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Back To The Future: 2009 nH1N1 (S-OIV) Pandemic

Back To The Future: 2009 nH1N1 (S-OIV) Pandemic. Edward L. Goodman, MD November 10, 2009. Descriptive Epidemiology. 1918 experience Subsequent pandemics in 20 th century Basic virology Antigenic drift and shift Pigs as mixing vessels The nH1N1 pandemic Epidemic Curves

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Back To The Future: 2009 nH1N1 (S-OIV) Pandemic

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  1. Back To The Future: 2009 nH1N1 (S-OIV) Pandemic Edward L. Goodman, MD November 10, 2009

  2. Descriptive Epidemiology • 1918 experience • Subsequent pandemics in 20th century • Basic virology • Antigenic drift and shift • Pigs as mixing vessels • The nH1N1 pandemic • Epidemic Curves • Age related attack rate • Age related morbidity • Unique risk groups • Pregnancy • Children • Mixed viral and bacterial infection

  3. The 1918 Pandemic • “Those who cannot remember the past are condemned to repeat it” • Santayana, G. Reason in Common Sense 1905

  4. Origins of a Pandemic • February 1918, Haskell County, Kansas • Violent influenza reported by Loring Miner, MD • Notified USPHS who ignored him • March 4, 1918, Camp Funston, Kansas • A cook reported for sick call • Within 3 weeks: 1100 soldiers admitted • 237 (20%) developed pneumonia • 38 died

  5. Spread • Philadelphia Naval Yard • Boston • Throughout the US East Coast • To Europe with the soldiers • Ultimately world wide including Alaska, Asia, Africa • Spared much of Australia • Strict quarantine of all ships

  6. The Cost • USA: 675,000 deaths out of population of 105 million (0.65%) • Worldwide: 50 to 100 million out of 1.8 billion died (5% of world’s population) • 2009: world population is 6.3 billion • Death would have occurred in 73 to 350 million • Distribution of deaths: more than half between ages of 16 and 40 (ages 21-30 had the highest death rates) • Late onset neurologic disorders (Parkinson’s Disease)

  7. Descriptive Epidemiology of a Pandemic

  8. And then…….

  9. Epidemic Curves

  10. Dallas County Texas

  11. Dominant Strain

  12. Morbidity and Mortality • Ambulatory Cases are not tracked by Health Departments • Hospitalized cases are reportable • Surrogate for severity • More often have viral studies done

  13. 77 Autopsies reported to CDC. MMWR Oct 2, 2009

  14. Pediatric Deaths • Through Oct 17 2009 100 deaths reported in children • First 36 deaths were reported in detail

  15. Why Children Are So Vulnerable • They have no prior exposure to similar virus • Thus, they have no cross reactive antibody

  16. Why So Vulnerable? • Young adults may be immunologically naïve but they have robust cellular immune system • ARDS pathophysiology • Osterholm, MT. Preparing for the Next Pandemic. NEJM 2005; 352:1839-42

  17. Proposed Mechanism of the Cytokine Storm Evoked by Influenzavirus Osterholm, M. T. N Engl J Med 2005;352:1839-1842

  18. Another Highly Vulnerable Group: Pregnant Women

  19. Deaths in Pregnant Women

  20. Controversies and Questions • Should Rapid Flu Testing be done routinely?

  21. Diagnosis - Rapid Antigen Tests Viral antigen in respiratory secetions; nucleoprotein 30 min. Sensitivity 40-80% Specificity 85-100% Cost $20

  22. Comparison of Available Influenza Diagnostic Tests (CDC, 09/29/09)

  23. Controversies and Questions • Should antiviral treatment be routine? • Should routine antiviral chemoprophylaxis be given to exposed persons?

  24. 77 Autopsies reported to CDC. MMWR Oct 2, 2009

  25. Controversies and Questions • Who should be vaccinated? • Why the problems with vaccine?

  26. Problems with the monovalent H1N1 vaccine • Low yield in egg yolk cultures • Problems with distribution • Inopportune time for getting health care reform! • Talking heads from political left and right

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