Influenza A (H1N1)

Is PANDEMIC Imminent?

National Center for Disease Prevention and Control, DOH

Influenza is usually a respiratory infection

Transmission
– Regular person-to-person transmission
– Primarily through contact with respiratory
droplets
– Transmission from objects (fomites) possible

National Center for Disease Prevention and Control, DOH

 Transmission of Influenza
• Limited studies, varying
interpretations
• Contact, droplet, and droplet
nuclei (airborne) transmission all
likely occur
– Relative contribution of each
unclear
• Droplet thought most important
– Coughing, sneezing, talking
– Most studies either
• Animals or human experiments
under artificial conditions
• Outbreak investigations
– Unclear of infection source

National Center for Disease Prevention and Control, DOH

 Key Characteristics
Communicability

– Viral shedding can begin 1 day

before symptom onset
– Peak shedding first 3 days of
illness
– Correlates with temperature
– Subsides usually by 5-7th day in
adults
– can be 10+ days in children
– Infants, children and the
immunocompromised may shed
the virus longer

National Center for Disease Prevention and Control, DOH

Incubation period
– Time from exposure to onset of symptoms
– 1 to 4 days (average = 2 days)

Seasonality
– In temperate zones, sharp peaks in winter months
– In tropical zones, circulates year-round with
seasonal increases.

National Center for Disease Prevention and Control, DOH

 Clinical Illness, Seasonal Influenza
• Abrupt onset
• Fever and constitutional symptoms: body aches,
headaches, fatigue
• Cough, rhinitis, sore throat
• GI symptoms and myositis more common in
young children
• Sepsis-like syndrome in infants
• Complications: viral and bacterial pneumonia,
febrile seizures, cardiomyopathy,
encephalopathy/encephalitis, worsening
underlying chronic conditions
National Center for Disease Prevention and Control, DOH
 Individuals at Increased Risk for
Hospitalizations and Death
• Elderly > 65 years
• Children less than two years
• Certain chronic diseases
– Heart or lung disease, including asthma
– Metabolic disease, including diabetes
– HIV/AIDs, other immunosuppression
– Conditions that can compromise respiratory function or the handling
of respiratory secretions
• Pregnant women

National Center for Disease Prevention and Control, DOH

 Vaccination
• Influenza vaccine is the best prevention for seasonal
influenza.
• Inactivated viruses in the vaccine developed from
three circulating strains (generally 2 Type A and 1 Type
B strain)
– Therefore, seasonal “flu shot” only works for 3 influenza
subtypes and will not work on pandemic strains.
• Live, intranasal spray vaccine for healthy non-pregnant
persons 5-49 years
• Inactivated, injectable vaccine for persons 6 months
and older
National Center for Disease Prevention and Control, DOH
 Influenza Viruses
• Classified into types A, B, and C
• Only Types A and B cause
significant disease
• Types B and C limited to humans
• Type A viruses
• More virulent
• Affect many species C Goldsmith, CDC

National Center for Disease Prevention and Control, DOH

 Influenza A Viruses
• Influenza A viruses categorized by subtype
• Classified according to two surface proteins
• Hemagglutinin (H) – 16 known
– Site of attachment to host cells
– Antibody to HA is protective
• Neuraminidase (N) – 9 known
– Helps release virions from cells
– Antibody to NA can help modify disease severity

National Center for Disease Prevention and Control, DOH

 Nomenclature

Virus type Strain number Virus subtype

A / Sydney / 05 / 97 (H3N2)

Place virus Year isolated

isolated

National Center for Disease Prevention and Control, DOH

 Influenza A (H1N1) is a novel virus
• Unusual combination of genetic material from
pigs, birds & humans which have re-assorted
• human-to-human transmission occurs through
respiratory droplets generated from sneeze or
cough
• Affects all age groups
• Vaccines for human seasonal flu can not
protect humans against the novel virus

National Center for Disease Prevention and Control, DOH

 Swine Influenza Viruses
• RNA viruses
• Pigs can be infected by avian influenza and
human influenza viruses as well as swine
influenza viruses.
• reassort and new viruses that are a mix of
swine, human and/or avian influenza viruses
can EMERGE

National Center for Disease Prevention and Control, DOH

 Genetic Reassortment

SIV

National Center for Disease Prevention and Control, DOH

 Signs & Symptoms of Influenza A (H1N1)

• Fever
• Lethargy
• Lack of appetite
• Coughing
• Runny Nose
• Sore throat
• Nausea / Vomiting
• Diarrhea

