2009 H1N1 July 25th update

1. 2009 H1N1 Info gathered by Mona Youssef

2. "quadruple reassortant" virus Study has shown virus to be different from the normally circulating North American pig virus.It has two genes from flu viruses that normally circulate in pigs in Europe and Asia , avian genes and human genes. How is it then that it made its first appearance in Mexico and the US?

3. Genomic mapping of the virus revealed that it has been present and circulating in pigs for the past 7.5 to ten years (obviously undetected due to laxity in surveillance of pigs).

4. Charecteristics • Influenza virus can survive on environmental surfaces and remain infectious for up to 2-8 hours after being deposited on the surface. • Virus is destroyed by: • heat 75-100 degrees Celcius. • chemical germicides: chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols. *wipes or gels with alcohol in them should be rubbed into hands until they are dry. A person can sneeze on someone’s luggage in an airport, and start an outbreak in a country without even entering it!

5. Swine flu virus(Not novel H1N1) • Like all influenza viruses, swine flu viruses change constantly. • Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses. • When influenza viruses from different species infect pigs, the viruses can reassort (i.e. swap genes) and new viruses that are a mix of swine, human and/or avian influenza viruses can emerge. • Over the years, different variations of swine flu viruses have emerged. There are currently four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. • Most of the recently isolated influenza viruses from pigs have been H1N1 viruses. H3 subtypes infect older population and tend to be more severe.

6. Drinking water? • No completed research for novel H1N1 virus. • 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.

7. Swimming Pools • No completed research for novel H1N1 virus. • Free chlorine levels recommended by CDC (1–3 parts per million [ppm or mg/L] for pools and 2–5 ppm for spas) are adequate to disinfect avian influenza A (H5N1) virus. • It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination.

8. Dealing with the Deceased • Transport of deceased persons does not require any additional precautions when bodies have been secured in a transport bag. Hand hygiene should be performed after completing transport. • For deceased persons with confirmed, probable, or suspect novel influenza A (H1N1): • limit contact with the body in health care settings to close family members • Direct contact with the body is discouraged • Necessary contact may occur as long as hands are washed immediately with soap and water. NO need for mass burials yet….

9. Autopsy: • Standard Precautions. • Additional respiratory protection is needed procedures that generate aerosols (e.g., use of oscillating saws). • minimize the number of personnel participating in post mortem examinations. • Follow standard safety procedures for preventing percutaneous injuries during autopsy.

10. He says ice-cream made him feel better, and Thank God has now recovered full health. But the rest of the planet has a quick –paced pandemic marching on…. 'Patient Zero' in Swine Flu Outbreak Identified as 5-Year-Old Mexican Boy: Edgar Hernandez

11. Timeline

12. Mexico MidMarch: La Gloria,Veracruz, 60% of the town's population is sickened by a respiratory illness of unknown provenance. April 23 :S-OIV (swine origin influenza virus) confirmed, same strain detected in two California children as in Mexico. PAHO informed of Mexico cluster of S-OIV April 16 : Mexico Authorities notify the PAHO (Pan American Health Organization) of the atypical pneumonia. Canadian labs

13. WHO • April 24: 2009 H1N1 first disease outbreak notice. • April 25: WHO Director General declares a formal “Public health emergency of international concern” • April 27: “containment of the outbreak is not feasible” pandemic alert raised from phase 3 to phase 4. • April 29: phase 4 to phase 5. • June 11: phase 5 to phase 6. During this time interim, the WHO was vastly criticized for not announcing phase 6

14. WHO Report 95 AFFECTED COUNTRIES Nothing’s holding this virus back…….!!!

15. A pandemic means an epidemic of an infectious disease, that spreads throughout a large number of people and can spread worldwide. A pandemic begins when: there is person-to-person sustained transmission on multiple continents. keyword

16. TheWorld Health Organization uses a six stage phase for alerting the general public to an outbreak

17. Phase 1 – animal to animal transmission. Phase 2 – an animal influenza virus is capable of human infection. Phase 3 - small outbreaks among close populations but not through human to human contact. Phase 4 -Human to human transmission Phase 5 - spread across two countries or more in one of the WHO regions (continents). Phase 6 – spread across two countries or more in one of the WHO regions plus spread to another WHO region.

18. W.H.O. identifies the following six epidemiological sub-regions. - African Region - Eastern Mediterranean Region - European Region - Region of the Americas - South-East Asian Region - Western Pacific Region

22. Even an island in the middle of the ocean isn’t out of its reach….

24. June 15/2009

30. Graveness of the situation In one week, the United Nations agency raised the alert level twice, from phase 3 to phase 5, in response to the sustained transmission of H1N1 in Mexico and the United States.( 1976 swine flu Hsw1N1 outbreak never passed phase 3. The vaccine developed caused 10 per million Guillain Barre syndrome as compared to the 1-2 per million with the seasonal flu vaccine and was banned.)

