Influenza A virus subtype H1N1

From Wikipedia, the free encyclopedia

Influenza A(H1N1) virus is a subtype of

influenzavirus A and the most common cause of
influenza (flu) in humans. Some strains of H1N1 are
endemic in humans and cause a small fraction of all
influenza-like illness and a large fraction of all
seasonal influenza. H1N1 strains caused roughly half
of all human flu infections in 2006.[1] Other strains of
H1N1 are endemic in pigs (swine influenza) and in
birds (avian influenza).

In June 2009, World Health Organization declared

that flu due to a new strain of swine-origin H1N1 was
responsible for the 2009 flu pandemic. This strain is
often called "swine flu" by the public media.

Nomenclature

The various types of influenza viruses in humans.

Solid squares show the appearance of a new strain,
causing recurring influenza pandemics. Broken lines
indicate uncertain strain identifications.[2]

Influenza A virus strains are categorized according to

two proteins found on the surface of the virus:
hemagglutinin (H) and neuraminidase (N). All
influenza A viruses contain hemagglutinin and
neuraminidase, but the structures of these proteins
differ from strain to strain, due to rapid genetic
mutation in the viral genome.

Influenza A virus strains are assigned an H number

and an N number based on which forms of these two
proteins the strain contains. There are 16 H and 9 N
subtypes known in birds, but only H 1, 2 and 3, and N
1 and 2 are commonly found in humans.[3]

2009 A(H1N1) pandemic

In the 2009 flu pandemic, the virus isolated from

patients in the United States was found to be made
up of genetic elements from four different flu viruses
– North American Mexican influenza, North American
avian influenza, human influenza, and swine
influenza virus typically found in Asia and Europe –
"an unusually mongrelised mix of genetic
sequences."[13] This new strain appears to be a result
of reassortment of human influenza and swine
influenza viruses, in all four different strains of
subtype H1N1.

Preliminary genetic characterization found that the

hemagglutinin (HA) gene was similar to that of swine
flu viruses present in U.S. pigs since 1999, but the
neuraminidase (NA) and matrix protein (M) genes
resembled versions present in European swine flu
isolates. The six genes from American swine flu are
themselves mixtures of swine flu, bird flu, and
human flu viruses.[14] While viruses with this genetic
makeup had not previously been found to be
circulating in humans or pigs, there is no formal
national surveillance system to determine what
viruses are circulating in pigs in the U.S.[15]

On June 11, 2009, the WHO declared an H1N1

pandemic, moving the alert level to phase 6, marking
the first global pandemic since the 1968 Hong Kong
flu.[16]

What is the new influenza A(H1N1)?

Updated 11 June 2009

What is the new influenza A(H1N1)?

This is a new influenza A(H1N1) virus that has never

before circulated among humans. This virus is not
related to previous or current human seasonal
influenza viruses.

How do people become infected with the virus?

The virus is spread from person-to-person. It is

transmitted as easily as the normal seasonal flu and
can be passed to other people by exposure to
infected droplets expelled by coughing or sneezing
that can be inhaled, or that can contaminate hands
or surfaces.

To prevent spread, people who are ill should cover

their mouth and nose when coughing or sneezing,
stay home when they are unwell, clean their hands
regularly, and keep some distance from healthy
people, as much as possible.

There are no known instances of people getting

infected by exposure to pigs or other animals.

The place of origin of the virus is unknown.

What are the signs and symptoms of infection?

Signs of influenza A(H1N1) are flu-like, including

fever, cough, headache, muscle and joint pain, sore
throat and runny nose, and sometimes vomiting and
diarrhoea.
Why are we so worried about this flu when
hundreds of thousands die every year from
seasonal epidemics?

Seasonal influenza occurs every year and the viruses

change each year - but many people have some
immunity to the circulating virus which helps limit
infections. Some countries also use seasonal
influenza vaccines to reduce illness and deaths.

But influenza A(H1N1) is a new virus and one to

which most people have no or little immunity and,
therefore, this virus could cause more infections than
are seen with seasonal flu. WHO is working closely
with manufacturers to expedite the development of a
safe and effective vaccine but it will be some months
before it is available.

The new influenza A(H1N1) appears to be as

contagious as seasonal influenza, and is spreading
fast particularly among young people (from ages 10
to 45). The severity of the disease ranges from very
mild symptoms to severe illnesses that can result in
death. The majority of people who contract the virus
experience the milder disease and recover without
antiviral treatment or medical care. Of the more
serious cases, more than half of hospitalized people
had underlying health conditions or weak immune
systems.

Most people experience mild illness and

recover at home. When should someone
seek medical care?
A person should seek medical care if they experience
shortness of breath or difficulty breathing, or if a
fever continues more than three days. For parents
with a young child who is ill, seek medical care if a
child has fast or labored breathing, continuing fever
or convulsions (seizures).

Supportive care at home - resting, drinking plenty of

fluids and using a pain reliever for aches - is
adequate for recovery in most cases. (A non-aspirin
pain reliever should be used by children and young
adults because of the risk of Reye's syndrome.)

Clinical:Influenza A H1N1

Names

Swine Flu.

Signs and Symptoms

Fever, cough, sore throat, body aches, headache,

chills and fatigue.

Causes

Diagnosis

Exams and tests

Treatment

Treatment in Pregnancy: Cases of H1N1 influenza

have been reported in pregnancy in the United
States (Novel Influenza A (H1N1) Virus Infections in
Three Pregnant Women --- United States, April--May
2009).
Pregnancy is a state of alterations in the
immunological, cardiovascular, and respiratory
systems that place patients at increased risk during
some illnesses. With seasonal influenza, pregnant
women are at increased risk of morbidity and
mortality, with complications such as respiratory
failure. It is not yet known whether pregnant women
with Influenza A H1N1 will be similarly affected.
Pregnant women who become ill with flu-like
symptoms should contact their health care worker
early in the course of illness to confirm the diagnosis
of influenza and to determine if antiviral medications
are indicated. The CDC is preferentially
recommending oseltamivir at this time, because its
systemic absorption may provide better protection
against mother-to-child transmission.[1] Treatment
should be initiated within 48 hours of symptom onset
and a 5 day course is recommended. Pregnant
women with exposure to confirmed, probable, or
suspected H1N1 influenza should consider taking a
preventative course of oseltamivir or zanamivir for
10 days.[2] Illness with influenza is NOT a
contraindication to nursing. Furthermore, pregnancy
or nursing are NOT contraindications to taking
antiviral zanamivir or oseltamivir.[3]

