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-Influenza-epidemiology,prevention and control

This document provides an overview of influenza, including its history, epidemiology, types, transmission, prevention, and control. It discusses how influenza is caused by orthomyxoviruses, with type A being the most severe and causing pandemics. Seasonal epidemics typically peak between November to March in temperate regions. Prevention methods include annual vaccination and practicing respiratory hygiene and isolation precautions.

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INFLUENZA Epidemiology, Prevention and Control SPEAKER:- Shubhanshu Gupta TEACHER I/C:- Dr.Dheeraj Mahajan DATE:- 09/09/2014 1
Contents 1. History 2. About the disease and types 3. Epidemiological trends 4. Prevention and Control. 5. Pandemic Influenza(h1n1) 2009 6. Special-avian Influenza(outbreaks). 7. Newer vaccines and strains. 2
History of influenza • 412 BC - first mentioned by Hippocrates • 1580 - first pandemic described • 1580-1900 - 28 pandemics 3
Discovery of Influenza Virus • First isolated from a pig in 1931 (swine flu) • Isolated from human in 1933 4
5 WHAT IS INFLUENZA? (ALSO KNOWN AS THE FLU) • The flu is a contagious respiratory illness • It is caused by influenza viruses • It can cause mild to severe illness and at times can lead to death • It can be prevented by getting the flu vaccination each year
Influenza: A Viral infection • Acute respiratory infection caused by Influenza virus – Three types A, B and C. • Currently viruses circulating in human population – Influenza A (H3N2), A (H1N1) and B Strains. • All known pandemics (global outbreaks) were caused by Influenza A. • Animal influenza viruses may affect humans in special circumstances – Bird Flu: A (H5N1). 6
Naming influenza viruses 16 9 Type Hemagglutinin Neuraminidase A/Hong Kong/156/97 (H5N1) Origin Year isolated Strain ID 7
Influenza types Type A Potentially severe illness Epidemics and pandemics Rapidly changing Type B Usually less severe illness Epidemics More uniform Type C Usually mild or asymptomatic illness Minimal public health impact 8
Classification of Influenza virus • Classified on the basis of hemagglutinin (HA) and neuraminidase (NA). • 16 subtypes of HA and 9 subtypes of NA are known to exist in animals (HA 1-16, NA 1-9). • 3 subtypes of HA (1-3) and 2 subtypes of NA (1- 2) are human influenza viruses. HA 5, 7, 9 and NA 7 can also infect humans 9
Epidemiology • Worldwide distribution • Outbreaks usually occur suddenly. • Flu spreads through communities resulting in an epidemic. Cases tend to peak after about 3 weeks and begin to subside after another 3-4 weeks 10
Causative Agent of Influenza • Caused by a virus belonging to the MYXOVIRUS group which comprises of Orthomyxovirus and Paramyxovirus • Influenza virus is an Orthomyxovirus 11
Influenza A Virus Structure • Hemagglutinin (HA) – Receptor binding (sialic acid) – Membrane fusion – Neutralizing antibody target • Neuraminidase (NA) – Remove sialic acid residues – Virion release • Ion channel (M2) – H+-dependent uncoating – Influenza A only • Influenza A subtypes based on HA (16) and NA (9) – H1N1, H3N2 – A/Hong Kong/8/68 12
Influenza Antigenic Changes • Antigenic Shift – major change, new subtype – caused by exchange of gene segments – may result in pandemic • Example of antigenic shift – H2N2 virus circulated in 1957-1967 – H3N2 virus appeared in 1968 and completely replaced H2N2 virus 13
• Antigenic Drift – minor change, same subtype – caused by point mutations in gene – may result in epidemic • Example of antigenic drift – in 2002-2003, A/Panama/2007/99 (H3N2) virus was dominant – A/Fujian/411/2002 (H3N2) appeared in late 2003 and caused widespread illness in 2003-2004 14
15 Priority Groups/ CDC Recommendations • People 65 years of age and older • People 2-64 years with chronic health conditions • Children 6-23 months • Pregnant women • Healthcare personnel who provide direct patient care • Household contact and out-of-home caregivers of children less than 6 months of age
Epidemiology cont. • Peak season is November through March • Each year about 10 to 20% of indians develop influenza • Overcrowding enhances transmission. 16
Seasonality Incubation period • Time from exposure to onset of symptoms • 1 to 4 days (IQ range = 2-3 days) • Peak shedding first 3 days of illness Seasonality • In temperate zones, increases in winter months – Driven by mutations and viral preference for cold, dry weather conditions • In tropical zones, circulates year-round – Fall-winter and rainy season increase has been observed – More international data is needed 27
Influenza spread occurs in seasonal patterns Northern hemisphere Tropics Southern hemisphere Influenza activity peak: November-March2,3 . Year-round activity3,4 Influenza activity peak: April-September4,5 10 8 6 4 2 0 1 3 5 7 9 11 13 15 40 42 44 46 48 50 52 Week 50 40 30 20 10 0 J F M A M J J A S O N D Month ILI/1000 Population ILI/1000 Population 20 18 16 14 12 10 8 6 4 2 0 1 5 9 13 17 21 25 29 33 37 41 49 Week 45 ILI Consultations/ 1000 Population E.g. India 18
