Emerging and Re-emerging Infectious Diseases Epidemiology & Control mmmmm Infectious Diseases CHP400 COMMUNITY HEALTH PROGRAM-II Emerging and Re-emerging Infectious Diseases mmmmm mmmmm Novel H1N1 (Swine) Epidemiology & Control Mohamed M. B. Alnoor

Content Swine Influenza A (H1N1) Previous influenza pandemics mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Content mmmmm Previous influenza pandemics Definitions Transmission Through Species Transmission to humans Pandemic-Alert Levels and WHO Regions mmmmm The Global H1N1 Pandemic mmmmm Lessons Learned form Past Pandemics Prevention of H1N1 infection Who Should Be Vaccinated? Antiviral Protection Summary

Previous influenza pandemics mmmmm Novel H1N1 mmmmm Previous influenza pandemics mmmmm Pandemic Deaths in the US Deaths Worldwide Population Affected Spanish Flu (H1N1) 1918-1919 500,000 40 million Persons 20-40 years Asian Flu (H2N2) 1957-58 70,000 1-2 million Infants, elderly Hong Kong Flu (H3N2) 1968-69 36,000 700,000 mmmmm mmmmm

They do not normally infect humans mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Definition: mmmmm What is swine flu? Swine Influenza (swine flu) is a respiratory disease of pigs caused by Type A influenza viruses causing regular outbreaks in pigs. mmmmm mmmmm They do not normally infect humans

three people. Definition: What is swine flu? mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Definition: mmmmm What is swine flu? Swine flu viruses have been reported to spread from person-to-person but in the past this transmission was limited and not sustained beyond three people. mmmmm mmmmm

This swine influenza A (H1N1) virus mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Definition: mmmmm What is swine flu? This swine influenza A (H1N1) virus is contagious and is spreading from human to human. mmmmm mmmmm

Swine Influenza A (H1N1) Transmission Through Species mmmmm Novel H1N1 Swine Influenza A (H1N1) Transmission Through Species mmmmm mmmmm North American swine North American avian North American human Eurasian swine Avian Virus Human Virus Swine Virus Avian/Human Reassorted Virus mmmmm mmmmm Swine/ Reassortment in Pigs

Transmission to humans: mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Transmission to humans: mmmmm How does swine flu spread? Contact with: - infected pigs - contaminated environments mmmmm mmmmm - a person with swine flu Infected people may be able to infect others beginning 1 day before fever begins until 24 hours after fever ends. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick (same as seasonal flu) Sometimes people may become infected by touching something with live flu viruses on it and then touching their mouth or nose. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions Airborne(from infected people) - coughing - sneezing

Swine Influenza A (H1N1) Pandemic-Alert Levels mmmmm Novel H1N1 Swine Influenza A (H1N1) Pandemic-Alert Levels mmmmm Phase 1: Animals viruses, no humans infections. Phase 2: Virus in domesticated/wild animals, caused infection in humans: a potential pandemic threat.” Phase 3: Reassortant v: sporadic cases or small clusters in humans. Phase 4: Reassortant v:community-level outbreaks. Phase 5: There is human-to-human spread of the virus into at least two countries in one WHO region. Phase 6: Phase 5 + community-level outbreaks in at least one other country in a different WHO region. A global pandemic is occurring. mmmmm mmmmm mmmmm

WHO Regions African Region South East Asia Region mmmmm Novel H1N1 WHO Regions mmmmm mmmmm African Region South East Asia Region East Mediterranean Region Region of the Americas European Region Western Pacific Region

mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm mmmmm mmmmm mmmmm

Lessons Learned form Past Pandemics mmmmm Novel H1N1 Lessons Learned form Past Pandemics mmmmm mmmmm Pandemics are unpredictable: - Mortality - severity of illness - pattern of spread Capacity to cause severe disease in nontraditional groups is a major determinant of pandemic impact mmmmm mmmmm Epidemiology reveals waves of infection: Ages/areas not initially infected likely vulnerable in future waves Subsequent waves may be more severe

Lessons Learned form Past Pandemics mmmmm Novel H1N1 Lessons Learned form Past Pandemics mmmmm mmmmm Public health interventions delay, but do not stop pandemic spread Quarantine, travel restriction show little effect Temporary banning of public gatherings, potentially effective mmmmm mmmmm Delaying spread is desirable: Quarantine, travel restriction show little effect: Does not change population susceptibility Temporary banning of public gatherings, closing schools potentially effective in case of severe disease and high mortality Delaying spread is desirable: Fewer people ill at one time improve capacity to cope with sharp increase in need for medical care

Prevention of H1N1 INFECTION mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Prevention of H1N1 INFECTION mmmmm General prevention and control measures Tips to Reduce the Infection Respiratory hygiene and cough etiquette mmmmm mmmmm Social-Distancing

Prevention of H1N1 INFECTION mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Prevention of H1N1 INFECTION mmmmm Tips to Reduce the H1N1 Influenza Infection Use a tissue when coughing or sneezing. Frequently wash hands with warm water and soap . Try not to touch your eyes, nose or mouth . Wipe down kitchen and bathroom countertops, home and office phones, keyboards , etc If exhibiting symptoms, stay home. If coworkers or family members become ill, consider taking anti-viral medication . mmmmm mmmmm Pandemics may not be avoidable but spread of the disease and the ensuing mortality rates can be reduced. To help check the spread of the disease, the Centers for Disease Control and Prevention suggests the following guidelines: 1.Use a tissue when coughing or sneezing; dispose of the tissue immediately. 2. Frequently wash hands with warm water and soap or an alcohol-based hand cleanser. Soap and water is best. Keep nails short and pay good attention to cleaning cuticles. 3. Try not to touch your eyes, nose or mouth unless your hands are freshly washed. 4. Wipe down hard surfaces with disinfecting cleaner or use a spray. Common areas of transmission are kitchen and bathroom countertops, home and office phones, keyboards, doorknobs, shopping cart handles, and steering wheels of company or rental vehicles. 5. If exhibiting symptoms, stay home. The influenza virus is capable of being passed from the day prior to symptoms being noticed to seven days after becoming ill. Committing to voluntary isolation when ill is an effective way to help reduce the spread of the disease. 6. If coworkers or family members become ill, consult your doctor about the possibility of taking a prescription anti-viral medication such as Tamiflu or Relenza. This is especially important if you take care of children or the elderly.

