CHOTANI © 2009. Rashid A. Chotani, MD, MPH, DTM Adjunct Assistant Professor Uniformed Services University of the Health Sciences (USUHS) 240-367-5370 [email protected].

CHOTANI © 2009.

Rashid A. Chotani, MD, MPH, DTMAdjunct Assistant ProfessorUniformed Services University of the Health Sciences (USUHS)[email protected]

Just-in-Time LectureInfluenza A(H1N1) (Swine Flu) Pandemic (Version 15, first JIT lecture issued April 26)

December 28, 2009 (4:00 PM EST)

CHOTANI © 2009.

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, MacedoniaDr. 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 , IsraelDr. Nurka Pranjic, Medical School University of Tuzla, Bosnia and HerzegovinaDr. Shakir Jawad, Uniformed Services University of the Health Sciences, USA

Dr. Hiroya Goto, Ministry of Defense, JapanDr. Osamu Usami, National Cancer Institute, USA

Afham A. Chotani, USA

Truly a global efforthttp://www.pitt.edu/~super1/

Acknowledgement

CHOTANI © 2009.

1. Influenza Virus2. Definitions3. Introduction4. History in the US5. Spread/Transmission 6. Timeline/Facts7. Response 8. Status Update

• US • Mexico• Canada• European Union• Globally

9. Case-Definitions10. Guidelines

• Clinicians• Laboratory Workers• General Population

11. Treatment12. Other Protective Measures13. Summary14. Timeline of Emergence15. Lessons Learned from Past Pandemics16. Conclusion & Recommendations

OUTLINE

http://www.usuhs.mil/pat/deinococcus/FrontPage_DR_Web_work/features_repeat/USUHS.gif

CHOTANI © 2009.

Credit: L. Stammard, 1995

• 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)

Virus


H1 N1H2 N2H3 N3H4 N4H5 N5H6 N6H7 N7H8 N8H9 N9

H10H11H12H13H14H15H16

Haemagglutinin subtype Neuraminidase subtype

CHOTANI © 2009.

• 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

Definitions General


CHOTANI © 2009. Source: Bean B, et al. JID 1982;146:47-51

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.

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-to-human 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 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


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

Avian Virus

Human Virus

Swine Virus

Avian/HumanReassorted Virus

Reassortment in Pigs


CHOTANI © 2009.

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


CHOTANI © 2009.

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


CHOTANI © 2009.

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


CHOTANI © 2009.

Swine Influenza A(H1N1) Global Response

• The WHO raises the alert level to Phase 6• 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


CHOTANI © 2009.

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

• EUROPEAN UNION & EFTA COUNTRIES: April 27- December 28• 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


CHOTANI © 2009.

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

Source: WHO

Swine Influenza A(H1N1)Status Update

ECDC reported a total of 12,776 deaths – December 28, 2009


CHOTANI © 2009.

Swine Influenza A(H1N1) CDC Estimates from April-November 14, 2009, By Age Group

Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm

2009 H1N1 Mid-Level Range* Estimated Range *Cases 0-17 years ~16 million ~12 million to ~23 million18-64 years ~27 million ~19 million to ~38 million65 years and older ~4 million ~3 million to ~6 million

Cases Total ~47 million ~34 million to ~67 millionHospitalizations 0-17 years ~71,000 ~51,000 to ~101,00018-64 years ~121,000 ~87,000 to ~172,00065 years and older ~21,000 ~15,000 to ~29,000

Hospitalizations Total ~213,000 ~154,000 to ~303,000Deaths 0-17 years ~1,090 ~790 to ~1,55018-64 years ~7,450 ~5,360 to ~10,57065 years and older ~1,280 ~920 to ~1,810

Deaths Total ~9,820 ~7,070 to ~13,930


CHOTANI © 2009.

Swine Influenza A(H1N1) Symptoms Reported in US Hospitalized Patients

Symptoms 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%



CHOTANI © 2009.

4816

22080

7434

2187513

6741

0

5000

10000

15000

20000

25000

0-4 5-24 25-49 50-64 >=65 UK

Age Grougs

Cas

es

Swine Influenza A(H1N1) Lab-Confirmed Cases in the US as of July 24, 2009 (n=43,771)

11%

50%

17%

5%

1%15%

Percent Represents proportion of Total Cases

Source: Dr. Anthony Fiore, Influenza Division, NCIRD, CDC


CHOTANI © 2009.