Medications

Prevention

Chemoprophylaxis recommended

The CDC recommends that certain groups should

receive a 10-day prophylactic course of oseltamivir
or zanamivir antiviral medications:
 Pregnant women in close contact with a
confirmed, probable, or suspected case of H1N1
influenza[4]
 Household close contacts with a high risk of
complications of influenza (persons with certain
chronic medical conditions, age over 65, age under
5) who have close contact with a confirmed or
probable case of H1N1 influenza
 Healthcare personnel having close contact with a
confirmed, probable, or suspected case of H1N1
influenza without appropriate personal protective
equipment

Because of increased risks of influenza in pregnancy,

the Advisory Committee on Immunization Practices,
the American College of Obstetricians and
Gynecologists, and the WHO have recommended
that all pregnant women be offered inactivated
influenza vaccine.[5][6] The vaccine may be given in
any trimester. Influenza vaccination is intended to
prevent seasonal influenza and has been shown in a
randomized controlled trial to be effective.[7] At this
time, however, influenza vaccination will not protect
against 2009 Influenza A H1N1 flu.

Chemoprophylaxis may be considered

The CDC suggests that chemoprophylaxis with a 10-

day course of oseltamivir or zanamivir may be
considered for the following groups:

 Household close contacts with a high risk of

complications of influenza (persons with certain
chronic medical conditions, age over 65, age under
5) who have close contact with a suspected case of
H1N1 influenza
 Children attending school or daycare who are at
high-risk for complications of influenza (children with
certain chronic medical conditions) and who had
close contact (face-to-face) with a confirmed,
probable, or suspected case
 Health care workers who are at high-risk for
complications of influenza (e.g., persons with certain
chronic medical conditions, persons 65 or older, and
pregnant women) who are working in an area of the
healthcare facility that contains patients with
confirmed swine-origin influenza A (H1N1) cases, or
who is caring for patients with any acute febrile
respiratory illness
 Travelers to Mexico who are at high-risk for
complications of influenza (e.g., persons with certain
chronic medical conditions, persons 65 or older,
children younger than 5 years old, and pregnant
women)
 First responders who are at high-risk for
complications of influenza (e.g., persons with certain
chronic medical conditions, persons 65 or older,
children younger than 5 years old, and pregnant
women) and who are working in areas with
confirmed cases of swine-origin influenza A (H1N1)
virus infection.
Influenza A H1N1

Introduction

Influenza A H1N1 2009, aka Swine Flu, is a new

strain of influenza virus not previously seen. This
strain is unusual in that it appears to be a cross
between swine Influenza A H1N1 viruses found in
North America, Asia, and Europe, as well as North
American avian influenza viruses, and human
influenza viruses.[1] To avoid misunderstandings, as
of April 30, 2009, the World Health Organization is
now referring to the virus as 2009 Influenza A H1N1.
Although the virus does contain elements of swine
Influenza, there is no documented risk from eating
pork. To date, only those in close contact with swine
(farmers/handlers) have ever contracted a Swine
influenza infection from pigs themselves. [2]

The virus was first identified in the US in two children

on April 17. [3] It appears to have first occurred in La
Gloria, Mexico in March, when there was a large
outbreak of an unusual respiratory illness in the
town. [4] Since then, it has now spread to and been
identified in multiple countries, including the US,
Canada, New Zealand, Hong Kong, China, and
throughout Europe.

For perspective, as Dr Margaret Chan Director-

General of the World Health Organization, observed,
balancing information alerts can be a difficult
challenge: "Last week, Mexican researchers
published clinical profiles of early H1N1 cases in the
New England Journal of Medicine. As noted, the full
clinical spectrum of this disease is not yet fully
understood. We do not fully understand the
predictive factors for severe or fatal infections.
However, as more and more data become available,
we are getting a better grip on warning signs that
can signal the need for urgent medical care.
Symptoms of concern include difficulty in breathing,
shortness of breath, chest pain and severe or
persistent vomiting. In adults, a high fever that lasts
for more than three days is a warning sign,
particularly when accompanied by a general
worsening of the patient’s condition. Lethargy in a
child, that is, a child that has difficulty waking up or
is no longer alert, or is not playing, is a warning sign.
For a pandemic of moderate severity, this is one of
our greatest challenges: helping people to
understand when they do not need to worry, and
when they do need to seek urgent care. This is one
key way to help save lives."[5]

Summary of Key Points for Protection

These are the essential points to understand to

protect yourself and your community: see How
Influenza A H1N1 is Spread see Household Infection
Control Precautions

The mode of transmission of influenza viruses is

thought to occur from person to person in respiratory
droplets of coughs and sneezes. These infected
droplets land on the mouth, nose or eyes of people
nearby, or are spread when a person touches
respiratory droplets on another person or an object
and then touches their own (or another person's)
mouth or nose (or rubs their eyes) before washing
their hands. Influenza A H1N1 is not spread by pork
or other food.

Masks will provide barrier protection against the

large infective droplets that are believed to cause
transmission. They are not effective against small
viral particles that may be airborne. N-95 masks
must fit tightly to work effectively. [6] Don’t panic if
you do not have an N-95 surgical mask. An important
part of prevention is to keep droplets away from your
nose, mouth, and eyes. If you don't have a surgical
mask, use a cloth bandana or similar to cover your
nose and mouth. While there may be airborne
transmission, droplets are probably a significant
route and the one that individuals can best protect
against through good hygiene practices.

The essence of protecting yourself: Practice good

hygiene. Keep your hands away from your face,
or wash them first.

Wash your hands often.Wash with soap and

water. Utilize hot water and scrub with soap for 30
seconds, including between fingers and under
fingernails. Be sure to use a (paper) towel to turn off
the faucet handles so as not to recontaminate your
hands. The same applies to doorknobs. If you can't
wash your hands, use an alcohol-based hand
sanitizer with at least 60% alcohol.

Cover coughs and sneezesTeach your family to

cover their nose and mouth when they cough or
sneeze, dispose of the used tissues promptly, and
wash their hands (or use alcohol-based hand
sanitizer) immediately, before they contaminate
other surfaces with infective secretions.

"Social distancing" Keep ill family members away

from others in the home and at home unless they
need medical care. If ill and you have to go out, wear
a mask to catch coughs and sneezes and reduce the
transmission of infective droplets to others. In
general, do not share drinks or eating utensils. Do
not share towels. Color coding towels for different
family members can help reduce spread, too.

