Influenza A (H1N1)qr
(Quadruple Reassortment)
“The Emerging Pandemic!”
By
Michael Fraser RN
Of
Irish First Point
Responder Institute
“Republic of Ireland”
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

Mission of Presentation
“To provide the people of Ireland a
universal teaching aid to respond to
Influenza A (H1N1).”
Medical Management of Biological Casualties
6/2/2009 2
Revised and Modified 25/05/2009

Virus Names Associated with Recent
Outbreak
• Swine-Origin Influenza Virus (S-OIV)
• North-American Influenza
• Swine Influenza A(H1N1)
• A(H1N1)
• Novel Influenza A(H1N1)
• Nouvelle Grippe A (H1N1) Spanish
• A(H1N1)-SOIV
• Influenza A(H1N1)swl (Swine like)
• Influenza A (H1N1) May 3 2009
• A(H1N1) May 8 2009
• Influenza A(H1N1)qr (Quadruple Reassortment)
– May 29 2009-new name suggested by author!
Virus will be referred to at different points of Presentation!
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

Influenza A(H1N1)
Objectives
• Identify Who pandemic Phases In relation to too European and Irish
Alert Levels
• Identify Global Health Regulation for Ireland
• Biological triage
• Identify global and Irish Influenza Surveillance Systems
• Influenza A(H1N1) Worldwide Epidemiology
• Surveillance processes and systems
• Zoonosis of Swine Influenza Virus (SIV), Signs and Symptom Post-
mortem findings, Past Outbreaks and differences of SIV and S-
OIV/Novel Influenza Virus
• Influenza virus antigenic shift and drift
• Categorizing Influenza Virus “Viral Nomenclature
• Emergence of Some Influenza Viruses in Humans
• Swine Influenza (SIV) Reassortment
• Swine Influenza Host Range
• Pathogenesis of Triple Reassortment and Quadruple reassortmentCasualties
Medical Management of Biological
6/2/2009 Revised and Modified 25/05/2009

Influenza A(H1N1)
Objectives Continued
• Epidemiological Risk Factors Influenza A(H1N1)
• Specific Investigational Triggers Influenza
A(H1N1)
• Irish resources for Influenza A(H1N1)
• Influenza A(H1N1) Transmission, Personal
Prevention, Human Signs and Symptoms, High
Risk Groups, Diagnosis, Case Definitions
• Recommended Initial PPE Protection Levels for
all levels of response
• Handling Human Remains (HHR)
• Reporting Suspect Influenza A (H1N1) Virus Infection
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

Influenza A(H1N1)
Objectives Continued
• Influenza A(H1N1) Antivirals
Treatment Schedule,Adverse
Effects
• Special Considerations for
Children
• Pregnancy
• Typical Antiviral Clinic Process
Flow Chart
• Post Exposure Prophylaxis
(PEP)
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

Influenza A(H1N1)
Objectives Continued
• Influenza A(H1N1) Irelands Laboratories Overview, Specimen
Collection, Laboratory Precautions,
• Shipping Infectious Substances
• Infection Control In Health Care Setting
• Environmental Waste
• Vaccine
• Antiviral treatments and considerations ,(PIEG) On Antivirals
Algorithms
• Bioethics
• Quarantine
• Infection Prevention and Control Guidance for the Ambulance
Service
• Influenza A(H1N1) Business Continuity with checklist
• Case Studies Spain. England, and Mexico “Estimated Ratio”
• IFPRI Pandemic Theory (“Pandemic Systems Model”)
– Under development
• Closing Discussion
6/2/2009
Medical Management of Biological Casualties
Revised and Modified 25/05/2009

World Health Organization (WHO)
Pandemic Phase Advisories
• The World Health Organisation raised its pandemic alert level to 4,
verifying human-to-human swine flu, hours after the first British cases of
the disease were confirmed. April 28 2009
• WHO flu expert Keiji Fukuda pointed out that it is too late to contain the
swine flu
\"Containment is not a feasible operation. Countries should now focus on
mitigating the effect of the virus,”
3 to 4 Phase 4 to 5 Phase
April 27 2009 April 29 2009
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009
Avian Influenza H5N1 Phase 1-3

International Health Regulations
• Following 2003 SARS, the World
Health Organization (WHO) revised
the International Health
Regulations
• IHR contain operational definition
of a “public health emergency of
international concern” that
triggers increased control
responsibilities for nations
• 194 countries worldwide
Medical Management of Biological Casualties
6/2/2009 9
Revised and Modified 25/05/2009

International Health
Regulations (IHR) 2005
• New influenza virus sub‐types and clusters of
unknown and unusual disease are notifiable to
WHO in accordance with the Annex 2 decision
instrument of the IHR (2005)
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

Global Pandemic Curve
First confirmed
Case in Spain was
the catalyst in
WHO activating
phase 5
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

MADRID -- Spain Became the First
Country in Europe Influenza A (H1N1)
• MADRID --In Catalonia Spain,
officials confirmed the first
European case of an infection in
a person who had not (recently)
travelled to Mexico, in a person
whose girlfriend had done so,
the second WHO region to
experience transmission of this
strain of H1N1
Medical Management of Biological Casualties
6/2/2009 12
Revised and Modified 25/05/2009

Who Pandemic Phases and
Recommended Actions
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

Irelands Recommended Actions
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

Bioevent Disasters
SEIRV Triage Model Categories
• Susceptible
• Exposed
• Infectious
• Removed
• Vaccinated
Medical Management of Biological Casualties
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“Biological Triage” Mitigation
High Transmissibility:
• Influenza Mitigation:
• Identify & treat primary Susceptible
infections
Exposed
• Preventative Goal: Infectious
• Prevent secondary infections Removed
 (containment of clustered
in-country transmissions) Vaccinated
According to WHO: Influenza A(H1N1) Secondary attack rate of 22-33%
compared to 5-15% for seasonal influenza
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 25/05/2009

EU Alert Levels in WHO Phase 6
EU alert level Description
EU Alert Level One No confirmed human cases
infected with the pandemic virus
in any EU Member State
EU Alert Level Two One or more confirmed human
case(s) infected with the
pandemic virus in any EU
Member State
EU Alert Level Three A confirmed outbreak
(transmission) with the
pandemic virus in any EU
Member State
EU Alert Level Four Widespread transmission in EU
Member States
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 29/04/2009

Influenza A(H1N1)
Epidemiology
6/2/2009 18
Medical Management of Biological Casualties
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WHO Influenza A(H1N1)
“Confirmed Cases” May 29 2009
• 29 May 2009 -- As of 06:00 GMT, 29 May 2009, 53 countries have officially
reported 15,510 cases of influenza A(H1N1) infection, including 99 deaths.
Awaiting Map
for 29 2009
Medical Management of Biological Casualties
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WHO Influenza A(H1N1)
“Confirmed Cases” June 1 2009
• 1 June 2009 -- As of 06:00 GMT, 1 June 2009, 62 countries have officially
reported 17 410 cases of influenza A(H1N1) infection, including 117
deaths.
6/2/2009 21

Laboratory-confirmed A(H1N1) Influenza Cases
By Date According to WHO
• A semi-logarithmic chart of laboratory-confirmed A(H1N1)
influenza cases by date according to WHO reports
Medical Management of Biological Casualties
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2009 Influenza A(H1N1)
Outbreak In Ireland
Country Cases of human Confirmed Under
swine influenza cases of human Investigation
swine influenza
Ireland 11 (4 neg) 7
(April 30 2009
1st case)
NI 68 (62 neg) 2 4
May 1 2009
• May 25 2009 Dr Tony Holohan, Chief Medical Officer of the Department of Health & Children today) said
that laboratory test results have today confirmed a second case of Influenza Type A (H1N1) in Ireland. The
patient, an adult female residing in the East, recently arrived from New York !
• It advised people in Ireland who have travelled to the affected areas and who develop flu-like symptoms to
seek medical help.
• “If you develop an influenza-like illness and have recently returned – within the last 7 days – from Mexico,
Texas or California, you should contact your GP,”
said Dr Kelleher
6/2/2009 23
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1) (EU) and EFTA
ECDC June 2 2009
Medical Management of Biological Casualties
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Distribution of confirmed cases of influenza A(H1N1) virus
infection by date of reporting, EU and EFTA countries,
27 April to June 2 2009
6/2/2009 27

Influenza A(H1N1)
Outbreak in Japan 2009
• May 23
total
confirmed
276
• May 26
increased
to 350
• June 1 Note: Increase
2009 spike in Japan!
Japan 379
Medical Management of Biological Casualties
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Influenza A(H1N1)
Outbreak in Japan 2009
• Japan notified 67 new confirmed cases in
past 24 hours, representing a 32% increase in
cases according to ECDC
Medical Management of Biological Casualties
6/2/2009 29
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Influenza A(H1N1)
Outside (EU) and EFTA ECDC Progression Maps and tables June 1 2009 2009
6/2/2009 30

2009 Influenza A(H1N1)
Outbreak In The United States ay 2009
Medical Management of Biological Casualties
6/2/2009 31
Revised and Modified 25/05/2009

2009 Influenza A(H1N1)
Outbreak In The United States
U.S Human
The date of the onset of Cases of
symptoms of the first confirmed Swine Flu
case was 28March 2009 in the Updates
United States.
June 1 2009
Table. U.S. Human Cases of
H1N1 Flu Infection
USA –
Confirmed Cases :10,053 cases
17 deaths
Medical Management of Biological Casualties
6/2/2009 34
Revised and Modified 25/05/2009

2009 Influenza A(H1N1)
Outbreak In The United States
6/2/2009 35

Influenza A(H1N1)
Outbreak in Canada June 1 2009
• As of June 1st 2009, a total of 1,530 laboratory-confirmed cases of
H1N1 flu virus have been reported in 9 provinces and 3 territories in
Canada
PHAC is reporting
every 3 days
Medical Management of Biological Casualties
6/2/2009 37
Revised and Modified 25/05/2009

2009 Influenza A(H1N1)
Outbreak in Canada
• May 29, 2009, the average age reported is 22 years or
younger (median: 17 years; range: <1 – 80 years)
6/2/2009 38

2009 Influenza A(H1N1)
Outbreak in Canada
The following graph, also
known as an epidemic
curve, is up to date as of
May 27, 2009. The graph
illustrates the course of
the current H1N1 flu virus
outbreak in Canada. It
shows the date when
symptoms of H1N1 flu
virus began for each of the
laboratory-confirmed
cases.
Medical Management of Biological Casualties
6/2/2009 39
Revised and Modified 25/05/2009

Estimates of the Basic Reproductive
Rate (Ro)
• There have already been several estimates of the basic reproductive
rate (Ro), which all lie between 1 and 2; the range 1.4 to 1.9 being
most probable.
• The basic reproduction number is the mean number of secondary
cases a typical single infected case will cause in a population with
no immunity to the disease in the absence of interventions to
control the infection.
• It is often denoted R0. When R0 < 1 the infection will die out in the
long run (provided infection rates are constant); but if R0 > 1 the
infection will be able to spread in a population
• See case study
“How to they Do it”
Influenza A (H1N1) Estimates of the Basic Reproductive Rate in
Mexico”
Medical Management of Biological Casualties
6/2/2009 40
Revised and Modified 25/05/2009

Influenza A(H1N1)
HPSC Confirmed cases
Next figures: Tuesday 2nd June 2009 Medical Management of Biological Casualties
6/2/2009 41
Revised and Modified 25/05/2009

ECDC May 8 2009
Cumulative Epidemic Curve:
Medical Management of Biological Casualties
6/2/2009 42
Revised and Modified 29/04/2009

Influenza A(H1N1)
Health Service Executive
• The Health Service Executive is advising anyone from Ireland who has
recently returned from Mexico, California or Texas (within seven days),
and develops an influenza-like illness, to telephone their family doctor for
advice.
• Dr. Kevin Kelleher, head of Health Protection with the HSE said:
• ‘Ireland has been preparing for situations like this for several years, and
we have robust and detailed plans in place to respond. The H1N1 swine
flu virus is sensitive to the antiviral drugs of which we have in place
ample stockpiles for Ireland.
• We are and will continue to closely follow the emerging situation. '
6/2/2009 Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Irish Alert Levels In WHO Phase 6
Irish Alert Level Description
Irish Alert Level 1 Cases only outside Ireland (in a
country or countries with or
without extensive Irish
travel/trade links
Irish Alert Level 2 New virus isolated in Ireland
Irish Alert Level 3 Outbreak(s) in Ireland
Irish Alert Level 4 Widespread activity in Ireland
First Confirmed case
In Dublin Ireland
April 3 2009
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 29/04/2009

Zoonosis
Swine Influenza Virus (SIV)
“Zoonotic diseases are those diseases
transmitted between animals and people
and thus compromising public health as well
as endangering livelihoods by affecting their
livestock.”
6/2/2009 45

Global Early Warning System for Major Animal
Diseases, including Zoonoses (GLEWS)
• The Global Early Warning System for Major Animal
Diseases, including Zoonoses (GLEWS) is a joint FAO, World
Organisation for Animal Health (OIE) and WHO initiative to
improve the early warning capacity to animal disease
threats for the benefit of the international community
• Certain animal health events with potential public health
implications are included in the scope of the International
Health Regulations (2005) (IHR(2005))
• Intersectoral collaboration, including between the
veterinary, food safety and public health sectors is needed
to effectively address the prevention of zoonotic diseases
6/2/2009 46

(GLEWS)
Zoonotic and Non-Zoonotic Diseases
• Zoonotic • Non zoonotic
• Anthrax • African Swine Fever (ASF)
• Bovine Spongiform Encephalopathy (BSE) • Classical Swine Fever (CSF)
• Brucellosis (B. melitensis) • Contagious Bovine Pleuropneumonia (CBPP)*
• Crimean Congo Hemorrhagic Fever • Foot and Mouth Disease (FMD)*
• Ebola Virus • Peste des Petits Ruminants (PPR)
• Foodborne diseases • Rinderpest – Stomatitis/Enteritis
• Highly Pathogenic Avian Influenza (HPAI)
• Japanese Encephalitis
• Marburg Hemorrhagic Fever
• New World Screwworm
• Nipah Virus
• Old World Screwworm WHO States :
• Q Fever GLEWS is a joint system that builds on the added value of
• Rabies combining and coordinating the alert mechanisms of FAO,
• Rift Valley Fever* (RVF) OIE and WHO for the international community and
stakeholders to assist in prediction, prevention and control of
• Sheep Pox*/Goat Pox
animal disease threats, including zoonoses, through sharing
• Tularemia
of information, epidemiological analysis and contribute to
• Venezuelan Equine Encephalomyelitis joint field missions to assess and control the outbreak.
• West Nile Virus
6/2/2009 47

Office of Emergency Planning (OEP)
Roles and Responsibilities for Infectious Diseases (Animals)
• Strategic Emergency Planning Guidance – Lead, Principal and Other Support Roles:
• DAFF (Department of Agriculture Fisheries & Food)
• DEHLG (Department of the Environment Heritage & Local Government)
• DOD (Department of Defence)
• HSE (Health Service Executive)
• DTRANS (Department of Transport)
• IRCG (Irish Coast Guard)
• DAST (Department of Arts, Sport & Tourism)
Emergency/Incident Lead Government Lead Response Principal Other Potential Support Remarks
Type Department Agency as per Support Role Roles
Framework
Infectious Diseases DAFF DF (DOD) Local Authorities (DEHLG) HSE role relates to
(Animal) HSE AGS (DJELR) zoonotic diseases;
DFA infectious animal
CD (DOD) diseases with a
DTRANS human health
(IRCG/MSO/Shipping) dimension
DAST
6/2/2009 48

Swine Influenza (SIV)
Past Outbreak History
• 1918 (H1N1)
– Spanish flu (H1N1viruses like swine flu) Possible emergence from swine or an avian
host of a mutated H1N1 virus Pandemic with >20 -40 million deaths globally
• 1976 (H1N1)
– United Sates/New Jersey Virus enzootic to US swine herds since or before 1930 –
One Adult with Severe Pneumonia
• 1988 Swine Influenza United States/Wisscosin Swine Virus
– Pregnant Women dead after exposure to infected pig (Emergency c-section
performed and saved baby)
• 1993 Swine Influenza ((H3N2) The Netherlands Swine Influenza-ressortant between old
human H3N2(1973-75 similarities) and avian H1N1
– 2 Children with mid disease. Father suspected into have transmitted the virus from
close contact with pigs
• 1958-2005 Case report summary
– 19 US, 6 Czechoslovakia, 4 nether land, 3 Russia, 3 Switzerland ,1 Canada (17%
mortality rate) Case report summary
• 2005-2009- 11 sporadic cases of infection in humans with triple-reassortant swine
influenza A H1
• 2009 Novel H1N1 Strain influenza A virus Pig to Human/Human to Human transmission
• 2 009- Novel H1N1 Strain influenza virus
– Human-to-Pig Transmission of the Novel H1N1 Strain influenza virus in a swine herd
6/2/2009 49
in Alberta Medical Management of Biological Casualties
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Swine Influenza (SIV)
Past Outbreak
• 1976 U.S. outbreak
• In early 1976, the novel A/New
Jersey/76 (Hsw1N1) influenza virus President Ford
receives swine
caused severe respiratory illness in flu vaccination
13 soldiers with 1 death at Fort
Dix, New Jersey A/Victoria/75
(H3N2) spread simultaneously, also
caused illness, and persisted until
March Video from 1976
Swine Influenza
• 230 soldiers were infected with Outbreak
the A/New Jersey virus
6/2/2009 50
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Zoonosis
Swine Influenza Virus (SIV)
• Two types of virus have been isolated in
Ireland :
1. H1N1 was isolated for the first time in
November 1991
– The H1N1 isolated in Ireland, is different from
the strains circulating in Europe and
elsewhere, and probably represents a
separate introduction of an avian strain into
Irish pigs. It is serologically related to
Weybridge 79 and OMS/2899/82
2. H3N2 was isolated for the first time in
June 1993
– The H3N2 virus isolated is serologically related
to OMS/3633/84
• No evidence for the existence of H1N2 in
Swine influenza virus. Colorized
transmission electron micrograph
(37,800X) of the A/New Jersey/76
(Hsw1N1) virus under plate magnification.
Irish pigs has so far been detected
Image taken during the virus' first
developmental passage through a chicken
egg. Courtesy of the CDC/Dr. E. Palmer;
R.E. Bates.
6/2/2009 Medical Management of Biological Casualties
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Swine Influenza in Pigs
Virus Subtypes
• Influenza A was first recognized as a clinical illness in pigs in 1918,
which coincided with the 1918-1919 influenza pandemic in humans
• H1N1 influenza A virus was first isolated from pigs in the United
States in 1930.
• H1N2 viruses that resulted from reassortant between the triple
reassortant H3N2 viruses and classical H1N1 swine viruses have
been isolated occasionally in the United States.
• Avian H4N6 virus was recognized in pigs in Canada in 1999, but
spread beyond the original farm of detection was not identified.
• A novel H3N1 influenza virus was isolated from pigs in the United
States in the mid 2000s; this virus may have risen from
reassortment of an H3N2 turkey isolate, a human H1N1 isolate, and
currently circulating swine influenza viruses
6/2/2009 52
Medical Management of Biological Casualties
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Swine Influenza (SIV) Signs and
Symptoms In Swine
• Symptoms of infected pigs include:
– Fever (102-106°F)
– Depression
– Coughing (barking)
– Sneezing
– Difficulty breathing
– Red or inflamed eyes
– Lack of appetite
– Discharge from the nose or eyes
– Reduced fertility or abortion (boars and sows)
– Mortality up to 15%
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 26/04/2005

Swine Influenza (SIV)
Differential Diagnosis In Swine
• The following diseases must be considered in
the differential diagnosis:
– Aujeszky's disease
– Atrophic rhinitis
– Enzootic (mycoplasmal) pneumonia
– Actinobacillus pleuropneumoniae
• (serotype 1-2-4-7-9-11, serotype 2, serotype 1-9-11 or
serotype 4-7)
– Bacterial pneumonia due to Pasteurella or
Haemophilus spp.
6/2/2009 54
Medical Management of Biological Casualties
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Swine Influenza (SIV)
Porcine Diagnostic
• Veterinary diagnostic kits:
• Influenza A Antibody Competition ELISA kit
• Influenza A Antigen Capture Kit
• The kit detects antibodies directed against the A
nucleoprotein in a wide range of species (avian,
porcine, equine), including wild and zoo animals.
6/2/2009 55

Swine Influenza (SIV)
Post-mortem findings In Swine
• Post-mortem findings include:
• The lesions are confined to the
respiratory system and are not very
specific.
• Hyperaemic of the mucosa of the
respiratory tract
• Excess production of mucus
• Atelectasis and emphysema of the
cardiac and apical lobes of the lungs,
• Enlarged bronchial and mediastinal
lymph nodes
• In fatal cases there may be an acute
interstitial pneumonia
6/2/2009 56
Medical Management of Biological Casualties
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Swine Influenza (SIV)
Examples of Vaccines For Porcine!
• Schering-Plough Animal Health Corporation: MaxiVac Excells
• Novartis : PneumoSTAR® SIV Swine Vaccine
• Pfizer Animal Health: FluSure vaccine
6/2/2009 57

National Biosecurity
Importation of Swine In Ireland Directives
• Swine- are prohibited to be
imported from non-EU
countries, except in compliance
with Directive 72/462/EEC.
• Licence issued in accordance
with the Importation of
Livestock Orders, 1970 to 1992
(S.I. No. 296 of 1970 and S.I.
298 of 1992).
6/2/2009 58
Medical Management of Biological Casualties
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Influenza A(H1N1)
Food Safety of Pork “INFOSAN”
• Paris, 7 May 2009
• Joint FAO/WHO/OIE Statement on influenza A(H1N1)
and the safety of pork
• Influenza viruses are not known to be transmissible
to people through eating processed pork or other
food products derived from pigs.
• Heat treatments commonly used in cooking meat (e.g.
70°C/160°F core temperature) will readily inactivate any
viruses potentially present in raw meat products.
Authorities and consumers should ensure that meat from sick pigs or pigs
found dead are not processed or used for human consumption under any
6/2/2009 circumstances.! 59
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Influenza A (H1N1) Prevention
Department of Agriculture and Food
and Fisheries (DAFF)
• Agriculture and Food and fisheries (DAFF) will
institute biosecurity measures
• These control measures focus on animal
health issues and aim to prevent any further
spread of the disease among animals
6/2/2009 60

Irish BIosecurity Measures
For Pig Farms:
• Normal biosecurity measures on pig farms Include:
• Limit the access to essential personnel (farm employees,
veterinarians and essential service people)
• Implement policies that prevent employees who present signs of
flu-like illness from having contact with the pigs or other people on
the holding
• Prevent access of international visitors or people who have recently
returned from international travel, particularly from swine influenza
affected regions, into your holding
• Implement a shower-in/shower-out procedure and the use of farm-
specific clothing and footwear for employees entering the holding
• At minimum, employees should don farm footwear and completely
wash hands and arms before having contact with the pigs
• Enforce heightened personal hygiene practices including frequent
hand washing for all people in contact with pigs
6/2/2009 61
Medical Management of Biological Casualties
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Biosecurity On Pig Farms
$ Profits $
QUALITY ASSURANCE
REDUCED MEDICATION REDUCED MORTALITY
IMPROVED
REDUCED ZOONOSIS REDUCED DISEASE
PERFORMANCE
BIOSECURTY
6/2/2009 62