MONTHLY INFLUENZA ACTIVITY REPORTED BY-INDIAN SENTINEL DOCTOR’S NETWORK FEB-MAR Karnataka Uttar Pradesh Himachal Pradesh Andhra Pradesh Maharashtra Orissa Gujarat Rajasthan Madhya Pradesh Jharkhand Jammu Kashmir Punjab Chattisgarh Uttaranchal Haryana Bihar New Delhi Tamil Nadu Kerala Sikkim West Bengal Arunachal Pradesh • Location: Delhi ( Jan-Mar 2008 ) Assam Nagaland Manipur Tripura Mizoram Meghalaya  Total Sample Collected :86 samples  Total No. of Sample +ve :12 Samples > 40% positivity • Location: Chennai (22nd Feb-22nd March 2008)  Total Sample Collected : 55 Samples  Total No. of Sample +ve : 23 Samples  % + ve : 41.82 % +ve  Influenza A :13 Samples (56.5%)  Influenza B : 10 Samples (43.3%) 2008 No Report  % +ve :14%+ve  Influenza A/H1N1 : 6 Samples  Influenza B : 4 Samples  Not determined but +ve : 2 Samples Source: Sentinel Doctor’s Network,March 2008 > 10 % positvity 19
March- April August - October 20
India 2011 J J A S Influenza virus circulation peaks in June-August 21
Global surveillance network: 106 Member countries 136 NIC 6 WHO CCS 4 ERLS 11 H5 Ref Labs 22
Influenza Activity And Peaks 23
WHO National Influenza Center (as of April 2011) • Pune (NIV), • Kasauli (CRI) • Mumbai(Haffkine Institute) 24
Influenza: Transmission • Incubation period: 1-4 days, average 2 days. • Transmission may start 1 or 2 days before onset of symptoms and last for a week. • Immunocompromised patients may transmit the virus for up to a month after onset of symptoms . • Virus particles spread through coughing and sneezing . • One infectious particle can generate up to 1,000 virus particles. 25
 Influenza transmission is by 3 ways : 1. Direct transmission into the mucous membrane of a person . 2. Airborne route – that is via droplets .(0.5-5 μm diameter) 3. Contaminated surfaces, handles etc… 26
27
Common Symptoms • Respiratory disease • Abrupt onset of symptoms • Fever (up to 104° F) • Chills (sometimes shaking) • Muscle aches and pains • Sweating • Dry Cough • Nasal congestion • Sore throat • Headache • Malaise • Fatigue 28
Influenza Pathogenesis • Respiratory transmission of virus • Replication in respiratory epithelium with subsequent destruction of cells • Viremia usually not demonstrable • Viral shedding in respiratory secretions for 5-10 days 29
Laboratory Testing for Influenza • Rapid diagnostic tests  Can provide results <30 minutes  ~ 70+% sensitive, 90+% specific • Serology  Must used paired serum samples  >2 week delay for results 30 .Viral culture  Gold standard  Results take 7 days  Influenza isolates for yearly vaccine development .RT-PCR  Most sensitive  Becoming more widely available .Immunofluorescence  Requires intact cells and laboratory skill/experience
CDC swab kit available Method: horizontal, away from nasal septum 31
Influenza Complications • Pneumonia – primary influenza – secondary bacterial • Reye syndrome • Myocarditis • Guillian barre syndrome • Death ~0.5-1 per 1000 cases 32
PREVENTION and CONTROL OF INFLUENZA 33
Importance of the Early Treatment 34
Infection control at Individual level • Respiratory Hygiene / Cough Etiquette – Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing – Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use • Hand hygiene – Hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash after having contact with respiratory secretions and contaminated objects /materials • Use of mask – Three layered surgical mask – For cases and immediate family and social contacts. 35
Personal Protective Equipment (PPE) 36
N-95 Filtering Masks • Protect from inhalation of airborne particles. • Fit tightly to face. • Approved by NIOSH. • Particles<100μm. 37
• Protect from spit and mucous discharges in procedures only. • Do not have adequate filtering. • Do not pass the fit test. • Approved by FDA. 38 Droplet precautions: Surgical Masks
Isolation Precautions 39
Cough etiquette • Respiratory etiquette – Cover nose / mouth when coughing or sneezing • Hand washing! 40
Prevention of Swine Flu 41
Control Measures • Immunoprophylaxis with vaccine • Chemoprophylaxis and chemotherapy 42
Influenza Vaccines • Inactivated subunit (TIV) – intramuscular – trivalent – split virus and subunit types – duration of immunity 1 year or less • Live attenuated vaccine (LAIV) – intranasal – trivalent – duration of immunity at least 1 year 43
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Vaccination Schedules Age group Dosage (im/sc) No. of doses 6-35 months 0.25 ml 1 or 2* 3-8 years 0.5 ml 1 or 2* > 9 years 0.5 ml 1 * 2 doses at least 1 month apart for children receiving vaccine for the first time 45
Flumist®: Efficacy and limitations •Live viruses with limited replication in the upper respiratory tract •Prevents (>90%) disease symptoms •Limited use: Only approved for people 5 to 49 years old in good health condition •Children between 5 and 8 years old: two doses with an interval of 60 days (if not previously vaccinated with Flumist®) .Expensive ($70?) Cold adapted influenza viruses: ca A/Ann Arbor/6/60 (H2N2) ca B/Ann Arbor/1/66 46