Seek medical care promptlyif you have a serious

underlying disease (see Risk Factors), are pregnant,
or become ill with severe flu-like symptoms or
warning signs of more serious illness – such as:

• shortness of breath or difficulty breathing,

especially if the patient is turning blue
• bloody or purulent sputum
• chest pain (other than with coughing)
• altered mental status
• high fever that persists beyond 3 days
• low blood pressure.

Milder symptoms of influenza, including fever,

generalized aches, sore throat, cough, runny nose,
vomiting, and diarrhea, can be treated at home,
symptomatically, since antiviral medication is no
longer recommended except for high risk individuals
or those developing complications. Take precautions
if visiting your healthcare provider, including washing
your hands frequently, using mask or cover over
mouth and nose, and distancing yourself from others
as much as possible to prevent further spread. See
Treatment.

Warning Do not give aspirin (acetylsalicylic acid) to

children or teenagers who have the flu; this can
cause serious and possibly fatal Reye’s syndrome.[7]
NSAIDS such as ibuprofen and acetominophen
(Tylenol) are safe for symptomatic relief.

More detailed information about swine flu follows.

Other Names

Influenza A(H1N1)

Swine influenza

Swine-origin influenza

In order to avoid further misunderstandings, as of

April 30, 2009, the World Health Organization is now
referring to the virus as 2009 Influenza A H1N1
rather than swine flu. Only those in close contact
with swine (farmers and pig handlers) can be
infected by pigs although pigs can be infected by
humans [3]. There is no harm of contracting the virus
from eating pork products.

Types

It is known that swine are "incubators" for influenza

A, being susceptible to not only swine influenza, but
avian and human also. When a swine is infected with
multiple strains of virus, the genetic elements which
make up the virus are able to recombine within
individually infected cells. Thus, a virus can be
packaged with a swine, human and/or avian
elements or combinations thereof. As this
recombination occurs, the resulting virus can be
either more or less pathogenic (capable of causing
illness). While various strains of influenza have
previously been identified as combining swine, avian,
and human elements, the 2009 Influenza A H1N1
appears to be an entirely new strain. While related to
the human influenza H1N1 virus, it contains a novel
combination of genetic material, including a cross of
swine Influenza A H1N1 viruses found in North
America, Asia, and Europe, as well as North American
avian influenza viruses, and human influenza viruses.
[5] This Influenza A H1N1 has not been previously
recognized in either people or pigs. It is not yet clear
where or how it arose nor how it was initially
transmitted to humans. To reemphasize, Influenza A
H1N1 does not require a prior exposure to pigs. It is
not transmitted by eating pork products, and it is
spread from person-to-person.

Causes and Transmission

H1N1 flu is an infection caused by a novel Influenza

A strain, a cross between swine Influenza A H1N1
viruses found in North America, Asia, and Europe, as
well as North American avian influenza viruses, and
human influenza viruses.[8]

As with regular, seasonal influenza, transmission of

Influenza A H1N1 is person to person, by spread of
droplets from the respiratory secretions of infected
individuals. These can directly contact healthy
people’s nose, mouth, or eyes, resulting in infection,
or by contamination of surfaces with infective
droplets. For more information, see How Influenza A
H1N1 is Spread.

How Influenza A H1N1 is Spread

How does swine flu spread?

Influenza viruses can be directly transmitted from

pigs to people and from people to pigs. Human
infection with flu viruses from pigs are most likely to
occur when people are in close proximity to infected
pigs, such as in pig barns and livestock exhibits
housing pigs at fairs.

Droplet transmission

The main way that influenza viruses are thought to

spread is from person to person in respiratory
droplets of coughs and sneezes. This can happen
when droplets from a cough or sneeze of an infected
person are propelled through the air and deposited
on the mouth or nose of people nearby. This is why
masks are recommended if you are within 6 feet of
an infected person. Influenza viruses may also be
spread when a person touches respiratory droplets
on another person or an object and then touches
their own mouth, nose, or eyes (or someone else’s
mouth, nose, or eyes) before washing their hands.

Direct and indirect contact transmission

"Direct contact transmission" means skin-to-skin

contact (such as hand-to-hand) between an infected
person and a susceptible person. "Indirect contact" is
transmission by touching contaminated objects. It is
unclear how much transmission of swine flu occurs
by these routes; primary transmission appears to be
from droplets contacting the nose, mouth, or eyes of
a susceptible person. Influenza A viruses can live for
24 to 48 hours on nonporous environmental surfaces
and less than 12 hours on porous surfaces.[9]

Airborne transmission

Airborne transmission may occur with influenza

viruses, but is not felt to be the primary mode of
transmission. It is most likely to be of concern during
aerosol generating procedures, such as intubation,
suctioning, bronchoscopy, nebulizer treatments, or
similar hospital or health care facility associated
procedures. There is no evidence to date of
widespread airborne transmission as can occur with
TB or chicken pox.[10]

Other transmission routes It is not yet known if other

routes, such as ocular, conjunctival, or
gastrointestinal infections, can occur. Until more is
known, it is recommended that all respiratory
secretions and bodily fluids (including diarrheal stool)
of novel H1N1 influenza cases should be considered
potentially infectious.[11]

Incubation and Infectious Period

Adults with Influenza A H1N1 virus infection should

be considered potentially contagious for up to 7 days
following illness onset. Children, especially younger
children, might potentially be contagious for longer
periods.People are infectious for at least 24
hours prior to developing symptoms. Persons
who continue to be ill longer than 7 days after illness
onset should be considered potentially contagious
until symptoms have resolved. The duration of
infectiousness might vary by Influenza A H1N1 virus
strain.

Prevention-Infection Control

Surgical masks will provide barrier protection against

large droplets that are considered to be the primary
route of influenza and SARS transmission. N-95
respirators provide additional protection against
possible airborne transmission. Don’t panic if you
don’t have an N-95 mask. The key to prevention is to
keep droplets away from your nose, mouth, and
eyes. If you don’t have a surgical mask, use a cloth
bandana or similar to cover your nose and mouth.
Change them frequently, launder and use hot dryer.

Keep your hands away from your face, or wash

them first. Don’t share drinks or eating utensils.

Routine cleaning and disinfection strategies used

during influenza seasons can be applied to the
environmental management of Influenza A H1N1.
More information can be found from the CDC. [12].
Appropriate hospital disinfectants include any one of
the following, at the concentration respectively
indicated:

• ethanol diluted to 70% in water

• Lysol diluted to 5% in water
• bleach diluted to 10% in water

Household Infection Control Precautions

Lessening the Spread of Flu

"Social distancing" is important. Keep the sick person

away from other people as much as possible.

