甲流h1n1精品课件influenza a（h1n1） （swine flu）

RashidA Chotani MD MPH DTMAdjunctAssistantProfessorUniformedServicesUniversityoftheHealthSciences USUHS 240 367 5370chotani Just in TimeLectureInfluenzaA H1N1 SwineFlu Pandemic Version12 firstJITlectureissuedApril26 Tuesday June11 2009 11 30PMEST TheAuthoracknowledgestheefforts hardworkanddiligenceforhostingthislecture web management translationsandthankstheentireSupercourseTeam speciallythefollowingDr RonaldE LaPorte UniversityofPittsburgh USADr EugeneShubnikov InstituteofInternalmedicine Novosibirsk RussiaDr FainaLinkov UniversityofPittsburgh USADr MitaLovalekar UniversityofPittsburgh USADr Nicol sPadillaRaygoza UniversidaddeGuanajuato M xicoDr AliArdalan TehranUniversityofMedicalSciences IranDr MehrdadMohajery TehranUniversityofMedicalSciences IranDr SeyedAmirEbrahimzadeh TehranUniversityofMedicalSciences IranDr NasrinRahimian TehranUniversityofMedicalSciences IranDr MohdHasni UniversityofKebangsaan MalaysiaDr KawkabShishani TheHashemiteUniversity JordanDr NesrineEzzatAbdlkarim BeirutArabUniversity LebanonDr KhowlahAlmohaini UniversityofPittsburgh USADr DucNguyen UniversityofTexas USADr ElisavetaJasnaStikova University Ss CyrilandMethodius Skopje MacedoniaDr Mich leCazaubon Secr taireGledelaSoci t Fran aised Ang iologie FranceDr YangYingyun PekingUnionMedicalCollege ChinaDr JesseHuang PekingUnionMedicalCollege ChinaShimonWeitzman BenGurionUniversityoftheNegev IsraelDr NurkaPranjic MedicalSchoolUniversityofTuzla BosniaandHerzegovinaDr ShakirJawad UniformedServicesUniversityoftheHealthSciences USADr HiroyaGoto MinistryofDefense JapanDr OsamuUsami NationalCancerInstitute USAAfhamA Chotani USATrulyaglobalefforthttp www pitt edu super1 Acknowledgement InfluenzaVirusDefinitionsIntroductionHistoryintheUSSpread TransmissionTimeline FactsResponseStatusUpdateMexicoUSCanadaEuropeanUnionGloballyCase DefinitionsGuidelinesCliniciansLaboratoryWorkersGeneralPopulationTreatmentOtherProtectiveMeasuresSummaryTimelineofEmergenceLessonsLearnedfromPastPandemicsConclusion Recommendations OUTLINE Credit L Stammard 1995 Virus Epidemic alocatedclusterofcasesPandemic worldwideepidemicAntigenicdriftChangesinproteinsbygeneticpointmutation selectionOngoingandbasisforchangeinvaccineeachyearAntigenicshiftChangesinproteinsthroughgeneticreassortmentProducesdifferentvirusesnotcoveredbyannualvaccine DefinitionsGeneral Source BeanB etal JID1982 146 47 51 SurvivalofInfluenzaVirusSurfacesandAffectofHumidity Temperature Hardnon poroussurfaces24 48hoursPlastic stainlesssteelRecoverablefor 24hoursTransferabletohandsupto24hoursCloth paper tissueRecoverablefor8 12hoursTransferabletohands15minutesViableonhands 5minutesonlyathighviraltitersPotentialforindirectcontacttransmission Humidity35 40 Temperature28C 82F InfluenzaTheNormalBurdenofDisease SeasonalInfluenzaGlobally 250 000to500 000deathsperyearIntheUS peryear 35 000deaths 200 000Hospitalizations 37 5billionineconomiccost influenza pneumonia 10billioninlostproductivityPandemicInfluenzaAneverpresentthreat