H1N1 2009 pandemic What you need to Know

1. H1N1 2009 pandemicWhat you need to Know Ali Hassoun, MD Alabama Infectious Diseases Center Huntsville, AL

2. What is ‘the flu’? An illness caused by influenza virus • A sudden onset respiratory illness with fever • Affects nose, throat, air passages, and lung • Yearly epidemics • Occurs worldwide causing significant illness

3. How are viruses different from other germs? • Much smaller than animal cells or bacteria • Viruses need to get a life! • Need to be inside our cells to live • Our cells become virus factories • Influenza virus kills cells in breathing passages

4. What does an influenza virus look like? • Hemagglutinin protein • Allows virus to stick to cells of some animals and not others • Neuraminidase protein • Helps release new virus from cells • Genes (RNP) divided into 8 parts • Allows 2 or more viruses to mix and match genes Fig.1 Electron micrograph Fig.2 Schematic of influenza virus

5. Why are the numbered “H” and “N” important? • Used to subtype influenza A strains • 16 different H’s • 9 different N’s • Current human subtypes • A(H1N1) and A(H3N2) primarily • Antibodies against H’s and N’s made by our immune system protect us • H and N subtypes are basis for flu vaccines H1N1

6. How is influenza spread? • Patients with pandemic H1N1 influenza A virus infection are likely to be contagious from one day prior to the development of signs and symptoms until resolution of fever. • Incubation– Typically 2 days • Range 1 to 4 days • Viral shedding • Can begin 1 day before the onset of symptoms • Peak shedding first 3 days of illness • Correlates with fever • Subsides usually by 7 days • Can be 10+ days in children

7. Is flu only spread through the air? • Large droplet mostly • Generated by coughing, sneezing, talking • “spitting distance” • Contact with contaminated hands or surfaces, sometimes • Microscopic droplets less common • Certain other bodily fluids (eg, diarrheal stool) should also be considered potentially infectious

8. the consequences of yearly epidemics in U.S.A? • > 36,000 die and 200,000 are hospitalized • 5 to 20% of general population infected • Nursing home attack rates of up to 60% • 85% of flu-related deaths in ages > 65 • Over $10 billion lost

9. Credit: US National Museum of Health and Medicine What about past flu pandemics? 1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu” A(H1N1) A(H2N2) A(H3N2) 20-40 m deaths 675,000 US deaths 1-4 m deaths 70,000 US deaths 1-4 m deaths 34,000 US deaths

10. H1N1 2009 pandemic • In March and April 2009, an outbreak of respiratory illnesses was first noted in Mexico, which was eventually identified as being related to H1N1 influenza A. The outbreak spread rapidly to the United States, Canada, and throughout the world as a result of airline travel • As of July 31, 2009, over 162,000 laboratory-confirmed cases had been reported in over 160 countries • In the United States, as of July 24, 2009, over 43,000 confirmed cases had been reported from 55 states and territories. • In Alabama as of August 19, 1587 confirmed cases and madison county had 115 cases

11. Novel H1N1 Confirmed and Probable Case Rate in the United States, By Age Group

12. What are symptoms of H1N1 flu? • Fever, usually > 101oF, and chills • Sore throat • Nasal congestion and runny nose • Headache • Body and muscle aches • Dry cough • Tiredness and weakness • Nausea, vomiting, diarrhea. gastrointestinal manifestations appear to be more common

13. Who is at risk for severe infection with H1N1 virus? • the most common risk factors for influenza complications • Chronic lung disease (asthma or chronic obstructive pulmonary disease) • Immunosuppressive conditions • Cardiac disease • Pregnancy • Diabetes mellitus • Obesity

14. How is H1N1 influenza treated? • Treatment is mostly supportive with rest, fluids, cough medicine, and antipyretics such as Tylenol. Aspirin should be avoided. • It can be treated with antivirals. Mainly for at risk population and hospitalized patients with more than mild symptoms. • Oseltamivir (Tamiflu)– • capsules and oral liquid • Zanamivir (Relenza)– • Inhaled powder

15. Will a regular flu vaccine protect me? • No protection from current flu vaccine • H1N1 vaccine will be available mid October, initially will be indicated: • Pregnant women, • People who live with and care for children younger than 6 months of age, • Healthcare and emergency medical services personnel, • People between the ages of 6 months and 24 years • People ages 25–64 years of age who have chronic health conditions (such as asthma, heart disease, or diabetes) or compromised immune systems.

