Rashid A' Chotani, MD, MPH, DTM

1
?????? ????? ??????? ???? ???????? ????????
(H1N1)?????? ???????? ???????? ??????? ?????
????? ????? (Version 4, first JIT lecture issued
April 26)Tuesday, April 28, 2009

• Rashid A. Chotani, MD, MPH, DTM
• Adjunct Assistant Professor
• Uniformed Services University of the Health
  Sciences (USUHS)
• 240-367-5370
• chotani_at_gmail.com

2
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3
???????
Credit L. Stammard, 1995
4

5
????????? ??????

• ?????? (Epidemic) ????? ????? ??????? ?? ?????
• ?????? ??????? (Pandemic ) ???? ???? ?? ??????
• ?????? ????????? Antigenic drift
• ?? ???? ?????? ?????? ??????? ???? ?? ??????????
• ?????? ??????? ?? ???????? ???????
• ???? ????????? Antigenic shift
• ??????? ?? ?????????? ???? ????? ?????? ???????
• ????? ??????? ?????? ?? ???? ??????? ?????????
  ???????

6
???????? ???????? ?????

• ???????? ????????? ??? ????? ???? ????????? ????
  ???????? ?????? ?? (A) ???? ???? ??? ????
  ???????? ??? ????????? ?????????
• ???????? ????????? ???? ?? ???? ??????? ?????
  ???? ??????? ??? ????? ?????? ????? ???? ?? ?????
  ???? ???? ??? ??????? ?? ???????
• ???? ???????? ??????? ??????? ???????? ?????????
  ???? ??? ??????? ????? ???????? ??? ???????? ????
  ??? ?? ???? ?? ????? ?????? ?? ??? ????

7
???????? ???????? ?????? ?? ???????? ???????

• ???? ???????? ????????? ??? ?? ??? 1976 ?? ???
  ????? ???? ??? ????? 200 ???? ????? ????? ????
  ???? ???? ?????
• ???? ?? 40 ????? ??? ?? ??????? ?????? ?????
• ?? ????? ?????? ???????? ??? ????? 500 ???? ????
  ???????? ??? ??? ????? (Guillain-Barre syndrome)
• 30 ??? ????? ?????? ??? ??? ???????
• ?? ????? 1988 ?? ????? ???? ???? ???? ?????? ????
  ??? ??????? ???????? ????????? ?????? ??? 8
  ????
• ?? ????? ????? 2005 ?????? ???? 2009?? ??????? ??
  ?? ????? 15 ???? ????? ??? ????? ?????????
  ?????????

8
???????? ???????? ????? ?????? ?? ????????
???????

• ??? ???? 2009 ?? ????? 64 ???? ????? ????? ??????
  ????? ?? ???????? ???????? A (H1N1) ?? ??? ??????
  ????? ??????? ???? ??????
• 5 ????? ?? ??????? ??????????
• ???? ????? ?? 64 ????? 16 ??? (????? 7-54)
• ???? ??????? 2-7 ????
• ????? ?????? ???????? ????????? ????? ???
  ???????? ???????
• ?? ??? ??????? ???? ??? ???? ?? A/H1N1 ??? ???
  ???????? ??????? ?? ???????? ?? ?????
• ??????? ?? ?????? ??????? ?? ??????? ??????? ??
  ???????? ???????? ???? ?? ????? ?? ???????? ????
  ???? ?? ???????? ???????

Source CDC
9
???????? ???????? ????? ?????? ?? ????????
???????

• ???? ??????? ??? ??????? CDC ??? ??? ??? ???????
  ???? ?????? ??? ?????
• ??????? ????? ??? ????? ????? ?? 4 ????? ??????
  ?? ???????
• ???????? ?????? ????????
• ?????? ?????? ????????
• ????? ?????? ????????
• ???????? ?????? ?????
• ???????????? ??????? Strategic National Stockpile
  (SNS)????? ?? ????? ?????
• ????? ????? ?????????
• ????? ????? ???????
• ????? ????? ???????
• ?????? ???????? ??? ?? ???????? ???? 1.5 ?????
  ??????? ???????? ????????
• ?? 27 ????? 2009 ???? ???? ??????? ??? ???????
  ????? ????? ??? ??????? ??? ??????? ??????