Fluzone Intradermal • Licensed by FDA in May 2011 • Approved only for persons 18 through 64 years of age • Dose is 0.1 mL administered in the deltoid area by a specially designed microneedle and injector system • Formulated to contain more HA (27 mcg) than a 0.1 mL dose of regular Fluzone formulation (9 mcg) 47
Fluzone TIV Formulations Formulation (age) HA per dose • Adult (>36 mos) - 45 mcg/0.5 mL • Pediatric (6-35 mos) - 22.5 mcg/0.25 mL • High dose (>65 yrs) - 180 mcg/0.5 mL • Intradermal (18-64 yrs) - 27 mcg/0.1 mL 48
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Nasal Spray Vaccine • Live, attenuated vaccine administered by nasal spray. • Option for those healthy people ages 2 to 49 years old. • Option for health care workers who take care of sick persons or care for babies under 6 months of age and who are healthy between 2 and 49 years of age. • Not to be used in pregnancy. • Not to be used by those who care for or live with someone with a compromised immune system or children less than 2 years of age. 50
Comparison of Influenza Vaccines Vaccine type Composition Immunogenicity Reactogenecity Whole-virus (no longer used) Whole virus +++ +++ Split-virion Surface proteins, nucleocapsid and matrix proteins ++ ++ Subunit Surface proteins ++ + Virosomal Surface proteins plus virosomes ++ + Adjuvanted Surface proteins plus adjuvant +++ ++ Intradermal (subunit) Surface proteins +++ ++ +Low; ++ Medium; +++ High. 51
52 Who Should Not be Vaccinated? • Those with severe allergy to chicken eggs • Those who have had a severe reaction to a flu vaccine in the past • Those who have developed Guillain Barre Syndrome within 6 weeks of getting a flu vaccine previously • Children less than 6 months of age • Those who have a moderate or severe illness with fever (May return for the vaccine when symptoms lessen)
. Medical conditions like  Asthma, heart disease  Blood disorders like sickle cell anaemia  Liver disorders , kidney disorders  Endocrine disorders like diabetes mellitus.  Metabolic disorders ( inherited metabolic disorders or mitochondrial isorders)  Immunocompromised states – HIV/AIDS; prolonged steroid therapy; malignancies.  Morbidly obese (BMI > 40)  Long term aspirin therapy. 53
Vaccine Information Adverse Events  Intramuscular Injection (TIV) • Local Reactions:  pain 20-50% redness 10-13% swelling 6-8% • Muscle aches: 18-30% • Headache: 14-30% • Malaise: 14-22% • Fever: 2-3% • Allergic reactions: <1 in 1 million • Guillain Barre Syndrome: 1 in 1 million.  Intradermal (ID) • Local Reactions: redness 76% hardness 58% swelling 57%  pain 51%  itching 47% • Systemic side effects: similar to TIV  Nasal Spray (LAIV) • Local Reactions: cough 14%  runny nose 45% sore throat 28%  chills 9% 54
Antivirals drugs • M2 ion channel inhibitors: – Amantadine – Rimantidine • Neuraminidase inhibitors: – Tamiflu™ (oseltamivir)-in the form of pills/tablets – Relenza® (zanamivir)-in the form of inhaled powder 55
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What is Pandemic Influenza? • Pandemic influenza is a respiratory (or breathing) illness that is new to humans and can make them very sick. • It happens about 3 times per century and spreads around the world, killing many people and making many people sick. • Pandemic influenza also causes many serious problems in municipalities, such as problems with food, water, and electricity. 57
Prerequisites for pandemic influenza A new influenza virus emerges to which the general population has little/no immunity The new virus must be able to replicate in humans and cause disease The new virus must be efficiently transmitted from one human to another 58
Human Influenza – A public health problem each year – Usually some immunity built up from previous exposures to the same subtype – Infants and elderly most at risk – Result of Antigenic Drift Influenza Pandemics – Appear in the human population rarely and unpredictably – Human population lacks immunity to a new influenza A virus subtype – All age groups, including healthy young adults, may be at increased risk for serious complications – Result of Antigenic Shift 59 Seasonal Epidemics vs. Pandemics
What is H1N1? • A new virus that emerged in 2009 in Mexico City and quickly spread across the globe. • H1N1 declared a pandemic in June 2009.Initially referred to as “swine” influenza because the virus was found to contain genetic material from swine influenza A strains, as well as avian and human strains. -A human virus, and people get it from people – not from pigs. During 2011 India reported 603 cases,275 deaths, case fatality rate=12.44%. 60
Case definitions for pandemic Influenza • Suspected case: with onset in 7 days of close contact OR within 7 days of travel to community OR residing in community with a confirm case of pandemic influenza A. • Probable case: suspected case + positive for influenza A by immunofluorescence assay. • Confirmed case: laboratory confirmed pandemic influenza A case by: RT-PCR,VIRUS CULTURE and FOUR FOLD RISE IN ANTIBODY TITRE. 61