31. 19/6/2009 WHO report 19/6/2009 WHO report

32. Countries of origin. Mixing of NH1N1 with seasonal flu virus could result in a strain resistant to tamiflu(NH1N1 is already resistant to other antivirals Mixing with H5N1 could produce strains capable of human to human transmission(Death toll of H5N1 is app. 66%)

33. And then Fate has it that the first detected viral strains resistant to tamiflu would show up in China! NOT Australia, and Not Chilli

34. Consequences of a declaration of a full pandemic • Institution of pandemic response plans, which may include measures affecting hospitals, schools or public events. • Provision of support for developing countries including: drugs, diagnostic tests, and medical staff • WHO would be expected to make an announcement to specify whether • manufacturers should switch from making seasonal to pandemic flu vaccines.

35. June 5 CDC Report: • Testing • CDC has developed a PCR diagnostic test kit • Distributed test kits throughout U.S. nation as well as internationally. • Vaccine • CDC has isolated the new H1N1 virus, made a candidate vaccine virus that can be • used to create vaccine. • (Novartis manufactures first vaccine June 11 2009) • Strategic National Stockpile • CDC has deployed 25 percent of the supplies in the Strategic National Stockpile • (SNS) to all states in the continental United States and U.S. territories. • This included antiviral drugs, personal protective equipment, and respiratory • protection devices.

36. Previous Global Pandemics

37. 1918 - Spanish Flu (originated in birds). First hit soldiers in Europe during World War I, as their immune systems were weakened by war. The mortality rate was highest between 20 to 50 year olds. There was never any vaccine developed, after about 18 months, the virus seemed to just disappear. The final death toll was written as 40 million people worldwide. Soldiers whose immunity was weakened by war. Many of the victims who have died in Mexico have been young and otherwise healthy. society's healthiest demographic

38. 1957 - Asian Flu This flu started in birds in Asia. In September schools and public places started closing in an effort to contain the virus. In December the virus started to subside, but reappeared in January. over two million people died Reappeared

39. 1968 - The Hong Kong Flu This is the mildest pandemic It was first found in the early months of 1968 in Hong Kong, and was declared a global pandemic by December. Children were out of school and were therefore not able to spread it as much. It made a mild reappearance in 1970 and 1972. it claimed about a million lives Reappeared…!!! Seasonal influenza normally claims app. ¼ to ½ a million lives yearly.

40. What we do know

41. Novel H1N1 spreads just as easily as regular winter flu. Disease spectrum ranges from very mild self-limited disease to Death. Novel H1N1 virus tends to affect younger people just like the seasonal H1N1. (Older adults were shown to possess serum neutralizing antibodies to the new virus, most likely due to cross‐immunity with human H1N1 viruses. ) Novel H1N1 virus tends to affect younger people just like the seasonal H1N1. (Older adults were shown to possess serum neutralizing antibodies to the new virus, most likely due to cross‐immunity with human H1N1 viruses. )

42. The southern hemisphere is about to enter winter, when seasonal flu cases normally spike. • We have to be prepared for changes in: • The amount of illness • The severity of illness • The characteristics of the virus • The reactions of our communities Early evidence in the southern hemisphere points to novel H1N1 potentially crowding out the seasonal flu viruses which is something that's been seen in previous pandemics.

43. Simultaneous circulation of the seasonal flu strains with the Novel H1N1 raises the possibility of mixing of the strains. Seasonal flu vaccine production is to continue as is, in an attempt to reduce the chances of the viruses mingling together in the same environment. Seasonal H1N1 virus that we've had this past year is resistant to Tamiflu.

44. Influenza is unpredictable. 

45. Characteristics of reported cases of influenza A(H1N1) by country Of note , the prevailing clinical picture in other countries has been GIT related.

46. Data limitations : • countries are using different surveillance methods and case definitions. • Caution must be exercised in interpreting information such as age as it may reflect • patterns of travel or the occurrence of outbreaks in special settings such as schools. • Due to early stage of disease spread and the limited number of settings : • Incomplete picture of the epidemiological and clinical characteristics of the • virus. • Estimates of important epidemiological parameters such as incubation • period, attack rate and case fatality ratio may not be broadly applicable.

47. WHO Pandemic (H1N1) 2009 briefing note 4 July 24/2009 WHO currently recommends shifting surveillance efforts to following trends in illness cases rather than testing all ill patients which can severely stress national resources. Top priority is to determine which groups of people are at highest risk of serious disease. WHO is now relying on information obtained from special research and clinical studies and other data provided by countries directly through frequent expert teleconferences on clinical, virological and epidemiological aspects of the pandemic.

48. VACCINE

49. A review of 2009 production status for northern hemisphere seasonal vaccine indicates that: • Industry plans to produce approximately 480 million doses of trivalent seasonal • vaccine in 2009. • Of this, 350 and 430 million doses will be available by 30 June and 31 July 2009, • respectively. • For influenza A (H1N1), it is estimated that up to 4.9 billion doses could be produced • over a 12‐month period IF there is initiation of a full‐scale production. • In this situation, there is a potential access for the UN of supplies of up to 400 million • doses. A lot of Ifs……..

50. Currently available data indicate that: • Immunization with recent or shortly to be available trivalent seasonal vaccine is unlikely to provide public health benefits in terms of protection against influenza A (H1N1). • Unknowns: • optimal antigen content, • the required number of doses, • the required intervals between doses • and the interchangeability of different products is currently unknown for influenza A (H1N1) vaccines. • the safety profile