22.9

26.7

6.97

3.92

1.3

0

5

10

15

20

25

30

0-4 5-24 25-49 50-64 >=65

Age Grougs

Cas

es

Swine Influenza A(H1N1) Lab-Confirmed Cases in the US as of July 24, 2009 (n=37,030*)

n=4816

n=22080

n=7434

n=2187n=513

Rate Per 100,000 Population by Age Group

*Excludes 6,741 Cases with missing dataRate/100,000 by Single Year Age Groups: Denominator Source: 2008 Census Estimated, US Census Bureau



CHOTANI © 2009.

953

1718

1184

658

225 273

0

500

1000

1500

2000

0-4 5-24 25-49 50-64 >=65 UK

Age Grougs

Ho

spit

aliz

atio

ns

Swine Influenza A(H1N1) Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011)

19%

34%

24%

13%

4%5%

Percent Represents proportion of Total Hospitalizations



CHOTANI © 2009.

4.5

2.1

1.1 1.2

1.7

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0-4 5-24 25-49 50-64 >=65

Age Grougs

Ho

spit

aliz

atio

ns

Swine Influenza A(H1N1) Hospitalizations of Lab-Confirmed Cases in the US as of July 24, 2009 (n=5,011)

N=953

N=1718

N=1184

13%

N=658

n=225

Rate Per 100,000 Population by Age Group



CHOTANI © 2009.

7

48

124

71

26 26

0

50

100

150

0-4 5-24 25-49 50-64 >=65 UK

Age Grougs

Nu

mb

er o

f D

eath

s

Swine Influenza A(H1N1) Deaths Among Lab-Confirmed Cases in the US as of July 24, 2009 (n=302)

2%

16%

41%

24%

9% 9%



CHOTANI © 2009.

Swine Influenza A(H1N1) Mexico Epidemic Curve Confirmed, by Day

0

200

400

600

800

1000

1200

3/1/

2009

4/1/

2009

5/1/

2009

6/1/

2009

7/1/

2009

8/1/

2009

9/1/

2009

10/1

/200

9

11/1

/200

9

12/1

/200

9

Day

No

. o

f C

on

firm

ed C

ases

Source: Secretaria de Salud, Mexico

Total Number of Confirmed Cases = 66,415*

As of December 09, 2009

*NOTE: Numbers can change

Epidemiological Alert

4/13/09

School Closure4/24/09

Suspension of Non-essential Activities5/1/09

School Open5/12/09


CHOTANI © 2009.

7,467

10,509

19,781

12,980

7,2855,079

3,0941,287 640

0

3,000

6,000

9,000

12,000

15,000

18,000

21,000

0-4 5-9 10-19 20-29 30-39 40-49 50-59 60+ NA

No

. Co

nfi

rme

d C

as

es

Age Group

Swine Influenza A(H1N1) Mexico Confirmed Case Distribution, by Age

Total Number of Confirmed Cases = 68,123




CHOTANI © 2009.

Swine Influenza A(H1N1) Mexico Confirmed Death, by Age Groups

2.34.6 4.4 3.3 2.9

811.1 8.5

13.79.2 9.6 9.6 7.3

2.7 1 0.90

25

50

75

100

<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

No

. of

De

ath

s

0

25

50

75

100

Ca

se

-Fa

talit

y (

%)

Deaths %

Deaths = 823



Male: 50.7%

Female: 49.3%

69.7% Deaths


CHOTANI © 2009.

1.3

2.1

2.9

4.5

10.7

12.8

12.9

37.1

0 5 10 15 20 25 30 35 40

Autoimmune

Neoplasm

Infectious

Respiratory

Other

Cardiovascular

Smoker

Metabolic

Percent

Swine Influenza A(H1N1) Mexico Death, by Underlying Condition

N=823




CHOTANI © 2009.

Swine Influenza A(H1N1) Mexico Deaths, by Symptoms

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%



N=823


CHOTANI © 2009.

