• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
swine flu
 

swine flu

on

  • 1,167 views

 

Statistics

Views

Total Views
1,167
Views on SlideShare
1,162
Embed Views
5

Actions

Likes
0
Downloads
73
Comments
0

2 Embeds 5

http://www.webicina.com 4
http://www.slideshare.net 1

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    swine flu swine flu Presentation Transcript

    • SWINE FLU PANDEMIC (H1N1)
    • NOMENCLATURE -
      • Some authorities object to calling the flu outbreak "swine flu".
      • H1N1 influenza virus
      • CDC - "Novel influenza A (H1N1)“
      • Pig Flu
      • Mexican flu
      • Mexican virus
      • SI, short for "swine influenza".
      • H1N1 Flu
      • New Flu
    • NOMENCLATURE -
      • North American influenza
      • WHO -"Influenza A (H1N1) virus, human
      • In July 2009 WHO - pandemic H1N1/09 virus to distinguish it from the current seasonal H1N1 viruses
    • Historical context -
      • Annual influenza epidemics -5–15% of the global population.
      • Most cases are mild
      • Severe illness in 3–5 million people
      • 250,000–500,000 deaths worldwide
    • Historical context - Pandemic Year Influenza A virus subtype People infected (approx) Deaths (est.) Case fatality rate Seasonal flu Every year mainly A/H3N2, A/H1N1, and B 5–15% (340 million – 1 billion) 250,000–500,000 per year <0.05%
    • 20th century flu pandemics - Pandemic Year Influenza A virus subtype People infected (approx) Deaths (est.) Case fatality rate 1918 flu pandemic 1918–19 H1N1 0.5 to 1 billion (near 50%) 20 to 100 million [ >2.5% Asian flu 1956–58 H2N2 2 million <0.1% ? Hong Kong flu 1968–69 H3N2 1 million <0.1%
    • 1918 - 1919 Pandemic -
      • Thought to have originated in China
      • Most devastating epidemic in recorded world history
      • Known as &quot;Spanish Flu“
      • Killed more people than the Great War
      • Most deadly for people ages 20 to 40
    • 1918 - 1919 Pandemic -
      • Infected 28% of all Americans
      • 675,000 Americans died-ten times as many as in the world war
      • Mortality rate at 2.5%
      • In India the mortality rate was extremely high at around 50 deaths from influenza per 1,000 people
    • 1918 - 1919 Pandemic -
    • Pandemic H1N1/09 virus -
      • Novel strain of influenza A
      • The strain contained genes from four different flu viruses:
      • North American swine influenza,
      • North American avian influenza,
      • Human influenza,
      • Two swine influenza viruses typically found in Asia and Europe.
      • The first full genetic sequencing of the virus on 6 May
    • Virus source and name -
      • Derived originally from a strain that lived in pigs
      • This origin gave rise to the common name of &quot;swine flu“
      • Not a food-borne illness
      • There is no risk in eating pork
    • Virus origins -
      • New York Times
      • Most likely emerged in pigs in Asia, but then traveled to North America in a human
      • Oxford University's Department of Zoology-
      • This strain has been circulating among pigs, possibly among multiple continents, for many years prior to its transmission to humans
    • Virus origins -
      • Consensus is
      • Movement of live pigs between Eurasia and North America seems to have facilitated the mixing of diverse swine influenza viruses,
      • Leading to the multiple re assortment events associated with the genesis of the (new H1N1) strain
    • Virulence -
      • Most infections continue to be mild
      • Deaths so far are &quot;a tiny fraction&quot; of people who die every year from seasonal flu
      • Medical journalists suggest that the news media may be overreacting
    • Mutation potential -
      • Both H1N1 and H5N1 are unstable so the chances of them exchanging genetic material are higher
      • Hybrid of:
      • More virulent Asian-lineage HPAI (highly pathogenic avian influenza) A/H5N1 strain (media labeled &quot;bird flu&quot;)
      • More human-transmissible Influenza A strains such as this novel 2009 swine-origin A/H1N1 strain
    • Initial outbreaks -
      • Virus first evolved around September 2008
      • Circulated in the human population for several months before the first cases were identified
    • Role Of Mexico -
      • Outbreak was first detected in Mexico City on March 18, 2009
      • Within days of the outbreak, Mexico City was &quot;effectively shut down,&quot;
      • Scientists tried to understand why there were so many deaths in Mexico while infections in the United States and Canada were relatively mild