vaccine Prevention of H1N1 INFECTION Swine Influenza A (H1N1) mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Prevention of H1N1 INFECTION mmmmm Specific preventive measures vaccine mmmmm mmmmm The H1N1 Inactivated Vaccine (the shot) The H1N1 Live Attenuated Vaccine (the nasal spray)

Who Should Be Vaccinated? mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Who Should Be Vaccinated? The groups recommended to receive the 2009 H1N1 influenza vaccine include: mmmmm Pregnant women Contacts and caregivers <6 months Healthcare and emergency personnel All people from 6 mo - 24 years mmmmm mmmmm Children from 6 mo - 18 years Young adults 19 - 24 years Pregnant women (higher risk of complications and take care of infants who cannot be vaccinated)Household contacts and caregivers for children younger than 6 months of age(younger infants are at higher risk of influenza-related complications and cannot be vaccinated) Healthcare and emergency medical services personnel (source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity) All people from 6 months through 24 years of age: Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, andYoung adults 19 through 24 years of age(many cases of 2009 H1N1 influenza were seen in these healthy young adults who often live, work, and study in close proximity, and they are a frequently mobile population)Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.(1- Asthma, 2- Neurological and neuro-developmental conditions. 3- Chronic lung disease [COPD] , 4- Heart disease, 5- Blood, Endocrine, Kidney, Liver and Metabolic disorders , 6- Weakened immune system due to disease or medication, 7- < 19 years, receiving long-term aspirin therapy. Persons 25 - 64 years (higher risk of complications from influenza)

Who Should NOT Be Vaccinated? mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Who Should NOT Be Vaccinated? mmmmm People with allergy to chicken eggs or had a severe reaction to an influenza vaccination. Children younger than 6 months of age People who have a moderate-to-severe illness with a fever (delay vaccination.) History of Guillain–Barré Syndrome. mmmmm mmmmm

Swine Influenza A(H1N1) Antiviral Protection mmmmm Novel H1N1 Swine Influenza A(H1N1) Antiviral Protection mmmmm mmmmm Treatment (Antiviral drugs ) Make illness milder and recovery faster May prevent serious flu complications Work best if started within 2 days of symptoms. Warning! Do NOT give aspirin: Reye’s syndrome. mmmmm mmmmm Reye's syndrome is a potentially fatal disease affecting the brain and liver. The classic features are a rash, vomiting, and liver damage. It has been associated with aspirin consumption by children with viral illness.

Importance of the Early Treatment mmmmm Novel H1N1 Importance of the Early Treatment mmmmm mmmmm Prognosis and days before treatment mmmmm mmmmm Recovered m Total number Dead 1 day 2 days 3 days >4 days Days from onset till initiation of treatment

Swine Influenza A(H1N1) Antiviral Protection mmmmm Novel H1N1 Swine Influenza A(H1N1) Antiviral Protection mmmmm mmmmm Treatment (Antiviral drugs ) Who to treat Suspected or confirmed influenza with: Illness requiring hospitalization Progressive, severe, or complicated illness, regardless of previous status Patients at risk for severe disease mmmmm mmmmm Children <2, 2-4 Adults > 65 Pregnancy & 2wks postpartum Persons with certain conditions: Persons with increased risk of complications because of certain medical conditions: 1- Asthma, 2- Neurological and neuro-developmental conditions 3- Chronic lung disease [COPD] , 4- Heart disease, 5- Blood, Endocrine, Kidney, Liver and Metabolic disorders , 6- Weakened immune system due to disease or medication, 7- < 19 years, receiving long-term aspirin therapy.

Swine Influenza A(H1N1) Antiviral Protection mmmmm Novel H1N1 Swine Influenza A(H1N1) Antiviral Protection mmmmm mmmmm Prophylaxis (Antiviral drugs ) Who may be considered: Vaccine takes 10 – 14 days to act Close contact of a person with H1N1 : Persons at high risk for complications of influenza; Health care workers and emergency medical personnel; Pregnant women. mmmmm mmmmm When the vaccine is not available

The hajj Season Swine Influenza A (H1N1) mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm The hajj Season mmmmm The health authorities of Saudi Arabia has advised certain populations against attending Hajj Children younger than 10 Adults older than 65 Pregnant women Those with chronic health conditions mmmmm mmmmm That was the position of many countries Vaccination against H1N1 required

The hajj Season Swine Influenza A (H1N1) mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm The hajj Season mmmmm To ensure pilgrim and resident safety, Saudi Arabia has set up: Health screenings at all ports of entry H1N1 vaccine secured Antiviral medication is available mmmmm mmmmm Meeting of Arab health ministers(In July) working very closely with World Health Organization Other international experts Schools started by mid-October

Summary Swine Influenza A (H1N1) This is a NEW virus mmmmm Novel H1N1 Swine Influenza A (H1N1) mmmmm Summary mmmmm This is a NEW virus This virus is contagious and is spreading from human to human. mmmmm The disease has low fatality mmmmm This will not be the last pandemic