Source CDC
10
???????? ???????? ???????? ??????? ?? ????????
??????? ????? ????? 28 ????? 2009
????? ????? ??????? ??????? 64 (?? ???? ?????)
All cases were identified in New York City
Source CDC
11
????? ??????? ??????? ?? ???? ????????? ???????
????????
45
10
6
26
12
???????? ???????? ????? ?????? ?? ???????

• ??????? 2498 ???? ????? ???? 159 ????? 1311 ?????
  ???????? ?? 24 ?? ??? 32 ????? ?? ???????
• 26 ???? ???? ???????
• ?????? ?????? ?? ????? 13 2009
• ???? ????? ?? ?????? ?????
• ????? ?????? 854 ???? ?????? ????? 59 ???? ?????
• ????? ???? 24 ???? ? 3 ?????
• ????? ????? ??? ?????? 4 ????? ??? ?????
• ???? ????? ?? ????? ?????? ??? ???? ????? ???
  ????? ??????? ???? ??????? ?? ??????? ??????

Source WHO, CDC, PAHO ProMED
13
???????? ???????? ????? ?????? ?? ???????

• ???? ??????? ?? ??????? ??????? ???????? ????????
  (20-50 ????) ??? ???? ????? ?? ??????????
  ????????? ???? ???? ???? ???? ???? ????? ????
• ??????? ???? ??????? ??? ??????? ???? 14 ???? ??
  ??????? ????? ???? ??????? ????? ?? ???????
  ?????? ?? 7 ???? ????? ????? ???????? ?????? ????
  ???? ???? ?? ??????? ?? ???????? ??????? (?????
  ????)
• ????? ???? ?????? ??? ???????? ???????? ?? 18
  ???? ?? ???? ????????. 12 ???? ???? ?????? ??????
  ?????? ???????? ???????? ?? ??????????

Source WHO, CDC ProMED
14
????? ?????? ?? ??????
Source WHO. http//www.who.int/csr/don/2009_04_2
8/en/index.html
15
????? ?????? ?? ??????

• ????? ????? ???????? ??? ????? ?????? ??? ???????
  4? ???? ???? ?????? ??????? ??????? ??? ????? ???
  ???? ?? ???? ????? ?? ??? ???? ??? ?????
• ?????? ???????? ?? ??????? ??? ?????? ????????
  ?????? ?? ??? 2004 ? ???? ?? ????? ?????? ????
  ??? ????? ??? ????? 33 ??????? ?????.
• 105 ???? ?? ??????? ??????? ???????? ??? 7 ?????
  (??? ?? ???????)
• Case-fatality 7
• 2504 ???? ????? ??? ?? ?????? ???????? ??? 152
  ????? (??? ?? ???????)
• Case-fatality 6
• 1318 ???? ????? ????????
• ???? ????? Androulla ??????? ??????? ????????
  ???? ??????? ??? 27 ??? ??????? ?? ???????
  ???????? ????? ??? ????? ??? ??????? ???????? ??
  ???????? ??????? ???????? ??? ?? ??????? ????????
  ????

16
???????? ???????? ???????? ?? ????
????????????? ???????? ?? ????????
17
???????? ???????? ???????? ??? ???????

• ?? ???? ??????? ?? ???????? ??????? ?? ???????
  ??????? ???????? ???????? ????????
• ?? ???? ??????? ???? ???? ????????? ????????
• ?? ????? ?????? ???????? ???????? ?? ????? ????
  ?????? ???? ?? ???? ??? ?????????? ????????? ??
  ???? ???? ?? ??? ????????