    • Spread -
      • New strain has spread widely beyond North America
      • Initially, most cases outside North America were following recent travel to Mexico or the U.S.
    • Spread -
      • By May 15 in-country transmission had been reported
      • As of June 17 most countries within the European Union had documented in-country transmission
    • India -
      • Saturday , May 16
      • A 23 year old passenger
      • Arrived at Hyderabad from US
    • India -
    • Gujarat -
      • Ahmedabad
      • July 6 2009, Saturday
      • Thai national
    • Pandemic declared -
      • On June 11, 2009, the WHO 's Chan declared the outbreak had become a pandemic
      • Declared a Pandemic Alert Level of six
      • A move to phase 6 means that &quot;emergency plans are instantly triggered around the globe”
    • By July 2009 -
      • Northern Hemisphere-
      • The flu has been reported in more than 100 countries
      • Southern Hemisphere
      • There is a mixed picture
    • By August 2009 -
      • Areas of tropical Asia are reporting increasing rates of illness as they enter their monsoon season
      • In the northern temperate zones, overall rates are declining in both North America and Europe
      • The cases are bout to rise again with the fall of winter (WHO)
    • Epidemiological factors -
      • Host Factors-
      • Majority of cases in healthy young adults
    • Epidemiological factors -
      • Transmission-
      • The transmission is by droplet infection (coughs and sneezes) and fomites
      • Communicability-
      • From 1 day before to 7 days after the onset of symptoms.
      • Children may spread the virus for a longer period.
    • Immunity -
      • Pseudo-pandemic of 1947
      • 1976 swine flu outbreak by the
      • 1977 Russian flu H1N1
      • People who have contracted flu prior to 1957 may have some immunity
      • That does not mean that everyone over 52 is immune
    • Clinical Features –
      • WHO guidelines, August 20 2009
    • Clinical Features – Uncomplicated influenza
      • Influenza‐like illness symptoms :
      • Fever
      • Cough
      • Sore throat
      • Rhinorrhea
      • Headache
      • Muscle pain
      • Malaise
      • No shortness of breath, No dyspnoea
    • Clinical Features – Uncomplicated influenza
      • Gastrointestinal illness  may also be present
      • Diarrhoea 
      • Vomiting
      •   Especially in children, but without evidence of dehydration. 
    • Clinical Features – Complicated or Severe Influenza
      • Clinically (shortness of breath, dyspnoea,  tachypnea, hypoxia) 
      •  
      • Radiological signs of lower respiratory tract  disease (e.g. pneumonia)
      • CNS findings (e.g. encephalopathy)
      • Severe dehydration
    • Clinical Features – Complicated or Severe Influenza
      • Presenting secondary complications:
      • renal failure
      • multi‐organ failure
      • septic shock.
      • Other complications
      • musculoskeletal (rhabdomyolysis) 
      • cardiac (myocarditis).  
    • Clinical Features – Complicated or Severe Influenza
      • Exacerbation of underlying chronic disease
      • Asthma
      • chronic obstructive pulmonary disease
      • chronic hepatic or renal failure
      • Diabetes 
      • other cardiovascular conditions. 
    • Clinical Features – Complicated or Severe Influenza
      • Any other condition or clinical presentation requiring hospital admission for clinical  management. 
    • Clinical Features - Progressive disease
      • Symptoms and signs suggesting oxygen impairment or cardiopulmonary insufficiency: 
      • Shortness of breath (with activity or at rest)
      • Turning blue
      • Bloody or coloured sputum
      • Chest pain
      • Low blood pressure
      • In children, fast or laboured breathing. 
      • Hypoxia as indicated by pulse oximetry 
    • Clinical Features - Progressive disease
      • Symptoms and signs suggesting CNS complications:
      • Altered mental status
      • Unconscious
      • Drowsiness
      • Difficult to awaken
      • Recurring or persistent convulsions
      • Confusion
      • Severe weakness or paralysis. 
    • Clinical Features - Progressive disease
      • Severe dehydration: 
      • decreased activity
      • Dizziness
      • decreased urine output
      • lethargy.
    • Clinical Features - Progressive disease
      • Evidence of sustained virus replication or  invasive secondary bacterial infection: 
