Dr' Jarbas Barbosa

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Dr. Jarbas Barbosa Area Manager Health
Surveillance Disease Prevention and Control
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Timeline (1)

• April 10 an outbreak of influenza-like illness
  in Veracruz, Mexico detected.
• April 11 PAHO IHR requested verification.
• April 12 Mexican government confirmed outbreak
  investigation.
• April 16 A case of atypical pneumonia in the
  Mexican state of Oaxaca triggered enhanced
  surveillance
• April 18 two cases of the new A (H1N1) virus
  infection identified in two southern California
  counties in USA.

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Timeline (2)

• April 23 new influenza A (H1N1) virus infection
  confirmed in several patients in Mexico.
• April 26 38 cases reported by Mexico and the USA
• April 27 Canada and Spain reported first
  confirmed cases
• April 28 UK, Israel, New Zealand
• April 27 WHO declared phase 4
• April 29 WHO declared phase 5
• June 11 WHO declared phase 6 pandemic
• In 9 weeks all WHO regions reporting cases of
  pandemic
  (H1N1) 2009

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Epidemiology of Pandemic (H1N1) 2009 Virus
Infection
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Emergence of a pandemic
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Pandemic (H1N1) 2009Number of laboratory
confirmed cases as reported to WHO (18 April to
30 August 2009)
18 April 2009
30 August 2009
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Number of confirmed cases and deaths Pandemic
(H1N1) 2009

• Worldwide Widespread geographic distribution
• 188 countries and territories affected
• at least 2,837 deaths in 62 countries
  (cumulative numbers as of August 30, 2009)
• In the Americas
• 35/35 countries affected
• 120,629 confirmed cases and 2,467 deaths as of
  September 3, 2009, 1600

Communicate directly to IHR Point of Contact at
WHO Regional Office (ihr_at_paho.org)
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Pandemic (H1N1) 09 virus characteristics

• All viruses to date are homogeneous
  antigenically and react well with antisera
  raised against
  California/4/2009 and
  California/7/2009
• To date, no recognized genetic markers
  associated with virulence
• (Viruses isolated from severe cases do not show
  sequence differences)
• Virus replicates more in lungs and causes more
  severe pneumonia in animals (ferrets, mice,
  primates) than seasonal H1N1 (unpublished)

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Confirmed Cases in Argentina by date of onset
Initial spread in large cities
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Distribution of confirmed pandemic influenza A
(H1N1) 2009 cases by age group in selected
countries
Source Ministries of Health of the countries in
the Region
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Hospitalized or severe confirmed cases
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Deaths among confirmed cases

2 Age range for the 90 women in childbearing
age not specified. Numerator includes pregnant
and puerperal women. 3 Among women between 15
and 49 years old 4 Among women between 15 and
44 years old. 5 Not specified if this
percentage is among total deaths or among total
deaths women in childbearing age
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Distribution of respiratory virus by
epidemiological week (EW), Chile EW 1-34
Jan
Feb
Mar
Apr
Jun
Jul
May
Aug
Epidemiological week
Source Chile Ministry of Health
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Distribution of respiratory virus by age group.
Argentina, January- September 2009
Source Argentina Ministry of Health
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Distribution of outpatient visits by
Epidemiological Week in different regions of
Chile.
National Rate (100,000 hab)
of cases per Region
Source Chile Ministry of Health
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Epidemiology of Pandemic (H1N1) 2009 Virus
Infection

• 60 of the confirmed cases being detected in
  persons with less than 20 years of age.
  Hospitalized cases and deaths occurred in adults.
• Hospitalization and case/fatality in young adults
  higher than seasonal influenza.
• Epidemiologic and serologic evidence for low
  susceptibility in older adults.
• At-risk groups Pregnant women, people with
  chronic diseases and underlying health
  conditions, young children, people with
  immunosuppression.
• Replacement of influenza seasonal virus.

Source WHO
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WHO Surveillance Guidelines

• For countries not yet affected
• Document first appearance of the pandemic virus
  and to collect sufficient information for risk
  assessment.
• Once affected
• Detect any changes in the epidemiological,
  virological or clinical presentation.
• Unusual or unexpected public health events, e.g.
  clusters of severe unexplained acute respiratory
  illness or unexplained deaths.

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Qualitative Indicators for the monitoring of
Pandemic (H1N1) 2009
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Monitoring of Respiratory Disease Activity in
Americas Region

• Northern Temperate zone
• US and Canada Overall, low levels of ILI
  activity, below epidemic threshold.
• Increasing ILI activity in the southeastern US.
• In Canada, 11-17 of severe cases are indigenous.
• Southern temperate zone
• Chile and Argentina Continued regional to
  widespread geographic activity
• The majority of respiratory virus detections are
  now due to Respiratory Syncitial Virus (RSV).

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Monitoring of Respiratory Disease Activity in
Americas Region

• Equatorial South America
• Bolivia, Ecuador and Venezuela Continue to
  experience widespread geographic influenza
  activity with increasing respiratory disease
  trend in most countries.
• Brazil Regional geographic activity, especially
  in later affected tropical areas. ILI
  consultations (15 of all visits) are falling,
  but remain significantly above seasonal
  historical average.
• Tropical Central America
• Costa Rica, El Salvador, Guatemala, Honduras and
  Panama Continue to experience widespread
  geographic influenza activity, but the
  respiratory disease trend is now beginning to
  decrease. Impact on the healthcare system
  continues to be moderate.

