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H1 N1


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Lecture by Dr. Naji Aoun, Infectious diseases specialist, Hotel Dieu, held at Le Bristol Hotel, Sept. 28, 2009 under the sponsorship of LIONS Midtown Club and Hoffmann-La Roche

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H1 N1

  1. 1. Get the Facts About Novel H1N1 Influenza
  2. 2. Novel H1N1 Influenza <ul><li>Novel H1N1 (referred to a swine flu early on) is a new influenza virus that is spreading from person-to-person. </li></ul><ul><li>The United States government has declared a public health emergency in the U.S. in response to the H1N1 outbreak. </li></ul><ul><li>CDC’s response goals are to: </li></ul><ul><ul><ul><li>reduce transmission and illness severity </li></ul></ul></ul><ul><ul><ul><li>provide information to help health care providers, public health officials, and the public address the challenges posed by this emergency. </li></ul></ul></ul>
  3. 3. Novel H1N1 Influenza <ul><li>The first cases of human infection with novel H1N1 influenza virus were detected in April 2009 in San Diego and Imperial County, California and in Guadalupe County, Texas. </li></ul><ul><li>The virus has spread rapidly. </li></ul><ul><li>The WHO has raised the level of alert as to 6 meaning that it has become a pandemic problem. </li></ul>
  4. 4. The virus <ul><li>Several types: A, B, C…. </li></ul><ul><li>Types A et B are pathogen for human race </li></ul><ul><li>The sub-types are determined by 2 membrane proteins: </li></ul><ul><ul><li>Hemaglutinine (H) </li></ul></ul><ul><ul><li>Neuraminidase (N) </li></ul></ul><ul><li>Has a high potential level for </li></ul><ul><li>mutation </li></ul>
  5. 5. Hosts and Reservoirs <ul><li>Type A: </li></ul><ul><ul><li>Exists in humans and animals </li></ul></ul><ul><ul><li>The sub types are different and distinct </li></ul></ul><ul><li>Type B et C: </li></ul><ul><ul><li>Exclusively in humans </li></ul></ul><ul><li>Reservoir in animals: </li></ul><ul><ul><li>Pigs, aquatic birds </li></ul></ul><ul><ul><li>Located in the digestive tube: fecal transmission </li></ul></ul><ul><ul><li>Several sub-types for influenza A : </li></ul></ul><ul><ul><ul><li>15 HA </li></ul></ul></ul><ul><ul><ul><li>9 NA </li></ul></ul></ul><ul><li>Reservoirs in humans : </li></ul><ul><ul><li>3 sub-types circulate H1N1, H1N2 et H3N2. </li></ul></ul><ul><ul><li>H1 has better affinity than H3 for cell receptors. </li></ul></ul>
  6. 6. Mutation properties <ul><li>Antigenic shift or punctual mutations H (and/or N) => Epidemic strain </li></ul><ul><ul><li>Acquired human immunity during previous outbreaks will selected the mutant virus. It will grow and cause a new outbreak. </li></ul></ul><ul><ul><li>Influenza B virus will mutate via this mode exclusively. </li></ul></ul><ul><li>Gene reassortment between H (and/or N) of human and animal origin => Pandemic strain </li></ul><ul><ul><li>Primum movins: simultaneous infection of a patient or animal (pig) by 2 A strains </li></ul></ul><ul><ul><li>Only concerns type A mutations </li></ul></ul>
  7. 7. Mutation properties
  8. 10. Mortality rates Mortality during the last 3 pandemic outbreaks 1918-19 1957-58 1968-69 Spanish influenza A(H1N1) Asian influenza A(H2N2)   Hong Kong Influenza A(H3N2) ≈ 30 millions death worldwide 1 million death worldwide 0,8 million death worldwide
  9. 11. Novel H1N1 Influenza <ul><li>CDC expects that more cases, more hospitalizations, and more deaths from this outbreak will occur over the coming days and months. </li></ul><ul><li>Influenza is always serious – each year in the United States, seasonal influenza results, on average, in an estimated 36,000 deaths and more than 200,000 hospitalizations from flu-related causes. </li></ul><ul><li>This outbreak certainly poses the potential to be at least as serious as seasonal flu, if not more so, especially given the fact that there currently is no vaccine against this virus. </li></ul><ul><li>Because this is a new virus, most people will not have immunity to it, and illness may be more severe and widespread as a result. </li></ul>
