Epidemic • An excess over the expected incidence of disease within a geographical area during a specified time period
Flu Terms Defined • H1N1 Influenza (H1N1flu)is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and do happen. • Bird fluis commonly used to refer to Avian flu (see below). Bird flu viruses infect birds, including chickens, other poultry and wild birds such as ducks. • Avian flu (AI)is caused by influenza viruses that occur naturally among wild birds. Low pathogenic AI is common in birds and causes few problems. Highly pathogenic H5N1 is deadly to domestic fowl, can be transmitted from birds to humans, and is deadly to humans. There is virtually no human immunity and human vaccine availability is very limited. • Pandemic flu is virulent human flu that causes a global outbreak, or pandemic, of serious illness. Because there is little natural immunity, the disease can spread easily from person to person. Currently, there is no pandemic flu. • Seasonal (or common) fluis a respiratory illness that can be transmitted person to person. Most people have some immunity, and a vaccine is available.
WHAT IS SWINE FLU ? • a respiratory disease of pigs caused by • type A influenza viruses (H1N1 subtype) Influenza A Virus • H1N1 and H3N2 are the yearly winter human influenza A viruses • H1N1 Subtype • H=Hemagglutinin # 1-16 First name of a flu virus is the H# • N=Neuraminidase #1-9 Last name of a flu virus is the N# • It causes regular outbreaks in pigs. • People do not normally get swine flu, but human infections can and do happen • Swine flu viruses have been reported to spread from person-to-person, but in the past, this transmission was limited and not sustained beyond three people
What is new about the Swine Influenza? • The world Health Organization has confirmed that at least some of the human cases are never-before-seen version of H1N1 strain of Influenza Type A. • H1N1 is the same strain which causes seasonal outbreaks of flu in humans on regular basis. But latest version of H1N1 is different: it contains genetic material that is typically found in strains of the virus that affect humans, birds and swine. • Flu viruses have the ability to swap genetic components with other, and it seems likely that the new version of H1N1 resulted from a mixing of different versions of the virus, which may usually affect different species, in the same animal host. • Pigs provide an excellent ‘melting pot’ for these viruses to mix and match with each others.
Novel H1N1 Flu • What is H1N1 (swine flu)?H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people. This new virus was first detected in people in the United States in April 2009. Other countries, including Mexico and Canada, have reported people sick with this new virus. This virus is spreading from person-to-person, probably in much the same way that regular seasonal influenza viruses spread. • Why is this new H1N1 virus sometimes called “swine flu”?This virus was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs in North America. But further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and avian genes and human genes. Scientists call this a “quadruple reassortant” virus.
Epidemic and Pandemic Alert and Response (EPR) • In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1no viruses circulating among animals have been reported to cause infections in humans. • In Phase 2an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat. • In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. Limited human-to-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained the level of transmissibility among humans necessary to cause a pandemic. • Phase 4is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion
Phase 5is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short. • Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way. • During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave. • Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature. • In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required.
Is this new H1N1 virus contagious?CDC has determined that this new H1N1 virus is contagious and is spreading from human to human. However, at this time, it is not known how easily the virus spreads between people.
HOW DOES SWINE FLU SPREAD ? • Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. • Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. • Sometimes people may become infected by • touching something with flu viruses on it and then touching their mouth or nose.
IS IT SAFE IF I EAT PORK ? • Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. • Eating properly handled and cooked pork products is safe.
Is there a risk from drinking water? Tap water that has been treated by conventional disinfection processes does not likely pose a risk for transmission of influenza viruses. • Current drinking water treatment regulations provide a high degree of protection from viruses. No research has been completed on the susceptibility of the novel H1N1 flu virus to conventional drinking water treatment processes. However, recent studies have demonstrated that free chlorine levels typically used in drinking water treatment are adequate to inactivate highly pathogenic H5N1 avian influenza. • It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination. • To date, there have been no documented human cases of influenza caused by exposure to influenza-contaminated drinking water.
