Influenza A H1N1

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Influenza A (H1N1)
ROMEO ALMAZAN BITUIN, MD, MHA
Medical Specialist III
HEMS Coordinator
Dr. Jose
Fabella Memorial Hospital
Department of Health

National Center for Disease Prevention and
Control, DOH
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Influenza A (H1N1)

• Is PANDEMIC Imminent?

National Center for Disease Prevention and
Control, DOH
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• Influenza is usually a respiratory infection
• Transmission
• Regular person-to-person transmission
• Primarily through contact with respiratory
  droplets
• Transmission from objects (fomites) possible

National Center for Disease Prevention and
Control, DOH
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Transmission of Influenza

• Limited studies, varying interpretations
• Contact, droplet, and droplet nuclei (airborne)
  transmission all likely occur
• Relative contribution of each unclear
• Droplet thought most important
• Coughing, sneezing, talking
• Most studies either
• Animals or human experiments under artificial
  conditions
• Outbreak investigations
• Unclear of infection source

National Center for Disease Prevention and
Control, DOH
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Key Characteristics

• Communicability
• Viral shedding can begin 1 day before symptom
  onset
• Peak shedding first 3 days of illness
• Correlates with temperature
• Subsides usually by 5-7th day in adults
• can be 10 days in children
• Infants, children and the immuno-compromised may
  shed the virus longer

National Center for Disease Prevention and
Control, DOH
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• Incubation period
• Time from exposure to onset of symptoms
• 1 to 4 days (average 2 days)
• Seasonality
• In temperate zones, sharp peaks in winter months
  
• In tropical zones, circulates year-round with
  seasonal increases.

National Center for Disease Prevention and
Control, DOH
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Clinical Illness, Seasonal Influenza

• Abrupt onset
• Fever and constitutional symptoms body aches,
  headaches, fatigue
• Cough, rhinitis, sore throat
• GI symptoms and myositis more common in young
  children
• Sepsis-like syndrome in infants
• Complications viral and bacterial pneumonia,
  febrile seizures, cardiomyopathy,
  encephalopathy/encephalitis, worsening underlying
  chronic conditions

National Center for Disease Prevention and
Control, DOH
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Individuals at Increased Risk for
Hospitalizations and Death

• Elderly 65 years
• Children less than two years
• Certain chronic diseases
• Heart or lung disease, including asthma
• Metabolic disease, including diabetes
• HIV/AIDs, other immuno-suppression
• Conditions that can compromise respiratory
  function or the handling of respiratory
  secretions
• Pregnant women

National Center for Disease Prevention and
Control, DOH
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Vaccination

• Influenza vaccine is the best prevention for
  seasonal influenza.
• Inactivated viruses in the vaccine developed from
  three circulating strains (generally 2 Type A and
  1 Type B strain)
• Therefore, seasonal flu shot only works for 3
  influenza subtypes and will not work on pandemic
  strains.
• Live, intranasal spray vaccine for healthy
  non-pregnant persons 5-49 years
• Inactivated, injectable vaccine for persons 6
  months and older

National Center for Disease Prevention and
Control, DOH
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Influenza Viruses

• Classified into types A, B, and C
• Only Types A and B cause significant disease
• Types B and C limited to humans
• Type A viruses
• More virulent
• Affect many species

C Goldsmith, CDC
National Center for Disease Prevention and
Control, DOH
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Influenza A Viruses

• Influenza A viruses categorized by subtype
• Classified according to two surface proteins
• Hemagglutinin (H) 16 known
• Site of attachment to host cells
• Antibody to HA is protective
• Neuraminidase (N) 9 known
• Helps release virions from cells
• Antibody to NA can help modify disease severity

National Center for Disease Prevention and
Control, DOH
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Nomenclature
Strain number
Virus subtype
Virus type

• A / Sydney / 05 / 97 (H3N2)

Place virus isolated
Year isolated
National Center for Disease Prevention and
Control, DOH
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Influenza A (H1N1) is a novel virus

• Unusual combination of genetic material from
  pigs, birds humans which have re-assorted
• human-to-human transmission occurs through
  respiratory droplets generated from sneeze or
  cough
• Affects all age groups
• Vaccines for human seasonal flu can not protect
  humans against the novel virus

National Center for Disease Prevention and
Control, DOH
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Swine Influenza Viruses

• RNA viruses
• Pigs can be infected by avian influenza and human
  influenza viruses as well as swine influenza
  viruses.
• Re-assort and new viruses that are a mix of
  swine, human and avian influenza viruses can
  EMERGE

National Center for Disease Prevention and
Control, DOH
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Genetic Re-assortment
SIV
National Center for Disease Prevention and
Control, DOH
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Signs Symptoms of Influenza A (H1N1)

• Fever
• Lethargy
• Lack of appetite
• Coughing
• Runny Nose
• Sore throat
• Nausea / Vomiting
• Diarrhea

National Center for Disease Prevention and
Control, DOH
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Swine H1N1 vs. Human H1N1

• swine H1N1 flu virus NOT the same as human H1N1
  virus
• antigenically very different from human H1N1
  viruses
• vaccines for human seasonal flu can not protect
  humans from swine H1N1

National Center for Disease Prevention and
Control, DOH
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Transmission Food-Borne?

