history Preliminary diagnosis/Autopsy results * As of November 24, 2009. † Monovalent inactivated, split-virus or subunit vaccines. § Live, attenuated monovalent vaccine. SOURCE: Safety of Influenza A (H1N1) 2009 Monovalent Vaccines --- United States, October 1--November 24, 2009, MMWR. December 11, 2009 / 58(48);1351-1356 CHOTANI © 2009. Swine Influenza A(H1N1) Vaccine Protection • CDC’s Advisory Committee on Immunization Practices (ACIP) recommends the following groups to receive the novel H1N1 influenza vaccine: • Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated; • Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus; • Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity; • All people from 6 months through 24 years of age • Children from 6 months through 18 years of age because we have seen many cases of novel H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and • Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and, • Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza. CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Face Mask and Respirator Protection Setting Persons not at increased risk of severe illness from influenza (Non-high risk persons) Persons at increased risk of severe illness from influenza (High-Risk Persons) Community No 2009 H1N1 in community Facemask/respirator not recommended Facemask/respirator not recommended 2009 H1N1 in community: not crowded setting Facemask/respirator not recommended Facemask/respirator not recommended 2009 H1N1 in community: crowded setting Facemask/respirator not recommended Avoid setting. If unavoidable, consider facemask or respirator Caregiver to person with influenza-like illness Facemask/respirator not recommended Avoid being caregiver. If unavoidable, use facemask or respirator Other household members in home Facemask/respirator not recommended Facemask/respirator not recommended No 2009 H1N1 in community Facemask/respirator not recommended Facemask/respirator not recommended 2009 H1N1 in community Facemask/respirator not recommended but could be considered under certain circumstances Facemask/respirator not recommended but could be considered under certain circumstances Respirator Consider temporary reassignment. Respirator Home Occupational (non-health care) Occupational (health care) Caring for persons with known, probable or suspected 2009 H1N1 or influenza-like illness CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Other Protective Measures Defining Quarantine vs. Isolation vs. Social-Distancing • Isolation: Refers only to the sequestration of symptomatic patents either in the home or hospital so that they will not infect others • Quarantine: Defined as the separation from circulation in the community of asymptomatic persons that may have been exposed to infection • Social-Distancing: Has been used to refer to a range of nonquarantine measures that might serve to reduce contact between persons, such as, closing of schools or prohibiting large gatherings CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Other Protective Measures Personnel Engaged in Aerosol Generating Activities • CDC Interim recommendations: • Personnel engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator • Pending clarification of transmission patterns for this virus, personnel providing direct patient care for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator when entering the patient room • Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Other Protective Measures Infection Control of Ill Persons in a Healthcare Setting • Patients with suspected or confirmed case-status should be placed in a single-patient room with the door kept closed. If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling. • The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. CHOTANI © 2009. Source: CDC Swine Influenza A(H1N1) Other Protective Measures Infection Control of Ill Persons in a Healthcare Setting • Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Maintain adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. • Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure. CHOTANI © 2009. Source: CDC Summary • • • • • 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 • • Europe: Widespread and active transmission continued to be observed throughout the continent • • • • • Approximately 53% of hospitalized cases in Canada had an underlying medical condition Overall pandemic influenza activity appears to have recently peaked across a majority of countries Western and Central Asia: Virus circulation remains active throughout the region, however disease trends remain variable East Asia: Influenza transmission remains active but appears to be declining overall Central and South America and the Caribbean: influenza transmission remains geographically widespread but overall disease activity has been declining or remains unchanged in most parts, except for in Barbados and Ecuador, were recent increases in respiratory diseases activity have been reported Southern Hemisphere: Sporadic cases of pandemic influenza continued to be reported without evidence of sustained community transmission. CHOTANI © 2009. Summary • In the US • • • • In Mexico • • • • Number of deaths being reported is rising Vaccine • • • Majority of the cases reported in health young adults (20-29 years) Globally • • 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 • • Highest incidence of lab-confirmed cases reported among 5-24 years old Highest hospitalization rate among 0-4 years old Underlying health conditions confers high risk of complications and deaths Total Adverse Events: 5.4% (0.3% fatal) Sanofi Pasteur & MedImmune vaccine recalled due to potency issues Anti-virals (oseltamivir and zanamivir) • CHOTANI © 2009. Oseltamivir resistance reported recently in immunocompromised patents Timeline of Emergence Influenza A Viruses in Humans Reassorted Influenza virus (Swine Flu) 1976 Swine Flu Outbreak, Ft. Dix H1 Avian Influenza H9 H7 H5 H5 H1 H3 H2 H1 1918 1957 Spanish Influenza H1N1 Asian Influenza H2N2 CHOTANI © 2009. 1968 1977 Hong Russian Kong Influenza Influenza H3N2 1997 2003 1998/9 2009 Lessons Learned form Past Pandemics • 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 • • • • • 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 • • Cytokine Storm? World War I –8.3 million military deaths over 4 years 25-35% of the world infected CHOTANI © 2009. Lessons Learned form Past Pandemics • 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 • • • • Temporary banning of public gatherings, closing schools potentially effective in case of severe disease and high mortality Delaying spread is desirable • CHOTANI © 2009. Does not change population susceptibility Delay spread in Australia— later milder strain causes infection there Fewer people ill at one time improve capacity to cope with sharp increase in need for medical care Conclusion/Recommendations 1. Past experience with pandemics have taught us that the second wave is worse than the first causing more deaths due to: • • • 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 • • CHOTANI © 2009. Most of these deaths however have been reported in cases with underlying medical conditions 60 years and above age group seems to show some protection against this strain suggesting past exposure and some immunity Conclusion/Recommendations 3. Each locality/jurisdiction needs to • • • • 4. Have enhanced disease and virological surveillance capabilities Develop a plan to house large number of severely sick and provide care if needed to deal with mildly sick at home (voluntary quarantine) Healthcare facilities/hospitals need to focus on increasing surge capacity and stringent infection prevention/control General population needs to follow basic precautions In the Northern Hemisphere influenza viral transmission traditionally stops by the beginning of May but in pandemic years (1957) sporadic outbreaks occurred during summer among young adults • CHOTANI © 2009. This novel H1N1 strain has survived high humidity or temperature and continued to spread during the summer months and will continue to spread and cause infection Conclusion/Recommendations 5. School Closures: • • • • 6. Preemptive school closures merely delay the spread of disease Once schools reopen the disease transmits and spreads Puts unbearable pressure on single-working parents and would be devastating to the economy Closure after identification of a large cluster would be appropriate as absenteeism rate among students and teachers would be high enough to justify this action Burden of Disease & Mortality • • Actual burden of the disease will be higher than the regular seasonal flu despite the availability of vaccine, antivirals and excellent public knowledge With the variation in reporting it is very difficult to appreciate the total number of deaths It is imperative to appreciate that “times-have-changed” 7. • • CHOTANI © 2009. Though this strain has spread very quickly across the globe and seems to be highly infectious, today we are much better prepared than 1918 There is better surveillance, communication, understanding of infection control, vaccines, anti-virals, antibiotics and advancement in science and resources to produce countermeasures quickly