START March 2009 April 2009 May 2009 Pandemic H1N1 rapidly spread worldwide: May 2009 Cumulative cases 1-10 11-50 51–500 500-5,000 >5,000 29 May *, 15,510 cases including 99 deaths reported by 53 countries 62
Pandemic influenza in the 20th Century 1918 “Spanish Flu” 1957 “Asian Flu” 1968 “Hong Kong Flu” 20-40 million deaths 1 million deaths 1 million deaths H1N1 H2N2 H3N2 1920 1940 1960 1980 2000 63
Pandemic Phases 64
WHO Pandemic Phases and Currently Circulating Novel Viruses • H1N1 – April 25, 2009: Declaration of a Public Health Emergency of International Concern – April 28, 2009: WHO declares Phase 4 – April 29, 2009: WHO declares Phase 5 – June 11, 2009: WHO declares Phase 6 • H5N1 – First human cases reported 1997 – Increase in reports of human cases began in 2003 – WHO Phase 3 65
Pandemic Precautions • If a pandemic occurs: – Avoid crowded conditions and close contact with other people – Consider wearing respirators or other protective equipment – Follow good hygiene measures – Practice social distancing – Quarantine ill individuals – Vaccination 66
What is Avian Influenza (Bird Flu)? • It is a disease that spreads from bird to bird, causing some birds to become very sick or die. • It can spread from birds to humans, but not easily. • It is not yet capable of spreading from human to human except in very rare cases. • There is a risk that it could become pandemic influenza, but this has not happened yet with the type of bird flu that has recently killed so many chickens. 67
– Direct and close contact with sick or dead poultry. • Visiting a live poultry market. – No evidence of sustained person-to-person spread. – Limited probable person-to-person spread. 37 Human H5N1 Epidemiology
Pathogenicity • High pathogenicity avian influenza (HPAI) – Causes severe disease in poultry – Contains subtypes H5 or H7 • Low pathogenicity avian influenza (LPAI) – Causes mild disease in poultry – Contains other H subtypes • Includes non-HPAI H5 and H7. • LPAI H5 or H7 subtypes can mutate into HPAI. 69
Worldwide H5N1 Outbreak in Humans: 2003 - 2007 39
Avian Influenza (outbreaks) • In 2003, the avian influenza virus strain H7N7 occurred in poultry farms in the Netherlands, spreading to Germany and Belgium. Infection, mainly conjunctivitis occurred in 83 humans with 1 death. The outbreak was controlled by destroying over 30 million domestic poultry.In 2003, the avian influenza virus, H9N2 was identified in a child in Hong Kong with influenza who recovered. • 2011- 62 cases in cambodia,indonesia,china,bangladesh. 71
Newer strains and vaccines for Influenza • Influenza A (H1N1) – Retain current vaccine strain A/California/7/2009 (H1N1)-like virus. • Influenza A (H3N2) – Replace current vaccine strain A/Victoria/361/2011 (H3N2) - like virus with an A(H3N2) virus antigenically like the cell-propagated prototype virus A/Victoria/361/2011. • Influenza B – Replace current vaccine strain with a B/Massachusetts/2/2012-like virus (B/Yamagata lineage) – Retain current B/Wisconsin/1/2010 - like virus (B/Yamagata lineage) – Replace current vaccine strain with an alternative candidate vaccine virus from the B/Victoria lineage 72
Recent Influenza Vaccine Approvals • Fluarix Quadrivalent December 14, 2012 • First licensed quadrivalent inactivated influenza vaccine to prevent seasonal influenza • For use in persons ages 3 years and older • Contains four strains of the influenza virus, two influenza A strains (H1N1 and H3N2) and two influenza B strains (Yamagata and Victoria lineages) • Flublok – January 16, 2013 • Trivalent vaccine • First licensed influenza vaccine manufactured using an insect virus (baculovirus) expression system and recombinant DNA technology • For use in persons ages 18 through 49. 73
Influenza Vaccine Presentations 2011-2012 Vaccine Dose form Age Fluzone TIV (sanofi pasteur) SDS, SDV, MDV 6 months and older Fluarix TIV FluLaval TIV (GSK) SDS MDV 3 years and older 18 years and older Fluvirin TIV (Novartis) SDS, MDV 4 years and older Afluria TIV (CSL) SDS 9 years and older Flumist LAIV (MedImmune) Nasal spray 2-49 years (healthy, nonpregnant) SDS=single dose syringe; SDV=single dose vial; MDV=multidose vial 74
WHO Recommended strains 2011 - 12 season • It is recommended that vaccines for use in the 2011- 2012 influenza season (northern hemisphere) contain the following: an A/California/7/2009 (H1N1)-like virus; an A/Perth/16/2009 (H3N2)- like virus; Brisbane Brisbane Brisbane A/H1N A/H3N2 B 1 California Perth Brisbane a B/Brisbane/60/2008-like 2011v-i1r2u sse. ason WHO recommended strain are similar to 2010-11 season northern hemisphere strains 75
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-Influenza-epidemiology,prevention and control

  • 1.
    INFLUENZA Epidemiology, Preventionand Control SPEAKER:- Shubhanshu Gupta TEACHER I/C:- Dr.Dheeraj Mahajan DATE:- 09/09/2014 1
  • 2.
    Contents 1. History 2. About the disease and types 3. Epidemiological trends 4. Prevention and Control. 5. Pandemic Influenza(h1n1) 2009 6. Special-avian Influenza(outbreaks). 7. Newer vaccines and strains. 2
  • 3.
