Novel AH1N1 The quadruple reassortant virus

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Novel AH1N1 The quadruple reassortant virus

• Claire Perez- Ong MD, DPAFP
• Caloocan Health Department

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Influenza A virusshould we be concerned?

• Annual influenza epidemics are estimated to
  affect 515 of the global population, resulting
  in severe illness in 35 million patients and
  causing 250,000500,000 deaths worldwide.

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Flu pandemics over the last 100 years
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Other facts

• The influenza virus has also caused several
  pandemic threats over the past century, including
  the pseudo-pandemic of 1947, the 1976 swine flu
  outbreak and the 1977 Russian flu, all caused by
  the H1N1 subtype.

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A New Virus Emerges

• March and April, 2009 Novel influenza A (H1N1) ,
  a new flu virus of swine was first detected in
  Mexico and the United States
• April 15, 2009. The first novel H1N1 patient in
  the United States was confirmed by laboratory
  testing at CDC
• April 17, 2009. The second patient was confirmed
  on It was quickly determined that the virus was
  spreading from person-to-person.
• April 22CDC activated its Emergency Operations
  Center to better coordinate the public health
  response.
• April 26, 2009 United States Government
  declared a public health emergency
• CDC has determined that this new H1N1 virus is
  contagious and is spreading from human to human.
  However, at this time, it is not known how easily
  the virus spreads between people.

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Why is this new AH1N1 virus sometimes called
swine flu?

• This virus was originally referred to as swine
  flu because laboratory testing showed that many
  of the genes in this new virus were very similar
  to influenza viruses that normally occur in pigs
  in North America. But further study has shown
  that this new virus is very different from what
  normally circulates in North American pigs. It
  has two genes from flu viruses that normally
  circulate in pigs in Europe and Asia and avian
  genes and human genes. Scientists call this a
  "quadruple reassortant" virus

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It is a mutated strain
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Are we on the 4th flu pandemic?

• On June 11, 2009, Director-General Margaret Chan
  of the World Health Organization declared that
  the world is now at the start of the 2009
  Influenza pandemic   after raising the  Pandemic
  Alert Level  for the novel Influenza A virus from
  Level  5 to Level 6.
• This means that the new A (H1N1) virus has now
  spread and caused sustained community level
  outbreaks in at least one or two countries in two
  WHO Regions.  It has initially affected US and
  Mexico (North America) which are the epicenters
  of this pandemic and has shown a fast and
  steadily increasing number of cases
• It is contagious and easily transmissible from
  person to person.

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15 June 2009 -- As of 1700 GMT, 15 June 2009,
76 countries have officially reported 35, 928
cases of influenza A(H1N1) infection, including
163 deaths.
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DOH Local Update as of June 17, 2009

• Total Confirmed positive cases 311
• New cases 64
• gender males 40
• females 24
• Age range 1-62 yrs
• Median 18 yrs
• Nationalities 2 foreigners 62 Filipinos
• Recovered cases 93

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Philippine outbreaks update as of June 16,2009

• JAEN, NUEVA ECIJA
• 194 ILI Cases (as of June 12) 20 confirmed
• Affected Barangays1. Hilera (no. of cases
  decreasing)2. Pakul3. Lambakin
• Intervention1.  School Closure2.  Active
  Disease Surveillance3.  Health Education4. 
  Social Distancing

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Philippine outbreaks update as of June 16,2009

• CANDELARIA HIGH SCHOOL
• 49 ILI Cases 8 Confirmed
• Affected Barangays 1.  Bambang - 23 ILI
  Found2.  Sta. Ana - 7 ILI Found3.  Matungas
• Intervention Epidemiologic Investigation
  On-going

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Contact numbers

• Influenza A (H1N1) hotline
• 032 (711-1001)( 711-1002)
• Email doh_hems_at_yahoo.com
• doh_hemsopcen_at_yahoo.com

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FREQUENTLY ASKED QUESTIONS

• FAQS

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How does it spread?

