This document provides an outline on influenza virus including definitions, types, transmission, treatment guidelines, and the 2009 H1N1 pandemic. It discusses the virus structure and types A, B, and C. It outlines seasonal flu, pandemics, and the 2009 H1N1 outbreak in Mexico and the US. Treatment guidelines recommend antiviral medications like oseltamivir and zanamivir. It also discusses case definitions, personal protective equipment, and infection control measures.

2. Influenza Virus Definitions Introduction History Spread/Transmission Timeline/Facts Response Status Update Case-Definitions Guidelines Treatment Other Protective Measures Summary Timeline of Emergence Conclusion & Recommendations OUTLINE

3. Virus Credit: L. Stammard, 1995 ss RNA, enveloped Viral family: Orthomyxoviridae Size: 80-200nm or .08 – 0.12 μm (micron) in diameter Three types A, B, C Surface antigens H (haemaglutinin) N (neuraminidase)

5. Epidemic – a located cluster of cases Pandemic – worldwide epidemic Antigenic drift Changes in proteins by genetic point mutation & selection Ongoing and basis for change in vaccine each year Antigenic shift Changes in proteins through genetic reassortment Produces viruses not covered by annual vaccine Definitions Aaa a Aaa a

6. Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature* Hard non-porous surfaces 24-48 hours Plastic, stainless steel Recoverable for > 24 hours Transferable to hands up to 24 hours Cloth, paper & tissue Recoverable for 8-12 hours Transferable to hands 15 minutes Viable on hands <5 minutes only at high viral titers * Humidity 35-40%, Temperature 28 C (82 F) Affects of humidity on infectivity influenza, Loosli et al, 1943 Source: Bean B, et al. JID 1982;146:47-51 Aaa aa Aaa aa

7. Seasonal Influenza Globally: 250,000 to 500,000 deaths per year US (per year) ~35,000 deaths >200,000 Hospitalizations $37.5 billion economic cost (influenza & pneumonia) Pandemic Influenza An ever present threat Influenza The Normal Burden of Disease

8. Swine Influenza A(H1N1) Introduction Outbreaks of influenza among pigs Do not normally infect humans Human cases of swine flu in people around pigs Human-to-human spread documented

9. Swine Influenza A(H1N1) History in US New Jersey, USA 1976 – > 200 cases with serious illness & one death >40 million vaccinated Program stopped after 500 cases of Guillain-Barre syndrome 30 people died as a direct result of the vaccination 1988- 1 female died Dec 2005 – Feb 2009- 12 human cases

10. 2009 Swine Influenza A(H1N1) T ransmission Through Species Reassortment in Pigs NOT REPORTED IN PIGS Contains gene segments from 4 different influenza types: North American swine North American avian North American human and Eurasian swine Avian Virus Human Virus Swine Virus Avian/Human Reassorted Virus

11. Swine Influenza A(H1N1) US Response Congress asked for an additional $1.5 billion April 27, 2009- CDC travel advisory against all non-essential travel to Mexico Source: CDC

12. Swine Influenza A(H1N1) Global Response The WHO raises the alert level to Phase 6 WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3 April 27, 2009: Alert Level raised to Phase 4 April 29, 2009: Alert Level raised to Phase 5 June 11, 2008: Alert Level raised to Phase 6 (Pandemic Phase) Source: WHO

13. Pandemic Phases Phase 1-3 Preparedness Phase 5-6 Pandemic

14. 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

15. 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

16. 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

17. Clinical features Fever Myalgia Headache Cough; respiratory symptoms progress with disease Complications Primary viral pneumonia Secondary bacterial pneumonia Exacerbation of bronchial asthma

18. Case Definitions 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

19. 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: real-time RT-PCR viral culture 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. Source: CDC

20. Other definitions 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

21. High risk groups / Co-morbidities <5 yrs; Older age group  65 yr pregnancy chronic lung disease (eg., COPD, cystic fibrosis,asthma) congestive heart failure renal failure immunosuppression (due to underlying disease or therapy) haematological abnormalities (anemia, haemaglobinopathies) Diabetes mellitus Chronic hepatic disease

22. Swine Influenza A(H1N1) 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 Source: CDC

23. 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%.

