New Human Influenza A(H1N1)

Anthony Z. San Juan, MD PHSAE

RESU, CHD-MM


Swine Influenza (Swine Flu)
A respiratory disease of pigs caused
by type A influenza virus
Causes high levels of illness and low
death rates in pigs;
Occurs during the late fall and winter months
similar outbreaks in humans;
Swine Flu Virus Subtypes
Four main Influenza A virus subtypes:
H1N1, H1N2, H3N1 and H3N2
Mixing of influenza viruses from different species
- human, avian, and swine in the pigs body can
reassort into a new virus, reassortant strain called
the New Human Influenza A (H1N1), capable of
causing pandemic.
Composition : 45% swine, 35% avian and 20%
human influenza virus

Swine Flu in Humans
Persons with direct exposure to sick pigs.

Antibody evidence of virus transmission from
the patient to health care workers who had
close contact with the patient

CDC reported one human swine influenza virus
infection every one to two years in the US
SIV
Genetic Reassortment
Swine Flu in Humans/
New Influenza A H1N1
(Symptoms)
Fever Lethargy

Lack of appetite Coughing

Runny nose Sore throat

Nausea Vomiting

Diarrhea
Period of Communicablity
Incubation Period:

1 to 3 days from exposure to a known case.

Period of Communicability

1 day before symptoms occur to 7 days after
onset of signs and symptoms of the illness.
Mode of transmission
Directly transmitted from pigs
to people and from people to pigs,
when people are in close proximity
to infected pigs, such as pig barns
and livestock.


Human-to-Human transmission of swine flu can also
occur (through coughing, sneezing and touching
something with flu viruses on it and then touching
their mouth and nose).
Diagnostic Test
Collect respiratory specimen (nasopharyngeal
swab) within the first 4-5 days of illness

Send the specimen to RITM for Real Time-
Polymerase Chain Reaction (RT-PCR).

IF non-subtypable, specimen is sent to CDC.
Documented case of human-to-human
spread of swine flu
September 1988, a 32 y. o. pregnant woman was
hospitalized for pneumonia and then died 8 days later.
H1N1 flu virus was detected. 4 days before getting sick,
patient visited a county fair swine exhibition where there
was widespread influenza like illness among the swine.

One to three health care personnel who had contact
with this patient developed mild influenza-like illnesses
with antibody evidence of swine flu infection.
Treatment for swine flu in humans
Antivirals:

1. Oseltamivir
2. Zanamivir
3. Amantadine
4. Rimantadine

CDC recommends the use of oseltamivir
or during the first two days of the illness.
Name of
Pandemic
Date Deaths Subtype
Involved
Pandemic
Severity
Index
Asiatic
(Russian)
Flu
1889-
1890
1 million H2N2(?) ?
Spanish Flu 1918-
1920
20-100
million
H1N1 5
Asian Flu 1957-
1958
1-1.5
million
H2N2 2
Hongkong
Flu
1968-
1969
0.75-1
million
H3N2 2
Known Human Pandemics
Swine-Origin Influenza H1N1 of 2009
aka New Influenza A H1N1
Mexico from April 17-23

854 cases of severe atypical pneumonia including
59 deaths
Close contacts affected: health care workers, family
members
Age range: 25-45 years old
Profile of Cases
cases with pneumonia required mechanical
ventilation
the progression of the disease was rapid
fatal
Transmission of Swine Flu Virus
among pigs
Close contact among sick pigs

Possibly from contaminated objects between
infected and uninfected pigs.
Signs of Swine Flu in Pigs
Sudden onset of fever
Depression
Coughing (barking)
Discharge from the nose or eyes
Sneezing and breathing difficulties
Eye redness or inflammation
Going off feed
How common is swine flu
among pigs?
H1N1 and H3N2 viruses are endemic among pig
populations in the U.S.

Outbreaks among pigs occur in colder weather
months (late fall and winter).

H1N1 is common throughout pig populations
worldwide, with 25% of the pig population
showing antibody evidence of infection.
Vaccine for swine flu available?
Vaccines are available for
pigs to prevent
swine influenza.

No vaccine to protect
human from the New
Influenza H1N1.
0
20000
40000
60000
80000
100000
120000
2003 2004 2005 2006 2007
Year
N
o
.

o
f

c
a
s
e
s
Data Source: FHSIS
0
5000
10000
15000
20000
25000
2003 2004 2005 2006 2007
Year
N
o
.

o
f

c
a
s
e
s
Data Source: FHSIS
Affected Countries Confirmed Cases Deaths
Mexico 1626 45
USA 2254 2
Canada 280 1
Spain 93 1
United Kingdom 39 0
Germany 11 0
New Zealand 7 0
Israel 7 0
France 12 0
Austria 1 0
Denmark 1 0
Ireland 1 0
New Human Influenza A H1N1
Country Confirmed Cases Deaths
Italy 9 0
Netherlands 3 0
Switzerland 1 0
Honkong 1 0
South Korea 3 0
El Salvador 2 0
Costa Rica 8 1
Guatemala 1 0
Poland 1 0
Portugal 1 0
Total 4379 46
New Human Influenza A (H1N1)
May 03
WHO Recommendations
Public Health Emergency of International Concern
(PHEIC)

