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March- April 2009 Vol.12 : No.8

Special Issue: Human Swine Influenza: a pandemic threat

INTRODUCTION

Influenza (Flu) pandemics are caused by newinfluenza viruses that have recently adapted tohumans and resemble major natural disastersboth in terms of recurrence and magnitude.The influenza virus, known to be circulating asa pathogen in the human population since atleast the 16

century is notable for its uniqueability to cause recurrent epidemics and globalpandemics. Genetic re-assortments in theinfluenza virus cause fast and unpredictableantigenic changes in important immune targetsleading to recurrent epidemics of febrilerespiratory disease every 1 to 3 years,consistently necessitated the development ofnew vaccines. Each century has seen somepandemics rapidly progressing to all parts ofthe world due to emergence of a novel virus towhich the overall population holds noimmunity.

SWINE FLU IN PIGS

Swine Influenza (swine flu) is a respiratorydisease of pigs caused by type A influenzavirus that regularly causes outbreaks ofinfluenza in pigs. Swine flu viruses cause highlevels of illness and low death rates in pigs.Swine influenza viruses usually circulateamong swine throughout the year, but mostoutbreaks occur during the late fall and wintermonths similar to outbreaks in humans. Theclassical swine flu virus (an influenza type AH1N1 virus) was first isolated from a pig in1930. H3N2 influenza viruses begancirculating among pigs from 1998. The H3N2viruses initially were introduced into the pigpopulation from humans.Like all influenza viruses, swine flu viruseschange constantly. Pigs can be infected byavian influenza, human influenza viruses aswell as swine influenza viruses and hence thepigs are known to be a mixing vessel. Wheninfluenza viruses from different species infectpigs, the viruses can re-assort (i.e. swap genes)and new viruses , a mix of swine, human and/oravian influenza viruses - can emerge leading todevelopment of new novel strain for whichhuman beings do not have no immunity. Thereare four main influenza type A virus subtypesthat have been isolated in pigs: H1N1, H1N2,H3N1 and H3N2. However, most of the recentlyisolated influenza viruses from pigs have beenH1N1 viruses.

Swine flu virus spreads mostly through closecontact among pigs and possibly fromcontaminated objects moving between infectedand uninfected pigs. Symptoms of swine flu inpigs can include sudden onset of fever,depression, coughing (barking), dischargefrom the nose or eyes, sneezing, breathingdifficulties, eye redness or inflammation, andgoing off feed.

SWINE FLU IN HUMANS

Swine flu viruses do not normally infect humans.However, sporadic human infections with swineflu have occurred. Most commonly, these casesoccur in persons having direct exposure to pigs.In addition, there have been sporadic cases ofone person spreading swine flu to others.Occasional human swine influenza virusinfection occurs every one to two years in theU.S., but from December 2005 through February2009, 12 cases of human infection with swineinfluenza have been reported.

SWINE FLU OUTBREAK

Recently, human cases of swine influenza A(H1N1) virus infection have been recentlyreported in several countries. This is a novelinfluenza A virus that has not been identified inpeople before, and human-to-humantransmission of the virus appears to beongoing and thus represents a real pandemicthreat. WHO has upgraded the phasing ofpandemic influenza from Phase -3 to Phase - 5

Aler t

Monthly Newsletter of National Institute of Communicable Diseases,Directorate General of Health Services, Government of India

Influenza A HA and NA SubtypesInfluenza A HA and NA Subtypes

H15, H16H14H13H12H11H10H3H2H1H9H8H7H6H5H4N9N8N7N6N5N3N4N2N1

The above diagram shows various subtypes ofInfluenza, A virus which infects humans, swine,birds, poultry and horses and other animals, butwild birds are the natural hosts for these viruses.Influenza type A viruses are divided into subtypesand named on the basis of two proteins on thesurface of the virus: hemagglutinin (HA) andneuraminidase (NA. There are 16 known HAsubtypes and 9 known NA subtypes. Many differentcombinations of HA and NA proteins are possible. .For example, an “H1N1” virus has an HA 1 proteinand an NA 1 protein Only some influenza Asubtypes (i.e., H1N1, H1N2, and H3N2) arecurrently in general circulation among people.Other subtypes are found most commonly in otheranimal species.

Current Situation:

The current situationregarding the outbreak of swine influenzaA(H1N1) is evolving rapidly. As on 29 April2009, nine countries have officially reported148 confirmed cases of swine influenzaA/H1N1 infection. Of these, United States hasreported 91 laboratory confirmed humancases, including one death. Mexico hasreported 26 confirmed human cases includingseven deaths.The following countries have reportedlaboratory confirmed cases with no deaths -Austria (1), Canada (13), Germany (3), Israel(2), New Zealand (3), Spain (4) and the UnitedKingdom (5). All these cases have history oftravel to Mexico.Unlike the experience in Mexico, the UnitedStates is currently reporting infection by theidentical virus strain or less severe clinicalspectrum of disease.

Mexican health officialshave reported several hundred suspect cases,including several deaths associated with swineinfluenza A (H1N1) virus infection

In Mexico,many patients have experienced rapidly

progressive pneumonia, respiratory failure andacute respiratory distress syndrome (ARDS)requiring mechanical ventilation.

