Rashid A. Chotani, MD, MPH, DTM - PowerPoint PPT Presentation

1 / 81
About This Presentation
Title:

Rashid A. Chotani, MD, MPH, DTM

Description:

– PowerPoint PPT presentation

Number of Views:142
Avg rating:3.0/5.0
Slides: 82
Provided by: rei136
Learn more at: https://sites.pitt.edu
Category:
Tags: dtm | mph | chotani | rashid

less

Transcript and Presenter's Notes

Title: Rashid A. Chotani, MD, MPH, DTM


1
Just-in-Time LectureInfluenza A(H1N1) (Swine
Flu) Pandemic (Version 15, first JIT lecture
issued April 26)December 28, 2009 (400 PM EST)
  • Rashid A. Chotani, MD, MPH, DTM
  • Adjunct Assistant Professor
  • Uniformed Services University of the Health
    Sciences (USUHS)
  • 240-367-5370
  • chotani_at_gmail.com

2
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

3
OUTLINE
  • Influenza Virus
  • Definitions
  • Introduction
  • History in the US
  • Spread/Transmission
  • Timeline/Facts
  • Response
  • Status Update
  • US
  • Mexico
  • Canada
  • European Union
  • Globally
  • Case-Definitions
  • Guidelines
  • Clinicians
  • Laboratory Workers
  • General Population
  • Treatment

4
Virus
Credit L. Stammard, 1995
5

6
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

7
Survival of Influenza Virus Surfaces and Affect
of Humidity Temperature
  • Hard non-porous surfaces 24-48 hours
  • Plastic, stainless steel
  • Recoverable for gt 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 lt5 minutes only at high viral
    titers
  • Potential for indirect contact transmission
  • Humidity 35-40, Temperature 28C (82F)

Source Bean B, et al. JID 198214647-51
8
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)
  • gt200,000 Hospitalizations
  • 37.5 billion in economic cost (influenza
    pneumonia)
  • gt10 billion in lost productivity
  • Pandemic Influenza
  • An ever present threat

9
Swine Influenza A(H1N1) Introduction
  • Swine Influenza (swine flu) is a respiratory
    disease of pigs caused by type A influenza that
    regularly cause outbreaks of influenza among pigs
  • Most commonly, human cases of swine flu happen in
    people who are around pigs
  • Swine flu viruses do not normally infect humans,
    however, human infections with swine flu do
    occur, and cases of human-to-human spread of
    swine flu viruses have been documented

10
Swine Influenza A(H1N1) History in US
  • A swine flu outbreak in Fort Dix, New Jersey, USA
    occurred in 1976 that caused more than 200 cases
    with serious illness in several people and one
    death
  • More than 40 million people were vaccinated
  • However, the program was stopped short after over
    500 cases of Guillain-Barre syndrome, a severe
    paralyzing nerve disease, were reported
  • 30 people died as a direct result of the
    vaccination
  • In September 1988, a previously healthy
    32-year-old pregnant woman in Wisconsin was
    hospitalized for pneumonia after being infected
    with swine flu and died 8 days later.
  • From December 2005 through February 2009, a total
    of 12 human infections with swine influenza were
    reported from 10 states in the United States

11
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

12
Swine Influenza A(H1N1) Transmission Through
Species
Reassortment in Pigs
13
Swine Influenza A(H1N1) March 2009Timeline
  • In March and early April 2009, Mexico experienced
    outbreaks of respiratory illness and increased
    reports of patients with influenza-like illness
    (ILI) in several areas of the country
  • April 12, the General Directorate of Epidemiology
    (DGE) reported an outbreak of ILI in a small
    community in the state of Veracruz to the Pan
    American Health Organization (PAHO) in accordance
    with International Health Regulations
  • April 17, a case of atypical pneumonia in Oaxaca
    State prompted enhanced surveillance throughout
    Mexico
  • April 23, several cases of severe respiratory
    illness laboratory confirmed as influenza A(H1N1)
    virus infection were communicated to the PAHO
  • Sequence analysis revealed that the patients were
    infected with the same strain detected in 2
    children residing in California
  • Samples from the Mexico outbreak match swine
    influenza isolates from patients in the United
    States

Source CDC
14
Swine Influenza A(H1N1) March 2009Facts
  • Virus described as a new subtype of A/H1N1 not
    previously detected in swine or humans
  • CDC determines that this virus is contagious and
    is spreading from human to human
  • The virus contains gene segments from 4 different
    influenza types
  • North American swine
  • North American avian
  • North American human and
  • Eurasian swine