SwineInfluenzaA H1N1 Introduction SwineInfluenza swineflu isarespiratorydiseaseofpigscausedbytypeAinfluenzathatregularlycauseoutbreaksofinfluenzaamongpigsMostcommonly humancasesofswinefluhappeninpeoplewhoarearoundpigsSwinefluvirusesdonotnormallyinfecthumans however humaninfectionswithswinefludooccur andcasesofhuman to humanspreadofswinefluviruseshavebeendocumented SwineInfluenzaA H1N1 HistoryinUS AswinefluoutbreakinFortDix NewJersey USAoccurredin1976thatcausedmorethan200caseswithseriousillnessinseveralpeopleandonedeathMorethan40millionpeoplewerevaccinatedHowever theprogramwasstoppedshortafterover500casesofGuillain Barresyndrome asevereparalyzingnervedisease werereported30peoplediedasadirectresultofthevaccinationInSeptember1988 apreviouslyhealthy32 year oldpregnantwomaninWisconsinwashospitalizedforpneumoniaafterbeinginfectedwithswinefluanddied8dayslater FromDecember2005throughFebruary2009 atotalof12humaninfectionswithswineinfluenzawerereportedfrom10statesintheUnitedStates SwineInfluenzaA H1N1 TransmissiontoHumans ThroughcontactwithinfectedpigsorenvironmentscontaminatedwithswinefluvirusesThroughcontactwithapersonwithswinefluHuman to humanspreadofswinefluhasbeendocumentedalsoandisthoughttooccurinthesamewayasseasonalflu throughcoughingorsneezingofinfectedpeople SwineInfluenzaA H1N1 TransmissionThroughSpecies ReassortmentinPigs SwineInfluenzaA H1N1 March2009Timeline InMarchandearlyApril2009 Mexicoexperiencedoutbreaksofrespiratoryillnessandincreasedreportsofpatientswithinfluenza likeillness ILI inseveralareasofthecountryApril12 theGeneralDirectorateofEpidemiology DGE reportedanoutbreakofILIinasmallcommunityinthestateofVeracruztothePanAmericanHealthOrganization PAHO inaccordancewithInternationalHealthRegulationsApril17 acaseofatypicalpneumoniainOaxacaStatepromptedenhancedsurveillancethroughoutMexicoApril23 severalcasesofsevererespiratoryillnesslaboratoryconfirmedasinfluenzaA H1N1 virusinfectionwerecommunicatedtothePAHOSequenceanalysisrevealedthatthepatientswereinfectedwiththesamestraindetectedin2childrenresidinginCaliforniaSamplesfromtheMexicooutbreakmatchswineinfluenzaisolatesfrompatientsintheUnitedStates Source CDC SwineInfluenzaA H1N1 March2009Facts VirusdescribedasanewsubtypeofA H1N1notpreviouslydetectedinswineorhumansCDCdeterminesthatthisvirusiscontagiousandisspreadingfromhumantohumanTheviruscontainsgenesegmentsfrom4differentinfluenzatypes NorthAmericanswineNorthAmericanavianNorthAmericanhumanandEurasianswine SwineInfluenzaA H1N1 USResponse TheStrategicNationalStockpile SNS isreleasingone quarterofitsAnti viraldrugsPersonalprotectiveequipmentandReparatoryprotectiondevicesPresidentObamatodayaskedCongressforanadditional 1 5billiontofighttheswinefluOnApril27 2009 theCDCissuedatraveladvisorythatrecommendsagainstallnon essentialtraveltoMexico Source CDC SwineInfluenzaA H1N1 GlobalResponse TheWHOraisesthealertleveltoPhase6WHO salertsystemwasrevisedafterAvianinfluenzabegantospreadin2004 AlertLevelraisedtoPhase3InLateApril2009WHOannouncedtheemergenceofanovelinfluenzaAvirusApril27 