Swine Influenza Transmission
• Swine diseases can be spread in a number of ways, including:
• Through diseased swine or healthy swine incubating disease
• Through animals other than swine (farm animals, pets, wild birds
and other wildlife, vermin and insects)
• On the clothing and shoes of visitors and employees moving from
farm-to-farm
• In contaminated feed, water, bedding and soil
• From the carcasses of dead animals
• On contaminated farm equipment and vehicles
• In airborne particles and dust blown by the wind
An Egyptian policeman wears a mask
as he stands guard in front of a pick
up truck full of pigs at the main
slaughterhouse in Cairo April 30, 2009
6/2/2009 63
Medical Management of Biological Casualties
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Zoonosis
Swine Influenza Virus (SIV)
How Can Pigs Be protected?
• The following actions can potentially
prevent swine influenza:
• Vaccinating animals
• Ensuring farm workers maintain good
hygiene
• Following strict biosecurity practices
• Providing adequate ventilation in
barns
• Identifying and segregating sick
animals as early as possible
6/2/2009 64
Medical Management of Biological Casualties
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Limit the Risk of Transmission
SIV On Pig Farms
1. Decreasing the spread of SIV includes:
2. Traffic control
3. Isolation
4. Sanitation
5. Herd health management
6. Program maintenance
7. Ensue Personal Protection Equipment(PPE)
onsite and an active fit testing program
8. Application of HACCP (Hazard Analysis of Critical
Control Points)
6/2/2009 65
Medical Management of Biological Casualties
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Swine Influenza (SIV)
Traffic control:
• Traffic control:
• Anyone exhibiting signs of respiratory illness should
avoid contact with animals
• Workers in swine facilities who have been exposed to
influenza or someone diagnosed with influenza should
avoid contact with animals until they have been
checked by a healthcare worker
• Avoid contact with swine outside regular employment
• Control and restrict visitors' access to the herd
• Require all visitors to wear clean boots, clothing and
gloves and wash hands thoroughly on entry and exit
• Prevent other animals from coming into contact with
the herd
• Maintain records of the movement of people, animals
and equipment on and off the premises
6/2/2009 66
Medical Management of Biological Casualties
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Swine Influenza (SIV)
Isolation:
• Isolation:
• Only obtain new animals from reputable sources and limit
the frequency of introducing new pigs to the herd
• House newborn, weaned, feeder, and breeding pigs
separately
• Move pigs in groups during each production stage, in an
all-in-all-out manner
6/2/2009 67
Medical Management of Biological Casualties
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Swine Influenza (SIV)
Sanitation:
• Sanitation:
• Routinely clean and disinfect buildings,
barns, equipment, clothing and footwear
• Designate a cleaning area for vehicles and
equipment
• Promptly dispose of dead pigs in a
manner that minimizes the chance of
spread of any disease
• Implement a manure management
program
• Avoid borrowing equipment and vehicles
from other farms
6/2/2009 68
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Swine Influenza (SIV)
Herd Health Management:
• Herd health management:
• Monitor herd health daily and employ veterinary services
• Uniquely identify all groups of animals for traceability purposes
(where they came from and where they are sold to)
• In consultation with a veterinarian, consider vaccinating animals
• Isolate sick pigs and immediately report any signs of illness to your
veterinarian or the nearest Department of Agriculture office
A Litter-Bed Pigpen for Breeding
and Growing-Finishing Pigs.
6/2/2009 69
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Swine Influenza (SIV)
Program Maintenance:
• Program maintenance:
• Train all staff on your biosecurity program and
monitor its effectiveness
• Be aware of any diseases in your area and
adjust your biosecurity program accordingly
• Recommend farm workers discuss an annual
flu vaccination with their doctor.
– Vaccination may reduce the amounts of
virus shed if infected during human
influenza outbreaks, and limit the potential
for human influenza virus infection of pigs. Full View of the
The effectiveness of current human
Litter-Bed Pig
vaccines against this new strain is not
known at this time Farm.
6/2/2009 70
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HACCP (Hazard Analysis of Critical
Control Points) On PIG Farms
• Application of HACCP (Hazard Analysis of Critical Control
Points) procedures will help to identify areas of greatest
risk to the business and allow for development of
preventative strategies
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A General
Biosecurity Checklist For Swine
6/2/2009 72
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Veterinary Surveillance
• This disease is a scheduled and notifiable disease
in Ireland (Class B)
• Porcine surveillance: The Department of
Agriculture and Food and Fisheries (DAFF) (in
collaboration with the porcine industry
undertakes active and passive surveillance for
porcine
• Notification procedures is agreed between the
department of Agriculture and Food and Fisheries
the HSE in the event of Influenza being identified
or highly suspected from porcine
6/2/2009 73

Swine Influenza (SIV)
Pharmacovigilance for Veterinarians
• EU Veterinary Suspected Adverse Reaction
form for Veterinary and Health Professionals
6/2/2009 74

Swine Influenza (SIV)
Preplanning for Veterinarians Visits:
• The veterinarians should:
• Prepare and plan the visit by
Veterinarians
Porcine log Book
2009
contacting the producer
beforehand
• Park in designated areas or as far
as possible from animals
• Keep a log book of farms visited
6/2/2009 75
Medical Management of Biological Casualties
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Swine Influenza (SIV)
Interim Recommendations For Veterinarians:
• Use appropriate personal protective equipment:
– FFP 2-3 respirator masks, gloves, impermeable coveralls, protective clothing
and footwear and eye protection
• Wash hands thoroughly after handling animals
• Leave as you arrived and clean and sanitize vehicles and equipment
• Dispose of protective equipment in a safe manner:
– either leave it on the farm to be appropriately disposed or
– remove it and place it in “contaminated materials” containers for transport to
the office
• Prioritize work by attending low-risk jobs first and then observe animals
for concerns
• Avoid or minimize contact with manure storage, feed supplies, and water
supplies
• Until more is known about how this illness affects swine, if swine influenza
is suspected – do not travel to another swine farm for 48 hours
6/2/2009 76
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Swine Influenza (SIV)
Personnel Protection
• On arrival at a site, personnel should:
• Disinfect footwear in foot-bath
• Put on washable or disposable protective clothing (footwear and
overalls)
• Wash hands
• Before departure personnel should:
• Disinfect footwear and protective clothing (or leave on site if
disposable)
• Wash hands
• Contacts who work on pig farms should remain off work for 7 days
as soon as diagnosis is suspected!
6/2/2009 77

Veterinarians
Donning and Doffing PPE
6/2/2009 78
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Department of Agriculture
Local District Veterinary Offices (DVO)
COUNTY ADDRESS TELEPHONE
Carlow Athy Road, Carlow 059 9170022
Cavan Farnham St., Cavan 049 4368200
Clare Government Offices, Kilrush Road, Ennis, Co. Clare 065 6866042
Cork North Hibernian House, 80A South Mall, Cork 01 4149900
Cork Central Hibernian House, 80A South Mall, Cork 01 4149900
Cork West Darrara, Clonakilty Co. Cork 023 36200
Donegal Meeting House St, Raphoe, Co. Donegal 074 9145298
Dublin/ St John’s House, High St, Tallaght, Co. Dublin 01 4149900
Wicklow East
Galway Dockgate Building, Merchants Rd., Galway 091 507600
Kerry Spa Road, Tralee, Co. Kerry 066 7145052
Kildare/ Poplar House, Poplar Square, Naas, Co. Kildare 045 873035
Wicklow West
Kilkenny Hebron Road, Kilkenny 056 7772400
Laois Abbeyleix Road, PortLaoise, Co. Laois 057 8674400
Leitrim Cranmore Road, Sligo 071 9682000
Limerick Houston Hall, Ballycummin Avenue, 061 500900
Raheen Industrial Estate, Raheen, Co. Limerick
Longford Ballinalee Road, Longford 043 50020
Louth North Quay, Drogheda, Co. Louth 041 9838933
Mayo Michael Davitt House, Castlebar, Co Mayo 094 9035300
Meath Athlumney, Kilcairn, Navan, Co Meath 046 9082900
Monaghan Main Street, Ballybay, Co. Monaghan 042 9748800
Offaly Clonminch, Tullamore, Co. Offaly 057 9346037
Roscommon Convent Road, Roscommon 090 6630100
Sligo Cranmore Road, Sligo 071 9142023
Tipperary North St Conlon’s Road, Nenagh, Co. Tipperary 067 50014
Tipperary South Government Offices, Davis Street, Tipperary 062 80100
Waterford Govt. Offices, The Glen, Co. Waterford 051 301700
Westmeath Bellview, Dublin Road, Mullingar, Co. Westmeath 044 9339300
Wexford Vinegar Hill Lane, Enniscorthy, Co Wexford 053 9242008
6/2/2009 79

EU Possible Quarantine Zones for Infected
Influenza A(H1N1) Pig Farms
Surveillance zones
Surveillance zone (minimum of 10
km radius from the infected
premises) Inplace for 30 days
Protection Zone
Quarantined Pig Farm Restricted
zone (minimum of 1 -3 km radius
from the infected premises)
Controls must be kept in place
for at least 21 days
Infected Premises
Restricted
Zone
Contaminated
Porcine Farm
There are no
controls on
people visiting
the Zone
Zone A
Adapted from EU Quarantine for
Avian Flu
DAFF:Information on Avian
Influenza Control Measures
Buffer Zone
6/2/2009 80
Zone B

Risk vs. Benefit Analysis for Decontamination
Decontamination is defined as :
What are the outcomes of “The process of removing or neutralising a hazard from the environment, property
or life form. Its objectives are to prevent further harm and optimise the chance for
natural stabilization? full clinical recovery or restoration of the object exposed to the contaminant”.
Yes
Can I change the outcomes No Do nothing except protect
of natural stabilization by
exposures!
the intervention?
What are the cost of the Risk
intervention in terms of risk EXCEEDS Do nothing except protect
versus benefit? benefit exposures!
Benefit “Decontamination Process”
EXCEEDS Refers to removal of clothing, neutralization of contaminate, verification of
contaminate neutralization, and isolation of all contaminated waste.
benefit
Engage in intervention
operations as long as the
benefit exceeds the risk

Quarantine Zones for Infected
Influenza A(H1N1) Pig Farms
Agriculture and Food (DAF) will institute biosecurity measures . These control measures focus on animal health issues and aim to
prevent any further spread of the disease among animals.
Pending confirmation of the outbreak, if deemed necessary, all the porcine in the holding may be culled and destroyed.
• Zone A : Infected premises • Buffer Zone: Surveillance zone
• Risk vs. Benefit Analysis • The Surveillance Zone must stay in place for at least 30 days
after the preliminary cleaning and disinfection of the infected
• The Protection Zone must stay in place for at least 21 premises has been carried out.
days after the preliminary cleaning and disinfection of • Identification of all porcine holdings
the infected premises has been carried out, and then the
• Prohibition on porcine fairs, markets, shows or other
Zone becomes part of the Surveillance Zone gatherings
• Killing and disposal of all porcine • Prohibition on the release of porcine, porcine products
• Cleaning and disinfection of the premises
Checkpoints will be
• Destruction or treatment of manure, slurry and bedding put in place to control
movements of
• Tracing and destruction of porcine meat and carcasses vehicles transporting
porcine or porcine
produced during risk period related products
• Epidemiological investigation and tracing of high-risk into/out of the Zones.
contacts
• Prohibition on porcine entering or leaving
• Controls on people, vehicles and other things entering
or leaving
• Zone B: Free from Disease
• Controls on re-stocking • A Further Restricted Zone may be declared outside the
Surveillance Zone if this is considered necessary to
control the disease. The measures to be applied in this
Zone will be determined depending on a risk assessment
6/2/2009 carried out at the time. 82
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Maximum Decontamination Infected Premises Footbath
Layout Level C & D Protection Boot Cover
Tape &
(PPE) Reduction Outer Glove
Removal Glove Wash Segregated
Removal
(Hypothetical example ) Equipment
Stripper/ 6 5 4 3 2 1 Drop
Bagger
Boot Cover Boot Cover &
Removal Glove Rinse
Zone A
7 Suit/Safety Boot Wash
Canister or
9 8 Suit/Safety Boot Rinse
Mask Change
and Redress - Boot Cover/
Outer Gloves 10 Safety Boot Removal
11 Splash Suit Removal
CONTAMINATION 12 Inner Glove Wash
REDUCTION The contamination hazards at hazardous sites
Inner Glove Rinse vary greatly, the methods of decontamination
ZONE 13
may be adjusted by omitting, adding, or
changing the stations identified to reflect the
14 Face Piece Removal
contamination hazards at a site!
15 Inner Glove Removal
These figures are adapted from the, NIOSH/OSHA/USCG/EPA
Occupational Safety and Health Guidance Manual for
16 Inner Clothing Removal Hazardous Waste Site Activities.
CONTAMINATION
CONTROL LINE
SUPPORT Dryer/ 17 18 Field
Dresser
ZONE Wash

Minimum WIND DIRECTION
Decontamination Layout 20
Levels C & D Protection Redress: Boot Covers
and Outer Gloves
Zone A
Decon 20
Solution Tank
Change-Over
Point (If needed)
Infected Premises
Remove
Water Boots/Gloves
and
Decon Outer Outer
Equipment Garments Garments
Drop (For Disposal
Remove and Off Site
Boot Covers Decontamination)
and Outer Gloves
Footbath
Plastic
Sheet
Can
Zone A
(10 gallon) Remove
SCBA
(If needed)
Contamination Reduction Corridor

Basic Personnel Decontamination
Vehicle decon “Contamination Reduction Corridor” Setup Vehicle decon
Decon Water
Solution
Inner
Washer Rinser Stripper
Zone A
Equipment glove
Drop
bagger removal
Zone
Contaminated
Porcine Farm Entry Wash Rinse Can PPE Removal Exit
(10 gallon
Support
Footbath Can Can Can
Zone A
10 gallon 10 gallon 10 gallon
Footbath if no Decon pools
CRC setup
Storage and Garbage
Plastic (Tarp or Visqueen)
Barrier tape and pylons
Contamination Reduction Corridor
6/2/2009 85

Vehicle Decontamination
• Only allow essential vehicles onto the site. Staff, service vehicles etc. should be parked outside the
perimeter. Insist that all vehicles that have to enter the site have been cleaned and disinfected
beforehand
• Vehicle cleaning and disinfection:
• On arrival at the farm, wheels, wheel arches, outside and underside must be disinfected
• Before leaving the farm, wheels, wheel arches, outside and underside must be washed and
disinfected, ensuring that the surfaces are visibly clean (must be dry)
• Wash and disinfect all surfaces which may have come into contact with contaminated material,
such as:
– Wheels, wheel arches, outside and underside
– Trailer
– Equipment (e.g. trolleys, crates, modules, delivery pipes, sheeting, covers)
– Wipe areas of the driver’s cab that may have been contaminated, with disinfectant
– Drivers should avoid contact with porcine or other porcine on premises outside the infected area for at least 3 days (72 hours)
A list of approved disinfectants can be
found at: http://www.agriculture.gov.ie
6/2/2009 86

Swine Influenza and
Influenza A(H1N1) Virus
Swine influenza Influenza A(H1N1) Virus
• Swine influenza is • The Influenza Virus contains
commonly transmitted genes from pig, bird and
through direct contact or human influenza viruses, in
close proximity with pigs. a combination that has
never been observed before
Secondary cases following anywhere in the world
human-to-human
• 2009 Quadruple
transmission have been ressortment of three
reported in the past but viruses—a human virus, an
they have been very rare avian virus , and 2 porcine
• 1998 Triple reassortment viruses
6/2/2009 87
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Influenza Virus
Influenza Type A and Its Subtypes
3 integral membrane
proteins that coordinate
fusion are :
1. NA
Pink - 2. HA
Hemagglutinin 3. M2
Yellow -
Neuraminidase
CDC
6/2/2009 Medical Management of Biological
Casualties

Phylogenetic Comparison To Other
Negative-sense RNA Viruses
• Influenza strains are
subtyped A, B, or C
• Based on the
relatedness of the
matrix (M1) and
nucleoprotein (NP)
antigens
6/2/2009 89
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Influenza Virus
Influenza Type A
Influenza A viruses are pleomorphic virions
(that is, they vary in shape)
They have negative-sense, single-stranded HA - hemagglutinin
RNA and an RNA genome that is SEGMENTED
There are eight RNA segments in influenza A NA - neuraminidase
The nucleocapsid is helical
Virions contain RNA polymerase packaged
within the virus particle helical nucleocapsid (RNA plus
These viruses are enveloped and have two
NP protein)
membrane glycoproteins: lipid bilayer membrane
1. HA - hemagglutinin - This is the
attachment and fusion protein polymerase complex
2. NA - neuraminidase - This is
important in release. It removes sialic
acid from proteins of the virus and the
host cell
M1 protein
M1 protein unnderlies the lipid bilayer, is
the most abundant protein
Genome organized in 7 or 8 segments.
3 integral membrane proteins that
coordinate fusion are NA, HA, and M2 (not
shown)
NP protein important for subtyping
NS protein, not shown, important for
virulence
6/2/2009 90

ORTHOMYXOVIRIDAE
Influenza Type A (H1N1)
PROPERTY ORTHOMYXOVIRIDAE
Influenza A(H1N1)
Genome segmented
RNA synthesis nuclear
Need for mRNA primer yes
Hemagglutinin,neuraminidase Influenza A and B have both but on 2
different proteins (HA and NA)
Syncytia formation no (HA functions at acid pH)
6/2/2009 91
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Replication of Influenza A virus
• 1. A virion attaches to the host cell membrane via HA
and enters the cytoplasm by receptor-mediated
endocytosis
• • HA2 promotes fusion of the virus envelope and the
endosome membranes
• 2.The major envelope protein M1 dissociates from the
nucleocapsid and viral RNA segments are translocated
into the nucleus
• 3. In the nucleus, the viral polymerase complexes
transcribe (STEP 3a) and replicate (STEP 3b) the viral
RNA segments
• 4. Newly synthesized mRNAs migrate to cytoplasm
where they are translated into viral proteins
• 5a. Newly synthesised M1 viral proteins move to the
nucleus - bind freshly synthesized 21 y y copies of viral
RNA segments.
• 5 b. Posttranslational processing of HA, NA, and M2
includes transportation via Golgi apparatus to the cell
membrane
• 6. The newly formed nucleocapsids migrate into the
cytoplasm - interact via M1 with a region of the cell
membrane where HA, NA and M2 have been inserted
• 7. Then the newly synthesized virions bud from
infected cell. NA destroys the sialic acid moiety of
cellular receptors, thereby releasing the progeny
6/2/2009
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Influenza A (H1H1)
2009 Genetic Origins
• HA (or H1): Hemagglutinine type 1 , swine,
also in the 1918 influenza Catch host's cell
receptors
• NA (or N1): Neuraminidase type 1, swine,
Eurasian, help start the infection
• PA: avian, north America
• PB1: human, likely from the 1993 H3N2
influenza
• PB2: avian, from north America
• NP: swine, north America
• M: swine, Eurasia
• NS: swine, north America
– Non-structural proteins
NEP (Nuclear Export Protein):, swine North
America
6/2/2009 93
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Definition of Pandemic
• The word “pandemic” comes from the Greek “pan-“, “all” +
“demos”, “people or population” = “pandemos” = “all the
people.”
• A pandemic affects all (nearly all) of the people.
• By contrast, “epi-“ means “upon.” An epidemic is visited
upon the people. And “en-“ means “in.” An endemic is in
the people.
Technical report - Pandemic influenza
6/2/2009 94
preparedness in the EU/EEA

Past & Potential Flu Pandemics
• Disease Year Deaths
• Russian Flu 1889/1890 1 million
• Spanish Flu 1918/1919 20-40 ?100 million
• Asian Flu 1957 3-4 million
• Hong Kong Flu 1968 1-4 ?50 million
• SARS 2003 774
• Avian Flu 2003 256 ongoing
• Swine Flu 2009 767 Unconfirmed
(confirmed 117)
6/2/2009 95
Medical Management of Biological Casualties

Timeline of 2009 Hybrid “quadruple reassortant” new
influenza A(H1N1)—a human virus, an avian virus
, and 2 porcine viruses Swine
Emergence of Some
No Vaccine
Influenza
H1 Quadruple Reassortment Result
Influenza Viruses in 2009 Influenza A (H1N1) (Swine Origin) 117 Deaths
Avian
Humans Influenza
Pandemic
vaccines
1997: In Hong Kong, avian influenza A (H5N1)
H5 Total of 256 Deaths 2009 WHO
Russian
H9 1997-2009:avian influenza A (H9N2)
Influenza H7 1980- 2003: Avian influenza A (H7N7)
B Russian Flu (H2N2) 1889/1890 1 million Russian Flu (H2N2 A/USSR/90/77 (H1N1).
2002 Severer Acute Respiratory Virus (SARS-CoV)
1900 Old Hong Kong Influenza H3N8? Asian 774 deaths
Influenza
Old Hong Kong
Regular vaccines
Influenza H2 1957 (Asian Flu) 1-4 million deaths H2N2
Spanish “Triple reassortment”
Influenza H3
H2
1968 (Hong Kong Flu) 1-4 million deaths H3N2
Aggressive H3N2
Hong Kong
H1 1918 (Spanish Flu) 20-40 million deaths H1N1
Influenza Swine to Human
1998/9
1918 1957 1968 1977 1993 1997 2003 2009
6/2/2009 By 1993, a bird flu virus had adapted to pigs, grabbed a few human flu 96
Medical Management of Biological Casualties
US 1976 Swine Influenza virus genes, and infected two young Dutch children, even displaying
evidence of limited human-to-human transmission.
Revised and Modified 29/04/2009

Past & Potential Flu
Pandemics Summary
Epidemics Year Approx Approx Approx Case fatality
(avail. data) Infected Deaths Mortality % Rate/
Russian Flu 1889/1890 unknown 1 million unknown 0.75–1 death
per 1000
Spanish flu 1918/1919 500 million 20-40 /?50 2.5 -10%
million +
Asian flu 1956-58 45 million 3-4 million 0.58 deaths
/1000
persons
Hong Kong 1968-69 50 million 1-4 million
flu
Avian flu 1990-today 421 257 61% 610
SARS 2002-03 8,096 774 9.6% 96
Swine flu 1976 117
2009 Ongoing
6/2/2009 97
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Epidemiology of Ireland
Spanish Influenza 1818-1819
• Ireland: 10,651 influenza • The deaths per 100,000
deaths registered by age group:
(Unconfirmed 20000) under 5 years 295
– Male : 5,591 5-10 years 120
– Female: 5,060 10-15 years 103
• Mortality Rate: of 243 per 15-20years 223
100,000 population 20-25 years 329
– The mortality rate 25-35 years 380
varied by region: 35-45 years 239
• Leinster: 304 per 45-55 years 222
100,000
• Ulster: 302 per 1918 Flu Pandemic In 55-65 years 226
100,000 Ireland
65-75 years 221
• Munster: 159 per < 75 years 256
100,000
• Connaught: 114 per
100,000
6/2/2009 98
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Irelands Road to
Pandemic Preparedness
• 1999 -World Health Organisation (WHO)
– “Influenza Pandemic Plan”
• 2001- Ireland Developed
– “A Model Plan for Influenza Pandemic Preparedness”
• 2002- Plan was revised
• 2004- Influenza Pandemic Preparedness Plan
• 2005- WHO published
– “WHO Global Influenza Preparedness Plan”
• 2007 –Ireland Developed
– “National Plan for Pandemic Influenza”
6/2/2009 99
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Scientific Models of the Impact of an
Influenza Pandemic
• USA: Pandemic Severity Index
• United Kingdom: Empiric HPA Model
Irelands “National Pandemic Influenza Plan”
uses the HPA Model
Health Protection Surveillance Centre
25-27 Middle Gardiner St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
Gani and Meltzer Model are also used See Website for download for
to predict ICU rates and Ro rates in the
National Pandemic Plan
clinicians
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Pre-Pandemic Planning:
The Pandemic Severity Index
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Pandemic Severity Index
• The pandemic severity index levels are:
• Category 1, CFR of less than 0.1%
• Category 2, CFR 0.1% to 0.5%
• Category 3, CFR 0.5% to 1%
• Category 4, CFR 1% to 2%
• Category 5, CFR 2% or higher
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Pandemic Severity Index
• Class I
• A Class I pandemic is characterized by a widespread novel infection that, while it may cause
sickness, does not create large scale deaths or economic impacts. The 1968 Flu is a good example
of a Class I pandemic. Also, the current outbreak of Chikungunya could be considered a Class I
pandemic. The observed death rate worldwide would not increase significantly from a Class I
pandemic.
• Class II
• A Class II pandemic is characterized by a novel infection that has a low infection rate or a minimal
case fatality rate and thus any serious effects on economies or overall mortality rates is minimized.
The current HIV/AIDS pandemic can be considered a Class II pandemic. In any one year, a Class II
pandemic would kill up to 1 million people.
• Class III
• A Class III pandemic is characterized by novel infection that spreads quickly but has a low total
mortality rate. The 1918 pandemic would be considered a Class III pandemic. Note: between 50 -
100 million people died during the 1918 pandemic. A class III pandemic would kill approximately
2% of all humans or 120 million people.
• Class IV
• A Class IV pandemic is characterized by a novel infection that spreads quickly but has a medium
level of mortality rates. The Black Death of 1347 - 1350 would be considered a Class IV pandemic. A
Class IV pandemic would directly kill 40% of humans. A Class IV pandemic would kill 2.4 billion
people. If Influenza A (H1N1) acquires the ability to easily infect humans to humans at the current
CFR, it would be a Class IV pandemic.
• Class V
• A Class V pandemic is characterized by a novel infection that spreads quickly, has a high infection
rate and a high mortality rate. There are no documented records of a Class V pandemic, but some
experts believe that the new world indigenous peoples were affected by old world diseases in a
Class V manner. A class V pandemic would directly kill off approximately 90% of living humans. A
6/2/2009 V pandemic would kill 5.4 billion people.
class 103
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Community Mitigation Strategy by
Example on Pandemic Severity Scale
6/2/2009 104
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Irelands Pandemic Mitigation
“Empiric HPA Model”
• The Empiric HPA model outlines a single wave
pandemic over 15 weeks with a peak of clinical
cases and deaths occurring weeks six and seven .
According to this
model, just over
20% of cases and
deaths occur in
each of these
weeks.
6/2/2009 105