• NO
• Influenza A (H1N1) viruses are not transmitted
  through food
• Safe to eat properly handled and cooked pork and
  pork products
• Cook pork at an internal temperature of 70C
  (160F)

National Center for Disease Prevention and
Control, DOH
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Diagnosis and Laboratory Confirmation

• Clinically diagnosed
• Respiratory Specimen
• first 4 to 5 days of illness
• can shed for 10 days or longer
• Specimens sent to US CDC
• ONLY laboratory that can isolate and identify
  swine influenza type A virus

National Center for Disease Prevention and
Control, DOH
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Treatment

• Influenza A (H1N1) is sensitive to
• Oseltamivir (tamiflu)
• Zanamivir
• Self medication is discouraged, may induce drug
  resistance
• Chemoprophylaxis
• Oseltamivir

National Center for Disease Prevention and
Control, DOH
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Vaccine

• No Influenza A (H1N1) vaccine yet
• Process of production is underway, but may take 5
  6 months
• Seasonal influenza vaccine provides protection
  against the seasonal human influenza strains only

National Center for Disease Prevention and
Control, DOH
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Influenza A (H1N1) is a Public Health Emergency
of International Concern (PHEIC)

• Serious Public Health Impact
• Unusual or Unexpected
• International disease spread
• Interference with international travel or trade

WHO Recommends intensifying and enhancing
national surveillance systems for Influenza-like
Illnesses and atypical pneumonia
National Center for Disease Prevention and
Control, DOH
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Pandemic Alert Phase 5
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Influenza A (H1N1) Preparedness Plan

• Goal
• To minimize the public health socio-economic
  impact of influenza pandemic in the Philippines
• Objectives
• To maintain a functional command control
  structure during an influenza pandemic
• To adopt early warning system for pandemic
  influenza
• To identify monitor cases of pandemic influenza
• To manage large numbers of ill dying people
• To maintain essential services during a pandemic
• To prevent spread through public health
  interventions
• To manage public anxiety panic ensure
  effective appropriate information, education
  campaign

National Center for Disease Prevention and
Control, DOH
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What has been done?

• Activation of the DOH Management Committee on
  Prevention and Control of Re-Emerging Infectious
  Diseases (DOHMC-PCREID) with the Secretary of
  Health as the Chairperson of the DOH Central
  Command
• Enhanced health surveillance in hospitals,
  seaports, and airports which include thermal
  scanning of arriving passengers from affected
  countries
• emergency procurement of 4 additional thermal
  scanners

National Center for Disease Prevention and
Control, DOH
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What has been done?

• Health Declaration Checklist to screen for
  potential signs symptoms possible exposure to
  the virus
• Health Alert Notice (HAN) distributed to all
  arriving travelers who are strongly advised to
  monitor body temperature daily up to 10 days from
  date of arrival to contact health authorities
  A.S.A.P. if they become ill during this period

National Center for Disease Prevention and
Control, DOH
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National Center for Disease Prevention and
Control, DOH
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What has been done?

• Issuance of travel advisory to the public
• No travel ban but travelers are asked to
  reconsider their plans to travel to affected
  countries unless extremely necessary
• The World Health Organization does not recommend
  any travel restrictions or closure of borders at
  this time
• Activation of DOH HOTLINE [phone] /
  632-7111002) for immediate reporting of
  suspected Influenza A (H1N1), flu-like illness
  and atypical pneumonia by DOH regional Offices,
  LGUs, hospitals, and the public

National Center for Disease Prevention and
Control, DOH
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Influenza A (H1N1) Surveillance Reporting Flow
Influenza-like Illness Surveillance
Bureau of Quarantine
Referral Hospitals
Event-based Surveillance
Daily zero reporting
Response needed?
Inform other offices, agencies, etc. involved in
the response
Probable/ Confirmed
Yes
NEC/HOTLINE Surveillance Team
WHO
No
Cases under investigation
Probable/ Confirmed
EXECOM Central Command
End
Media
National Center for Disease Prevention and
Control, DOH
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What has been done?

