Rtn Dr Niraj Shrestha,Rotary Club Swoyambhu

Kathmandu Model Hospital,Blue Cross Hospital

Swine flu

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs

Most commonly, human cases of swine flu happen in people who are around pigs

Swine flu viruses do not normally infect humans, however, human infections with swine flu do occur, and cases of human-to-human spread of swine flu viruses have been documented

Swine Influenza A(H1N1) Introduction

The first cases of human infection with novel H1N1 influenza virus were detected in April 2009 in San Diego and Imperial County, California and in Guadalupe County, Texas.

The virus has spread rapidly.The virus is widespread in the United

States at this time and has been detected internationally as well.

Novel H1N1 Influenza

In March and early April 2009, Mexico experienced outbreaks of respiratory illness and increased reports of patients with influenza-like illness (ILI) in several areas of the country

April 12, the General Directorate of Epidemiology (DGE) reported an outbreak of ILI in a small community in the state of Veracruz to the Pan American Health Organization (PAHO) in accordance with International Health Regulations

April 17, a case of atypical pneumonia in Oaxaca State prompted enhanced surveillance throughout Mexico

April 23, several cases of severe respiratory illness laboratory confirmed as influenza A(H1N1) virus infection were communicated to the PAHO

Sequence analysis revealed that the patients were infected with the same strain detected in 2 children residing in California Samples from the Mexico outbreak match swine

influenza isolates from patients in the United States

Swine Influenza A(H1N1) March 2009Timeline

Source: CDC

the potential to be as serious as seasonal flu, if not more so, especially given the fact that there currently is no vaccine against this virus.

new virus, most people will not have immunity to it, and illness may be more severe and widespread as a result.

Swine flu is different from seasonal flu because:

a new strain of the virusHumans do not have an immunity from

itImmunizations received last fall or this

winter do not offer protection against the H1N1 swine flu

Influenza A, H1N1 (swine flu)

Credit: L. Stammard, 1995

• RNA, enveloped

• Viral family: Orthomyxoviridae

• Size: 80-200nm or .08 – 0.12 μm (micron) in diameter

• Three types• A, B, C

• Surface antigens• H (haemaglutinin)• N (neuraminidase)

Virus

H1 N1H2 N2H3 N3H4 N4H5 N5H6 N6H7 N7H8 N8H9 N9

H10H11H12H13H14H15H16

Haemagglutinin subtype Neuraminidase subtype

Timeline of EmergenceInfluenza A Viruses in Humans

1918 1957 1968 1977 1997

1998/9

2003

H1

H1H3

H2

H7

H5H5H9

SpanishInfluenza

H1N1

AsianInfluenza

H2N2

RussianInfluenza

AvianInfluenza

Hong Kong

InfluenzaH3N2

2009

H1

Reassorted Influenza virus (Swine Flu)

1976 Swine Flu

Outbreak, Ft. Dix

Epidemic – a located cluster of cases Pandemic – worldwide epidemic Antigenic drift

Changes in proteins by genetic point mutation & selection

Ongoing and basis for change in vaccine each year

Antigenic shift Changes in proteins through genetic reassortment Produces different viruses not covered by annual

vaccine

Definitions General

Source: Bean B, et al. JID 1982;146:47-51

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)

Influenza The Normal Burden of Disease

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

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

Swine Influenza A(H1N1)Transmission Through Species

Avian Virus

Human Virus

Swine Virus

Avian/HumanReassorted Virus

Reassortment in Pigs

Virus described as a new subtype of A/H1N1 not previously detected in swine or humans

CDC determines that this virus is contagious and is spreading from human to human

The virus contains gene segments from 4 different influenza types: North American swine North American avian North American human and Eurasian swine

Swine Influenza A(H1N1) March 2009Facts

The WHO raises the alert level to Phase 6 WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3 In Late April 2009 WHO announced the emergence of a novel influenza A virus April 27, 2009: Alert Level raised to Phase 4 April 29, 2009: Alert Level raised to Phase 5 June 11, 2008: Alert Level raised to Phase 6