• Transmission of novel influenza A (H1N1) is being
  studied as part of the ongoing outbreak
  investigation, but limited data available
  indicate that this virus is likely transmitted in
  ways similar to other influenza viruses.

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• Seasonal human influenza viruses are thought to
  be transmitted between persons primarily through
  large-particle respiratory droplet transmission
  (e.g., when an infected person coughs or sneezes
  near a susceptible person).
• Transmission via these large-particle droplets
  requires close contact between source and
  recipient persons because droplets do not remain
  suspended in the air and generally travel only a
  short distance (lt 6 feet).

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• Contact with contaminated surfaces is another
  possible source of transmission and transmission
  via small-droplet nuclei (also called airborne
  transmission) might also occur, but the
  contribution of these modes of transmission to
  influenza epidemiology is uncertain.

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• Because data on the transmission of novel H1N1
  viruses are limited, the potential for ocular,
  conjunctival, or gastrointestinal infection is
  unknown. Since this is a novel influenza A (H1N1)
  virus in humans, transmission from infected
  persons to close contacts might be common. All
  respiratory secretions and bodily fluids
  (diarrheal stool) of novel influenza A (H1N1)
  cases should be considered potentially
  infectious.

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What is close contact?

• Defined as having cared for or lived with a
  person who is a confirmed, probable or suspected
  case of novel influenza A (H1N1), or having been
  in a setting where there was a high likelihood of
  contact with respiratory droplets and/or body
  fluids of such a person. Examples of close
  contact include kissing or embracing, sharing
  eating or drinking utensils, physical
  examination, or any other contact between persons
  likely to result in exposure to respiratory
  droplets.

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Who are at risk of H1N1?

• Children younger than 5 years old. (The risk for
  severe complications from seasonal influenza is
  highest among children younger than 2 years old.
  )
• Adults 65 years of age and older.
• Persons with co-morbid conditions
• Chronic pulmonary (including asthma),
  cardiovascular (except hypertension), renal,
  hepatic, hematological (including sickle cell
  disease), neurologic, neuromuscular, or metabolic
  disorders (including diabetes mellitus)
• Immunosuppression, including that caused by
  medications or by HIV
• Pregnant women
• Persons younger than 19 years of age who are
  receiving long-term aspirin therapy
• Residents of nursing homes and other chronic-care
  facilities

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Is there an age specific trend with this virus?

• So far, with novel H1N1 flu, the largest number
  of novel H1N1 flu confirmed and probable cases
  have occurred in people between the ages of 5 and
  24-years-old. At this time, there are few cases
  and no deaths reported in people older than 64
  years old

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How long can an infected person spread this virus
to others?

• CDC believes that this virus has the same
  properties in terms of spread as seasonal flu
  viruses. With seasonal flu, studies have shown
  that people may be contagious from one day before
  they develop symptoms to up to 7 days after they
  get sick.  Children, especially younger children,
  might potentially be contagious for longer
  periods.

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What are the symptoms?

• The symptoms of this new H1N1 flu virus in people
  are similar to the symptoms of seasonal flu and
  include
• Fever
• Headache
• Extreme tiredness
• Dry cough
• Sore throat
• Runny or stuffy nose
• Muscle aches
• Stomach symptoms, such as nausea, vomiting, and
  diarrhea, also can occur but are more common in
  children than adults

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Can the new H1N1 flu virus be spread through
water in swimming pools, spas, water parks,
interactive fountains, and other treated
recreational water venues?

• Influenza viruses infect the human upper
  respiratory tract. There has never been a
  documented case of influenza virus infection
  associated with water exposure

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Can one get it from food such as pork products
or drinks?

• No documented evidence to suggest contamination
  from food or water

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How long can influenza virus remain viable on
objects?

• Studies have shown that influenza virus can
  survive on environmental surfaces and can infect
  a person for up to 2-8 hours after being
  deposited on the surface.

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What kills influenza virus?