    History of influenza • 412 BC - first mentioned by Hippocrates • 1580 - first pandemic described • 1580-1900 - 28 pandemics 3
  • 4.
    Discovery of InfluenzaVirus • First isolated from a pig in 1931 (swine flu) • Isolated from human in 1933 4
  • 5.
    5 WHAT ISINFLUENZA? (ALSO KNOWN AS THE FLU) • The flu is a contagious respiratory illness • It is caused by influenza viruses • It can cause mild to severe illness and at times can lead to death • It can be prevented by getting the flu vaccination each year
  • 6.
    Influenza: A Viralinfection • Acute respiratory infection caused by Influenza virus – Three types A, B and C. • Currently viruses circulating in human population – Influenza A (H3N2), A (H1N1) and B Strains. • All known pandemics (global outbreaks) were caused by Influenza A. • Animal influenza viruses may affect humans in special circumstances – Bird Flu: A (H5N1). 6
  • 7.
    Naming influenza viruses 16 9 Type Hemagglutinin Neuraminidase A/Hong Kong/156/97 (H5N1) Origin Year isolated Strain ID 7
  • 8.
    Influenza types TypeA Potentially severe illness Epidemics and pandemics Rapidly changing Type B Usually less severe illness Epidemics More uniform Type C Usually mild or asymptomatic illness Minimal public health impact 8
  • 9.
    Classification of Influenza virus • Classified on the basis of hemagglutinin (HA) and neuraminidase (NA). • 16 subtypes of HA and 9 subtypes of NA are known to exist in animals (HA 1-16, NA 1-9). • 3 subtypes of HA (1-3) and 2 subtypes of NA (1- 2) are human influenza viruses. HA 5, 7, 9 and NA 7 can also infect humans 9
  • 10.
    Epidemiology • Worldwidedistribution • Outbreaks usually occur suddenly. • Flu spreads through communities resulting in an epidemic. Cases tend to peak after about 3 weeks and begin to subside after another 3-4 weeks 10
  • 11.
    Causative Agent ofInfluenza • Caused by a virus belonging to the MYXOVIRUS group which comprises of Orthomyxovirus and Paramyxovirus • Influenza virus is an Orthomyxovirus 11
  • 12.
    Influenza A VirusStructure • Hemagglutinin (HA) – Receptor binding (sialic acid) – Membrane fusion – Neutralizing antibody target • Neuraminidase (NA) – Remove sialic acid residues – Virion release • Ion channel (M2) – H+-dependent uncoating – Influenza A only • Influenza A subtypes based on HA (16) and NA (9) – H1N1, H3N2 – A/Hong Kong/8/68 12
  • 13.
    Influenza Antigenic Changes • Antigenic Shift – major change, new subtype – caused by exchange of gene segments – may result in pandemic • Example of antigenic shift – H2N2 virus circulated in 1957-1967 – H3N2 virus appeared in 1968 and completely replaced H2N2 virus 13
  • 14.
    • Antigenic Drift – minor change, same subtype – caused by point mutations in gene – may result in epidemic • Example of antigenic drift – in 2002-2003, A/Panama/2007/99 (H3N2) virus was dominant – A/Fujian/411/2002 (H3N2) appeared in late 2003 and caused widespread illness in 2003-2004 14
  • 15.
    15 Priority Groups/ CDC Recommendations • People 65 years of age and older • People 2-64 years with chronic health conditions • Children 6-23 months • Pregnant women • Healthcare personnel who provide direct patient care • Household contact and out-of-home caregivers of children less than 6 months of age
  • 16.
    Epidemiology cont. •Peak season is November through March • Each year about 10 to 20% of indians develop influenza • Overcrowding enhances transmission. 16
  • 17.
    Seasonality Incubation period • Time from exposure to onset of symptoms • 1 to 4 days (IQ range = 2-3 days) • Peak shedding first 3 days of illness Seasonality • In temperate zones, increases in winter months – Driven by mutations and viral preference for cold, dry weather conditions • In tropical zones, circulates year-round – Fall-winter and rainy season increase has been observed – More international data is needed 27
  • 18.
    Influenza spread occursin seasonal patterns Northern hemisphere Tropics Southern hemisphere Influenza activity peak: November-March2,3 . Year-round activity3,4 Influenza activity peak: April-September4,5 10 8 6 4 2 0 1 3 5 7 9 11 13 15 40 42 44 46 48 50 52 Week 50 40 30 20 10 0 J F M A M J J A S O N D Month ILI/1000 Population ILI/1000 Population 20 18 16 14 12 10 8 6 4 2 0 1 5 9 13 17 21 25 29 33 37 41 49 Week 45 ILI Consultations/ 1000 Population E.g. India 18
  • 19.