18
???????? ???????? ????? ??????? ?? ??????

• ?????? ??????? ??????? ????????? ???????? A
  (H1N1) ???? ??? ????? ?? ??? ???? ????? ???????
  ???? ??????? ?? ??????? ??????? ????? ????????
  ???????? A (H1N1) ?? ???? ??????? ??? ??????? ??
  ???? ???? ?? ????? ?? ???????? ???????
• real-time RT-PCR
• ????? ???????
• ?????? ???????? ??????? ????????? ???????? A
  (H1N1) ???? ??? ????? ?? ??? ???? ????? ???????
  ???? ??????? ????? ????
• ?????? ??????? A ???? ???? ??????? H1 and H3 by
  influenza RT-PCR
• ?????? ??????? A ?????? ????? ?????? influenza
  immunofluorescence assay (IFA) plus meets
  criteria for a suspected case
• ?????? ??????? ???? ??????? ????????? ???????? A
  (H1N1) ???? ??? ????? ?? ??? ???? ????? ???????
  ???? ??????? ???
• ???? 7 ???? ?? ??????? ?? ??? ???? (???? ?????
  ??????? ????????? ???????? A H1N1)
• ???? 7 ???? ?? ????? ??? ?? ???? ???? ???? ?????
  ?????? ????????? ???????? A H1N1
• ????? ?? ????? ?? ????? ???? ??? ????? ???? ?????
  ????

Source CDC
19
???????? ???????? ????? ??????? ?? ??????

• ???? ?????? ?????? ??????? ???????? ?????
  ???????? ???????? A(H1N1) ???? ??? 1 ??? ????
  ????? ? ???? 7 ???? ??? ???? ?????
• ????????/??????? ?????? ???? ??? ????? ??????
  ??? ??? ????? 6 ????? ?????? ?? ??? ???? ????
  ????? ?? ???? ????? ???? ???? ???????? ???????? A
  (H1N1) ???? ????? ???? ???? ??????
• ????? ?????? ??????? ?????? ???? ????? ?????
  ????? ?????? ??? ????? ?? ??????? ????? ??????
  ?????? ????? ? ?????? ?????? ??????? (?? ?? ????
  ??? ?? ?????? ????? ?????)
• ????????? ??????? ????? ????? ?????? ????
  ??????? ???????? ???? ????? ???????? ????????
  ???? ??? ??? ????? ????? ?????? ????
  ??????????????????(??????????)

Source CDC
20
???????? ???????? ??????? ???????? ????????

• ??? ???????? ???????? ????? ???? ????????
  ????????? ??????? ????????? ???????? ?? ??????
  ????? ?????? ?? ????? ?????? ??????? ???????
  ????? ?
• ??????? ?? ??????? ???? ?? ?????? ???? ??? ?????
  ????? ????????? ???????? A (H1N1)
• ?????? ??? ????? ?? ?????? ???? ??? ????? ?????
  ????????? ????????
• ????? ??? ????? ????? ?????? ????? ?????????
  ????????
• ??? ?? ???????? ????? ???????? ???????? ??? ???
  ????? ????? ?????? ?? ??????? (??? ???????)
• ??? ??? ?????? ??? ??????? ?????? ??????? ??????
  ??????? ?????? ????? ???????

Source CDC
21
???????? ???????? ??????? ???????? ????????

• ???????? ????????
• ????? ??????? ?????????? (ILI)
• ???? ????? ?????? ?????? ????? ??? ????????? ??
  ??? ??????? ?? ?????? .(??? ???? ??? ???
  ??????? ?????? ????? ???? ????? ??? ???? ???
  ????? ??? ????? ???? 2009)
• ????? ??? ?????? ??????? ?????? ????? ??????
  ????? ???????? ?????? ?????? ?????? ?? ??????? ??
  ???????
• ???????? ????? ?????? ?????? ???????? ????? ??
  ?????? ???? ?????????
• ??????? ?????? ????? ?? ??? ??????? ?? ???? ?????
  ????? ??????? ?????? ???????? ???????? A
  (H1N1)??? ????? ??????? ?? ?????? ?????????? (???
  ???????) ??? ????? ???? 7 ???? ?? ???? ????? ???
  ??????? ??????