• Influenza virus is destroyed by heat (167-212F
  75-100C). In addition, several chemical
  germicides, including chlorine, hydrogen
  peroxide, detergents (soap), iodophors
  (iodine-based antiseptics), and alcohols are
  effective against human influenza viruses if used
  in proper concentration for a sufficient length
  of time. For example, wipes or gels with alcohol
  in them can be used to clean hands. The gels
  should be rubbed into hands until they are dry.

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What are the drugs effective against H1N1?

• Ineffective AMANTADINE
• RIMANTADINE
• Effective OSELTAMIVIR
• ZANAMIVIR

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What are the recommended anti virals?

• Oseltamivir (brand name Tamiflu ) is approved to
  both treat and prevent influenza A and B virus
  infection in people one year of age and older.
• Zanamivir (brand name Relenza ) is approved to
  treat influenza A and B virus infection in people
  7 years and older and to prevent influenza A and
  B virus infection in people 5 years and older.

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What are the benefits of Antiviral Drugs

• Treatment In itself does not cure because we are
  dealing with a virus.
• If you get sick, antiviral drugs can make your
  illness milder and make you feel better faster.
  They may also prevent serious influenza
  complications.

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When is the optimal time to give anti-virals?

• Influenza antiviral drugs work best when started
  soon after illness onset (within two 2 days),
  but treatment with antiviral drugs should still
  be considered after 48 hours of symptom onset,
  particularly for hospitalized patients or people
  at high risk for influenza-related complications

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How long do we need to give the anti virals?

• Treatment should continued for 5 days or 24-48
  hrs after the acute symptoms resolve in
  immunocompetent patients.
• Antiviral treatment maybe prolonged for
  immunocompromised patients

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Can anti-virals prevent you from acquiring
Influenza?

• Prevention Influenza antiviral drugs also can be
  used to prevent influenza when they are given to
  a person who is not ill, but who has been or may
  be near a person with swine influenza. When used
  to prevent the flu, antiviral drugs are about 70
  to 90 effective.

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Who needs to be treated?

• Treatment is recommended for
• All hospitalized patients with confirmed,
  probable or suspected novel influenza (H1N1).
• Patients who are at higher risk for seasonal
  influenza complications (see above).

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Who needs pre-exposure prophylaxis?

• For pre-exposure chemoprophylaxis, antiviral
  medications should be given during the potential
  exposure period and continued for 10 days after
  the last known exposure to a person with novel
  (H1N1) influenza virus infection during the
  cases infectious period
• Infectious period is defined as one day before
  until 7 days after the cases onset of illness.

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Who needs post exposure prophylaxis?

• Close contacts of cases (confirmed, probable, or
  suspected) who are at high-risk for complications
  of influenza
• Health care personnel, public health workers, or
  first responders who have had a recognized,
  unprotected close contact exposure to a person
  with novel (H1N1) influenza virus infection
  (confirmed, probable, or suspected) during that
  persons infectious period.

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How about treatment for pregnant women?

• Oseltamivir and Zanamivir are "Pregnancy Category
  " medications, indicating that no clinical
  studies have been conducted to assess the safety
  of these medications for pregnant women.
• Pregnancy should not be considered a
  contraindication to Oseltamivir or Zanamivir use.
  Because of its systemic activity, Oseltamivir is
  preferred for treatment of pregnant women.
• The drug of choice for chemoprophylaxis is less
  clear. Zanamivir may be preferable because of its
  limited systemic absorption however, respiratory
  complications that may be associated with
  Zanamivir because of its inhaled route of
  administration need to be considered, especially
  in women at risk for respiratory problems.

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(DOH interim guidelines 1 WHO based)Recommended
daily dosage of antiviral agents for
chemoprophylaxis and treatment
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Antiviral medication dosing recommendations for
treatment or chemoprophylaxis of novel influenza
A (H1N1) infection.(Table extracted from IDSA
guidelines for seasonal influenza.)
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Dosing recommendations for antiviral treatment
of children younger than 1 year using Oseltamivir
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Dosing recommendations for antiviral
chemoprophylaxis of children younger than 1 year
using Oseltamivir
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Are there documented side when using these anti
virals?

