2. Swine origin influenza virus H1N1 Case Report Ibrahim D’Andrea

3. OVERVIEW  What we already know  Genetic history of SOI-V  Our role as Emergency physicians

4. PHASE 1- no animal influenza virus infecting humans PHASE 2- virus in animals has caused infection in humans PHASE 3- animal virus has caused clusters of human infection. No human to human PHASE 4- human to human transmission capable of sustained community outbreak PHASE 5- same virus causing 2 or more sustained community outbreaks in 2 countries in one WHO region PHASE 6 -phase 5 plus one sustained outbreak in another who region

5. NICD Stats as of 24 August 2009

9. CLINICAL PICTURE Influenza – like Severe acute respiratory infection Severe illness

10. Influenza - like Temp > 38 and any of the following Sore throat Rhinorrhoea/blocked nose/cough Myalgia Diarrhoea

11. Severe Acute Respiratory Infection 2 days to 3 months  Any child with sepsis or LRTI 3 months to 5 years  Any child with LRTI( bronchiolitis, pneumonia, bronchitis, pleural effusion) >5  Sudden onset fever>38 PLUS Cough and sore throat Shortness of breath with or without xray changes

12. Severe Illness Child -cough and difficulty breathing PLUS -danger signs:-can’t drink -vomiting -lethargy -unconscious -indrawing/stridor in calm child Adult -respiratory distress -dyspnoea -hypotension -hypoxia

13. TESTING SARI if: -testing will assist diagnosis - no other cause is found - influenza is part of the differential Comorbid disease and at risk and symptomatic Clusters of outbreak Any death from H1N1

14. Who is high risk? Underlying medical condition Immunosuppressed Any disease which would compromise respiratory function >65 years Patients on long-term aspirin therapy-Reye’s Nursing home residents Pregnant women

15. What to do Mild cases - avoid aspirin - high risk for treatment at discretion of physician when therapy can be started in 48 hours of infection SARI or severe infection - treat with oseltamivir or zanamivir

16. DRUGS OSELTAMIVIR Adults 75mg bd Children <15kg 30 mg bd 15-23 kg 45mg bd 24-40 kg 60mg bd >40 kg 75 bd For 5 days ZANAMIVIR Adults 10mg bd Children 10 mg bd Only for >12 years old For 5 days

17. Prophylaxis For high risk close contacts of suspected or confirmed cases. Daily dose instead of bd

18. 1918H1N1 1968H3N2 1998 H1N1 triple reassortment 1979 H1NI Eurasia Swine Origin Influenza Virus genetic composition

21. 1918 Spanish flu H1N1 Pandemic 40 – 50 000 000 dead within 1 year Genetic material appears to originate from birds Started in Europe Came South for the winter Returned to Europe with a vengeance

22. H1N1 Swine flu From the humans pigs got the flu. Before 1918 flu was unknown in swine Sep 30 to Oct 5 1918 at Cedar Rapids Swine show influenza entered swine history This became known as the North American Classic Swine flu and is endemic in swine today.

25. 1957 H2N2 PANDEMIC 3 Avian segments 5 Human segments Human H1N1 became extinct at the onset of H2N2 BUT in 1977 it was reintroduced into society from what is believed to be a lab leakage H2N2 subsequently became extinct as well

26. 1967 H3N2 Pandemic Two new genes from avian pool

28. H3N2 H1N1 Swine Avian origin 1998-2009 triple reassortment H1N2

29. 1979 Eurasian H1N1 Swine flu Introduced from birds into European pigs

30. Eurasian H1N1 Triple reassortment SOI-V H1N1

32. Genetic transmission of SOI-V H1N1

34. EMERGENCY MEDICINE Who are we? Why do we exist? What is our role in a pandemic??

35. A revolution (from the Latin revolutio, "a turn around") is a fundamental change in power or organizational structures that takes place in a relatively short period of time. Aristotle described two types of political revolution:LatinchangeAristotle Complete change from one constitution to another Modification of an existing constitution. [1] [1] REVOLUTION

36. Swinging along

37. —v.t. 1. to be the first to open or prepare (a way, settlement, etc.). 2. to take part in the beginnings of; initiate: to pioneer an aid program. 3. to lead the way for (a group); guide. PIONEER

39. References 1.Historical perspective – emergence of H1N1 virussesN Engl J Med 2009;361:279-85. 2.The origins of pandemic influenza- lessons from 1918 pandemic n engl j med 353;21 www.nejm.org november 24, 2005 3. Revised health workers handbook on pandemic influenza A(H1N1) 2009 “swine flu” 4. www.nicd.ac.zawww.nicd.ac.za 5.www.doh.gov.za/swineflu/swineflu-f.html 6.www.cdc.gov/h1n1flu/ 7. www.who.int/csr/disease/swineflu/en/