  10. 12. How does novel H1N1 Influenza spread? <ul><li>This virus is thought to spread the same way seasonal flu spreads: c lose contact (about 3-6 feet ) or one meter </li></ul><ul><li>Primarily through respiratory droplets </li></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Sneezing </li></ul></ul><ul><ul><li>Touching respiratory droplets on yourself, another person, or an object, then touching mucus membranes (e.g., mouth, nose, eyes) without washing hands </li></ul></ul>
  11. 13. Can you get novel H1N1 Influenza from eating pork? <ul><li>No. The novel H1N1 influenza virus (formerly referred to as swine flu) virus is not spread by food. </li></ul><ul><li>You cannot get novel H1N1 flu from eating pork or pork products. Eating properly handled and cooked pork products is safe. </li></ul>
  12. 14. How long can influenza virus remain viable on objects ? <ul><li>Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on the surface. </li></ul><ul><li>To prevent the spread of influenza virus, it is recommended that tissues and other disposable items used by an infected person be thrown in the trash. Additionally, persons should wash their hands with soap and water after touching used tissues and similar waste. </li></ul>
  13. 15. Risk from drinking water or swimming pools. <ul><li>Free chlorine levels typically used in drinking water or swimming pools treatment are adequate to inactivate highly pathogenic H5N1 avian influenza. </li></ul><ul><li>Free chlorine levels recommended by CDC (1–3 parts per million [ppm or mg/L] for pools and 2–5 ppm for spas). </li></ul><ul><li>It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination. </li></ul><ul><li>There has never been a documented case of influenza virus infection associated with water exposure . </li></ul>
  14. 16. Signs and symptoms <ul><li>Symptoms of novel H1N1 flu in people are similar to those associated with seasonal flu. </li></ul><ul><ul><li>Incubation : 1-7 days </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Sore throat </li></ul></ul><ul><ul><li>Runny or stuffy nose </li></ul></ul><ul><ul><li>Body aches </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>In addition, vomiting (25%) and diarrhea (25%) have been reported. (Higher rate than for seasonal flu.) </li></ul></ul>
  15. 17. People at higher risk of serious complications <ul><li>Include </li></ul><ul><li>People younger than 19 years of age who are receiving long-term aspirin therapy </li></ul><ul><li>people age 65 years and older, </li></ul><ul><li>children younger than 2 years old, </li></ul><ul><li>pregnant women, </li></ul><ul><li>people of any age with chronic medical conditions (such as asthma, diabetes, or heart disease …), </li></ul><ul><li>and people who are immunosuppressed (e.g., taking immunosuppressive medications, infected with HIV). </li></ul>
  16. 18. Watch for emergency warning signs <ul><li>Most people should be able to recover at home, but watch for emergency warning signs that mean you should seek immediate medical care. </li></ul><ul><li>In adults: </li></ul><ul><ul><ul><ul><li>Difficulty breathing or shortness of breath </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pain or pressure in the chest or abdomen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sudden dizziness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Confusion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Severe or persistent vomiting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flu-like symptoms improve but then return with </li></ul></ul></ul></ul><ul><ul><ul><ul><li>fever and worse cough </li></ul></ul></ul></ul>
  17. 19. Emergency warning signs in children <ul><li>If a child gets sick and experiences any of these warning signs, seek emergency medical care. </li></ul><ul><ul><li>In children: </li></ul></ul><ul><ul><li>Fast breathing or trouble breathing </li></ul></ul><ul><ul><li>Bluish or gray skin color </li></ul></ul><ul><ul><li>Not drinking enough fluids </li></ul></ul><ul><ul><li>Severe or persistent vomiting </li></ul></ul><ul><ul><li>Not waking up or not interacting </li></ul></ul><ul><ul><li>Irritable, the child does not want to be held </li></ul></ul><ul><ul><li>Flu-like symptoms improve but then return </li></ul></ul><ul><ul><li> with fever and worse cough </li></ul></ul>
