If You Look Like This

1. If You Look Like This�� 1

2. 2

3. Swine Flu � Test Your Knowledge 3

4. Swine flu is also known as� H5N1 Influenza A (H1N1) Piggy pox 4

5. Answer B Known as H1N1 based on serologic testing. H5N1 is the avian flu 5

6. Can you have swine flu without fever? Yes No 6

7. Yes A New England Journal of medicine article on the 1st 642 US cases found 94% had fever, 92% had cough, 66% had sore throat, 25% had diarrhea and 254 had vomiting. Most people will have fever, but never say never. Your temperature may, however, be only slightly elevated 7

8. Can someone carry swine flu without feeling sick? Yes No 8

9. Yes It is possible. A carrier may have a runny nose and/or a headache, but assume that it�s just a cold or allergies. However, it is also possible for someone to become infected with a flu virus and have no symptoms. 9

10. Surgical masks help keep flu or virions out. True False 10

11. False Surgical masks are actually designed to keep your germs in, though if someone coughs on you, it can help keep droplets out. The N95 respirator masks keeps �germs� out, but must be sealed airtight against a person�s skin. 11

12. Surgical masks Easily available and commonly used for routine surgical and examination procedures High-filtration respiratory mask Special microstructure filter disc to flush out particles bigger than 0.3 micron. These masks are further classified:� oil proof� oil resistant� not resistant to oil The more a mask is resistant to oil, the better it is The masks have numbers beside them that indicate their filtration efficiency. For example, a N95 mask has 95% efficiency in filtering out particles greater than 0.3 micron under normal rate of respiration. The next generation of masks use Nano-technologywhich are capable of blocking particles as small as 0.027 micron. Types of Protective Masks

13. The best way for people to protect themselves� Handwashing and using disinfectants Taking antivirals Tamiflu or Relenza Getting a vaccine 13

14. Washing your hands frequently is still the best means of protection. Also avoid touching the mouth and eyes after touching a hard surface (fomite). A vaccine is in the making and should be available in early to mid October. Tamiflu or Relenza are effective, but should not be taken �just in case.� They are a precious commodity and can be toxic/harmful to the individual. Overuse could actually make one more vulnerable by encouraging the resistant strains. 14

15. You can catch swine flu by� Feeding a person Feeding a pig Feeding a bird Feeding yourself with pork The 1st two answers are correct, but not the last two 15

16. The 1st two answers are correct H1N1 can be transmitted from swine to human if in close contact, but most people are at greater risk of catching it from another human who coughs or sneezes on or near you or on a surface you touch. Birds aren�t transmitting the disease and eating pork is safe. 16

17. Health experts advise against domestic travel on planes, trains and buses. True False 17

18. False The VP was wrong to tell people not to fly. Although this flu is passed between humans and the CDC recommends you not fly if you are feeling ill or diagnosed with the flu, they recommend most take normal precautions such as regular hand washing. 18

19. Which threat has killed the most Americans in the past? The Viet Nam war World War II The 1918 influenza pandemic Hurricane 19

20. The correct answer is C. The 1918 flu killed more than 600,000 Americans. Worldwide, the toll was over 50 million. By comparison, no single war has taken as many Americans in battle. The Galveston Hurricane of 1900, considered the deadliest in U.S. history, killed an estimated 8,000 people. 20

21. What is the best known cure for the new H1N1 virus? Antiviral drugs like Tamiflu or Relenza The H1N1 vaccine Antibiotics None of the above 21

22. The correct answer is D. There is no cure for H1N1. Antiviral medications can shorten the duration of the sickness in some cases Antibiotics can save you from deadly secondary bacterial infections, but are not effective against viral infections. Vaccine is the best way to prevent it to begin with. But there is no way to cure it once you get it, aside from getting rest, drinking plenty of fluids and checking (early on) with a doctor if you have flu symptoms � that's especially important for pregnant women, school-aged children and patients with co-morbid conditions (asthma, diabetes, heart disease or other ongoing health conditions�) 22