15
Swine Influenza A(H1N1) US Response
  • The Strategic National Stockpile (SNS) is
    releasing one-quarter of its
  • Anti-viral drugs
  • Personal protective equipment and
  • Reparatory protection devices
  • President Obama today asked Congress for an
    additional 1.5 billion to fight the swine flu
  • On April 27, 2009, the CDC issued a travel
    advisory that recommends against all
    non-essential travel to Mexico

Source CDC
16
Swine Influenza A(H1N1) Global Response
  • The WHO raises the alert level to Phase 6
  • WHOs 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
17
Swine Influenza A(H1N1)Status Update
  • US March December 28
  • Estimates
  • Symptomatic 55 million
  • Hospitalized 300,000
  • Deaths 13,000
  • Death among children since August 2009 221
  • Sub-type 99 Influenza A (H1N1)
  • Activity On decline
  • MEXICO March 01 December 23
  • Laboratory confirmed cases 68,123
  • Deaths 823
  • Activity On decline
  • CANADA As of December 23
  • Deaths 401
  • Activity On decline

Source Secretaria de Salud, Mexico, CDC, Public
Health Agency of Canada, European CDC, WHO
18
Swine Influenza A(H1N1)Status Update
  • GLOBALLY March 1-December 23
  • At least 11,516 Deaths
  • Africa Region (AFRO) 109
  • Americas Region (AMRO) 6,670
  • Eastern Mediterranean Region (EMRO) 663
  • Europe Region (EURO) 2,045
  • South-East Asia Region (SEARO) 990
  • Western Pacific Region (WPRO) 1,039