Source CDC
22
???????? ???????? ??????? ???????? ????????

• ??????? ?????? ?????? ??????? ???? ???? ?????????
  ?????? ???????? ?????????
• ?? 27 ????? 2009??? ??????? ?????? ?????? ???????
  ??? ??? ????? ???? ????????? ?????? ????????
  ????????? ????? ??????? ??? ??????? ???? ????
  ???????? ????????
• ??? ????? ??? ?????? ??? ????? ??????? ??????
  ???????? ????? ??????? ?? 26 ????? 2009
• ???? ?????? ?????
• ???? ??? (Tamiflu) ?????? ????? ???? ??? ??
  ?????? ????? ???? ???? ?????????? ?? ??????? ??
  ??? ????? ?????? ?????? ?????? ????? ??????? ???
  ?????. ???? ??? ???? ?? ??????? ?????? ??????
  ??????? ???? ????? ???????? ?????? ??? ?????
• ???? ??? ???????? (Relenza) ?????? ??????? ????
  ???????? ??????? ????? ?? ?????

23
???????? ??????????????? ????? ?????? ??????
???????

• ??? ????? ????? ?????? ??????? ??????? ?????
  ????? ???????? ???????? (H1N1) A ?? ??????? ????
  ????? ?????? ???? ?? ??????? ??????Biosafety
  level2(BSL-2( laboratory
• ??? ?? ???? ??? ??? ???? ??????? ???????? ????
  ????? ?????? ????? biosafety cabinet (BSC
• ??? ?? ???? ????? ????? ???????? ?????? ??????
  ??????? ???????? ????? ????? ???????? ???????? A
  (H1N1) ?? ??????? ???? ????? ?????? ???? ??
  ??????? ?????? ?? ??????? ????? ?? ????? ??????
  ?? ??????? ??????in a BSL-2 laboratory with BSL-3
  practices (enhanced BSL-2 conditions)
• ???????? ?????? ???? ??????
• ????????? ???????? ??????? ????????(????? ???
  ????? ????? ??????).
• ????/???? ????? ????? ?????? ??????? ?????? ??
  ????? ???? ?? ???????.
• ????? ?????.
• ???? ??? ???? ??????? ?? ??????.
• ?????? ??????/??????.
• ????? ??????(????????????? ?????? ?????)
• ???????
• ??? ????? ????????? ?????? ??? ?? ?????? ???????
  ??????? ?????? ?? ???? ???????

Source CDC
24
???????? ??????????????? ????? ?????? ??????
???????

• ???????? ????????
• ???? 70 ???????
• ???? 5 ?????
• ???? 10 ????
• ??? ??? ???? ???????? ????? ???????? ???????
  ????? ??? ????? ????. ????? ???????? ???????? ???
  ???????? ??????? ????? ????? ????? ???????.
• ??? ????? ???? ??????? ??? ????? ????? ??? ???
  ??????.
• ???????? ????? ?????? ??????? ???? ????? ?????
  ??? ??? ?? ?????? ?????? ?????? ???? ??? ??????
  ??? ???? ???? ?? ????? ????? ??????? ????? ??????
  ????? ???? 7 ???? ??? ?????? antiviral
  chemoprophylaxis with zanamivir or oseltamivir

Source CDC
25
???????? ??????????????? ????? ?????? ??????
???????