23. If I get the regular, seasonal flu vaccine, will that protect me from H1N1, too? Yes No Maybe 23

24. The correct answer is B. The seasonal vaccine is designed for a different strain of flu. Health officials recommend that Americans get both vaccines The seasonal flu vaccine is available now, so experts advise getting it first. If you choose to get both vaccines at the same time, avoid the weakened live-virus form of the seasonal flu vaccine, which is administered by nasal spray. According to the government, vaccinations given simultaneously should be the killed-virus form that is injected, each in a different part of the body. 24

25. The new H1N1 vaccine, which will be available later this fall, (somewhere around the first to second week of October) has been tested on: Healthy young adults Pregnant women Children aged 6 mos to 17 years old Elderly people All of the above 25

26. The correct answer is E. This summer, research institutions around the country tested the H1N1 vaccine on thousands of volunteers of all ages, including pregnant women. The National Institutes of Health oversaw the trials. (Similar studies are being conducted in several other countries.) So far, no safety problems have been found -- which is what scientists expected, since the H1N1 vaccine is made in the same way that regular seasonal flu vaccines are made every year. 26

27. One sneeze can contain how many viruses? Dozens Hundreds Billions 27

28. The correct answer is C. Influenza viruses are diabolically resilient. Their sole purpose is to reproduce. And one way they do that is to make you cough and sneeze. Each time you sneeze, it's like blowing a dandelion seed-puff of virus across the room -- which is why President Obama keeps nagging you to wash your hands and sneeze into your sleeve. 28

29. It is possible that fewer Americans will die from influenza (of all kinds) this year than in past years? True False 29

30. The correct answer is A. New pandemic influenza viruses tend to crowd out the normal seasonal flu viruses. It's sort of a survival-of-the-fittest situation, and the pandemic virus -- to which the population has little natural immunity -- is the fittest. (This crowding-out has already happened in the southern hemisphere with H1N1, in fact.) As a result, Americans may see many more people getting sick this fall, but many fewer dying overall, because H1N1 is more infectious but (so far) less deadly. Good news? Well, yes. And no. The people who will die will likely be much younger than in a normal flu season, because H1N1 targets children and young adults. 30

31. If I get the vaccine as soon as it is available -- probably in mid-October -- when will I have immunity against H1N1? Immediately In two days In three weeks Never 31

32. The correct answer is C. The early results of a vaccine trial in Australia found that a single dose of H1N1 vaccine was enough to confer immunity in adults. Three weeks after the 120 volunteers in the study received their vaccine shot, 97% had enough antibodies to be considered protected. That was welcome news for public health experts, who had previously thought that people would need two doses of the vaccine -- a process that would have taken about five weeks, from the delivery of the first shot to the point at which the body becomes immune. 32

33. If I am over 55, I am at higher risk and should get the vaccine as soon as it's available. True False 33

34. The correct answer is B. Finally, it pays to be old! Older people seem to have some built-in immunity to this new flu. They may have been exposed to a related strain when they were younger. So while they should still get the seasonal flu shot, older adults needn't consider the H1N1 vaccine a high priority in most cases. 34

35. Who should get the swine flu shot? According to guidelines drafted by the Centers for Disease Control and Prevention (CDC), there are five key populations that should be vaccinated against the H1N1 virus: Pregnant women People who live with or care for children younger than 6 months of age Children and young people between the ages of 6 months and 24 years Health care workers and emergency medical service providers People between 25 and 64 years of age who have chronic medical disorders or compromised immune systems. 35

36. The above groups account for approximately 159 million Americans. The CDC urges these at-risk populations to get both the swine flu shot and the seasonal flu shot. (The regular flu shot doesn't protect against the H1N1 virus.) So what should the remaining half of the U.S. population do this flu season? The answer isn't clear, especially in light of the 1976 swine flu debacle. 36