Swine Influenza A(H1N1) Canada Confirmed Cases & Deaths, by Province or Territory

0 0 01

859

330

3636

2259

1348

831

42 5

382 405

1444 38181201

1114

26687

488

0

500

1000

1500

2000

2500

3000

3500

4000

Britis

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Confirmed cases Hospitalized

As of July 15, 2009

Total Number of Confirmed Cases 10,156 = ; Death = 45; Cases reported from 13 of 13 Provinces

Source: Public Health Agency of Canada

1

3

3 6

15

0 00

0

17

00

0

Deaths

Since July 15 only deaths have been reported – now totaling 397


CHOTANI © 2009.

Swine Influenza A(H1N1) Canada Total Confirmed Deaths, by Province or Territory

7 70

16

3 1 1

106118

65

10

52

15

0

20

40

60

80

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120

Britis

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Total Number of Confirmed Death = 401; Deaths reported from 12 of 13 Provinces

Source: Public Health Agency of Canada


CHOTANI © 2009.

361 126 70 297 293 63668 297

1125

19538

2149

206 200885

2470

30 5 51 280 29814731336

164

2983

334 133 244

153812741176

13471

0

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Confirmed cases

Swine Influenza A(H1N1) EU & EFTA Confirmed Cases & Deaths

Total Number of Confirmed Cases = 53,513; 163 Death; 31 Countries; CFR 0.3%

April 27 – September 24, 2009

Source: ECDC

329 31

2

3

1

4 3

1

32 2

78

1

Deaths

Currently only deaths are being reported – now totaling 1,371


CHOTANI © 2009.

3

6

23

7

5

2

0

5

10

15

20

25

0-9 10-19 20-29 30-39 40-49 50-59

Age Group (Years)

Co

nfi

rme

d C

as

es

27 April to 8 May 2009n=46

Source: ECDC

Swine Influenza A(H1N1) EU & EFTA Countries Confirmed Case Distribution, by Age


CHOTANI © 2009.

3

3548

3645

2 3

49

13

256

229

303

25

3

59

228

27

3

30

57

116

53

2916

0

188

132

223

17

0

50

100

150

200

250

300

350

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No

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Co

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as

es

& D

ea

ths

Swine Influenza A(H1N1) EU & EFTA Deaths

Total Number of Deaths among Confirmed Cases = 1,832April 27 – December 28, 2009

Source: ECDC


CHOTANI © 2009.

6 3

207

2314 10 10

25

519

50

202

0

50

100

150

200

250

Alb

ania

Arm

enia

Belaru

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Ru

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Serb

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Ukrain

e

Countries

Co

nfi

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ea

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Swine Influenza A(H1N1) Other European Countries & Central Asia Confirmed Deaths

n=397

Source: ECDC



CHOTANI © 2009.

42

7

109

147

4071

16 275 1

5023 30

8

97110

15

415

627

0

50

100

150

200

250

300

350

400

450

Alg

eria

Bah

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an

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n

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ited A

rab E

mirates

Yem

en

Countries

Co

nfi

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d D

ea

ths

Swine Influenza A(H1N1) Mediterranean & Middle East Confirmed Deaths

n=1,246

Source: ECDC



CHOTANI © 2009.

1 38

2 1 2

93

51

0

10

20

30

40

50

60

70

80

90

100

Gh

ana

Mad

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Africa

Su

dan

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Countries

Co

nfi

rmed

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Swine Influenza A(H1N1) Africa Confirmed Deaths

n=116

Source: ECDC



CHOTANI © 2009.

401

823

2160

0

500

1000

1500

2000

2500

Can

ada

Mexico

US

A

Countries

Co

nfi

rmed

Dea

ths

Swine Influenza A(H1N1) North America Confirmed Deaths

n=3,384

Source: ECDC



CHOTANI © 2009.

4 31

47

41

23

31

1816

6

11 11

2 1 25

0

10

20

30

40

50

Bah

am

Barb

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an Islan

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t Kitts &

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ob

ago

Countries

Co

nfi

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ths

Swine Influenza A(H1N1) Central America & Caribbean Confirmed Deaths

n=222

Source: ECDC



CHOTANI © 2009.

617

58

1632

150 19396 52

205

33121

0

500

1000

1500

2000

Arg

entin

a

Bo

livia

Brazil

Ch

ile

Co

lom

bia

Ecu

do

r

Parag

uay

Peru

Urig

uay

Ven

ezuela

Countries

Co

nfi

rmed

Dea

ths

Swine Influenza A(H1N1) South America Confirmed Deaths

n=3,157

Source: ECDC



CHOTANI © 2009.