2009 AlertLevelraisedtoPhase4April29 2009 AlertLevelraisedtoPhase5June11 2008 AlertLevelraisedtoPhase6 Source WHO SwineInfluenzaA H1N1 May25 2009StatusUpdate MEXICO March01 June09 atotalof6 241Laboratoryconfirmedcases108deathsreportedAll32StatesUNITEDSTATES March28 June09 atotalof13 217Laboratoryconfirmedcases 27deathsAllSatesplusDistrictofColumbiaandPuertoRicoVastmajorityofcasesmildCANADA AsofJune10 atotalof2 978Laboratoryconfirmedcases 4deaths12of13States533newLaboratoryconfirmedcasesJune8Vastmajorityofcasesmild Source SecretariadeSalud Mexico CDC PublicHealthAgencyofCanada EuropeanCDC WHO SwineInfluenzaA H1N1 May25 2009StatusUpdate EUROPEANUNION EFTACOUNTRIES April27 May25 atotalof1 565Laboratoryconfirmedcasesnodeaths26countries126confirmedcasesreportedonJune09567in countrytransmissionsVastmajorityofcasesreportedbetween20 49yearsofageGLOBALLY March1 May25 atotalof27 737Laboratoryconfirmedcases from74countries144Deathsamonglaboratoryconfirmedcasesfrom7countriesMexico 108deathsUS 27deathsCanada 04deathChile 02deathsCostaRica 01deathColumbia 01deathDominicanRep 01death Source SecretariadeSalud Mexico CDC PublicHealthAgencyofCanada EuropeanCDC WHO SwineInfluenzaA H1N1 MexicoEpidemicCurveConfirmed byDay Source SecretariadeSalud Mexico TotalNumberofConfirmedCases 6 241 AsofJune09 2009 NOTE 54confirmedcasesnotincluded EpidemiologicalAlert SchoolClosure SuspensionofNon essentialActivities SchoolOpen SwineInfluenzaA H1N1 MexicoConfirmedCaseDistribution byAge TotalNumberofConfirmedCases 6 241 AsofJune09 2009 Source SecretariadeSalud Mexico NOTE 54confirmedcasesnotincluded SwineInfluenzaA H1N1 MexicoConfirmedCases Death byAgeGroups TotalNumberofConfirmedCases 6 241 Deaths 108 AsofJune09 2009 Source SecretariadeSalud Mexico NOTE 43confirmedcasesnotincluded 71 3 Deaths SwineInfluenzaA H1N1 MexicoDeath byOccupation N 80 SwineInfluenzaA H1N1 USConfirmedCases Deaths byState Source CDC TotalNumberofConfirmedCases 13 217 27Death 50States DistrictofColumbia PuetroRico AsofJune11 2009 12 30PMET SwineInfluenzaA H1N1 MMRWReport April28 MMWR April28 2009 58 Dispatch 1 347patientsreportedtoCDCwithknownages outof64 themedianagewas16years range 3 81years 38 81 wereaged 18years51 ofcaseswereinmalesOfthe25caseswithknowndatesofillnessonset onsetrangedfromMarch28toApril25FivepatientshospitalizedOf14patientswithknowntravelhistories3hadtraveledtoMexico40of47patients 85 hadnotbeenlinkedtotravelortoanotherconfirmedcase Source CDC http www cdc gov mmwr preview mmwrhtml mm58d0428a2 htm MMWR April30 2009 58 Dispatch 1 3NYCschool highschoolA 2 686studentsand228staffmembersApril23 24 222studentsvisitedtheschoolnursingofficeandleftschoolbecauseofillnessDOHMHcollectnasopharyngealswabsfromanysymptomaticstudentsApril24 Friday DOHMHcollectednasopharyngealswabsfromfivenewlysymptomaticstudentsidentifiedbytheschoolnurseandfournewlysymptomaticstudentsidentifiedatanearbyphysician sofficeApril27 SchoolclosedDOHMHalsoprovidednasopharyngealtestkitstoselectedphysicians