37. In 1976, a 19-year-old Army private stationed in Fort Dix, N.J., died from the swine flu, while another 115 soldiers stationed there tested positive for swine flu antibodies. The CDC was called in to investigate, and its scientists concluded that the soldiers had a strain similar to the Spanish Influenza of 1918, which was responsible for the deadliest human pandemic of the 20th century. Although the virus hadn't spread beyond the fort, the CDC convinced then-president Gerald Ford's advisors that a mass inoculation was required. Pharmaceutical companies rushed to develop a vaccine. 37

38. By mid-October of 1976, approximately 40 million people had been vaccinated against swine flu and not long after, reports of serious side effects began to pour in. Within a couple of months, 25 people died from Guillain-Barr�, a neuromuscular disorder that can result in paralysis or death, An additional 500 were diagnosed with the condition. (Doctor's don't know what causes Guillain-Barr�, but it can develop after a post-surgery infection or vaccination.) 38

39. Experts are not expecting any major health risks associated with the current H1N1 vaccine. "We aren't expecting any side effects beyond what we normally see.� Typical side effects include soreness at the injection site and mild body aches. 39

40. But it's too early to tell if the vaccine is safe and effective, cautions some experts. "According to clinical trial results it is safe and effective, but we won't know the side effects until large groups of people have been vaccinated.� 40

41. Today, while CDC spokesman Tom Skinner acknowledges the problems that plagued 1976 inoculation program, he says that this time around his agency and the FDA have taken extra steps to protect the public. "We have good surveillance monitors in place," he says, referring to the Vaccine Adverse Effect Reporting System (VAERS), a mechanism that allows the public to report and monitor adverse reactions to inoculations. 41

42. He also contends that the current swine flu virus, while contagious, is relatively mild. "The virulence is basically the same as seasonal influenza," he says. And even if that's too much for some to risk catching, one expert says that getting an H1N1 shot might not provide full protection if the virus mutates. "We've been told that the second viral wave might be more lethal, and that would make the vaccine less effective.� 42

43. Common side effects include Pain and redness at the injection site Drowsiness or tiredness Muscle aches Low grade fever Malaise Headache 43

44. Very rare side effects Severe allergic reaction (anaphylaxis) Guillian-Barre Syndrome (nervous system disorder featuring paralysis) From the evidence collected by experts: GBS is 4 to 7 times more likely after an attack of the actual flu than after the influenza vaccine There have been reports overseas of a possible association between influenza vaccinations and GBS 44

45. Questions?

46. What about viruses in general? 46

47. What is influenza?   Influenza (flu) is a contagious respiratory illness caused by viruses. Infection results in mild to severe illness and can lead to death. Every year, an average of 5 to 20 percent of the U.S. population gets the flu. Some influenza viruses can also infect birds, pigs, horses, seals, whales and other animals. 47

48. Seasonal Influenza Globally: 250,000 to 500,000 deaths per year In the US (per year) ~35,000 deaths >200,000 Hospitalizations $37.5 billion in economic cost (influenza & pneumonia) >$10 billion in lost productivity Pandemic Influenza An ever present threat

49. Influenza Virus The internal antigens (M1 and NP proteins) are the type-specific proteins (type-specific antigens) used to determine if a particular virus is A, B or C. The M1 proteins of all members of each type show cross reactivity. The NP proteins of all members of each type also show cross reactivity. The external antigens (HA and NA) show more variation and are the subtype and strain-specific antigens. These are used to determine the particular strain of influenza A responsible for an outbreak Flu strains are named after their types of hemagglutinin and neuraminidase surface proteins, so they will be called, for example, H3N2 for type-3 hemagglutinin and type-2 neuraminidase. If two different strains of influenza infect the same cell simultaneously, their protein capsids and lipid envelopes are removed, exposing their RNA, which is then transcribed to mRNA. The host cell then forms new viruses that combine antigens; for example, H3N2 and H5N1 can form H5N2 this way. Because the human immune system has difficulty recognizing the new influenza strain, it may be highly dangerous. The internal antigens (M1 and NP proteins) are the type-specific proteins (type-specific antigens) used to determine if a particular virus is A, B or C. The M1 proteins of all members of each type show cross reactivity. The NP proteins of all members of each type also show cross reactivity. The external antigens (HA and NA) show more variation and are the subtype and strain-specific antigens. These are used to determine the particular strain of influenza A responsible for an outbreak Flu strains are named after their types of hemagglutinin and neuraminidase surface proteins, so they will be called, for example, H3N2 for type-3 hemagglutinin and type-2 neuraminidase. If two different strains of influenza infect the same cell simultaneously, their protein capsids and lipid envelopes are removed, exposing their RNA, which is then transcribed to mRNA. The host cell then forms new viruses that combine antigens; for example, H3N2 and H5N1 can form H5N2 this way. Because the human immune system has difficulty recognizing the new influenza strain, it may be highly dangerous.

