2009 H1N1 Info gathered by Mona Youssef

Study has shown virus to be different from the normally circulating North American pig virus. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia , avian genes and human genes. "quadruple reassortant" virus How is it then that it made its first appearance in Mexico and the US?

Genomic mapping of the virus revealed that it has been present and circulating in pigs for the past 7.5 to ten years (obviously undetected due to laxity in surveillance of pigs).

Charecteristics Influenza virus can survive on environmental surfaces and remain infectious for up to 2-8 hours after being deposited on the surface. Virus is destroyed by: heat 75-100 degrees Celcius. chemical germicides: chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols. *wipes or gels with alcohol in them should be rubbed into hands until they are dry. A person can sneeze on someone’s luggage in an airport, and start an outbreak in a country without even entering it!

Swine flu virus (Not novel H1N1) Like all influenza viruses, swine flu viruses change constantly. Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses. When influenza viruses from different species infect pigs, the viruses can reassort (i.e. swap genes) and new viruses that are a mix of swine, human and/or avian influenza viruses can emerge. Over the years, different variations of swine flu viruses have emerged. There are currently four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. Most of the recently isolated influenza viruses from pigs have been H1N1 viruses. H3 subtypes infect older population and tend to be more severe.

Drinking water Swimming Pools and Spas No completed research for novel H1N1 virus. Research on H5N1 has shown: Free chlorine levels typically used in drinking water treatment are adequate to inactivate highly pathogenic H5N1 avian influenza. Free chlorine levels recommended by CDC to disinfect avian influenza A (H5N1) virus: for swimming pools :1–3 parts per million (ppm or mg/L) spas: 2–5 ppm It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination.

Dealing with the Deceased Transport of deceased persons does not require any additional precautions when bodies have been secured in a transport bag. Hand hygiene should be performed after completing transport. For deceased persons with confirmed, probable, or suspect novel influenza A (H1N1): limit contact with the body in health care settings to close family members Direct contact with the body is discouraged Necessary contact may occur as long as hands are washed immediately with soap and water. NO need for mass burials yet….

Autopsy: Standard Precautions. Additional respiratory protection is needed procedures that generate aerosols (e.g., use of oscillating saws). minimize the number of personnel participating in post mortem examinations. Follow standard safety procedures for preventing percutaneous injuries during autopsy.

He says ice-cream made him feel better, and Thank God has now recovered full health. But the rest of the planet has a quick –paced pandemic marching on…. 'Patient Zero' in Swine Flu Outbreak Identified as 5-Year-Old Mexican Boy: Edgar Hernandez

Timeline

April 23 : S-OIV (swine origin influenza virus) confirmed, same strain detected in two California children as in Mexico. PAHO informed of Mexico cluster of S-OIV MidMarch: La Gloria,Veracruz, 60% of the town's population is sickened by a respiratory illness of unknown provenance. Mexico April 16 : Mexico Authorities notify the PAHO (Pan American Health Organization) of the atypical pneumonia. Canadian labs

WHO April 24: 2009 H1N1 first disease outbreak notice. April 25: WHO Director General declares a formal “Public health emergency of international concern” April 27: “containment of the outbreak is not feasible” pandemic alert raised from phase 3 to phase 4. April 29: phase 4 to phase 5. June 11: phase 5 to phase 6. During this time interim, the WHO was vastly criticized for not announcing phase 6

WHO Report 95 AFFECTED COUNTRIES Nothing’s holding this virus back…….!!!

keyword A pandemic means an epidemic of an infectious disease, that spreads throughout a large number of people and can spread worldwide. A pandemic begins when: there is person-to-person sustained transmission on multiple continents.

The World Health Organization uses a six stage phase for alerting the general public to an outbreak

Phase 1 – animal to animal transmission. Phase 2 – an animal influenza virus is capable of human infection. Phase 3 - small outbreaks among close populations but not through human to human contact. Phase 4 - Human to human transmission Phase 5 - spread across two countries or more in one of the WHO regions (continents). Phase 6 – spread across two countries or more in one of the WHO regions plus spread to another WHO region.

W.H.O. identifies the following six epidemiological sub-regions.   - African Region - Eastern Mediterranean Region - European Region - Region of the Americas - South-East Asian Region - Western Pacific Region

Even an island in the middle of the ocean isn’t out of its reach….

June 15/2009

Who asked him to deny?

