SWINE FLUDr. Asad Ramlawi D.G PHC & PH Palestine

Influenza VirusH1-H16N1-N9

Types of Influenza VirusThree types: A, B, CInfluenza Type A can infect: People, birds, pigs, horses, seals, whales and others Classified into subtypes

Influenza Type B: Human virus Not classified according to SubtypeCause human epidemics but not pandemics

Influenza Type C cause mild illness in humansNot classified according to subtypeDo not cause epidemics or pandemics

Influenza Virus: Types A and B

Type A(Seasonal and avian influenza)Type B(Seasonal influenza)Can cause significant diseaseGenerally causes milder disease but may also cause severe disease Infects humans and other species (e.g., birds; H5N1)Limited to humansClassified according to subtypesNo classified according to subtypesCan cause epidemics and pandemics (worldwide epidemics)Generally causes milder epidemics

Influenza A Virus Subtyping

Influenza A subtypes are determined by two surface glycoproteins:

Hemagglutinin (HA)

Neuraminidase (NA)

16 HAs and 9 NAs

Species Infected by Influenza A, HA and NA Subtypes

Influenza: Epidemiologic SuccessThe long-term epidemiologic success of influenza viruses is primarily due to antigenic variation that takes place in the two surface glycoproteins of the virus: HA and NA.

Antigenic variation renders an individual susceptible to new strains despite previous infection by influenza viruses or previous vaccination.

Influenza Epidemiologic Success: Antigenic DriftPoint mutations in the hemagglutinin gene cause minor antigenic changes to HA.Continuous processImmunity against one strain may be limited

These genetic changes often encode amino acid changes in the surface proteins and consequently in their antigenic properties.

Antigenic drift produces new virus strains that may not be recognized by antibodies to earlier influenza strains

Influenza Epidemiologic Success: Antigenic DriftAntigenic drift is one of the main reasons why people can get the flu more than one time (Seasonal epidemics) and why the vaccine formulation has to be evaluated and modified every year.

One or two of the three virus strains included in the annual influenza vaccine are updated:

6-8 months processTargeted at high-risk (inactivated)

Influenza Epidemiologic Success: Antigenic DriftGlobal surveillance of influenza viruses has shown that antigenic variation and the consequent epidemiologic behavior of influenza A viruses follows a relatively uniform pattern.

Each successive antigenic variant replaces its predecessor such that the co-circulation of distinct antigenic variants of a given subtype occurs for relatively short periods.

During the past decade, new epidemic variants of influenza often are first detected in China before they spread to other locations.

Influenza Epidemiologic Success: Antigenic ShiftGives rise to new influenza virus that can infect humans and has (new HA subtype NA) through:

Genetic reassortment (human and animal viruses)Direct animal (poultry) to human transmission

As most people have little or no protection against the new virus:Spread easily from person to personPandemic (worldwide spread) may occur

Influenza A Viruses in SwineInfluenza viruses reported in swine:H1N1 (swine classic)H1N1 (avian and human like)H3N2 (avian and human like)

Recent Transmissions of Swine Influenza in Humans1998 at present:Triple reassortant (human, avian and swine genes)2005-2009: 12 human cases in USATriple Reassortant Swine

Recent Transmissions of Swine Influenza in HumansNovel Swine Origin Influenza A H1N1First reported:California, April 15, 2009May 16: 36 countries 8,451 cases72 deaths (0.85 %)

Recent Transmissions of Swine Influenza in HumansNovel Swine Origin Influenza A H1N1 (2009)Triple Reassortant Swine

Novel Influenza A (H1N1)CDC developed a real time RT-PCR specific for novel influenza (H1N1)

PCR set up:Univ Flu ASw Flu ASW H1RPNovel influenza A (H1N1) Diagnostic FlowchartSw H1N1Univ. Flu A = PosSw Flu A = PosSw H1 = PosRepeat reaction from extractionContact NAMRU-3 or CDCUniv. Flu A = PosSw Flu A = PosSw H1 = NegUniv. Flu A = PosSw Flu A = NegSw H1 = PosUniv. Flu A = PosSw Flu A = NegSw H1 = NegRP = PosSTOP: Flu A virusSeasonal FluSubtype specimen Preserve remnant at -70C (if not available, then -20C) Specimen: swabs in VTMNucleic Acid Extraction:140 ul specimenPCR Universal Flu ANegative: Univ. Flu A Stop: Non-Flu A virusPositive: Univ. Flu A (continue with SwH1N1 primers)

Novel Influenza A (H1N1) Surveillance ActivitiesObjectives:Detect and confirm cases of novel influenza A (H1N1) infectionsEstablish the extent of international spreadAssist in the early severity assessment of the disease.

