CHOTANI © Рашид Хотани, врач, Мастер Общественного здравоохранения Доцент, Университет Наук о Здоровье Своевременная лекция Вспышка свиного гриппа A (H1N1 в США и Мексике: Возможность Эпидемии (Версия 5, первый вариант загружен 26 апреля 2009) Четверг, Апрель 308, 2009

CHOTANI © Автор выражает признательность за усилия, идею, размещение, веб-поддержку и переводы всей команде Суперкурс, особенно: Dr. Ronald E. LaPorte, University of Pittsburgh, USA Dr. Faina Linkov, University of Pittsburgh, USA Dr. Eugene Shubnikov, Institute of Internal Medicine, Russia Dr. Nicolás Padilla Raygoza, Universidad de Guanajuato, México Dr. Ali Ardalan, Tehran University of Medical Sciences, Iran Dr. Mehrdad Mohajeri, Tehran University of Medical Sciences, Iran Dr. Seyed Amir Ebrahimzadeh, Tehran University of Medical Sciences, Iran Dr. Nasrin Rahimian. Tehran University of Medical Sciences, Iran Это по настоящему глобальная работа Благодарность

CHOTANI © Вирус гриппа 2.Определения 3.Введение 4.Исторические данные(США) 5.Текущая ситуация в США 6.Текущая ситуация в Мексике 7.Текущая ситуация в мире 8.Распространение/передача 9.Выявление случаев 10.Рекомендации клиницисты работники лабораторий население 11.Лечение 12.Другие меры профилактики 13.Заключение 14.Выводы и рекомендации Содержание

CHOTANI © Credit: L. Stammard, 1995 РНК, в оболочке Вирусная сообщество: Ортомиксовирусы Размер: nm or.08 – 0.12 μm (микрон) в диаметре Три типа A, B, C Поверхноснтые Антигены H (гемаглютинин) N (нейроминидаза) Вирус

CHOTANI © Эпидемия – изолированные группы заболеваний Пандемия – мировая эпидемия Антигенная вариация Изменения белков из-за генетических точечных мутаций и селекций Продолжающиеся каждый год изменения вакцины Антигенное изменение Изменения белков через генетическую рекомбинацию Появляющиеся новые вирусы не покрываются ежегодной вакциной Определения: Главное

CHOTANI © Source: Bean B, et al. JID 1982;146:47-51 Выживание вируса гриппа на поверхностях в зависимости от влажности и температуры* Hard non-porous surfaces hours Plastic, stainless steel Recoverable for > 24 hours Transferable to hands up to 24 hours Cloth, paper & tissue Recoverable for 8-12 hours Transferable to hands 15 minutes Viable on hands

CHOTANI © Свиной Грипп: Введение Свиной Грипп это респираторное заболевание свиней вызываемое гриппом типа A, которое регулярно вызывает вспышки гриппа среди свиней Вирус свиного гриппа обычно не инфицирует людей, однако инфицирование людей свиным гриппом происходит и случаи распространения вируса свиного гриппа от человека к человеку задокументировны. Обычно, случаи свиного гриппа у людей случаются у людей, кто находится рядом со свиньями, но случаи заражения от людей также возможны.

CHOTANI © Свиной Грипп: Исторические данные(США Вспышка Свиного гриппа в Fort Dix, New Jersey, USA зафиксирована в 1976 и вызвала более 200 случаев заболевания с серьезными проявлениями у нескольких людей и одну смерть Более 40 миллионов людей были вакцинированы Однако, программа была остановлена вскорости после выявления 500 случаев синдрома Гийена Барре, серьезного неврологического заболевания с парезами 30 людей умерли в результате вакцинации В сентябре 1988, не имеющая расстройств здоровья 32 летняя беременная женщина в штате Wisconsin была внезапно госпитализирована с пневмонией после инфицирования свиным гриппом и умерла через 8 дней. С декабря 2005 по Февраль 2009, всего 12 инфекций свиным гриппом у людей были зарегистрированы в 10 штатах США