Serious Public Health Impact
Unusual or Unexpected
International disease spread
Interference with international travel or trade
WHO Pandemic Phases
Locations in Mexico:

Mexico State, Veracruz, Oaxaca, Baja California,
and San Luis Potosi

Locations in USA:

California, Kansas, New York, Ohio and Texas
1,995 people have been hospitalized with serious
cases of pneumonia

The epidemic is now in an extremely dangerous
phase with the no. of people infected mushrooming
even as authorities ramped up defenses.

The epidemic continue to rise that we need to
reinforce preventive measures (Health Secretary
Cordova, Mexico)

At this time, containment is not a feasible option
as the virus has spread to other countries (WHO-
Asst. Director-General Keiji Fukuda)

Updates of Swine Flu in Mexico:
Safety Measures done in Mexico:

Mexico cancelled school at all levels nationwide.

The government is considering complete shutdown,
including all public transportation.

Church services were postponed.

Public events like some of Mexicos most treasured
national holidays were cancelled.

Pres. Felipe assumed new powers to isolate
infected people.

Surgical masks are being given away on subway
system.

Health Staff asked to visit the homes of all those
suspected to have died from the disease.


WHO raised the alert level to phase 5, meaning
there is sustained human- to human transmission
of the virus causing outbreaks in two countries from
the same region of the globe.

Recommendations:
Heightened Surveillance
Early Detection and management of cases
Infection Control at all levels


Updates of Swine Flu in the Philippine

The country remains free from the deadly swine flu
virus. There are no recorded cases in relation to the
outbreak from Mexico and other infected countries.

Agriculture Sec. Arthur Yap imposed a temporary ban
on the entry of pork from Mexico and the US.

Sec. Duque discouraged travelers from going to
affected countries.



Monitoring through thermal scanners at the airports
of people going into our country from other countries,
especially where swine flu cases had been reported.

Foot baths were placed in the airports especially
for travelers from the US and Mexico.

Travelers manifesting symptoms of swine flu infection
will be brought to the RITM, SLH or LCP.

Lines of Defense
Points of Entry and Exit Screening
Enhanced Disease Surveillance (Case Under
Investigation, Probable, Confirmed)
Intensified Public Health Information and Advocacy
on Individual hand and respiratory hygiene
Rationale Stockpiling of Oseltamivir
Promotion of Infection Control in Health Care
Settings
Social Distancing
Local/National Emergency Powers
Proper Burial

Health Emergency Management
Structure
CENTRAL COMMAND
Surveillance Hospital
Operations
Field Operations
Quarantine
OPERATIONS LOGISTICS FINANCE PLANNING
Expert Panel
DOH Central Office
Directors
CHD Directors
Secretariat and
Liaison
DOH Hospitals
Admin
MMD
Procurement
CoBAC
Transport
Budget
Safety Team
Communication
Etc
Travel Advisory
The World Health Organization advises
no restriction of regular travel or closure
of borders. It is considered prudent for people
to delay international travel and for people
developing symptoms following international
travel to seek medical attention, in line with
Guidance from national authorities.
Recognition of New Influenza A H1N1
Suspect Cases:

>persons with with respiratory signs and symptoms
and hx of exposure with sick swine shall be
considered as a suspect case.
>persons with respiratory ssx and with hx of travel
to areas with swine flu outbreaks
>persons with respiratory ssx and with hx of
exposure to a swine flu human case.

: What else do we need to do?
Notification

report suspect case to municipal/city health
office/RESU


RESU Hotline 535-45-29
OPCEN 535-14-88

HEMS HOTLINE: 7111001:
7111002
immediately refer pt. to a referral center for
isolation and management


Tasks of Health Centers Staff:

1. Wear face masks while doing triaging.
2. Maintain a distance of 1 m. away from the patients.
3. Do Triage for detection of suspect swine flu cases.
4. Place suspect cases in a holding area while
awaiting transport to a referral center.
5. Provide patient with surgical mask and the care
takers of patient with mask and gloves.
6. Report suspect cases to the BHERT team to identify
and quarantine all close contacts in their house for
7 days.
7. Report suspect cases to the CESU/CHO.
8. Monitor ILI and pneumonia cases weekly.
Report to CESU.
9. Report sick pigs from backyard farms to BAI/CHO.