Specimen meets criteria for rRT-PCR Swine Flu Panel testingPerform rRT-PCR Swine Flu PanelInf A (+)Universal SW InfA (+)Novel SW H1 (+)Inf A (+)UniversalSW InfA (-)NovelSW H1 (-)Inf A (-)UniversalSW InfA (-)NovelSW H1 (-)Inf A (+)UniversalSW InfA (+)NovelSW H1 (-)Inf A (+)UniversalSW InfA (-)NovelSW H1 (+)Report Results To CDC per normal surveillance protocoland send specimens to CDC according to current guidance. Flu A positive specimens negative for human H1, H3, B , and swine H1 should be reported to CDC immediately for priority testing.Subtype specimens using rRT-PCR Flu Panel IVD test or other approved methods (as resources permit and the prevalence of other circulating strains dictates)

Report results To CDC per normal surveillance protocol

Repeat results from the extraction step in house, report results to CDC per normal surveillance protocol, and send specimens to CDC according to current guidanceRepeat results from the extraction step in house, report results to CDC per normal surveillance protocol, and send specimens to CDC according to current guidanceInf A (-)U. SW InfA (+)N. SW H1 (+)Or Inf A (-)U. SW InfA (-)N. SW H1 (+)OrInf A (-)U. SW InfA (+)N. SW H1 (-)Report results to CDC per normal surveillance protocol2009 Swine Influenza Testing: Testing AlgorithmOther ResultsRepeat results from the extraction step in house, report results to CDC per normal surveillance protocol* This algorithm assumes a positive RP result

Reassortment (in Animals and Humans)Migratory birds Reassortment in SwineReassortment in humansHuman Pandemic Strain

The new virus must be efficiently transmitted from one human to another

Prerequisites for pandemic influenzaA new influenza virus emerges to which the general population has little/no immunityThe new virus must be able to replicate in humans and cause disease

Phases of pandemic influenza

Inter-pandemic periodPhase 1No new influenza virus detected in humans. If a new influenza virus presents in animals, the risk of human infection is considered to be lowPhase 2No human infections, but a circulating animal influenza virus poses a risk to humansPandemic alert periodPhase 3Human infection(s) with a new virus, but no (or very infrequent) human-to-human spread Phase 4Small cluster(s) with limited human-to-human transmission but spread is highly localizedPhase 5Larger cluster(s) but human-to-human spread still localizedPandemic periodPhase 6Increased and sustained transmission in general population

cWHO Pandemic Phasesc

Interpandemic phase"Animal influenza outbreaks"Low risk for humans1High risk for humans2Pandemic Alert

"New influenza subtype in humans"No or only inefficient h2h transmission3Evidence for increased h2h transmission4Significant increase in h2h transmission5Pandemic6

Way Forwards:TransparencyThe media are not your enemiesNeed for a positive relationshipGive early, regular, accurate and consistent informationGet messages to the public (avoid confusion and panic)Let the world know what you are doingEarlyAccurateRegularConsistentMediaHealth WorkersThe PublicGovernment

What is Swine FluSwine influenza virus (referred to as SIV) refers to influenza cases that are caused by Orthomyxovirus endemic to pig populations. SIV strains isolated to date have been classified either as Influenza(virus C or one of the various subtypes of the genus Influenza virus A)

Different Strains circulate PeriodicallyIn the United States the H1N1 subtype was exclusively prevalent among swine populations before 1998; however, since late August 1998, H3N2 subtypes have been isolated from pigs. As of 2004, H3N2 virus isolates in US swine and turkey stocks were triple reassortants, containing genes from human (HA, NA, and PB1), swine (NS, NP, and M), and avian (PB2 and PA) lineages.

Swine Influenza (Flu)

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs. Swine 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 has been documented.

Swine Flu-Present StatusFrom December 2005 through February 2009, a total of 12 human infections with swine influenza were reported from 10 states in the United States. Since March 2009, a number of confirmed human cases of a new strain of swine influenza A (H1N1) virus infection in the U.S. and internationally have been identified. An investigation into these cases is ongoing.

