Joan E. Nichols PhD

Associate Professor Internal Medicine, Division

of Infectious DiseasesAssociate Director for

ResearchGalveston National

LaboratoryUTMB, Galveston

Swine Flu: The Pandemic That Wasn't?

Actually, not quite.

New, Emerging & Re-emerging Infectious Diseases, 2010

Anthrax

Chikungunya

2009 Asw H1N1 influenza

Infectious diseases respect no political or geographical

boundaries.

• We were reminded of this fact with the emergence and quick spread of the H1N1, 2009 “swine flu” throughout the world.

Seasonal Influenza A

• Each year in the United States,– 5% to 20% of the

population gets the flu– hospitalizations-200,000– deaths-36,000

How the Virus Spreads Flu viruses spread by:

Respiratory droplets-Can travel 3-6 feet.

Coughs and sneezes. Touching objects touched by an

infectious person. Virus survives up to 72 hours on most

surfaces. Is destroyed by:

- Heat (167-212°F [75-100°C]). -Chemical germicides, including chlorine, hydrogen peroxide, detergents (soap), and alcohols.

Seasonal Epidemics vs. PandemicsSeasonal 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

Influenza Pandemics

Appear in the human population rarely and unpredictably

Human population lacks any immunity

All age groups, including healthy young adults

Where Do “New” Influenza Viruses Come From?

• Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses and seals.

• Birds– All types of influenza viruses

circulate in birds.

• Pigs– Can be infected with avian and human viruses.

7

Naming Influenza Viruses

• Influenza type A viruses are named on the basis of two proteins on the surface of the virus particle: – Hemagglutinin (HA or H) and neuraminidase (NA). – Protective antibodies to HA and NA are made after natural infection or

treatment with a vaccine.

HNA

Influenza A California 2009 H1N1

Mechanism of Influenza A Antigenic Shift

H1N1 humanH3N7 avian

New Virus is made H1N7

Genetic Re-assortment Occurs

Influenza Pandemic

A pandemic is a global disease outbreak. An influenza pandemic occurs when a new influenza A virus emerges for which there is little or no immunity in the human population, begins to cause serious illness and then spreads easily person-to-person worldwide (Flu.gov, 2009).

For additional information on pandemic influenza visit: www.pandemicflu.gov

Influenza A Pandemics in the 20th Century

1920 1940 1960 1980 2000

H1N1

H2N2 H3N2

1918: “Spanish Flu”

1957: “Asian Flu”1968: “Hong Kong Flu”

20-40 million deaths

1-4 million deaths1-4 million deaths

Pandemics occur three or four times each century.

• 1918 Surgical masks provide a measure of protection against a killer flu for American baseball players in 1918.

What We’ve Learned from History

Pandemic influenza typically comes in waves. The great 1918-1919 pandemic came in 3 distinct ‘waves.’The second wave was very different – much more lethal.Over the summer the virus changed.

What We’ve Learned from History

This photograph shows victims crowded into an emergency hospital at Fort Riley, KS.National Museum of Health and Medicine, Armed Forces

In 1918 the final year of World War I—the Spanish flu killed worldwide, at least three times as many people as during the war.

15-45

Avian Influenza

• Bird to human transmission. (human-to-human rare)

• Can cause human disease.– 400 deaths since 2003

• We have little to no immunity to these viruses.

• We have a vaccine for H5N1.

Influenza A (H1N1): What We Know Now! H1N1, 2009 was an entirely

new virus: Genetic components came

from flu viruses that infect pigs, birds and humans.

The virus was easily transmitted among humans.

No one, except those who had been infected, or received vaccine is immune.

BEYOND PIGS: Despite its name, this strain of swine flu wasn’t spread from direct contact with pigs or pork, but rather was transmitted among humans.

H1N1, 2009 In the Beginning• On April 17, American health officials reported

that two children in California had been infected with an influenza strain rarely seen in humans.

• There were also reports of an unusual respiratory virus in Mexico. – Virtually all the tests they were using were coming

back negative for every strain of flu known.

• That raised the question: Is it a new flu virus, or was it something else?

• Scientists get very worried when there is an influenza A virus they cannot type.

• Past history tells us to be ready for new influenza strains to emerge.

• The president declared the H1N1 pandemic a national emergency on October 24, 2009.

• Media figures have accused the Administration, CDC and WHO of attempting to, "create panic and chaos" in order to "sell health care.“

• So Was the H1N1 Pandemic Real?

National Emergency

Data Says-WHO and CDC Were Right!1) Lab analyses showed that this influenza virus was

genetically very different from other influenza viruses circulating among people.

2) Epidemiological information provided by Mexico, the US and Canada demonstrated person-to-person transmission.

3) Clinical information, especially from Mexico, indicated this virus could cause severe disease and death.

4) Geographical spread was exceptionally rapid.• On 29 April 2009, WHO reported lab confirmed cases in 9

countries.• About 6 weeks later, on 11 June, WHO reported cases in 74

countries.• By 1 July, infections had been confirmed in 120 countries and

territories.• It is this global spread which led WHO to call for increasing phases

and finally, to announce that a pandemic was underway.

Containment Efforts in Mexico

• A Mexican passenger is checked by a doctor at Benito Juarez International Airport in Mexico City, on May 4, 2009.

• Mexico's toll from the A (H1N1) influenza virus increased to 22 dead and 568 infected cases (Health Minister Jose Angel Cordova).

A worker of the Cruz Azul's stadium, wearing a face mask, watches a Mexican soccer league match between Cruz Azul and Indios at the Cruz Azul's stadium in Mexico City, Saturday May 2, 2009.