50. The Biology of Orthomyxoviruses: Influenza ssRNA consists of 10 genes encoded on 8 separate RNA segments. 3 distinct influenza virus types: A, B, C; Type A causes most infections Virus attaches to, and multiplies in, the cells of the respiratory tract; finished viruses are assembled and budded off. 50

51. The Virus 51

52. Key to influenza are glycoprotein spikes � hemagglutinin (H) � 15 different subtypes; most important virulence factor; binds to host cells neuraminidase (N) � 9 subtypes � hydrolyzes mucus and assists viral budding and release Both glycoproteins frequently undergo genetic changes decreasing the effectiveness of the host immune response. Constant mutation is called, antigenic drift � influenza gradually change their amino acid composition Antigenic shift � one of the genes or RNA strands is substituted with a gene or strand from another influenza virus from a different animal host 52

53. Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature* Hard non-porous surfaces 24-48 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 <5 minutes only at high viral titers Potential for indirect contact transmission *Humidity 35-40%, Temperature 28C (82F) Affects of humidity on infectivity influenza, Loosli et al, 1943 Affects of humidity on infectivity influenza, Loosli et al, 1943

54. What is H1N1 flu? H1N1 is a new (novel) influenza virus.�� This new virus was first detected in people in the U.S. in April 2009 and was initially call �swine flu.� In some respects the H1N1 virus is just like any other influenza virus. It causes a predominantly respiratory illness.� This new virus has caused some anxiety around the world, though most of those who get it say it feels like regular flu.�� What is unique about this virus is that it is a mutated type of virus so that nobody in the U.S. or probably worldwide has any immunity to it. � That is why it has the ability to cause widespread infections 54

55. How is the H1N1 (swine) flu different from seasonal flu?  Unlike with the seasonal flu, young people are at higher risk of H1N1 infection than people 65 and older. However, infected people 65 or older are still at increased risk of H1N1 influenza-related complications. The worldwide spread of the H1N1 virus this spring was both rapid and unusual as it affected some countries outside of the time frame of a normal flu season. While most people who have become ill with the H1N1 virus have recovered without needing medical treatment, hospitalizations and deaths have occurred. 55

56. Swine Influenza A(H1N1) Transmission to Humans Through contact with infected pigs or environments contaminated with swine flu viruses Through contact with a person with swine flu Human-to-human spread of swine flu has been documented also and is thought to occur in the same way as seasonal flu, through coughing or sneezing of infected people

57. Why is H1N1 flu sometimes called �swine flu?� This virus was originally referred to as �swine flu� because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs in North America. 57

58. H1 N1 (2009) Influenza

59. Swine Influenza A(H1N1) Transmission Through Species Reassortment, or Viral Subunit Reassortment, is the exchange of DNA between viruses inside a host cell. Two or more viruses of different strains (but usually the same species) infect a single cell and pool their genetic material creating numerous genetically diverse progeny viruses. It is a type of genetic recombination. Reassortment can lead to a viral shifts under some conditions. Reassortment, or Viral Subunit Reassortment, is the exchange of DNA between viruses inside a host cell. Two or more viruses of different strains (but usually the same species) infect a single cell and pool their genetic material creating numerous genetically diverse progeny viruses. It is a type of genetic recombination. Reassortment can lead to a viral shifts under some conditions.

60. Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses, and seals. There are 16 different haemaglutinin subtypes and 9 different neuraminidase subtypes, all of which have been found among influenza A viruses in wild birds. Wild birds are the primary natural reservoir for all subtypes of influenza A viruses and are thought to be the source of influenza A viruses in all other animals. Most influenza viruses cause asymptomatic or mild infection in birds; however, the range of symptoms in birds varies greatly depending on the strain of virus. Infection with certain avian influenza A viruses (for example, some strains of H5 and H7 viruses) can cause widespread disease and death among some species of wild and especially domestic birds such as chickens and turkeys. Pigs can be infected with both human and avian influenza viruses in addition to swine influenza viruses. Infected pigs get symptoms similar to humans, such as cough, fever, and runny nose. Because pigs are susceptible to avian, human and swine influenza viruses, they potentially may be infected with influenza viruses from different species (e.g., ducks and humans) at the same time. If this happens, it is possible for the genes of these viruses to mix and create a new virus. Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses, and seals. There are 16 different haemaglutinin subtypes and 9 different neuraminidase subtypes, all of which have been found among influenza A viruses in wild birds. Wild birds are the primary natural reservoir for all subtypes of influenza A viruses and are thought to be the source of influenza A viruses in all other animals. Most influenza viruses cause asymptomatic or mild infection in birds; however, the range of symptoms in birds varies greatly depending on the strain of virus. Infection with certain avian influenza A viruses (for example, some strains of H5 and H7 viruses) can cause widespread disease and death among some species of wild and especially domestic birds such as chickens and turkeys. Pigs can be infected with both human and avian influenza viruses in addition to swine influenza viruses. Infected pigs get symptoms similar to humans, such as cough, fever, and runny nose. Because pigs are susceptible to avian, human and swine influenza viruses, they potentially may be infected with influenza viruses from different species (e.g., ducks and humans) at the same time. If this happens, it is possible for the genes of these viruses to mix and create a new virus.

61. How does H1N1 flu spread? The CDC believes that this H1N1 virus is spread in the same way that seasonal flu spreads. You could catch the flu directly from droplets from the cough or sneeze of an infected person, or by touching an object they recently touched, and then touching your eyes, mouth, or nose. That's why you should make washing your hands a habit, even when you're not ill. Infected people can start spreading flu germs up to a day before symptoms start, and for up to seven days after getting sick, according to the CDC. Children, especially younger children, might potentially be contagious for longer periods. 61

62. Can people catch H1N1 (swine) flu from eating pork? No. H1N1 (swine) influenza viruses are not transmitted by food. You can not get H1N1 (swine) influenza from eating pork or pork products. Eating properly handled and cooked pork and pork products is safe. Cooking pork to an internal temperature of 160�F kills the H1N1 (swine) flu virus as it does other bacteria and viruses 62

63. How do I know if I have H1N1 Flu? You will not be able to tell the difference between seasonal flu and H1N1 influenza without medical help. Only your medical practitioner and local health authority can confirm a case of influenza of H1N1 flu. 63

64. How can I avoid getting H1N1 flu? If possible, try to avoid close contact with people who maybe ill. Additionally: avoid touching your mouth and nose; clean hands thoroughly with soap and water, or cleanse them with an alcohol-based hand rub on a regular basis (especially if touching the mouth and nose, or surfaces that are potentially contaminated); reduce the amount of time you spend in crowded settings; practice good health habits including adequate sleep, eating nutritious food, and keeping physically active. 64

65. What are the signs of more severe illness with H1N1 flu? While most of the current H1N1 influenza cases have been mild so far, infected individuals should still be aware of some of the more severe illness with H1N1 flu. 65

66. What are the signs of more severe illness with H1N1 flu? In children, emergency warning signs that need urgent medical attention include: Fast breathing or trouble breathing Bluish skin color Dehydration, or not drinking enough fluids Sluggish, not waking up or not interacting Irritability to the point that the child does not want to be held Flulike symptoms improve but then return with fever and worse cough Fever with a rash 66