    MONTHLY INFLUENZA ACTIVITYREPORTED BY-INDIAN SENTINEL DOCTOR’S NETWORK FEB-MAR Karnataka Uttar Pradesh Himachal Pradesh Andhra Pradesh Maharashtra Orissa Gujarat Rajasthan Madhya Pradesh Jharkhand Jammu Kashmir Punjab Chattisgarh Uttaranchal Haryana Bihar New Delhi Tamil Nadu Kerala Sikkim West Bengal Arunachal Pradesh • Location: Delhi ( Jan-Mar 2008 ) Assam Nagaland Manipur Tripura Mizoram Meghalaya  Total Sample Collected :86 samples  Total No. of Sample +ve :12 Samples > 40% positivity • Location: Chennai (22nd Feb-22nd March 2008)  Total Sample Collected : 55 Samples  Total No. of Sample +ve : 23 Samples  % + ve : 41.82 % +ve  Influenza A :13 Samples (56.5%)  Influenza B : 10 Samples (43.3%) 2008 No Report  % +ve :14%+ve  Influenza A/H1N1 : 6 Samples  Influenza B : 4 Samples  Not determined but +ve : 2 Samples Source: Sentinel Doctor’s Network,March 2008 > 10 % positvity 19
  • 20.
    March- April August- October 20
  • 21.
    India 2011 JJ A S Influenza virus circulation peaks in June-August 21
  • 22.
    Global surveillance network: 106 Member countries 136 NIC 6 WHO CCS 4 ERLS 11 H5 Ref Labs 22
  • 23.
  • 24.
    WHO National InfluenzaCenter (as of April 2011) • Pune (NIV), • Kasauli (CRI) • Mumbai(Haffkine Institute) 24
  • 25.
    Influenza: Transmission •Incubation period: 1-4 days, average 2 days. • Transmission may start 1 or 2 days before onset of symptoms and last for a week. • Immunocompromised patients may transmit the virus for up to a month after onset of symptoms . • Virus particles spread through coughing and sneezing . • One infectious particle can generate up to 1,000 virus particles. 25
  • 26.
     Influenza transmissionis by 3 ways : 1. Direct transmission into the mucous membrane of a person . 2. Airborne route – that is via droplets .(0.5-5 μm diameter) 3. Contaminated surfaces, handles etc… 26
  • 27.
  • 28.
    Common Symptoms •Respiratory disease • Abrupt onset of symptoms • Fever (up to 104° F) • Chills (sometimes shaking) • Muscle aches and pains • Sweating • Dry Cough • Nasal congestion • Sore throat • Headache • Malaise • Fatigue 28
  • 29.
    Influenza Pathogenesis •Respiratory transmission of virus • Replication in respiratory epithelium with subsequent destruction of cells • Viremia usually not demonstrable • Viral shedding in respiratory secretions for 5-10 days 29
  • 30.
    Laboratory Testing forInfluenza • Rapid diagnostic tests  Can provide results <30 minutes  ~ 70+% sensitive, 90+% specific • Serology  Must used paired serum samples  >2 week delay for results 30 .Viral culture  Gold standard  Results take 7 days  Influenza isolates for yearly vaccine development .RT-PCR  Most sensitive  Becoming more widely available .Immunofluorescence  Requires intact cells and laboratory skill/experience
  • 31.
    CDC swab kitavailable Method: horizontal, away from nasal septum 31
  • 32.
    Influenza Complications •Pneumonia – primary influenza – secondary bacterial • Reye syndrome • Myocarditis • Guillian barre syndrome • Death ~0.5-1 per 1000 cases 32
  • 33.
    PREVENTION and CONTROLOF INFLUENZA 33
  • 34.
    Importance of theEarly Treatment 34
  • 35.
    Infection control atIndividual level • Respiratory Hygiene / Cough Etiquette – Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing – Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use • Hand hygiene – Hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash after having contact with respiratory secretions and contaminated objects /materials • Use of mask – Three layered surgical mask – For cases and immediate family and social contacts. 35
  • 36.
  • 37.
    N-95 Filtering Masks • Protect from inhalation of airborne particles. • Fit tightly to face. • Approved by NIOSH. • Particles<100μm. 37
  • 38.
    • Protect fromspit and mucous discharges in procedures only. • Do not have adequate filtering. • Do not pass the fit test. • Approved by FDA. 38 Droplet precautions: Surgical Masks
  • 39.
  • 40.
    Cough etiquette •Respiratory etiquette – Cover nose / mouth when coughing or sneezing • Hand washing! 40
  • 41.
  • 42.
    Control Measures •Immunoprophylaxis with vaccine • Chemoprophylaxis and chemotherapy 42
  • 43.
    Influenza Vaccines •Inactivated subunit (TIV) – intramuscular – trivalent – split virus and subunit types – duration of immunity 1 year or less • Live attenuated vaccine (LAIV) – intranasal – trivalent – duration of immunity at least 1 year 43
  • 44.
  • 45.
    Vaccination Schedules Agegroup Dosage (im/sc) No. of doses 6-35 months 0.25 ml 1 or 2* 3-8 years 0.5 ml 1 or 2* > 9 years 0.5 ml 1 * 2 doses at least 1 month apart for children receiving vaccine for the first time 45
  • 46.
    Flumist®: Efficacy andlimitations •Live viruses with limited replication in the upper respiratory tract •Prevents (>90%) disease symptoms •Limited use: Only approved for people 5 to 49 years old in good health condition •Children between 5 and 8 years old: two doses with an interval of 60 days (if not previously vaccinated with Flumist®) .Expensive ($70?) Cold adapted influenza viruses: ca A/Ann Arbor/6/60 (H2N2) ca B/Ann Arbor/1/66 46
  • 47.