Swine Flu 2009In late March and early April 2009, cases of human infection with swine influenza A (H1N1) viruses were first reported in Southern California and near San Antonio, Texas. Other U.S. states have reported cases of swine flu infection in humans and cases have been reported internationally as well.

Update - Status Swine FluThe United States Government has reported seven confirmed human cases of Swine Influenza A/H1N1 in the USA (five in California and two in Texas) and nine suspect cases. All seven confirmed cases had mild Influenza-Like Illness (ILI), with only one requiring brief hospitalization. No deaths have been reported.

Swine Flu in MexicoIn the Federal District of Mexico, surveillance began picking up cases of ILI starting 18 March. The number of cases has risen steadily through April and as of 23 April there are now more than 854 cases of pneumonia from the capital. Of those, 59 have died. In San Luis Potosi, in central Mexico, 24 cases of ILI, with three deaths, have been reported.

Swine Flu and VirusSwine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza virus that regularly causes outbreaks of influenza in pigs. Swine flu viruses cause high levels of illness and low death rates in pigs. Swine influenza viruses may circulate among swine throughout the year, but most outbreaks occur during the late fall and winter months similar to outbreaks in humans. The classical swine flu virus (an influenza type A H1N1 virus) was first isolated from a pig in 1930.

Cause by Reassortment of different strainsLike all influenza viruses, swine flu viruses change constantly. Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses. When influenza viruses from different species infect pigs, the viruses can reassort (i.e. swap genes) and new viruses that are a mix of swine, human and/or avian influenza viruses can emerge

Swine Flu differs from Human FluThe H1N1 swine flu viruses are antigenically very different from human H1N1 viruses and, therefore, vaccines for human seasonal flu would not provide protection from H1N1 swine flu viruses

Out breaks among PigsOutbreaks among pigs normally occur in colder weather months (late fall and winter) and sometimes with the introduction of new pigs into susceptible herds. Studies have shown that the swine flu H1N1 is common throughout pig populations worldwide, with 25 percent of animals showing antibody evidence of infection.

Present Swine Flu strainsAt this time, there are four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. However, most of the recently isolated influenza viruses from pigs have been H1N1 viruses.

How man is exposedMost commonly, these cases occur in persons with direct exposure to pigs (e.g. children near pigs at a fair or workers in the swine industry). In addition, there have been documented cases of one person spreading swine flu to others.

How Swine Flu presents in HumansThe symptoms of swine flu in people are expected to be similar to the symptoms of regular human seasonal influenza and include fever, lethargy, lack of appetite and coughing. Some people with swine flu also have reported runny nose, sore throat, nausea, vomiting and diarrhea

Is the eating Pork infects ?No. Swine influenza viruses are not transmitted by food. You can not get swine influenza from eating pork or pork products. Eating properly handled and cooked pork and pork products is safe. Cooking pork to an internal temperature of 160F kills the swine flu virus as it does other bacteria and viruses

Close proximity with PIGS spread the InfectionsInfluenza viruses can be directly transmitted from pigs to people and from people to pigs. Human infection with flu viruses from pigs are most likely to occur when people are in close proximity to infected pigs, such as in pig barns and livestock exhibits housing pigs at fairs. Human-to-human transmission of swine flu can also occur.

How Swine flu spread among PigsSwine flu viruses are thought to be spread mostly through close contact among pigs and possibly from contaminated objects moving between infected and uninfected pigs. Herds with continuous swine flu infections and herds that are vaccinated against swine flu may have sporadic disease, or may show only mild or no symptoms of infection.

Seek emergency medical care.IF - in ChildrenIn children emergency warning signs that need urgent medical attention include: Fast breathing or trouble breathing Bluish skin color.Not drinking enough fluids Not waking up or not interacting Being so irritable that the child does not want to be held Flu-like symptoms improve but then return with fever and worse cough Fever with a rash

Adults Need attention if Present withDifficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting

DiagnosisTo diagnose swine influenza A infection, a respiratory specimen would generally need to be collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding virus). However, some persons, especially children, may shed virus for 10 days or longer. Identification as a swine flu influenza A virus

CDC helps in DiagnosisRequires sending the specimen to CDC for laboratory testing as many laboratories in Developing world do not have facilities

Drugs which are effective in Swine FluThere are four different antiviral drugs that are licensed for use in the US for the treatment of influenza: Amantidine, rimantadine, oseltamivir and zanamivir. While most swine influenza viruses have been susceptible to all four drugs

Drugs proved resistant at PresentMost recent swine influenza viruses isolated from humans are resistant to Amantidine and Rimantadine

CDC recommends at PresentCDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with swine influenza viruses

Treatment of serious cases OseltamivirReduce significantly the risk of pneumonia( leading case of death for pandemic & seasonal influenza , Reduce the need for hospitalization

Cont,,, If Oseltamivir is unavailable or cant be used , zanamavir may be given.This recommendation applies to all patient groups( pregnant women, young children, and infants). Pregnant women & patients with underlying medical conditions recommended to receive AVT as soon as possible after symptom onset.