24. Samples for diagnosis Respiratory specimens including: bronchoalveolar lavage, tracheal aspirates, nasopharyngeal or oropharyngeal aspirates as washes, and nasopharyngeal or oropharyngeal swabs

25. 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

26. Personal Protective Equipment Before initiating collection of sample; a full complement of PPE should be worn PPE Masks (N-95) Gloves Protective eye wear (goggles) Hair covers Boot or shoe covers Protective clothing (gown or apron )

27. Surgical masks 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

28. 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

30. 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

31. Treatment principles Early implementation of infection control Precautions to minimize spread Early identification & Prompt treatment to prevent severe disease

32. Critical Measures Avoiding crowding patients together Hand hygiene PPE Isolation for patient & close contacts

33. Anti Viral medications Resistant to Amanatidine and Rimanatidine Neuraminidase inhibitors available Oseltamivir (Tamiflu) [ Rs 2250 for ten tablets] Zanamivir (Relenza)

34. 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. Source: CDC

35. Indications of anti-virals Oseltamivir To treat cases. To be given to all suspect cases and to provide chemoprophylaxis to immediate family and social contacts .

36. 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

37. 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

38. Discharge policy Adults 7 days after symptoms subside Children 14 days after symptoms subside

39. Managing close contacts Close Contacts (suspected, probable & confirmed cases) 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.

40. Infection Control Measures Prevention of pig to human transmission Health facility measures for human cases

41. Preventing Pig to Human transmission Farmers & Veterinarians Encourage face masks Major risk factor Not using gloves when dealing with sick animals

42. Managing Human Cases Pre Hospital Care Patient 3-layer surgical mask Personnel & Driver Full PPE & mask Ambulance Sanitise Sodium hypochlorite; Quaternary ammonium compounds Avoid aerosol generating procedures

43. Hospital care Patient Isolation facility 3-layer surgical masks Personnel to use PPE Aerosol generating procedures Nebulisation, ET, Sputum, suction PPE Hand hygiene Contaminated surfaces; equipments 70% Ethanol; 5% Benzalkonium chloride; 10% sodium hypochlorite Managing Human Cases

44. Swine Influenza A(H1N1) O ther Protective Measures Isolation : sequestration of symptomatic patents either in the home or hospital so that they will not infect others Quarantine : separation from circulation in the community of asymptomatic persons that may have been exposed to infection Social-Distancing : range of non-quarantine measures that might serve to reduce contact between persons, such as, closing of schools or prohibiting large gatherings Source: CDC

45. New strain No-one vaccinated or naturally immunised Reassortment virus Vaccine distant Human to human transmission known Unlike Bird Flu Pandemic concerns

46. MOHFW- Oseltamivir chemoprophylaxis Chemoprophylaxis for health care workers at high risk Chemoprophylaxis is advised for contacts with high risk

47. MOHFW- Oseltamivir Mass Chemoprophylaxis The strategy of containment by geographic approach by giving oseltamivir to every individual in a prescribed geographic limit of 5 km from the epicenter would be applied If the virus is lethal and causing severe morbidity and high mortality and If the cluster is limited by natural geographic boundaries

48. Timeline of Emergence Influenza A Viruses in Humans 1918 1957 1968 1977 1997 1998/9 2003 H1 H1 H3 H2 H7 H5 H5 H9 Spanish Influenza H1N1 Asian Influenza H2N2 Russian Influenza Avian Influenza Hong Kong Influenza H3N2 2009 H1 Reassorted Influenza virus (Swine Flu) 1976 Swine Flu Outbreak, Ft. Dix

49. Conclusion/Recommendations At present most of the deaths due to H1N1 strain has been reported from Mexico. The disease, though spreading rapidly across the globe, is of a mild form (exception Mexico)

50. Conclusion/Recommendations “ Times-have-changed ” We are much better prepared than 1918. Better surveillance, communication, understanding of infection control, anti-virals, antibiotics and advancement in science & resources to produce an affective vaccine

51. Identified isolation facilities DELHI Yellow Fever Quarantine Centre, Near AAI Residential Colony, New Delhi [APHO- 25652129, Dr S.K Singh:09868252314] Influenza Ward, Ward no 5, Second Floor, New Building, RML Hospital, Delhi-1

52. Delhi Nodal Officer DHS Office Tel:22307145 (24X7) Dr.R.P.Vashist (09212222456)