Contamination & Cleaning • How long can influenza virus remain viable on objects (such as books and doorknobs)?Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for up to 2-8 hours after being deposited on the surface. • What kills influenza virus?Influenza virus is destroyed by heat (167-212°F [75-100°C]). In addition, several chemical germicides, including chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols are effective against human influenza viruses if used in proper concentration for a sufficient length of time. For example, wipes or gels with alcohol in them can be used to clean hands. The gels should be rubbed into hands until they are dry.
How should linens, eating utensils and dishes of persons infected with influenza virus be handled? Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first. Linens (such as bed sheets and towels) should be washed by using household laundry soap and tumbled dry on a hot setting. Individuals should avoid “hugging” laundry prior to washing it to prevent contaminating themselves. Individuals should wash their hands with soap and water or alcohol-based hand rub immediately after handling dirty laundry. • Eating utensils should be washed either in a dishwasher or by hand with water and soap.
High-risk groups:A person who is at high-risk for complications of novel influenza (H1N1) virus infection is defined as the same for seasonal influenza at this time. As more epidemiologic and clinical data become available, these risk groups might be revised. • Children younger than 5 years old. The risk for severe complications from seasonal influenza is highest among children younger than 2 years old. • Adults 65 years of age and older. • Persons with the following conditions: • Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus); • Immunosuppression, including that caused by medications or by HIV; • Pregnant women; • Persons younger than 19 years of age who are receiving long-term aspirin therapy; • Residents of nursing homes and other chronic-care facilities.
Special Considerations for Children • Aspirin or aspirin-containing products (e.g. bismuth subsalicylate – PeptoBismol) should not be administered to any confirmed or suspected ill case of novel influenza H1N1 virus infection aged 18 years old and younger due to the risk of Reye syndrome. For relief of fever, other anti-pyretic medications such as acetaminophen or non- steroidal anti-inflammatory drugs are recommended. • Children younger than 4 years of age should not be given over-the-counter cold medications without first speaking with a healthcare provider
SIGNS AND SYMPTOMS • The symptoms of swine flu in people are similar to the symptoms of seasonal flu in humans and may include: • Fever (greater than 100°F or 37.8°C) • Sore throat • Cough • Stuffy nose • Chills • Headache and body aches • Fatigue • Some people have reported diarrhea and vomiting associated with swine flu.
What are its symptoms? • According to the Centers for Disease Control and Prevention (CDC), in humans the symptoms of swine flu appear to be similar to those produced by standard, seasonal flu. • These include fever, cough, sore throats, body aches, headache, chills and fatigue. • The 2009 outbreak has shown an increased percentage of patients reporting diarrhea and vomiting.
In children emergency warning signs that need urgent medical attention include: • Fast breathing or trouble breathing • Bluish skin color • Not drinking enough fluids • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with fever and worse cough • Fever with a rash • In adults, emergency warning signs that need urgent medical attention include: • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting
SIGNS AND SYMPTOMS • Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.
What Is the Range of Illness Severity Seen With Swine Flu? • Many cases of swine flu may be mild or even asymptomatic. • In the past, cases were identified by chance as part of regular seasonal influenza surveillance. • Most of the recent cases seen in the United States thus far have been mild as well. However, in Mexico, many patients' illnesses have been much more severe, have presented in young adults, and have included pneumonia, respiratory failure, and acute respiratory distress syndrome. • Illness-related fatalities have been recorded in Mexico. At this time, it is not clear why such differences in illness severity have been seen. • Early in epidemics it is difficult to gauge severity because the overall denominator of people infected is unknown.
HOW CAN SOMEONE WITH THE FLU INFECTSOMEONE ELSE ? • Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or more days after • N.B: Children, especially younger children, might be contagious for longer periods. • becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.