Irelands Mitigation Strategies
• The following scenario has been adopted for planning
purposes:
• A cumulative clinical attack rate of between 25% and
50% of the population
• A hospitalisation rate of between 0.55% and 3.70%
• A case fatality rate of between 0.37% and 2.50%
(equivalent to the 1957 and 1918 pandemics
respectively)
• Calculations are based on the Census 2006 Preliminary
Report, which puts the Irish population at 4,234,925
6/2/2009 106
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Irelands Assumed
Clinical Attack Rate: Scenario 1
• Scenario 1
• Irish population at
4,234,925
• Considers:
– Clinical Attack Rate of
25% 1,058,731 cases
– Hospitalisation Rate of
0.55% 5,823 over the 15 wks
– Mortality Rate of
0.37% 3,917 deaths
• Weekly number of cases,
hospitalisations and
deaths as predicted by
the empirical model.
6/2/2009 107
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Irelands Assumed
Clinical Attack Rate: Scenario 2
• Scenario 2
• Irish population at
4,234,925
• Considers :
– Clinical attack rate of
50%: 2,117,463 cases
– Hospitalisation rate of
3.7%: 78,346 over 15 wks
– Mortality rate of
2.5%.: 52,937 deaths
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WHO Phases 4 and 5
Irelands National Objectives
• To assess the extent of human-to-human transmission and
determine pandemic risk
• To detect, notify and characterise additional clusters (including the
identification of risk factors and other data concerning transmission
as requested by WHO)
• To assess the threat to human health and the impact of any control
measures, and identify resources required for enhanced control
• To determine and monitor public health resources required for
pandemic response
• Monitor the global situation (vaccine, antiviral availability, best
practice recommendations) and estimate the impact of antiviral
programmes (and vaccination programmes if used)
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WHO Phase 4-6, Irish Alert Level 1
(Ireland Not Yet Affected)
• 1.Establish surveillance of clinical conditions which have been linked to the novel
virus abroad, but which are not necessarily part of the clinical criteria for routine
influenza investigation
• 2.Travellers returning from areas with pandemic activity should be provided with
information and advised to seek medical attention if they become unwell.
• 3.All doctors should be advised to ask patients presenting with respiratory illnesses
about overseas travel
• Samples should be collected for influenza detection and sent to the NVRL from all
patients with respiratory illness who have:
– Fulfilled the case definition for pandemic influenza orBeen hospitalised with viral pneumonia
or
– Travelled to areas of known or potential pandemic influenza activity in the week preceding
onset of illness or;Have a flu-like illness and are family members or other close contacts of
either of the above
• 4.Departments of Public Health must immediately be notified of:
– All cases who have been hospitalised with viral pneumonia (or other particular clinical
features associated with the pandemic strain that form part of the case definition); and who
have travelled to areas of known or potential influenza activity in the week preceding onset of
illness and
– Those who have a flu-like illness and are family members or other close contacts of a person in
either of these categories
Medical Management of Biological Casualties
6/2/2009 Revised and Modified 29/04/2009

WHO Phase 4-6, Irish Alert Level 1
Once Ireland Is Affected!
• As soon as the first cases of pandemic influenza are
detected in the country the surveillance activities will
be focused on:
• Detecting community outbreaks
• Tracking trends in influenza disease activity and
identifying populations that are severely affected
• Real-time reporting between he following is essential:
– Healthcare institutions
– Clinicians
– Public Health
– Sentinel General Practitioners
– NRVL and Laboratories
– Pharmacists
–
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Influenza A(H1N1)
Information On Surveillance
• Further information: • International
http://www.hse.ie/eng/ • CDC, US
http://www.dohc.ie • PHAC
http://www.who.int/en
http://www.cdc.gov/swineflu/ • PAHO
http://ecdc.europa.eu/en/ • ECDC
• Links • HPA, UK
• • WHO
Irish
• Health Service Executive (HSE)
• Department of Health and
Children
• Department of Foreign Affairs
• Department of Agriculture
• Irish College of General
Practitioners (ICGP)
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Surveillance System:
EU Surveillance Networks
• Enter-net
• EuroHIV
Eurosurveillance
• EuroTB
• European Antimicrobial Resistance Surveillance System (EARSS)
• European Influenza Surveillance Scheme (EISS)
• European Programme for Intervention Epidemiology Training
(EPIET)
• European Scientific Working Group on Influenza (ESWI)
• European Surveillance of STIs (ESSTI)
• European Working Group for Legionella Infections (EWGLI)
• FluNet Global Salm-Surv (GSS)
• International Network of Paediatric Surveillance Units
6/2/2009 114

International Surveillance System
• International • Europe
• – The European Union
United Kingdom – EU Public Health
Eurosurveillance
British Paediatric Surveillance Unit (BPSU) – Health and Consumer Protection DG
• Communicable Disease Surveillance – World Health Organisation: Europe
Centre, (NI)
• Department of Health (UK)
• Worldwide
– Australia: Communicable Diseases
• Department of Health, Social Services and
Australia
Public Safety (NI)
– Australia: Immunise Australia
• Faculty of Public Health Medicine (UK)
Programme
• Health Promotion Agency (NI)
– Canada: Health Canada
• Scottish Executive Health Department
– New Zealand: Ministry of Health,
• Welsh Assembly Government New Zealand
• – USA: Centers for Disease Control
– World Health Organisation:
6/2/2009 International 115
•

Surveillance System:
National Surveillance Institutes in Europe
• Belgium: l'Institut scientifique de Santé • Netherlands: Rijksinstituut voor
Publique Volksgezondheid en Milieu (RIVM)
• Norway: Folkehelseinstituttet
• Czech Republic: Centrum Epidemiologie a
• Poland: Panstwowy Zaklad Higieny (PZH)
Mikrobiologie (CEM)
• Portugal: Direcção-Geral da Saúde
• Denmark: Statens Serum Institut (SSI) • Slovak Republic: Úrad Verejného
• Estonia: Tervisekaitseinspektsioon Zdravotnictva (UVZ)
• Finland: Kansanterveyslaitos (KTL) • Slovenia: Inštitut za varovanje zdravja (IVZ)
• Spain: Instituto de Salud Carlos III
• France: Institut de Veille Sanitaire (InVS)
• Sweden: Smittskyddsinstitutet (SMI)
• Germany: Robert Koch Institut (RKI) • UK (England & Wales): Health Protection
• Greece: Hellenic Center for Infectious Agency (HPA)
Diseases Control (KEEL) • UK (Northern Ireland): Communicable
Disease Surveillance Centre (CDSC)
• Hungary: Országos Epidemiológiai Központ
• UK (Scotland): Health Protection Scotland
(OEK) (HPS)
• Iceland: Landlæknir • U.S. Department of Health and Human
• Italy: Istituto Superiore di Sanità (ISS) Services
• (DHHS)
• Latvia: Sabiedribas veselibas agentura
(SVA)
• Luxembourg: Direction de la Sant
6/2/2009 116

Influenza Activity Index
Irish Influenza Activity Code, Name and Description
Index Index Name Index Description*
Code
0 No Report No reports received.
1 No Activity No ILI or laboratory confirmed influenza cases and no
influenza/ILI outbreaks in a HSE-Health Area.
2 Sporadic Activity Isolated case(s) of ILI or laboratory confirmed influenza
case(s) in a HSE-Health Area, or an influenza/ILI
outbreak in a single nstitution.
3 Localised Activity Increases in ILI in local areas (such as a city, county, or
district) within a HSE-Health Area, or outbreaks in two or
more institutions within an area, with laboratory
confirmed cases of influenza infection. Levels of activity
in the remainder of the HSE-Health Area would be
sporadic or have no activity
4 Regional Activity Increases in ILI in one or more regions with a population
comprising less than 50% of the HSE-Health Area’s total
population, with laboratory confirmed influenza cases in
the ffected region(s). Levels of activity in the remainder
of the HSE-Health Area would be sporadic or have no
activity.
5 Widespread activity Increases in ILI in one or more regions with a population
comprising 50% or more of the HSE-Health Area’s total
population, with laboratory confirmed influenza
infections
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Influenza-like illness (ILI) –Definition
Surveillance of Clusters/Outbreaks
• Influenza-like illness (ILI) -definition for
interim surveillance of clusters/outbreaks
• Three or more cases of ILI arising within
the same 72 hour period which meet the
same clinical case definition and where an
epidemiological link can be established
• ILI symptoms include:
– Acute onset of fever (temperature≥38oC)
– OR history of fever
– AND flu-like illness (two or more of the
Influenza-like
following symptoms: cough, sore throat, Illness/Influenza/Influenza A
myalgia, headache, rhinorrhea or (H1N1)
Outbreak Reporting Form
vomiting/diarrhoea)
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Influenza A(H1N1)–Definition
Surveillance of Clusters/Outbreaks
6/2/2009 New May 29 2009 120

Influenza
Irelands Surveillance Systems
• The role of HPSC as influenza surveillance co-
ordinator is to:
• Maintain and develop the current sentinel
influenza surveillance network
• Oversee enhancements as outlined e.g. year
round surveillance, surveillance of hospitalised
cases
• Promote year round surveillance of influenza
• Maintain close working relationship with the
National Virus Reference Laboratory (NVRL) and
the Irish College of General Practitioners (ICGP)
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Influenza A(H1N1)
Irelands Surveillance Systems
• World Health Organization “GOARN”
• European Influenza Surveillance System (EISS)
• Irish
• The National Influenza Surveillance System
• 1. Reporting of clinical data/influenza-like illness (ILI) by sentinel GPs
• 2. Virological reporting (NVRL)
• 3. Hospital surveillance comprising weekly data on total admissions, total
Emergency Department (A&E) admissions and total respiratory admissions
(upper respiratory tract infection, lower respiratory tract infection,
pneumonia, asthma, chronic bronchitis, and exacerbations of chronic
obstructive pulmonary disease) from sentinel hospitals
• 4. Surveillance of absenteeism rates in sentinel schools
• 5. Reports on outbreaks due to influenza or ILI
• 6. Mortality data (weekly review of all cause and pneumonia and influenza
registered deaths (uncoded)) from the General Registrar’s Office (GRO)
• 7. Weekly regional influenza indices based on clinical activity, virological
activity and outbreak activity. This is defined as no report, no activity,
sporadic activity, localised activity, and widespread activity
– Computerised Infectious Disease Reporting (CIDR)
– Hot Line:
• The Flu Information Line is available 24 hours a day and is your primary source of
information on Influenza A(H1N1).
• Freephone: 1800 94 11 00
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Computerised Infectious Disease Reporting
(CIDR) Dissemination Pathway
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The statutory requirement to notify all cases of
swine influenza A/H1N1 to the regional Director of
Public Health/Medical Officer of Health (DPH/MOH)
Under the Infectious Diseases (Amendment)
(No.3) Regulations 2003 (SI No.707 of 2003)
laboratory and clinical notification of swine
influenza A (H1N1) is mandatory
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Influenza A(H1N1)
Surveillance Systems
• Reporting of clinical data by
sentinel GPs
• Hospital Surveillance
• Enhanced surveillance
• Surveillance of absenteeism
rates in sentinel schools
• Mortality Surveillance
• Regional influenza activity by
HSE area
• Weekly Notifications of Influenza
Influenza A(H1N1) Infection
Weekly Surveillance Report
6/2/2009 125

Influenza A(H1N1)
“The Emerging Pandemic!”
“Quadruple Reassortment”
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Influenza Antigenic Changes- Drift
• Antigenic Drift
• Minor change, same
subtype
– Caused by point mutations
in gene
– May result in epidemic
• Example of antigenic drift
– In 1997, A/Wuhan/359/95
(H3N2) virus was dominant
– A/Sydney/5/97 (H3N2) This colorized image, released by the
U.S. Centers for Disease Control and
appeared in late 1997 and Prevention April 24, 2009, depicts the
influenza A H1N1 \"swine flu\" virus from
became the dominant virus an outbreak in 1976
in 1998
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Influenza Antigenic Changes - Shift
• Antigenic Shift
– Major change, new subtype
– Caused by exchange of gene
segments
– May result in pandemic
• Example of antigenic shift European
Surveillance
– H2N2 virus circulated in 1957-1967 Network for
Influenza in
– H3N2 virus appeared in 1968 and Pigs (ESNIP)
completely replaced H2N2 virus
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Categorizing Influenza Virus “Viral
Nomenclature”
Type of nuclear
material
Neuraminidase
Hemagglutinin
A/California/04/2009(H1N1)swl
Virus Geographic Strain Year of Virus
type origin number isolation subtype
Try These Two! A/New Jersey/76 (Hsw1N1)
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A/Victoria/75 (H3N2) Revised and Modified 29/04/2009

Influenza Type A Antigenic Shifts
Severity of
Year Subtype Pandemic
1889 H3N2 Moderate
1918 H1N1 Severe
1957 H2N2 Severe
1968 H3N2 Moderate
1977 H1N1 Mild
2009 H1N1 ? Ribbon representation
of the hemagglutinin
HA0 trimer from the
1918 influenza virus.
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Emergence H3N2 Viruses
Antigenetic Shift
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Emergence H3N2 Viruses
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Influenza A(H1N1)
Reassortment Diamond
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Influenza A(H1N1)
Host Range
6/2/2009 134
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Influenza A(H1N1)
Antigenic Shift Pathogenesis
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Origins Overview
2009 Influenza A (H1N1)
“Quadruple Reassortant”
new influenza A(H1N1)
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Influenza A(H1N1)
Epidemiological Risk Factors
• Epidemiological risk factors that should
raise suspicion of swine influenza
A(H1N1) include:
• Close contact to a confirmed case of
swine influenza A(H1N1) virus infection
while the case was ill
• Recent travel to an area where there
are confirmed cases of swine influenza
A (H1N1)
• Close contact: having cared for, lived
with, or had direct contact with
respiratory secretions or body fluids of
a probable or confirmed case of swine
influenza A(H1N1)
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Influenza A(H1N1)
Specific Investigational Triggers
• The primary focus of early investigation is to trigger the initial
investigation include:
• Clusters of cases of unexplained ILI or acute lower respiratory disease
• Severe, unexplained respiratory illness occurring in one or more health
care worker(s) who provide care for patients with respiratory disease
• Changes in the epidemiology of mortality associated with the occurrence
of ILI or lower respiratory tract illness, an increase in deaths observed from
respiratory illness or an increase in the occurrence of severe respiratory
disease in previously healthy adults or adolescents
• Persistent changes noted in the treatment response or outcome of severe
lower respiratory illness
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Influenza A(H1N1)
Microbiology:
• Influenza A viruses are negative-sense single-stranded
RNA viruses
• Family: Orthomyxoviridae
• Genus: Influenza virus A
• Enveloped virions are 80 to 120 nm in diameter, are 200
to 300 nm long, and may be filamentous
– They consist of spike-shaped surface proteins, a partially
host-derived lipid-rich envelope, and matrix (M) proteins
surrounding a helical segmented nucleocapsid (6 to 8
segments)
– The virus envelope glycoproteins (hemagglutinin [HA] and
neuraminidase [NA]) are distributed evenly over the virion
surface, forming characteristic spike-shaped structures;
antigenic variations in these proteins form the basis of the
classification system for influenza A virus subtypes
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Phylogenetic Analysis of Sequences of all Genes
Identified in A/California/04/2009
• Novel Swine-Origin Influenza A (H1N1) Virus Investigation
Team 10.1056/NEJMoa0903810, May 7, 2009
NML Winnipeg, Canada
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Has Breakthrough! Revised and Modified 29/04/2009

Comparison of H1N1 Swine Genotypes
in Recent Cases in the United States
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Emergence of a Influenza A (H1N1)
Virus in Humans
Supplement to: Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a novel swine origin
influenza A (H1N1) virus in humans. N Engl J Med 2009;361. DOI: 10.1056/NEJMoa0903810
6/2/2009 142

Influenza A(H1N1)
Infectious Period:
• The 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.
• The swine flu in humans is most contagious
during the first five days of the illness although
some people, most commonly children, can
remain contagious for up to ten days
,immunocompromised up to 1-3 months
• May 20 2009 : WHO Technical Consultation on
the severity of disease Report 20,05 May
Teleconferencex
• Ranging between
– 1–5 days (Spain)
– 4–6 days (UK)
– 2–7 days (US )
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Influenza A(H1N1)
Transmission:
• Direct and indirect contact
– Pig to human
• asymptomatic carrier pigs
– Human to human
– Human to Pig
• Droplet transmission
• Aerosol generating procedures (AGPs)
• Not transmissible by consumption of
pork
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Influenza A(H1N1)
Human Signs and Symptoms:
Fever (greater Exacerbation of underlying
chronic medical conditions
than 100°F or Includes:
37.8°C) Upper respiratory tract disease
(sinusitis, otitis media, croup)
EU > 38 °C lower respiratory tract disease
*NOTE: Some people, (pneumonia, bronchiolitis,
such as the elderly, status asthmaticus)
and people who are Cardiac (myocarditis,
immunocompromised, pericarditis)
may not develop a Musculoskeletal (myositis,
fever. rhabdomyolysis)
Neurologic (acute and post-
infectious encephalopathy,
encephalitis, febrile seizures,
status epilepticus)
Toxic shock syndrome
Secondary bacterial
pneumonia with or without
sepsis.
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Influenza A(H1N1)
High Risk Groups:
• There are insufficient data
available at this point to
determine who is at higher
risk for complications of
swine-origin influenza A
(H1N1) virus infection
• Therefore considerer
higher risk for swine-origin
influenza complications if:
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Groups at High Risk for Complications
From Influenza A(H1N1):
• High Risk groups include:
• Infants aged 12–24 months
• HIV-infected persons
• Adults aged >65 years
• Residents of any age of nursing homes or other
long-term care institutions
• Asthmatics or other chronic pulmonary
diseases, such as cystic fibrosis in children or
• Chronic obstructive pulmonary disease in Five-year-old Edgar
adults Hernandez, known as
• Hemodynamically significant cardiac disease \"patient zero\" survived the
• Immunosuppressive disorders or who are earliest documented case
receiving immunosuppressive drugs of swine flu. “April 2 2009”
• Sickle cell amenia and other
hemoglobinopathies
• Diseases that requiring long-term aspirin
therapy
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Symptoms Onset
of Influenza A(H1N1) in Canada
• As As of May 28, 2009, the
average age reported is 22
years or younger (median:
17 years; range: <1 – 86
years).
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Influenza A(H1N1)
High Risk Group Age
• High risk age 20-30 according
to ECDC as of May 5 2009
• Correlates with US, Mexico
and Canada statistics!
• ?Why
– Pre-exposure? Hand hygiene
– Pandemic prevention
techniques like social
distancing, avoidance, hand
hygiene not adhered to ?
– Needs further research
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Influenza A (H1N1)
Mexico, United Sates, Canada Age
Summary:
In Mexico In United States:
As of 20 May 2009, 16:30 AM ET, 48
states of the United States have
reported a total of 5,764confirmed
cases including 247 hospitalizations
and 8 deaths.
Median age: 17 years, range 1 month-
87 years
Gender: 51% female, 49% male
Underlying medical conditions (n=44):
63% (median age: 18 years)
Median time from illness onset to
hospital admission (n=32): 4 days
(range: 1-13 days)
Median length of hospital stay (n=32):
5 days (range 2-31)
In Canada: As of May 28, 2009, the average
age reported is 22 years or younger (median:
17 years; range: <1 – 86 years).
In Europe: Median age 33
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Influenza A (H1N1)
México Age Specific Attack Rate May 13
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Influenza A (H1N1)
México Age Specific Attack Rate May 20
6/2/2009 152

Influenza A (H1N1)
Summary of Age Specific Clinical Signs and
Fatality Rate May 20 2009
6/2/2009 153

México, United Sates, Canada
Age and Gender Summary: Influenza A (H1N1)
• The Mexican Ministry of Health published an
epidemiological update on May 7, 2009, on their website:
• Out of the 1204 confirmed cases studied, 49.5% are
females and 72% are in persons under the age of 29 years
of age.
• The Public Health Agency of Canada reported
epidemiological information of the confirmed cases on May
20, 2009
– The majority of the cases (97%) are under the age of 50
– The median age of Canadian cases is 22 years
– As of May 20, 2009, half the cases are 21 years of age or
younger (median: 21 years; range: <1 – 86 years)
– The majority of cases are linked to travel to Mexico
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Influenza A (H1N1)
General Diagnosis
• A Confirmed case of swine influenza
A(H1N1) virus infection is defined as
an individual with laboratory
confirmed swine influenza A(H1N1)
virus infection by one or more of the
following tests:
• Real‐time RT‐PCR ICycler® from
• Viral culture BioRad
• Four‐fold rise in swine influenza
A(H1N1) virus specific neutralizing
antibodies
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WHO Case Definitions to be Used For Investigations
of Swine Influenza A (H1N1) Cases
• Clinical case description
• Acute febrile respiratory illness (fever >38°C ) with the spectrum of disease from
influenza‐like illness to pneumonia.
• 1. A Confirmed case of swine influenza A(H1N1) virus infection is defined as an
individual with laboratory confirmed swine influenza A(H1N1) virus infection by
one or more of the following tests*:
– real‐time RT‐PCR
– viral culture
– four‐fold rise in swine influenza A(H1N1) virus specific neutralizing antibodies.
• 2. A Probable case of swine influenza A(H1N1) virus infection is defined as an
individual with an influenza test that is positive for influenza A, but is unsubtypable
by reagents used to detect seasonal influenza virus infection
OR
• A individual with a clinically compatible illness or who died of an unexplained
acute respiratory illness who is considered to be epidemiologically linked to a
probable or confirmed case.
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CDC Case Definitions to be Used For Investigations of
Swine Influenza A (H1N1) Cases
• Case Definitions for Infection with Swine Influenza A (H1N1) Virus
– A Confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an
acute 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
• four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies
– A Probable case of swine influenza A (H1N1) virus infection is defined as a person with an
acute respiratory illness with an influenza test that is positive for influenza A, but H1 and H3
negative by RT-PCR
– A Suspected case of swine influenza A (H1N1) virus infection is defined as:
• A person with an acute respiratory illness who was a close contact to a confirmed case of swine
influenza A (H1N1) virus infection while the case was ill OR
• A person with an acute respiratory illness with a recent history of contact with an animal with
confirmed or suspected swine influenza A (H1N1) virus infection OR
• A person with an acute respiratory illness who has travelled to an area where there are confirmed
cases of swine influenza A (H1N1) within 7 days of suspect case's illness onset.
• Infectious period for confirmed cases = 1 day before onset to 7 days after onset of
illness
• Day before onset = Day -1
• Onset day = Day 0
• Days after onset = Days 1-7
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CDC Case Definitions to be Used For
Investigations of
Swine Influenza A (H1N1) Cases Update
• A confirmed case of S-OIV infection is defined as a person with an acute
febrile respiratory illness with laboratory confirmed S-OIV infection at CDC
by one or more of the following tests:
– real-time RT-PCR
– viral culture
• A probable case of S-OIV 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
• A suspected case of S-OIV 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 S-OIV
infection, or
– within 7 days of travel to community either within the United States or
internationally where there are one or more confirmed cases of S-OIV
infection, or
– resides in a community where there are one or more confirmed cases of S-OIV
infection.
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Influenza A (H1N1) Case definition
of Close Contacts
• The definition of close contacts is:
Household members of confirmed or probable cases
• Close workplace contacts of a confirmed or probable case, including
sharing an office or cubicle area (sitting within one metre for at least 15
minutes)
• Members of a confirmed or probable case’s class or child care group and
their teacher/child care supervisor, where the case is a child aged between
0-12 years old
• Others identified by a confirmed or probable case, household members or
workplace contacts as having been in close physical contact (hugging,
kissing, sitting within one metre for at least 15 minutes) with the
confirmed case
• Passengers and crew travelling on aircraft with a confirmed or probable
case as defined below:
– Passengers seated in the same row, and within two (2) rows in front of and
behind the case;
– Any passengers who moved from elsewhere in the aircraft to spend more than
15 minutes near the case
– Airline staff (unless they did not visit the section of the plane in which the case
was seated)
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NDSC Case Definition Influenza
(Influenza A and B virus) (EU)
• Clinical description
• Clinical picture compatible with influenza i.e. sudden onset of disease,
cough, fever > 38 °C, muscular pain and/or headache.
• Laboratory criteria for diagnosis
• One of the following:
– Detection of influenza antigen, or influenza virus specific RNA
– Isolation of influenza virus
– Demonstration of a specific serum antibody response to influenza A or B (four
fold or greater rise).**
• Case classification
• Possible: Clinically compatible case with epidemiological link*
• Probable: N/A Case Definitions for Notifiable Diseases
Infectious Diseases (Amendment)
• Confirmed: Clinical case that is laboratory confirmed. (No. 3) Regulations 2003
(SI No. 707 of 2003)
• Note: Influenza of a new or re-emergent subtype is defined as influenza
caused by a novel or re-emerging influenza virus which is capable of
infecting humans and causing human illness, and to which a large
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proportion of the human population has little or no immunity.
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EU Case Definition
Novel Influenza Virus A(H1N1)
April 30 2009
• Clinical criteria • At least one of the
• Any person with one of the following
three: following three in the
• — fever > 38 °C AND signs and symptoms seven days before disease
of acute respiratory infection,
• — pneumonia (severe respiratory illness), onset:
• — death from an unexplained acute • — a person who was a close contact to a confirmed case of novel
influenza A(H1N1) virus infection while the case was ill,
respiratory illness. • — a person who has travelled to an area where sustained human-
• Laboratory criteria to-human transmission of novel influenza A(H1N1) is documented,
• At least one of the
• — a person working in a laboratory where samples of the novel
influenza A(H1N1) virus are tested.
following tests:
• — RT-PCR, • Case classification
• — viral culture (requiring BSL 3 facilities), • A. Case under investigation Any person meeting the clinical and
epidemiological criteria.
• — four-fold rise in novel influenza virus
A(H1N1) specific neutralising antibodies • B. Probable case
(implies the need for paired sera, from • Any person meeting the clinical AND epidemiological criteria AND
acute phase illness and then at with a laboratory result showing positive influenza A infection of an
convalescent stage 10-14 days later unsubtypable type.
minimum).
• C. Confirmed case
• Epidemiological criteria • Any person meeting the laboratory criteria for confirmation.
6/2/2009 161