CHOTANI © Свиной Грипп : Текущая ситуация в США Since March 2009, 91 of confirmed human cases with one death from 10 States have been reported. 1 st death reported in a child (22 months) that had came from Mexico who died in a hospital in the Houston area 5 cases (3 in CA & 2 in TX) hospitalized All have the same genetic pattern based on preliminary testing Virus is being described as a new subtype of A/H1N1 not previously detected in swine or humans Samples from the Mexico outbreak match swine influenza isolates from patients in the United States Source: CDC

CHOTANI © Свиной Грипп : Текущая ситуация в США CDC has determined that this virus is contagious and is spreading from human to human The virus contains gene segments from 4 different influenza types: North American swine, North American avian, North American human, and Eurasian swine The Strategic National Stockpile (SNS) is releasing one-quarter of its Anti-viral drugs Personal protective equipment and Reparatory protection devices President Obama today asked Congress for an additional $1.5 billion to fight the swine flu On April 27, 2009, the CDC issued a travel advisory that recommends against all non- essential travel to Mexico Source: CDC

CHOTANI © Свиной Грипп : Случаи у людей(США) на 28 апреля, 2009 MMWR, April 28, 2009 / 58(Dispatch); patients reported to CDC with known ages (out of 64), the median age was 16 years (range: 3-81 years), 38 (81%) were aged

CHOTANI © Свиной Грипп : Случаи у людей(США) на 29 апреля, 2009 Source: CDC Total Number of Confirmed Cases = 91; 1 Death

CHOTANI © Свиной Грипп :Текущая ситуация в Мексике A total of approximately 2,498 suspected cases, 159 deaths and 1311 hospitalizations (for pneumonia) have been reported in 31 of 32 States in Mexico (April 28, Ministry of Health) 26 Laboratory confirmed First case in Oaxaca, April 13, 2009 Woman died of pneumonia Mexico City: Over 854 cases of pneumonia, 59 of them fatal San Luis Potosi: 24 cases with 3 deaths Mexicali (near the US border): 4 cases with no deaths The illness outbreak in Mexico City prompted the country's health minister to cancel classes in Mexico City and advised students and adults to avoid crowded public places and large events Source: WHO, CDC, PAHO & ProMED

CHOTANI © Свиной Грипп :Текущая ситуация в Мексике The virus in Mexico has primarily struck otherwise healthy young adults, (20-50 years) which is a departure from seasonal influenza, which typically affects the very young and very old CDC's laboratory analyzed 14 samples from severely ill Mexican patients and found that 7 of them had the same swine flu mix as the virus that infected the US patients (preliminary report) Canada's national laboratory has confirmed swine flu A/H1N1 in 18 isolates from Mexican patients, 12 of which were genetically identical to the swine flu viruses from California Source: WHO, CDC & ProMED

CountryLab ConfirmedDeath in Lab ConfirmedSuspectedSuspected DeadHospitalizedTOTALTOTAL Dead Australia Austria Argentina Bolivia Brazil Belgium Canada Chile Columbia Costa Rica France Germany Guatemala Greece Honduras Hong Kong Israel Italy Ireland Mexico New Zealand Norway Peru Poland Russia Slovakia South Korea Spain Sweden Switzerland Uruguay USA UK Venezuela TOTAL CHOTANI © :00 AM April 30

CHOTANI © Свиной Грипп : Текущая ситуация в мире The WHO raised the alert level to Phase 5, meaning there are large clusters (e.g., cases lasting 2 to 4 weeks), but human-to- human spread is still localized. WHOs alert system was revised after Avian influenza began to spread in 2004, and April 27 was the first time it was raised above Phase 3 and on April 29 to Phase confirmed cases worldwide with 8 deaths (Mexico & US) Case-fatality ~ 5% 2,952 suspected cases worldwide with 160 deaths (Mexico & US) Case-fatality ~ 5% 1,318 hospitalized European Union (EU) Health Commissioner Androulla Vassiliou issued a travel advisory to the 27 EU member countries recommending that non-essential travel to affected parts of the U.S. and Mexico be suspended Inter-Pandemic Phase New Virus in Animals, NO Human Cases Low Risk of Human Cases1 High Risk of Human Cases2 Pandemic ALERT New Virus Causes Human Cases No or Very Limited Human-to- Human Transmission 3 Evidence of Increased Human-to- Human Transmission 4 Evidence of Significant Human- to-Human Transmission 5 PANDEMICEfficient & Sustained Human-to- Human Transmission 6