WHAT SHOULD I DO TO KEEP FROM GETTING THE FLU ? • First and most important: wash your hands. • Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. • Try not touch surfaces that may be contaminated with the flu virus. • Avoid close contact with people who are sick. SAFETY PRECAUTIONS:- • Avoid live animal markets, poultry and pig farms in affected countries • Always maintain high levels of personal hygiene, especially before and after food preparation and in-out of toilets. Regular wash your hands • Cook pork thoroughly • Do not consume half-done pork • Clean hard surfaces (kitchen worktops, door handles) frequently using a normal cleaning product. • While in an affected region, seek immediate medical attention if you develop influenza-like symptoms. (High Fever, body pain, coughing and red nose)
Do I need a face mask? • Although wearing a mask is unlikely to be effective in preventing the infection it may limit further spread of the virus.
What is a facemask? • Facemasks are loose-fitting, disposable masks that cover the nose and mouth. These include products labeled as surgical, dental, medical procedure, isolation, and laser masks. • Facemasks help stop droplets from being spread by the person wearing them. They also keep splashes or sprays from reaching the mouth and nose of the person wearing the facemask. They are not designed to protect you against breathing in very small particles. Facemasks should be used once and then thrown away in the trash.
TRAVEL HEALTH • WHO does not recommend any travel restrictions to areas outbreaks, including countries, which have reported, associated cases of human infection. • WHO does not, at present recommend the routine screening of travelers coming from affected areas.
WHAT CAN I DO TO PROTECT MYSELF FROM GETTINGSICK ? • There is no vaccine available right now to protect against swine flu. • There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these everyday steps to protect your health: • Cover your nose and mouth with a tissue when you cough or sneeze.Throw the tissue in the trash after you use it • Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective • Avoid touching your eyes, nose or mouth. Germs spread this way • Try to avoid close contact with sick people
WHAT IS THE BEST WAY TO KEEP FROM SPREADING THEVIRUS THROUGH COUGHING OR SNEEZING ? • If you are sick, limit your contact with other people as much as possible. Do not go to work , stay at home or in your hotel room . • Cover your mouth and nose with a mask when coughing or sneezing. It may prevent those around you from getting sick. Put your used tissue in the waste basket. • Cover your cough or sneeze if you do not have a mask. Then, clean your hands, and do so every time you cough or sneeze.
IS THERE A HUMAN VACCINE TO PROTECT FROM SWINEINFLUENZA ? • There are no vaccines that contain the current swine influenza virus causing illness in humans. It is not known whether current human seasonal influenza vaccines can provide any protection. • Influenza viruses change very quickly. It is important to develop a vaccine against the currently circulating virus strain for it to provide maximum protection to the vaccinated people. This is why WHO needs access to as many viruses as possible in order to select the most appropriate candidate vaccine virus.
Treatment is Available for Those Who Are Seriously III • It is expected that most people will recover without needing medical care. • If you have severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed. • Be aware that if the flu becomes wide spread, there will be little need to continue testing people, so your health care provider may decide not to test for the flu virus. • Antiviral drugs can be given to treat those who become severely ill with influenza. These antiviral drugs are prescription medicines (pills, liquid or an inhaler) with activity against influenza viruses, including H1N1 flu virus. These medications must be prescribed by a health care professional.
There are two influenza antiviral medications that are recommended for use against H1N1 flu. The drugs that are used for treating H1N1 flu are called oseltamivir (trade name Tamiflu ®) and zanamivir (Relenza ®). • As the H1N1 flu spreads, these antiviral drugs may become in short supply. • Therefore, the drugs will be given first to those people who have been hospitalized or are at high risk of complications. • The drugs work best if given within 2 days of becoming ill, but may be given later if illness is severe or for those at a high risk for complications.
Antiviral drugs are prescription medicines (pills, liquid or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. During the current outbreak, the priority use for influenza antiviral drugs during is to treat severe influenza illness.