  18. 20. If you get sick… <ul><li>CDC recommends that you stay home for at least 24 hours after your fever is gone , </li></ul><ul><li>whichever is longer, including </li></ul><ul><li>avoiding travel and not going to work </li></ul><ul><li> or school . </li></ul><ul><li>If you are sick, limit your contact </li></ul><ul><li>with other people as much as possible. </li></ul>
  19. 21. If you get sick… <ul><li>Your fever should be gone without the use of fever-reducing medicine. </li></ul><ul><li>If you leave the house to seek medical care, wear a facemask, if available and tolerable, and cover your coughs and sneezes with a tissue. </li></ul><ul><li>People may be contagious from one day before they develop symptoms to up to 7 days after they get sick. Children, especially younger children, might potentially be contagious for longer periods. </li></ul>
  20. 22. Case definitions <ul><li>A confirmed case of novel influenza A (H1N1) virus infection is defined as a person with an influenza-like illness ILI with laboratory confirmed novel influenza A (H1N1) virus infection by one or more of the following tests: </li></ul><ul><ul><li>real-time RT-PCR </li></ul></ul><ul><ul><li>viral culture </li></ul></ul><ul><li>A probable case of novel influenza A (H1N1) virus infection is defined as: </li></ul><ul><ul><li>a person with an influenza-like-illness who is positive for influenza A, but negative for human H1 and H3 by influenza RT-PCR </li></ul></ul>
  21. 23. Case definitions <ul><li>A suspected case of novel influenza A (H1N1) virus infection is defined as a person who does not meet the confirmed or probable case definition, and is not novel H1N1 test negative, and is/has: </li></ul><ul><ul><li>a previously healthy person < 65 years hospitalized for ILI </li></ul></ul><ul><li>OR </li></ul><ul><ul><li>ILI and resides in a state without confirmed cases, but has traveled to a state or country where there are one or more confirmed or probable cases </li></ul></ul><ul><li>OR </li></ul><ul><ul><li>ILI and has an epidemiologic link in the past 7 days to a confirmed case or probable case </li></ul></ul>
  22. 24. Recommended tests <ul><li>Real-time RT-PCR is the recommended test for confirmation of novel influenza A (H1N)1 cases via a nasopharyngeal swab. </li></ul><ul><li>Rapid influenza antigen test </li></ul><ul><li>Some commercially available rapid tests can distinguish between influenza A and B viruses. A patient with a positive rapid test for influenza A may meet criteria for a suspected case of novel influenza A (H1N1) virus infection. </li></ul>
  23. 25. Recommended tests <ul><li>However these tests have unknown sensitivity and specificity to detect human infection with novel influenza A (H1N1) virus in clinical specimens, and have suboptimal sensitivity to detect seasonal influenza viruses. </li></ul><ul><li>Compared to RT-PCR, the sensitivity of RIDTs for detecting novel influenza A (H1N1) virus infections ranged from 10-70%. </li></ul><ul><li>Therefore, a negative rapid test could be a false negative and should not be assumed a final diagnostic test for novel influenza A (H1N1) virus infection. </li></ul>
  24. 26. Algorithm to assist in the interpretation of RIDT results
  25. 27. Treatment is Available for Those Who Are Seriously III <ul><li>It is expected that most people will recover without needing medical care. </li></ul><ul><li>If you have severe illness or you are at high risk for flu complications , contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed. </li></ul><ul><li>Be aware that if the flu becomes widespread, less testing will be needed, so your health care provider may decide not to test for the flu virus. </li></ul>
  26. 28. Treatment <ul><li>Antiviral drugs can be given to treat those who become severely ill with influenza. These antiviral drugs are prescription medicines (pills, liquid or an inhaler) with activity against influenza viruses, including novel H1N1 flu virus. These medications must be prescribed by a health care professional. </li></ul>