      • (based on laboratory testing or clinical signs)
      • e.g. persistent high fever and other  symptoms beyond three days
    • Pneumonia -
      • Virus can cause pneumonia leading to death
      • Rapid onset, often within one day after infection
      • Attributed to &quot; cytokine storm “
      • Deaths among healthy young people during the first weeks of the 2009 flu pandemic were attributed to this cause
    • Deaths – India
      • Till August 21, 2009 (52)
      • Till August 24, 2009 (61)
      • The first death was a 14-year-old girl
      • First death in Ahmedabad was a 43-year-old man
    • Cases As of August 21 – Gujarat
      • 512 suspected cases- 82 have tested positive
      • 51 cases have been reported from Ahmedabad
      • 13 from Surat
      • 8 from Vadodara
      • 5 from Rajkot
      • 2 each from Gandhinagar and Bhavnagar
      • 1 from Daman and Jamnagar
    • Cases As of August 24 – Gujarat
      • 91(593) patients have tested positive
      • 6 casualties.
      • 56 cases was reported from Ahmedabad
      • Surat 14
      • Vadodara 9
      • Rajkot 6
      • Bhavnagar 2
      • one each from Kandla, Gandhinagar, Daman and Jamnagar,&quot;
    • Infection among animals -
      • Swine:
      • Before being transmitted to humans, the viruses have circulated in swine
      • which has allowed for the undetected persistence and evolution of this potentially pandemic strain for many years.
      • Birds:
      • In late August, the government of Chile discovered that the swine flu virus had jumped to birds
    • Laboratory Diagnosis –
      • (WHO guidelines 21 August 2009)
    • Laboratory Diagnosis –
      • All un-subtypable influenza A specimens are strongly recommended to be sent
      • immediately to one of the five WHO collaborating Centres for influenza for
      • diagnosis and further characterization.
    • Specimens -
      • Samples should be taken from
      • deep nostrils (nasal swab)
      • nasopharynx(nasopharyngeal swab)
      • Nasopharyngeal aspirate
      • throat or bronchial aspirate
      • It is not yet known which clinical specimen gives the best diagnostic yield.
    • Specimens -
      • There is, as yet, no information on the diagnostic value of non-respiratory specimens, e.g., stool samples.
      • Acute and convalescent serum specimens should be used for the detection of rising antibody titres
    • Molecular diagnostics -
      • Method of choice for influenza A (H1N1)
      • The following gene targets are important:
      • Type A influenza matrix gene
      • Haemagglutinin gene specific for influenza A (H1N1)swl virus
      • Haemagglutinin gene specific for seasonal
      • influenza A H1/H3 and other subtypes.
    • Molecular diagnostics -
      • Basis
      • Extract viral RNA from clinical specimen
      • protocols
      • type-specific conventional and realtime PCR
      • CDC realtime RT-PCR (rRT-PCR)
      • positive
      • if results from tests using two different PCR targets
    • Molecular diagnostics -
      • Conventional PCR - QIAamp Viral RNA Mini Kit
      • Real-time PCR - TaqMan® probe
    • Virus isolation -
      • MDCK cells and egg inoculation can be used
    • Rapid tests or immunofluorescence -
      • Sensitivity and specificity of immunofluorescence tests are currently unknown
      • These tests will not differentiate seasonal influenza from influenza A (H1N1)swl virus.
    • Serology -
      • HAI
      • Microneutralization tests
      • Four-fold or greater rise in specific influenza A (H1N1)swl virus antibody titres indicates recent infection with the virus.
      • Results obtained using the H1 monoclonal antibodies in the WHO kit should not be taken as conclusive (the kit used for detection of seasonal H1 virus)
    • Biosafety -
      • Diagnostic laboratory work on clinical specimens from patients who are suspected cases of influenza A (H1N1)swl virus infection should be conducted in:
      • BSL-2
    • Case Definitions -
      • Directorate General of Health Services
      • Ministry of Health and Family Welfare
      • Government of India
      • 30.04.09
    • Case Definition – suspected case
      • Person with acute febrile respiratory illness (fever ≥ 38.0 C) with onset.:
      • Within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection, or
      • Within 7 days of travel to community where there are one or more confirmed swine influenza A(H1N1) cases, or