ECDC reported a total of 12,776 deaths December
28, 2009
Source WHO
19
Swine Influenza A(H1N1) CDC Estimates from
April-November 14, 2009, By Age Group
Source CDC. http//www.cdc.gov/h1niflu/surveillan
ceqa.htm
20
Swine Influenza A(H1N1) Symptoms Reported in US
Hospitalized Patients
Source CDC. http//www.cdc.gov/h1niflu/surveillan
ceqa.htm
21
Swine Influenza A(H1N1) Lab-Confirmed Cases in
the US as of July 24, 2009 (n43,771)
Percent Represents proportion of Total Cases
50
17
15
1
11
5
Source Dr. Anthony Fiore, Influenza Division,
NCIRD, CDC
22
Swine Influenza A(H1N1) Lab-Confirmed Cases in
the US as of July 24, 2009 (n37,030)
Rate Per 100,000 Population by Age Group
n22080
n4816
n7434
n2187
n513
Excludes 6,741 Cases with missing
data Rate/100,000 by Single Year Age Groups
Denominator Source 2008 Census Estimated, US
Census Bureau
Source Dr. Anthony Fiore, Influenza Division,
NCIRD, CDC
23
Swine Influenza A(H1N1) Hospitalizations of
Lab-Confirmed Cases in the US as of July 24, 2009
(n5,011)
Percent Represents proportion of Total
Hospitalizations
34
24
19
13
5
4
Source Dr. Anthony Fiore, Influenza Division,
NCIRD, CDC
24
Swine Influenza A(H1N1) Hospitalizations of
Lab-Confirmed Cases in the US as of July 24, 2009
(n5,011)
Rate Per 100,000 Population by Age Group
N953
N1718
n225
13
N658
N1184
Source Dr. Anthony Fiore, Influenza Division,
NCIRD, CDC
25
Swine Influenza A(H1N1) Deaths Among
Lab-Confirmed Cases in the US as of July 24, 2009
(n302)
41
24
16
9
9
2
Source Dr. Anthony Fiore, Influenza Division,
NCIRD, CDC
26
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
Epidemiological Alert 4/13/09
School Open 5/12/09
NOTE Numbers can change
Source Secretaria de Salud, Mexico
27
Swine Influenza A(H1N1) Mexico Confirmed Case
Distribution, by Age
As of December 23, 2009
Total Number of Confirmed Cases 68,123
Source Secretaria de Salud, Mexico
28
Swine Influenza A(H1N1) Mexico Confirmed Death,
by Age Groups
As of December 23, 2009
Deaths 823
69.7 Deaths
Source Secretaria de Salud, Mexico
29
Swine Influenza A(H1N1) Mexico Death, by
Underlying Condition
As of December 23, 2009
N823
Source Secretaria de Salud, Mexico
30
Swine Influenza A(H1N1) Mexico Deaths, by
Symptoms
As of December 23, 2009
N823
Source CDC. http//www.cdc.gov/h1niflu/surveillan
ceqa.htm
31
Swine Influenza A(H1N1) Canada Confirmed Cases
Deaths, by Province or Territory
As of July 15, 2009
Total Number of Confirmed Cases 10,156 Death
45 Cases reported from 13 of 13 Provinces
15
Deaths
17
3
3
6
1
0
0
0
0
0
0
0
Since July 15 only deaths have been reported
now totaling 397
Source Public Health Agency of Canada
32
Swine Influenza A(H1N1) Canada Total Confirmed
Deaths, by Province or Territory
As of December 23, 2009
Total Number of Confirmed Death 401 Deaths
reported from 12 of 13 Provinces
Source Public Health Agency of Canada
33
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
78
Deaths
1
3
3
2
32
4
3
2
29
3
1
1
1
Currently only deaths are being reported now
totaling 1,371
Source ECDC
34
Swine Influenza A(H1N1) EU EFTA Countries
Confirmed Case Distribution, by Age
27 April to 8 May 2009 n46
Source ECDC
35
Swine Influenza A(H1N1) EU EFTA Deaths
April 27 December 28, 2009
Total Number of Deaths among Confirmed Cases
1,832
Source ECDC
36
Swine Influenza A(H1N1) Other European Countries
Central Asia Confirmed Deaths
As of December 28, 2009
n397
Source ECDC
37
Swine Influenza A(H1N1) Mediterranean Middle
East Confirmed Deaths
As of December 28, 2009
n1,246
Source ECDC
38
Swine Influenza A(H1N1) Africa Confirmed Deaths
As of December 28, 2009
n116
Source ECDC
39
Swine Influenza A(H1N1) North America Confirmed
Deaths
As of December 28, 2009
n3,384
Source ECDC
40
Swine Influenza A(H1N1) Central America
Caribbean Confirmed Deaths
As of December 28, 2009
n222
Source ECDC
41
Swine Influenza A(H1N1) South America Confirmed
Deaths
As of December 28, 2009
n3,157
Source ECDC
42
Swine Influenza A(H1N1) North-East South Asia
Confirmed Deaths
As of December 28, 2009
n1,820
Source ECDC
43
Swine Influenza A(H1N1) South-East Asia
Confirmed Deaths
As of December 28, 2009
n388
Source ECDC
44
Swine Influenza A(H1N1) Australia Pacific
Confirmed Deaths
As of December 28, 2009
n217
Source ECDC
45
Swine Influenza A(H1N1) EU EFTA Countries
Confirmed Deaths, by Week
As of December 28, 2009
n1,803
Source ECDC
46
Swine Influenza A(H1N1) Global Confirmed Deaths,
by Week
As of December 28, 2009
n12,682
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
Source ECDC
47
Global Distribution of Reported Laboratory
Confirmed Cases Deaths of Swine Influenza
A(H1N1), December 23, 2009
Source WHO
48
Geographic Spread of Influenza ActivityBased
Upon Country Reporting, Week 50, 2009 (07-23
December)
Source WHO
49
Impact on Healthcare Services Based Upon Degree
of Disruption, As a Result of Acute Respiratory
DiseasesWeek 50, 2009 (07-13 December)
Source WHO
50
Number of Specimens Positive for Influenza
Sub-Type
Source CDC
51
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
CFR 0.4
CFR 0.3
CFR 1.1
CFR 0.5
CFR 0.6
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.
Source WHO
52
Swine Influenza A(H1N1) US Case Definitions
  • A confirmed case of swine influenza A (H1N1)
    virus infection is defined as a person with an
    acute febrile respiratory illness with laboratory
    confirmed swine influenza A (H1N1) virus
    infection at CDC by one or more of the following
    tests
  • real-time RT-PCR
  • viral culture
  • A probable case of swine influenza A (H1N1) virus
    infection is defined as a person with an acute
    febrile respiratory illness who is
  • positive for influenza A, but negative for H1 and
    H3 by influenza RT-PCR, or
  • positive for influenza A by an influenza rapid
    test or an influenza immunofluorescence assay
    (IFA) plus meets criteria for a suspected case
  • A suspected case of swine influenza A (H1N1)
    virus infection is defined as a person with acute
    febrile respiratory illness with onset
  • within 7 days of close contact with a person who
    is a confirmed case of swine influenza A (H1N1)
    virus infection, or
  • within 7 days of travel to community either
    within the United States or internationally where
    there are one or more confirmed swine influenza
    A(H1N1) cases, or
  • resides in a community where there are one or
    more confirmed swine influenza cases.