    Fluzone Intradermal •Licensed by FDA in May 2011 • Approved only for persons 18 through 64 years of age • Dose is 0.1 mL administered in the deltoid area by a specially designed microneedle and injector system • Formulated to contain more HA (27 mcg) than a 0.1 mL dose of regular Fluzone formulation (9 mcg) 47
  • 48.
    Fluzone TIV Formulations Formulation (age) HA per dose • Adult (>36 mos) - 45 mcg/0.5 mL • Pediatric (6-35 mos) - 22.5 mcg/0.25 mL • High dose (>65 yrs) - 180 mcg/0.5 mL • Intradermal (18-64 yrs) - 27 mcg/0.1 mL 48
  • 49.
  • 50.
    Nasal Spray Vaccine • Live, attenuated vaccine administered by nasal spray. • Option for those healthy people ages 2 to 49 years old. • Option for health care workers who take care of sick persons or care for babies under 6 months of age and who are healthy between 2 and 49 years of age. • Not to be used in pregnancy. • Not to be used by those who care for or live with someone with a compromised immune system or children less than 2 years of age. 50
  • 51.
    Comparison of InfluenzaVaccines Vaccine type Composition Immunogenicity Reactogenecity Whole-virus (no longer used) Whole virus +++ +++ Split-virion Surface proteins, nucleocapsid and matrix proteins ++ ++ Subunit Surface proteins ++ + Virosomal Surface proteins plus virosomes ++ + Adjuvanted Surface proteins plus adjuvant +++ ++ Intradermal (subunit) Surface proteins +++ ++ +Low; ++ Medium; +++ High. 51
  • 52.
    52 Who ShouldNot be Vaccinated? • Those with severe allergy to chicken eggs • Those who have had a severe reaction to a flu vaccine in the past • Those who have developed Guillain Barre Syndrome within 6 weeks of getting a flu vaccine previously • Children less than 6 months of age • Those who have a moderate or severe illness with fever (May return for the vaccine when symptoms lessen)
  • 53.
    . Medical conditionslike  Asthma, heart disease  Blood disorders like sickle cell anaemia  Liver disorders , kidney disorders  Endocrine disorders like diabetes mellitus.  Metabolic disorders ( inherited metabolic disorders or mitochondrial isorders)  Immunocompromised states – HIV/AIDS; prolonged steroid therapy; malignancies.  Morbidly obese (BMI > 40)  Long term aspirin therapy. 53
  • 54.
    Vaccine Information AdverseEvents  Intramuscular Injection (TIV) • Local Reactions:  pain 20-50% redness 10-13% swelling 6-8% • Muscle aches: 18-30% • Headache: 14-30% • Malaise: 14-22% • Fever: 2-3% • Allergic reactions: <1 in 1 million • Guillain Barre Syndrome: 1 in 1 million.  Intradermal (ID) • Local Reactions: redness 76% hardness 58% swelling 57%  pain 51%  itching 47% • Systemic side effects: similar to TIV  Nasal Spray (LAIV) • Local Reactions: cough 14%  runny nose 45% sore throat 28%  chills 9% 54
  • 55.
    Antivirals drugs •M2 ion channel inhibitors: – Amantadine – Rimantidine • Neuraminidase inhibitors: – Tamiflu™ (oseltamivir)-in the form of pills/tablets – Relenza® (zanamivir)-in the form of inhaled powder 55
  • 56.
  • 57.
    What is PandemicInfluenza? • Pandemic influenza is a respiratory (or breathing) illness that is new to humans and can make them very sick. • It happens about 3 times per century and spreads around the world, killing many people and making many people sick. • Pandemic influenza also causes many serious problems in municipalities, such as problems with food, water, and electricity. 57
  • 58.
    Prerequisites for pandemicinfluenza A new influenza virus emerges to which the general population has little/no immunity The new virus must be able to replicate in humans and cause disease The new virus must be efficiently transmitted from one human to another 58
  • 59.
    Human Influenza –A public health problem each year – Usually some immunity built up from previous exposures to the same subtype – Infants and elderly most at risk – Result of Antigenic Drift Influenza Pandemics – Appear in the human population rarely and unpredictably – Human population lacks immunity to a new influenza A virus subtype – All age groups, including healthy young adults, may be at increased risk for serious complications – Result of Antigenic Shift 59 Seasonal Epidemics vs. Pandemics
  • 60.
    What is H1N1? • A new virus that emerged in 2009 in Mexico City and quickly spread across the globe. • H1N1 declared a pandemic in June 2009.Initially referred to as “swine” influenza because the virus was found to contain genetic material from swine influenza A strains, as well as avian and human strains. -A human virus, and people get it from people – not from pigs. During 2011 India reported 603 cases,275 deaths, case fatality rate=12.44%. 60
  • 61.
    Case definitions forpandemic Influenza • Suspected case: with onset in 7 days of close contact OR within 7 days of travel to community OR residing in community with a confirm case of pandemic influenza A. • Probable case: suspected case + positive for influenza A by immunofluorescence assay. • Confirmed case: laboratory confirmed pandemic influenza A case by: RT-PCR,VIRUS CULTURE and FOUR FOLD RISE IN ANTIBODY TITRE. 61
  • 62.