      • Resides in a community where there are one or more confirmed swine influenza cases.
    • Case Definition – probable case
      • person with an acute febrile respiratory illness who:
      • Is positive for influenza A, but unsubtypable for H1 and H3 by influenza RT-PCR or reagents used to detect seasonal influenza virus infection, or
      • Is positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case
      • Individual with a clinically compatible illness who died of an unexplained acute respiratory –illness who is considered to be epidemiologically linked to a probable
    • Case Definition – confirmed case
      • person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at WHO approved laboratories by one or more of the following tests:
      • Real Time PCR
      • viral culture
      • Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies.
    • Stratification of patients -
      • Ministry of H&FW 14 th August 2009
    • Stratification of patients - (Ministry of H&FW 14 th August 2009)
      • Category A –
      • Mild fever plus cough / sore throat with or without bodyache, headche, diarrhoea and vomitting
      • No testing for H1N1
      • No Oseltamivir
      • Only symptomatic treatment
      • Stay confine to home
    • Stratification of patients - (Ministry of H&FW 14 th August 2009)
      • Category B –
      • i. Above signs and symptoms plus
      • High grade fever and severe sore throat
    • Stratification of patients - (Ministry of H&FW 14 th August 2009)
      • Category B –
      • Addition of above sypmtoms and signs plus
      • one or more of the following conditions:
      • Children less than 5 years
      • Pregnant women
      • Age above 65 years
      • Having lung dz, heart dz, liver dz, kidney dz, blood disorders, diabetes, neurological disorders, cancer and HIV
      • Long term cortisone
    • Stratification of patients - (Ministry of H&FW 14 th August 2009)
      • For i. and ii. Both…..
      • Home treatment
      • Oseltamivir given
      • No tests for H1N1
      • Confine to home
    • Stratification of patients - (Ministry of H&FW 14 th August 2009)
      • Category C –
      • In addition to symptoms and signs of A and B if patients have one or more of the following:
      • Breathlessness, chest pain, drowsiness, low BP, sputum mixed with blood, bluish discolouration
      • Irritability among small children, refusal to accept feeds
      • Worsening of underlying chronic conditions
    • Stratification of patients - (Ministry of H&FW 14 th August 2009)
      • Immediate admission
      • Require testing for H1N1
      • Oseltamivir treatment
    • Management of H1N1 – (Ministry of H&FW guidelines)
      • Infrastructure support:
      • Isolation facilities
      • Beds kept one metre apart.
      • Dedicated doctors, nurses and paramedical workers.
      • Portable X Ray machine, ventilators, large oxygen cylinders, pulse oxymeter
      • Adequate quantities of PPE, disinfectants and medications
    • Pharmacological Management –
      • WHO guidelines 20 August 2009
    • Pharmacological Management – (WHO guidelines 20 August 2009)
      • Work by deactivating an enzyme the virus needs to grow and spread
      • To be most useful, they must be taken within 2 days of showing symptoms
      • Be given to particularly vulnerable people
    • Pharmacological Management – (WHO guidelines 20 August 2009)
      • Healthy people who catch mild to moderate cases of swine flu don't need the drug at all
      • CDC has warned that the indiscriminate use of antiviral medications to prevent and treat influenza could ease the way for drug-resistant strains to emerge
    • Antiviral susceptibilities of circulating  viruses ( June 2009 ) Oseltamivir  Zanamivir   M2 inhibitors Pandemic A(H1N1) 2009  S S R Seasonal A (H1N1)  R S S Seasonal A (H3N2)  S S R Influenza B  S S R Avian influenza (H5N1)  S S Variably resistant
    • Severe or Progressive symptoms
      • confirmed or strongly suspected
      • severe or progressive
      • antivirals are available. 
      • Treatment should be initiated as soon as possible.
      • Treated with oseltamivir
      • treated with zanamivir if
      • oseltamivir is not available
      • resistant to oseltamivir
    • Uncomplicated -
      • confirmed or strongly suspected
      • uncomplicated
      • antivirals are available. 
      • need not be treated with antivrals (Patients not in ”at risk” groups)
      • treated with oseltamivir or zanamivir
      • (Patients in ”at risk” groups)