CDC Recommendation • CDC recommends the use of oseltamivir or zanamivirfor the treatment and/or prevention of infection with swine influenza viruses. • Oseltamivir(brand name Tamiflu ®) is approved to both treat and prevent influenza A and B virus infection in people one year of age and older. • Zanamivir(brand name Relenza ®) is approved to treat influenza A and B virus infection in people 7 years and older and to prevent influenza A and B virus infection in people 5 years and older. • Recommendations for using antiviral drugs for treatment or prevention of swine influenza will change as we learn more about this new virus. • Clinicians should consider treating any person with confirmed or suspected swine influenza with an antiviral drug.
MINIMISING THE RISK OF AN EPIDEMIC • Culling – killing large numbers of infected and potentially infected animals • Quarantine – putting infected farms in quarantine • Vaccination?? • operations to minimize the risk of being infected by both swine flu and human flu simultaneously
Pandemic Preparedness Plans • Most countries have plans • Most plans focus on health sector • Plans should focus on continuity of government,utilities,Humanitarianrelief,financial services • Importance of cross –border planning • Ideal plans: -All of government involved -Link of plans of private Entities and voluntary sector -Engage Military -Involve Civil Defence -Priority to Public Information
Pandemic Preparedness Plans: -Action items indicated -Responsible Bodies Identified -Emphesis on Communicating information to public Plan must be revised regularly
How can I prepare for a pandemic? • Confirm a network of ‘flu-friends’, such as friends and relatives, to help you if you fall ill. Keep all important emergency telephone numbers in a safe place. • Have a stock of food and other supplies available at home that will last for two weeks. Current recommendations for stockpiling measures are: • 2-week supply of water per each family member • 2-week supply of non-perishable food for each family member • Adequate supply of on going medication • Soap / cleansing agents • Torches and batteries • Portable radio • Manual can opener • Bin bags • Sanitary items (toilet tissue, diapers, etc.)
Response & Investigation • What is CDC doing in response to the outbreak?CDC has implemented its emergency response. • The agency’s goals are • to reduce transmission and illness severity, • and provide information to help health care providers, public health officials and the public address the challenges posed by the new virus. • CDC continues to issue new interim guidance for clinicians and public health professionals. • In addition, CDC’s Division of the Strategic National Stockpile (SNS) continues to send antiviral drugs, personal protective equipment, and respiratory protection devices to all 50 states and U.S. territories to help them respond to the outbreak.
What epidemiological investigations are taking place in response to the recent outbreak? CDC works very closely with state and local officials in areas where human cases of new H1N1 flu infections have been identified. In California and Texas, where EpiAid teams have been deployed, many epidemiological activities are taking place or planned including:
Active surveillance in the counties where infections in humans have been identified; • Studies of health care workers who were exposed to patients infected with the virus to see if they became infected; • Studies of households and other contacts of people who were confirmed to have been infected to see if they became infected; • Study of a public high school where three confirmed human cases of H1N1 flu occurred to see if anyone became infected and how much contact they had with a confirmed case; and • Study to see how long a person with the virus infection sheds the virus.
Who is in charge of medicine in the Strategic National Stockpile (SNS) once it is deployed? • Local health officials have full control of SNS medicine once supplies are deployed to a city, state, or territory. Federal, state, and local community planners are working together to ensure that SNS medicines will be delivered to the affected area as soon as possible. • Many cities, states, and territories have already received SNS supplies. After CDC sends medicine to a state or city, control and distribution of the supply is at the discretion of that state or local health department. • Most states and cities also have their own medicines that they can access to treat infected persons.
Information provided by states and local health authorities should be consulted to determine whether public health authorities are advising that patients who test positive on a rapid influenza antigen test need additional testing. • In areas with many new confirmed cases of novel H1N1 flu infection and where community spread of H1N1 is occurring, patients who test positive on a rapid influenza diagnostic test can be treated empirically with antiviral medications if clinically indicated without further testing..
In areas with no or few confirmed cases of novel H1N1 flu, a nasopharyngeal swab/aspirate or nasal aspirate should be collected and sent to the state public health laboratory for RT-PCR to determine if the patient has H1N1 infection, seasonal influenza A virus infection, or a false-positive test result.