1、Rashid A. Chotani, MD, MPH, DTM Adjunct Assistant Professor Uniformed Services University of the Health Sciences (USUHS) 240-367-5370 ,Just-in-Time Lecture Influenza A(H1N1) (Swine Flu) Pandemic (Version 12, first JIT lecture issued April 26) Tuesday, June 11, 2009 (11:30 PM EST),The Author acknowle
2、dges the efforts, hard work and diligence for hosting this lecture, web-management & translations and thanks the entire Supercourse Team, specially the followingDr. Ronald E. LaPorte, University of Pittsburgh, USA Dr. Eugene Shubnikov, Institute of Internal medicine, Novosibirsk, Russia Dr. Faina Li
3、nkov, University of Pittsburgh, USA Dr. Mita Lovalekar, University of Pittsburgh, USA Dr. Nicols Padilla Raygoza, Universidad de Guanajuato, Mxico Dr. Ali Ardalan, Tehran University of Medical Sciences, Iran Dr. Mehrdad Mohajery, Tehran University of Medical Sciences, Iran Dr. Seyed Amir Ebrahimzade
4、h, Tehran University of Medical Sciences, Iran Dr. Nasrin Rahimian, Tehran University of Medical Sciences, Iran Dr. Mohd Hasni , University of Kebangsaan, Malaysia Dr. Kawkab Shishani, The Hashemite University, Jordan Dr. Nesrine Ezzat Abdlkarim, Beirut Arab University, Lebanon Dr. Khowlah Almohaini
5、, University of Pittsburgh, USA Dr. Duc Nguyen, University of Texas, USA Dr. Elisaveta Jasna Stikova, University “Ss. Cyril and Methodius”, Skopje, Macedonia Dr. Michle Cazaubon, Secrtaire Gle de la Socit Franaise d Angiologie, France Dr. Yang Yingyun , Peking Union Medical College, China Dr. Jesse
6、Huang, Peking Union Medical College, China Shimon Weitzman, Ben Gurion University of the Negev , Israel Dr. Nurka Pranjic, Medical School University of Tuzla, Bosnia and Herzegovina Dr. Shakir Jawad, Uniformed Services University of the Health Sciences, USA Dr. Hiroya Goto, Ministry of Defense, Japa
7、n Dr. Osamu Usami, National Cancer Institute, USA Afham A. Chotani, USATruly a global effort http:/www.pitt.edu/super1/,Acknowledgement,Influenza Virus Definitions Introduction History in the US Spread/Transmission Timeline/Facts Response Status Update Mexico US Canada European Union Globally Case-D
8、efinitions Guidelines Clinicians Laboratory Workers General Population Treatment Other Protective Measures Summary Timeline of Emergence Lessons Learned from Past Pandemics Conclusion & Recommendations,OUTLINE,Credit: L. Stammard, 1995,Virus,Epidemic a located cluster of cases Pandemic worldwide epi
9、demic 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 different viruses not covered by annual vaccine,Definitions General,Source: Bean B, et al. JID 1
10、982;146:47-51,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 Viabl
11、e on hands 5 minutes only at high viral titers Potential for indirect contact transmission*Humidity 35-40%, Temperature 28C (82F),Influenza The Normal Burden of Disease,Seasonal Influenza Globally: 250,000 to 500,000 deaths per year In the US (per year) 35,000 deaths 200,000 Hospitalizations $37.5 b
12、illion in economic cost (influenza & pneumonia) $10 billion in lost productivity Pandemic Influenza An ever present threat,Swine Influenza A(H1N1) Introduction,Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pi
13、gsMost commonly, human cases of swine flu happen in people who are around pigsSwine flu viruses do not normally infect humans, however, human infections with swine flu do occur, and cases of human-to-human spread of swine flu viruses have been documented,Swine Influenza A(H1N1) History in US,A swine
14、 flu outbreak in Fort Dix, New Jersey, USA occurred in 1976 that caused more than 200 cases with serious illness in several people and one death More than 40 million people were vaccinated However, the program was stopped short after over 500 cases of Guillain-Barre syndrome, a severe paralyzing ner
15、ve disease, were reported 30 people died as a direct result of the vaccinationIn September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu and died 8 days later. From December 2005 through February 2009, a total of
16、 12 human infections with swine influenza were reported from 10 states in the United States,Swine Influenza A(H1N1) Transmission to Humans,Through contact with infected pigs or environments contaminated with swine flu virusesThrough contact with a person with swine flu Human-to-human spread of swine
17、 flu has been documented also and is thought to occur in the same way as seasonal flu, through coughing or sneezing of infected people,Swine Influenza A(H1N1) Transmission Through Species,Reassortment in Pigs,Swine Influenza A(H1N1) March 2009 Timeline,In March and early April 2009, Mexico experienc