officesinthevicinityofhighschoolAApril26 7of9specimenscollectedonApril24werepositiveforthenewstrainofinfluenzaApril26 28 37 88 of42specimenscollectedtestedpositive bringingthetotalnumberofconfirmedcasesto44April27DOHMHconductedtelephoneinterviewswiththe44patientsMedianagewas15years range 14 21years Allwerestudents withtheexceptionofonestudentteacheraged21yearsThirty one 70 ofthe44werefemaleThirty 68 werenon Hispanicwhite seven 16 wereHispanic two 5 werenon Hispanicblack andfive 11 wereotherracesFourpatientsreportedtraveloutsideNYCwithintheUnitedStatesintheweekbeforesymptomonset andanadditionalpatienttraveledtoArubainthe7daysbeforesymptomonset Noneofthe44patientsreportedrecenttraveltoCalifornia Texas orMexico SwineInfluenzaA H1N1 MMRWReport April30 Source CDC http www cdc gov mmwr preview mmwrhtml mm58d0428a2 htm SwineInfluenzaA H1N1 MMRWReport April30 MMWR April30 2009 58 Dispatch 1 3IllnessonsetdatesrangedfromApril20toApril2410 23 ofthepatientshadillnessonsetonApril22 and28 64 hadillnessonsetonApril23 Figure Among35patientswhoreportedamaximumtemperature themeanwas102 2 F 39 0 C range 99 0 104 0 F 37 2 40 0 C Intotal 42 95 patientsreportedsubjectivefeverpluscoughand orsorethroat meetingtheCDCdefinitionforinfluenza likeillness ILI AtthetimeofinterviewonApril27 37patients 84 reportedthattheirsymptomswerestableorimproving three 7 reportedworseningsymptoms twoofwhomlaterreportedimprovement andfour 9 reportedcompleteresolutionofsymptomsOnlyonereportedhavingbeenhospitalizedforsyncopeandreleasedafterovernightobservation Source CDC http www cdc gov mmwr preview mmwrhtml mm58d0428a2 htm SwineInfluenzaA H1N1 CanadaConfirmedCases Death byProvinceorTerritory AsofJune11 20091500 EDT TotalNumberofConfirmedCases2 978 Death 4 12of13Provinces Source PublicHealthAgencyofCanada SwineInfluenzaA H1N1 EU EFTAConfirmedCases In CountryTransmission TotalNumberofConfirmedCases 1 565 0Death 26Countries 567In CountryTransmissions April27 June11 2009 1700CEST Source ECDC SwineInfluenzaA H1N1 EU EFTACountriesEpidemicCurveConfirmed byDay April27 June11 2009 1700CEST N 1 565 NumberofConfirmedCases Days Source ECDC 27Aprilto8May2009N 46 Source ECDC SwineInfluenzaA H1N1 EU EFTACountriesConfirmedCaseDistribution byAge Laboratory ConfirmedCasesofNewInfluenzaA H1N1 byCountries June11 2009 4 27 ChineseTaipeihasreported36confirmedcasesofinfluenzaA H1N1 with0deaths CasesfromChineseTaipeiareincludedinthecumulativetotalsprovidedinthetableabove Cumulativeandnewfiguresaresubjecttorevision 28 774Cases 144Deaths74Countries 108 2 1 1 1 Source WHO GlobalDistributionofReportedCumulativeLaboratoryConfirmedCasesofSwineInfluenzaA H1N1 byCountries June11 2009 14 00GMT Source WHO SwineInfluenzaA H1N1 USCaseDefinitions AconfirmedcaseofswineinfluenzaA H1N1 virusinfectionisdefinedasapersonwithanacutefebrilerespiratoryillnesswithlaboratoryconfirmedswineinfluenzaA H1N1 virusinfectionatCDCbyoneormoreofthefollowingtests real timeRT PCRviralcultureAprobablecaseofswineinfluenzaA H1N1 virusinfectionisdefinedasapersonwithanacutefebrilerespiratoryillnesswhois