67. What are the signs of more severe illness with H1N1 flu? In adults, symptoms that need emergency medical attention include: Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting If a person has any of the above symptoms they should seek medical care immediately. For any questions consult your regular medical provider or the local health department. 67

68. What should I do if someone I live with has confirmed H1N1 flu? Follow the same precautions you would to avoid ordinary seasonal flu. Limit your contact with the affected person. Avoid close contact such as kissing, and do not share towels, glasses or toothbrushes with the affected person. Avoid having visitors. If visitors must enter the home, they should avoid close contact with the affected person. Wash your hands with soap and water or with an alcohol-based hand rub. 68

70. What is a pandemic? It's probably important for people to first understand what a pandemic is. So if one goes to the World Health Organization a pandemic is defined by meeting three criteria: the emergence of a disease that is new to a population; the agent infects humans and results in serious illness and that agent is then easily spread amongst populations. 70

72. 1918 Pandemic Influenza 1918 H1N1 Pandemic 50 Million deaths worldwide 500,000 deaths in US alone Reduced U.S. life expectancy by 13 years

73. 1918 H1N1 Pandemic Note that the initial wave or �Herald wave� begins in the spring or summer then subsides until it re-emerges in the fall and winter with higher mortality (deaths). Note that the initial wave or �Herald wave� begins in the spring or summer then subsides until it re-emerges in the fall and winter with higher mortality (deaths).

76. Current Situation?

77. Current Situation There is reason to believe the worst may be over for Georgia Still significant risk to our student population Virus mutation Pregnant Disparity of Latinos and African Americans

78. 2009 H1N1 Deaths by Age

79. 2009 H1N1 Confirmed Cases by Age

80. High-Risk Groups: These groups of people are at risk of complications of influenza and are high priority for vaccination: 1. Pregnant women or women up to 4 weeks post-partum. 2. People with the following conditions: Chronic pulmonary conditions (asthma, COPD, cystic fibrosis) Chronic cardiac (heart) conditions. Except hypertension. Renal, hepatic disease. (kidney/liver) Sickle cell disease. Neurologic or neuromuscular disorders (compromise ability to clear airway secretions) 80

81. High-Risk Groups: Diabetes mellitus and other metabolic disorders Obesity Immunosuppression (caused by medications or HIV). 3. Persons younger than 19 yrs who are receiving long-term aspirin therapy. 4. Children younger than 5 yrs old. The risk for severe complications from seasonal influenza is highest among children younger than 2 years old. 5. Persons aged 65 yrs. and over with comorbid conditions. 81

82. Diagnostic testing Rapid enzyme immunoassay Type A: seasonal or new H1N1 Sensitivity for new H1N1 ~75%? PCR diagnostic kit available High-risk for complications Severe or hospitalized cases Prior approval: 800-392-0272.

83. CDC swab kit availableMethod: horizontal, away from nasal septum

84. Take these everyday steps to protect your health Wash your hands often with soap and warm water, especially after you cough or sneeze. Wash for 15 � 20 seconds. Alcohol-based hand wipes or gel sanitizers are also effective.

85. Take these everyday steps to protect your health Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it. Avoid touching your eyes, nose or mouth. Germs spread this way. Avoid contact with sick people.

86. If you get sick� Stay home if you�re sick for 7 days after your symptoms begin or until you�ve been symptom-free for 24 hours, whichever is longer. If you are sick, limit your contact with other people as much as possible.

