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Just-in-Time Lecture: Influenza A (H1N1) (Swine Flu) Pandemic
Just-in-Time Lecture: Influenza A (H1N1) (Swine Flu) Pandemic
Just-in-Time Lecture: Influenza A (H1N1) (Swine Flu) Pandemic
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, Novosibirsk, 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. Influenza Virus
2. Definitions
3. Introduction
4. History in the US
5. Spread/Transmission
6. Timeline/Facts
7. Response
8. Status Update
• Mexico
• US
• Canada
• European Union
• Globally
9. Case-Definitions
10. Guidelines
• Clinicians
• Laboratory Workers
• General Population
11. Treatment
12. Other Protective Measures
13. Summary
14. Timeline of Emergence
15. Lessons Learned from Past Pandemics
16. Conclusion & Recommendations
CHOTANI © 2009.
Virus
• RNA, enveloped
• Size:
80-200nm or .08 – 0.12 μm
(micron) in diameter
• A, B, C
• Surface antigens
• H (haemaglutinin)
• N (neuraminidase)
CHOTANI © 2009.
Haemagglutinin subtype Neuraminidase subtype
H1 N1
H2 N2
H3 N3
H4 N4
H5 N5
H6 N6
H7 N7
H8 N8
H9 N9
H10
H11
H12
H13
H14
H15
H16
Definitions
General
CHOTANI © 2009.
Survival of Influenza Virus
Surfaces and Affect of Humidity & Temperature*
• Seasonal Influenza
• Globally: 250,000 to 500,000 deaths per year
• In the US (per year)
• ~35,000 deaths
• >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
CHOTANI © 2009.
Swine Influenza A(H1N1)
History in US
CHOTANI © 2009.
Swine Influenza A(H1N1)
Transmission to Humans
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
CHOTANI © 2009.
Swine Influenza A(H1N1)
US Response
CHOTANI © 2009. Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO
Swine Influenza A(H1N1) May 25, 2009
Status Update
CHOTANI © 2009. Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO
Swine Influenza A(H1N1)
Mexico Epidemic Curve Confirmed, by Day
As of June 09, 2009
Total Number of Confirmed Cases = 6,241*
Suspension of Non-essential Activities
School Closure
400
School Open
400 385
350
No. of Confirmed Cases
309
290
300
270
262
250 224
221 217
214
199 201
200 186
176
168
158
148
150 128
127 126
Epidemiological Alert 122
112
92
100 77
90
85 75
76 76 69
71 65 61
59 59
52
50
50 31
41
3637 31 33
29 25
15 22 20
14 14 16
6 7 7 3 8 4 8 10 10 8
1 0 0 0 1 1 2 1 1 1 1 2 2 4 3 2 0 2 3 5 3 2 3 1 3 4 4
Day
*NOTE: 54 confirmed cases not included
1600
1400 1191
1200
1000
800 638
600 476
400 273
127
200 40
0
0-9 10-19 20-29 30-39 40-49 50-59 60+ NA
Age Group
Deaths %
Case-Fatality (%)
12
No. of Deaths
70
10 60
8 50
6 40
30
4
12 12 9.3
13.9 20
7.4 8.3 8.3
2 3.7
6.5
3.7
5.6
10
2.8 1.9
0.9 1.9 0.9
0 0
<1
1-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
>75
Age Group
House Bound 22
Independent Worker 15
Student 8
Tradesmen 5
N=80
Minor 5
Professional 4
Unemployed 3
Retired 2
0 5 10 15 20 25
Deaths
CHOTANI © 2009.
No. of Confirmed Cases
CHOTANI © 2009.
A
la
1000
1500
2000
2500
0
500
ba
A Ala ma
rk s
a k
94
A ns a
C ri z as
al o
3 9
C Coifor na
4
on lo n
547
n ra i a
D ec do
973
el tic
aw u
75
1
Fl ar t
395
G ori e
eo d
142
H rg a
247
aw i a
33
Id ai i
Il l ah
115
In in o o
16
di is
5
an
1357
K Io wa
K n a a
173
e
Lo n tusas
ui ck
M s y
as M M ian
sa a ai a
92 92 96134
ch ryl ne
a
M us nd
17
M ichetts
89
M in n i g
is e an 787
si so
1
298
M ssi ta
i p
M sso pi
N N on u
r
ew eb r tan i 1
H N sk a a 82 40 46 15
N am eva a
e p
60
N w J sh da
ew e i r
e
N N M rse
64
US States
or e ex y
128 148
N th Cw Yi co
or a o
th ro rk
108
As of June 11, 2009 (12:30 PM ET)
D lin
858
ak a
O o
kl O ta
Pe ah h io
O o
30 23 35
R nns re ma
h
So o y go
u d e lva n
Swine Influenza A(H1N1)
93167
So th Is n ia
u t Ca lan
r
299
Te h D o li d
US Confirmed Cases & Deaths, by State
nn ak n a
es o ta
18 60 10
Tesee
x
104
Ve U as
r ta
3
W
1670
as W Vi mo h
461
hi as rg n t
9
W n g hin i nia
es to gt
1
55
t n, o
1
W Vir D. n
577
i s gi C.
co n
Total Number of Confirmed Cases = 13,217; 27 Death; 50 States + District of Columbia + Puetro Rico
PuWy n s ia
24 6
er om i n
to in
R g
2217
ic
o
25 1
Source: CDC
Swine Influenza A(H1N1)
MMRW Report, April 28
Diarrhea 21 48%
1800 2
1562
1200
1
611
600
1
195 221
151 78 96
56 2 3 1 2
0
Columbia
Alberta
Saskatchewan
Manitoba
Ontario
Quebec
Brunswick
Nova Scotia
Prince Eward
Newfoundland
Yukon
Territories
Northwest
Nunavut
British
New
900 822
Transmission
600
380
357
300
127
71 90
56
7 1 14 4 2 4 10 2 4 2 4 8 21 7 4 3 12 1 23 13 7 11 6 3 19 18
1 4 1 4 1 1 2 1 4
0
Austria
Belgium
Bulgaria
Cyprus
Czech Rep.