positiveforinfluenzaA butnegativeforH1andH3byinfluenzaRT PCR orpositiveforinfluenzaAbyaninfluenzarapidtestoraninfluenzaimmunofluorescenceassay IFA plusmeetscriteriaforasuspectedcaseAsuspectedcaseofswineinfluenzaA H1N1 virusinfectionisdefinedasapersonwithacutefebrilerespiratoryillnesswithonsetwithin7daysofclosecontactwithapersonwhoisaconfirmedcaseofswineinfluenzaA H1N1 virusinfection orwithin7daysoftraveltocommunityeitherwithintheUnitedStatesorinternationallywherethereareoneormoreconfirmedswineinfluenzaA H1N1 cases orresidesinacommunitywherethereareoneormoreconfirmedswineinfluenzacases Source CDC SwineInfluenzaA H1N1 USCaseDefinitions InfectiousperiodforaconfirmedcaseofswineinfluenzaA H1N1 virusinfectionisdefinedas1daypriortothecase sillnessonsetto7daysafteronsetClosecontactisdefinedas withinabout6feetofanillpersonwhoisaconfirmedorsuspectedcaseofswineinfluenzaA H1N1 virusinfectionduringthecase sinfectiousperiodAcuterespiratoryillnessisdefinedasrecentonsetofatleasttwoofthefollowing rhinorrheaornasalcongestion sorethroat cough withorwithoutfeverorfeverishness High riskgroups Apersonwhoisathigh riskforcomplicationsofswineinfluenzaA H1N1 virusinfectionisdefinedasthesameforseasonalinfluenza seeReference Source CDC SwineInfluenzaA H1N1 GuidelinesforClinicians CliniciansshouldconsiderthepossibilityofswineinfluenzavirusinfectionsinpatientspresentingwithfebrilerespiratoryillnesswholiveinareaswherehumancasesofswineinfluenzaA H1N1 havebeenidentifiedorhavetraveledtoanareawherehumancasesofswineinfluenzaA H1N1 hasbeenidentifiedorhavebeenincontactwithillpersonsfromtheseareasinthe7dayspriortotheirillnessonsetIfswinefluissuspected cliniciansshouldobtainarespiratoryswabforswineinfluenzatestingandplaceitinarefrigerator notafreezer oncecollected theclinicianshouldcontacttheirstateorlocalhealthdepartmenttofacilitatetransportandtimelydiagnosisatastatepublichealthlaboratory Source CDC SwineInfluenzaA H1N1 GuidelinesforClinicians SignsandSymptomsInfluenza like illness ILI Fever cough sorethroat runnynose headache muscleaches Insomecasesvomitinganddiarrhea ThesecaseshadillnessonsetduringlateMarchtomid April2009 Casesofsevererespiratorydisease requiringhospitalizationincludingfataloutcomes havebeenreportedinMexicoThepotentialforexacerbationofunderlyingchronicmedicalconditionsorinvasivebacterialinfectionwithswineinfluenzavirusinfectionshouldbeconsideredNon hospitalizedillpersonswhoareaconfirmedorsuspectedcaseofswineinfluenzaA H1N1 virusinfectionarerecommendedtostayathome voluntaryisolation foratleastthefirst7daysafterillnessonsetexcepttoseekmedicalcare Source CDC FDAIssuesAuthorizationsforEmergencyUse EUAs ofAntiviralsOnApril27 2009 theU S FoodandDrugAdministration FDA issuedEUAsinresponsetorequestsbytheCentersforDiseaseControlandPrevention CDC fortheswinefluoutbreakOneofthereasonstheEUAscouldbeissuedwasbecausetheU S DepartmentofHealthandHumanServices HHS declaredapublichealthemergencyonApril26 2009TheswineinfluenzaEUAsaidinthecurrentresponse Tamiflu