  27. 29. Treatment <ul><li>Influenza A viruses, including two subtypes (H1N1) and (H3N2), and influenza B viruses, currently circulate worldwide, but the prevalence of each can vary among communities </li></ul><ul><li>Four prescription antiviral medications (oseltamivir, zanamivir, amantadine and rimantadine) are approved for treatment and chemoprophylaxis of influenza </li></ul>
  28. 30. Treatment <ul><li>The neuraminidase inhibitors have activity against influenza A and B viruses while the adamantanes have activity only against influenza A viruses. </li></ul><ul><li>If a patient tests negative for influenza, consider treatment options based on local influenza activity and clinical impression of the likelihood of influenza. </li></ul><ul><li>Because rapid antigen tests may have low sensitivity, treatment should still be considered during periods of high influenza activity for persons with respiratory symptoms consistent with influenza who test negative and have no alternative diagnosis </li></ul>
  29. 31. Treatment <ul><li>There are two influenza antiviral medications that are recommended for use against novel H1N1 flu. </li></ul><ul><li>Oseltamivir (trade name Tamiflu ®) and zanamivir (Relenza ®). As the novel H1N1 flu spreads, these antiviral drugs may become in short supply. </li></ul><ul><li>Therefore, the drugs may be given first to those people who have been hospitalized or are at high risk of severe illness from flu. </li></ul><ul><li>The drugs work best if given within 2 days of becoming ill, but may be given later if illness is severe or for those at a high risk for complications. </li></ul>
  30. 32. Treatment <ul><li>When treatment is indicated, health care providers generally should not wait for laboratory confirmation of influenza to begin treatment with antiviral drugs because laboratory testing can delay treatment and because a negative rapid test for influenza does not rule out influenza. The sensitivity of rapid influenza diagnostic tests can range from 10-70% for 2009 H1N1 virus. </li></ul>
  31. 33. Warning <ul><li>Aspirin or aspirin-containing products should not be administered to any confirmed or suspected ill case of novel influenza A (H1N1) virus infection aged 18 years old and younger due to the risk of Reye’s syndrome . </li></ul><ul><li>Check ingredient labels on over-the-counter cold and flu medications to see if they contain aspirin. </li></ul><ul><li>Children 5 years of age and older and teenagers with the flu can take medicines without aspirin, such as acetaminophen (Tylenol®) and ibuprofen (Advil®). </li></ul><ul><li>Children younger than 4 years of age should NOT be given over-the-counter cold medications without first speaking with a health care provider.  </li></ul>
  32. 34. What can you do to protect yourself from getting sick? <ul><li>There is no FDA approved vaccine right now to protect against this new H1N1 virus. </li></ul><ul><li>However, everyday actions can help prevent spread of germs that cause respiratory illnesses like influenza. </li></ul>
  33. 35. Take these everyday steps to protect your health <ul><li>Wash your hands often with </li></ul><ul><li>soap and warm water, </li></ul><ul><li>especially after you cough </li></ul><ul><li>or sneeze. Wash for 15 – 20 </li></ul><ul><li>seconds. </li></ul><ul><li>Alcohol-based hand </li></ul><ul><li>wipes or gel sanitizers are also </li></ul><ul><li>effective. </li></ul>
  34. 36. Take these everyday steps to protect your health <ul><li>Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it. Then wash your hands. </li></ul><ul><li>Avoid touching your eyes, nose or mouth. </li></ul><ul><li>Germs spread this way. </li></ul><ul><li>Avoid contact with sick people. </li></ul>
  35. 37. Chemoprophylaxis <ul><li>Persons who are candidates for chemoprophylaxis (e.g., residents, or persons who are at higher risk for influenza-related complications and have had recent household or other close contact with a person with laboratory confirmed influenza) should be provided with medications . </li></ul><ul><li>Duration of antiviral chemoprophylaxis post-exposure is 10 days after the last known exposure. </li></ul>
