Swine Influenza A(H1N1) May 25, 2009 Status Update
GLOBALLY: March 1-May 25
27,737 Laboratory confirmed cases, from 74 countries
144 Deaths among laboratory confirmed cases from 7 countries
Mexico: 108 deaths
US: 27 deaths
Canada: 04 death
Chile: 02 deaths
Costa Rica: 01 death
Columbia: 01 death
Dominican R: 01 death
Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO
Swine Influenza A(H1N1) Mexico Confirmed Case Distribution, by Age Total Number of Confirmed Cases = 6,241* As of June 09, 2009 Source: Secretaria de Salud, Mexico *NOTE: 54 confirmed cases not included
Swine Influenza A(H1N1) Mexico Confirmed Cases & Death, by Age Groups Total Number of Confirmed Cases = 6,241* Deaths = 108 As of June 09, 2009 Source: Secretaria de Salud, Mexico *NOTE: 43 confirmed cases not included 71.3% Deaths
Cough; respiratory symptoms progress with disease
Primary viral pneumonia
Secondary bacterial pneumonia
Exacerbation of bronchial asthma
Case under Investigation
An individual after 17th of April 2009**, presenting with
a. high fever >38°C, AND
b. One or more of the following respiratory symptoms: cough, shortness of breath, body ache, difficulty in breathing, AND
c. One or more of the following: close contact with a person diagnosed as Influenza A/H1N1 OR
recent travel to an area reporting cases of confirmed Influenza A/H1N1
Swine Influenza A(H1N1) US Case Definitions
A confirmed case - a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection by one or more of the following tests:
4-fold rise in titers
A probable case - a person with an acute febrile respiratory illness who is:
positive for influenza A, but negative for H1 and H3 by influenza RT-PCR, or
positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case
A suspected case - a person with acute febrile respiratory illness 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 either within the United States or internationally 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.
Infectious period 1 day prior to the case’s illness onset to 7 days after onset.
Close contact within about 6 feet of an ill person who is a confirmed or suspected case of influenza A H1N1 virus infection during the case’s infectious period.
Acute respiratory illness recent onset of at least two of the following: rhinorrhea, sore throat, cough (with or without fever / feverishness)
High-risk groups : the same for seasonal influenza
Consider swine influenza virus infections in patients presenting with febrile respiratory illness who
live in areas where human cases of swine influenza A(H1N1) have been identified OR
have traveled to an area where human cases of swine influenza A(H1N1) has been identified OR
have been in contact with ill persons from these areas in the 7 days prior to their illness onset
Infectiousness & Incubation period
From 1-7 days; more likely 1-4 days.
More contagious than seasonal influenza.
2° attack rate of seasonal influenza 5- 15%.
2° attack rate of H1N1 22- 33%.
Samples for diagnosis
Respiratory specimens including:
bronchoalveolar lavage, tracheal aspirates,
nasopharyngeal or oropharyngeal aspirates as washes, and
nasopharyngeal or oropharyngeal swabs
When to collect samples
As soon as possible after symptoms begin (preferably first 4-5 days; 10 days- children)
Before antiviral medications administration
Even if symptoms began more than 1 wk ago
Multiple specimens on multiple days could be collected if patient access available
Personal Protective Equipment
Before initiating collection of sample; a full
complement of PPE should be worn
Protective eye wear (goggles)
Boot or shoe covers
Protective clothing (gown or apron )
High-filtration respiratory mask
Special microstructure filter disc to flush out particles bigger than 0.3 micron. • oil proof • oil resistant • not resistant to oil
The more a mask is resistant to oil, the better it is
N95 mask has 95% efficiency in filtering out particles greater than 0.3 micron under normal rate of respiration.
Next generation of masks use Nano-technology (blocking particles as small as 0.027 micron)
Types of Protective Masks
How to Store Specimens
Store specimens at 4 °C before & during transportation within 48 hours
Store specimens at -70 °C beyond 48 hours
Do not store in standard freezer – keep on ice or in refrigerator
Avoid freeze-thaw cycles
Better to keep on ice for a week than to have repeat freeze and thaw
Swine Influenza A (H1N1) Guidelines for General Population
Covering nose and mouth with a tissue when coughing or sneezing
Dispose the tissue in the trash after use.
Hand washing with soap and water
Especially after coughing or sneezing.
Cleaning hands with alcohol-based hand cleaners
Avoiding close contact with sick people
Avoiding touching eyes, nose or mouth with unwashed hands
Early implementation of infection control
Precautions to minimize spread
Early identification &
Prompt treatment to prevent severe disease
Avoiding crowding patients together
Isolation for patient & close contacts
Anti Viral medications
Resistant to Amanatidine and Rimanatidine
Neuraminidase inhibitors available
[ Rs 2250 for ten tablets]
Swine Influenza A(H1N1) Treatment
No vaccine available
Use of anti-virals
illness milder and recovery faster
Prevent serious flu complications
Work best if started soon after getting sick (within 2 days of symptoms)
Warning! Do NOT give aspirin or aspirin-containing products to children or teenagers (up to 18 years old) -- Reye’s syndrome.
Indications of anti-virals
To treat cases.
To be given to all suspect cases and to provide chemoprophylaxis to immediate family and social contacts .
Swine Influenza A(H1N1) Treatment Source: CDC Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatment dose for 5 days. <3 months: 12 mg twice daily; 3-5 months: 20 mg twice daily; 6-11 months: 25 mg twice daily Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. 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 Oseltamivir (Tamiflu) Zanamivir (Relenza) Treatment Prophylaxis Treatment Prophylaxis Adults 75 mg capsule twice per day for 5 days 75 mg capsule once per day Two 5 mg inhalations (10 mg total) twice per day Two 5 mg inhalations (10 mg total) once per day Children 15 kg or less: 60 mg per day divided into 2 doses 30 mg once per day Two 5 mg inhalations (10 mg total) twice per day (age, 7 years or older) Two 5 mg inhalations (10 mg total) once per day (age, 5 years or older) 15–23 kg: 90 mg per day divided into 2 doses 45 mg once per day 24–40 kg: 120 mg per day divided into 2 doses 60 mg once per day >40 kg: 150 mg per day divided into 2 doses 75 mg once per day
Oseltamivir side effects
Generally well tolerated
Gastrointestinal side effects (transient nausea, vomiting) with above 300 mg/day.
Bronchitis, insomnia & vertigo.
Children- most frequently vomiting.
Infrequently, abdominal pain, epistaxis, bronchitis, otitis media, dermatitis and conjunctivitis
No recommendation for dose reduction in patients with hepatic disease.
Rare - fatal neuro-psychiatric illness in children & adolescents but no scientific evidence
7 days after symptoms subside
14 days after symptoms subside
Managing close contacts
Close Contacts (suspected, probable & confirmed
Advise to remain home (voluntary home quarantine) for at least 7 days after the last contact with the case.
Monitor fever for at least 7 days.
Prompt testing and hospitalization when symptoms reported.