1. Remind the sick person to cover their coughs,

and clean their hands with soap and water or an
alcohol-based hand rub often, especially after
coughing and/or sneezing.
2. Have everyone in the household clean their
hands often, using soap and water or an alcohol-
based hand rub.
3. Remind everyone to keep their hands away from
their face, and to wash hands frequently or use a
hand sanitizer (>60% alcohol based).
4. Ask your health care worker if antiviral
medications are indicated

If you are the caregiver

• Avoid being face-to-face with the sick person.

• When holding small children who are sick, place
their chin on your shoulder so that they will not
cough in your face.
• Clean your hands with soap and water or use an
alcohol-based hand rub after you touch the sick
person or handle used tissues, or laundry.
• Because you might become ill from your
exposure, and can infect other people before
you have any symptoms, wear a mask when you
have to leave the home, to prevent further
spread to others.
• Ask your health care provider whether you
should receive antiviral prophylaxis.
Household Infection Control Precautions: Cleaning,
Laundry, and Waste Disposal

Clean surfaces in the patient's room and the

bathroom fixtures used by the patient daily, with a
household disinfectant. When cleaning, wear
disposable gloves, and dispose of them after use. Or,
use household utility gloves. Wash your hands or use
sanitizer on them, before removing them if possible.
Then wash your hands.

Use an EPA-reg household disinfectant labeled for

activity against bacteria and viruses, or similar
disinfectant or chlorine bleach solution, following
label instructions. If a generic brand of chlorine is
used, mix 1/4 cup of chlorine bleach with 1 gallon of
cool water. The bleach should be mixed fresh daily. If
you can't smell the chlorine, discard the solution and
make a fresh mixture.

• Throw away tissues and other disposable items

used by the sick person in the trash. Wash your
hands after touching used tissues and similar
waste.
• Keep surfaces (especially bedside tables,
surfaces in the bathroom, and toys for children)
clean by wiping them down with a household
disinfectant according to directions on the
product label.
• Linens, eating utensils, and dishes belonging to
those who are sick do not need to be cleaned
separately, but importantly these items should
not be shared without washing thoroughly first.
• Wash linens (such as bed sheets and towels) by
using household laundry soap and tumble dry on
 a hot setting. Avoid “hugging” laundry prior to
washing it to prevent contaminating yourself.
Clean your hands with soap and water or
alcohol-based hand rub right after handling dirty
laundry
• Eating utensils should be washed either in a
dishwasher or by hand with water and soap.[13]

Infection Control in Special Settings-Summer

Camps

The CDC has expressed special concern regarding

the potential for spread of influenza H1N1 in summer
camps. Suggestions include pre-planning for dealing
with sick campers and staff, planning in-camp
cohorting and isolation for those who become ill,
screening incoming campers, and planning how to
transfer ill children home without infecting others
enroute. [14]

Other Infection Control Recommendations

Masks and Respirators

While single use of masks (protective against

droplets) or N-95 respirators (used when airborne
transmission is suspected)is recommended, this is
not always possible. Don’t panic if you don’t have an
N-95 mask. The key to prevention is to keep droplets
away from your nose, mouth, and eyes. If you don’t
have a surgical mask, use a cloth bandana or similar
to cover your nose and mouth. Change them
frequently, launder and use hot dryer.
A study of 48 HCW with H1N1 infections was done by
the CDC. Half were felt likely to have acquired the
infection nosocomially, rather than through
community exposure. Review showed only sporadic
compliance with isolation precautions.[15]

Reuse of respirators and masks

While intended for single use, sometimes this is not

practical and masks have to be reused. Drawn from
experience with SARS, the following steps would
allow a person to reuse a disposable N95 respirator if
necessary. These steps are intended for reuse of a
respirator by a single person:

1. Wear a protective covering such as a medical

mask or a clear plastic face shield—a loose-
fitting barrier that does not interfere with fit or
seal over the respirator.
2. Remove the barrier upon leaving the patient’s
room and perform hand hygiene. Surgical masks
should be discarded; face shields should be
cleaned and disinfected.
3. Remove the respirator and either hang it in a
designated area or place it in a bag. (Consider
labeling respirators with a user’s name before
use to prevent reuse by another individual.)
4. Use care when placing a used respirator on the
face to ensure proper fit for respiratory
protection and to avoid contact with infectious
material that may be present on the outside of
the mask.[16]
5. Perform hand hygiene after replacing the
respirator on the face.
While these recommendations were developed for a
different illness, Viral Hemorrhagic Fever, the CDC's
site, [4], has excellent visuals and step-by-step
instructions for infection control and for the use of
masks and gowns (personal protective equipment),
especially in resource-limited settings.[17]

Viral shedding

It is unclear at this time exactly when shedding

begins or how long it lasts. Current estimates are
based on the behavior of seasonal influenza. It is
believed that shedding begins one day before the
development of symptoms (contributing to person to
person spread), and lasts for seven days in adults.
Children are likely to shed virus and be infectious for
a few days longer.

Incubation

Again, the precise incubation period is not yet

known. It is likely 1 to 4 days, perhaps longer.

Chances of Developing Influenza A H1N1

The risk of developing illness after exposure is not

yet known for certain. According to WHO (reported in
UpToDate), the H1N1 transmissibility appears
substantially higher than that of seasonal influenza,
with a secondary attack rate of the H1N1 strain
estimated to be 22 to 33 percent, compared with 5 to
15 percent for seasonal influenza. The CDC has not
confirmed the higher attack rate in the US.[18]

Risk factors
Risk factors are not yet known, other than exposure
to pigs or people infected with Influenza A H1N1.

The current outbreak is atypical in that, thus far, the

majority of the deaths from Influenza A H1N1 have
occurred in Mexico. Furthermore, most have been in
young adults. Regular influenza typically affects
infants and the elderly the hardest.

With the H1N1, adults over the age of 60 may have

protective immunity from prior related infection.

Pregnancy is being identified as a clear risk for more

severe illness. (see Complications and "H1N1 in
Pregnancy)

Other groups at higher risk of infection and

complications from Influenza H1N1 include those
with chronic lung disease (including asthma),
cardiovascular disease, diabetes, and
immunosuppression (including autoimmune disease),
and morbid obesity.[19]

Signs and Symptoms

Symptoms of H1N1 flu are similar to the symptoms

of regular influenza and generally include fever,
cough, sore throat, body aches, headache, chills and
fatigue.

One thing that is different with this H1N1 flu is that

some people have reported diarrhea and vomiting as
well. About 12% of the patients in two Mexico City
Hospitals experienced severe diarrhea, with loose
stools multiple times per day. [20] Some reports from
Mexico also note a cough that is more productive of
phlegm than is typical.