Any closer we’ll probably find him in the living room watching TV

In one week, the United Nations agency raised the alert level twice, from phase 3 to phase 5, in response to the sustained transmission of H1N1 in Mexico and the United States. ( 1976 swine flu Hsw1N1 outbreak never passed phase 3. The vaccine developed caused 10 per million Guillain Barre syndrome as compared to the 1-2 per million with the seasonal flu vaccine and was banned.) Graveness of the situation Clippings from the past

19/6/2009 WHO report 19/6/2009 WHO report

Countries of origin. Mixing of NH1N1 with seasonal flu virus could result in a strain resistant to tamiflu (NH1N1 is already resistant to other antivirals Mixing with H5N1 could produce strains capable of human to human transmission (Death toll of H5N1 is app. 66%) Any half-brain would know that these three subgroups were the most imortant to keep an eye on...

And then Fate has it that the first detected viral strains resistant to tamiflu would show up in China! NOT Australia, and Not Chilli Surprise? Just when you think you know... You don’t!

Consequences of a declaration of a full pandemic Institution of pandemic response plans, which may include measures affecting hospitals, schools or public events. Provision of support for developing countries including: drugs, diagnostic tests, and medical staff WHO is still expected to make an announcement to specify whether manufacturers should switch from making seasonal to pandemic flu vaccines.

June 5 CDC Report: Testing CDC has developed a PCR diagnostic test kit for distribution throughout U.S. as well as internationally. Vaccine CDC has isolated the new H1N1 virus, for use as a candidate vaccine virus (Novartis manufactures first vaccine June 11 2009) Strategic National Stockpile CDC has deployed 25 percent of the supplies in the Strategic National Stockpile (SNS) to all states in the continental United States and U.S. territories. This included antiviral drugs, personal protective equipment, and respiratory protection devices.

Previous Global Pandemics

1918 - Spanish Flu (originated in birds). First hit soldiers in Europe during World War I, as their immune systems were weakened by war. The mortality rate was highest between 20 to 50 year olds. There was never any vaccine developed, after about 18 months, the virus seemed to just disappear. The final death toll was written as 40 million people worldwide. Many of the victims who have died in Mexico have been young and otherwise healthy.

1957 - Asian Flu This flu started in birds in Asia. In September schools and public places started closing in an effort to contain the virus. In December the virus started to subside, but reappeared in January. over two million people died Reappeared

1968 - The Hong Kong Flu This is the mildest pandemic It was first found in the early months of 1968 in Hong Kong, and was declared a global pandemic by December. Children were out of school and were therefore not able to spread it as much. It made a mild reappearance in 1970 and 1972. it claimed about a million lives Seasonal influenza normally claims app. ¼ to ½ a million lives yearly. Reappeared…!!!

What we do know

  Novel H1N1 virus tends to affect younger people just like the seasonal H1N1. (Older adults were shown to possess serum neutralizing antibodies to the new virus, most likely due to cross‐immunity with human H1N1 viruses. )   Novel H1N1 spreads just as easily as regular winter flu; ranging from very mild self-limited disease to Death. Pandemic (H1N1) influenza virus continues to be the predominant circulating virus of influenza, both in the northern and southern hemisphere. All pandemic H1N1 2009 influenza viruses analysed to date have been antigenically and genetically similar to A/California/7/2009-like pandemic H1N1 2009 virus.

Seasonal flu vaccine production is to continue as is, in an attempt to reduce the chances of the viruses mingling together in the same environment. Seasonal H1N1 virus that we've had this past year is resistant to Tamiflu. Influenza is unpredictable.

Characteristics of reported cases of influenza A(H1N1) by country Of note , the prevailing clinical picture in other countries has been GIT related.

Past Data limitations : countries were using different surveillance methods and case definitions. Caution must be exercised in interpreting information such as age as it may reflect patterns of travel or the occurrence of outbreaks in special settings such as schools. Due to early stage of disease spread and the limited number of settings : Incomplete picture of the epidemiological and clinical characteristics of the virus. Estimates of important epidemiological parameters such as incubation period, attack rate and case fatality ratio may not be broadly applicable.

The  objectives  of  on‐going  monitoring  of  influenza  activity  throughout  the  pandemic     are  to  track: global  geographical  spread   disease  trend   intensity   impact  of  the  pandemic  on  health‐care  services   the  number  of  deaths  due  to  acute  respiratory  disease   (by  age  group  if  available)   changes  in  viral  antigenicity  and  antiviral  sensitivity.  