Reporting Suspect
Influenza A (H1N1) Virus Infection
• Clinicians must contact their state
public health department to report
suspected cases of Influenza A
(H1N1) virus infection and to obtain
information on what clinical and
epidemiological data to collect and
specimen shipment protocols in
their region.
1.Health and Safety regulations on biological hazards (Safety, Health and Welfare at
Work Act 2005 (No. 10 of 2005)
2.European Agreement concerning the International Carriage of Dangerous Goods by
road (ADR) Regulations (2007 edition).
3.S.I. No 29 of 2004 - Carriage of Dangerous Goods by Road Regulations, 2004.
6/2/2009 162
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Influenza A (H1N1)
Case Surveillance Form
• Health Protection Surveillance
Centre
25-27 Middle Gardiner St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
• See Website for download for
clinicians
1-6 pages
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Surveillance Form for Contacts of
Influenza A(H1N1)
• Health Protection Surveillance
Centre
25-27 Middle Gardiner St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
• See Website for download for
clinicians
6/2/2009 164
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Influenza A (H1N1) Triage
Initial Patient Management
• Should be managed as follows:
• Physical barrier (i.e. window or plexiglass barrier) or the receptionist should
maintain a 2 metre (6 foot) distance from all patients whenever possible
• In settings where such a separation is not possible, healthcare workers are advised
to maintain whatever separation is feasible.
• If there is no barrier, and a 2 metre (6 foot) distance cannot be achieved, a fit
tested FFP 2-3 respirator and eye protection should be worn by the receptionist
• Alcohol-based hand rub (ABHR) should be readily available for both staff and
patients
• Patient should be asked to perform hand hygiene using an ABHR and given a
surgical mask to put on covering their nose and mouth
• Patient should be placed in a separate area of the office (i.e. examination room). If
an examination room or separate room is not available, the patient should remain
masked
• Provide hands-free garbage and laundry receptacles.
• Remove magazines and toys from the waiting rooms to reduce potential contact
exposures
6/2/2009 165

Influenza A (H1N1) Triage
Health Care Setting Screening
• All patients who present to a health care setting
should be screened for fever and respiratory
symptoms.
• This should include:
• Passive screening: visual alerts posted at the
entrances to all health care settings asking patients
to report whether they have fever and any new or
worsening respiratory symptoms, and
• Active screening: At first contact, staff asks about
fever and respiratory symptoms
• Respiratory symptoms include cough, sore throat,
coryza (runny nose), and myalgias (general body
aches)
• Routine practices ,contact and droplet precautions
for clinicians
• Additional precautions Influenza-like Illness/Influenza/Influenza A (H1N1)
Outbreak Reporting Form
6/2/2009 166

Influenza A (H1N1) Triage
Health Care Setting Guidelines
• The following infection control practices are indicated when
assessing patients with fever and respiratory symptoms:
• Before a clinical assessment:
• Ensure patient is still wearing a surgical mask
• Perform hand hygiene (alcohol based hand rub or soap and
water) before and after patient assessment
• Put on gloves
• A gown is needed only when there is a risk of clothing or
skin contamination (such as when examining young
children who may have difficulty controlling their
secretions)
• Consider most appropriate respiratory protection
6/2/2009 167

Influenza A (H1N1) Triage
Health Care Setting Guidelines
• Wear a surgical mask:
• If the patient is compliant with respiratory hygiene
practices (e.g. wearing a surgical mask) or If the patient has
a weak or no cough.
• Wear an FFP2-3 respirator:
– If conducting an aerosol-generating medical procedure (e.g,
obtaining a nasopharyngeal swab) on a suspect ILI case
– All individuals in the room should wear an FFP2-3 respirator
– When the patient is coughing forcefully and is unable or
unwilling to comply with respiratory hygiene (e.g., coughing
patient who is unable or unwilling to wear a surgical mask)
6/2/2009 168

Influenza A (H1N1) Triage
Health Care Setting Guidelines
• After a clinical assessment:
• Eye or face protection should be removed after
leaving the case’s room and disposed of in either a
hands-free waste receptacle (if disposable) or in a
separate receptacle to go for reprocessing (if
reusable)
• The surgical mask or FFP2-3 respirator should be
removed by the straps, being careful not to touch
the mask or respirator itself, after leaving the
case’s room and disposed of in a hands-free waste
receptacle
• HCWs should perform hand hygiene after
removing the respiratory protection and after
leaving the case’s room
• Affected surfaces that may have been
contaminated with droplets need to be cleaned.
Routine office cleaning products are effective for
respiratory viruses including influenza; no special
cleaning products are needed.
• There is no indication for use of personal air-
purifying respirators (PAPRs) in the care of a
6/2/2009 169
suspect ILI/Influenza A(H1N1) case

Influenza A(H1N1) Public Health
Management of Contacts Resources
• Health Protection
Surveillance Centre
25-27 Middle Gardiner St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
• See Website for download
for clinicians
6/2/2009 170
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Influenza A(H1N1)
Advice to General Practitioners on
Management of a Possible Case Resources
• Health Protection
Surveillance Centre
25-27 Middle Gardiner
St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
• See Website for
download for clinicians
6/2/2009 171
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Clinical Management of Human Infection With
New Influenza A (H1N1) virus: Initial Guidance
Resources
6/2/2009 172

Influenza A(H1N1)
Who's Summary of Clinical Guidelines
Modalities Strategies
Antibiotics In case of pneumonia, empiric treatment for community acquired
pneumonia (CAP) per published guidelines pending microbiologic results
(e.g. 2-3 days); tailored therapy thereafter if pathogen(s) identified.
Antiviral therapy If treatment needed, oseltamivir or zanamivir. The new influenza A (H1N1)
virus is currently resistant to amantadine and rimantadine.
Corticosteroids Moderate to high dose steroids are NOT recommended. They are of
unproven benefit and potentially harmful.
Infection control Standard plus Droplet Precautions. For aerosol-generating procedures use
particular respirator (N95, FFP2 or equivalent), eye protection, gowns,
gloves, and an airborne precaution room, that can be naturally or
mechanically ventilated, per WHO guidance
NSAIDS, Paracetamol or acetaminophen given orally or by suppository. Avoid
antipyretics administration of salicylates (aspirin and aspirin containing products) in
children and young adults (< 18 years old) due to risk of Reye’s syndrome.
Oxygen therapy Monitor oxygen saturation and maintain SaO2 over 90% (95% for pregnant
women) with nasal cannulae or face mask.
6/2/2009 173

Influenza A(H1N1)
Diagnostics - Chest X-ray
• Approximately 2-5% of confirmed
cases in the US and Canada as well
as 6% in Mexico have been
hospitalised
• In Mexico
– One-third of those hospitalised
required mechanical ventilation
• Of those hospitalised in California
– 15 of 25 (60%) tested had
radiographic changes suggestive of
pneumonia including ten with
multilobar infiltrates
– Four (13%) required mechanical
ventilation
6/2/2009 174

Guidance on Laboratory procedures when
pandemic influenza is present outside Ireland
(Irish Alert Level 1)
• Samples should be collected for influenza investigation
(including viral culture when advised by WHO) from all
patients who:
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Taking Specimens for Influenza Virus Testing From
Patients with Suspected Swine Influenza
• Health Protection Surveillance
Centre
25-27 Middle Gardiner St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
• See Website for download for
clinicians
6/2/2009 176
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Guidance on Laboratory procedures when pandemic
influenza is present outside Ireland (Irish Alert Level 1)
• 1. Samples should be collected for influenza investigation (including viral
culture when advised by WHO) from all patients who:
• Have been hospitalised with viral pneumonia;
– Have travelled to areas of known or potential influenza activity in the week
preceding onset of illness and have symptoms associated with the pandemic
influenza strain
– Have a flu-like illness and are family members or other close contacts of either
of the above.
• 2. All samples from “highly suspicious cases” must be promptly referred to
NVRL for investigation, as per agreed procedures. Any influenza strains
detected should be provisionally characterised at the NVRL urgently and
referred with available phylogenetic data urgently to the WHO
Collaborating Centre in London for confirmation and sub typing.
• 3. NVRL should validate any novel diagnostic tests to ensure that “best
practice” methodologies are utilised and can be introduced immediately
• 4. NVRL should monitor the developments regarding the laboratory
diagnosis and “bedside” diagnosis of the new influenza strain.
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Influenza A(H1N1)
Irelands Laboratories Overview
• Approximately 34 (BL3) laboratories
distributed among the universities an
biotechnology companies in Ireland.
• These predominantly handle up to Category 3
pathogens or conduct genetic manipulations
under regulation of the Environmental
Protection Agency.
• High containment Class 3 (+) laboratory has
been commissioned at the University College
Dublin National Virus Reference Laboratory
(UCD NVRL)
• Environmental and clinical specimens are
investigated in a Class 3 containment
laboratory at Cherry Orchard Hospital, Dublin.
• Novel Influenza A H1N1 in BSL-3 practices
(enhanced BSL-2 conditions)
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Influenza A(H1N1)
National Virus Reference Laboratory
• Postal address:
Medical Microbiology,
CRID Building,
University College Dublin,
Belfield,
Dublin 4,
Ireland.
Telephone Number: +353-1-716 1325/1236
Fax Number: +353-1-716 1239
Email: margaret.brindley@ucd.ie
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Influenza A(H1N1)
Specimen Collection
• Clinicians should obtain a respiratory
swab for swine influenza testing and
place it in a refrigerator (not a freezer).
– A diagnosis of confirmed swine flu
requires laboratory testing of a
respiratory sample (a simple nose and
throat swab)
– Collected during the first five days
• Once collected, the clinician should
contact their state or local health
department to facilitate transport and
timely diagnosis at a public health
laboratory
• Laboratories should send all
unsubtypable influenza A specimens as
soon as possible to NRVL
• Spill containment measures should be in
place!
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Influenza A(H1N1)
Laboratory Precautions
• Viral isolation on clinical specimens from patients who are
suspected cases of swine influenza A (H1N1) virus infection
should be performed in a BSL2 laboratory with BSL3
practices (enhanced BSL2 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)
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Influenza A(H1N1)
Laboratory Precautions
• Routine laboratory procedures, including
diagnostic work and PCR analysis:
• Biosafety Level 2 (BSL2), as detailed in the
WHO Laboratory biosafety manual, 3rd
edition.
• Examples of routine laboratory
procedures that require BSL2 include:
• Diagnostic testing of serum, blood
(including haematology and clinical
chemistry), respiratory tract specimens, or
other specimens
• Manipulations involving neutralized or
inactivated (lysed, fixed, or otherwise
treated) virus particles and/or incomplete,
non-infectious portions of the viral
genome
• Routine examination of mycotic and
6/2/2009 182
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Influenza A(H1N1)
Laboratory Precautions
• Viral isolation on clinical
specimens from patients who are
suspected or confirmed cases of
influenza A (H1N1) infection
should only be performed in
laboratories capable of meeting
the following additional essential
(minimal) containment Bio containment :BL3(+) Two
microbiological safety cabinets
requirements: (msc ) class I and class I/ III) at
• Practices recommended for NVRL
containment laboratories —
Biosafety Level 3 in the WHO
Laboratory biosafety manual, 3rd
edition
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Influenza A(H1N1)
Laboratory Precautions
• A controlled ventilation system maintains
directional airflow into the laboratory room
• Exhaust air from the laboratory room is not
recirculated to other areas within the building
– Air should be HEPA filtered, if reconditioned NRVL BL3(+) Has
and recirculated within the laboratory. two microbiological
– When exhaust air from the laboratory is safety cabinets (class
discharged to the outdoors, it must be I and class I/ III)
dispersed away from occupied buildings and air
intakes.
– This air may be discharged through HEPA filters
• All manipulations of infectious or potentially
infectious materials must be performed in
appropriately maintained and validated BSCs.
(Ireland: NRVL Uses msc class I and class I/ III)
• Access to the laboratory is restricted when
work is in progress
6/2/2009 184
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Influenza A(H1N1)
Laboratory Precautions
• Viral isolation on clinical specimens :
• Biosafety Level Three plus (BL3+) containment
laboratory
• PPE
• Laboratory workers should wear protective
equipment, including:
– Disposable gloves
NRVL Layout of Bio
– Solid front or wrap-around gowns Containment :BL3(+)
– Scrub suits
– Coveralls with sleeves that fully cover the
forearms
– Head coverings
– Shoe covers or dedicated shoes
– Eye protection (goggles or face shield)
– Respiratory protection (fit-tested particulate
respirator, e.g. EU FFP2, US NIOSH-certified N95
or equivalent, or higher protection), because of
the risk of aerosol or droplet exposure
6/2/2009 185
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Influenza A(H1N1)
Laboratory Precautions Summary
• Clinical laboratory testing • Viral isolation
(laboratory diagnostic work)
• Diagnostic laboratory work on • Growth of the virus in cell culture
clinical samples from patients or embryonated eggs should be
who are suspected cases of novel performed in a BSL-2 laboratory
influenza A H1N1 virus infection with BSL-3 practices.
should be conducted in a • All viral manipulations should be
biosafety level 2 (BSL-2) done inside a microbiological
laboratory. safety cabinets (msc ) class I and
• All sample manipulations with class I/ III) that is certified
the potential for creating an annually.
aerosol should be done inside a
microbiological safety cabinets
(MSC) that is certified annually.
Bio containment :BL3(+) Two microbiological
safety cabinets (msc ) class I and class I/ III) at
NVRL
6/2/2009 186

Influenza A(H1N1)
Laboratory Precautions
• Animal work
• The following activities require animal facility —
Biosafety Level 3 facilities and work practices, as
detailed in the WHO Laboratory biosafety
manual, 3rd edition.
– Inoculation of animals for potential recovery of the
agent from influenza A (H1N1) specimens
– Any protocol involving animal inoculation for
confirmation and/or characterization of putative
influenza A (H1N1) agents
– Bio containment :BL3(+) At NRVL
6/2/2009 187
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Influenza A(H1N1)
Laboratory Precautions
• Waste
• All waste disposal procedures should be followed as outlined in
your facility standard laboratory operating procedures.
• Appropriate disinfectants
• 70% Ethanol
• 5% Lysol
• 10% Bleach
• Influenza viruses can survive on environmental surfaces and can
infect a person for up to 2 to 8 hours after being deposited on an
environmental surface
• Commonly used surfaces such as door handles, handrails, table
surfaces etc. should be cleaned first and then disinfected with a
chlorine releasing disinfectant (1000 ppm) twice daily
Detailed information on
• Disinfectants with proven activity against enveloped viruses disinfectants and their
recommended use can be
include chlorine, alcohol, peroxygen, quaternary ammonium found in Laboratory
biosafety manual, 3rd
compounds and phenolic compounds and should be adequate if ed., Geneva, World
Health Organization,
2004
used according to manufacturer’s recommendations.
6/2/2009 188
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Influenza A(H1N1)
Laboratory Precautions
• Personnel should self monitor for fever and
any symptoms Never
place
knee on
• Accidental exposure: floor
– Antiviral chemoprophylaxis with zanamivir or
oseltamivir for 7 days( See PEP slide)
Center for Disease
Control and
Prevention, shows
a negative-stained
image of the
swine flu virus.
6/2/2009 189
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Post-exposure Prophylaxis (PEP) for close contacts of probable or
confirmed human case(s) of Influenza A(H1N1) in WHO
Pandemic Alert Phase 5
• Post exposure prophylaxis is indicated for
close contacts that were exposed to a
probable or confirmed case during the
period when the case was symptomatic
and for 24 hours before onset of
symptoms AND the contact’s last
exposure occurred no more than 7 days
previously.
• Any probable or confirmed human case
of influenza A(H1N1)should be notified to
the local DPH as soon as possible.
• Example:
• Accidental exposure ,then ate dinner
with colleagues., took four hour plane
ride home !
• All would be on the PEP Protocol !
6/2/2009 190

NRVL Testing for Influenza A(H1N1)
• Preferred Respiratory Specimens
• Swabs
– Nasopharyngeal Aspirates
• Storing Clinical Specimens
• Shipping Clinical Specimens
• Recommended Tests HSE :Taking
specimens for
• Other Influenza Tests influenza virus testing
from patients with
– Rapid Influenza Antigen Test suspected swine
– Immunofluorescence (DFA or IFA) influenza
– Viral Culture
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NRVL Testing for Influenza A(H1N1)
• Taking specimens for influenza virus
testing from patients with suspected
influenza A (H1N1):
• As with all respiratory viruses, diagnosis
of influenza virus depends on the
collection of high-quality specimens,
their rapid transport to the virology
laboratory and appropriate storage
before laboratory testing
• Virus is best detected in specimens
containing infected cells and secretions
• Specimens should ideally be taken
preferably during the first 3-5 days after
onset of clinical symptoms
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NRVL Testing for Influenza A(H1N1)
• Before taking specimens:
• Before a specimen is taken, it should
first be discussed with the Director or
Public Health as outlined in the
national algorithm for the
management of persons with possible
influenza A (H1N1)
• Infection prevention and control
precautions
• While not strictly an aerosol
generating procedure it is
recommended that the same
National Algorithm
precautions are followed when taking
nasal and throat viral swabs to out
rule influenza A (H1N1)
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NRVL Testing for Influenza A(H1N1)
• Infection prevention and control precautions:
• While not strictly an aerosol generating procedure it is
recommended that the same precautions are followed when taking
nasal and throat viral swabs to out rule influenza A (H1N1)
• The following Infection Prevention and Control Precautions should
be taken:
– Hand hygiene
– Standard Precautions
– FFP2 or FFP3 mask (correctly fitted)
– Eye protection (i.e. goggles)
– Long-sleeved disposable gown (single use only)
– Gloves (some of these procedures require sterile gloves)
– Hand hygiene post procedure
• Refer to donning and removal of PPE document
6/2/2009 194
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Influenza A(H1N1)
Infection Prevention and Control Precautions
• Nasal and throat viral swabs: • Nasopharyngeal aspirate,
• The following precautions should transtracheal aspirate,
be taken: bronchoalveolar lavage and
• Hand hygiene biopsy of lung or tracheal tissues
at post-mortem, nebulizers ,
• Surgical mask BIPAP are all considered aerosol
• Goggles (if risk of splashing or generating procedures:
spraying) • The following precautions should
• Plastic apron be taken:
• Gloves • Hand hygiene
• Hand hygiene post procedure • FFP2 or FFP3 respiratory mask
• Goggles
• Long sleeved disposable gown
• Gloves (some of these procedures
require sterile gloves)
• Hand hygiene post procedure
Update May 21 2009
6/2/2009 195

NRVL Testing for Influenza A(H1N1)
• Respiratory specimens to take:
• A. Upper respiratory tract
– Nasopharyngeal (NP) and oropharyngeal (OP) swab
– Nasopharyngeal aspirate
– Sputum
• B. Lower respiratory tract
– Where clinically indicated, invasive procedures can be performed for
the diagnosis of viral lower respiratory tract infections:
– Transtracheal aspirate (TA)
– Bronchoalveolar lavage (BAL)
– Post-mortem lung or tracheal tissue
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NRVL Testing for Influenza A(H1N1)
• Swabs to use:
– Specific viral swab (contains viral transport medium in the
container of the swab)
– Regular swab – after taking the specimen the swab should
be broken off into a bottle containing virus transport
medium
– Nasopharyngeal secretions should be aspirated into a
sterile plastic mucous extractor. Transport the mucous
extractor with the secretions
– A transtracheal aspirate/ broncho-alveolar lavage should
be transported in a sterile container
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Influenza A (H1N1)
Nasopharyngeal Swabs
• According to PHAC And CDC : Nasopharyngeal Swabs
• Ideally, swab specimens should be collected using (COPAN flocked swab)
swabs with a synthetic tip (eg, polyester or Dacron)
and a plastic shaft
• Optimal specimens continue to be Nasopharyngeal
Swabs (COPAN flocked swab) but Starplex non-
flocked swabs are also acceptable for
nasopharyngeal and nasal samples.
• Do not use wired shaft pertussis swab as it
interferes with the test and give a false negative
result
• Swabs with cotton tips and wooden shafts are not
recommended
• Specimens collected with swabs made of calcium
alginate are not acceptable
• The swab specimen collection vials should contain
3 mL of VTM (eg, containing protein stabilizer,
antibiotics to discourage bacterial and fungal
growth, and buffer solution), such as M4RT or the
BD Universal Viral Transport System
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Influenza A(H1N1)
Flocked Swabs and Copan-Manufactured VTM
for Influenza A(H1N1)
• CDC Recommends Flocked Swabs and
Copan-Manufactured VTM for H1N1
Influenza A(H1N1):
Optimal specimens
continue to be
Nasopharyngeal Swabs
(COPAN flocked swab)
6/2/2009 199

Influenza A(H1N1)
Nasopharyngeal Flocked Swabs Procedure
• “Specimens for the
laboratory
diagnosis of Novel
A (H1N1)Influenza
should be collected
in the following
order of priority:
1. Nasopharyngeal
aspirates
2. Acute serum
3. Convalescent
serum
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Influenza A(H1N1)
Nasopharyngeal (NP) , Oropharyngeal (OP) Swab
• Nasopharyngeal (NP) and oropharyngeal (OP) swab
collection:
• Collect specimen with a sterile Dacron/nylon swab with a non-wooden
shaft (do NOT use calcium alginate swabs or swabs with wooden sticks)
• For NP swab, insert swab into each nostril parallel to the palate and leave
in place for a few seconds to absorb secretions. Swab both nostrils
• For OP swab, swab the posterior pharynx and tonsillar areas, avoiding the
tongue
• Place swab immediately into sterile vials containing 2 ml of viral transport
media
• Label each specimen container with patient’s FIRST AND LAST NAME, date
of birth, medical record number, date of collection, specimen type
• Place specimen vial onto ice or in refrigerator prior to and during
transport.
• Do not freeze
6/2/2009 201

Novel A (H1N1)Influenza
Nasopharyngeal Aspirates Overview
• Ideally, swab specimens should be collected using swabs with a synthetic tip
(eg, polyester or Dacron) and an aluminium or plastic shaft
• Swabs with cotton tips and wooden shafts are not recommended
• Specimens collected with swabs made of calcium alginate are not acceptable
• The swab specimen collection vials should contain 3 ml of VTM (eg, containing
protein stabilizer, antibiotics to discourage bacterial and fungal growth, and
buffer solution), such as M4RT or the BD Universal Viral Transport System
6/2/2009 202
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Novel A (H1N1)Influenza
Nasopharyngeal Aspirates Procedure
• Hierarchy “Specimens
for the laboratory
diagnosis of Novel A
(H1N1)Influenza
should be collected in
the following order of
priority:
1. Nasopharyngeal
aspirates
2. Acute serum
3. Convalescent
serum
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Influenza A(H1N1)
Nasopharyngeal Aspirates Collection
• Nasopharyngeal wash/aspirates collecion:
• Have the patient sit with head tilted slightly backward
• Instill 1ml-1.5ml of nonbacteriostatic saline (pH 7.0) into
one nostril
• Insert the tubing into the nostril parallel to the palate
• Aspirate nasopharyngeal secretions. Repeat this procedure
for the other nostril
• Rinse the catheter into viral transport medium (syringe or
bulb) or aspirate viral transport media through catheter into
collection trap
• Label specimen container with patient’s FIRST AND LAST
NAME, date of birth, medical record number, date of
collection, specimen type
• Place specimen vial onto ice or in refrigerator prior to and
during transport
• Do not freeze
6/2/2009 204

Influenza A(H1N1)
Broncheoaveolar Lavage (BAL) Collection
• Broncheoaveolar lavage or tracheal
aspirate:
• During bronchoalveolar lavage or
tracheal aspirate, use a double-tube
system to maximize shielding from
oropharyngeal secretions
• Centrifuge half of the specimen, and
fix the cell pellet in formalin
• Place the remaining unspun fluid in
sterile vials with external caps and
internal O-ring seals
• If there is no internal O-ring seal, then
seal tightly with the available cap and
secure with Parafilm®
6/2/2009 205

Influenza A(H1N1)
Sputum Collection
• Sputum collection:
• Educate the patient about the difference
between sputum and oral secretions
• Have the patient rinse the mouth with water and
then expectorate deep cough sputum directly
into a sterile screw-cap sputum collection cup or
sterile dry container.
• Label specimen container with patient’s FIRST
AND LAST NAME, date of birth, medical record
number, date of collection, specimen type
• Place specimen vial onto ice or in refrigerator
prior to and during transport
• Do not freeze
6/2/2009 206