  36. 38. Should antiviral agents be used for post exposure chemoprophylaxis in healthy individuals? <ul><li>Antiviral agents are discouraged for prevention of illness in healthy children or adults based on potential exposure in community, school, camp or other settings. </li></ul><ul><li>In addition, there are no safety data regarding long term or frequent use of antiviral agents in children, and limited data for healthy adults. </li></ul>
  37. 39. Vaccination <ul><li>Vaccines prepared for the 2009--10 season will include: </li></ul><ul><ul><li>A/Brisbane/59/2007 (H1N1)-like, </li></ul></ul><ul><ul><li>A/Brisbane/10/2007 (H3N2)-like, </li></ul></ul><ul><ul><li>and B/Brisbane/60/2008-like antigens. </li></ul></ul><ul><ul><li>The influenza B virus component of the 2009--10 vaccine is from the Victoria lineage. </li></ul></ul><ul><li>These viruses will be used because they are representative of seasonal influenza viruses that are predicted to be circulating in the United States during the 2009--10 influenza season. </li></ul><ul><li>Seasonal influenza vaccines are not expected to provide substantial protection against infection with the recently identified novel influenza A (H1N1), and guidance for the prevention of infection against this virus will be published separately. </li></ul>
  38. 40. Vaccination <ul><li>All children aged 6 months--18 years should be vaccinated annually. </li></ul><ul><li>Pregnant women. </li></ul><ul><li>Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population </li></ul><ul><li>Children and adolescents at higher risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children and adolescents, including those who: </li></ul><ul><ul><li>are aged 6 months--4 years (59 months); </li></ul></ul><ul><ul><li>have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematological or metabolic disorders (including diabetes mellitus); </li></ul></ul><ul><ul><li>are immunosuppressed (caused by medications or by HIV); </li></ul></ul><ul><ul><li>are receiving long-term aspirin therapy and therefore might be at risk for experiencing Reye syndrome after influenza virus infection; </li></ul></ul><ul><ul><li>are residents of long-term care facilities; and will be pregnant during the influenza season. </li></ul></ul>
  39. 41. Vaccination <ul><li>Annual vaccination against influenza is recommended for any adult. </li></ul><ul><li>persons aged 50 years and older; </li></ul><ul><li>women who will be pregnant during the influenza season; </li></ul><ul><li>persons who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematological or metabolic disorders (including diabetes mellitus); </li></ul><ul><li>persons who have immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus; </li></ul><ul><li>residents of nursing homes and other long-term care facilities; </li></ul><ul><li>health-care personnel ; </li></ul><ul><li>household contacts and caregivers of children aged <5 years and adults aged 50 years and older, with particular emphasis on vaccinating contacts of children aged <6 months; and </li></ul><ul><li>household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza. </li></ul>
  40. 42. Swine Flu Parties <ul><li>What is CDC’s recommendation regarding &quot;swine flu parties&quot;? &quot;Swine flu parties&quot; are gatherings during which people have close contact with a person who has novel H1N1 flu in order to become infected with the virus. The intent of these parties is the hope of having natural immunity novel H1N1 flu virus that might circulate later and cause more severe disease. </li></ul><ul><li>CDC does not recommend &quot;swine flu parties&quot; as a way to protect against novel H1N1 flu in the future. While the disease seen in the current novel H1N1 flu outbreak has been mild for many people, it has been severe and even fatal for others. </li></ul><ul><li>There is no way to predict with certainty what the outcome will be for an individual. </li></ul>