16. When should I call my healthcare provider? • Call if you get concerned about your symptoms especially if you or a family member are high risk. • If you have a fever and two or more other flu symptoms especially if symptoms are severe • Your provider may recommend tests or treatment with antivirals • If unable to drink fluids, have dark urine, or feel dizzy when standing (signs of dehydration) • If you have a fever for more than 3 to 5 days even if you have already been treated • If you start to recover from the flu symptoms and you get fever again.

17. When to Seek Emergency Medical Care • has difficulty breathing or chest pain • has purple or blue discoloration of the lips • is vomiting and unable to keep liquids down • has signs of dehydration such as dizziness when standing, absence of urination, or in infants, a lack of tears when they cry • has seizures (for example, uncontrolled convulsions) • is less responsive than normal or becomes confused

18. What should I do if I’m exposed to someone with H1N1 influenza? • Anti-viral prophylaxis is recommended for certain groups of people. • Household close contacts who are at high-risk of complications of a confirmed or probable case • Your healthcare provider can tell you if you need preventative medication • If you are not in a high-risk group you should: • Limit your contact with others in the community • Stay home at the earliest sign of flu symptoms For updates see: http://www.cdc.gov/h1n1flu/recommendations.htm

19. What should People with novel H1N1 flu do ? • Check with their health care provider about whether they should take antiviral medications • Keep away from others as much as possible. Do not go to work or school while ill • Stay home for at least 24 hours after fever is gone, except to seek medical care or for other necessities. (Fever should be gone without the use of a fever-reducing medicine.) • Drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to keep from being dehydrated • Cover coughs and sneezes. Clean hands with soap and water or an alcohol-based hand rub often and especially after using tissues and after coughing or sneezing into hands • Wear a facemask – if available and tolerable – when sharing common spaces with other household members to help prevent spreading the virus to others. • be watchful for emergency warning signs that might indicate you need to seek medical attention.

20. Placement of the sick person • Keep the sick person in a room separate from the common areas of the house. Keep the sickroom door closed. • Unless necessary for medical care or other necessities, people who are sick with an influenza-like-illness should stay home and keep away from others as much as possible • If possible, sick persons should use a separate bathroom. This bathroom should be cleaned daily with household disinfectant.

21. Protect other persons in the home • The sick person should not have visitors other than caregivers. • If possible, have only one adult in the home take care of the sick person. • If you are in a high risk group for complications from influenza, you should attempt to avoid close contact (within 6 feet) with household members who are sick with influenza. • Avoid having sick family members care for infants and other groups at high risk for complications of influenza. • All persons in the household should clean their hands frequently, including after every contact with the sick person or the person’s room or bathroom. • Use paper towels for drying hands after hand washing or dedicate cloth towels to each person in the household. For example, have different colored towels for each person. • If possible, consideration should be given to maintaining good ventilation in shared household areas (e.g., keeping windows open in restrooms, kitchen, bathroom, etc.). • Antiviral medications can be used to prevent the flu, so check with your health care provider to see if some persons in the home should use antiviral medications.

22. What about masks in a pandemic? Masks outside a healthcare setting can be considered in some circumstances. • Facemasks considered for crowded settings (avoid if possible and minimize time) • Protect wearer from others’ cough and protect others from wearer’s cough • Single use • Respirators (N95) considered when close contact with infected person is unavoidable • Care of sick person at home • Requires fit-testing to be effective • Single use

23. What about household cleaning, laundry, and waste disposal? • Throw away tissues and other disposable items used by sick person in the trash (wash hands) • Keep surfaces clean by wiping down with a household disinfectant according to label • Eating utensils and dishes of sick person • Do not need to be cleaned separately; wash thoroughly in dishwasher or with soap and water • Linens and towels • Household laundry soap and tumble dry on hot • Avoid “hugging” laundry prior to washing to prevent contaminating yourself • Clean hands with soap and water or alcohol-based hand rub right after handling dirty laundry

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