Influenza A(H1N1)
Stool Collection
• In the USA, gastrointestinal symptoms (nausea,
vomiting and/or diarrhoea) have occurred in up to 38%
of outpatients with confirmed influenza A(H1N1)
• Diarrhoea has been uncommon in hospitalised cases
• SOP (Standard operating procedure) on collection
• Full PPE (in case of splashes)
• Place in Biological Bag
• Do not freeze!
6/2/2009 207

Influenza A(H1N1)
Influenza A(H1H1) Serology Suites
• Acute Serum Suites • Convalescent Serum Suites
• Immediate • 14 days after
• Specimens: • Specimens:
– Blood in clotted tube (red top) – Blood in clotted tube (red top)
– Blood in EDTA (purple top) – Blood in EDTA (purple top)
• {Full blood count) – {Full blood count)
• Additional routine blood work
according to physicians orders or
follow pre ordered Influenza-like
illness ,Influenza A(H1H1) suites
as institutional protocols
6/2/2009 208

Influenza A(H1N1) Serology
Acute and Convalescent Serum Sample
• Acute and Convalescent serum samples:
• Collect 5-10 ml whole blood in a serum separator or
red top tube Allow the blood to clot, centrifuge briefly,
and collect all resulting sera in vial with external caps
and internal O-ring seals
• Refrigerate at 4°C
• The minimum amount of serum needed for testing is
200 ml, which can easily be obtained from 5 ml of
whole blood
• A minimum of 1 cc of whole blood is needed for
testing of paediatric patients
• If possible, collect 1 cc in an EDTA tube and in a
clotting tube
• If only 1 cc can be obtained, use a clotting tube
• Label specimen container with patient’s FIRST AND
LAST NAME, date of birth, medical record number,
date of collection, specimen type
6/2/2009 209

Influenza A(H1N1) and Blood Safety
• 2009 H1N1 Influenza Virus and Blood Safety:
•
Bld cultures Aerobic
No case of transfusion transmitted seasonal influenza has ever then anaerobic
been reported in the United States or elsewhere, and, to date,
no cases of transfusion transmitted H1N1 flu have been
reported!
• Safety of Plasma Derivatives
• The newly emerging 2009 H1N1 Influenza Virus is a large lipid-
enveloped virus. Validation studies performed by the product
manufacturers have shown that viruses with similar
characteristics to this agent are effectively inactivated and/or
removed by the manufacturing processes in place for these
products
• Individuals who are not in good health are not suitable to donate
blood and blood establishments must defer these potential
donors therefore….
• Blood donor screening procedures currently in place at blood
establishments should identify persons with symptoms of H1N1
flu infection
6/2/2009 210

Influenza A(H1N1) and Blood Safety
• Irish Blood Transfusion Service advisory
• Swine Flu Important Information
• “We are asking all donors who have returned from Mexico
or the United States of America in the last 14 days NOT to
attend any blood donor clinic at this time. This situation is
under review on a daily basis and further updates will be
available here. Please note that this precaution is in the
interest of donor and recipient safety. Your patience and
cooperation is greatly appreciated”
6/2/2009 211

Influenza A(H1N1)
Shipping Clinical Specimens
• Clinical specimens should be
shipped on dry ice in appropriate
packaging
• All specimens should be labelled
clearly and include information
requested by the appropriate state
public health laboratory
• Suspect case specimens shipped
from the state public health
laboratory to the NRVL should
include all information required for
seasonal influenza surveillance
isolate or specimen submission
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Swine Influenza Virus Real-time RT-PCR
Detection Panel (Swine Flu Test Kit)
• Countries with the PCR Capacity in
Place to Diagnose Influenza
A(H1N1) Virus Infection in
Humans Doc Available at WHO
• 23 EU and EFTA countries are
currently able to perform PCR to
diagnose influenza A(H1N1) virus
infection in humans
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Influenza A(H1N1) Laboratory Tests
Molecular Diagnostics:
• Molecular diagnostics:
• According to WHO the following protocols are
currently available:
1. Influenza A type-specific conventional and
realtime PCR
2. CDC realtime RT-PCR (rRT-PCR) protocol for
the detection and characterization of
influenza A (H1N1) (version 2009)
6/2/2009 214

Swine Influenza Virus Real-time RT-PCR
Detection Panel (Swine Flu Test Kit)
• Instructions how to obtain CDC real time RT-PCR Kits
for detection of Influenza A( H1 N1)
• Thr rRT-PCR kits includes the following primers
/probes:
– Universal Influenza A(Infa)
– Swine Influenza A(swIfa)
– SwineH1 (swH1)
– RNaseP (Control)( RP)
• The rRT-PCR kits can also include detailed procedures CDC-developed PCR
as well as positive control materials diagnostic test to detect
novel H1N1 virus
• Send the following e-mail to flouder@cdc.gov
• I would like to request a rRT-PCR primers/probe kit for
Swine A/H1 Flu
• Contact name:
• Institution Name:
• Contact phone #:
•
6/2/2009 Institution Shipping Address(No PO Box): 215
Medical Management of Biological Casualties
• Preferred Shipping carrier: Revised and Modified 29/04/2009

Influenza A(H1N1)
Virus Real-time RT-PCR Detection Panel
• INTENDED USE:
The Influenza A(H1N1)
Virus Real-time RT-PCR Detection Panel is intended for use in real-
time RTPCR assays on an ABI 7500 Fast Dx Real-Time PCR
instrument in conjunction with clinical and epidemiological
information
• Test from nasopharyngeal or nasal swab
BinaxNOW® Real-time PCR Biosystems 7500
Influenza A & B detection of Mexican Real-Time PCR
Test Swine Flu Kit
A C
B
6/2/2009 216

Influenza A(H1N1)
Laboratory Tests
• Real-time RT-PCR for influenza A, B, H1, H3
– swine-origin influenza A (H1N1) virus will test positive for influenza A and
negative for H1 and H3 by real-time RT-PCR
• Rapid influenza antigen test
• Immunofluorescence (DFA or IFA):
• Viral culture:
• Please Read below in narration!
• Emergency Use Authorization of Swine Flu Test Kit : NML Winnipeg
• Centers for Disease Control and Prevention (CDC) has developed the Swine
Influenza Virus Real-time RT-PCR Detection Panel (Swine Flu Test Kit) for
the presumptive presence of swine influenza A (H1N1) virus from the
nasal or nasopharyngeal swab.
• Swine Influenza Test Kit will be made available on the CDC Swine Flu
website.
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Influenza A(H1N1)
Recommended Tests
• Real-time RT-PCR for influenza A, B, H1, H3
at a state health department laboratory is
recommended
• Currently, S-OIV will test positive for
influenza A and negative for H1 and H3 by
real-time RT-PCR
• If reactivity of real-time RT-PCR for
influenza A is strong (eg, Ct <30), it is more
suggestive of a novel influenza A virus
• Confirmation of Novel Influenza is
performed at the NRVL currently, but may
be available in public health laboratories
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CDC Rt-PCR Testing Algorithm and Results Interpretation
The overall approach to influenza virus detection by RT-PCR should be
considered in the context of the national situation, e.g., how many
swl = swine like
specimens can be handled (throughput), what gene sequence to target for
RT-PCR, and whether to use concurrent or sequential testing for RT-PCR of
PCR Assays AIV = Avian Influenza virus
M, NP and HA genes. PCR = Polymerase chain reaction
Influenza A-swl subtype specific
Influenza type A (universal)
PCR (H1 gene)
Matrix gene PCR
(other genes targets are optional
Test for Seasonal influenza
H1-and N3 using specific Confirmed Positive
Positive Positive
PCR H1N1 swl
And tested negative
Positive Negative for seasonal
influenza H1 or H3
specific PCR
Check for lab Negative Positive
confirmation by Influenza A Negative
retesting from original Other than H1N1 swl
sample Negative for influenza
A viruses (check for
Positive Check for lab other pathogens
confirmation by
Positive retesting from original Negative
Confirmed Positive sample Test for H5N1 or other AIV or
H1 or H3 Influenza B
6/2/2009 219

Influenza A (H1N1)
CDC Influenza Laboratory Images
• Images below of the newly identified H1N1
influenza virus were taken in the CDC
Influenza Laboratory.
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Laboratory Images
Influenza A (H1N1)
• This preliminary negative stained transmission electron
micrograph depicts some of the ultrastructural morphology of
the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith
and A. Balish.
• This preliminary negative stained transmission electron
micrograph depicts some of the ultrastructural morphology of
the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith
and A. Balish.
• Comparison to;
• Swine influenza virus. Colorized transmission electron
micrograph (37,800X) of the A/New Jersey/76 (Hsw1N1) virus
under plate magnification. Image taken during the virus' first
developmental passage through a chicken egg. Courtesy of the
CDC/Dr. E. Palmer; R.E. Bates.
• Negative stained transmission electron micrograph of
recreated 1918 influenza virions. Courtesy of CDC/ Dr. Terrence
Tumpey
E-medicine resource
6/2/2009 221

Submission of Tissue Specimens for the
Pathologic Evaluation of Influenza A(H1N1)
• Central (hilar) lung with segmental
bronchi, right and left primary bronchi,
trachea (proximal and distal)
• Representative pulmonary
parenchyma from right and left lung
• For patients with suspected
myocarditis, encephalitis, or
rhabdomyalysis, myocardium (right
and left ventricle), central nervous
system (cerebral cortex, basal ganglia,
pons, medulla, and cerebellum), and
skeletal muscle, respectively
• Any other organ showing significant
gross or microscopic pathology
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Influenza A(H1N1)
Submission of Specimens
• General Guidelines for Shipping
Pathology Specimens:
• Packaging and Shipping
Guidelines Layout of Bio Containment
:BL3(+)
– Formalin-fixed wet tissues OL: Outer lobby
S: Shower
– Formalin-fixed paraffin- IL: Inner Lobby
LAB: Laboratory
embedded blocks
– Glass slides with sections from
paraffin-embedded blocks
– Fresh frozen tissue
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Influenza A(H1N1)
NRVL Submission of Specimens
• Postal address:
Medical Microbiology,
CRID Building,
University College Dublin,
Belfield,
Dublin 4, Bio containment :BL3(+) Two
microbiological safety cabinets
Ireland. (msc ) class I and class I/ III) at
NVRL
Telephone Number: +353-1-716 1325/1236
Fax Number: +353-1-716 1239
Email: margaret.brindley@ucd.ie
6/2/2009 224

Influenza A(H1N1)
Who Submission of Specimens
• All samples from “highly suspicious cases” must be promptly
referred to NVRL for investigation, as per agreed procedures.
• Any influenza strains detected should be provisionally characterised
at the NVRL urgently and referred with available phylogenetic data
urgently to the WHO Collaborating Centre in London for
confirmation and sub typing
• Dr A. Hay
• WHO Collaborating Centre for Reference and Research on Influenza
• National Institute for Medical Research
• Mill Hill, London NW7 1AA, United Kingdom
• Fax: +44 208 906 44 77
• Email: whocc@nimr.mrc.ac.uk
• http://www.nimr.mrc.ac.uk/wic/
6/2/2009 225
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225
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NRVL Testing for Influenza A(H1N1)
• 1. Health and Safety regulations on
biological hazards (Safety, Health and
Welfare at Work Act 2005 (No. 10 of
2005)
• 2. European Agreement concerning
the International Carriage of
Dangerous Goods by road (ADR)
Regulations (2007 edition)
• 3. S.I. No 29 of 2004 - Carriage of
Dangerous Goods by Road
Regulations, 2004
• Biosafety: “Directive 90/679/EEC in
S.I. No. 248/1998 — Safety, Health
and Welfare At Work (Biological
Agents) (Amendment) Regulations,
1998.”
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Influenza A(H1N1)
Who Shipment Protocol
Adapted from E-tool_Intro
Shipping requirements for influenza A (H1N1) specimens
are described under:
http://www.who.int/csr/resources/publications/swineflu/in
structions-shipments/en/index.html
All Shippers Must take the E-tool-intro coarse to be able to
ship Infectious Substances “Category A”
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Influenza A(H1N1)
Who Shipment Protocol
• If the shipment also includes other dangerous
goods (such as liquid nitrogen or dry ice),
shippers must be trained appropriately in the
transport of those goods.
• Additional information can be found in the WHO
document “Guidance on regulations for the
transport of infectious substances”, available at:
• http://www.who.int/csr/resources/publications/
biosafety/WHO_HSE_EPR_2008_10/en/index.ht
ml
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Influenza A(H1N1)
Who Submission of Specimens
• Shippers should note:
• Specimens collected directly from humans or animals that
are suspected or confirmed to be infected with the swine
influenza A(H1N1) virus, including specimens from the
respiratory tract (swabs) and blood specimens, should be
shipped as:
• \"BIOLOGICAL SUBSTANCE, CATEGORY B\" and assigned
to UN 3373.
• Swine influenza A(H1N1) virus cultures (i.e. virus isolates)
must be shipped as:
• Category A \"INFECTIOUS SUBSTANCE; AFFECTING
HUMANS\" and assigned to UN 2814.
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Influenza A(H1N1)
Who Shipment of Specimens
• Category A , Category B, Or Exempt
• Packaging Samples
• All samples must be packaged using triple packaging.
• Triple packaging provides three layers of containment to
protect the substances being shipped.
• These layers are primary, secondary, and outer containers.
• The following diagram shows the basic concept of triple
packages.
Must be
packaged using
triple packaging
230
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This Packaging is Used For Category A
Infectious Substances
6/2/2009 231
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Category A: Markings and Labels
MARKINGS
• All shippers must properly mark and label
Category A packages. The following is a list of markings
and labels for Category A packages:
Markings
• Shipper’s name, address, and telephone number
u 4G/CLASS 6.2/02
• Receiver’s name, address, and telephone number n F/BVT 312103
• Name and telephone number of responsible person (who is
available 24 hours a day until shipment arrives) INFECTIOUS SUBSTANCE,
AFFECTING HUMANS
• UN Specification Marking UN2814
• Proper Shipping Name and UN Number
LABELS
Labels
• Infectious substance label
• Package orientation label (only used when primary container
exceeds 50ml)
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Influenza A(H1N1)
Category A Packing Requirements
• Primary container is leakproof
• Secondary container is leakproof
• Outer container is rigid Triple Packaging Example
• Pressure tested at 95kPa
• Drop tested from 9m
• Puncture tested at 7kg
• UN specification marking
• Shipper must be trained
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Steps For Packaging
Category A Samples
Swine influenza A(H1N1)
1. Open secondary container. virus cultures (i.e. virus
isolates ) must be shipped
2. Insert absorbent material. as:
3. Don gloves. Category A \"INFECTIOUS
SUBSTANCE; AFFECTING
4. Cushion primary container. HUMANS\" and assigned to
UN 2814.
5. Place primary container in secondary container.
Needs
6. Doff gloves. Dangerous Goods
Declaration
7. Close secondary container.
8. Place secondary container in outer container.
9. Insert laboratory test instructions and description of materials.
10.Close outer container.
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Dangerous Goods Declaration
• All shipments of Category A
pathogens require a properly
completed Dangerous Goods
Declaration. This declaration
must be signed by the
shipper and serves as a legal
contract between the shipper
and operator.
• Samples classified as
Category B or Exempt do not
require this form.
Completed Form
6/2/2009 235
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Air Waybill
• All goods being
shipped by air must
have a completed
Air Waybill.
6/2/2009 236
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This Packaging is Used For Category B
Infectious Substances
6/2/2009 237
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Category B
Packaging Requirements
• Primary container is leakproof
• Secondary container is leakproof
• Outer container. Either secondary or outer container is rigid
– If the shipment is transported by air, the outer container must be rigid.
• Pressure tested at 95kPa
• Drop tested from 1.2m
6/2/2009 238
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Category B: Markings and Labels
• All shippers must properly mark and label MARKINGS
Category B packages. The following is a list
of markings and labels for Category B
packages:
Markings
• Shipper’s name, address, and telephone number UN 3373
BIOLOGICAL SUBSTANCE,
CATEGORY B
• Receiver’s name, address, and telephone number
• UN Number
• Proper Shipping Name
Labels
• None are required (unless shipping with dry ice)
6/2/2009 239
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Steps For Packaging Category B Sample
Specimens collected directly
1. Open secondary container. from humans or animals that are
suspected or confirmed to
2. Insert absorbent material. be infected with the swine
influenza A(H1N1) virus,
3. Don gloves. including specimens from the
respiratory tract (swabs) and
4. Cushion primary container. blood specimens, should be
shipped as :
5. Place primary container in secondary container.
\"BIOLOGICAL
6. Doff gloves. SUBSTANCE, CATEGORY B\"
7. Close secondary container. and assigned to UN 3373.
8. Place secondary container in outer container. Does Not Need
Dangerous Goods
9. Insert laboratory test instructions and description of Declaration
materials.
10. Close outer container.
6/2/2009 240
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Exempt Packaging Requirements
• Primary container is leakproof
• Secondary container is leakproof
• Outer packaging must be of adequate
strength
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Medical Management of Biological Casualties
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Exempt Packaging Requirements
Primary container (leakproof)
Secondary container
(leakproof)
Absorbent and cushioning
material
Outer packaging
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Exempt Marking Labels
• All shippers must properly mark and label MARKINGS
Exempt packages. The following is a list of
markings and labels for Exempt packages:
• Markings
• Shipper’s name, address, and telephone number
EXEMPT HUMAN SPECIMEN
• Receiver’s name, address, and telephone number
• Proper Shipping Name
EXEMPT ANIMAL SPECIMEN
Labels
• None are required (unless shipping with dry ice)
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Steps For Packaging Exempt Sample
1. Open secondary container.
2. Insert absorbent material.
3. Cushion primary container.
4. Place primary container in secondary container.
5. Close secondary container.
6. Place secondary container in outer container.
7. Insert laboratory test instructions and description of materials.
8. Close outer container.
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Health Protection Agency (HPA)
Cat B Packaging Poster
6/2/2009 245

Biosaftey :
Spill Clean-up Procedure
1. Wear gloves and protecting clothing, including face and eye
protection if indicated.
2. Cover the spill with a cloth or paper towels to contain it.
3. Pour an appropriate disinfectant over the cloth or paper
towels and the immediately surrounding area (5% bleach
solutions are generally appropriate, but for spills on aircraft,
quaternary ammonium disinfectants should be used).
4. Apply the disinfectant concentrically beginning at the outer
margin of the spill area, working towards the centre.
5. After about 30 min, clear away the materials. If there is broken
glass or other sharps are involved, use a dustpan or a piece of
stiff cardboard to collect the materials and deposit them into a
puncture-resistant container for disposal.
6. Clean and disinfect the area of the spillage (if necessary, repeat
steps 2–5).
7. Dispose of contaminated materials into a leak-proof, puncture-
resistant waste disposal container.
8. After successful disinfection, report the incident to the
competent authority and inform them that the site has been
6/2/2009 246
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Post-exposure Prophylaxis (PEP) for close contacts of probable1
or confirmed2 human case(s) of Influenza A(H1N1) in WHO
Pandemic Alert Phase 5
6/2/2009 247

Canadian Lab Working on
Influenza A(H1N1) Vaccine
• No Vaccine available at this time!
NML Winnipeg
• Late on May 6, Canada's National
Microbiology Laboratory first
completed the sequencing of the virus,
publishing the result to GenBank
• Samples from Mexico, Nova Scotia and
Ontario had the same sequence, ruling
out genetic explanations for the greater
severity of the Mexican cases
6/2/2009 248
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Influenza A(H1N1)
Vaccine Resource Update
• For more Information:
• Recommendations of the
Strategic Advisory Group
of Experts (SAGE) on
Influenza A (H1N1)
vaccines 19 May 2009
• http://www.who.int/csr/r
esources/publications/swi
neflu/SAGEH1N1vaccinere
commendation2009_05_
19.pdf
6/2/2009 249

Influenza A (H1N1) Vaccine Development Process
Seasonal 1. Collection of specimens and disease/epidemiology data
(All year round)
A(H1N1)
2. Diagnosis and virus isolation ,preliminary analysis
(Hrs to 3 wks)
2a. Virus Isolation in eggs
(1-3 wks)
3. Ferret antisera production Vaccine
development
(3-5 weeks) Approx 12-16
months
4. Thorough antigenic and genetic analysis
(1-3 wks)
4a. Serological Studies
(3-16 wks)
5.Review and selection of candidate viruses for vaccine use
(1-3 wks)
6a. Classical Reassortment of 6b. Reassortment of high
high growth viruses growth using reverse genetics
(3-4wks) and full safety testing (8 wks)
7a. Antigenic and genetic 9a. Development of 9b. Development of 7b. Antigenic and genetic
characterizations of
8. Evaluation of growth
standardized reagents standardized reagents characterizations of
reassortments property
fir inactivated vaccines for inactivated ressortment
(3 wks)
(4wks) (6wks) vaccines (3 wks) (4wks)
Availability of vaccine virus and standardised reagents
Adapted from WHO H5N1
vaccine development

Influenza A(H1N1)
Antiviral Purpose in Pandemics
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Influenza A(H1N1)
Antiviral Medications
2 Classes of Medications Available
• M2 Inhibitors :Adamantanes
– Amantadine, Rimantadine
– Activity only against influenza A viruses
• Neuraminidase inhibitors
– Oseltamivir, Zanamivir. (Primivir experimental)
– Activity against influenza A and
B viruses
Class Effective Against Drug Name (INN) Brand Name Year Approved Manufacturer
M2 inhibitors Influenza A Amantadine Symmetrel 1976 Endo
(adamantane Pharmaceuticals
derivatives Rimantadine Flumadine 1994 Forest Laboratories
Neuraminidase Influenza A & B Zanamivir Relenza 1999 GlaxoSmithKline
inhibitors Hoffmann-La
Oseltamivir Tamiflu 1999 Rochene
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Influenza A(H1N1) Antivirals
Oseltamivir, Zanamivir
• Chemically related
• Different routes of administration
– Oseltamivir (Tamiflu): Tablet, suspension
– Zanamivir (Relenza): Orally inhaled powder
• Mechanism of action:
– Block active site of neuraminidase
– Reduce the amount of viral particles
released from infected cells
• Decrease shedding of influenza A and
influenza B viruses
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6/2/2009 254

Influenza A(H1N1)
Neuraminidase Inhibitor Resistance
• Cross-resistance
• Frequency
– 5.5% in oseltamivir pediatric
treatment study (U.S.)
The Strategy for the
– 18% in oseltamivir pediatric Control of
treatment study (Japan) Antimicrobial
Resistance in Ireland
• Global Neuraminidase
Inhibitor Susceptibility
Network
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Influenza A(H1N1)
Antivirals
• Director Schuchat said that the virus was resistant to
Amantadine and Rimantadine
• Susceptible to Oseltamivir (Tamiflu) and Zanamivir
(Relenza)
OSELTAMIVIR
(TAMIFLU)
for the prevention
of Influenza A
(H1N1)
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Influenza A(H1N1)
Antiviral Resistance
• This swine influenza A (H1N1) virus is sensitive (susceptible) to the
neuraminidase inhibitor antiviral medications zanamivir and oseltamivir.
• It is resistant to the adamantane antiviral medications amantadine and
rimantadine
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Pandemic Influenza Expert Group
(PIEG) On Antivirals
• According to the Pandemic Influenza Expert
Group (PIEG)
• Treatment with NAI (within 48 hours) for
seasonal influenza leads to reduction of:
• 0.4 -1 days in duration of symptoms
• 25-43% of complications requiring antibiotics
• 55% in Lower Respiratory Tract Infections
• 34% in need for antibiotics
• 59% in hospitalisations
• 44% in otitis in children
6/2/2009 259
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Influenza A(H1N1)
Antiviral Chemoprophylaxis
• Antiviral chemoprophylaxis (pre-exposure or post-exposure)
with either oseltamivir or zanamivir is recommended for the
following individuals:
• Household close contacts who are at high-risk for complications of
influenza (persons with certain chronic medical conditions, elderly)
of a confirmed or suspected case
• School children who are at high-risk for complications of influenza
(persons with certain chronic medical conditions) who had close
contact (face-to-face) with a confirmed or suspected case
• Travellers to Mexico who are at high-risk for complications of
influenza (persons with certain chronic medical conditions, elderly)
• Border workers (Mexico) who are at high-risk for complications of
influenza (persons with certain chronic medical conditions, elderly)
• Health care workers or public health workers who had unprotected
close contact with an ill confirmed case of swine influenza A (H1N1)
virus infection during the case’s infectious period
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Influenza A(H1N1)
Antiviral Treatment
• Only 2 antiviral medications
are equally efficacious when
used for early treatment
– Decrease the duration and symptoms
of uncomplicated influenza by
approximately 1 day
– Decrease viral shedding
• Early treatment with
neuraminidase inhibitors can
reduce some complications
– Otitis media, lower respiratory tract
complications, antibiotic use,
hospitalizations
6/2/2009 265
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Influenza Antiviral Treatment
• Oseltamivir: ≥1 year; Zanamivir: ≥7 years
– Dosage varies by age and weight
• Early treatment of Swine influenza
– Begin within 48 hours of illness onset
• Duration: 5 days
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Influenza A(H1N1)
Empiric Antiviral Treatment
Medication Dosing Recommendations
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Table: Recommended Daily Dosage of Seasonal Influenza
Antiviral Medications for Treatment and Chemoprophylaxis for
the 2008-09 Season—United States
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Antiviral Adult
Recommended Dosages Summary
6/2/2009 269
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(PIEG) On Antivirals
Treatment Schedule:
• Adults - Oseltamivir 75mg every 12 hours for
5 days
– (Dose to be reduced by 50% if creatinine
clearance is less than 30ml/minute i.e. 75mg od)
• Children Children Dose
Child aged >1yr; body weight Oseltamivir 30mg 12-hourly
15kg or lower (>1yr-<3yrs)
16-23kg (3yr-<7yrs) Oseltamivir 45mg 12-hourly
23-40kg Oseltamivir 60mg 12 hourly
Child 40kg or over Oseltamivir 75mg 12-hourly
6/2/2009 270
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EMEA Dosing recommendations for
antiviral chemoprophylaxis of children
younger than 1 year using oseltamivir
• Age 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
• During a pandemic, if Tamiflu is prescribed to
children under the age of one, the recommended
dosage is 2 to 3 mg per kg body weight
•
6/2/2009 (EMEA May 8 report) 271
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Emergency Use Authorization of
Tamiflu (Oseltamivir) In US
• Oseltamivir is not licensed for use in children
less than 1 year of age in US
• If used Oral suspension
6/2/2009 272