One disturbing finding as of May 2009, is that about

1/3 of the patients at two Mexican hospitals had no
fever when screened. This is troublesome, as doctors
often use the presence of fever to help diagnose flu
when screening patients. In fact, “textbooks say that
in an influenza outbreak the predictive value of fever
and cough is 90 percent,” Dr. Richard Wenzel,
prominent epidemiologist and former president of
the International Society for Infectious Diseases,
noted. [21] The atypical symptoms with the H1N1 flu,
with lack of fever being common, as well as the
presence of diarrhea, both of which are unusual in
seasonal influenza, are likely to confuse practitioners
and lead to delays in diagnosis.

The symptoms of H1N1 flu have been a bit different

in the 642 confirmed US cases from April 15th
through May 5th that have been analyzed. Fever was
the most common presenting symptom, (94% of
~394 patients for whom more complete information
was available), followed by cough (92%), and sore
throat (66%); 25% of patients had diarrhea, and 25%
had vomiting. Hospitalization was required by 9%,
almost half of whom had underlying
immunocompromising conditions.[22]

As with regular influenza, H1N1 flu infections can be

complicated by pneumonia and respiratory failure,
and deaths have been reported. To date, a
disproportionate number of deaths have been in
Mexico (1.2%) and Argentina (2.4%) compared to the
US (0.7%).[23] It is not known why the illness has been
more severe in these countries thus far. (see
Controversy below). This outbreak has also thus far
been different than seasonal influenza in that most of
the deaths have been in young adults, rather than in
young children, elderly, and otherwise
immunosuppressed people.

Special Populations

H1N1 in Pregnancy

Symptoms of H1N1 in pregnancy are similar to the

general population, and may include myalgia, dry
cough, shortness of breath, low-grade fever,
diarrhea, headache, dysphagia, and inspiratory chest
pain. Pregnant women are one of the high-risk
populations at risk for developing complications from
seasonal influenza, such as pneumonia, respiratory
distress, dehydration, and preterm delivery. It is now
apparent that pregnancy is a risk factor for more
serious complications and death from H1N1
infections, especially illness in the second or third
trimesters.

Twenty cases of H1N1 (15 confirmed and 5 probable)

have been reported by the CDC as of May 10, 2009.
In the Morbidity and Mortality Weekly Report
(MMWR) Dispatch, one case of maternal death in a
33-year old woman at 35 weeks gestation was
presented. The patient presented initially with
symptoms of myalgia, dry cough, and low-grade
fever. Four days after presentation, the patient
developed severe respiratory distress requiring
intubation and cesarean delivery of a viable infant.
Subsequent postpartum treatment with antivirals
and broad-spectrum antibiotics was initiated. The
patient died two weeks postpartum.[24]

Physiologic changes in pregnancy that account for

increased complication rates include changes in the
immune system, decreased functional residual
capacity, increased baseline oxygen consumption,
hypoalbuminemia predisposing to pulmonary edema,
increased risk of aspiration, and increased cardiac
output. Complication rates rise with increasing
gestational age and with presence of co-morbidities
such as asthma, diabetes, cardiac disease,
immunosuppressive conditions, tobacco use, and
other hisk-risk medical conditions. [25]

A review of cases reported in July, 2009 confirms the

increased risk of complications in pregnant women.
Because of this, they should begin treatment with
the antiviral drug oseltamivir as soon as possible
after symptom onset, even if later than the 48 hour
optimal window for initiating therapy. WHO has also
recommended that pregnant women be a priority
group for immunization with the H1N1 vaccine in
development.[26]

Complications

The complications of H1N1 flu are likely to be similar

to those of seasonal influenza—most commonly
pneumonia and respiratory failure. Pneumonia is
expected to affect 10% of people with pandemic
influenza. [27] It is important to note that
staphylococcal pneumonia is a common cause of
pneumonia following influenza. The rise in more
severe and difficult to treat MRSA (methicillin-
resistant staphylococcal aureus) pneumonia is likely
to result in more complications and deaths.
Treatment guidelines are available from the
Infectious Diseases Society of America (IDSA)[28] and
the American Thoracic Society (ATS).[5]. [29]

Other complications of seasonal influenza include

worsening of chronic underlying medical conditions,
other respiratory tract infections (sinusitis, otitis,
asthma), cardiac (myocarditis, pericarditis),
neurologic (seizures, encephalitis), musculoskeletal
(myositis, rhabdomyolysis) toxic shock.[30]

Groups at Higher Risk

As with seasonal influenza, groups at higher risk of

complications from H1N1 include those with chronic
lung disease (including asthma), cardiovascular
disease, diabetes, and immunosuppression, hepatic,
hematological, neurologic, or neuromuscular
disorders. Pregnancy is increasingly being recognized
as a risk factor for complications. Some studies
suggest that extreme obesity may also be a risk
factor for more severe disease.

Signs and symptoms of more severe illness

warranting medical attention include:

* shortness of breath or difficulty breathing,

especially if the patient is turning blue
* bloody or purulent sputum
* chest pain (other than with coughing)
* altered mental status
* high fever that persists beyond 3 days
 * low blood pressure.

In children, danger signs include fast or difficult

breathing, lethargy or lack of alertness, difficulty in
waking up, and little or no desire to play.[31]

Expected Outcome

The outcome is too early to predict. The H1N1 flu

reports initially more severe illness in Mexico, for
unknown reasons (see Controversy). In contrast, the
US cases have been more mild, with fewer cases of
pneumonia, respiratory failure, and death.[32]

For comparison, every year 5% to 20% of the

population in the US becomes ill with influenza. More
than 200,000 people are hospitalized from flu-related
complications. The mortality from seasonal influenza
in the US is estimated to be 36,000.[33]

Perspective is added by Dr. Richard Wenzel, expert

epidemiologist and former President of the
International Society for Infectious Diseases. He
notes, "First let's look at the meaning of the deaths
in context of the expected mortality rates. In the
1918-19 Avian flu pandemic, the mortality was 2.5%
-- 25 times the rate we see with the seasonal arrival
of flu each year of one in a thousand or 0.1%. If the
160 deaths in Mexico are truly related to swine flu
and the disease is very virulent -- for example with a
very high 1% mortality -- the real number of cases
must be 16,000 -- not the 2,500 currently reported.
On the other hand, if the new Swine flu is acting
more like our seasonal flu, the real number of cases
in Mexico is 160,000, 0.1% of which accounts for the
160 deaths."[34]

The World Health Organization Rapid Pandemic

Assessment Collaboration has determined that
approximately 23,000 Mexicans were infected with
the virus by the end of April, 2009 [6]. Thus, the
mortality rate for Influenza A H1N1 is 0.4%, higher
then normal seasonal flu, but not as high as the
1918-1919 pandemic.