Source CDC
53
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 cases 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 cases infectious period
  • Acute respiratory illness is defined as recent
    onset of at least two of the following
    rhinorrhea or nasal congestion, sore throat,
    cough (with or without fever or feverishness)
  • High-risk groups A person who is at high-risk
    for complications of swine influenza A(H1N1)
    virus infection is defined as the same for
    seasonal influenza (see Reference)

Source CDC
54
Swine Influenza A(H1N1) Guidelines for Clinicians
  • Clinicians should consider the possibility of
    swine influenza virus infections in patients
    presenting with febrile respiratory illness who
  • live in areas where human cases of swine
    influenza A(H1N1) have been identified or
  • have traveled to an area where human cases of
    swine influenza A(H1N1) has been identified or
  • have been in contact with ill persons from these
    areas in the 7 days prior to their illness onset
  • If swine flu is suspected, clinicians should
    obtain a respiratory swab for swine influenza
    testing and place it in a refrigerator (not a
    freezer)
  • once collected, the clinician should contact
    their state or local health department to
    facilitate transport and timely diagnosis at a
    state public health laboratory

Source CDC
55
Swine Influenza A(H1N1) Guidelines for Clinicians
  • Signs and Symptoms
  • Influenza-like-illness (ILI)
  • Fever, cough, sore throat, runny nose, headache,
    muscle aches. In some cases vomiting and
    diarrhea. (These cases had illness onset during
    late March to mid-April 2009)
  • Cases of severe respiratory disease, requiring
    hospitalization including fatal outcomes, have
    been reported in Mexico
  • The potential for exacerbation of underlying
    chronic medical conditions or invasive bacterial
    infection with swine influenza virus infection
    should be considered
  • Non-hospitalized ill persons who are a confirmed
    or suspected case of swine influenza A (H1N1)
    virus infection are recommended to stay at home
    (voluntary isolation) for at least the first 7
    days after illness onset except to seek medical
    care

Source CDC
56
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
  • 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
57
Swine Influenza A(H1N1) Biosafety Guidelines for
Laboratory Workers
  • Diagnostic work on clinical samples from patients
    who are suspected cases of swine influenza A
    (H1N1) virus infection should be conducted in a
    BSL-2 laboratory
  • All sample manipulations should be done inside a
    biosafety cabinet (BSC)
  • Viral isolation on clinical specimens from
    patients who are suspected cases of swine
    influenza A (H1N1) virus infection should be
    performed in a BSL-2 laboratory with BSL-3
    practices (enhanced BSL-2 conditions)
  • Additional precautions include
  • recommended personal protective equipment (based
    on site specific risk assessment)
  • respiratory protection - fit-tested N95
    respirator or higher level of protection
  • shoe covers
  • closed-front gown
  • double gloves
  • eye protection (goggles or face shields)
  • Waste
  • all waste disposal procedures should be followed
    as outlined
  • in your facility standard laboratory operating
    procedures

Source CDC
58
Swine Influenza A(H1N1) Biosafety Guidelines for
Laboratory Workers
  • Appropriate disinfectants
  • 70 per cent ethanol
  • 5 per cent Lysol
  • 10 per cent bleach
  • All personnel should self monitor for fever and
    any symptoms. Symptoms of swine influenza
    infection include diarrhea, headache, runny nose,
    and muscle aches
  • Any illness should be reported to your supervisor
    immediately
  • For personnel who had unprotected exposure or a
    known breach in personal protective equipment to
    clinical material or live virus from a confirmed
    case of swine influenza A (H1N1), antiviral
    chemoprophylaxis with zanamivir or oseltamivir
    for 7 days after exposure can be considered

Source CDC
59
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
  • 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
60
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