National Center for Disease Prevention and Control, DOH

 Swine H1N1 vs. Human H1N1
• swine H1N1 flu virus NOT the same as human
H1N1 virus
• antigenically very different from human H1N1
viruses
• vaccines for human seasonal flu can not
protect humans from swine H1N1

National Center for Disease Prevention and Control, DOH

 Transmission: Food-Borne?
• NO
• Influenza A (H1N1) viruses are not transmitted
through food
• Safe to eat properly handled and cooked pork
and pork products
• Cook pork at an internal temperature of 70°C
(160°F)

National Center for Disease Prevention and Control, DOH

 Diagnosis and Laboratory Confirmation

• Clinically diagnosed
• Respiratory Specimen
• first 4 to 5 days of illness
• can shed for 10 days or longer
• Specimens sent to US CDC
• ONLY laboratory that can isolate and
identify swine influenza type A virus

National Center for Disease Prevention and Control, DOH

 Treatment
• Influenza A (H1N1) is sensitive to:
– Oseltamivir
– Zanamivir

• Self medication is discouraged, may induce

drug resistance
• Chemoprophylaxis
– Oseltamivir

National Center for Disease Prevention and Control, DOH

 Vaccine
• No Influenza A (H1N1) vaccine yet
• Process of production is underway, but may
take 5 – 6 months
• Seasonal influenza vaccine provides protection
against the seasonal human influenza strains
only

National Center for Disease Prevention and Control, DOH

Influenza A (H1N1) is a Public Health Emergency
of International Concern (PHEIC)
Serious Public Health Impact
Unusual or Unexpected
International disease spread
Interference with international travel or trade

**WHO Recommends intensifying and enhancing national

surveillance systems for Influenza-like Illnesses and atypical
pneumonia

National Center for Disease Prevention and Control, DOH

Pandemic Alert Phase 5
Influenza A (H1N1) Preparedness Plan
• Goal:
– To minimize the public health & socio-economic impact of
influenza pandemic in the Philippines
• Objectives:
– To maintain a functional command & control structure during an
influenza pandemic
– To adopt early warning system for pandemic influenza
– To identify & monitor cases of pandemic influenza
– To manage large numbers of ill & dying people
– To maintain essential services during a pandemic
– To prevent spread through public health interventions
– To manage public anxiety & panic & ensure effective &
appropriate information, education & campaign

National Center for Disease Prevention and Control, DOH

 What has been done?
• Activation of the DOH Management Committee
on Prevention and Control of Re-Emerging
Infectious Diseases (DOHMC-PCREID) with the
Secretary of Health as the Chairperson of the
DOH Central Command
• Enhanced health surveillance in hospitals,
seaports, and airports which include thermal
scanning of arriving passengers from affected
countries
– emergency procurement of 4 additional thermal
scanners

National Center for Disease Prevention and Control, DOH

 What has been done?
• Health Declaration Checklist to screen for
potential signs & symptoms & possible
exposure to the virus
• Health Alert Notice (HAN) distributed to all
arriving travelers who are strongly advised to
monitor body temperature daily up to 10 days
from date of arrival & to contact health
authorities A.S.A.P. if they become ill during
this period

National Center for Disease Prevention and Control, DOH

National Center for Disease Prevention and Control, DOH
 What has been done?
• Issuance of travel advisory to the public
– No travel ban but travelers are asked to reconsider
their plans to travel to affected countries unless
extremely necessary
– The World Health Organization does not recommend
any travel restrictions or closure of borders at this
time
• Activation of DOH HOTLINE (+632-7111001 /
+632-7111002) for immediate reporting of
suspected Influenza A (H1N1), flu-like illness and
atypical pneumonia by DOH regional Offices,
LGUs, hospitals, and the public
National Center for Disease Prevention and Control, DOH
 Influenza A (H1N1) Surveillance Reporting Flow

Bureau of Influenza-like Illness Event-based

Referral Hospitals Surveillance
Quarantine Surveillance

Daily zero
reporting
Inform other offices, Probable/
Yes
agencies, etc. involved Response NEC/HOTLINE Confirmed
in the response WHO
needed? Surveillance Team

No Probable/ Cases under

Confirmed investigation

End EXECOM

Central Command

Media

National Center for Disease Prevention and Control, DOH

 What has been done?
• Firmed up national stockpile of Personal
Protective Equipment (PPE) & the antiviral drug
(Oseltamivir) and other logistics
– Priority will be high-risk exposure groups consisting of
frontline health workers and surveillance teams
– Interim Guidelines on Clinical Management of
Influenza A (H1N1) Virus Infection and the Use of
Antivirals
– Interim Guidelines on the Use of Personal Protective
Equipments and Infection Control During Influenza A
(H1N1) Outbreaks

