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Abbas Morovvati
Outline
1-Influenza Virus 2- Swine Influenza3- Surface Proteins4-Pandemic influenza5-Influenza Pathogenesis
Influenza Virus
Influenza Highly infectious viral illness Virus was first isolated in 1933 Single-stranded RNA virus Orthomyxoviridae family 3 types A B C Subtypes of type A determined by
hemagglutinin (H) and neuraminidase (N)
Swine Influenza Type A Subtype H1N1
Type A - moderate to severe illness- all age groups potential for
epidemic- humans and other animal
Type B - milder disease- primarily affects children- humans only
Type C - rarely reported in humans- no
epidemics
Influenza Virus Surface Proteins
neuraminidase
haemagglutinin
Antigenic Drift
Gradual change in the virus with mutations and substitutions in the amino acid chain of the surface proteins(neuraminidase and haemagglutinin)
A new strain can trigger a new epidemicusually prevail for 2-5 years before next antigenic drift
Antigenic Shift
A type A influenza virus with a completely novel haemagglutinin or neuraminidase formation moves into the human species from other host species
The primary source is birds with recombination in swine or humans
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Outline
1-Influenza Virus 2- Swine Influenza3- Surface Proteins4-Pandemic influenza5-Influenza Pathogenesis
Influenza Virus
Influenza Highly infectious viral illness Virus was first isolated in 1933 Single-stranded RNA virus Orthomyxoviridae family 3 types A B C Subtypes of type A determined by
hemagglutinin (H) and neuraminidase (N)
Swine Influenza Type A Subtype H1N1
Type A - moderate to severe illness- all age groups potential for
epidemic- humans and other animal
Type B - milder disease- primarily affects children- humans only
Type C - rarely reported in humans- no
epidemics
Influenza Virus Surface Proteins
neuraminidase
haemagglutinin
Antigenic Drift
Gradual change in the virus with mutations and substitutions in the amino acid chain of the surface proteins(neuraminidase and haemagglutinin)
A new strain can trigger a new epidemicusually prevail for 2-5 years before next antigenic drift
Antigenic Shift
A type A influenza virus with a completely novel haemagglutinin or neuraminidase formation moves into the human species from other host species
The primary source is birds with recombination in swine or humans
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Influenza Virus
Influenza Highly infectious viral illness Virus was first isolated in 1933 Single-stranded RNA virus Orthomyxoviridae family 3 types A B C Subtypes of type A determined by
hemagglutinin (H) and neuraminidase (N)
Swine Influenza Type A Subtype H1N1
Type A - moderate to severe illness- all age groups potential for
epidemic- humans and other animal
Type B - milder disease- primarily affects children- humans only
Type C - rarely reported in humans- no
epidemics
Influenza Virus Surface Proteins
neuraminidase
haemagglutinin
Antigenic Drift
Gradual change in the virus with mutations and substitutions in the amino acid chain of the surface proteins(neuraminidase and haemagglutinin)
A new strain can trigger a new epidemicusually prevail for 2-5 years before next antigenic drift
Antigenic Shift
A type A influenza virus with a completely novel haemagglutinin or neuraminidase formation moves into the human species from other host species
The primary source is birds with recombination in swine or humans
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Swine Influenza Type A Subtype H1N1
Type A - moderate to severe illness- all age groups potential for
epidemic- humans and other animal
Type B - milder disease- primarily affects children- humans only
Type C - rarely reported in humans- no
epidemics
Influenza Virus Surface Proteins
neuraminidase
haemagglutinin
Antigenic Drift
Gradual change in the virus with mutations and substitutions in the amino acid chain of the surface proteins(neuraminidase and haemagglutinin)
A new strain can trigger a new epidemicusually prevail for 2-5 years before next antigenic drift
Antigenic Shift
A type A influenza virus with a completely novel haemagglutinin or neuraminidase formation moves into the human species from other host species
The primary source is birds with recombination in swine or humans
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Influenza Virus Surface Proteins
neuraminidase
haemagglutinin
Antigenic Drift
Gradual change in the virus with mutations and substitutions in the amino acid chain of the surface proteins(neuraminidase and haemagglutinin)
A new strain can trigger a new epidemicusually prevail for 2-5 years before next antigenic drift
Antigenic Shift
A type A influenza virus with a completely novel haemagglutinin or neuraminidase formation moves into the human species from other host species