61
Comparison of Available Influenza Diagnostic
Tests1
Source CDC
62
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 Reyes
    syndrome. For relief of fever, other anti-pyretic
    medications are recommended such as acetaminophen
    or non steroidal anti-inflammatory drugs.
  • Treatment is recommended for
  • All hospitalized patients with confirmed,
    probable or suspected novel influenza (H1N1).
  • Patients who are at higher risk for seasonal
    influenza complications
  • If patient is not in a high-risk group or is not
    hospitalized, healthcare providers should use
    clinical judgment to guide treatment decisions

Source CDC
63
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
    persons infectious period.
  • Pre-exposure Antivirals should only be used in
    limited circumstances, and in consultation with
    local medical or public health authorities.
  • Antiviral Use for Control of Novel H1N1 Influenza
    Outbreaks
  • A cornerstone for the control of seasonal
    influenza outbreaks in nursing homes and other
    long term care facilities.
  • If outbreaks were to occur, it is recommended
    that ill patients be treated with oseltamivir or
    zanamivir and that chemoprophylaxis with either
    oseltamivir or zanamivir be started as early as
    possible to reduce the spread of the virus as is
    recommended for seasonal influenza outbreaks in
    such settings.
  • Children Under 1 Year of Age
  • Oseltamivir is not licensed for use in children
    less than 1 year of age. Because infants
    experience high rates of morbidity and mortality
    from influenza, infants with novel (H1N1)
    influenza virus infections may benefit from
    treatment using oseltamivir.

Source CDC
64
Swine Influenza A(H1N1) Antiviral Protection
Dosing recommendations for antiviral treatment of
children younger than 1 year using oseltamivir.
Recommended treatment dose for 5 days. lt3 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. lt3
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
Source CDC
65
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)

66
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
SOURCE Safety of Influenza A (H1N1) 2009
Monovalent Vaccines --- United States, October
1--November 24, 2009, MMWR. December 11, 2009 /
58(48)1351-1356
67
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
SOURCE Safety of Influenza A (H1N1) 2009
Monovalent Vaccines --- United States, October
1--November 24, 2009, MMWR. December 11, 2009 /
58(48)1351-1356
68
Swine Influenza A(H1N1) Vaccine Protection
  • CDCs 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.

Source CDC
69
Swine Influenza A(H1N1) Face Mask and Respirator
Protection
Source CDC
70
Swine Influenza A(H1N1) Other Protective Measures
  • Defining Quarantine vs. Isolation vs.
    Social-Distancing
  • Isolation Refers only to the sequestration of
    symptomatic patents either in the home or
    hospital so that they will not infect others
  • Quarantine Defined as the separation from
    circulation in the community of asymptomatic
    persons that may have been exposed to infection
  • Social-Distancing Has been used to refer to a
    range of non-quarantine measures that might serve
    to reduce contact between persons, such as,
    closing of schools or prohibiting large gatherings

Source CDC
71
Swine Influenza A(H1N1) Other Protective Measures
  • Personnel Engaged in Aerosol Generating
    Activities
  • CDC Interim recommendations
  • Personnel engaged in aerosol generating
    activities (e.g., collection of clinical
    specimens, endotracheal intubation, nebulizer
    treatment, bronchoscopy, and resuscitation
    involving emergency intubation or cardiac
    pulmonary resuscitation) for suspected or
    confirmed swine influenza A (H1N1) cases should
    wear a fit-tested disposable N95 respirator
  • Pending clarification of transmission patterns
    for this virus, personnel providing direct
    patient care for suspected or confirmed swine
    influenza A (H1N1) cases should wear a fit-tested
    disposable N95 respirator when entering the
    patient room
  • Respirator use should be in the context of a
    complete respiratory protection program in
    accordance with Occupational Safety and Health
    Administration (OSHA) regulations.

Source CDC
72
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.

Source CDC
73
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.

Source CDC
74
Summary
  • WHO raised the alert level to Phase 6 on June 11,
    2009
  • As of December 28, 2009, worldwide more than 208
    countries and overseas territories or communities
    have reported laboratory confirmed cases of
    pandemic influenza H1N1 2009, including at least
    13,000 deaths
  • Northern Hemisphere Overall disease activity has
    recently peaked.
  • Central and Eastern Europe, and in parts of West,
    Central, and South Asia Continued increases in
    influenza activity
  • United States and Canada Influenza activity
    continues to be geographically widespread but
    overall levels of influenza-like-illness has
    declined substantially
  • Approximately 53 of hospitalized cases in Canada
    had an underlying medical condition
  • Europe Widespread and active transmission
    continued to be observed throughout the continent
  • Overall pandemic influenza activity appears to
    have recently peaked across a majority of
    countries
  • Western and Central Asia Virus circulation
    remains active throughout the region, however
    disease trends remain variable
  • East Asia Influenza transmission remains active
    but appears to be declining overall
  • Central and South America and the Caribbean
    influenza transmission remains geographically
    widespread but overall disease activity has been
    declining or remains unchanged in most parts,
    except for in Barbados and Ecuador, were recent
    increases in respiratory diseases activity have
    been reported
  • Southern Hemisphere Sporadic cases of pandemic
    influenza continued to be reported without
    evidence of sustained community transmission.