Swine Influenza A(H1N1) Global Response

Source: WHO

Infectious period for a confirmed case of swine 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 swine influenza A(H1N1) virus infection during the case’s infectious period

Acute respiratory illness is defined as recent onset of at least two of the following: rhinorrhea or nasal congestion, sore throat, cough (with or without fever or feverishness)

High-risk groups: A person who is at high-risk for complications of swine influenza A(H1N1) virus infection is defined as the same for seasonal influenza (see Reference)

Swine Influenza A(H1N1) US Case Definitions

Source: CDC

Signs and symptoms

May cause more serious symptoms in individuals with chronic medical conditions

Pneumonia, respiratory failure, and deaths have been reported.

Signs and Symptoms contd.

in patients presenting with febrile respiratory illness who Live or have traveled in areas where human cases of swine

influenza A(H1N1) have been identified or

have been in contact with ill persons from these areas in the 7 days prior to their illness onset

obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer) transport and timely diagnosis at a state public health laboratory

Swine Influenza A(H1N1) Guidelines for Clinicians

Source: CDC

Diagnostic work on clinical samples conducted in a BSL-2 laboratory

Viral isolation performed in a BSL-2 laboratory with BSL-3 practices (enhanced BSL-2 conditions)

Additional precautions include: recommended personal protective equipment (based on site specific risk

assessment) respiratory protection - fit-tested N95 respirator or higher level of protection shoe covers closed-front gown double gloves eye protection (goggles or face shields)

Swine Influenza A(H1N1) Biosafety Guidelines for Laboratory Workers

Source: CDC

People are contagious as long as they have symptoms, and

up to 7 days after they become sickChildren, especially infants, may be

contagious for longer periodsViruses can live 2 hours or longer on surfaces

like tables, desks, and doorknobs.

How Long Can an Infected Person Spread it to Others?

Covering nose and mouth with a tissue when coughing or sneezing Dispose the tissue in the trash after use.

Handwashing with soap and water Especially after coughing or sneezing.

Cleaning hands with alcohol-based hand cleaners

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

Swine Influenza A(H1N1) Guidelines for General Population

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. Practice good health habits: get enough sleep, eat nutritious food, keep physically active.If you smoke, quit.

If you get sick…

Most people should be able to recover at home, but watch for emergency warning signs that mean you should seek immediate medical care.

Watch for emergency warning signs

In adults: • Difficulty breathing or shortness of

breath • Pain or pressure in the chest or

abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then

return with fever and worse cough

If a child gets sick and experiences any of these warning signs, seek emergency medical care.

In children: Fast breathing or trouble breathing Bluish or gray skin color Not drinking enough fluids Severe or persistent vomiting Not waking up or not interacting Irritable, the child does not want to be held Flu-like symptoms improve but then return

with fever and worse cough

Emergency warning signs in children

No vaccine available

Antivirals for the treatment and/or prevention of infection: Oseltamivir (Tamiflu) or Zanamivir (Relenza)

Use of anti-virals can make illness milder and recovery faster

They may also prevent serious flu complications

For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms)

Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing products (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers (up to 18 years old) who are confirmed or suspected ill case of swine influenza A (H1N1) virus infection; this can cause a rare but serious illness called Reye’s syndrome. For relief of fever, other anti-pyretic medications are recommended such as acetaminophen or non steroidal anti-inflammatory drugs.

Swine Influenza A(H1N1) Treatment

Source: CDC

People who can receive FREE vaccine are: Anyone 65 years of age and over All Indigenous people 15 years of age and over All Anyone 65 years of age and over All Indigenous people 15 years of age and over All pregnant women at any stage of pregnancy Anyone over 6 months of age with medical conditions that increase their

risk of severe influenza*. People with medical conditions that increase their risk of severe influenza.