  41. 43. Prevention and Control Measures in Acute-Care Facilities <ul><li>Strategies for the prevention and control of influenza in acute care facilities include the following: </li></ul><ul><li>Annual influenza vaccination of all eligible patients and health care personnel, </li></ul><ul><li>Implementation of Standard and Droplet Precautions for infected individuals, </li></ul><ul><li>Active surveillance and influenza testing for new illness cases, </li></ul><ul><li>Restriction of ill visitors and personnel, </li></ul><ul><li>Rapid administration of influenza antiviral medications for treatment and prevention during outbreaks, </li></ul><ul><li>and Respiratory Hygiene/Cough Etiquette. </li></ul>
  42. 44. Infection Control Measures <ul><li>In addition to influenza vaccination, the following infection control measures are recommended to prevent person-to-person transmission of influenza and to control influenza outbreaks in acute care facilities: </li></ul><ul><li>1. Surveillance </li></ul><ul><ul><li>Conduct active surveillance for respiratory illness and use rapid influenza testing to identify outbreaks early so that infection control measures can be promptly initiated to prevent the spread of influenza in the facility. </li></ul></ul>
  43. 45. Infection Control Measures <ul><li>2. Education </li></ul><ul><li>Educate personnel about the importance of influenza vaccination, signs and symptoms of influenza, control measures and indications for obtaining influenza testing. </li></ul><ul><li>3. Influenza Testing </li></ul><ul><li>Perform influenza testing (e.g., rapid diagnostic test, immunofluorescence) and viral cultures for influenza when clusters of respiratory illness occur or when influenza is suspected in a patient or healthcare provider. </li></ul>
  44. 46. Infection Control Measures <ul><li>4. Antiviral Chemoprophylaxis </li></ul><ul><li>Influenza antiviral chemoprophylaxis may be given to patients and healthcare personnel in accordance with current recommendations. </li></ul><ul><li>On the basis of influenza virus testing results conducted at CDC and Canada indicating high levels of resistance of influenza A virus to the adamantane class of antiviral mediations , CDC and ACIP recommend that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A. </li></ul>
  45. 47. Infection Control Measures <ul><li>4. Antiviral Chemoprophylaxis </li></ul><ul><li>Two FDA-approved influenza antiviral medications are recommended for use in the United States during the 2007-08 influenza season: oseltamivir (Tamiflu®) and zanamivir (Relenza®). </li></ul><ul><li>Oseltamivir and zanamivir are chemically related antiviral medications known as neuraminidase inhibitors that have activity against both influenza A and B viruses. </li></ul>
  46. 48. Infection Control Measures <ul><li>5. Respiratory Hygiene/Cough Etiquette </li></ul><ul><ul><li>Respiratory hygiene/cough etiquette should be implemented beginning at the first point of contact with a potentially infected person to prevent the transmission of all respiratory tract infections in acute care settings. </li></ul></ul><ul><ul><li>Respiratory hygiene/cough etiquette includes: </li></ul></ul><ul><ul><ul><li>Posting visual alerts instructing patients and persons who accompany them to inform healthcare personnel if they have symptoms of respiratory infection </li></ul></ul></ul><ul><ul><ul><li>Providing tissues or masks to patients and visitors who are coughing or sneezing so that they can cover their nose and mouth </li></ul></ul></ul><ul><ul><ul><li>Ensuring that supplies for hand washing are available where sinks are located; providing dispensers of alcohol-based hand rubs in other locations </li></ul></ul></ul><ul><ul><ul><li>Providing space for coughing persons to sit at least 3 to about 6 feet away from others, if feasible </li></ul></ul></ul>
  47. 49. Infection Control Measures <ul><li>6. Standard Precautions: </li></ul><ul><ul><li>During the care of any patient, health care personnel should adhere to Standard Precautions </li></ul></ul><ul><li>7. Droplet Precautions </li></ul><ul><ul><li>In addition to Standard Precautions, healthcare personnel should adhere to Droplet Precautions during the care of a patient with suspected or confirmed influenza for 7 days after the onset of illness </li></ul></ul><ul><li>8. Restrictions for Ill Visitors and Ill Health-care Personnel </li></ul>