The primary source is birds with recombination in swine or humans
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Antigenic Drift
Gradual change in the virus with mutations and substitutions in the amino acid chain of the surface proteins(neuraminidase and haemagglutinin)
A new strain can trigger a new epidemicusually prevail for 2-5 years before next antigenic drift
Antigenic Shift
A type A influenza virus with a completely novel haemagglutinin or neuraminidase formation moves into the human species from other host species
The primary source is birds with recombination in swine or humans
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Antigenic Shift
A type A influenza virus with a completely novel haemagglutinin or neuraminidase formation moves into the human species from other host species
The primary source is birds with recombination in swine or humans
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Pandemic influenza
The fact is that flu is one of the most formidable infections confronting humankind The virus mutates constantly as it circulates among birds pigs and humans So each new flu season brings new challenges
First pandemic known in 15th century In pandemic response and planning prediction of the
future is not possible Thought is to hope for best but plan for worst
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Recent Pandemics
1889-1890 ndash first recorded pandemic 1918 ldquoSpanishrdquo flu- 20-40 million deaths 1957 ldquoAsianrdquo flu- 1 million deaths 1968 ldquoHong Kongrdquo flu- 1 million deaths 1976 ldquoSwinerdquo flu ndash unreported deaths
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Influenza Pathogenesis
Respiratory transmission of virus Replication in respiratory
epithelium with subsequent destruction of cells
Viremia rarely documented Viral shedding in respiratory
secretions for 5-10 days
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Symptoms of influenza include
ndash Feverndash Coughndash Headachendash Myalgiandash Fatigue and weaknessndash Chest discomfortndash Nausea diarrhea with swine flu
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Risk factors for complications
Age gt 65 yearsResidence of nursing homes and other
chronic care facilitiesChronic cardiac or pulmonary
disordersChronic conditions such as diabetesLong term ASA therapy Immunosuppression
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Diagnosis
Symptoms of cough and fever has a 30ndash 40 predictive power Symptoms with surveillance (flu in
community) has a 70 - 80 predictive power
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Current Pandemic Influenza Phase (as of June 15 2009) Phase 6
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
World Health Organization Pandemic Influenza Phases (2009)
Pandemic Influenza Phase Characterization of Phase Public Health Goals
Phase 3Human infection(s) with a new subtype but no human-to-human spread or at most rare instances of spread to a close contact
Ensure rapid characterization of the new virus subtype and early detection notification and response to additional cases
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to human
Contain the new virus within limited foci or delay spread to gain time to implement preparedness measures including vaccine development
Phase 5
Larger cluster(s) but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
Maximize efforts to contain or delay spread to possibly avert a pandemic and to gain time to implement pandemic response measures
Phase 6Pandemic increased and sustained transmission in general population
Minimize the impact of the pandemic
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
How does novel H1N1 Influenzaspread
This virus is thought to spread the same way seasonal flu spreads bull Primarily through respiratory droplets bull Coughing bull Sneezing bull Touching respiratory droplets on yourself another person or an object then touching mucus membranes (eg mouth nose eyes) without washing hands
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
Persons at High Risk
Persons at increased risk of severe illness from influenza include people older than 65 years children younger than five years
pregnant women and people of any age with certain chronic medical conditions like diabetes asthma immune-suppression or
chronic lung disease See Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus
Transmission 1048698 Information on care of certain groups at increased risk of severe
illness from influenza can be found at the following links 1048698 Pregnant Women and Novel Influenza A (H1N1) Considerations for
Clinicians 1048698 H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease
and Stroke) 1048698 Interim GuidancemdashHIV-Infected Adults and Adolescents
Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus
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