Diagnosis

Lab Diagnosis

Patients with symptoms suggesting H1N1 flu should

have respiratory swab for influenza testing obtained
and placed in a refrigerator (not a freezer). Swabs
are usually obtained from the nasopharynx, though
throat swabs, nasal wash or aspirate or bronchial
wash or aspirate specimens are also suitable. Dacron
or polyester-tipped swabs should be used. Cotton
tipped swabs are not advised. Calcium alginate
swabs are unacceptable. Ideally, the specimen
should be placed in a collection vial containing viral
transport media. A specimen that is unsubtypable
influenza A will be sent by the lab to the Viral
Surveillance and Diagnostic Branch of the CDC’s
Influenza Division for further diagnostic testing.
Rapid diagnostic tests have already been developed
and distributed to state health departments by the
CDC, based on real-time reverse transcriptase (RT)-
PCR. Test results can be available within several
hours.
Case Definitions

The CDC has the following case definitions for H1N1

flu: A confirmed case of H1N1 influenza A virus
infection is defined as a person with an acute febrile
respiratory illness with laboratory confirmed
Influenza A H1N1 virus infection at CDC by one or
more of the following tests:

1. real-time RT-PCR
2. viral culture

A probable case of Influenza A H1N1 virus infection is

defined as a person with an acute febrile respiratory
illness who is:

• positive for influenza A, but negative for H1 and

H3 by influenza RT-PCR, or
• positive for influenza A by an influenza rapid test
or an influenza immunofluorescence assay (IFA)
plus meets criteria for a suspected case

A suspected case of Influenza A H1N1 virus infection

is defined as a person with acute febrile respiratory
illness with onset

• within 7 days of close contact with a person who

is a confirmed case of Influenza A H1N1 virus
infection, or
• within 7 days of travel to community either
within the United States or internationally where
there are one or more confirmed Influenza A
H1N1 cases, or
• resides in a community where there are one or
more confirmed Influenza A H1N1 cases.
[35]

Infectious period for a confirmed case of Influenza A

H1N1 virus infection is defined as 1 day prior to the
case’s illness onset to 7 days after onset.

Close contact is defined as: within about 6 feet of an

ill person who is a confirmed or suspected case of
Influenza A H1N1 virus infection during the case’s
infectious period.

Treatment

There are four influenza antiviral drugs approved for

use in the United States (oseltamivir, zanamivir,
amantadine and rimantadine). The Influenza A H1N1
virus that has been detected in humans in the United
States and Mexico are resistant to amantadine and
rimantadine so these drugs will not work against the
Influenza A H1N1 virus. Laboratory testing on
Influenza A H1N1 so far indicate that they are
susceptible (sensitive) to neuraminidase inhibitor
class of drugs, oseltamivir and zanamivir. Resistance
to Tamiflu has been reported in patients from
Denmark, Japan, Hong Kong, Canada, and the US (as
of 8/11/2009).[36], [37], [38], [39]

Treatment: For pregnant and other high-risk

individuals, antiviral drugs should be started as soon
as possible, and should be started within 48
hours of symptoms to be most effective. The
drugs may make your illness milder and help you feel
better faster. They may also prevent serious
influenza complications, like pneumonia.
Because most of the illness in patients who are not
considered “high risk” has been mild and self-limited,
the CDC and WHO have revised their guidelines.
They note that “persons with suspected novel H1N1
influenza who present with an uncomplicated febrile
illness typically do not require treatment.” [40]

Priority access to antivirals should be given to

patients at increased risk of complications due to
underlying health problems and to hospitalized
patients. Zanamivir (Relenza) or oseltamivir (Tamiflu)
should be given for 5 days.

Treatment is recommended for:

• Children younger than 5 years of age

(particularly those less than 2 years of age)

• Individuals 65 years of age or older

• Individuals younger than 19 years of age who

are receiving long-term aspirin therapy and who
therefore might be at risk for Reye syndrome
after influenza virus infection

• Pregnant women

• Individuals with chronic medical conditions

requiring ongoing medical care, including:
o Chronic pulmonary disease, including
asthma (particularly if systemic
glucocorticoids have been required during
the past year)
o Cardiovascular disease, except isolated
hypertension
o Active malignancy
 o Chronic renal insufficiency
o Chronic liver disease
o Diabetes mellitus
o Hemoglobinopathies such as sickle cell
disease
o Immunosuppression, including HIV infection
(particularly if CD4 <200 cells/microL),
organ or hematopoietic stem cell
transplantation, inflammatory disorders
treated with immunosuppressants
o Individuals who have any condition that can
compromise handling of respiratory
secretions (eg, cognitive dysfunction, spinal
cord injuries, seizure disorders,
neuromuscular disorders, cerebral palsy,
metabolic conditions)
o Children with an underlying metabolic
disorder, such as medium-chain acyl-CoA
dehydrogenase deficiency, who are unable
to tolerate prolonged fasting

• Children with poor nutritional and fluid intake

because of prolonged vomiting and diarrhea

• Residents of nursing homes and other chronic

care facilities [41]

Antiviral doses recommended for treatment of

Influenza A H1N1 virus infection in adults or children
1 year of age or older are the same as those
recommended for seasonal influenza and are
available from the CDC.[42]

Antivirals
Each antiviral medication has pros and cons. The
advantage of Oseltamivir(Tamiflu) is that it is
administered orally and gives higher systemic levels.
Oseltamivir is therefore the recommended treatment
for lower respiratory tract complications. In contrast,
Zanamivir (Relenza) is delivered by oral inhalation
with low systemic absorption. The main side effect is
that inhaled zanamivir has been temporally
associated with bronchospasm and therefore
patients with pre-existing airway disease (asthma or
COPD) appear to be at increased risk for this severe
adverse reaction.