Influenza A(H1N1)
Antiviral Treatment
• Suspected Cases
• Empiric antiviral treatment is recommended for any ill
person suspected to have swine influenza A (H1N1) virus
infection.
• Antiviral treatment with either zanamivir alone or with a
combination of oseltamivir and either amantadine or
rimantadine should be initiated as soon as possible after
the onset of symptoms.
• Recommended duration of treatment is five days.
• Recommendations for use of antivirals may change as
data on antiviral susceptibilities become available.
• Adults Antiviral doses and schedules recommended for
treatment of swine influenza A (H1N1) virus infection
are the same as those recommended for seasonal
influenza: Except fpr children!
6/2/2009 273
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Influenza A(H1N1)
Oseltamivir (Tamiflu) Adverse Effects
• Metabolized by liver, excreted in • Dosage reduction:
urine – Kidney disease
• Adverse effects • Severe Effects
• Gastrointestinal (nausea, vomiting)
Other side effects may include: • 1. Hallucinations
• headache 2. Delusional behaviour
3. Loss of contact with reality
• diarrhoea 4. Convulsions
• nausea 5. Nausea and vomiting
• vomiting 6. Psychosis
• nasal irritation 7. Suicidal behaviour
8. Death of both adults and
• bronchitis children
• cough
• sinus inflammation
• ear, nose and throat infections
• dizziness
6/2/2009 274
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Oseltamivir (Tamiflu)
Children Dosing Fact Sheets
6/2/2009 275
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Oseltamivir (Tamiflu)
Children Fact Sheets
6/2/2009 276
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Influenza A(H1N1)
Zanamivir (Relenza) Adverse Effects
• Not metabolized, excreted – headache
unchanged – diarrhea
• Adverse effects – nausea
– Gastrointestinal (nausea, – vomiting
diarrhea) – nasal irritation
– Headache – bronchitis
– Cough (bronchospasm in – cough
persons with pulmonary – sinus inflammation
disease: not recommended – ear, nose and throat infections
for persons with underlying
pulmonary disease) • dizziness
6/2/2009 277
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Influenza A(H1N1)
Zanamivir (Relenza) 10 Steps
• The Diskhaler has three parts:
• Don’t take it apart until you have looked at the step-by-step
guide
• The Rotadisk fits into the Diskhaler
• The Rotadisk fits onto the wheel of the Diskhaler
• Each of the four blisters on the Rotadisk contains a single dose of Relenza
6/2/2009 278

Influenza A(H1N1)
Zanamivir (Relenza) Application Steps
1 Remove the blue cover
– Check that the mouthpiece is clean, inside and
outside
2 Hold the white sliding tray as shown and pull it
out until it stops
3 Gently squeeze the finger grips on the sides of
the white tray. Remove the tray from the main
body
– The white tray should come out easily
4 Place a new Relenza Rotadisk on the wheel
– Make sure the printed side is up, with the blisters
facing downwards. The blisters fit into the holes in
the wheel.
5. Push the white tray back into the main body If
your not ready replace the blue cover 279
6/2/2009

Influenza A(H1N1)
Zanamivir (Relenza) Application Steps
6. Hold the Diskhaler horizontally
• To get your dose ready to inhale:
• Do this just before you inhale a dose
a) Flip the lid up as far as it will go
b) The lid must be fully vertical, to make sure
that the blister is pierced completely
c) Push the lid back down.
• Your Diskhaler is now ready for use. Keep it
horizontal until you have inhaled your dose
• Use diskhaler immediately after set up!
6/2/2009 280

Influenza A(H1N1)
Zanamivir (Relenza) Application Steps
7. Don’t put the Diskhaler into your mouth yet Breathe out as
far as is comfortable, keeping the Diskhaler away from
your mouth
– Don’t blow into the Diskhaler. If you do,you’ll blow
the powder out of the Rotadisk
• To prepare the next blister (the second part of your
dose):
8. Pull the white tray out as far as it will go (don’t remove it
completely), then push it back in again
• This will turn the wheel so the next blister will appear
– Repeat if necessary until a full blister is positioned under the
piercing needle.
– Repeat steps 6 and 7 to inhale the medicine.
9. After you’ve inhaled the full dose (normally two blisters):
• Wipe the mouthpiece with a tissue and replace the blue
cover. It’s important to keep the Diskhaler clean.
• To replace the Rotadisk:
10. When all four blisters are empty, remove the Rotadisk from
the Diskhaler and insert a new one, using steps 1 to 5.
6/2/2009 281

Zanamivir (Relenza) Fact Sheets
6/2/2009 282
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Guidelines for Reporting Suspected Adverse Reactions
to Antiviral Medicines an Influenza Pandemic
“Pharmacovigilance”
• How to report?
The most efficient way to report adverse reactions to the IMB in a
pandemic situation is via our online reporting system at www.imb.ie
1. On-line at www.imb.ie and follow the links to ‘On-line
Reporting’ to complete a Human Medicines Adverse Reaction
Report
2. ‘Freepost system’ – Adverse Reaction Report Forms (yellow
cards) can be obtained directly from the Pharmacovigilance Unit of
the IMB or downloaded from the website under the ‘Publications
section’. A supply of yellow cards/Adverse Reaction Report Forms
may be requested by telephoning the Pharmacovigilance Unit of the
IMB at 01-676 4971
6/2/2009

Guidelines for Reporting Suspected Adverse Reactions
to Antiviral Medicines an Influenza Pandemic
“Pharmacovigilance”
Yellow card
Pharmacovigilance Section,
Irish Medicines Board, )
Kevin O'Malley House,
Earlsfort Centre,
Filled out by Public Health
Earlsfort Terrace,
Dublin 2,
Ireland.
Tel :353-1-676 4971
Fax: 353-1-634 3514
Email:
284
imbpharmacovigilance@imb.ie
6/2/2009

Influenza A(H1N1)
Special Considerations for Children
• Aspirin or aspirin-containing products
(e.g. bismuth subsalicylate – Pepto
Bismol) should not be administered
to any confirmed or suspected ill case
of swine influenza A (H1N1) virus
infection aged 18 years old and
younger due to the risk of Reye
syndrome.
• For relief of fever, other anti-pyretic
medications are recommended such
as acetaminophen or non steroidal
anti-inflammatory drugs.
6/2/2009 285
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Influenza A(H1N1)
Antivirals “Pregnant Women”
• Oseltamivir, zanamivir, amantadine,
and rimantadine are all “Pregnancy
Category C\" medications, indicating
that no clinical studies have been
conducted to assess the safety of these
medications for pregnant women
• EU: Following a review of the available
data for Tamiflu and Relenza, the CHMP
concluded that the benefits of using
these medicines in pregnant or
breastfeeding women outweigh the
risks in case of an Influenza A/H1N1
pandemic
6/2/2009 286
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Influenza A(H1N1)
Irelands National Antiviral Stockpile (INAS)
• Mobilization plans to be Irish Alert Level Description
tested for National Stock Pile Irish Alert Level 1 Cases only
outside Ireland (in
during this Swine-Origin a country or
Influenza Virus (S-OIV ) countries with or
outbreak if the Irish Alert without extensive
Irish travel/trade
Level Hits 2 links
• Surveillance and monitoring Irish Alert Level 2 New virus isolated
must be In place for future in Ireland
exercise improvements for Irish Alert Level 3 Outbreak(s) in
Ireland
mobilizations of Irelands
Irish Alert Level 4 Widespread
National Antiviral Stockpile activity in Ireland
Alert levels will increase in Phase 6
declaration by WHO
6/2/2009 287
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Pandemic Influenza Expert Group
(PIEG) On Antivirals
Irelands National Antiviral Stockpile
• One million treatment packs of Oseltamivir (Tamiflu) are stockpiled
• This quantity is sufficient to treat 25% of the population and is in line with
international trends
• 63kg of the API has also been purchased
– Active Pharmaceutical Ingredient (API), oseltamivir phosphate powder, should be purchased
to treat young children between the ages of one and five years
– Arrangements have been put in place so that API powder will be converted to paediatric
capsules, which will be used for all children aged one to 11 years of age
• 706,000 packs of zanamivir (Relenza) have now been ordered
• This is sufficient to cover 20% of the population over the age of seven
• 500,000 surgical masks, five million pairs of disposable gloves and 150,000 surgical
gowns for health care providers
6/2/2009 288
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Influenza A(H1N1)
WHO Country Antiviral Distribution Plan
6 May 2009
• WHO headquarters stocks distributed to –
–
Honduras
Indonesia
countries. Regional stock distribution is – Kenya
not included here so this is not the full list of –
–
Kiribati
Kyrgyzstan
countries receiving antivirals from WHO – Lao People's Democratic Republic
globally –
–
Lesotho
Liberia
– Afghanistan
– Madagascar
– Angola
– Malawi
– Armenia
– Mali
– Azerbaijan
– Mauritania
– Bangladesh
– Benin – Mexico
– Bhutan – Mongolia
– Bolivia – Mozambique
– Burkina Faso – Myanmar
– Burundi – Nepal
– Cambodia – Nicaragua
– Cameroon – Niger
– Central African Republic – Nigeria
WHO/Tom Moran
– Chad – Pakistan
– Comoros – Papua New Guinea WHO staff prepare boxes of
– Congo – Republic of Moldova antiviral drugs for countries
– Cote d´Ivoire – Rwanda
– Cuba – Sao Tome and Principe
May 8 2009
– Democratic People's Republic of Korea – Senegal
– Democratic Republic of the Congo – Sierra Leone
– Democratic Republic of Timor-Leste
– Solomon Islands
– Djibouti
– Somalia
– Eritrea
– Sri Lanka
– Ethiopia
– Sudan
– Gambia
– Georgia – Tajikistan
– Ghana – Togo
– Guinea – Uganda
– Guinea-Bissau – Ukraine
– Guyana – United Republic of Tanzania
– Haiti – Uzbekistan
– Viet Nam 289
6/2/2009 – Yemen
– Zambia
– Zimbabwe

Typical Antiviral Clinic
Process Flow Chart
Queue Medical Assessment (screeners)
Antivirals/ Contraindication Require Antiviral
Triage Vaccination (to EXIT) Med Consult
Home, hosp,
MD Antiviral/Vaccination Area
Medical
Orientation Post Antiviral/Vaccination Evaluation
and Education Education
Form collection EXIT
Registration
290
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Influenza Vaccination Clinic
Map Example:
6/2/2009 291
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Guidance for Pharmacy Staff
Influenza A (H1N1)
• Full Tamiflu info @
http://www.emea.europa.eu/humandocs/PDFs/EPAR/tamiflu/H-402-PI-en.pdf
6/2/2009 292

Influenza A(H1N1)
Standard Precautions
• Health Protection Surveillance
Centre
25-27 Middle Gardiner St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
• See Website for download for
clinicians
6/2/2009 293
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Influenza A(H1N1)
Irish Universal Respiratory Hygiene
• Pandemic Influenza
Preparedness for Ireland:
Advice of the Pandemic
Influenza Expert Group
• The following are
components of a universal
respiratory hygiene
strategy to be adopted in
all health care facilities
• Read in Narration!
Breaking the Chain
of Infection
6/2/2009 294
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Influenza A(H1N1)
Transmission-Based Precautions
• Contact Precautions
• Contact precautions should be applied in
addition to Standard Precautions to prevent
transmission of highly transmissible
organisms that are transmitted from person
to person via the contact route (e.g.
Methicillin resistant Staphylococcus aureus)
• Airborne Precautions
• Airborne Precautions should be applied, in
addition to Standard Precautions, to prevent
transmission of highly transmissible
organisms that are transmitted via the air
from one person to another (e.g.
Tuberculosis)
• Droplet Precautions
• Droplet Precautions should be applied, in
addition to Standard Precautions, to prevent
transmission of highly transmissible
organisms that are transmitted via
respiratory secretions from one person to
another (e.g. Influenza)
6/2/2009 295

Influenza A(H1N1)
YOUR 4 MOMENTS FOR HAND HYGIENE
(Canadian)
1. Clean your hands when
entering before touching the 2, Clean your hands
immediately before any
patient or any object or
furniture in the patient’s aseptic procedure.
environment. To protect the patient
To protect the patient/ patient against harmful organisms,
environment from harmful including the patient’s own
organisms carried on your organisms, entering his or
hands her body.
4. Clean your hands when
3. Clean your hands leaving after touching
immediately after an patient or any object or
exposure risk to body fluids furniture in the patient’s
(and after glove removal). environment.
To protect yourself and the To protect yourself and the
health care environment from health care environment
harmful patient organisms. from harmful patient
See WHO Hygiene Protocol organisms
witch has 5 Steps
Irish has 6 Steps
6/2/2009 296
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The “My 5 Moments for Hand
Hygiene” Approach (WHO)
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

6 Step Irish
Hygiene Protocol
• Ireland
In 2006-7, Ireland organised a national campaign called
‘Clean Hands Save Lives’.
• Same as the following!
• All have 6 Steps in essence!
A doctor checks patients presenting symptoms of the swine flu virus, now named influenza A(H1N1), kept in
isolation at the National Institute of Respiratory Diseases (INER) in Mexico City on May 5, 2009. (LUIS
ACOSTA/AFP/Getty Images)
6/2/2009 298
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Guidelines for Hand Hygiene in
Irish Health Care Settings
• Audit: In 2008 (Q1-3) the median rate of alcohol hand rub
consumption increased to 17.9 litres per 1,000 bed-days
used, from 10.5 and 15.0 in 2006 and 2007 respectively
This represents a 19.3% increase since 2007
Good Resource
But needs Updating
6/2/2009 299

Pandemic Planning “Hand Washing”
6/2/2009 300

Influenza A(H1N1)
Protocol for Surveillance of Influenza-like Illness in
Healthcare Workers during Pandemic Phase 5
• Health Protection
Surveillance Centre
25-27 Middle Gardiner St
Dublin 1, Ireland.
t: +353 1 8765300
f: +353 1 8561299
e: hpsc@hse.ie
• See Website for
download for clinicians
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Public Health Management of
Influenza A(H1N1) Contacts
• Close Contacts Definition (interim)
• Household members of a case
• Roommates of cases in hospitals or institutions such as nursing homes,
• People occupying the same room with a case (<1metre) for at least 4 hours
• People who have contact with fomites contaminated with respiratory secretions
(e.g. those handling tissues recently used by others or touching the hands of
infectious persons who have handled tissues or touched their nose)
• Travellers by plane sitting in the same row or in the 2 rows ahead or behind on a
long haul flight (at least four hours duration) of a case that was symptomatic either
on the flight or within 24 hours of the flight (only symptoms generating droplets
such as sneezing and coughing count here)
• Persons caring for a sick traveller, as described above
• Health/social care workers who provided direct clinical, personal care or examined
a symptomatic patient without wearing appropriate Personal Protective
Equipment (PPE) for Standard, Droplet and Contact Precautions:
• Routine Care (including taking nasal and throat swabs for viral testing)
– Surgical mask, Plastic Apron, Gloves (and goggles if risk of splashing/spraying)
• Aerosol generating procedures
– FFP2 or FFP3 respirator mask, goggles, long sleeved gown and gloves
6/2/2009 302

Public Health Management of
Influenza A(H1N1) Contacts
• Management of Contacts
• Household contacts: request to go into home quarantine until test result
• If positive, remain in voluntary home quarantine for 7 days.
• All other actions wait until the test result comes back as Influenza A unsubtypable (probable).
• If A unsubtypable:
• Chemoprophylaxis for close contacts as defined above (1 course = 10 days)
• Surveillance: Active - contacts to self-monitor for symptoms for 7 days, check temp twice
daily.
– Staff from local office of Director of Public Health will make contact daily to ensure asymptomatic.
• No ongoing quarantine for non household contacts of a positive case
• Health care workers who have worn appropriate PPE don’t need chemoprophylaxis; they
should self monitor for symptoms and will be followed daily by Public Health
• Taking serology may be relevant in certain circumstances in order to better understand
transmission. In these circumstances paired samples should be taken (first sample when
identified as a contact and second sample 14 days later).
• Contacts who are workers on pig farms should not work for 7 days following contact with a
case to reduce the risk of human-to-pig transmission.
6/2/2009 303

Post-exposure Prophylaxis (PEP) for close contacts of probable1
or confirmed2 human case(s) of Influenza A(H1N1) in WHO
Pandemic Alert Phase 5 (Update June 2 2009)
6/2/2009 304

Influenza A(H1N1)
Surveillance of Healthcare Workers
• Healthcare worker (HCW) • Porters
includes: • Domestic staff
• Hospital clinician teams • Receptionists
• General practitioners • Administration staff
• Public health doctors • Ambulance staff
• Laboratory scientists • Mortuary workers
• Physiotherapists
• Professional support staff
Safety, Health
and Welfare at
Work Act 2005
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Influenza A(H1N1)
Surveillance of Healthcare Workers
Clinical criteria
• Acute onset of fever (temperature > 38 °C or history of
fever and two or more of the following:
• Cough
• Sore throat
• Myalgia
• Headache
• Rhinorrhoea or
• Vomiting/Diarrhoea
• Pneumonia
• Febrile respiratory illness
• Acute respiratory illness (ARI)
HPSC May 21 Update
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Healthcare Workers with Probable
Influenza A(H1N1)
• Report to occupational health department
• The relevant line manager should notify the occupational
health department:
• If there is an apparent increase in absenteeism rates
among a particular group of HCWs or in a particular area
• If there is an apparent cluster of acute respiratory illness
among a particular group of HCWs or in a particular area
• If a HCW becomes ill with a severe lower respiratory tract
infection or pneumonia
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Healthcare Workers with Probable
Influenza A(H1N1)
• Single cases
• If a HCW is admitted to hospital with
respiratory symptoms including pneumonia
(severe respiratory illness) and they have at
least one of the following in the seven days
before disease onset:
– Been a close contact of a confirmed case of
swine influenza A (H1N1) virus infection while
the case was ill
– Have travelled to an area where sustained
human-to-human transmission of swine
influenza A (H1N1) is documented
– Worked in a laboratory where samples of the
swine influenza A (H1N1) virus are tested
6/2/2009 308
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Healthcare Workers with Probable
Influenza A(H1N1) Occupational Health Role
• If a HCW has been involved in caring for or examining a
symptomatic patient with swine influenza A (H1N1)
infection the following actions should be taken:
• 1.Inform the regional DPH/MOH if the HCW provided
direct clinical or personal care or examined the
symptomatic patient without appropriate Personal
Protective Equipment (PPE). Discuss contact management
with DPH/MOH.
• 2.For HCWs who did not wear PPE* while caring for
symptomatic patient: institute post-exposure prophylaxis
with oseltamivir (Tamiflu) as soon as possible unless more
than 7 days have elapsed since the last exposure. The dose
of oseltamivir is 75mg daily for 10 days following last
exposure.
• 3.Provide all HCW contacts with clear public health
recommendations and information on swine influenza A
(H1N1) (available at www.hpsc.ie/hpsc/).
6/2/2009 309
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Healthcare Workers with Probable
Influenza A(H1N1) Occupational Health Role
• 4. Request that any febrile respiratory or other
unexplained illness within 7 days of last contact be
reported
• 5. If the HCW contact becomes unwell they should
be investigated and treated (liaise with DPH/MOH).
They should also be advised to discontinue work
immediately
• 6. Advise all contacts to strictly adhere to all
infection control and prevention precautions as
follows:
– Avoid touching their faces, including their eyes and
nose and mouth with their hands
– Wash hands frequently. This means washing with
soap and running water for a minimum of 15-20
seconds or the use of an alcohol-based hand sanitiser
if the hands are not visibly soiled
– Cover their mouth with a tissue when they cough
and/sneeze, and dispose carefully in a bin afterwards
6/2/2009 310
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Healthcare Workers with Probable
Influenza A(H1N1)
• Unusual clusters or syndromes
• If there are unusual clusters of disease or
syndromes among HCWs
• The DPH/MOH will immediately inform HPSC
of any unusual clusters of disease or
syndromes among HCWs
Definition of a healthcare cluster:
A cluster is defined as two or more healthcare workers in the same healthcare
facility/unit with unexplained acute respiratory illness and with fever ≥38°C, or
with severe lower respiratory tract infection or pneumonia, and with onset of
illness within a period of 14 days of each other.
6/2/2009 311
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Healthcare Workers “Fitness for Work”
Occupational Health Role
• Fitness for Work
• Occupational health advice on fitness for work (or on the need for work
restrictions at a given time) should be sought by:
• Healthcare workers who develop symptoms of ILI (Influenza Like Illness),
who should report to their line manager in the first instance
• Healthcare workers recovering from ILI
• Healthcare workers who have been in unprotected contact with suspect or
confirmed cases of ILI (either in the community or at work)
• Healthcare workers who have been prescribed antiviral therapy by their
GP or a Public Health Doctor
• Healthcare workers who have pre-existing medical conditions which
might increase their risk of severe influenza complications
• Pregnant healthcare workers
• Healthcare workers who cannot achieve an adequate ‘seal’ with the PPE
provided by their employer
6/2/2009 312

Influenza A(H1N1)
Infection Control In Health Care Setting
• CDC Interim recommendations:
• The ill person should wear a surgical
mask when outside of the patient room
• 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
• Wear masks outside the Room
6/2/2009 313
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Influenza A(H1N1)
Infection Control In Health Care Setting
• 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 FFP2-3
respirator mask
• 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 FFP2-3
respirator mask when entering the patient
room.
6/2/2009 314
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Influenza A(H1N1)
Infection Control In Health Care Setting
• CDC Interim recommendations:
• 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
• Wear disposable non-sterile
gloves, gowns, and eye protection
(e.g., goggles) to prevent
conjunctival exposure.
6/2/2009 315
Medical Management of Biological Casualties
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Influenza A(H1N1)
Infection Control In Health Care Setting
• For visible soiled hands WHO recommends the
following technique
6/2/2009 316

Influenza A(H1N1)
HealthCare Environmental Waste
• In aerosol generating activities (e.g., collection of
clinical specimens, endotracheal intubation, nebulizer
treatment, bronchoscopy, and resuscitation involving
emergency intubation or cardiac pulmonary
resuscitation) SOP must be in place
• Appropriate disinfectants
– 70% Ethanol
– 5% Lysol
– 10% Bleach
• According to PIEG: Commonly used surfaces such as
door handles, handrails, table surfaces etc. should be
cleaned first and then disinfected with a chlorine
releasing disinfectant (1000 ppm) twice daily.
6/2/2009 317
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Swine influenza A (H1N1)
Infection Prevention and Control Precautions for use when caring for patients
with suspected or confirmed swine influenza A (H1N1)
6/2/2009 318
Medical Management of Biological Casualties
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Swine influenza A (H1N1)
Infection Prevention and Control Precautions for use when
caring for patients with suspected or confirmed swine influenza
A (H1N1)
• Standard Precautions require all HCWs to:
• A. Assume that every person is potentially infected or colonized with an
organism that could be transmitted in the healthcare setting.
• B. Apply a set of work practices to blood, all body fluids (except sweat),
mucous membranes and non intact skin:
– Hand hygiene
– Use of personal protective equipment
– Management of spillages of blood and body fluids
– Appropriate patient placement
– Management of sharps
– Safe injection practices
– Respiratory hygiene and cough etiquette
– Management of needle stick injuries
– Management of waste
– Management of laundry
– Decontamination of reusable medical equipment
– Decontamination of the environment. 319
Medical Management of Biological Casualties
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Swine influenza A (H1N1)
Infection Prevention and Control Precautions for use when
caring for patients with suspected or confirmed swine influenza
A (H1N1)
6/2/2009 320
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Swine influenza A (H1N1)
Infection Prevention and Control Precautions for use when
caring for patients with suspected or confirmed swine influenza
A (H1N1)
6/2/2009 321