75
Summary
  • In the US
  • Highest incidence of lab-confirmed cases reported
    among 5-24 years old
  • Highest hospitalization rate among 0-4 years old
  • Underlying health conditions confers high risk of
    complications and deaths
  • In Mexico
  • Majority of the cases reported in health young
    adults
  • 70 of the deaths were reported in healthy young
    adults, 20-54 years
  • Individuals 60 seem to be protected as the
    number of cases and have a lower case-fatality
    compared to the rest of the population
  • In EU
  • Majority of the cases reported in health young
    adults (20-29 years)
  • Globally
  • Number of deaths being reported is rising
  • Vaccine
  • Total Adverse Events 5.4 (0.3 fatal)
  • Sanofi Pasteur MedImmune vaccine recalled due
    to potency issues
  • Anti-virals (oseltamivir and zanamivir)
  • Oseltamivir resistance reported recently in
    immunocompromised patents

76
(No Transcript)
77
Lessons Learned formPast Pandemics
  • First outbreaks March 1918 in Europe, USA
  • Highly contagious, but not deadly
  • Virus traveled between Europe/USA on troop ships
  • Land, sea travel to Africa, Asia
  • Warning signal was missed
  • August, 1918 simultaneous explosive outbreaks in
    in France, Sierra Leone, USA
  • 10-fold increase in death rate
  • Highest death rate ages 15-35 years
  • Cytokine Storm?
  • Deaths from primary viral pneumonia, secondary
    bacterial pneumonia
  • Deaths within 48 hours of illness
  • Coincident severe disease in pigs
  • 20-40 million killed in less than 1 year
  • World War I 8.3 million military deaths over 4
    years
  • 25-35 of the world infected

78
Lessons Learned formPast 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
  • Does not change population susceptibility
  • Delay spread in Australia later milder strain
    causes infection there
  • Temporary banning of public gatherings, closing
    schools potentially effective in case of severe
    disease and high mortality
  • Delaying spread is desirable
  • Fewer people ill at one time improve capacity to
    cope with sharp increase in need for medical care

79
Conclusion/Recommendations
  • 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
  • At present most of the deaths due to the novel
    H1N1 strain has been reported from the Americas.
  • Disease seems to be affecting the healthy strata
    of the population based upon epidemiological data
  • Anecdotal data suggests that the number of deaths
    among the pediatric population has risen recently
    due to infection with the novel H1N1
  • Most of these deaths however have been reported
    in cases with underlying medical conditions
  • 60 years and above age group seems to show some
    protection against this strain suggesting past
    exposure and some immunity

80
Conclusion/Recommendations
  • Each locality/jurisdiction needs to
  • Have enhanced disease and virological
    surveillance capabilities
  • Develop a plan to house large number of severely
    sick and provide care if needed to deal with
    mildly sick at home (voluntary quarantine)
  • Healthcare facilities/hospitals need to focus on
    increasing surge capacity and stringent infection
    prevention/control
  • General population needs to follow basic
    precautions
  • In the Northern Hemisphere influenza viral
    transmission traditionally stops by the beginning
    of May but in pandemic years (1957) sporadic
    outbreaks occurred during summer among young
    adults
  • This novel H1N1 strain has survived high humidity
    or temperature and continued to spread during the
    summer months and will continue to spread and
    cause infection

81
Conclusion/Recommendations
  • School Closures
  • Preemptive school closures merely delay the
    spread of disease
  • Once schools reopen the disease transmits and
    spreads
  • Puts unbearable pressure on single-working
    parents and would be devastating to the economy
  • Closure after identification of a large cluster
    would be appropriate as absenteeism rate among
    students and teachers would be high enough to
    justify this action
  • 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
  • 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
Write a Comment
User Comments (0)
About PowerShow.com