    • Uncomplicated -
      • “ at risk” means:
      • Infants and children aged less than 5
      • elderly (>65 years)
      • nursing home residents
      • pregnant women
      • patients with chronic co‐morbid conditions
      • Immunosuppression 
    • Oseltamivir -
      • Dose (75 mg capsules) –
      • Upto 12 years:
      • Weight‐adjusted doses: 
      • - 30 mg twice daily for ≤ 15 kg 
      • - 45 mg twice daily for >15 to 23 kg 
      • - 60 mg twice daily for >23 to 40 kg 
      • - 75 mg twice daily for >40 kg 
      • ≥ 13 years:
      • - 75 mg twice daily
    • Oseltamivir -
      • Reductions in risk of pneumonia, otitis media and hospitalization 
      • in pregnant women safe
      • Safe in children < 1 year of age
    • Oseltamivir -
      • Gastrointestinal side effects
      • Bronchitis
      • Insomnia
      • Vertigo
      • Angina
      • pseudo membranous colitis
      • peritonsillar abscess
      • Rarely anaphylaxis and skin rashes
      • Rare reporting of fatal neuro-psychiatiric illness, there is no there is no
      • scientific evidence for a causal relationship
    • Oseltamivir -
      • In children
      • Most frequently- vomiting
      • Infrequently-
      • abdominal pain
      • Epistaxis
      • Bronchitis
      • otitis media
      • Dermatitis
      • conjunctivitis
    • Zanamivir – (VIRENZA, Cipla)
      • Dose (5 mg capsules) –
      • Upto 12 years:
      • ( 5- 12 years, not licensed for use in younger age groups)
      • - 10 mg (2 inhalations) twice daily
      • ≥ 13 years:
      • - 10 mg (2 inhalations) twice daily
    • Zanamivir – (VIRENZA, Cipla)
      • Inhibition of influenza virus neuraminidase
      • Hepatic disorders
      • Renal disorders
      • Pregnant safety not
      • Children established
      • Geriatric
      • Contraindicated in patients with a known hypersensitivity
    • Zanamivir – (VIRENZA, Cipla)
      •   No significant difference between zanamivir and placebo in the occurrence of complications or adverse events.
      • Avoided in pregnant, lactating and infant patients
      • Not effective in uncomplicated influenza patients without risk factors
    • Supportive therapy -
      • -IV Fluids.
      • ‐ Parentral nutrition.
      • ‐ Oxygen therapy/ ventilatory support(PaO2 <60 mmHg with oxygen therapy)
      • ‐ Antibiotics for secondary infection.
      • ‐ Vasopressors for shock.
      • ‐ Paracetamol or ibuprofen
      • -Plenty of oral fluids.
      • -topical decongestants,
      • -airway, breathing and circulation (ABC);
      • Salicylate / aspirin is strictly contra-indicated – REYE’s syndrome
    • Discharge Policy -
      • Adult patients should be discharged 7 days after symptoms have subsided.
      • Children should be discharged 14 days after symptoms have subsided.
      • The family of patients discharged earlier should be educated on personal hygiene and infection control measures at home;
      • children should not attend school during this period.
    • Oseltamivir resistant virus -
      • WHO has also been notified of 12 cases
      • 8 have been associated with post exposure prophylaxis
      • two have been from immunocompromised
      • mutation in the Neuraminidase (referred to as H275Y) that confers resistance to oseltamivir, though the viruses remain sensitive to zanamivir
    • Prevention – Personal Protection Equipment
      • • Gloves (nonsterile)
      • • Mask
      • • Long-sleeved cuffed gown
      • • Protective eyewear
      • • Cap
      • • Plastic apron
    • Respiratory Hygiene/Cough Etiquette -
      • Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing
      • Use tissues to contain respiratory secretions and dispose
      • Perform hand hygiene
    • Hand Hygiene -
      • Step 1: wash palms and fingers
      • Step 2: Wash back of hands.
      • Step 3: Wash fingers and knuckles.
      • Step 4: Wash thumbs.
      • Step 5: Wash fingertips.
      • Step 6: Wash wrists.
    • “ Close Contact&quot;
      • World Health Organization :
      • 1 m or less
      • Occupational Safety and Health Administration 6 feet or less
      • UK Health Protection Agency :
      • considers facial masks unnecessary for the general public and some experts feel it may lead to a false sense of security
    • Containment -
      • Containment is not a feasible operation
      • Did not recommend closing borders or restricting travel
      • Number of countries also advised against travel to known affected regions
