1. بسم الله الرحمن الرحیم

2. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Influenza Overview It is a highly contagious disease It is a disease of the respiratory system Can affect people of all ages People most susceptible are the elderly, small children and immuno-compromised Complications include pneumonia, bronchitis, nose and ear infection.

3. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Influenza Overview 10-20% of the US population come down with the flu each year. 250,000 people die world wide. Vaccines are the first line of defense. Antiviral medication is also available

4. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Spanish 1918 Pandemic Influenza A H1N1 http://www.stanford.edu/group/virus/uda/

5. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Spanish Influenza 1918 The most devastating flu pandemic the world had seen. Named Spanish influenza because of the severe loss in Spain. 8 million people died in May 1918. In the U.S, first signs were seen in early spring in military camps in Kansas, but received little attention because of the war in Europe.

6. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Spanish Influenza 1918 By the fall, hospitals were overwhelmed with patients, many of whom were dying 2- 3 days after exhibiting symptoms. The pandemic was extremely sudden. No one was prepared. In the US, the average life span was reduced by 10 years. ~675,000 American deaths.

7. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Spanish Influenza 1918 40 million people worldwide were dead from the flu. Most striking was the high morbidity of young people (20-40 years old). Millions of hospitalizations, secondary bacterial pneumonias, and middle ear infections in infants and young children. Caused by H1N1 strain that resembled most closely swine origin.

8. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا 1957 Asian Influenza—A(H2N2) Re-assortment of avian and human strains. Re-assortment thought to have occurred in pigs. 70,000 deaths in America. First identified in China in February 1957, it spread to the US by June 1957

9. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا 1968 Hong Kong Influenza—A(H3N2) Also re-assortment of avian and human strains. 34,000 deaths in America. Started in Hong Kong in early 1968 and spread to America by the end of the year. A(H3N2) is still circulating in human population today.

10. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا 1: epidemic, 2: probable pandemic, 3: pandemic Potter, C.W: Textbook of Influenza by Nichols, Webster, Hay, Blackwell Science 1998 30 years 10 Recorded Influenza Pandemics 10 20 19 events with pandemic potential; 12 since December 2003 2005 H1 H2 H3 (from ducks) H1 37 years?

11. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Reassortment (in Animals and Humans) Migratory birds Reassortment in Swine Human virus Avian Virus Reassortment in humans Human Pandemic Strain

12. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا is an infectious disease caused by type A strains of influenza virus The disease in birds has two forms; - Mild illness - Highly pathogenic avian influenza”,which was first recognized in Italy in 1878, is rapidly fatal, with a mortality approaching 100%. Birds can die on the same day that symptoms first appear 12

13. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Infected birds shed virus in saliva, nasal secretions and feces. spread among susceptible birds when they have contact with contaminated excretions. The viruses do not usually directly infect humans Most cases of infection in humans have resulted from contact with infected poultry or contaminated surfaces. 13

14. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا 1997: In Hong Kong, avian influenza A (H5N1) This was the first time an avian influenza virus had ever been found to transmit directly from birds to humans; - 18 people were hospitalized, - 6 of them died. - authorities killed about 1.5 million chickens 14

15. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا 1998-99 : in China H9N2 Several additional human infections were reported. 1999: In Hong Kong, avian influenza A H9N2 - were confirmed in 2 children. - Both patients recovered, and no additional cases were confirmed. - Poultry was the source of infection and the main mode of transmission was from bird to human.

16. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا 2003: Two cases of avian influenza A (H5N1); -Infection occurred among members of a Hong Kong family that had traveled to China. - One person recovered, the other died. How or where these 2 family members were infected was not determined. 16

17. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Beginning in mid-2003 eight countries in south-east Asia experienced the largest and most severe outbreaks of highly pathogenic avian influenza in poultry. The causative agent, the H5N1 strain of Influenzavirus A, has since become endemic in domestic birds in several of the initially affected countries.

18. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا From July 2005 to the end of the year The virus expanded its geographical presence in birds beyond the initial focus in Asia. Country reported their first outbreaks, in both wild and domestic birds, included : Russian Federation, Kazakhstan, Turkey, Romania Ukraine. Croatia and Mongolia reported detection of the virus in wild birds only.

19. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Beginning in February 2006 the geographical presence of the virus in birds expanded again, This time dramatically: between then and early April 2006, 32 countries, located in Africa, Asia, Europe and the Middle East, had reported their first cases of infection in wild or domestic birds, or both.

20. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا The fastest and most extensive geographical spread The fastest and most extensive geographical spread since the disease was first described in 1878. Poultry in some of the world’s most densely populated areas poorly served by systems for health care and disease surveillance. This situation increases the likelihood that human cases may not be detected promptly or at all.

21. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا New role of migratory birds first observed in 2005, Some species of migratory birds have acquired an ability to carry the H5N1 virus in its highly pathogenic form over long distances. Partly responsible for the dramatic recent spread of the virus to new areas. The involvement of migratory birds in the epidemiology of this disease increases the likelihood of further spread the complexity of control measures in animals, elimination of the virus in wild birds is considered impossible.

22. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Pandemic start The spread of the virus to new areas is of concern for human health as it increase opportunities for human exposures and infections. Each human case gives the virus an opportunity to develop into a form that spreads efficiently and sustainably among humans, at which point a pandemic is expected to start.

23. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Other mammalian species Detection of H5N1 virus in a small number of dead domestic cats in some countries, and in two additional mammalian species that prey on wild birds the stone marten and the mink. At present, infection in these additional mammalian species is not thought to play a significant role in the epidemiology of the disease or to introduce added risks for human infection. Due to close association between domestic cats and people, vigilance for signs that cats are becoming more widely infected is essential.

24. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا The first human cases in the present outbreak occurred in December 2003 in Viet Nam. By June 2007, close to 333 laboratory-confirmed human cases had been reported from 12 countries(204 dead): Azerbaijan Cambodia China Djibuti Egypt Indonesia Iraq Lao Nigeria Thailand Turkey Viet Nam. In humans, the virus causes severe disseminated disease affecting multiple organs and systems. Infection has been fatal in more than half of the cases. For unknown reasons, most cases have occurred in previously healthy children and young adults.

25. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا 15 June 2007 Country 20032004200520062007Total casesdeathscasesdeathscasesdeathscasesdeathscasesdeathscasesdeaths Azerbaijan000000850085 Cambodia000044221177 China110085138322516 Djibouti000000100010 Egypt00000018101853615 Indonesia 000020135545252210080 Iraq000000320032 Lao People's Democratic Republic 000000002222 Nigeria000000001111 Thailand0017125233002517 Turkey00000012400 4 Viet Nam332920611900009342 Total4446329843115795033313191

26. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

27. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

28. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

29. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

30. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

31. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

32. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

33. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

34. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

35. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا WHA Resolution WHA Resolution acknowledged the serious threat to human health represented by the outbreaks in poultry and the associated human cases, and stressed the need for all countries to collaborate with WHO and the international community in order to lessen the risk of the H5N1 influenza virus causing a pandemic among humans.

36. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Although neither the timing nor the severity of the next pandemic can be predicted, the risk that a pandemic virus will emerge is directly linked to the presence of the virus in poultry and is expected to persist. Since mid-2003, some 60 countries had reported the virus in domestic or wild birds. Of the 29 countries with outbreaks in poultry, only two have successfully eliminated the virus from their territories and maintained a disease-free status.

37. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا The virus does not cross easily from birds to humans. Behaviours associated with a high risk of infection include the slaughter, butchering,defeathering, and preparation for consumption of infected birds. Properly cooked poultry and poultry products are safe to eat.

38. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Investigation of instances of possible human-to-human transmission is difficult, as family members are usually exposed to the same animal or environmental sources as well as to one another. Several instances of limited human-to-human transmission have occurred, but in no case has the virus spread beyond a first generation of close contacts or caused illness in the general community.

39. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا very close contact Data from these incidents suggest that transmission requires very close contact with an ill person. The WHO level of pandemic alert remains at phase 3: a novel influenza virus subtype is causing human infections, but does not spread efficiently or sustainably from one person to another.

40. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Pandemic Influenza: Morbidity and Mortality in EMR At an expected attack rate of 35%, it is expected that in the EMR (in millions):  More than 180 will fall ill  96 - 168 require medical care  6.4 - 28.1 need hospitalization  0.15 - 0.75 may die Will disrupt economy, social and political life Level of preparedness influences death toll

41. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Burden in Health Care Services: Sources of Data FluAid Analysis: CDC Software for estimating morbidity and mortality that could result from influenza pandemic Released on September 2005 World Health Statistics 2005: Number of doctors, nurses and hospital beds Age Distribution: Assumed as follows: Age Group% Less than 1850 19 - 6445 More than 655

42. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Country Total PopulationNumber of Hospital beds / 100,000 Afghanistan 259712544 Bahrain 754,33128 Djibouti 720,99216 Egypt 74,878,31322 Iran ((Islamic Rep.) 70,675,07616 Iraq 26,555,22713 Jordan 5,750,13917 Kuwait 2,671,42122 Lebanon 3,760,30330 Libya 5,768,46939 Morocco 31,564,4528 Oman 3,020,26420 Pakistan 161,150,5807 Palestine (Occupied) 3,815,250NA Qatar 627,56724 Saudi Arabia 25,625,68722 Somalia 10,741,6634 Sudan 35,039,8027 Syria 18,650,33415 Tunisia 10,041,69017 United Arab Emirates 3,106,45822 Yemen21,480,3026

43. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Country Doctors (N) (Per 10,000)Nurses (N) (Per 10,000) Afghanistan 4,935 (2)5,714 (2) Bahrain 1,396 (19)3,447 (46) Djibouti 115 (2)577 (8) Egypt 166,230 (22)198,428 (27) Iran ((Islamic Rep.) 84,103 (12)113,787 (16) Iraq 16,730 (6)32,132 (12) Jordan 12,995 (23)16,963 (30) Kuwait 4,274 (16)11,220 (42) Lebanon 10,529 (28)4,362 (12) Libya 6,980 (12)28,842 (50) Morocco 16,414 (5)28,408 (9) Oman 4,198 (14)9,816 (33) Pakistan 124,086 (8)75,741 (5) Palestine (Occupied) NA Qatar 1,475 (24)3,439 (55) Saudi Arabia 39,207 (15)82,771 (32) Somalia 430 (0)2,148 (2) Sudan 5,957 (2)28,032 (8) Syria 26,670 (14)35,063 (19) Tunisia 8,134 (8)30,326 (30) United Arab Emirates 5,250 (17)10,935 (35) Yemen4,726 (2)9,666 (5)

44. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا MINIMIU M MAXIMU M Country DeathsHospitalizations Outpatent visitsDeathsHospitalizations Outpatent visits Afghanistan 17,296106,90817,575,106172,916602,63835,611,246 Bahrain 183667115,5518353,118194,808 Djibouti 176638110,4457982,981186,198 Egypt 18,20166,22811,470,14782,876309,58919,337,536 Iran (I. R.) 17,17962,51110,826,27878,224292,21118,252,039 Iraq 6,45523,4874,067,81529,391109,7936,857,937 Jordan 1,3985,086880,8296,36423,7741,484,990 Kuwait 6502,363409,2172,95711,045689,902 Lebanon 9153,326576,0184,16115,546971,109 Libya 1,4025,102883,6366,385238,1501,489,723 Morocco 7,67227,9194,835,16434,936130,5068,151,610 Oman 7342,672462,6563,34312,487779,991 Pakistan 39,171142,53524,685,663178,363666,28741,617,593 Palestine (O) NA Qatar 15255596,1346952,595162,071 Saudi Arabia 6,22922,6663,925,44128,363105,9516,617,906 Somalia 2,6129,5001,645,44811,88944,4132,774,065 Sudan 8,51730,9925,367,53138,782144,8649,049,127 Syria 4,53316,4962,856,93020,64277,1124,816,502 Tunisia 2,4418,8821,538,22511,11541,5182,593,295 UAE 7552,749475,8593,43812,844802,252 Yemen 5,22118,9993,290,43523,77488,8115,547,349 Total 141,892560,28196,094,528740,2472,936,233167,987,249 Estimates of Deaths, Hospitalizations and Outpatient Visits in the EMR During Pandemic Influenza

45. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Key Strategic Actions for Pandemic Influenza 1.Reduce human exposure to H5N1 2.Strengthen the early warning system 3.Intensify rapid containment operations 4.Build capacity to cope with a pandemic 5.Coordinate global science and accelerate vaccine development & expansion of production capacity Building public health capacity to deal with influenza will lead to stronger national systems for alert and response linked to a comprehensive global alert and response system that will serve to protect us from whatever nature has in store for us in the future

46. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Influenza Type A Antigenic Shifts Year 1889 1918 1957 1968 20?? Year 1889 1918 1957 1968 20?? Subtype H2N2 H1N1 H2N2 H3N2 H?N? Subtype H2N2 H1N1 H2N2 H3N2 H?N? Severity Moderate Severe Moderate ? Severity Moderate Severe Moderate ? 29 yrs 39 yrs 11 yrs ? yrs

47. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Pandemic Phases Interpandemic phase "Animal influenza outbreaks" Low risk for humans 1 High risk for humans 2 Pandemic Alert "New influenza subtype in humans" No or only inefficient h2h transmission 3 Evidence for increased h2h transmission 4 Significant increase in h2h transmission 5 Pandemic 6

48. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Epidemic/Pandemic Control Requirements 1.Strong national public health systems and capacity 2.Specific preparedness for key priority disease threats (e.g. diagnostics, therapies, vaccines, containment measures) 3.An effective international system and partnership for coordinated alert and response

49. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا WHO Global Influenza Surveillance Network 1 laboratory  1 laboratory national network Annual output ~ 175,000-220,000k samples; 15,00-40,000 isolates; 2,000- 10 000 viruses characterized 112 specialised laboratories in 83 countries 4 international reference centres

50. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا National Pandemic Preparedness Building on a regionally implemented strategy for strengthening national early warning and response systems Rapid increase in number of countries with plans or with plans in preparation From < 50 countries 6 months ago to approx 140/194 today (70%)

51. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Global coordination of scientific collabration Public health measures Vaccine development Epidemiology Diagnosis Clinical Management Cluster Investigation… 42 publications and guidelines since April 2004 on H5N1 with 11 further documents in pipeline Global Scientific Coordination, Knowledge Management

52. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا Influenza specimen lab result during 2005 & 2006 Total sample received 647 Positive for influenza 71 Positive for H1N1 28 Positive for H3N2 23 Positive for influenza type b 20 Pending 4