AllowforTamiflutobeusedtotreatandpreventinfluenzainchildrenunder1yearofage andtoprovidealternatedosingrecommendationsforchildrenolderthan1year TamifluiscurrentlyapprovedbytheFDAforthetreatmentandpreventionofinfluenzainpatients1yearandolder TamifluandRelenza Allowforbothantiviralstobedistributedtolargesegmentsofthepopulationwithoutcomplyingwithfederallabelrequirementsthatwouldotherwiseapplytodispenseddrugsandtobeaccompaniedbywritteninformationabouttheemergencyuseofthemedicines SwineInfluenzaA H1N1 GuidelinesforClinicians Source FDA SwineInfluenzaA H1N1 BiosafetyGuidelinesforLaboratoryWorkers DiagnosticworkonclinicalsamplesfrompatientswhoaresuspectedcasesofswineinfluenzaA H1N1 virusinfectionshouldbeconductedinaBSL 2laboratoryAllsamplemanipulationsshouldbedoneinsideabiosafetycabinet BSC ViralisolationonclinicalspecimensfrompatientswhoaresuspectedcasesofswineinfluenzaA H1N1 virusinfectionshouldbeperformedinaBSL 2laboratorywithBSL 3practices enhancedBSL 2conditions Additionalprecautionsinclude recommendedpersonalprotectiveequipment basedonsitespecificriskassessment respiratoryprotection fit testedN95respiratororhigherlevelofprotectionshoecoversclosed frontgowndoublegloveseyeprotection gogglesorfaceshields Wasteallwastedisposalproceduresshouldbefollowedasoutlinedinyourfacilitystandardlaboratoryoperatingprocedures Source CDC SwineInfluenzaA H1N1 BiosafetyGuidelinesforLaboratoryWorkers Appropriatedisinfectants70percentethanol5percentLysol10percentbleachAllpersonnelshouldselfmonitorforfeverandanysymptoms Symptomsofswineinfluenzainfectionincludediarrhea headache runnynose andmuscleachesAnyillnessshouldbereportedtoyoursupervisorimmediatelyForpersonnelwhohadunprotectedexposureoraknownbreachinpersonalprotectiveequipmenttoclinicalmaterialorlivevirusfromaconfirmedcaseofswineinfluenzaA H1N1 antiviralchemoprophylaxiswithzanamiviroroseltamivirfor7daysafterexposurecanbeconsidered Source CDC FDAIssuesAuthorizationsforEmergencyUse EUAs ofDiagnosticTestsOnApril27 2009 theU S FoodandDrugAdministration FDA issuedEUAsinresponsetorequestsbytheCentersforDiseaseControlandPrevention CDC fortheswinefluoutbreakOneofthereasonstheEUAscouldbeissuedwasbecausetheU S DepartmentofHealthandHumanServices HHS declaredapublichealthemergencyonApril26 2009TheswineinfluenzaEUAsaidinthecurrentresponse DiagnosticTest AllowCDCtodistributetherRT PCRSwineFluPaneldiagnostictesttopublichealthandotherqualifiedlaboratoriesthathavetheequipmentandpersonneltoperformandinterprettheresults SwineInfluenzaA H1N1 BiosafetyGuidelinesforLaboratoryWorkers Source CDC SwineInfluenzaA H1N1 GuidelinesforGeneralPopulation CoveringnoseandmouthwithatissuewhencoughingorsneezingDisposethetissueinthetrashafteruse HandwashingwithsoapandwaterEspeciallyaftercoughingorsneezing Cleaninghandswithalcohol basedhandcleanersAvoidingclosecontactwithsickpeopleAvoidingtouchingeyes noseormouthwithunwashedhandsIfsickwithinfluenza stayinghomefromworkorschoolandlimitcontactwithotherstokeepfrominfectingthem SwineInfluenzaA H1N1 Treatment Nov