Denmark
Estonia
Finland
France
Germany
Greece
Hungry
Iceland
Ireland
Italy
Luxembourg
Netherlands
Norway
Poland
Portugal
Romania
Slovakia
Spain
Sweden
Switzerland
United Kingdom
Country
Days
CHOTANI © 2009. Source: ECDC
Swine Influenza A(H1N1)
EU & EFTA Countries Confirmed Case Distribution, by Age
20
Confirmed Cases
15
10
7
6
5
5
3
2
0
0-9 10-19 20-29 30-39 40-49 50-59
Age Group (Years)
108
1 1
Chinese Taipei has reported 36 confirmed cases of influenza A (H1N1) with 0 deaths. Cases from Chinese Taipei are included in the
cumulative totals provided in the table above.
Cumulative and new figures are subject to revision
CHOTANI © 2009. Source: WHO
Global Distribution of Reported Cumulative Laboratory Confirmed
Cases of Swine Influenza A(H1N1) by Countries, June 11, 2009
(14:00 GMT)
• Waste
• all waste disposal procedures should be followed as outlined
in your facility standard laboratory operating procedures
• Appropriate disinfectants
• 70 per cent ethanol
• 5 per cent Lysol
• 10 per cent bleach
• No vaccine available
• Antivirals for the treatment and/or prevention of infection:
• Oseltamivir (Tamiflu) or
• Zanamivir (Relenza)
• 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.
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)
Other Protective Measures
CHOTANI © 2009.
Summary
• WHO raised the alert level to Phase 6 on June 11, 2009
• There is a disparity between the % case-fatality-rate between Mexico (1.73%), USA
(0.20%) and Canada (0.13%)
• The overall global case-fatality (28,774 cases and 144 deaths) is 0.50%
• ~ 1,500 cases worldwide (reported) needed hospitalization
• Majority in Mexico
• Epidemiological Data
• US
• Median Age 16 years (range: 1-81 years)
• Over 80% of the cases in <18 years
• 60% female; 40% Male
• Mexico
• Majority of the cases reported in health young adults
• 71.3% 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
• 52% female; 48% Male
• EU
• Majority of the cases reported in health young adults (20-29 years).
• In-country transmission (36%) has been documented
• No vaccine is available
• Anti-virals available
CHOTANI © 2009.
Timeline of Emergence
Influenza A Viruses in Humans
Reassorted Influenza
virus (Swine Flu)
H1
1976 Swine
Flu Outbreak,
Ft. Dix Avian
Influenza
H9 H7
H5 H5
H1
H3
H2
H1
CHOTANI © 2009.
Lessons Learned form
Past Pandemics
CHOTANI © 2009.
Lessons Learned form
Past Pandemics
CHOTANI © 2009.
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 anti-virals and antibiotics
(to treat secondary bacterial infections)
• Though difficult, there is likelihood that there will be a vaccine for this
strain by the emergence of the second wave
• In the US each year ~35,000 deaths are attributed to influenza resulting in
>200,000 hospitalizations, costing $37.5 billion in economic cost
(influenza & pneumonia) and >$10 billion in lost productivity
• Based upon past experience and the way the current H1N1 pandemic is
acting (current wave is contagious, spreading rapidly and in
Mexico/Canada based upon preliminary data affecting the healthy), there
is a likelihood that come fall there might be a second wave which could be
more virulent
CHOTANI © 2009.
Conclusion/Recommendations
2. At present most of the deaths due to H1N1 strain has been reported
from Mexico.
• The disease, though spreading rapidly across the globe, is of a mild form
(exception Mexico)
• Most people do not have immunity to this virus and, as it continues to
spread. More cases, more hospitalizations and some more deaths are
expected in the coming days and weeks
• Disease seems to be affecting the healthy strata of the population based
upon epidemiological data from Mexico and EU
• 60 years and above age group seems to show some protection against
this strain suggesting past exposure and some immunity
• Of concern is the disease spread in Australia
CHOTANI © 2009.
Conclusion/Recommendations
6. School Closures:
• Preemptive school closures will merely delay the spread of disease
• Once schools reopen (as they cannot be closed indefinitely), the disease
will be transmitted and spread
• Furthermore, this would put unbearable pressure on single-working
parents and would be devastating to the economy (as children cannot be
left alone)
• 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
7. High priority should be given to develop and include the present
“North American” (swine) influenza A(H1N1) virus in next years
vaccine. A critical look at manufacturing capacity is called for
8. 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,
anti-virals, antibiotics and advancement in science and resources to
produce an affective vaccine
CHOTANI © 2009.