• Oseltamivir nausea and vomiting more frequently
  seen in adults for treatment and prophylaxis ,
  less severe if take n with food.
• Zanamivir bronchospasm, respiratory depression
  after inhalation for patients with underlying
  airway disease. Hypersensitivity reaction ,
  oropharngeal or facial edema, diarrhea, nausea,
  sinusitis, bronchitis, cough, dizziness , ear,
  nose and throat infections.

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What else can we do to lessen the spread of this
virus?

• 1. Observe proper personal hygiene
•  Cover  your  nose and mouth when coughing or 
  sneezing
•  Wash hands regularly with soap and water, at
  least for 20 seconds (or use alcohol-based hand
  sanitizers) especially after handling patients
  and specimen, before and after eating, after
  using the toilet and as necessary.
•  Avoid touching your eyes, nose or mouth. Germs
  spread this way

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What else can we do to lessen the spread of this
virus?

• 2.  Increase your bodys resistance
•  Have at least  8 hours of  sleep Be
  physically active Manage your stress Drink
  plenty of fluids Eat  nutritious food,
  especially fruits and vegetables3. Social
  distancing.
•  Avoid crowded places. Avoid close contact
  with sick people. Stay home if you are sick
  until you are free from symptoms to prevent the
  spread of the virus.

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Whats New?

• CDC has developed a PCR diagnostic test kit to
  detect this novel H1N1 virus and has now
  distributed test kits to all states in the U.S.
  and the District of Columbia and Puerto Rico. The
  test kits are being shipped internationally as
  well. This will allow states and other countries
  to test for this new virus.

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How about vaccinations?

• The U.S. Government is aggressively taking early
  steps in the process to manufacture a novel H1N1
  vaccine, working closely with manufacturing. CDC
  has isolated the new H1N1 virus, made a candidate
  vaccine virus that can be used to create vaccine,
  and has provided this virus to industry so they
  can begin scaling up for production of a vaccine,
  if necessary. Making vaccine is a multi-step
  process requiring several months to complete.

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Where do we refer cases?

• DOH Hospitals designated as Referral Centers for
  Emerging and Re-emerging Infectious Diseases
• National Referral Center
• Research Institute for Tropical Medicine
  (RITM)Alabang, Muntinlupa, Metro ManilaTel No.
  809-7599
• Sub-national Referral Center
• A. Luzon and Metro Manila   San Lazaro
  Hospital   Quiricada St., Sta. Cruz, Manila  
  Tel. No. [phone] to 78
•    Lung Center of the Philippines   Quezon
  Avenue, Quezon CIty   Tel. No. [phone] /
  924-0707
• B. Visayas      Vicente Sotto Medical Center  
  Cebu City   Tel. No. [phone] / 254-0057
• C. Mindanao
•    Davao Medical Center   Bajada, Davao City  
  Tel. No. [phone]
• Satellite Referral Hospitals    Regional
  Hospitals/Medical Centers of 16 regions

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How do we increase surveillance?

• We should follow the WHO guidelines for the
  surveillance of Influenza A (H1N10 ) for a
  unified reportin of probable and confirmed cases
  and for diffreentiating the application of
  clinical management and anti-viral use

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Clinical case descriptions

• AFI acute febrile illness ( fever gt 38C) is the
  common feature in all probable cases. The
  spectrum of disease ranges from influenza-like
  illness to pneumonia
• ILI influenza like illness persons exhibiting
  symptoms that are commonly associated with
  Influenza

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Suspect case of Influenza A

• Defined as an individual with influenza like
  illness who has a close contact with an ill
  confirmed case of Influenza A (H1N1) virus
  infection OR
• A person with influenza like illness with a
  recent contact with an animal with confirmed or
  suspected Influenza A (H1N1) virus infection
  within ten days preceding the onset of ILI OR
• A person with influenza A (H1N1) within 7 days of
  onset of illness