Triage Flow
Patients with respiratory symptoms
Yes
No
With history of exposure/travel
Yes No
Put patient in a holding area, arrange
transport to a referral center, inform
BHERT team and report to CHO/CESU
Manage accordingly
Manage accordingly
What is BHERT?
Barangay Health Emergency Response Team
Composed of the following:
Barangay Chairman - Head
Health Center Physician Asst Head
Nurse
Midwife
Sanitary Inspector
BHW
Barangay Kagawad on Health
Barangay Tanod
Barangay Driver
Tasks of BHERT Team:

1. Monitor for one week new visitors who just arrived from
swine flu endemic countries and wear masks and
maintain a 1 m. distance from these people.

2. Refer symptomatic suspect cases to referral centers.

3. Quarantine close contacts of suspect case at home
for one week to observe for development of signs and
symptoms of swine flu.

4. Identify/ quarantine exposed persons for 7 days
and monitor for signs and symptoms of illness.
5. Report suspect cases to the Health Center.

City Health Office:

1. Ensure availability of face masks and gloves for
the health staff involved in the triage of patients,
transport and referral of suspect case.

2. Intensify surveillance of ILI and pneumonia cases
in the city.

3. Report suspect cases to the RESU.



Community:

1. Practice personal hygiene:
>cough etiquette (cover mouth and nose when
you cough or sneeze with a hanky or tissue)
>wash hands often with soap and water esp.
after you cough or sneeze
>avoid touching your eyes, nose and mouth.

2. Practice social distancing
>limitation to public places
>cancellation of mass gathering
>avoid practice of kissing and holding hands
Hospital:
1. Do triaging in the OPD section.
2. Isolate suspect case in a single room. If not available,
cohort them separately in designated multi-bed rooms
or wards; beds should be 1 meter apart and with
physical barrier (curtain, partition)

3. Reinforce standard precautions
with droplet and contact
precautions.

4. Use appropriate PPEs for those entering patients room
consisting of mask (N95), gown, mask, goggles
and gloves.

4. Limit no. of health care workers (HCW) who have direct
contact with patients; they should not look after other
patients. Designated HCW should be properly trained
on infection control.

5. Restrict visitors from isolation room.

6. HCW should monitor his/her own temperature twice
daily and report to Infection Control Committee or
Hospital Chief any febrile event.

7. HCW who has fever and who has direct patient contact
should be treated immediately.

8. Post-exposure prophylaxis with Oseltamivir 75 mg OD
X 7days p.o. should be given to HCW who had contact
with droplets from a patient without having PPE.

9. Dispose wastes properly by placing it in a sealed,
impermeable bags clearly labeled biohazard.

10.Disinfect linen and reusable materials that have been
in contact with patient.

11.Report to CESU/CHO all suspect cases admitted and
those seen at the OPD
Referral of Suspected Case of
New Human Influenza A-H1N1
Port of Entry
BOQ
Referral Centers
Thermal Scans
Health Declaration Checklist
Isolation of suspect case
Give pt. and care giver masks
Refer to RITM, SLH, LCP
Scenario: A suspect case wasnt referred to a referral center
NEC/ BHERT informs RESU/ CESU of suspect case
Give complete name, age, nationality,
home or hotel address, date of arrival
no. of close contacts
CESU follow-up suspect case
CESU Feedback to RESU/NEC
>Advice contacts to self monitor body temperature 2x a day
and refer to RESU if someone gets febrile.
>While waiting for the ambulance, stay inside the house
so as not to create panic.
> Give verbal and written feedback to RESU.
Ambulance picks up and brings suspect case to
referral center
Follow up laboratory results
>Tell driver and other staff to wear mask.
>Disinfect ambulance after pts conduct to hospital
If (-) If (+),
> Suspect case is discharged
> Close contacts are released
from quarantine.
>Suspect case stays
>quarantine close contacts
for 10 days
Reminders during case
investigation
>Upon entering the room, wear mask
>Maintain 1 m. distance from suspect case.
>Put pt. in a separate room and give him and the care
giver masks.
>Explain (routine procedure) that incoming travelers
from affected countries with fever and other symptoms
will be referred to a hospital
>close contacts will be under home quarantine for 7-10
days.
If lab result of suspect case is negative, contacts will be
released from quarantine.
Pharmaceutical (Anti-Virals) Stockpile
452,900 capsules NONE
Non-Pharmaceutical (Masks) Stockpile
37,400 pcs.
21,800 pcs.
Wash your hands with soap and water frequently
and thoroughly, especially after coughing,
sneezing and blowing or wiping your nose.
Cover your mouth and nose with disposable
tissues when coughing or sneezing and dispose of
used tissues properly.
If you don't have a tissue, cough or sneeze into your
sleeve.
If you are sick, stay at home and keep away
from work, school or crowds as much as
possible.
Common-sense precautions:
If you need medical attention:
Contact your doctor or
healthcare provider before
travelling to see them and
report your symptoms. Explain
why you think you have
influenza H1N1 (e.g., recent
travel or contact with someone
known to have the illness).
Follow the advice given to you
for care.
Take care to cover your nose
and mouth during travel.

Thank You
and
God Bless