Medical conditions include:

Cardiac disease Chronic respiratory conditions Chronic illnesses Chronic neurological condition People with impaired immunity and

Children aged 6 months to 10 years having long term aspirin therapy.

Flu vaccine

Q:  How long does protection from the vaccine last?A:  The vaccine takes 2 weeks to work and will last for about 12 months. Low levels of protection may persist for another year after. For ongoing protection a new vaccine is required each year.

Q:  Can I catch influenza from having the vaccine?A:  No. The vaccine does not contain any live influenza virus. Some people have a sore arm or a mild temperature after they have received the vaccine and this is a normal reaction. However, it does take around 2 weeks before the body is fully  protected after vaccination. If you are exposed to someone with influenza infection during this time you may still become sick because your body is not yet fully protected.

Q:  Does the 2015 seasonal influenza vaccine include protection against swine flu?A:  Yes. The vaccine contains the 2009 Pandemic (H1N1) Influenza (swine flu) strain plus 2 other strains predicted to be the most commonly occurring this year. People who want to protect themselves against the 3 strains should get the 2014 seasonal influenza vaccine.

Q:  If a person had flu (influenza) previously, do they still need the 2015 seasonal influenza vaccine?A:  Yes. Having had flu offers protection against that flu strain but not the other strains of flu. The 2014 seasonal influenza vaccine is recommended to protect against strains of flu that are causing infections this yea

Oseltamivir (Tamiflu) Zanamivir (Relenza)

Treatment Prophylaxis Treatment Prophylaxis

Adults 75 mg capsule twice per day for 5 days

75 mg capsule once per day

Two 5 mg inhalations (10 mg total) twice per day

Two 5 mg inhalations (10 mg total) once per day

Children 15 kg or less: 60 mg per day divided into 2 doses

30 mg once per day Two 5 mg inhalations (10 mg total) twice per day (age, 7 years or older)

Two 5 mg inhalations (10 mg total) once per day (age, 5 years or older)

15–23 kg: 90 mg per day divided into 2 doses

45 mg once per day

24–40 kg: 120 mg per day divided into 2 doses

60 mg once per day

>40 kg: 150 mg per day divided into 2 doses

75 mg once per day

Swine Influenza A(H1N1) Treatment

Source: CDC

Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatment dose for 5 days. <3 months: 12 mg twice daily; 3-5 months: 20 mg twice daily; 6-11 months: 25 mg twice daily

Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. Recommended prophylaxis dose for 10 days. <3 months: Not recommended unless situation judged critical due to limited data on use in this age group; 3-5 months: 20 mg once daily; 6-11 months: 25 mg once daily

Isolation: Refers only to the sequestration of symptomatic patents either in the home or hospital so that they will not infect others

Quarantine: Defined as the separation from circulation in the community of asymptomatic persons that may have been exposed to infection

Social-Distancing: Has been used to refer to a range of non-quarantine measures that might serve to reduce contact between persons, such as, closing of schools or prohibiting large gatherings

Swine Influenza A(H1N1) Other Protective Measures

Source: CDC

Personnel Engaged in Aerosol Generating Activities CDC Interim recommendations:

Personnel engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) should wear a fit-tested disposable N95 respirator

personnel providing direct patient care should wear a fit-tested disposable N95 respirator when entering the patient room

Swine Influenza A(H1N1) Other Protective Measures

Source: CDC

Infection Control of Ill Persons in a Healthcare Setting

Patients with suspected or confirmed case-status should be placed in a single-patient room with the door kept closed.

 If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used.

Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter.

The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils washed with soap and water .

Swine Influenza A(H1N1) Other Protective Measures

Source: CDC

Infection Control of Ill Persons in a Healthcare Setting

Standard, Droplet and Contact precautions used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved.

  hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions.

should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure.

Swine Influenza A(H1N1) Other Protective Measures

Source: CDC

Types of Protective Masks

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 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-technology capable of blocking particles as small as 0.027 micron.