Swine influenza A (H1N1)
Infection Prevention and Control Precautions for use when
caring for patients with suspected or confirmed swine influenza
A (H1N1)
6/2/2009 322

Swine influenza A (H1N1)
Infection Prevention and Control Precautions for use when
caring for patients with suspected or confirmed swine influenza
A (H1N1)
6/2/2009 323

Aerosol Generating Procedures
According to WHO
• Aerosol generating • Nebulisation
procedures: • Non-invasive positive
• Intubation and related pressure ventilation
procedures, e.g. manual • Bi-level positive airway
ventilation pressure (BiPAP)
• Respiratory and airway • High frequency oscillating
suctioning (including ventilation
tracheostomy care)
• Nasopharyngeal aspiration
• Cardiopulmonary
resuscitation
• Bronchoscopy
• Autopsy procedures
6/2/2009 324

Recommended Initial PPE
Protection Levels
AGENT CATEGORY MINIMUM LEVEL OF PROTECTION
UNKNOWN LEVEL A
NERVE LEVEL A(1)
BLISTER LEVEL A(2)
BLOOD LEVEL B(3)
CHOKING LEVEL B(3)
BIOLOGICAL High Efficiency Particulate Air FILTER w/LEVEL C
RADIOLOGICAL High Efficiency Particulate Air FILTER w/LEVEL C
(1) High concentrations may result in nerve agent
poisoning
(2) Sufficient vapor will cause blisters
(3) Level A may be required in an enclosed area
6/2/2009 Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Personal Protective Equipment PPE
• PPE = Personal Protective Equipment
• PPP = Personal Protective Practices
• PPE + PPP = Prevention
Personal Protection is not just “personal”:
It is also about preventing spread of disease
to others!
6/2/2009 326

Influenza A(H1N1)
Personal Protective Equipment PPE
• Avian flu indicated that using a face mask with a
rating of N99, N100 or P100 in the United States
• A rating of FFP3 in Europe should be effective in
protecting against transmission
– 99% efficiency FFP3
Respirator Mask
• N95 or FFP2 face masks provide about 94%
efficiency
– 94% efficiency Particle
Recent work by Viscusi5 suggests that most N95
Respirator N95
(FFP2) respirators stored in warehouse and
laboratory conditions are likely to maintain there
filtration capacity for up to 10 years
6/2/2009 327
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

HPA-Recommendations For Extending
The Lifespan Of Masks:
• Use out-of-date facemasks and respirators to the extent available
• Use lower grade respirators to the extent available (where a respirator is indicated)
• Out-of-date but in-grade respirators are preferred to incorrect grade but in-date
stock
• Layered facemasks might be considered as a last resort when no respirators (of any
grade) are available for the performance of aerosol generating procedures
however this will impact on the supply of facemasks for other uses
• Re-use of any device is not recommended except as absolute last resort
• Decontamination of facemasks is not recommended
• Experimental work suggests that high efficacy respirators can be decontaminated
without degradation using certain regimens, but these are unlikely to prove
practical and there are insufficient data to be certain of a reliable effect. This
should only be considered if practical and then as a measure of last resort
• Hospitals can perform individual risk assessments to minimise all but essential
non-pandemic use of facemasks and determine whether alternatives measures
could be adopted
• Masking patients with a facemask as an alternative to masking HCWs might be a
more efficient use of limited quantities of masks in certain circumstances
• Any other nose/mouth covering could be considered once facemask are
exhausted, but there are no data in support of specific items other than the DIY
6/2/2009 328
cotton mask described by Dato et al

Influenza A(H1N1)
Personal Protective Equipment PPE
• Disposable particulate respirators (e.g. NIOSH N95 or
European EN149: 2001
• FFP2; NIOSH N99 or European EN149: 2001 FFP3; or NIOSH
N100)
• Must have Fit Testing Program
FFP2 9300 valved disposable
respirator
FFP3 valved moulded cup mask
6/2/2009 329
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Respiratory Protection Programme
• Example
6/2/2009 330

Influenza A(H1N1)
Respiratory Protection Programme
• A respiratory protection programme for staff
advised to wear respirators should be provided
by each healthcare facility to ensure compliance
with the following health and safety legislation
and standards:
 Safety, Health and Welfare at Work Act, 2005
 Safety, Health and Welfare at Work (General
Application) Regulations 2007 (S.I. No. 299 of
2007). Chapter 3 of Part 2: Personal Protective
Equipment
 Safety, Health and Welfare at Work (Biological
Agents) Regulations 1994 (S.I. No. 146 of 1994)
(as amended by S.I. 248 of 1998).
 IS EN 529:2005 (Irish Standard on Respiratory
Protective Devices)
6/2/2009 331

Influenza A(H1N1)
Respiratory Protection Programme
• Governance:
• Identify department responsible to deliver the
respiratory protection programme
• Identify personnel responsible for the
implementation of the respiratory protection
programme
• Allocation of resources to deliver the
programme
• Selection, purchase and supply of suitable
masks to each healthcare facility
• Storage and maintenance of equipment
• Disposal of used equipment
• Record keeping
6/2/2009 332

Influenza A(H1N1)
Respiratory Protection Programme
• Theoretical information, training and instruction including:
• Types of risk
• Knowledge and understanding of respiratory equipment including
limitations
• Personal factors including medical conditions, improper fitting
• Fit testing and fit checking
• Practical training including:
• An initial fit test using qualitative/ quantitative methods
• Ongoing fit check to confirm the seal each time the mask is donned
• Donning, removing and disposing of mask
6/2/2009 333

Influenza A(H1N1)
Respiratory Protection Programme
• Persons with excessive facial hair, the
following options may be considered:
• HCW agrees to remove the beard / facial hair
• HCW agrees to be otherwise deployed
• Pre-exposure prophylaxis (with antiviral
medication) be considered
• Use of powered air respirator be considered
• If none of these options is deemed Types of respirators that can be fit tested
with this method include:
appropriate or possible (and only in • Filtering facepieces FFP1, FFP2,
FFP3;
exceptional circumstances) a bearded HCW • Half facemask respirators fitted with
a particulate or combined filter
may proceed in the clinical care of such
patients, only having been fully informed of
the risks and in the knowledge that an FFP2 or
FFP3 respirator cannot ensure adequate
protection
6/2/2009 334

Influenza A(H1N1)
Personal Protective Equipment (PPE)
• Influenza A (H1N1)
• Infection
Prevention and
Control Precautions
for use when caring
for patients with
suspected or
confirmed swine
influenza A (H1N1)
6/2/2009 335
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

How To Perform a Particulate
Respirator Seal Check
6/2/2009 336
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Donning and Doffing
Personal Protective Equipment (PPE)
Donning PPE Doffing PPE
6/2/2009 337
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
First Responders (PRAs)
Personal Protective Equipment (PPE):
• Interim recommendations:
• When treating a patient with a suspected case of swine-origin influenza
as defined above, the following PPE should be worn:
– Fit-tested disposable FF3 respirator and eye protection (e.g., goggles; eye
shield), disposable non-sterile gloves, and gown, when coming into close
contact with the patient.
• When treating a patient that is not a suspected case of swine-origin
influenza but who has symptoms of acute febrile respiratory illness, the
following precautions should be taken:
– Place a standard surgical mask on the patient, if tolerated. If not tolerated,
EMS personnel may wear a standard surgical mask.
– Use good respiratory hygiene – use non-sterile gloves for contact with
patient, patient secretions, or surfaces that may have been contaminated.
Follow hand hygiene including hand washing or cleansing with alcohol
based hand disinfectant after contact.
• Encourage good patient compartment vehicle airflow/ ventilation to
reduce the concentration of aerosol accumulation when possible.
•
6/2/2009 338
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Secondary Responders
Health Professionals (PPE)
• 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 FFP2 9300 valved disposable
disposable FFP2-3 respirator respirator
mask
• Fit-tested disposable FF3
respirator and eye protection
(e.g., goggles; eye shield),
disposable non-sterile gloves,
and gown, when coming into
close contact with the swine
influenza
6/2/2009
FFP3 valved moulded cup mask
339
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Tertiary Responders
Mortuary (PPE)
• However, for people who must
directly handle remains, such as
recovery personnel, or persons
identifying remains or preparing
the remains for burial or
cremation, there can be a risk
of exposure to such viruses or
bacteria.
• Fit-tested disposable FF3 respirator
and eye protection (e.g., goggles;
eye shield), disposable non-sterile
gloves, and gown, when coming into
close contact with the fatalities
• Increase level of protection if
needed!
6/2/2009 340
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Handling Human Remains (HHR)
• Potentially contaminated human remains must be
segregated from the general population of a hospital
or other facility as soon as the risk is recognized.
• Only those wearing the appropriate level of PPE should
perform segregation of contaminated human remains
• Segregation involves:
• Placing the human remains along with all personal
effects and clothing into an impermeable body bag
(double bagged if possible)
• Attaching available identifying information to the body
and bag
• Decontaminating the outside of the body bag (HAZMAT
teams may assist with determining the most
appropriate agent to use), using extreme care to avoid
tearing the body bag during handling,
• Moving the bagged human remains to a secure holding
area
• Notifying the medical examiner of the circumstances of
the death, and releasing the human remains to
personnel designated by the medical examiner
6/2/2009 341
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Handling Human Remains
Health Care setting
• Influenza A (H1N1) handling of Human
Remains
Civil Registration Act 2004.
Pt.5
Provision of
particulars, and
registration, of
deaths.
6/2/2009 342
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Handling Human Remains
Medical Examiner
• Influenza A (H1N1) handling of Human
Remains
6/2/2009 343
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Handling Human Remains
Funeral Service
• Influenza A (H1N1) handling of Human
Remains
6/2/2009 344
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A (H1N1) Dispatchers Guide
Infection Prevention and Control Guidance for
the Emergency Dispatcher
• Recommendations for 999
• It is important for the Emergency Operators to
question callers to ascertain if there is anyone at
the incident location who is possibly afflicted by
the swine-origin influenza A (H1N1) virus, to
communicate the possible risk to EMS personnel
prior to arrival, and to assign the appropriate
EMS resources
• Emergency Operators should review existing
medical dispatch procedures and coordinate any
modifications with their EMS medical director
and in coordination with their local department
of public health
6/2/2009 345
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A (H1N1) Dispatchers Guide
Infection Prevention and Control Guidance for
the Emergency Dispatchers
Interim recommendations:
• Call takers should screen all callers for any
symptoms of acute febrile respiratory illness.
– Callers should be asked if they, or someone at the
incident location, has had nasal congestion,
cough, fever or other flu-like symptoms
– If the emergency operator call taker suspects a
caller is noting symptoms of acute febrile
respiratory febrile illness, they should make sure
any first responders and EMS personnel are aware
of the potential for “acute febrile respiratory
illness” before the responders arrive on scene
6/2/2009 346
Medical Management of Biological Casualties
Adapted from “Dispatchers Guide to CBRNE” Revised and Modified 29/04/2009

Confirmed Influenza A(H1N1)
in The Geographic Area
• Step 1: Address scene safety:
– If emergency operator advises potential for acute febrile respiratory illness
symptoms on scene, EMS personnel should don PPE for suspected cases of
swine-origin influenza prior to entering scene.
– If emergency operator has not identified individuals with symptoms of acute
febrile respiratory illness on scene, EMS personnel should stay more than 6
feet away from patient and bystanders with symptoms and exercise
appropriate routine respiratory droplet precautions while assessing all
patients for suspected cases of swine-origin influenza.
• Step 2:
• Assess all patients for symptoms of acute febrile respiratory illness (fever
plus one or more of the following: nasal congestion/ rhinorrhea, sore
throat, or cough).
– If no symptoms of acute febrile respiratory illness, provide routine EMS care.
– If symptoms of acute febrile respiratory illness, don appropriate PPE for
suspected case of swine-origin influenza if not already on.
6/2/2009 347
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Infection Prevention and Control Guidance for
the Ambulance Service
• If the ambulance service is informed that a
patient is suspected or confirmed to have
swine influenza (A/H1N1) the following
precautions should be taken:
• 1.On arrival to the house
– Ambulance staff to decontaminate hands (alcohol
gel), don gloves, gowns/aprons, FFP3 masks (fit
check to ensure good seal) and eye protection if
splashing anticipated. Wash hands before
donning and after removing gloves.
• Inform the hospital of admission of potentially
infectious person
Before leaving the house
• Request patient to wear a surgical mask An ambulance driver
• A patient with suspected or confirmed flu wearing a face mask
drives in Hospital La Fe in
should not travel with any other patients Valencia, Spain
6/2/2009 348
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Infection Prevention and Control Guidance for
the Ambulance Service
In ambulance:
• Change gloves and decontaminate hands after
every patient procedure
• Use single use or single patient use medical
equipment where possible
• Use disposal linen if available
6/2/2009 349
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Infection Prevention and Control Guidance for
the Ambulance Service
• Arrival to hospital
• Ensure arrangements in place for receipt of the patient before the
patient leaves the ambulance
• Transfer patient to the care of hospital staff
• Remove PPE in the following order
1. Gloves
2. Apron/gown
3. Decontaminate hands
4. Eye wear (if applicable)
5. Mask (do not touch front of mask when removing)
6. Decontaminate hands
6/2/2009

Influenza A(H1N1)
Infection Prevention and Control Guidance for the
Ambulance Service
• Before ambulance is used again
• Cleaning and disinfecting
– Surfaces (stretcher, chair, door handles etc) should be cleaned
with a detergent and a hypochlorite solution 1000pmm
• Laundry
– Place reusable blankets in an alginate bag, then into a red
laundry bag and sent for laundry
• Medical equipment
– Follow manufacturer’s instructions for cleaning/disinfecting
reusable equipment
• Management of waste
– Waste contaminated with blood or body fluid should be
disposed of as Healthcare Risk waste
– Management of sharps – as per Standard Precautions
– Management of spillages – as per Standard Precautions
6/2/2009 351
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Guidance for the Ambulance Service with
Suspected /Probable or Confirmed Case
• Post Exposure Prophylaxis “PEP” form
6/2/2009 352

Influenza A(H1N1)
Bioethics
1. Equity of access to antivirals and
vaccines
2. Transparency, honesty and good
communications
3. Individual autonomy v. public good
 Freedom vs. Quarantine
4. Imperatives of urgency in outbreak Dr. Darina
situations O’Flanagan
5. Duty of care of healthcare workers
and value of reciprocity of employers
6/2/2009 353

Influenza A(H1N1)
Global Migration and
Quarantine
The WHO has no free-standing
international quarantine authority
“Quarantine” is still a country-by-
country power!
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6/2/2009 354
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Preventive Methods
1. Isolation Suspected swine flu patient
(left) is escorted by a
quarantine officer to
2. Quarantine Ambulance
3. Social Distancing
4. EU and Irish Quarantine Statue hard to find
therefore US example Used!
5. In Ireland voluntary quarantine measures are
presented in HPSC Post Exposure Prophylaxis
“PEP” form
QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER
6/2/2009 355
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Irish Post-exposure Prophylaxis (PEP)
• Post-exposure Prophylaxis (PEP) for close contacts of probable or
confirmed human case(s) of Influenza A(H1N1)
Updated PEP June 2 2009 doesn’t
mention voluntary Quarantine!
6/2/2009 356

Influenza A(H1N1)
Preventive Methods
• Definitions:
• Isolation
• The separation of an individual, or individuals,
infected with a communicable disease from non
infected individuals either in the home or
hospital
• Quarantine
• The separation of an individual, or individuals,
exposed to a communicable disease, from non
infected and non-exposed individuals
• Social distancing:
• Refer to a range of non quarantined measures
that might serve to reduce contact between
persons, such as, closing of schools or
prohibiting large gathering
QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
New Definition of Quarantine
• “Means the physical separation, including confinement or
restriction of movement, of an individual or individuals who are
present within an affected area, as defined herein, or who are
known to have been exposed or may reasonably be suspected to
have been exposed to a communicable disease of public health
threat and who do not yet show signs or symptoms of infection
with the communicable disease of public health threat in order to
prevent or limit the transmission of the communicable disease of
public health threat to other unexposed and uninfected
individuals.”
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Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Rationale for Isolation &
Quarantine
• Isolation is a fairly common infection
control measure used to prevent the
spread of disease to non-infected
family, healthcare professionals,
patients, etc.
• Quarantine in an extreme public health Hong Kong Hotel
Quarantined Due
measure used to prevent the spread of to Swine Flu Case
disease to the community 300 people at a Hong Kong
hotel have been placed under
quarantine after a guest
there became China's first
confirmed swine flu case.
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Medical Management of Biological Casualties
Revised and Modified 29/04/2009

When might Isolation &
Quarantine be Considered?
• Isolation is used primarily in health
care facilities with highly infectious
patients (e.g., varicella, measles, TB)
• Quarantine is used in extreme
circumstances when disease spread
cannot be prevented by other means,
such as by post-exposure prophylaxis
(e.g. ,SARS))
• Quarantine is also used when
exposed individuals refuse other
disease prevention means, such as
vaccination (e.g., smallpox)
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Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Preconditions to Imposition of
Quarantine or Isolation
• Any quarantine or isolation is implemented in
the least restrictive environment necessary to
contain the communicable disease of public
health threat
• Any quarantined persons shall be confined
separately from any isolated persons
Metropark Hotel
• Upon determining that any quarantined person
Wanchai after a
can be reasonably believed to have become Mexican traveller
infected with a communicable disease of public was determined to
health threat, the infected person shall be have the virus
promptly removed from quarantine and placed
in isolation
QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Preconditions to Imposition of
Quarantine or Isolation
• The health and disease status of any quarantined and
isolated persons shall be monitored regularly to determine
if such persons require continued quarantine or isolation
• Any quarantined or isolated persons shall be immediately
released from quarantine or isolation upon a determination
that such quarantined or isolated persons pose no risk of
transmitting the communicable disease of public health
threat to other persons
• The site of any quarantine or isolation shall be, to the
extent practicable, safely and hygienically maintained with
adequate food, clothing, health care, and other essential
needs made available to the persons who are subject to any
order of quarantine and isolation Movie media
QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Preventive Methods
“Order of Quarantine” US Example
• Ex parte-prepared by the Commissioner:
• Sets forth:
• Nature of the Public Health Threat including the
specific disease if practical
• Reasons why quarantine is required – Voluntary
Compliance has failed or would be ineffective
• Sufficient information to provide notice
• Means by which the quarantine to be Biohazard
implemented warning:
• Geographic parameters (if any) This building
• Duration of quarantine Under
• Penalty for non-compliance Quarantine until
• Provided to those covered individually if possible, further notice
otherwise by a means determined by the
Commissioner
QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1) Isolation
“Order of Isolation” US Example
• Order of Isolation
• Ex parte-issued by the
Commissioner
• Sets forth:
– Identity of isolated persons
– Bases for the isolation
– Specific communicable disease
– Site of the isolation
– Date and time when isolation
commences
– Any conditions of the isolation
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Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
International Quarantine
• BEIJING, May 6 (Xinhua) -- Passengers quarantined in
the Chinese mainland who took the same flight with a
Mexican national later diagnosed with influenza
A/H1N1 in Hong Kong will be out of quarantine on
Thursday if they display no flu-like symptoms, China's
Ministry of Health said Wednesday
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6/2/2009 365
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Quarantine Airports
• Quarantine Triage “Red” passenger could get
escorted to restricted area RED (Terminal)
• There will be a documentation, and a qualified
medical expert about the situation and the
upcoming procedures.
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6/2/2009 366

Influenza A(H1N1)
International Quarantine Reporting
• Potential Quarantine Database (THAD)(Canadian)
• International Health Regulations
• Border Health Initiatives
• Security and Prosperity Partnership
• Global Public Health Information Network (GPHIN)
• Passive and Active Surveillance
ICU of the Jinan Infectious Disease
Hospital in Jinan,China
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6/2/2009 367
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Quarantine Ethics
• Targeting versus stigmatizing
• Care in all communications
• Public health officials,
clinicians & the community
must combat fear, stigma
and discrimination through
health education and
communication
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6/2/2009 368
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
In-Shelter Isolation
Biohazard warning:
This House Has been
self quarantined
until further notice
Please keep Clear by 20 feet
QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER
6/2/2009 369
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
International Quarantine
Recommendations
• Quarantine is a net not a shield
• Enhance communication strategies
• Use traveller data to inform syndromic definitions
• Create port risk assessment tool
• Identify essential key partners for training
– Border Services
– Cruise Lines and Airlines
– Cargo Ships
• Establish International Quarantine Working Group
QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER
6/2/2009 370
Medical Management of Biological Casualties
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Influenza A(H1N1)
Irish Travel Advisory May 23 2009
6/2/2009 371

Public Health Management for Contacts of
Probable or Confirmed Case of Influenza A
(H1N1) on a Aircraft (Update June 2 2009)
6/2/2009 372

Influenza A(H1N1)
Management OF Passengers Or Crew Members With
Symptoms Of Influenza
• Minimize the number of personnel directly exposed to the ill person
Separate the ill person (6 feet) from others as much as possible without
compromising flight safety
• Have the ill person wear a facemask, if it can be tolerated, to reduce the
number of droplets coughed or sneezed into the air
• If a facemask can not be tolerated, provide tissues and ask the ill person to
cover his or her mouth and nose when coughing or sneezing along with a
plastic bag for proper disposal of contaminated tissues
• Gloves are not intended to replace proper hand hygiene. Gloves should be
carefully removed and discarded and hands should be cleaned
immediately following activities involving contact with body fluids. Gloves
should not be washed or reused
• Personnel having close contact with an ill person should wear a facemask
at a minimum or, ideally, a NIOSH-certified particulate respirator rated N-
95 or better Leaflets warning
passengers of possible
• Dispose of soiled material, gloves, items contaminated with body fluids,
and disposable respirators in a sturdy plastic bag that is tied shut and not swine flu symptoms
reopened, and disposed of according to state solid waste regulations
6/2/2009 373
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Irish Port Health Travel Alert Resources
• 29 April, 2009, notices were put in place at
Irish ports and airports
6/2/2009 374
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Risk Travel Advisories
• HSE guidance for aircraft
cleaning when swine
influenza (Influenza A
(H1N1) is suspected in a
passenger or crew member
Chinese health workers in protective outfits examine passengers
onboard an AeroMexico flight AM 98 that landed at Pudong
international airport in Shanghai from Mexico Thursday, April 30, 2009
1-3 Pages
6/2/2009 375
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Irish Embassy in México
• Embassy • Ambassador
His Excellency Dermot Brangan
Travel Advisory
• Address: First Secretary Security Status
Embassy of Ireland Sarah Mangan May 18 2009
Secretary
Cda. Blvd. Avila Camacho, 76-3
Myles Doherty
Col. Lomas de Chapultepec Honorary Consulate
11000 Mexico D.F. • Address:
Mexico Honorary Consulate of Ireland
Telephone: Av. Coba 15
Mza.8
+52 55 5520 5803 SM22
Fax: Cancún
Security Status
+ (52 55) 55 20 58 92 77500 Quintana Roo May 23 2009
Telephone: Exercise Caution
Email: +52 998 112 5436
Submit your query here Fax:
Website: +52 998 884 9940
www.irishembassy.com.mx Email:
consul@gruporoyale.com
Honorary Consul:
Anthony Leeman
6/2/2009 376

Influenza A(H1N1)
Advice for Travellers to Ireland Update
6/2/2009 377

Influenza A(H1N1)
Passenger Health Questionnaire
6/2/2009 378
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Aircraft Cleaning Guidance
6/2/2009 379
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Cabin Air Quality –
Risk of Contagious Viruses
Suspected SARS
Passenger coming
into Frankfurt
Airport
6/2/2009 380
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Ship Cleaning Guidance
6/2/2009 381
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

EU SHIPSAN TRAINET
• EU SHIPSAN TRAINET project which started in 2008 and will be completed
in May 2011
• This project foresees the development of:
a) Harmonised communicable diseases surveillance including ILI syndrome
by using standardised reporting forms
b) A manual providing hygiene standards (e.g. for disinfection and
cleaning), and outbreak management guidelines for airborne diseases
c) Training of port health personnel and crew members on hygiene issues
and outbreak management
d) A communication network for collection and sharing of surveillance and
ship inspection data among competent authorities
• Eurosurveillance, Volume 14, Issue 21, 28 May 2009
• Perspectives
• Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET
project communication
6/2/2009 382

Influenza A(H1N1)
Surveillance
• A quarantine officer monitors passengers
walking through a temperature screening
checkpoint at Suvarnabhumi airport in
Bangkok on April 24
Thermal Scanning
6/2/2009 383
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Surveillance
• Monitor ... a thermal camera monitors the
body temperature of passengers to identify
possible swine flu infections at Incheon
International Airport, South Korea / AP
6/2/2009 384
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Surveillance Around the World
• A passenger goes through a disinfection process at the
arrival terminal at the Juanda airport in Surabaya, in
Indonesia's East Java province April 27, 2009
6/2/2009 385
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Travel Advisories
6/2/2009 386
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