• Firmed up national stockpile of Personal
  Protective Equipment (PPE) the antiviral drug
  (Oseltamivir) and other logistics
• Priority will be high-risk exposure groups
  consisting of frontline health workers and
  surveillance teams
• Interim Guidelines on Clinical Management of
  Influenza A (H1N1) Virus Infection and the Use of
  Antivirals
• Interim Guidelines on the Use of Personal
  Protective Equipments and Infection Control
  During Influenza A (H1N1) Outbreaks

National Center for Disease Prevention and
Control, DOH
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Interim Guidelines on Clinical Management of
Influenza A (H1N1) Virus Infection and the Use of
Antivirals

• Case definitions for infections with Influenza A
  (H1N1)
• Clinical Management of Influenza A (H1N1) Virus
  Infection
• Use of Antiviral Agents
• Priority groups to receive antiviral agents for
  prophylaxis
• Health workers
• First responders
• Workers providing essential services
• For treatment, priority will be the patients
  considered at high risk of severe disease
• Discharge guidelines

National Center for Disease Prevention and
Control, DOH
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Interim Guidelines on the Use of Personal
Protective Equipments Infection Control During
Influenza A (H1N1) Outbreaks

• Rational use of personal protective equipments
• Guidelines on the use of masks
• Public health measures
• Personal hygiene
• Guidelines on infection control in health care
  setting

National Center for Disease Prevention and
Control, DOH
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What has been done?

• National Referral Centers for EID readied in the
  event of suspected or confirmed swine flu cases
• Research Institute of Tropical Medicine (RITM)
• Lung Center of the Philippines
• San Lazaro Hospital
• Vicente Sotto Memorial Medical Center
• Davao Medical Center
• Organized the DOH Central Command for A (H1N1)
  that will oversee the operations of the different
  components of the A(H1N1) Task Force
• Planning, Operations, Financing, Logistics

National Center for Disease Prevention and
Control, DOH
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Health Emergency Management Structure
National Center for Disease Prevention and
Control, DOH
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What has been done?

• Convened a meeting of all Metro Manila DOH
  Hospitals to orient them on the situation come
  up with a response plan for hospitals
• Secretary Francisco T. Duque IIII called for a
  DOH Command Conference to check the readiness
  plans command control systems of all regions
  nationwide
• Secretary Francisco T. Duque III is made de facto
  Crisis Manager of the national Disaster
  Coordinating Council (NDCC) to coordinate
  government efforts in responding to the threat of
  Influenza A/H1N1

National Center for Disease Prevention and
Control, DOH
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What has been done?

• Request of Php 93.5 M calamity fund for the
  preparedness phase of a possible pandemic
• Meeting with Metro Manila private hospitals and
  DOH retained hospitals on referral procedures to
  DOH-Designated Hospitals for the Isolation
  Treatment of suspected Influenza A (H1N1) cases
  as well as contingency plans for a worse case
  scenario

National Center for Disease Prevention and
Control, DOH
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DOH Medical City Joint Forum (May 4, 2009)

• Guidance on
• Surveillance
• Case definitions, case reporting forms
• Infection control
• Will the private hospitals be allowed to admit
  cases? As of now, only the referral hospitals
  will be allowed to admit cases
• Use of oseltamivir
• Prophylaxis, treatment
• Societal approach rather than health sectors only
• Updates to be provided on a regular basis

National Center for Disease Prevention and
Control, DOH
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Public Health Advisory

• Cover nose and mouth with a tissue when coughing
  or sneezing.
• Wash hands regularly with soap and water,
  especially after you cough or sneeze.
  Alcohol-based hand cleaners are also effective
• Avoid close contact with sick people.
• If sick, self-monitor and stay home from work or
  school and limit contact with others.
• Consult your doctor immediately should signs and
  symptoms of flu persist.

National Center for Disease Prevention and
Control, DOH
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Risk Communications Challenges

• How to communicate with stakeholders minimizing
  fear and panic
• Informing or instructing widely
• divergent audiences
• Minimizing / overcoming
• misinformation, rumors and myths
• Encouraging the adoption of
• appropriate protective actions
• Building trust

National Center for Disease Prevention and
Control, DOH
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Whats next?

• Coordination with other concerned agencies
  regarding national response in the event of a
  pandemic
• OP, DA, DILG, DFA, NDCC

National Center for Disease Prevention and
Control, DOH
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Thank you for listening
and God Bless Us All !
National Center for Disease Prevention and
Control, DOH