Additionally, influenza A (H1N1)virus is resistant to

amantadine and rimantadine. Therefore, where
oseltamivir-resistant seasonal H1N1 influenza A virus
is known to be circulating, Zanamivir is preferentially
recommended.[43]

Treatment in Pregnancy Cases of H1N1 influenza

have been reported in pregnancy in the United
States (Novel Influenza A (H1N1) Virus Infections in
Three Pregnant Women --- United States, April--May
2009). With seasonal influenza, pregnant women are
at increased risk of complications such as respiratory
failure. It is now known that pregnant women with
H1N1 infections are at higher risk of complications.
Pregnant women who become ill with flu-like
symptoms should contact their health care worker
early in the course of illness to confirm the diagnosis
of influenza and to determine if antiviral medications
are indicated. The CDC is preferentially
recommending oseltamivir at this time, because its
systemic absorption may provide better protection
against mother-to-child transmission.[44] Treatment
should preferably be initiated within 48 hours of
symptom onset but should be started even if later in
the case of pregnant women. A 5 day course is
recommended. Pregnant women with exposure to
confirmed, probable, or suspected H1N1 influenza
should consider taking a preventative course of
oseltamivir or zanamivir for 10 days.[45] Illness with
influenza is NOT a contraindication to nursing.
Furthermore, pregnancy or nursing are NOT
contraindications to taking antiviral zanamivir or
oseltamivir.[46]

Fever In addition to antiviral therapy, fever in

pregnancy should be treated with acetaminophen to
reduce the risk of complications for the infant—birth
defects if fever occurs during the first trimester or,
neonatal seizures, encephalopathy, cerebral palsy,
and neonatal death if the fever occurs during labor.
[47]

Antibiotics

Breastfeeding

Breastfeeding is acceptable in women affected by

the H1N1 virus. Maternal antibodies may confer
immunity to the breastfeeding neonate. However,
current (8/11/09) recommendations are that the ill
patient should consider avoiding close contact with
her newborn until she has received antiviral
medications for 48 hours, her fever has resolved, and
she can control coughs and secretions. During this
period, the newborn should be cared for in a
separate room by another person who is well, and
the patient should be encouraged to express her milk
to be given to the newborn by a well individual. (See
"Breastfeeding" below). Once the patient begins
contact with her newborn, she should be encouraged
to wear a facemask, change to a clean gown or
clothing, adhere to strict hand hygiene and cough
etiquette, and begin breastfeeding, if possible.
Protective measures should be continued for at least
seven days after the onset of influenza symptoms;
these measures might need to be continued until the
patient is free of symptoms for 24 hours.[48]

Prevention: Antiviral drugs can also be given

prophylactically, i.e., to prevent influenza when they
are given to a person who is not ill, but who has been
exposed to flu. When used to prevent the flu, these
drugs are about 70% to 90% effective. The duration
of treatment will vary depending on the person's
health, or whether there is ongoing exposure, for
example. Post-exposure prophylaxis is currently
recommended only for those patients with underlying
diseases or pregnancy. Post-exposure
chemoprophylaxis is generally given for 10 days
after the last known exposure to an ill confirmed
case of swine flu.

Because of the concern that pregnant women may

have a more severe illness, the CDC recommends
that pregnant women who are in close contact with a
confirmed, probable, or suspected case-patient
receive a 10-day prophylactic course of antivirals.[49]

Vaccines:
The "flu shot" is intended to prevent seasonal
influenza. It will not protect against 2009 Influenza A
H1N1 flu.

No vaccine is yet available to prevent this disease. In

testimony before Congress on 4/30/09, CDC and FDA
officials projected that 600 million doses of an egg-
based vaccine against 2009 Influenza A H1N1 could
be available within 6 months.[50] After a new virus is
identified, the seed strain is grown with a standard
strain and attenuated in eggs. The virus is harvested
from the egg whites and then killed with chemicals,
and the outer proteins, or antigens, are further
purified. The vaccine is then tested: a) for sterility b)
to confirm the protein concentration and c) for safety
by testing in animals, before being tested in people.
Because the seasonal influenza vaccine has to be
newly developed and produced each year, there is
considerable experience with the development and
production process. Nonetheless, the process takes a
minimum of 6 months.[51] An H1N1 vaccine should be
available by fall, 2009. Clinical trials of the new H1N1
vaccine began on 8/10/09 in the US. It can be given
at the same time as the regular, seasonal "flu shot,”
but it is anticipated that the new vaccine will require
two separate injections.

Priorities in vaccination:

Because there will initially be limited supplies of

vaccine, the CDC’s Advisory Committee on
Immunization Practices (ACIP) has prioritized who
should receive the vaccine as it becomes available.
These key populations include pregnant women,
people who live with or care for children younger
than 6 months of age, healthcare and emergency
services personnel, persons between the ages of 6
months and 24 years old, and people ages of 25
through 64 years of age who are at higher risk for
novel H1N1 because of chronic health disorders or
compromised immune systems. Current studies
indicate the risk for infection among persons age 65
or older is less than the risk for younger age groups.
Therefore, as vaccine supply and demand for vaccine
among younger age groups is being met, programs
and providers should offer vaccination to people over
the age of 65.[52] One concern is the shortened
development time available for vaccine production
and testing. Between 409,000 to 970,000 people
would need to be vaccinated to detect a risk at a
level similar to that of the increased Guillain-Barre
incidence that was associated with the 1976
immunization campaign for swine flu.[53]

Warning! Do not give aspirin (acetylsalicylic acid) to

children or teenagers who have the flu; this can
cause serious and possibly fatal Reye’s syndrome.[54]
NSAIDS (non-steroidal anti-inflammatory drugs) such
as ibuprofen (Motrin, Advil, and other) and naproxen
(Aleve, Naprosyn, Anaprox and other), and
acetominophen [Tylenol] are safe for symptomatic
relief.

Research

Controversy

• Transmission
Seasonal influenza is thought to be spread primarily
by droplets and therefore the CDC has previously
advised regular masks or other avoidance of surfaces
contaminated by droplets as standard preventive
measures.[55]

Despite this, current H1N1 flu recommendations by

many experts include airborne precautions in
addition to contact precautions and the use of N-95
respirators rather than masks in healthcare settings,
in particular, until more is known about the
transmission of the H1N1 influenza A virus.[56]

• Travel advisories

For updated information about travel advisories, see

the United States Centers for Disease Control and
Prevention website (http://wwwn.cdc.gov/travel/)
and/or the World Health Organization website
(http://www.who.int/csr/disease/swineflu/en/index.ht
ml).

There has been conflicting news about air travel. On

the one hand some countries are urging travel bans
or warnings, especially to Mexico. More
commonsense recommendations have been given by
experts such as Dr. Richard Wenzel. He noted, “that
to put the influenza outbreak and air travel issue into
perspective, if this were January and the US were in
the midst of a widespread seasonal flu epidemic, no
one would be talking about avoiding air travel or
subways.