What are the differences between
Influenza A (H1N1) and the Common cold?
Symptoms Influenza A(H1N1) Common Cold
Onset Suddenly Slowly
Fever Characteristically High (102- Rare
104oF)
Headache Prominent Rare
General aches and pain Usual, often severe
Fatigue, weakness Can be prolonged for a number Quite mild
of weeks
Extreme exhaustion Early and prominent Never
Stuffy nose Sometimes Common
Sneezing Sometimes Usual
Sore throat Sometimes Common
Chest discomfort, cough Common, can be severe Mild to moderate, hacking
cough
Diarrhoea, vomiting Unknown but probably quite Not associated with the
common common cold in adults
6/2/2009 387
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Personal Steps To Take
If you Experience Flu-like Symptoms
6/2/2009 388

Influenza A (H1N1)
Adult Emergency Warning Signs for Re-consult
• 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
6/2/2009 389
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A (H1N1)
Children Emergency Warning Signs for Re-consult
• In children emergency warning signs
that need urgent medical attention
include:
• Fast breathing or trouble breathing
• Bluish skin colour
• 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
6/2/2009 390
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A (H1N1) in Educational
Institutions/Schools
6/2/2009 391

Influenza A(H1N1)
Ambulatory Care Clinics
• In elective ambulatory care clinics (e.g. physiotherapy clinics, Well Baby and Well
Woman clinics, outpatient follow-up clinics), where patients present for
appointments:
• It is suggested that clinic visits for patients who are ill with ILI symptoms be
deferred until they are well.
• This may be facilitated by reminder calls to patients to reschedule their
appointments if they have ILI and by signage at the entrance to the clinic
reminding patients to not attend clinic and to reschedule for when their
symptoms have resolved.
• The Well Women Centre
• 67, Pembroke Road,Ballsbridge, Dublin 4. (near Jury's Hotel)
Tuesday / Wednesday 10.00 am - 7.30 pm
Monday / Thursday / Friday 8.00 am - 7.30 pm
Saturdays 10.00 am - 4.00 pm
Tel: (01) 660 9860 / 668 1108 / 6683714
Fax: (01) ) 660 3062
• info@wellwomancentre.ie
6/2/2009 392

Influenza A(H1N1)
Breastfeeding Mothers
• The risk for influenza A (H1N1)
transmission through breast milk is
unknown
– However, reports of viremia with seasonal
influenza infection are rare
• Suspected or confirmed ill mothers
– Should continue breastfeeding and
increase feeding frequency
• Rational:
– Infants who are not breastfeeding are
particularly vulnerable to infection and
hospitalization for severe respiratory
illness
• Mothers should wear a mask!
• Mask not tolerated, have tissues available
6/2/2009 393

Influenza A(H1N1)
Infection Control for Parents
• Instruct parent and caretakers on how to protect their infant from
the spread of germs that cause respiratory illnesses like influenza A
(H1N1):
• Wash adults’ and infants’ hands frequently with soap and water,
especially after infants place their hands in their mouths
• Keep infants and mothers as close together as possible and
encourage early and frequent skin-to-skin contact between mothers
and their infants
• Limit sharing of toys and other items that have been in infants'
mouths. Wash thoroughly with soap and water any items that have
been in infants' mouths
• Keep pacifiers (including the pacifier ring/handle) and other items
out of adults' or other infants' mouths prior to giving to the infant
• Practice cough and sneeze etiquette
6/2/2009 394

Influenza A (H1N1)
HPSC On Personal Resources
• Women who are Pregnant or Breastfeeding:
http://www.hpsc.ie/hpsc/A-
Z/EmergencyPlanning/AvianPandemicI
nfluenza/SwineInfluenza/Adviceforthe
GeneralPublic/File,3732,en.pdf
6/2/2009 395

Influenza A(H1N1)
Personal Prevention HSE Leaflet
http://www.hpsc.ie/hpsc/A-
Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/Educationaland
6/2/2009 396
Childcaresettings/File,3653,en.pdf Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Personal Prevention
• 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
– Eat nutritious food
• Try not touch surfaces that may be contaminated
with the flu virus
• Avoid close contact with people who are sick.
6/2/2009 397
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Personal Prevention From Spreading the Virus
Preventing the spread of Swine
Influenza includes:
• If you are sick, limit your contact with other
people as much as possible
• Do not go to work or school if ill
• Cover your mouth and nose with a tissue
when coughing or sneezing
• I t 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 tissue. Then, clean your hands, and
do so every time you cough or sneeze
6/2/2009 398
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Personal Prevention From Spreading the Virus
• Washing your hands often will help protect you
from germs
• Wash with soap and water or clean with alcohol-
based hand cleaner
• We recommend that when you wash your hands --
with soap and warm water -- that you wash for 15
to 30 seconds
• When soap and water are not available, alcohol-
based disposable hand wipes or gel sanitizers may
be used
• You can find them in most supermarkets and
drugstores
• If using gel, rub your hands until the gel is dry.
– The gel doesn't need water to work; the alcohol in
it kills the germs on your hands
6/2/2009 399
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Correct Hand-washing Protocol
1st step: 2nd step: 3rd step:
Palm to palm Palm of right hand over Palm to palm with
Attention: including back of left hand and palm fingers
wrists (30 sec). of left hand over back of Interlaced(30 sec).
right hand(30 sec).
4th step: 5th step: 6th step:
Back of fingers to Rotational rubbing o fright Rotational rubbing, backwards
opposing palms with thumb clasped in left palm and forwards with clasped
fingers interlocked(30 and vice versa (30 sec). fingers of right hand in left
sec). palm and vice versa (30 sec).
6/2/2009 400
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Personal Prevention From Spreading the Virus
• Alcohol-based disposable hand wipes or gel
sanitizers may be used
6/2/2009 401
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Personal Prevention From Spreading the Virus
• Cover your mouth and nose with a tissue when
coughing or sneezing
• No Tissue
6/2/2009 402
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza has a 72% attack rate in exposed
persons
in a 4.5 hour plane flight
Communicability is highest 1-2 days
before to 4-5 days after onset
REMEMBER – SOCIAL
DISTANCING IS 6 FEET!
6/2/2009 403
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Personal Prevention From Spreading the Virus
• Respiratory
Etiquette/ Cough
Etiquette
Breaking the Chain
of Infection
6/2/2009 404

Information Leaflet on
Influenza A (H1N1)
• The HSE has produced an
information leaflet for the
public on A(H1N1) 'swine'
Flu and Pandemic Flu.
• Contains Hotline!
• The Flu Information Line is
available 24 hours a day and
is your primary source of
information on Influenza 1-8 pages
A(H1N1). Will be Distributed throughout
• Freephone 1800 94 11 00 Ireland
6/2/2009 405
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A (H1N1)
Personal Resources
• People with specific medical conditions:
6/2/2009 406

Influenza A (H1N1)
Personal Resources
• People with HIV AIDS:
6/2/2009 407

European Union
Hand Hygiene Campaigns
6/2/2009 408
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Internet Address of National
Campaigns
6/2/2009 409
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Many Countries Worldwide
Are Committed To Improve Hand Hygiene
You are part
of a global
movement!
Countries committed in 2005, 2006, 2007 and 2008
Current status, March 2009 Countries planning to commit in 2009
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A (H1N1)
UK Mass Media Video
Swine Flu Information - NHS 24
http://www.nhs24.com/content/default.asp?
page=home_SwineFlu
6/2/2009 411

Influenza A(H1N1)
Business Continuity
• An outbreak of swine flu dampened tentative
hopes for the global economy, sending markets
lower on Monday and analysts fear a possible
pandemic could force countries further into
recession.
• The World Bank estimated in 2008 that a flu
pandemic could cost $3 trillion and result in a
nearly 5 percent drop in world gross domestic
product, damaging prospects of recovery in a
world economy deep in financial crisis.
6/2/2009 412
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Business Continuity
• Excellent resource for
Business Continuity
Planning
• Business Continuity
Planning Checklist
Responding to an
Influenza Pandemic
available inside!
6/2/2009 413
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A(H1N1)
Checklists
• Hospital Pandemic Influenza Planning Checklist
• Home Health Care Services Pandemic Influenza Planning Checklist
• Health Insurer Pandemic Influenza Planning Checklist
• Travel Industry Pandemic Influenza Planing Checklist
• Business Pandemic Influenza Planning Checklist
• Law Enforcement Pandemic influenza Planning checklist
• Child Care AND Preschool Pandemic Influenza Planning Checklist
• School District (K-12) Pandemic Influenza Planning Checklist
• Colleges And Universities Pandemic Influenza Planning Checklist
• State And Local Pandemic Influenza Planning Checklist
• CDC website for download!
6/2/2009 414

Influenza A(H1N1)
Case
!
Studies
The purpose of these case studies is to give a better
picture of the interrelationships of pandemic
preparedness and mitigation efforts in foreseeing and
managing an emerging pandemic on a global scale !
6/2/2009 415

Influenza A(H1N1)
Overview of
Case Studies from Spain and England
Added feature
“How do they do it!”
Estimation of the Reproduction Ratio
for influenza A(H1N1) in Mexico
Overview of Euro Surveillance Articles
By
Michael Fraser RN
Of
Irish First Point
Responder Institute
“Republic of Ireland”
02/06/2009 416

Influenza A(H1N1)
Case Studies Objectives
• Review Spain's Case Study
• Review England's case Study
• Review preliminary estimation of the
reproduction ratio for new influenza A(H1N1)
from the outbreak in Mexico
02/06/2009 417

Influenza A(H1N1)
Spain Case Study Overview
New influenza A(H1N1) virus infections in
Spain, April-May 2009
http://www.eurosurveillance.org/ViewArticl
e.aspx?ArticleId=19209
Overview of Euro Surveillance Articles
By
Michael Fraser RN
Of
Irish First Point
Responder Institute
“Republic of Ireland”
02/06/2009 418

Influenza A(H1N1)
Spain Surveillance Teams
• Coordinating Centre for Health Alerts and
Emergencies, Spanish Ministry of Health and
Social Policy, Madrid, Spain
• National Centre for Epidemiology and National
Centre for Microbiology, Instituto de Salud
Carlos III, Madrid, Spain
• Regional Surveillance and Alert Teams from
the Autonomous Communities in Spain
• National Influenza Laboratory Network, Spain
02/06/2009 419

2009 Influenza A(H1N1)
Outbreak in Spain
• April 25 2009:
– First case: The man, aged 23, had returned from
Mexico on April 22 and had been quarantined on
the 25th
• May 17 2009
– I01 cases
• June 2 2009
– 180 cases
6/2/2009 420
Medical Management of Biological Casualties
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Influenza A(H1N1)
Spain's Outbreak Initial Timeline
02/06/2009 421

Case definition and case classification, new
influenza A(H1N1) infection, Spain, 25 April-7
May, 2009
02/06/2009 422

Influenza A(H1N1)
Spain's Confirmed Cases
• Confirmed cases of new influenza virus A(H1N1)
• As of 11 May, 98 laboratory-confirmed cases of infection with the new
influenza virus A(H1N1) have been reported in Spain out of 640 possible
cases investigated. The geographical distribution of reported cases by
region is shown in
02/06/2009 423

Spain's Geographical distribution
Confirmed Cases
• Seventy-six confirmed cases (78%) acquired the infection abroad; all these cases
had a history of travel to Mexico. Of the 45 cases for whom this information was
available, 16 (36%) were symptomatic during the inbound flight from Mexico.
Dates of return from affected areas were available for 70 confirmed cases and
ranged from 20 to 29 April
02/06/2009 424

Cases of laboratory-confirmed new
influenza virus A(H1N1) infection
• Cases of laboratory-confirmed new influenza virus A(H1N1) infection, by date of
travel return to Spain, as of 11 May, 2009 (n=70) Information on disease onset was
available for 93 cases. The first of the 93 cases reported onset of illness (any
symptom) on 19 April, and the most recent case reported onset on 4 May
02/06/2009 425

Geographical distribution
• Geographical distribution of cases of laboratory-
confirmed new influenza virus A(H1N1) infection,
Spain, as of 11 May 2009
02/06/2009 426

Influenza A(H1N1) “Spain”
Demographic and Clinical Features
• Cases ranged in age from 14 to 55 years, with an average of 24 years (standard deviation (SD)
6.3) and a median of 22; 50 (51%) cases were male.
• The most frequently reported symptoms were fever (96%) and cough (95%). Four cases did
not have fever. Among 41 cases for whom this information was available, 17 (41%) reported
diarrhoea
02/06/2009 427

Influenza A(H1N1) “Spain”
Specimens
• Nose and throat swabs from cases who met clinical and
epidemiological criteria were taken and referred to the
national influenza reference laboratory (WHO National
Influenza Centre) at the Instituto de Salud Carlos III for
confirmation
• Two independent assays have been used for diagnosis
• Reverse transcription (RT)-nested PCR designed for typing
the nucleoprotein gene and another one for subtyping the
haemagglutinin gene
• An alternative RT-PCR was done in case the first two PCR
gave contradictory results
• The strain identified in all cases was confirmed as
genetically similar to viruses previously isolated from
cases in California (A/California/04/2009
02/06/2009 428

Influenza A(H1N1) “Spain”
Discussion
• Spain was the first country in Europe to report a laboratory-
confirmed case of new influenza A(H1N1) virus
• Several factors may have contributed:
• Intense air traffic and contacts with Mexico
• Timely alert with high media coverage that raised early
awareness among public health and healthcare
professionals, as well as among the public.
• Extremely efficient surveillance system and a sensitive case
definition that was distributed early in the event made it
possible to detect cases at the very beginning of the
outbreak and to trace more than 2,000 close contacts
02/06/2009 429

Influenza A(H1N1) “Spain”
Conclusion
• Conclusion
• The evolution of this outbreak of influenza
A(H1N1) in Spain is difficult to predict. Though
notification of new confirmed cases has
decreased and the disease seems mild, they will
continue to monitor changes in the epidemiology
and/or clinical severity of new influenza A(H1N1)
virus infections in Spain in order to implement
appropriate prevention and control measures.
02/06/2009 430

References
Epidemiology of new influenza A(H1N1)
in the United Kingdom, April - May 2009
http://www.eurosurveillance.org/View
Article.aspx?ArticleId=19213
02/06/2009 431

Influenza A(H1N1)
England Case Study
Epidemiology of new influenza A(H1N1)
in the United Kingdom, April - May 2009
http://www.eurosurveillance.org/View
Article.aspx?ArticleId=19213
By
Michael Fraser RN
Of
Irish First Point
Responder Institute
“Republic of Ireland”
02/06/2009 432

Influenza A(H1N1)
England's Surveillance Teams
• Health Protection Agency and Health
Protection Scotland new influenza A(H1N1)
investigation teams:
• Health Protection Agency, London, United
Kingdom
• Health Protection Scotland, Glasgow, United
Kingdom
02/06/2009 433

Influenza A(H1N1)
United Kingdom Outbreak 2009
6/2/2009 434

HPA Swine Influenza Case Definition
9th May 2009 version 2.0
• The Health Protection Agency is using the • Epidemiological criteria
following case definition for swine flu. • At least ONE of the following:
• Clinical criteria – Onset of symptoms within seven days of visiting areas
where sustained human to human transmission of
• Any person with ONE of the following: swine influenza A/H1N1 is occurring*
• Fever *≥38°C] OR a history of fever, AND – Onset of symptoms within seven days of close contact
with a probable or confirmed case swine flu A (H1N1)
• flu-like illness (TWO O R MORE of the following virus infection.
symptoms: cough, sore throat, rhinorrhea, limb /
joint pain, headache, vomiting / diarrhoea) OR • Case classification:
• Severe / life-threatening illness suggestive of an • A. Possible case
infectious process. – Any person meeting the clinical and epidemiological
criteria
• B. Probable case
• Laboratory criteria
– Any person meeting the clinical and epidemiological
• At least ONE of the following tests: criteria AND with a positive influenza A infection which
– Specific PCR for swine influenza is untypable
– Four-fold rise in swine influenza A (H1N1) virus specific • C. Confirmed case
antibodies (acute phase sera and convalescent >10-14 – Any person with laboratory confirmation
days later)
• D. Discarded case
– Any suspect case not fulfilling the possible case
definition, a possible case that tests flu A negative or a
probable case that tests swine influenza H1N1
negative.
6/2/2009 435

Influenza A(H1N1)
England Case Study Overview
• On 27 April, the first two confirmed United
Kingdom cases of new influenza A(H1N1) virus
infection were reported in Scotland, in a
couple returning from travel to Mexico.
• Health Protection Agency (HPA) and the
Devolved Administrations strengthened
national surveillance of respiratory illness
amongst travellers returning from affected
areas
02/06/2009 436

Cases of laboratory confirmed new
influenza A(H1N1)
• Cases of laboratory confirmed new influenza
A(H1N1) by day of report and travel history, United
Kingdom, 11 May 2009 (n=65)
02/06/2009 437

Cases of laboratory confirmed new
influenza A(H1N1) by age group and sex
• Cases of laboratory confirmed new influenza
A(H1N1) by age group and sex, United
Kingdom, 11 May 2009 (n=65)
02/06/2009 438

Influenza A(H1N1)
Confirmed Travel history
• 65 cases, twenty-four reported a history of recent
travel from Mexico and five from the US
• 36 (56%) cases report no recent overseas travel
and acquired their infection through secondary
transmission in the United Kingdom
• Cases are mainly affecting 10-19 year olds
• Secondary cases are linked to transmission in
different household/close contact settings and
schools
02/06/2009 439

Influenza A(H1N1)
Clinical picture
• The First Few Hundred (FF100 project) aims to
collect information about a limited number of the
earliest laboratory confirmed cases of new
influenza A(H1N1) and their close contacts
• Purpose:
• Gain an early understanding of some of the key
clinical, epidemiological, and virological
parameters of the new influenza A(H1N1) virus
• To facilitate real-time modelling efforts to make
predictions of the future course of the United
Kingdom epidemic
02/06/2009 440

Influenza A(H1N1)
Clinical signs and Symptoms
• Signs and symptoms • Children were more likely to
include: have:
• Fever (94%), – Dry cough (83% vs. 55% OR =
5.7 95% CI: 0.97-34.2)
• Sore throat (82%) – Malaise (89% vs. 69% OR =
• Headache (81%) 8.1 95% CI 0.78-85.0)
• Chills (80%) – Epistaxis (24% vs. 6% OR = 4.9
95% CI: 0.46-52.4) than
• Malaise (80%) adults.
• Diarrhoea (28%) – Females were more likely to
• Arthralgia (56%) were vomit than males (40% vs.
11%, OR=6.7; 95% CI: 1.1-
moderately frequently 41.1) and have diarrhoea
reported. (39% vs. 14%, OR = 4.0 95%
• Epistaxis and one a seizure CI: 0.8-19.8).
(Five cases)
02/06/2009 441

Influenza A(H1N1)
England Case Study Conclusions
• United Kingdom continues to observe sporadic
importations of new influenza A(H1N1) virus from
affected areas predominately Mexico
• Healthy young adults and children are being
proportionately more affected than other parts of the
population
• Based on the limited United Kingdom case series to
date; the clinical presentation of cases continues to be
relatively mild.
• Further work is on-going to describe more fully the
emerging epidemiological, virological and clinical
characteristics of this new influenza A(H1N1).
02/06/2009 442

Estimation of the Reproduction
Ratio for influenza A(H1N1) from the
Outbreak in Mexico
“How do They do It”
Boëlle PY, Bernillon P, Desenclos JC. A preliminary
estimation of the reproduction ratio for new influenza
A(H1N1) from the outbreak in Mexico, March-April 2009.
Euro Surveill. 2009;14(19):pii=19205. Available online:
http://www.eurosurveillance.org/ViewArticle.aspx?Article
Id=19205
Overview of Euro Surveillance Articles
By
Michael Fraser RN
Of
Irish First Point
Responder Institute
“Republic of Ireland”
02/06/2009 443

Influenza A(H1N1)
México
6/2/2009 444

Influenza A(H1N1)
México
6/2/2009 445

2009 Influenza A(H1N1)
Outbreak in México
(PAHO Epi Alert)
Black=Deaths Red=Confirmed Cases
6/2/2009 446
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Influenza A (H1N1)
México Age Specific Attack Rate May 13
6/2/2009 447
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

México
• Figure shows the number of confirmed (N = 97) and probable (N = 260)*
cases of swine-origin influenza A (H1N1) virus (S-OIV) infection, by date of
illness onset, in Mexico, during March 15 to April 26, 2009.
• From March 15 through April 17, the daily number of confirmed and
probable cases combined did not exceed five cases. However, the start of
a substantial increase is indicated on April 18. This increase peaks at
approximately 55 cases on April 22 and 23, before declining to fewer than
10 cases on April 26.
6/2/2009 448

Influenza A (H1N1)
Summary of Age Specific Clinical Signs and
Fatality Rate May 20 2009
6/2/2009 449

Influenza A (H1N1)
México Age Specific Attack Rate May 20
6/2/2009 450

México's Age Specific Case Fatality
Rate
6/2/2009 451

México Current Situation
6/2/2009 452

HPA Case Study Mexico's
Hospitalization and Deaths
6/2/2009 453

Estimation of the
Reproduction Ratio in México
• Purpose:
• Sustained human-to-human transmission is
necessary to trigger influenza pandemic and
estimating the reproduction ratio (average
number of secondary cases per primary case)
is necessary for forecasting the spread of
infection and forecasting mitigation measures
02/06/2009 454

Estimation of the Reproduction Ratio
In México
• Two parameters must be estimated for this
new virus using mathematical and
computational models:
1. The reproduction ratio (R), which measures
the average number of secondary cases per
primary case
2. The generation interval, which measures the
average time between infection in a primary
case and its secondary cases
02/06/2009 455

Estimation of the Reproduction Ratio for
Influenza A (H1N1)
Methods for Estimating R
• Two different approaches were used to
estimate R:
• M1 - Intrinsic growth rate
• M2 - Real time estimation
02/06/2009 456

Methods for Estimating
Generation Interval Distribution
• The two methods require full specification of the
generation interval distribution
• As no information regarding the actual generation
interval in Mexico is available, they used three
plausible candidate values of the generation interval
(denoted GI) derived from different approaches:
• 1. (denoted as PAN) obtained from household studies
from the 1957 and 1968 pandemics
• 2. Derived from viral excretion in experimental
influenza infection (denoted as VIR)
• 3. Hypothetical distribution introduced in Elveback
(denoted ELV)
02/06/2009 457

Methods for Estimating
Generation Interval Distribution
• Their values with mean standard deviation
(SD) were the following:
• PAN = 3.1 +/- 1.9 days
• VIR = 2.6 +/- 1 day
• ELV = 4.6 +/- 1.5 days
02/06/2009 458

Estimation of the Reproduction Ratio for
influenza A(H1N1)
M1 - Intrinsic Growth Rate
• When using M1, the period starting on 9 April
and ending on 24 April yielded the best fit for
exponential growth, with daily rate r = 0.30
[CI95% 0.28-0.34]
02/06/2009 459

Estimation of the Reproduction Ratio for
Influenza A(H1N1)
M2 - Real Time Estimation
• With method M2:
• Estimates of the daily reproduction ratio R(t) in the
outbreak of new influenza A(H1N1) in Mexico, calculated
with method M2 (see Methods) using three generation
interval values: PAN GI (top), VIR GI (middle) and ELV GI
02/06/2009 460

Epidemic Growth Rates and
Reproduction Ratio Estimates
• Epidemic growth rates estimated for the new
influenza A(H1N1) epidemic in Mexico and
corresponding reproduction ratio estimates
calculated with method M1
02/06/2009 461

Results and Conclusion
• A comprehensive analysis of all available data
has independently led to the range of 1.4-1.6
• Early estimates show that the reproduction
ratio in Mexico was in a range similar to that
of past influenza pandemics of 1967-68
02/06/2009 462

Pandemic System Model
Coming soon!
Performance Improvement in
Preparing for Pandemics
6/2/2009 463

References
See Narration!
02/06/2009 464

Influenza A (H1N1)
Further information and References
• Further information: • International
http://www.hse.ie/eng/ • CDC, US
http://www.dohc.ie • PHAC
http://www.who.int/en
http://www.cdc.gov/swineflu/ • PAHO
http://ecdc.europa.eu/en/ • ECDC
• http://www.nathnac.org/pro/swinefl • HPA, UK
u.htm • WHO
• Links
•
Irish
• Health Service Executive (HSE)
• Department of Health and Children
• Department of Foreign Affairs
• Department of Agriculture
• Irish College of General Practitioners
(ICGP)
6/2/2009 465
Medical Management of Biological Casualties
Revised and Modified 29/04/2009

Disclaimer:
• The opinions expressed by authors contributing
to this PPT do not necessarily reflect the opinions
of The Irish First Point Responder Institute or the
Editorial team or the institutions with which the
authors are affiliated.
• Neither the Irish First Point Responder Institute
nor any person acting on behalf of the IFPRI is
responsible for the use which might be made of
the information in this PPT.
02/06/2009 466

The End
of
Influenza A (H1N1)
By
Michael Fraser RN
Of
Irish First Point
Responder Institute
“Republic of Ireland”
6/2/2009 467
Medical Management of Biological Casualties
Revised and Modified 29/04/2009