17 6

509

51

880

107

2 126 2 1

148

35 35

0

200

400

600

800

1000

Afg

han

istan

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Nep

al

Pakistan

So

uth

Ko

rea

Sri L

anka

Taiw

an

Countries

Co

nfi

rmed

Dea

ths

Swine Influenza A(H1N1) North-East & South Asia Confirmed Deaths

n=1,820

Source: ECDC



CHOTANI © 2009.

16 10

1

77

3019

191

53

0

50

100

150

200

Bru

nei

Baru

ssalam

Cam

bo

dia

Ind

on

esia

Lo

as PD

R

Malaysia

Ph

illipp

ines

Sin

gap

ore

Th

iland

Vietn

am

Countries

Co

nfi

rmed

Dea

ths

Swine Influenza A(H1N1) South-East Asia Confirmed Deaths

n=388

Source: ECDC



CHOTANI © 2009.

191

1 1

20

2 1 10

50

100

150

200

Au

stralia

Co

ok Islan

d

Marsh

all Island

New

Zealan

d

Sam

oa

So

lom

on

Island

To

ng

a

Countries

Co

nfi

rmed

Dea

ths

Swine Influenza A(H1N1) Australia & Pacific Confirmed Deaths

n=217

Source: ECDC



CHOTANI © 2009.

1 1 212 17

2 5 317 23 21 17 15 22 16 15 12

24

49 43

84100

169188

208

267

319

151

0

50

100

150

200

250

300

350

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

No

of

Co

nfi

rmed

Dea

ths

Swine Influenza A(H1N1) EU & EFTA Countries Confirmed Deaths, by Week

n=1,803

Source: ECDC



CHOTANI © 2009.

19 7 5 6 1 23

170

85 110146

207 212261

436396

461422 405

235

485

190 212181

129

1046

303330

566 581

936

1231

1066

1177

642

0

200

400

600

800

1000

1200

1400

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

No

of

Co

nfi

rmed

Dea

ths

Swine Influenza A(H1N1) Global Confirmed Deaths, by Week

n=12,682

Source: ECDC

* 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.

Global Distribution of Reported Laboratory Confirmed Cases & Deaths of Swine Influenza A(H1N1), December 23, 2009

Source: WHO


CHOTANI © 2009.

Geographic Spread of Influenza ActivityBased Upon Country Reporting, Week 50, 2009 (07-23 December)

Source: WHO


CHOTANI © 2009.

Impact on Healthcare Services Based Upon Degree of Disruption,

As a Result of Acute Respiratory DiseasesWeek 50, 2009 (07-13 December)

Source: WHO


CHOTANI © 2009.

Number of Specimens Positive for Influenza Sub-Type

Source: CDC


CHOTANI © 2009.

Laboratory-Confirmed Cases & Deaths of New Influenza A(H1N1) by WHO Regions, September 20, 2009

8264

130448

11621

53000

30293

85299

41 2948 72 154 340 3620

20000

40000

60000

80000

100000

120000

140000

Africa R

egio

n(A

FR

O)

Am

ericasR

egio

n (A

MR

O)

Eastern

Med

iterranean

Reg

ion

(EM

RO

)

Eu

rop

e Reg

ion

(EU

RO

)

So

uth

-East A

siaR

egio

n(S

EA

RO

)

Western

Pacific

Reg

ion

(WP

RO

)

WHO Region

No

. Co

nfi

rme

d C

as

es

& D

ea

ths

*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.

At least 318,925 Cases & Over 3917 DeathsOverall Case-Fatality Rate (CFR) in Confirmed ~ 1.2%

Source: WHO

CFR = 0.5%

CFR = 2.5%

CFR = 0.6%

CFR = 1.1%

CFR = 0.3%

CFR = 0.4%


CHOTANI © 2009.

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


CHOTANI © 2009.

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)

Source: CDC


CHOTANI © 2009.

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


CHOTANI © 2009.


• 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


CHOTANI © 2009.

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


CHOTANI © 2009.

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


CHOTANI © 2009.


• 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


CHOTANI © 2009.

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


CHOTANI © 2009.

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 Availability TypicalProcessing Time2

Sensitivity3 for2009 H1N1influenza

Distinguishes 2009 H1N1 influenza from other influenza A

viruses?