CHOTANI © Свиной Грипп: Межвидовая Передача Рекомбинация через Свиней Avian Virus Human Virus Swine Virus Avian/Human Reassorted Virus

CHOTANI © Свиной Грипп : Передача человеку Через контакт с инфицированными свиньями или предметами загрязненными вирусами свиного гриппа Через контакт с человеком, болеющим свиным гриппом Передача от человека к человеку свиного гриппа, была также документировна и происходила точно также как при сезонных инфекциях, через кашель, чихание инфицированных людей

CHOTANI © Свиной Грипп : Подтверждение случаев в США (обновлено) A confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests: real-time RT-PCR viral culture A probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness who is: positive for influenza A, but negative for H1 and H3 by influenza RT-PCR, or positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case A suspected case of swine influenza A (H1N1) virus infection is defined as a person with acute febrile respiratory illness with onset within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection, or within 7 days of travel to community either within the United States or internationally where there are one or more confirmed swine influenza A(H1N1) cases, or resides in a community where there are one or more confirmed swine influenza cases. Source: CDC

CHOTANI © Свиной Грипп : Подтверждение случаев в США Infectious period for a confirmed case of swine influenza A (H1N1) virus infection is defined as 1 day prior to the cases illness onset to 7 days after onset Close contact is defined as: within about 6 feet of an ill person who is a confirmed or suspected case of swine influenza A (H1N1) virus infection during the cases infectious period Acute respiratory illness is defined as recent onset of at least two of the following: rhinorrhea or nasal congestion, sore throat, cough (with or without fever or feverishness) High-risk groups: A person who is at high-risk for complications of swine influenza A (H1N1) virus infection is defined as the same for seasonal influenza (see Reference) Source: CDC

CHOTANI © Свиной Грипп : Рекомендации клиницистам Clinicians should consider the possibility of swine influenza virus infections in patients presenting with febrile respiratory illness who live in areas where human cases of swine influenza A (H1N1) have been identified or have traveled to an area where human cases of swine influenza A (H1N1) has been identified or have been in contact with ill persons from these areas in the 7 days prior to their illness onset If swine flu is suspected, clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer) once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory Source: CDC

CHOTANI © Свиной Грипп : Рекомендации клиницистам Signs and Symptoms Influenza-like-illness (ILI) Fever, cough, sore throat, runny nose, headache, muscle aches. In some cases vomiting and diarrhea. (These cases had illness onset during late March to mid-April 2009) Cases of severe respiratory disease, requiring hospitalization including fatal outcomes, have been reported in Mexico The potential for exacerbation of underlying chronic medical conditions or invasive bacterial infection with swine influenza virus infection should be considered Non-hospitalized ill persons who are a confirmed or suspected case of swine influenza A (H1N1) virus infection are recommended to stay at home (voluntary isolation) for at least the first 7 days after illness onset except to seek medical care Source: CDC

CHOTANI © FDA Issues Authorizations for Emergency Use (EUAs) of Antivirals On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued EUAs in response to requests by the Centers for Disease Control and Prevention (CDC) for the swine flu outbreak One of the reasons the EUAs could be issued was because the U.S. Department of Health and Human Services (HHS) declared a public health emergency on April 26, 2009 The swine influenza EUAs aid in the current response: Tamiflu: Allow for Tamiflu to be used to treat and prevent influenza in children under 1 year of age, and to provide alternate dosing recommendations for children older than 1 year. Tamiflu is currently approved by the FDA for the treatment and prevention of influenza in patients 1 year and older. Tamiflu and Relenza: Allow for both antivirals to be distributed to large segments of the population without complying with federal label requirements that would otherwise apply to dispensed drugs and to be accompanied by written information about the emergency use of the medicines. Свиной Грипп : Рекомендации клиницистам