WHO PHASES OF PANDEMIC ALERT

(Source: WHO)

Phase 1

No animal influenza virus circulatingamong animals has been reported tocause infections in humans.

Phase 2

An animal influenza virus circulatingamong domesticated or wild animalsis known to have caused infection inhumans, and is therefore considereda specific potential pandemic threat.

Phase 3

An animal or human-animal influenzareassortant virus has caused sporadiccases or small clusters of disease inpeople, but has not resulted in human-to-human transmission sufficient tosustain community-level outbreaks.

Phase 4

Human-to-human transmission(H2H)of an animal or human-animalinfluenza reassortant virus able tosustain “community-level outbreakshas been verified.

Phase 5

The same identified virus has causedsustained community level outbreaksin two or more countries in one WHOregion

Phase 6

The

pandemic phase

, ischaracterized by community leveloutbreaks in at least one other countryin a different WHO region in addition tothe criteria defined in

Phase 5

Post PeakPeriod

Levels of pandemic influenza in mostcountries with adequate surveillancehave dropped below peak levels

Possiblenew wave

Level of pandemic influenza activity inmost countries with adequatesurveillance rising again

PostPandemicPeriod

Levels of Influenza activity havereturned to levels seen for seasonalinfluenza in most countries withadequate surveillance.

The current WHO phase of pandemic alert is 5

WHO has declared the outbreak as

PUBLIC HEALTH EMERGENCY OF INTERNATIONALCONCERN (PHEIC)

(Source: WHO: Pandemic influenzapreparedness and response)

INFLUENZA SURVEILLANCE

Surveillance is the foundation of all efforts tounderstand and control influenza. The monitoring ofinfluenza disease patterns is essential foridentification of high risk groups, planning ofprevention and response activities for complicationsand for estimating the burden of disease in terms ofhealth and economic impact.It is important to use standardized case definitionsthat enable comparisons between different areaswithin a country and also between countries. Thereare two case definitions used by the influenzasurveillance system:1

.Influenza-like illness (ILI)

is defined (accordingto WHO criteria) as:•Sudden onset of a fever over 38°C, AND•Cough or sore throat, AND•An absence of other diagnoses.2.

Severe Acute Respiratory Infections (SARI):

For persons

≥ 5 years

the definition for SARI isadapted from the WHO protocol on rapidresponse:

•Sudden onset of fever over 38°C, AND•Cough or sore throat, AND•Shortness of breath or difficulty in breathing, AND•Requiring hospital admission

For children <5 years old:

definition is adaptedfrom the program for Integrated Management ofChildhood Illness (IMCI):Any child <5 years old clinically suspected ofhaving Pneumonia or Severe/very SeverePneumonia and requiring hospital admission.3.

Confirmed case

of influenza is defined as anycase with laboratory test results positive forinfluenza virus.

CASE DEFINITION OF SWINE FLU INHUMANS

suspected case

of swine influenza A (H1N1)virus infection is defined as a person with acutefebrile respiratory illness (fever

≥

C) with onset.



within 7 days of close contact with a person whois a confirmed case of swine influenza A (H1N1)virus infection,



within 7 days of travel to areas where there areone or more confirmed swine influenza A(H1N1)cases,



resides in a community where there are one ormore confirmed swine influenza cases.A

probable case

of swine influenza A (H1N1) virusinfection is defined as a person with an acutefebrile respiratory illness who:



is positive for influenza A, but unsubtypable forH1 and H3 by influenza RT-PCR or reagentsused to detect seasonal influenza virus infection,



is positive for influenza A by an influenza rapidtest or an influenza immunofluorescence assay(IFA) plus meets criteria for a suspected case,



individual with a clinically compatible illness whodied of an unexplained acute respiratory illnesswho is considered to be epidemiologically linkedto a probable or confirmed case.A

confirmed case

of swine influenza A (H1N1) virusinfection is defined as a person with an acute febrilerespiratory illness with laboratory confirmed swineinfluenza A (H1N1) virus infection at WHO approvedlaboratories by one or more of the following tests:



Real Time PCR



Viral culture



Four-fold rise in swine influenza A (H1N1) virusspecific neutralizing antibodies

OTHER DEFINITIONS

Close contact

is defined within 6 feet of an illperson who is a confirmed, probable or suspectedcase of swine influenza A (H1N1) virus infectionduring the infectious period.

Acute respiratory illness

is defined as illness ofrecent onset with least two of the following:rhinorrhea or nasal congestion, sore throat, cough(with or without fever).

High-risk group

for complications of influenza

isdefined as a person such as:



resident of institutions for elderly people andthe disabled;



people with certain chronic health conditions(chronic heart or lung disease, metabolic orrenal disease or immunodeficiencies);



elderly people and very young children.

Infectious period

:The infectious period for aconfirmed case of swine influenza A (H1N1) virusinfection is defined as 1 day prior to the onset ofillness to 7 days after onset.

TRANSMISSION



Influenza viruses can be directly transmitted frompigs to people and from people to pigs.



Human infection with flu viruses from pigs aremost likely to occur when people are in close