A shut down of all schools, universities, museums and theatres was extended to bars and discos.

Sunday Masses were also cancelled – the first such closure since Mexico's religious wars of the 1920s.

Containment Efforts in Mexico

Members of the cleaning brigades of Mexico City's government disinfect a subway station on May 2, 2009 in Mexico City. (MIGUEL CASTILLO/AFP/Getty Images)

Containment Efforts in Mexico

Containment Efforts in US

• May 20th 2009. The number of confirmed swine flu cases exceeded 10,000.

• Twenty-six schools in New York City and several others around the country were closed.

Spread of Virus in the US

Monday, April 27Monday, May 11

H1N1 Influenza A Virus, 2009

It’s Official: The First Flu Pandemic of the 21st CenturyOn June 11, 2009

Community-level outbreaks in multiple parts of the world

WHO raised the pandemic alert level to Phase 6

A global pandemic was underway

Declaration was reflection of the spread of the virus – not of the severity of the disease it causes

World Health Organization, Retrieved July 7, 2009

H1N1 Influenza A Virus, 2010• In Georgia, after a

period of weeks of inactivity, hospitalizations from H1N1 have spiked, and so have deaths.

• There were more hospitalizations in two weeks from H1N1 in Georgia than in October, 2009 when the pandemic's second wave hit its stride.

H1N1 didn't follow the rules.Virus in N. Hemisphere in the

summer

H1N1 Did Not Follow the Rules

• More than 85% of the H1N1(2009) deaths were in people younger than 60, with an overall mean age of 37.4.

• Mean age of 76 in those who die of seasonal flu.

H1N1 Today

Lessons Learned

• So what have health authorities, scientists, and vaccine makers learned?

• That viral outbreaks of this sort are even less predictable than scientists thought and that the defenses in place today would have been utterly inadequate against a more virulent strain.

Education Helped

Educating the public To recognize the disease. Keeping distance from other people who

appear ill. Stay home until no longer infectious,

except to obtain medical care. Wash your hands.

Educating employers and schools To recognize the disease. Dismiss workers and students who

develop symptoms immediately. Consider closing, if severe.

How to wash hands with soap and water

Community Measures

Mitigation Plans Worked

• Pandemic Outbreak: No Community Measures Used

• Pandemic Outbreak: With Measures Taken

Num

ber o

f Dai

ly C

ases

Delay onset of outbreak

Reduce the peak burden on hospitals/infrastructure

Decrease a) number of cases of death and illness and b) overall health impact

1

2

3

VaccinationMany people at high risk were afraid to get the H1N1 vaccine because they thought it was unproven.

In reality, it was manufactured just like the seasonal flu vaccine and tested enough to reassure the Food & Drug Administration that it was safe.

Nearly 25 percent of Americans have received the H1N1 swine flu vaccination.

Coverage among children aged 6 months through 17 years ranged from 21.3% in Georgia to 84.7% in Rhode Island.

Conventional Methods of Influenza Vaccine Production Need to be Changed

• Egg propagation:

Time consuming, expensive and incompatible with growing virus from avian influenza strains. It would take roughly 900 million chicken eggs to make vaccine for 300 million people.

Looking Ahead

• The WHO and FDA recommended that the pandemic H1N1 influenza strain be included in the flu vaccine for the coming fall and winter.

CDC estimates for H1N1 flu between April 2009 and Jan. 16, 2010:• Among those younger than 18

– 19 million cases and 82,000 hospitalizations and 1,230 deaths.

• For those 18 to 64– About 33 million cases, 150,000 hospitalizations and 8,980 deaths.

• For those 65 and older– About 5 million cases, 25,000 hospitalizations and 1,480 deaths.

• Total range of deaths -8,330 to 17,160.

Summary 2009 H1N1 Pandemic

Educate to Innovate

thought about what makes a kite fly. All had fun exploring the world around them.

                                                                President Obama has said that learning science and math “… goes beyond the facts in a biology textbook or the questions on an algebra quiz. It's about the ability to understand our world.”

He made these comments last year at the launch of STEM (campaign to improve science, technology, engineering, and math education).

Be a mentor and help to influence the future one student at time.

At the 2010 White House Egg Roll

Gertrude B. Elion 1918 to 2-21-1999The Nobel Prize in

Physiology or Medicine 1988

                      The Nobel Prize in Physiology or Medicine 1988

                      The Nobel Prize in Physiology or

                      The Nobel Prize in Physiology or

• She received the Nobel Prize for medicine in 1988 for the development of drugs such as azathioprine.

• These and other drugs aid in organ transplant surgery by keeping the body from rejecting the new organ.

• The achievements of Gertrude B. Elion will continue to have a profound impact on countless lives, for her breakthroughs in pharmacology have improved treatments for an extraordinary range of illness, from leukemia to rheumatoid arthritis, herpes virus, and kidney disease...

Mentors that made a difference to me

• Dame Julia Margaret Polak, DBE, FMedSci (born 1939, Argentina) is a current head of the Centre for Tissue Engineering and Regenerative Medicine at Imperial College London.

• Polak is one of the longest surviving recipients of a heart and lung transplant in the United Kingdom.

• It was her transplant in 1995 which caused her to change her career direction from Pathology towards the newly developing field of Tissue Engineering.

Mentors that made a difference to me

For more information on

the GNL, please visit

www.utmb.edu/gnl

"No pessimist ever discovered the secrets of the stars, or sailed to an uncharted land, or opened a new heaven to the human spirit." Helen Keller