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Probable case of Influenza A (H1N1)

• Defined as an individual with an influenza test
  that is positive for Influenza A, but is
  nonsubtypable by reaagents used to detect
  seasonal influenza virus infection OR
• An individual with a clinically compatible
  illness or who died of an unexplained acute
  respiratory illness who is considered to be
  epidemiologically linked to a probable or
  confirmed case

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Confirmed case of Influenza A (H1N1)

• An individual with a laboratory confirmed
  influenza a (H1N1) virus infection by one or more
  of the ff tests
• Real time RT-PCR
• Viral Culture

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Case Under Investigation (CUO)?

• YES to all three questions
• Arrived in the Philippines from an Influenza
  A(H1N1) affected country (list varies daily) in
  the past 10 days?
• EXPOSURE
• Has fever?
• Has cough, colds, or sore throat?

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Isolation

• Precautions in adults around 7-10 days after
  onset of illness
• In children younger than 12 yrs virus shedding
  can still occur for 21 days after onset of illness

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What happens to a Case Under Investigation (CUO)?

• Individual is admitted to a referral hospital for
  observation until laboratory results are released
  (usually within 48hrs).
• A case investigation form is filled up and
  submitted to the National Epidemiology Center and
  its regional counterpart.
• A specimen is collected and sent to RITM for
  laboratory analysis.
• Based on the attending physicians assessment,
  the individual may be discharged from the
  referral hospital when lab results are negative
  for A(H1N1).

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Notification

• gtreport suspect case to municipal/city health
• office/RESU
• CESU 288-88-11 loc. 2283
• RESU Hotline [phone]
• OPCEN 535-14-88
• gtimmediately refer pt. to a referral center for
• isolation and management

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Referral of CUOs
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What is a Mitigation response?

• DOH will shift focus in preparing households and
  health facilities to respond to the challenge
  posed by A (H1N1) in anticipation of more
  confirmed cases
•  We have to make sure that our health system is
  equipped to treat and manage particularly severe
  cases which may require more intensive care in
  our hospitals and that mild cases are
  appropriately treated at home

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Mitigation Response Level 2

• 1. Command System
• DOH----?NCR---?LGU--?Task force for A H1N1

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Mitigation Response Level 2

• 2. Surveillance system
• A. Laboratory Surveillance
• Random Sampling
• B. Disease Surveillance
• NO Contact Tracing

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Mitigation Response Level 2

• 3. Health facilities
• OPD vs. Confinement
• Admit CONFIRMED cases with Signs of
  respiratory infection
• If confirmed but STABLE-Home Care
• TRIAGING

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Mitigation Response Level 2

• 4. Public Health Intervention
• Containment measures
• Non- pharmacological means-
• Quarantine, Isolation, Social
  distancing
• 5. Risk Communication
• Focus on Awareness

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CHD Influenza A Plan of Action for Public Health

• 1. Organize Emergency Structure
• 2. Organize Speakers Bureau
• 3. Follow Interim guidelines

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CHD Influenza A Plan of Action for Public Health

• 4. Intensify Health education and information
• A. Emphasize non-pharmacologic
  measures
• -Social distancing
• -Hand washing
• -Cough etiquette
• B. 5 DONTS
• DONT rush to ER
• panic
• come to school when sick
• hoard anti-virals
• dont hesitate to eat pork

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CHD Influenza A Plan of Action for Public Health

• 5. Contact tracing
• 6. Surveillance of Clustering of cases.
• 24/7 operation
• Provide necessary logistics

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Control measures

• Sending of Specimen
• 8072774-Clinical labs, RITM (transport specimen
  with styropor with ice send by hospital
  personnel, not relatives
• Training of Specimen collection

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Operating Centers

• 24/7 6AM -10Pm
• 8422245
• 8072628 loc 205

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RITM Contact persons

• DR. OLVEDA-RITM Director
• RT-PCR
• 1323 specimens as of June 12 32
  2.4
• June 14
  255/1563 16.3

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• THANK YOU