18、ed outbreaks of respiratory illness and increased reports of patients with influenza-like illness (ILI) in several areas of the countryApril 12, the General Directorate of Epidemiology (DGE) reported an outbreak of ILI in a small community in the state of Veracruz to the Pan American Health Organiza
19、tion (PAHO) in accordance with International Health RegulationsApril 17, a case of atypical pneumonia in Oaxaca State prompted enhanced surveillance throughout MexicoApril 23, several cases of severe respiratory illness laboratory confirmed as influenza A(H1N1) virus infection were communicated to t
20、he PAHO Sequence analysis revealed that the patients were infected with the same strain detected in 2 children residing in California Samples from the Mexico outbreak match swine influenza isolates from patients in the United States,Source: CDC,Swine Influenza A(H1N1) March 2009 Facts,Virus describe
21、d as a new subtype of A/H1N1 not previously detected in swine or humansCDC determines that this virus is contagious and is spreading from human to humanThe virus contains gene segments from 4 different influenza types: North American swine North American avian North American human and Eurasian swine
22、,Swine Influenza A(H1N1) US Response,The Strategic National Stockpile (SNS) is releasing one-quarter of its Anti-viral drugs Personal protective equipment and Reparatory protection devicesPresident Obama today asked Congress for an additional $1.5 billion to fight the swine fluOn April 27, 2009, the
23、 CDC issued a travel advisory that recommends against all non-essential travel to Mexico,Source: CDC,Swine Influenza A(H1N1) Global Response,The WHO raises the alert level to Phase 6 WHOs alert system was revised after Avian influenza began to spread in 2004 Alert Level raised to Phase 3 In Late Apr
24、il 2009 WHO announced the emergence of a novel influenza A virus 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,Source: WHO,Swine Influenza A(H1N1) May 25, 2009 Status Update,MEXICO: March 01-June 09, a total o
25、f 6,241 Laboratory confirmed cases 108 deaths reported All 32 StatesUNITED STATES: March 28-June 09, a total of 13,217 Laboratory confirmed cases, 27 deaths All Sates plus District of Columbia and Puerto Rico Vast majority of cases mildCANADA: As of June 10, a total of 2,978 Laboratory confirmed cas
26、es, 4 deaths 12 of 13 States 533 new Laboratory confirmed cases June 8 Vast majority of cases mild,Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO,Swine Influenza A(H1N1) May 25, 2009 Status Update,EUROPEAN UNION & EFTA COUNTRIES: April 27- May 25, a total
27、 of 1,565 Laboratory confirmed cases no deaths 26 countries 126 confirmed cases reported on June 09 567 in-country transmissions Vast majority of cases reported between 20-49 years of ageGLOBALLY: March 1-May 25, a total of 27,737 Laboratory confirmed cases, from 74 countries 144 Deaths among labora
28、tory 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 Rep.: 01 death,Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO,Swine Influenza A(H1N1) Mexico Epidemi
29、c Curve Confirmed, by Day,Source: Secretaria de Salud, Mexico,Total Number of Confirmed Cases = 6,241*,As of June 09, 2009,*NOTE: 54 confirmed cases not included,Epidemiological Alert,School Closure,Suspension of Non-essential Activities,School Open,Swine Influenza A(H1N1) Mexico Confirmed Case Dist
30、ribution, 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,Sou
31、rce: Secretaria de Salud, Mexico,*NOTE: 43 confirmed cases not included,71.3% Deaths,Swine Influenza A(H1N1) Mexico Death, by Occupation,N=80,Swine Influenza A(H1N1) US Confirmed Cases & Deaths, by State,Source: CDC,Total Number of Confirmed Cases = 13,217; 27 Death; 50 States + District of Columbia
32、 + Puetro Rico,As of June 11, 2009 (12:30 PM ET),Swine Influenza A(H1N1) MMRW Report, April 28,MMWR, April 28, 2009 / 58(Dispatch);1-3 47 patients reported to CDC with known ages (out of 64) the median age was 16 years (range: 3-81 years) 38 (81%) were aged 18 years 51% of cases were in males Of the
33、 25 cases with known dates of illness onset, onset ranged from March 28 to April 25 Five patients hospitalized Of 14 patients with known travel histories 3 had traveled to Mexico 40 of 47 patients (85%) had not been linked to travel or to another confirmed case,Source: CDC. http:/www.cdc.gov/mmwr/pr
34、eview/mmwrhtml/mm58d0428a2.htm,MMWR, April 30, 2009 / 58(Dispatch);1-3 NYC school (high school A) 2,686 students and 228 staff members April 23-24, 222 students visited the school nursing office and left school because of illness DOHMH collect nasopharyngeal swabs from any symptomatic students April
