1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Presented by: Abdulrahman Al-Zahrani Sub intern

3. Epidemic data YearInfluenza A Virus subtype People infected Deaths Spanish flu1918-1919H1N1500 million50 millions Asian flu1956-1958H2N22 millions Hong kong flu1968-1969H3N21 million

4. The CDC determined that the strain contained genes from four different flu viruses – North American swine influenza, North American avian influenza, human influenza, and swine influenza virus typically found in Asia and Europe. This new strain appears to be a result of the reassortment of two swine influenza viruses, one from North America and one from Europe

5. HAHemaggluti nin swine (H1) North America NANeuraminida se swine (N1)Europe PARNA polymerase subunitRNA polymerase subunit PA avian North America PB1RNA polymerase subunitRNA polymerase subunit PB1 human 1993 H3N2 strain PB2RNA polymerase subunitRNA polymerase subunit PB2 avian North America NPNucleoprotei n swine North America MMatrix proteinMatrix protein M1, M2M1 M2 swineEurasia NSNon- structural proteins NS1NS1 swine North America

6. First diagnosis: the CDC received a sample on April 14 from 10 years old boy who fell ill on March 30 in San Diego County,California. A second case was confirmed on April 17 in 9 years old girl who had fallen ill on March 28 in Imperial County,California Spread within Mexico : The outbreak was first detected in Mexico City, where surveillance began picking up a surge in cases Influenza like illness (ILI) starting March 18

9. New strain Widespread human transmission Virulence Lack of data

10. PhaseDescription 1No animal influenza virus circulating among animals have been reported to cause infection in humans 2An animal influenza virus circulating in domesticated or wild animals is known to have caused infection in humans and is therefore considered a specific potential pandemic threat. 3An animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. 4Human to human transmission of an animal or human-animal influenza reassortant virus able to sustain community-level outbreaks has been verified. 5The same identified virus has caused sustained community level outbreaks in two or more countries in one WHO region. 6In addition to the criteria defined in Phase 5, the same virus has caused sustained community level outbreaks in at least one other country in another WHO region.

13. In children emergency warning signs that need urgent medical attention include: Fast breathing or trouble breathing Bluish or gray skin color Not drinking enough fluids Severe or persistent vomiting 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

14. In adults, emergency warning signs that need urgent medical attention include: Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting Flu-like symptoms improve but then return with fever and worse cough PCR diagnostic test kit Senstivity 50-70 Specficity

15. Cover your nose and mouth with a tissue when you cough or sneeze. Wash your hands often with soap and water. Try to avoid close contact with sick people. Stay home if you are sick for 7 days after your symptoms begin or until you have been symptom-free for 24 hours, whichever is longer.

16. Oseltamivir (Tamiflu) Zanamivir (Relenza)

17. http://www.who.int/csr/disease/swineflu/en/ http://www.cdc.gov/h1n1flu/