National Center for Disease Prevention and Control, DOH

 Interim Guidelines on Clinical Management of Influenza A
(H1N1) Virus Infection and the Use of Antivirals

• Case definitions for infections with Influenza A (H1N1)

• Clinical Management of Influenza A (H1N1) Virus
Infection
• Use of Antiviral Agents
– Priority groups to receive antiviral agents for prophylaxis
• Health workers
• First responders
• Workers providing essential services
– For treatment, priority will be the patients considered at
high risk of severe disease
• Discharge guidelines

National Center for Disease Prevention and Control, DOH

Interim Guidelines on the Use of Personal Protective Equipments & Infection
Control During Influenza A (H1N1) Outbreaks

• Rational Use of personal protective

equipments
• Guidelines on the use of masks
• Public health measures
• Personal hygiene
• Guidelines on infection control in health care
setting

National Center for Disease Prevention and Control, DOH

 What has been done?
• National Referral Centers for EID readied in the
event of suspected or confirmed swine flu cases
– Research Institute of Tropical Medicine (RITM)
– Lung Center of the Philippines
– San Lazaro Hospital
– Vicente Sotto Memorial Medical Center
– Davao Medical Center
• Organized the DOH Central Command for A
(H1N1) that will oversee the operations of the
different components of the A(H1N1) Task Force
– Planning, Operations, Financing, Logistics

National Center for Disease Prevention and Control, DOH

 Health Emergency Management Structure

Central
Command

Secretariat &
Safety Team
Liaison

Planning Operations Logistics Finance

DOH Central
CHD Directors Surveillance Quarantine Administration Procurement Budget
Office Directors

Hospital
DOH Hospitals Expert Panel Field Operations COBAC MMD
Operations

Public
Information Etc… Transport
Office

National Center for Disease Prevention and Control, DOH

 What has been done?
• Convened a meeting of all Metro Manila DOH Hospitals
to orient them on the situation & come up with a
response plan for hospitals
• Secretary Francisco T. Duque IIII called for a DOH
Command Conference to check the readiness plans &
command & control systems of all regions nationwide
• Secretary Francisco T. Duque III is made de facto Crisis
Manager of the national Disaster Coordinating Council
(NDCC) to coordinate government efforts in responding
to the threat of Influenza A/H1N1

National Center for Disease Prevention and Control, DOH

 What has been done?
• Request of Php 93.5 M calamity fund for the
preparedness phase of a possible pandemic
• Meeting with Metro Manila private hospitals
and DOH retained hospitals on referral
procedures to DOH-Designated Hospitals for
the Isolation & Treatment of suspected
Influenza A (H1N1) cases; as well as
contingency plans for a worse case scenario

National Center for Disease Prevention and Control, DOH

 DOH – Medical City Joint Forum
(May 4, 2009)

• Guidance on
– Surveillance
• Case definitions, case reporting forms
– Infection control
• Will the private hospitals be allowed to admit cases? As of
now, only the referral hospitals will be allowed to admit
cases
– Use of oseltamivir
• Prophylaxis, treatment
• Societal approach rather than health sectors only
• Updates to be provided on a regular basis

National Center for Disease Prevention and Control, DOH

 Public Health Advisory
• Cover nose and mouth with a tissue when
coughing or sneezing.
• Wash hands regularly with soap and water,
especially after you cough or sneeze. Alcohol-
based hand cleaners are also effective
• Avoid close contact with sick people.
• If sick, self-monitor and stay home from work or
school and limit contact with others.
• Consult your doctor immediately should signs
and symptoms of flu persist.

National Center for Disease Prevention and Control, DOH

 Risk Communications Challenges
• How to communicate with stakeholders
minimizing fear and panic
• Informing or instructing widely
divergent audiences
• Minimizing overcoming
misinformation, rumors and myths
• Encouraging the adoption of
appropriate protective actions
• Building trust

National Center for Disease Prevention and Control, DOH

 What’s next?
• Coordination with other concerned agencies
regarding national response in the event of a
pandemic
– OP, DA, DILG, DFA, NDCC

National Center for Disease Prevention and Control, DOH

Thank you for listening!

National Center for Disease Prevention and Control, DOH