CHOTANI © Свиной Грипп : Рекомендации по биологической защите работникам лабораторий Diagnostic work on clinical samples from patients who are suspected cases of swine influenza A (H1N1) virus infection should be conducted in a BSL-2 laboratory All sample manipulations should be done inside a biosafety cabinet (BSC) Viral isolation on clinical specimens from patients who are suspected cases of swine influenza A (H1N1) virus infection should be performed in a BSL-2 laboratory with BSL-3 practices (enhanced BSL-2 conditions) Additional precautions include: recommended personal protective equipment (based on site specific risk assessment) respiratory protection - fit-tested N95 respirator or higher level of protection shoe covers closed-front gown double gloves eye protection (goggles or face shields) Waste all waste disposal procedures should be followed as outlined in your facility standard laboratory operating procedures Source: CDC

CHOTANI © Свиной Грипп : Рекомендации по биологической защите работникам лабораторий Appropriate disinfectants 70 per cent ethanol 5 per cent Lysol 10 per cent bleach All personnel should self monitor for fever and any symptoms. Symptoms of swine influenza infection include diarrhea, headache, runny nose, and muscle aches Any illness should be reported to your supervisor immediately For personnel who had unprotected exposure or a known breach in personal protective equipment to clinical material or live virus from a confirmed case of swine influenza A (H1N1), antiviral chemoprophylaxis with zanamivir or oseltamivir for 7 days after exposure can be considered Source: CDC

CHOTANI © FDA Issues Authorizations for Emergency Use (EUAs) of Diagnostic Tests On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued EUAs in response to requests by the Centers for Disease Control and Prevention (CDC) for the swine flu outbreak One of the reasons the EUAs could be issued was because the U.S. Department of Health and Human Services (HHS) declared a public health emergency on April 26, 2009 The swine influenza EUAs aid in the current response: Diagnostic Test: Allow CDC to distribute the rRT-PCR Swine Flu Panel diagnostic test to public health and other qualified laboratories that have the equipment and personnel to perform and interpret the results. Свиной Грипп : Рекомендации работникам лабораторий

CHOTANI © Свиной Грипп: Инструкции для Населения Закрывайте нос и рот платком, когда кашляете или чихаете Выбрасывайте платок после использования Мойте руки с мылом и водой Особенно после кашля и чихания Очищайте руки с помощью салфеток с содержанием алкоголя Избегайте контактов с заболевшими Не дотрагивайтесь до глах, носа и рта невымытыми руками Если заболели гриппом, оставайтесь дома (ни на работу, ни на учебу) и ограничьте контакт с другими, чтобы не заразить их Source: CDC

CHOTANI © Свиной Грипп : Лечение No vaccine available Antivirals for the treatment and/or prevention of infection: Oseltamivir (Tamiflu) or Zanamivir (Relenza) Use of anti-virals can make illness milder and recovery faster They may also prevent serious flu complications For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms) Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing products (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers (up to 18 years old) who are confirmed or suspected ill case of swine influenza A (H1N1) virus infection; this can cause a rare but serious illness called Reyes syndrome. For relief of fever, other anti-pyretic medications are recommended such as acetaminophen or non steroidal anti-inflammatory drugs. Source: CDC

CHOTANI © Свиной Грипп : Другие меры профилактики Defining Quarantine vs. Isolation vs. Social-Distancing Isolation: Refers only to the sequestration of symptomatic patents either in the home or hospital so that they will not infect others Quarantine: Defined as the separation from circulation in the community of asymptomatic persons that may have been exposed to infection Social-Distancing: Has been used to refer to a range of non- quarantine measures that might serve to reduce contact between persons, such as, closing of schools or prohibiting large gatherings Source: CDC