• ??????? ?????? ?????? ??????? ???? ???? ?????????
  ?????? ???????? ???????
• ?? 27 ????? 2009????? ??????? ?????? ??????
  ??????? ???? ????? ??? ??? ???? ??????? ???
  ??????? ???? ???? ???????? ????????
• ??? ????? ??? ?????? ??? ????? ??????? ??????
  ???????? ????? ??????? ?? 26 ????? 2009
• ?????? ?? ??????? ????????? ????????
• ??? ?????? ?????? ???? ??????? ??? ??????? ??
  ????? ????? ???????? rRT-PCR ????? ??? ?????
  ????? ?????????? ???????? ??????? ???????? ????
  ????? ???????

26
??????? ?????

• ????? ????? ????? ?????? ????? ?????? ???????
  ???? ??????? ???????? ??? ?????????.
• ??? ?????? ?????? ? ??????? ????? ??? ??????
  ???????
• ????? ?????? ????? ???? ????? ??? ??????.
• ???? ???????? ????????? ??????.
• ???? ??? ??????? ????? ?? ???? ????? ?????????.
• ??? ??? ???? ???????????? ???? ?? ?????? ?????
  ?????? ??? ??????? ?? ????? ???? ???????? ??
  ??????? ??? ?? ???? ??? ??????

Source CDC
27
???????? ???????? ??????

• ?? ???? ????
• ?????? ????????? ??????? ?? ??? ???? ??????
• Oseltamivir (Tamiflu) or
• Zanamivir (Relenza)
• ??????? ?????? ????????? ????? ??? ?????? ??????
• ???? ???? ????????? ???????
• ???????? ?????? ????????? ???? ???? ??? ???
  ?????? ??? ?????? (????? ?? ???? ???????)
• ?????! ?? ???? ?????? ?? ???? ????? ????? ???????
  ????????? (????? 18 ???) ????? ?? ?????? ????????
  ?? ??????? ???????? ???? ?? ???? ??? ???? ???
  ???? ???? Reyes syndrome. ?????? ?? ?????? ?????
  ???? ??? ?????????????? ?? ?? ?????? ??????????
  ?? ??? ???????????

Source CDC
28
???????? ???????? ????? ?????? ????

• ????? ??????? ????? ? ????? ????? ? ???????
  ?????????
• ????? ???? ??? ??? ??????? ????? ???? ?????
  ???????? ???? ?? ?????? ?? ???????? ??? ?? ??????
  ?????? ???????
• ????? ????? ???? ???? ??? ?? ??????? ???????
  ????? ?? ???? ????? ??????? ?????? ?? ???????
  ?????? ??????
• ??????? ????????? ??? ??????? ??????? ???
  ?????? ?? ???????? ????? ????? ???? ?? ???? ???
  ????? ??????? ??? ??????? ? ?????? ??????? ????
  ???????? ???????

Source CDC
29
???????? ???????? ????? ?????? ????

• ??????? ????? ??????? ?? ????? ????? ??????
  Aerosol ?????
• ?????? ????? ??????? ??? ???????
• ??????? ????? ??????? ?? ????? ????? ??????
  aerosol ????? (??? ???? ?????? ? ??? ???????
  ???????? ? ????? ???????? ???????? ?? ?????
  ??????? ???? ????? ??? ??????? ???????? ?? ?????
  ????? ????????) ??????? ??????? ???? ?? ???????
  ????????? ???????? A (H1N1) ?? ??????? ?????
  ?????? a fit-tested disposable N95 respirator
• ?? ?????? ????? ????? ?????? ??? ???????? ???
  ???????? ?? ????? ??????? ???????? ???????
  ??????? ???? ?? ??????? ????????? ???????? A
  (H1N1) ?????? a fit-tested disposable N95
  respirator ??? ???? ???? ??????
• ??????? respirator ??? ?? ???? ?? ???? ??????
  ????? ?????? ??????? ?????? ???? ?????? ???????
  ?????? ????????? (OSHA)

Source CDC
30
???????? ???????? ????? ?????? ????