Rapid influenza diagnostic tests (RIDT)4

Antigen detection

Wide 0.5 hour 10 – 70% No

Direct and indirectImmunofluorescence

assays (DFA and IFA)5

Antigen detection

Wide 2 – 4 hours 47–93% No

Viral isolation in tissue cellculture

Virus isolation

Limited 2 -10 days - Yes 6

Nucleic acid amplification tests

(including rRT-PCR) 7

RNA detection

Limited8 48 – 96 hours [6-8 hours toperform test]

86 – 100% Yes

Source: CDC


CHOTANI © 2009.

• 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: • 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

Swine Influenza A(H1N1) Antiviral Protection

Source: CDC


CHOTANI © 2009.

• 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.

• 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


CHOTANI © 2009. Source: CDC

Oseltamivir (Tamiflu) Zanamivir (Relenza)

Treatment Prophylaxis 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.

• 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)

• 4.5 million doses recalled due to decreased potency in the US

Swine Influenza A(H1N1) Vaccine Protection


CHOTANI © 2009.

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

Influenza vaccine receivedAll reports of adverse

events*

Serious adverse events†

Total Fatal NonfatalNonserious

events†

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

Unknown 229 17 7.4 1 0.4 16 7 212 92.6

Seasonal total 4,672 283 6.1 16 0.3 267 5.7 4,389 93.9

Live, attenuated influenza vaccine 480 35 7.3 0 --- 35 7.3 445 92.7

Trivalent inactivated 4,028 232 5.8 15 0.4 217 5.4 3,796 94.2

Unknown 164 16 9.8 1 0.6 15 9.1 148 90.2

* 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)

SexH1N1

vaccine type

Vaccination to onset (days)

Medical history Preliminary diagnosis/Autopsy results

1 Male MIV† 1Febrile seizures (one after measles, mumps, rubella vaccination) Sudden death, no evidence of trauma

2 Female MIV 0Encephalopathy, central apnea, traumatic brain damage, seizures Sudden cardiopulmonary arrest

9 Female LAMV§ 6Trisomy 21, leukemia (in remission), cardiac disease (neutropenia on vaccination day) Pneumococcal pneumonia/H1N1 influenza

18 Male LAMV 0No 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 2Hypertension, hyperlipidemia, pulmonary embolism, deep vein thrombosis

Pulmonary embolus/Negative for H1N1 in lung tissue

49 Female MIV 3Type 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 0Driver involved in motor vehicle crash leaving clinic after H1N1 vaccination Trauma

61 Male MIV 13Hypertension, diabetes, peripheral vascular disease, end stage renal disease

Cardiac/Respiratory arrest, gram- negative sepsis

77 Male MIV 2Lung cancer atrial fibrillation, recurrent deep venous thrombosis hypertension, hyperlipidemia Suspected myocardial infarction

* 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.

• 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.

Swine Influenza A(H1N1) Vaccine Protection

Source: CDC


CHOTANI © 2009.

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

Home

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

Occupational (non-health care)

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

Occupational (health care)

Caring for persons with known, probable or suspected 2009 H1N1 or influenza-like illness

Respirator Consider temporary reassignment. Respirator

Source: CDC


CHOTANI © 2009.

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


CHOTANI © 2009.


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


CHOTANI © 2009.

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


CHOTANI © 2009.

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


CHOTANI © 2009.

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.


CHOTANI © 2009.

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


CHOTANI © 2009.

Timeline of EmergenceInfluenza A Viruses in Humans

1918 1957 1968 1977 1997

1998/9

2003

H1

H1

H3H2

H7

H5H5H9

SpanishInfluenza

H1N1

AsianInfluenza

H2N2

RussianInfluenza

AvianInfluenza

Hong Kong

InfluenzaH3N2

2009

H1

Reassorted Influenza virus (Swine Flu)

1976 Swine Flu Outbreak,

Ft. Dix


CHOTANI © 2009.

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


CHOTANI © 2009.

• 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

Lessons Learned formPast 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 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• 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


CHOTANI © 2009.


3. 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

4. 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


CHOTANI © 2009.


5. 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

6. 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

7. 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


CHOTANI © 2009. Rashid A. Chotani, MD, MPH, DTM Adjunct Assistant Professor Uniformed Services University of the Health Sciences (USUHS) 240-367-5370 [email protected].

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acknowledgement slide