"This flu has an exotic name and origin, and diseases

with exotic names and origins sometimes create
extreme reactions," said Wenzel, who is chair of
internal medicine at Virginia Commonwealth
University in Richmond. "It creates a fear above and
beyond the familiar."

Influenza spreads mostly through large droplets,

which would typically spread within a foot or two of
an infected traveler, Wenzel said, adding that newer,
larger airliners generally recirculate about 50% of the
air, which is generally clean and circulates in a
laminar (top to bottom), unidirectional pattern.”[57]

• Masks

“A surgical or procedure mask should be worn by

health-care personnel who are in close contact (i.e.,
within 3 feet) with a patient who has symptoms of a
respiratory infection, particularly if fever is present,
as recommended for standard and droplet
precautions.”[58]

“If supplies of N95 (or higher) respirators are not

available, surgical masks can provide benefits
against large droplet exposure, and should be worn
for all health care activities for patients with
confirmed or suspected pandemic-influenza.”[59]

Use of N-95 respirators are being recommended by

the CDC until more is known about transmission of
this new H1N1 flu.

Surgical masks have been distributed by the Mexican

government to the public, and use has been
widespread.
In contrast, the United Kingdom’s Health Protection
Agency, recommends against mask use by the
public.[60]

• Mask efficacy studies

There have been two recent studies of the efficacy of

masks in preventing viral transmission.

MacIntyre et. al. conducted a prospective cluster-

randomized trial comparing surgical masks, non–fit-
tested P2 masks, and no masks in prevention of
influenza-like illness (ILI) in Australian households
during the 2006 and 2007 winter seasons. Intent to
treat analysis showed no significant differences
between the groups, but compliance with use of face
masks was poor--<50% reported using the masks
most of the time. The authors conclude however,
that results would be expected to be better during an
influenza pandemic, as there would be a higher
perception of risk. They also observe, “During the
height of the SARS epidemic of April and May 2003 in
Hong Kong, adherence to infection control measures
was high; 76% of the population wore a face mask,
65% washed their hands after relevant contact, and
78% covered their mouths when sneezing or
coughing (28).” They estimate that there would be a
relative reduction in risk of 60-80% with adherent
mask use.[61] Cowling et. al. also conducted a
randomized prospective trial, and also found that
compliance with mask use was poor, meaning that
conclusive recommendations were not possible. [62]

Recent news
 • Human transmission to swine

Preliminary reports suggest that the new H1N1

influenza virus has been transmitted from a farm
worker in Alberta, Canada, to a herd of swine. The
worker had developed a flu-like illness after traveling
to Mexico in mid-April. He had contact with the pigs
on April 14; 10% of the herd were noted to be ill on
April 24. All involved are said to be recovering. The
herd is quarantined. Transmission of flu from humans
to pigs has occurred previously.[63] The major concern
is whether infections in swine with this human H1N1,
rather than the typical swine flu strains, will lead to
reassortment of the different strains of influenza.

• Antivirals

Which antiviral should be used, Relenza or Tamiflu?

According to a new study in PLOS, mathematical

modeling by researchers at Harvard and the
University of Hong Kong suggest that Relenza be
used as first line therapy at this time, to reduce the
likelihood of resistance to Tamiflu, which is in greater
supply. Treating as few as 1% of patients with
Relenza could significantly delay the emergence of
resistance to Tamiflu. [64]Videos of the simulation are
available at the site.[65]

• Why has the illness been more severe in Mexico?

The initial H1N1 flu infections have been more severe

in Mexico than in the US or other countries. There are
several hypotheses: Malnutrition may be more
widespread in the affected Mexican areas. There may
be co-infections there with other organisms, resulting
in more severe illness. Air pollution in Mexico city is a
significant problem. Access to health care may be
more limited or more delayed.

One striking feature in Mexico was that the mortality

was highest in young adults, rather than in young
children or the elderly, as with seasonal flu.[66] This
pattern has been seen with deaths from Avian
influenza as well, and in the 1918-1919 Spanish
influenza epidemic. One hypothesis is that this is
perhaps due to a more robust immunological
response in young adults, called “cytokine storm,”
and that the higher mortality is due to the
inflammatory response to the infection rather than
the infection itself. [67]

Epidemiology and Prevention

Historical Perspective

Antiviral prophylaxis

Vaccination

Infection Control

Community Mitigation and Social Distancing

Outbreaks

The current swine flu outbreak was detected in April,

2009. It appears that Mexico is the epicenter of the
outbreak.
An association of influenza and pigs was noted in the
1918 pandemic; swine flu isolation from a human
was identified first in 1974. An outbreak of swine
influenza virus caused a respiratory illness among 13
soldiers in Fort Dix, New Jersey; no exposure to pigs
was found there.

Regularly updated counts of U.S. human cases, are

available at the CDC website at
www.cdc.gov/swineflu/[68].

As of June 25, 2009, there have been almost 28,000

cases in the U.S., roughly half of the world's total,
with 3065 hospitalizations and 127 deaths.
Mathematical modeling from the CDC suggests that
the new Influenza A (H1N1) has infected as many as
1 million in the U.S., and that 6% of some urban
populations may have been infected.[69], [70]

Updated counts of international human cases, are

available at the WHO website at
www.who.int/csr/disease/swineflu/en/index.html
[www.who.int/csr/disease/swineflu/en/index.html].

HealthMap is a reliable source of information with a

frequently updated map showing the status of swine
flu infections graphically.[71]

On June 11, 2009, the World Health Organization

raised the threat level of Influenza H1N1 to Level 6,
the highest alert level.[72] The announcement
acknowledged that there is a pandemic, or
widespread outbreaks of Influenza H1N1 throughout
the world, underway.
 Phase Description
No viruses in animals are found to have
Phase 1
infected people.
Potential pandemic-an influenza virus in
Phase 2
animals has infected people.
Limited human-to-human transmission, with
Phase 3
isolated cases or small clusters of cases.
Sustained human-to-human transmission,
Phase 4 able to cause community level outbreaks,
with increased risk of a pandemic.
Widespread human-to-human infection, with
spread to at least two countries in one
Phase 5
region, indicating that a pandemic is
imminent.
Widespread human infection with
Phase 6 community level outbreaks in at least two
regions; a pandemic is underway.
This signifies that levels of disease appear
to be dropping, but it is not yet known if
Post-Peak there will be a recurrence, or second wave
period of infection. In previous pandemics, waves
have occurred months after the initial
outbreak.
Post-
Influenza activity is back to its baseline
Pandemic
seasonal level.
period
[73]