• ?????? ?????? ?? ??????? ???????? ?? ?????
  ??????? ??????
• ??????? ??????? ??? ?? ??????? ??? ?? ??? ?? ????
  ?? ???? ????? ???? ?? ????? ????? ?????. ?? ???
  ????? ? ???? ????? (AIIR) ?? ???? ???? ??? ?????
  ????? ?????? ???? ???? ?????? ?? 6 ??? 12
  ???????. ???? ?? ?????? ??????? ?? ????? ??????
  ??? ?????? ?????? ???? ?????? ?????? ???????
  (HEPA) .
• ??? ?????? ?????? ???? ????? ??? ?????? ?? ??????
  ? ?????? ?????? ???? ?????? ????? ??????
  ????????? ?????? ?? ??????. ??????? ?????? ??
  ??????? ???? ???????? ??? ???? ??? ????? ????????
  ?????? ??? ????????? ?? ??? ????? ?????. ???????
  ???????? ???????? ???? ????? ?????????? ????
  ??????? ??? ??????? ??????? ????????? ????????

Source CDC
31
???????? ???????? ????? ?????? ????

• ?????? ?????? ?? ??????? ???????? ?? ?????
  ??????? ??????
• ??????? ? ??????? ???????? ??????? ????? ??
  ?????? ??? ????? ?????? ?? ???? ??????? ?
  ???????? ????? ???? 7 ???? ??? ???? ????? ??
  ??????? ??? ???? ?????? ???????. ???????? ???
  ???????? ??? ????? ?????? ?? ????? ??????
  ???????? ?????? ?? ???????? ?????? ??? ????? ???
  ????? ???????? ?????? ???????? ???? ?? ?????
  ???????? ?????? ???????.
• ??????? ????? ?????? ??????? ?? ?????? ????
  ??????? ???????? ?? ??????? ??????? ??? ??
  ??????? ????? ?????? ?????? ???? ?????? ????
  ????? ??? ??? ???? ?????? ?????? ???????? ?
  ?????? ????? (??? ??????) ???? ?????? ??????
  ?????

Source CDC
32
????? ??????? ???????

• ??????? ????????
• ???? ?????? ????? ??????? ???? ?????? ??? ?????
  ??????? ?? ????????
• ??????? ???????? ????? ???????
• ???? ???????? ???? ?? 0.3 ??????. ??? ???????
  ????
• ?????? ??????
• ??? ???? ??????
• ??? ?????? ??????
• ??????? ??????? ????? ??? ??? ????? ?????. ???
  ???? ?????? ? N95 ??? ????? 95 ?? ?????
  ???????? ???? ?? 0.3 ?????? ??? ???? ??????
  ???????
• ????? ?????? ?? ??????? ?????? ????? ??????
  ?????? ??? ????? ?????? ????????? 0.027 ??????.

33
???????

• ????? ????? ???????? ???? ????? ?????? ???
  ??????? 4 ? ???? ???? ?????? ??????? ??????? ???
  ????? ??? ???? ?? ???? ????? ?? ??? ???? ???
  ?????
• 105 ???? ?? ??????? ??????? 7
• 2504 ???? ????? ??? ?? ??????
• Case-fatality rate 6-7
• 1318 ???? ????? ????????
• ?? ???????? ??????? ???? ??? 64 ???? 16 ???
  (????? 7-54)
• ?? ???????? ???? ????? (20-50 ???) ?????? ??????
• ?? ???? ????
• ?????? ????????? ????????
• Oseltamivir (Tamiflu) or
• Zanamivir (Relenza)
• ??????? ???????? ???? ????? ????? ?27 ???? ?????
  ???? ????? ??? ??????? ?? ??????? ??????? ??
  ?????? ??? ??????? ??????
• ???????? ??????? ????? ????? ????? ?27 ???? ?????
  ???? ????? ??? ??????? ?? ??????? ??????? ??
  ?????? ??? ??????? ??????