Worldwide, around 40% of severe cases are occurring in previously health children & adults, ( < 50 yrs.) Some of these patients experience a sudden & very rapid deterioration in their clinical condition, usually day 5 or 6 following the onset of symptoms.

Clinical deterioration Primary viral pneumoniaWhich destroys the lung tissue & does not respond to antibioticsFailure of multiple organs ( heart , kidney & liver)

Clinicians, patients, and those providing home based care need to: Be alert to warning signals that indicate to more severe illness.To take urgent action which should include treatment with oseltamivirIn case of sever illness, clinicians may consider using higher doses of oseltamivir for longer duration.

AVT for children WHO recommends prompt AVT to children With severe or deteriorating illness Those at risk of more severe or complicated illness. These recommendation includes all children under the age of 5 yrs. Children older than 5yrs need NOT be given AVT unless their persist or worsense

Danger signs in children :Fast or difficult breathingLack of alertnessDifficulty in waking up Little or no desire to play.

How long can an infected person spread swine flu to others? People with swine influenza virus infection should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children, especially younger children, might potentially be contagious for longer periods.

How long can viruses live outside the body? We know that some viruses and bacteria can live 2 hours or longer on surfaces like cafeteria tables, doorknobs, and desks. Frequent hand washing will help you reduce the chance of getting contamination from these common surfaces.

No Vaccines to HumansBut available to PIGSVaccines are available to be given to pigs to prevent swine influenza. There is no vaccine to protect humans from swine flu. The seasonal influenza vaccine will likely help provide partial protection against swine H3N2, but not swine H1N1 viruses.

Avoid close contact

Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.Aerosols spread the virus in any environment

Stay home when you are sick.

If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.

Cover your mouth and nose.

Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick

Clean your hands.

Washing your hands often will help protect you from germs.Hand washing proved to be best procedure in prevention of Majority of Communicable diseases.

Avoid touching your eyes, nose or mouth.

Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

Practice other good health habits.

Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious.Unnecessary Migration of people from epidemic and endemic areas to be reduced.

Is eating Pork meat safe during Epidemics Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork products is safe.

Healthy Habits reduces the Attacks

Simple measures carry get good BenefitsCover your mouth and nose. Use a tissue when you cough or sneeze and drop it in the trash. If you dont have a tissue, cover your mouth and nose as best you can.

Clean Hands saves youClean your hands often. Clean your hands every time you cough or sneeze. Hand washing stops germs. Alcohol-based gels and wipes also work well.

Cartoonists Imagination on Swine Flu

Surveillance

Distribution of Pandemic H1N1/09 cases by Age group from first case 10/6 to 26/8 of onset of outbreak

Age group ( year) No. of cases % < 110.8 %1-4 129.8 %5-91713.8 %10-193226 %20-292520.3 %30-391512.2 %40-491613 %> 50 54.1 %Total 123100%

Distribution of Pandemic H1N1/09 cases by Sex from first case 10/6 to 26/8 of onset of outbreak

Distribution of cases by District

District No. of cases %

Hebron11 %Jenin11 %Al-Quds 1210 %Bethlehem1411 %Ramallah7561 %Nablus1714 %Tulkarm32 %Total123100%

Distribution of cases by Nationality

Nationality No. of cases %

Palestinian 10182 %Germany10.8 %USA2010.3 %Italy 10.8 %Total123100%

Distribution of Pandemic H1N1/09 Cases by Source of Infection

Source No. of cases %

Imported4839 %Local7158 %Unknown 43 %Total123100%

Distribution of Pandemic H1N1/09 cases by Place of Treatment 10/6 to 26/8

Percentage of Cases that have symptoms for Pandemic H1N1/09 from first case 10/6 to 26/8

Distribution of Pandemic H1N1/09 cases by Occupation from first case 10/6 to 26/8

*****Organise your informationKnow what you want to sayUnderstand what the media want to knowUse press releases, conferences and interviews to