87. WARNING! Do not treat children with ASPIRIN Aspirin treatment in children with the flu or other viral infections has a known association with Reyes Syndrome � a potentially fatal complication 87

88. FAQ Are you saying this pandemic will be as bad as 1918? NO � vaccine will be available sooner � potential for large numbers of deaths are possible Advances in medical care � antibiotics How do we know if someone has H1N1 or seasonal influenza Difficult to determine � subtle clues / symptoms Fever, chills, cough, sore throat Treated the same � NO TESTING

89. FAQ What should we do for people who have ILI? Rest, fluids, control fever with acetaminophen / naproxen / ibuprofen Seek care at campus / student health Isolate to room / home Single caregiver (already exposed and not high risk preferred) Close contacts should take antivirals

90. Conclusion/Recommendations Past experience with pandemics have taught us that the second wave is worse than the first causing more deaths due to: Primary viral pneumonia, Acute Respiratory Distress Syndrome (ARDS), & Secondary bacterial infections, particularly pneumonia Fortunately compared to the past now we have anti-virals and antibiotics (to treat secondary bacterial infections) Based upon past experience and the way the current H1N1 pandemic is acting (current wave is contagious, spreading rapidly and in Mexico/Canada based upon preliminary data affecting the healthy), there is a likelihood that come fall there might be a second wave which could be more virulent Two candidate vaccine the CDC is analyzing contain a mix of genes from the new swine flu virus with components of other viruses that allow them to grow better in the eggs that manufacturers use to produce vaccine. If one or both prove usable, manufacturers could begin producing pilot lots for testing this summer to see if the shots are safe, trigger immune protection and require one dose or two. Two candidate vaccine the CDC is analyzing contain a mix of genes from the new swine flu virus with components of other viruses that allow them to grow better in the eggs that manufacturers use to produce vaccine. If one or both prove usable, manufacturers could begin producing pilot lots for testing this summer to see if the shots are safe, trigger immune protection and require one dose or two.

91. Conclusion/Recommendations At present most of the deaths due to H1N1 strain has been reported from Mexico. The disease, though spreading rapidly across the globe, is of a mild form (exception Mexico) Most people do not have immunity to this virus and, as it continues to spread. More cases, more hospitalizations and some more deaths are expected in the coming days and weeks Disease seems to be affecting the healthy strata of the population based upon epidemiological data from Mexico and EU

92. Conclusion/Recommendations 92 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 increasing surge capacity and stringent infection prevention/control General population needs to follow basic precautions

93. Conclusion/Recommendations 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 by the end of June or will cause disease in a few cases (influenza virus cannot survive high humidity or temperature) Will reappear in autumn in North America with the likelihood of being a highly pathogenic second wave Will continue to circulate and cause disease in the Southern Hemisphere Basic Precautions Cover nose and mouth with a tissue when coughing or sneezing Handwashing with soap and water Avoiding close contact with sick people Avoiding touching eyes, nose or mouth with unwashed hands If sick with influenza, staying home from work or school and limit contact with others to keep from infecting them Basic Precautions Cover nose and mouth with a tissue when coughing or sneezing Handwashing with soap and water Avoiding close contact with sick people Avoiding touching eyes, nose or mouth with unwashed hands If sick with influenza, staying home from work or school and limit contact with others to keep from infecting them

94. Conclusion/Recommendations Border Closure and Travel Restrictions: The disease has already crossed all 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 94

95. Conclusion/Recommendations School Closures: Preemptive school closures will merely delay the spread of disease Once schools reopen (as they cannot be closed indefinitely), the disease will be transmitted and spread Furthermore, this would put unbearable pressure on single-working parents and would be devastating to the economy (as children cannot be left alone) Closure after identification of a large cluster would be appropriate as absenteeism rate among students and teachers would be high enough to justify this action Please send comments to Dr. Chotani at chotani@gmail.comPlease send comments to Dr. Chotani at chotani@gmail.com

96. Conclusion/Recommendations High priority should be given to develop and include the present �North American� (swine) influenza A(H1N1) virus in next years vaccine. A critical look at manufacturing capacity is called for It is imperative to appreciate that �times-have-changed� Though this strain has spread very quickly across the globe and seems to be highly infectious, today we are much better prepared than 1918. There is better surveillance, communication, understanding of infection control, anti-virals, antibiotics and advancement in science and resources to produce an affective vaccine 96

97. Cartoonists Imagination on Swine Flu