CHOTANI © Свиной Грипп : Другие меры профилактики Personnel Engaged in Aerosol Generating Activities CDC Interim recommendations: Personnel engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator Pending clarification of transmission patterns for this virus, personnel providing direct patient care for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator when entering the patient room Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Source: CDC

CHOTANI © Infection Control of Ill Persons in a Healthcare Setting Patients with suspected or confirmed case-status should be placed in a single-patient room with the door kept closed. If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling. The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. Свиной Грипп : Другие меры профилактики Source: CDC

CHOTANI © Infection Control of Ill Persons in a Healthcare Setting Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Maintain adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure. Свиной Грипп : Другие меры профилактики Source: CDC

CHOTANI © Хирургические маски Легкодоступны и обычно используются в рутинных хирургических и проверочных процедурах Респираторные маски высокой фильтрации Диск-фильтр специальной микроструктуры для задержки частиц больше 0,3 микронов. Классификация: маслонепроницаемые маслорезистентные не резистентные к маслу Чем более маска резистентна к маслу, тем она лучше Маски имеют номера, указывающие их фильтрующую эффективность. К примеру маска N95 имеет 95% эффективность при фильтрации частиц свыше 0.3 микрон при нормальной степени респирации. Следющее поколение масок использует нанотехнологии. Они способны задерживать частицы размером до микрон. Типы защитных масок

CHOTANI © Заключение Существуют доказательство циркуляции форм вирусов ранее не обнаруженных у свиней и людей ВОЗ повысила уровень эпидемиологической тревоги на фазу 5, означающую что существуют большие кластеры (25-50 случаев в течение 2 -4 недель, но распространение от человека к человеку пока локализовано. 164 подтвержденных случая по всему миру (10 стран) и 8 смертей (Мексика и США); Летальность ~ 5% 2,952 подозрительных случая в мире (34 страны) с 160 смертями (Мексика и США); Летальность ~ 5% 1,318 людей госпитализировано В США эпидемиологические данные одного исследования обнародованы 47 пациентов (из 64), средний возраст 16 лет ( с 3 до 81 лет) 38 (81%) в возрасте

CHOTANI © Выводы/Рекомендации 1.At present, there are cases in Canada and the United States who do not have a history of travel to Mexico, so there are now 3 countries reporting human to human spread of the virus – the virus should be renamed North American H1N1 influenza 2.Most people do not have immunity to this virus and, as it continues to spread, more cases, more hospitalizations and more deaths are expected in the coming days and weeks. Each locality/jurisdiction needs to have enhanced disease and virological surveillance capabilities develop a plan to house large number of severely sick and provide care if needed & to deal with mildly sick at home (voluntary quarantine) healthcare facilities/hospitals need to focus on stringent infection prevention and control 3.In the Northern Hemisphere influenza viral transmission traditionally stops by the beginning of May but in pandemic years (1957) sporadic outbreaks occurred during summer among young adults Likelihood that this wave will fade in North America within the next 3-5 weeks (influenza virus cannot survive high humidity or temperature) will reappear in autumn in North America as a highly pathogenic second wave will continue to circulate and cause disease in Australia & New Zealand

CHOTANI © Выводы/Рекомендации 4.Border Closure and Travel Restrictions: The disease has already crossed borders and continents, thus, border closure or travel restrictions will not change the course of the spread of disease Most recently, the 2003 experience with SARS demonstrated the ineffectiveness of such measures In China, 14 million people were screened for fever at the airport, train stations, and roadside checkpoints, but only 12 were found to have probable SARS Singapore reported that after screening nearly 500,000 air passengers, none were found to have SARS passive surveillance methods (in which symptomatic individuals report illness) can be important tools 5.School Closures: Preemptive school closures will just delay the spread of disease, once they reopen (as they cannot be closed indefinitely), the disease will spread again. Furthermore, this would put unbearable pressure on single-working parents and would be devastating to the economy Closure after identification of a large cluster would be appropriate as the absenteeism rate among students and teachers would be high enough to justify this action 6.High priority should be given to include the present North American (swine) influenza A/H1N1 virus in next years vaccine