35、 24 (Friday), DOHMH collected nasopharyngeal swabs from five newly symptomatic students identified by the school nurse and four newly symptomatic students identified at a nearby physicians office April 27, School closed DOHMH also provided nasopharyngeal test kits to selected physicians offices in t
36、he vicinity of high school A April 26, 7 of 9 specimens collected on April 24 were positive for the new strain of influenza April 26-28, 37 (88%) of 42 specimens collected tested positive, bringing the total number of confirmed cases to 44 April 27 DOHMH conducted telephone interviews with the 44 pa
37、tients Median age was 15 years (range: 14-21 years) All were students, with the exception of one student teacher aged 21 years Thirty-one (70%) of the 44 were female Thirty (68%) were non-Hispanic white; seven (16%) were Hispanic; two (5%) were non-Hispanic black; and five (11%) were other races Fou
38、r patients reported travel outside NYC within the United States in the week before symptom onset, and an additional patient traveled to Aruba in the 7 days before symptom onset. None of the 44 patients reported recent travel to California, Texas, or Mexico,Swine Influenza A(H1N1) MMRW Report, April
39、30,Source: CDC. http:/www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm,Swine Influenza A(H1N1) MMRW Report, April 30,MMWR, April 30, 2009 / 58(Dispatch);1-3 Illness onset dates ranged from April 20 to April 24 10 (23%) of the patients had illness onset on April 22, and 28 (64%) had illness onset on
40、 April 23 (Figure). Among 35 patients who reported a maximum temperature, the mean was 102.2F (39.0C) (range: 99.0-104.0F 37.2-40.0C) In total, 42 (95%) patients reported subjective fever plus cough and/or sore throat, meeting the CDC definition for influenza-like illness (ILI) At the time of interv
41、iew on April 27, 37 patients (84%) reported that their symptoms were stable or improving, three (7%) reported worsening symptoms (two of whom later reported improvement), and four (9%) reported complete resolution of symptoms Only one reported having been hospitalized for syncope and released after
42、overnight observation,Source: CDC. http:/www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm,Swine Influenza A(H1N1) Canada Confirmed Cases & Death, by Province or Territory,As of June 11, 2009 1500 (EDT),Total Number of Confirmed Cases 2,978 = ; Death = 4; 12 of 13 Provinces,Source: Public Health Age
43、ncy of Canada,Swine Influenza A(H1N1) EU & EFTA Confirmed Cases & In-Country Transmission,Total Number of Confirmed Cases = 1,565; 0 Death; 26 Countries; 567 In-Country Transmissions,April 27 - June 11, 2009 (1700 CEST),Source: ECDC,Swine Influenza A(H1N1) EU & EFTA Countries Epidemic Curve Confirme
44、d, by Day,April 27 June 11, 2009 (1700 CEST) N=1,565,Number of Confirmed Cases,Days,Source: ECDC,27 April to 8 May 2009 N=46,Source: ECDC,Swine Influenza A(H1N1) EU & EFTA Countries Confirmed Case Distribution, by Age,Laboratory-Confirmed Cases of New Influenza A(H1N1) by Countries, June 11, 2009,4,
45、27,Chinese Taipei has reported 36 confirmed cases of influenza A (H1N1) with 0 deaths. Cases from Chinese Taipei are included in the cumulative totals provided in the table above. Cumulative and new figures are subject to revision,28,774 Cases & 144 Deaths 74 Countries,108,2,1,1,1,Source: WHO,Global
46、 Distribution of Reported Cumulative Laboratory Confirmed Cases of Swine Influenza A(H1N1) by Countries, June 11, 2009 (14:00 GMT),Source: WHO,Swine Influenza A(H1N1) US Case Definitions,A confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respira
47、tory 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 A probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness who is: positive f
48、or 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 of swine influenza A (H1N1) virus infection is defined as a person with acut
49、e 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
50、A(H1N1) cases, or resides in a community where there are one or more confirmed swine influenza cases.,Source: CDC,Swine Influenza A(H1N1) US Case Definitions,Infectious period for a confirmed case of swine influenza A(H1N1) virus infection is defined as 1 day prior to the cases illness onset to 7 da
51、ys after onsetClose contact is defined as: within about 6 feet of an ill person who is a confirmed or suspected case of swine influenza A(H1N1) virus infection during the cases infectious periodAcute respiratory illness is defined as recent onset of at least two of the following: rhinorrhea or nasal congestion, sore throat, cough (with or without fever or feverishness)High-risk groups: A person who is at high-risk for complications of swine influenza A(H1N1) virus infection is defined as the same for seasonal influenza (see Reference),