Believed to have come from neighbouring India2 death at 2010,14 death at 2014, no death in between

yearsIn 2015, 43 suspected positive cases 1 death till now Risk of being epidemic given crowded conditions and

lack of awareness and ill equipped hospitalsHelp desks at border towns like

birgunj,mahendranagar,sunauliRespiratory swabs being sent to National Health

Laboratory ,Teku from different hospitals inside valley and outside hospitals

In Nepal

WHO raised the alert level to Phase 6 on June 11, 2009

The overall global case-fatality is 0.50%

Epidemiological Data US Median Age 16 years (range: 1-81 years) Over 80% of the cases in <18 years 60% female; 40% Male

Mexico Majority of the cases reported in health young adults 71.3% of the deaths were reported in healthy young adults, 20-54 years

EU Majority of the cases reported in health young adults (20-29 years). Nepal 43 suspected positive cases 1 death

No vaccine is available,just seasonal flu vaccine available

Anti-virals available

Summary

Lessons Learned formPast Pandemics

First outbreaks March 1918 in Europe, USA Highly contagious, but not deadly Virus traveled between Europe/USA on troop

ships Land, sea travel to Africa, Asia Warning signal was missed

August, 1918 simultaneous explosive outbreaks in in France, Sierra Leone, USA 10-fold increase in death rate Highest death rate ages 15-35 years

Cytokine Storm? Deaths from primary viral pneumonia, secondary

bacterial pneumonia Deaths within 48 hours of illness Coincident severe disease in pigs

20-40 million killed in less than 1 year World War I –8.3 million military deaths over 4

years 25-35% of the world infected

FDA Issues Authorizations for Emergency Use (EUAs) of Antivirals

On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued EUAs in response to requests by the Centers for Disease Control and Prevention (CDC) for the swine flu outbreak

One of the reasons the EUAs could be issued was because the U.S. Department of Health and Human Services (HHS) declared a public health emergency on April 26, 2009

The swine influenza EUAs aid in the current response: Tamiflu: Allow for Tamiflu to be used to treat and prevent influenza in children

under 1 year of age, and to provide alternate dosing recommendations for children older than 1 year. Tamiflu is currently approved by the FDA for the treatment and prevention of influenza in patients 1 year and older.

Tamiflu and Relenza: Allow for both antivirals to be distributed to large segments of the population without complying with federal label requirements that would otherwise apply to dispensed drugs and to be accompanied by written information about the emergency use of the medicines.

Swine Influenza A(H1N1) Guidelines for Clinicians

Source: FDA

Thought to be spread in the same way that seasonal flu spreads

Mainly from person to person when an infected person coughs or sneezes and spreads tiny particles into the air

Sometimes by touching something with flu viruses on it, and then touching the mouth, nose or eyes

How Does It Spread?

If you have symptoms: Fever, body aches, runny nose, sore throat, nausea,

or vomiting or diarrheaAnd you would typically see your health care

provider, do so.If you have these symptoms but would not

normally see your health care provider, there is no need to do so

Stay home and avoid contact with others as much as possible

What To Do If You Get Sick

Pandemics are unpredictable Mortality, severity of illness, pattern of spread

A sudden, sharp increase in the need for medical care will always occur

Capacity to cause severe disease in nontraditional groups is a major determinant of pandemic impact

Epidemiology reveals waves of infection Ages/areas not initially infected likely vulnerable in future

waves Subsequent waves may be more severe

1918- virus mutated into more virulent form 1957 schoolchildren spread initial wave, elderly died in

second wave

Public health interventions delay, but do not stop pandemic spread Quarantine, travel restriction show little effect