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Clinical presentation and evolution
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Initial Clinical Presentation

• Short incubation period (1-2(-4) days)
• Onset of the disease usually abrupt with
• - Typical systemic symptoms
• high fever and chills(94)
• severe malaise
• fatigue and weakness
• headache or myalgia
• Respiratory tract signs non-productive cough
  (92), sore throat (66), and rhinitis
• Gastrointestinal manifestations diarrhea and
  vomiting (25)

Emergence of a Novel Swine-Origin Influenza A
(H1N1) Virus in Humans. N Engl J Med 2009360.
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Complications - Severe cases

• Signs and symptoms
• Dysnea
• Cough
• Hemopthysis

• Predominant age group 20-59 years
• Age range 1-80 years
• Sex ratio 1
• Underlying conditions 60-80
• COPD, asthma
• diabetes,
• cardiovascular disease
• pregnancy
• obesity

• Investigation findings
• Chest x-ray multilobar infiltrates (100)
• Sat O2 lt 90 (100)
• Renal failure and/or hepatic affectation (50)
  Multiorganic failure

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Complications - Severe cases

• Diagnosis Primary influenza pneumonia
• Complications Mechanical ventilation secondary
  pneumonia
• Antiviral treatment in severe cases
• - After 7 days of initiation of symptoms worse
  evolution
• 1 3 days of initiation of symptoms better
  outcome

 Source Dr. Luis Septien Stute. Hospital General
de Mexico
Source MoH Argentina, Canada, Chile, Dominican
Republic, Mexico, Uruguay and USA
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Estimated by data pooling Percentages calculated
on the immediate lower step
Source MoH Argentina, Canada, Chile, Dominican
Republic, Mexico, Uruguay and USA
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Age-related distribution of deaths from severe
pneumonia compared to influenza seasons
2006-08(Mexico, 24 March- 29 April 2009)

• During 5-weeks period, 2155 cases of severe
  pneumonia with 821 hospitalizations 100 deaths

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Key challenges

• Identification of predictors for severity among
  young adults with no underlying diseases.
• Oseltamivir resistance surveillance.
• Algorithms for clinical management of severe
  cases.

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WHO-SAGE recommendations on pandemic (H1N1) 2009
vaccines- 7th July 09

• Health-care workers as a first priority to
  protect the essential health infrastructure
• SAGE suggested the following groups for
  consideration (countries need to determine their
  order of priority based on country-specific
  conditions)
• Pregnant women
• Above 6 months with one of several chronic
  medical conditions
• Healthy young adults of 15 to 49 years of age
• Healthy children
• Healthy adults of 50 to 64 years of age and
• Healthy adults of 65 years or above.
• Post-marketing surveillance of the highest
  possible quality
• Promoting production and use of vaccines
  formulated with oil-in-water adjuvant and live
  attenuated influenza vaccines.

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International Passenger Departures from
MexicoMarch 1st to April 30th 2008
Risk assessment Mapping destinations of flights
N Engl J Med 361(2)212-4 (July 9, 2009)
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PAHO/WHO Response to A/H1N1 in the Americas
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What is PAHO doing?

• PAHO has been working with countries since 2004
  on pandemic preparedness and on the International
  Health Regulations.
• Is tracking the regional situation and advising
  countries on surveillance, laboratory and
  infection control measures required to identify
  and treat cases and trace contacts.
• Has mobilized experts to several countries of the
  Region in epidemiology, virology, laboratory
  analysis, infection control, emergency response,
  logistics, risk communication including
  actualization of treatment guidelines.
• Has distributed laboratory diagnostic kits
  through Collaborating Centers to National
  Influenza Centers.

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What is PAHO doing?

• Has deployed a stockpile of Oseltamivir (Tamiflu)
  to countries in the Region.
• Weekly teleconferences with Ministries of Health
  and Epidemiology Chiefs of all countries in the
  Region.
• Provides risk communication support to countries.
  
• Weekly publication of regional updates including
  qualitative indicators .
• Development of technical guidelines and
  translation, publication and dissemination of WHO
  materials.
• Mobilizing additional resources.

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What should countries do?

• Adapt plans and interventions to the current
  pandemic, which is assessed as moderate.
• Calibrate their response to the current severity
  assessment.
• Implement public health measures based on the
  epidemiological situation
• Continue monitoring for increases in severity,
  genetic changes and strengthening health systems
  to ensure continuity and rapid adjustments.

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Pandemic (H1N1) 2009Summary

• So far, high but variable transmissibility in
  countries.
• 5-45 years old people most commonly affected.
• Hospitalization rates and case-fatality in young
  adults higher than during seasonal influenza.
• Co-circulation of seasonal and pandemic viruses.
• Groups at risk for severe illness pregnant
  women those with asthma, obesity, chronic heart
  or lung disease, cancer, immunosuppression.

Source WHO
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Pandemic (H1N1) 2009Summary

• In the Northern Hemisphere transmission is
  expected to increase during fall and winter.

• Every country needs to be prepared for this
  situation in the following areas
• Surveillance
• Public health measures
• Health services
• Antivirals and vaccines
• Risk communication

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Thank you Please visit PAHO Pandemic (H1N1)
2009 web page for regular updates www.paho.org