    • Quarantines -
      • countries began quarantining foreign visitors suspected of having or being in contact
      • In India, after the travellers of a flight were detected positive asked the other passengers to stay home until further orders
      • Home quarantine:
      • people to be quarantined at home if they have been in close contact with someone who has swine flu
    • Pre-screening advisories by some governments
      • India 's Minister of State for Health, said
      • there should be &quot;some kind of screening&quot; for outbound travellers in the U.S., claiming that most people coming from that country have been tested positive for influenza
      • . &quot;The U.S. is the main source (of swine flu) as far as India is concerned,&quot;
    • Other measures -
      • Schools are closed now (August 10, 2009) in many cities Like Pune , Mumbai , New Delhi
      • The CDC advised sick people to stay home from work, school, or social gatherings
      • Not known to be transmissible to people through eating processed pork
    • Chemo Prophylaxis -
      • WHO guidelines 20 August 2009
    • Chemo Prophylaxis - Indications
      • Risk of human‐to‐human transmission is high or low but,
      • the likelihood of complications of infection is high 
      • Oseltamivir or Zanamivir might be used
    • Chemo Prophylaxis - Oseltamivir
      • Begin as soon as exposure identified and continue for 5‐7 days after last known exposure (minimum of two weeks)
      • Weight adjusted doses (upto 12 years)
      • - 30 mg/day for ≤ 15 kg 
      • - 45 mg/day for >15 to 23 kg 
      • - 60 mg/day for >23 to 40 kg
      • -75 mg/day for >40 kg
      • ≥ 13 years
      • 75 mg/day  
      •  
    • Chemo Prophylaxis - Zanamivir
      • Begin as soon as exposure identified and continue for 5‐7 days after last known exposure
      • (minimum of two weeks)
      • 1‐4 yrs: not used
      • ≥ 5 yrs: 10 mg (2 inhalations) once daily  
    • Chemo Prophylaxis - ContraIndications
      • If the likelihood of complications of infection is low even if :
      • “ at risk” groups
      • health care workers
      •   This recommendation applies independent of  risk of human to human transmission
    • Vaccine -
      • 1957 and 1968: vaccines arrived too late
      • 1918 without vaccine estimated 50 million people died.
      • It takes approximately five to six months for the first supplies of approved vaccine to become available once a new strain of influenza virus with pandemic potential is identified and isolated.
      • WHO does not expect the swine flu vaccine to be widely available until the end of 2009
    • Vaccine -
      • seasonal flu vaccine provides little or no protection against H1N1 swine flu
      • Reassortant vaccine virus (NIBRG‐121xp)  has been developed
      • originally developed from an A/California/7/2009(H1N1)v virus 
      • National Institute for Biological Standards and Control (NIBSC), United Kingdom.
    • Vaccine -
      • Two injections will be required three weeks apart for the swine flu
      • A third will be needed for seasonal flu to provide maximum immunity.
    • Vaccine – safety??
      • Influenza vaccines have been used for more than 60 years and have an established record of safety in all age groups
      • Though some serious adverse reactions are seen, the incidence is very low.
      • WHO is aware of some media reports that have expressed concern about the safety of vaccines for pandemic influenza.
    • Vaccine -
      • Time constraints mean that clinical data at the time when pandemic vaccines are first administered will inevitably be limited
      • For these reasons, WHO advises all countries administering pandemic vaccines to conduct intensive monitoring for safety and efficacy,
    • Global surveillance of pandemic – ( WHO guidelines)
      • Early detection, investigation and risk  assessment  
      • After detection of the pandemic virus:  description of the epidemiology and assessment of the early cases 
      • Continuous epidemiological and virological monitoring of influenza activity 
      • Analysis and publication of surveillance data by WHO 
    • Estimates of total cases -
      • Not possible:
      • Most people who have respiratory illnesses don't find out exactly what caused it. Even most people with influenza don't know exactly which type of influenza caused their illness.“
      • 12% to 24% of Americans might get swine flu this fall and winter
    • THANK YOU