    START March 2009 April 2009 May 2009 Pandemic H1N1 rapidly spread worldwide: May 2009 Cumulative cases 1-10 11-50 51–500 500-5,000 >5,000 29 May *, 15,510 cases including 99 deaths reported by 53 countries 62
  • 63.
    Pandemic influenza inthe 20th Century 1918 “Spanish Flu” 1957 “Asian Flu” 1968 “Hong Kong Flu” 20-40 million deaths 1 million deaths 1 million deaths H1N1 H2N2 H3N2 1920 1940 1960 1980 2000 63
  • 64.
  • 65.
    WHO Pandemic Phases and Currently Circulating Novel Viruses • H1N1 – April 25, 2009: Declaration of a Public Health Emergency of International Concern – April 28, 2009: WHO declares Phase 4 – April 29, 2009: WHO declares Phase 5 – June 11, 2009: WHO declares Phase 6 • H5N1 – First human cases reported 1997 – Increase in reports of human cases began in 2003 – WHO Phase 3 65
  • 66.
    Pandemic Precautions •If a pandemic occurs: – Avoid crowded conditions and close contact with other people – Consider wearing respirators or other protective equipment – Follow good hygiene measures – Practice social distancing – Quarantine ill individuals – Vaccination 66
  • 67.
    What is AvianInfluenza (Bird Flu)? • It is a disease that spreads from bird to bird, causing some birds to become very sick or die. • It can spread from birds to humans, but not easily. • It is not yet capable of spreading from human to human except in very rare cases. • There is a risk that it could become pandemic influenza, but this has not happened yet with the type of bird flu that has recently killed so many chickens. 67
  • 68.
    – Direct andclose contact with sick or dead poultry. • Visiting a live poultry market. – No evidence of sustained person-to-person spread. – Limited probable person-to-person spread. 37 Human H5N1 Epidemiology
  • 69.
    Pathogenicity • Highpathogenicity avian influenza (HPAI) – Causes severe disease in poultry – Contains subtypes H5 or H7 • Low pathogenicity avian influenza (LPAI) – Causes mild disease in poultry – Contains other H subtypes • Includes non-HPAI H5 and H7. • LPAI H5 or H7 subtypes can mutate into HPAI. 69
  • 70.
    Worldwide H5N1 Outbreak in Humans: 2003 - 2007 39
  • 71.
    Avian Influenza (outbreaks) • In 2003, the avian influenza virus strain H7N7 occurred in poultry farms in the Netherlands, spreading to Germany and Belgium. Infection, mainly conjunctivitis occurred in 83 humans with 1 death. The outbreak was controlled by destroying over 30 million domestic poultry.In 2003, the avian influenza virus, H9N2 was identified in a child in Hong Kong with influenza who recovered. • 2011- 62 cases in cambodia,indonesia,china,bangladesh. 71
  • 72.
    Newer strains andvaccines for Influenza • Influenza A (H1N1) – Retain current vaccine strain A/California/7/2009 (H1N1)-like virus. • Influenza A (H3N2) – Replace current vaccine strain A/Victoria/361/2011 (H3N2) - like virus with an A(H3N2) virus antigenically like the cell-propagated prototype virus A/Victoria/361/2011. • Influenza B – Replace current vaccine strain with a B/Massachusetts/2/2012-like virus (B/Yamagata lineage) – Retain current B/Wisconsin/1/2010 - like virus (B/Yamagata lineage) – Replace current vaccine strain with an alternative candidate vaccine virus from the B/Victoria lineage 72
  • 73.
    Recent Influenza VaccineApprovals • Fluarix Quadrivalent December 14, 2012 • First licensed quadrivalent inactivated influenza vaccine to prevent seasonal influenza • For use in persons ages 3 years and older • Contains four strains of the influenza virus, two influenza A strains (H1N1 and H3N2) and two influenza B strains (Yamagata and Victoria lineages) • Flublok – January 16, 2013 • Trivalent vaccine • First licensed influenza vaccine manufactured using an insect virus (baculovirus) expression system and recombinant DNA technology • For use in persons ages 18 through 49. 73
  • 74.
    Influenza Vaccine Presentations 2011-2012 Vaccine Dose form Age Fluzone TIV (sanofi pasteur) SDS, SDV, MDV 6 months and older Fluarix TIV FluLaval TIV (GSK) SDS MDV 3 years and older 18 years and older Fluvirin TIV (Novartis) SDS, MDV 4 years and older Afluria TIV (CSL) SDS 9 years and older Flumist LAIV (MedImmune) Nasal spray 2-49 years (healthy, nonpregnant) SDS=single dose syringe; SDV=single dose vial; MDV=multidose vial 74
  • 75.
    WHO Recommended strains2011 - 12 season • It is recommended that vaccines for use in the 2011- 2012 influenza season (northern hemisphere) contain the following: an A/California/7/2009 (H1N1)-like virus; an A/Perth/16/2009 (H3N2)- like virus; Brisbane Brisbane Brisbane A/H1N A/H3N2 B 1 California Perth Brisbane a B/Brisbane/60/2008-like 2011v-i1r2u sse. ason WHO recommended strain are similar to 2010-11 season northern hemisphere strains 75
  • 76.