Does not change population susceptibility Delay spread in Australia— later milder strain causes infection

there Temporary banning of public gatherings, closing schools

potentially effective in case of severe disease and high mortality

Delaying spread is desirable Fewer people ill at one time improve capacity to cope with

sharp increase in need for medical care

Lessons Learned formPast Pandemics

Prevention:VaccinationShot or nasal sprayHand washing –frequently and thoroughlyAlcohol based hand sanitizerAvoid touching eyes, nose and mouth. Germs spread this way

Conclusion/Recommendations

1. 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) Though difficult, there is likelihood that there will be a vaccine for this

strain by the emergence of the second wave In the US each year ~35,000 deaths are attributed to influenza resulting in

>200,000 hospitalizations, costing $37.5 billion in economic cost (influenza & pneumonia) and >$10 billion in lost productivity

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

Conclusion/Recommendations

2. 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

• 60 years and above age group seems to show some protection against this strain suggesting past exposure and some immunity

• Of concern is the disease spread in Australia

3. 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

Conclusion/Recommendations4. 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

5. 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

Conclusion/Recommendations

6. 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

7. 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

8. 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

Complications:Symptoms can sometimes lead to life threatening complications such as pneumonia and respiratory failure. And it can make conditions like diabetes or asthma worse. If you have symptoms like shortness of breath, severe vomiting , abdominal pain, dizziness or confusion along with the symptoms of flu please consult a physician right away. Complications:Death usually occurs due to secondary bacterial infection of the lungs.Swine flu?Symptoms are very similar to the less dangerous viral flu. However, nausea and vomiting may be more severe in case of swine flu.Lab test (nasopharyngeal swab) is the only way to differentiate between the two. High risk people:Children < 5 years oldPeople 65 or older Children and teens (under age 18) who are getting long-term aspirin therapy, and who might be at risk for Reye’s sundromeafter being infected with swine flu.Pregnant womenPeople in nursing homes and other long-term care facilitiesHealthcare workersAdults and children who have chronic lung, heart, liver, blood, nervous system, neuromuscular, or metabolic problemsAdults and children who have suppressed immune systems (including those who take medications to suppress their immune systems or who have HIV)Treatment:Antiviral drugs :Oseltamivir(Tamiflu) and zanamivir(Relenza)Resistance to Tamifluhave been found.Best when taken within 48 hours of the first symptom of flu.Antibiotics do not work.For symptomatic relief:Medicines for pain relief and fever controlTreatment:Remain hydrated with lots of fluidsRest enough to help your immune system fight infectionPrevention:Vaccination

The swine flu virus has been spreading its tentacles in Nepal.  In the past two weeks, the number of people detected with the dreaded flu has crossed 35, sending chill among the locals of Kathmandu. The National Public Health Laboratory has reported that the rise in the number of swine flu cases has taken place lately and the Epidemiology and Disease Control Department (EDCD) has issued preventive measures.With the present rate of affliction, the disease now threatens to take the shape of an epidemic in crowded capital.  According to EDCD, if the number of people with disease infection reaches 15 to 20 per day then the disease can be termed as an epidemic one.Given the lack of awareness among the people regarding the severity of the flu, the disease may cause real trouble in the capital. The government is yet to launch considerable awareness as well as mobilise health institutions and health workers for the preventive measures to make the effect of the disease less severe for the masses.The swine flu (of which virus strain is known, as A H1N1) is highly contagious among the people as it spreads from person to persons after coming into close contact with the infect

If your child has these symptoms, seek immediate medical care: Fast breathing or trouble breathing Bluish skin color Not drinking enough fluids Not waking up or not interacting Being so irritable that the child does not want to be

held Flu-like symptoms improve but then return with fever

and worse cough Fever with a rash.

What To Do ifYour Child is Sick

Frequently wash your hands with soap and water for 15-20 seconds

Alcohol-based hand cleaners are OK

Cover your coughs and sneezes by coughing and sneezing into your arm, not your hands. Or, sneeze into a tissue and discard it

Avoid touching your nose, eyes and mouth

Try to avoid close contact with people who appear sick, and have a fever and cough

What Can You Do to Protect Yourself and Others?