Reporting  requirements     • National  health  authorities  from  all  countries  should  inform  WHO  on  a  weekly  basis  of  their  qualitative  assessment  of  the  geogrphical  spread,  trend  of  cases,  intensity  of  disease,  impact  on  the  health‐care  system,  and  deaths.   • National  health  authorities  from  countries  with  established  influenza  surveillance  systems  should  report  on  a  weekly  basis  data on  ILI  and/or  SARI   • National  influenza  centres  or  reporting  laboratories  are  asked  to  report  weekly  via  FluNet  on  the  number  of  specimens  collected  and  processed   for  influenza  and  the  number  of  specimens  tested  that  are  positive  for  influenza  by  subtype.  

Case  definition  for  the  reporting  of  pandemic  (H1N1)  2009  virus  infections  in  humans     The  following  case  definition  should  be  used  to  report  confirmed  cases  of  pandemic  (H1N1)  2009  virus  infection  to  WHO:      An  individual  with  laboratory‐confirmed  pandemic  (H1N1)  2009  virus  infection   by  one  or  more  of  the  following  tests:   polymerase  chain  reaction  (PCR);   viral  culture;    4‐fold  rise  in  pandemic  (H1N1)  2009  virus  virus‐specific  neutralizing  antibodies.  

VACCINE

A review of 2009 production status for northern hemisphere seasonal vaccine indicates that: Industry plans to produce approximately 480 million doses of trivalent seasonal vaccine in 2009. Of this, 350 and 430 million doses will be available by 30 June and 31 July 2009, respectively. For influenza A (H1N1), it is estimated that up to 4.9 billion doses could be produced over a 12‐month period IF there is initiation of a full‐scale production. In this situation, there is a potential access for the UN of supplies of up to 400 million doses. A lot of Ifs……..

Currently available data indicate that: Immunization with recent or shortly to be available trivalent seasonal vaccine is unlikely to provide public health benefits in terms of protection against influenza A (H1N1). Unknowns: optimal antigen content, the required number of doses, the required intervals between doses and the interchangeability of different products is currently unknown for influenza A (H1N1) vaccines. the safety profile

After considering the following issues: the need for any recommendation to balance both risks and benefits, the current uncertainty about the severity of influenza A (H1N1) illness, the readiness of vaccine seed strains and reagents for large‐scale vaccine production, the current status of production of seasonal vaccine for the Northern hemisphere, The risks associated with a premature cessation of seasonal vaccine production,

Two doses of vaccine may be needed. The combination of A (H1N1) vaccine with trivalent seasonal vaccine would have significant regulatory limitations. Moving into production now could result in starting vaccine production with strains of lower growth potential, as was the case for H5N1 A/Vietnam/2004. The yields were less than 50% of those usually obtained with seasonal vaccine viruses. (currently NH1N1 yields are 25% to 50 % of the normal yields for seasonal influenza) Using a poorly growing A (H1N1) virus could reduce global supplies of A (H1N1) vaccine. The Working Group Declares that: It is premature to recommend commercial‐scale production of influenza A (H1N1) vaccine.

The Working Group did make the following recommendations for immediate action: The WHO Secretariat, should recommend which vaccine viruses should be used for vaccine development as soon as possible (ii) Essential reagents to calibrate antigenic content should be made available as a priority (iii) The WHO Secretariat is encouraged to collaborate actively with its Collaborating Centres, Essential Regulatory Laboratories, and with industry, to assess the growth property of vaccine viruses and identify those with best growth potential, in order to maximize output of vaccine.

(iv) Manufacturers are urged to develop clinical trial batches and accelerate initiation of clinical trials of influenza A (H1N1) vaccines and to start preparing for a potential future recommendation to move to commercial‐scale production. (v) The above activities should not interfere with the present production of the Northern hemisphere seasonal vaccines (vi) The number of needed doses of A (H1N1) vaccine will depend on the spread of influenza A (H1N1) virus in the next few weeks and on a better definition of the groups to be targeted (vii) An evidence‐based recommendation for the groups to be targeted for vaccination still requires more data

Medpage 7/24/2009 from an article written by Dr. Zalman S. Agus: The FDA is likely to approve 2009 H1N1 (swine flu) vaccines before trial data can prove their safety and effectiveness against the virus. Having a licensed vaccine doesn't mean that an immunization program will kick-off immediately -- that call has to come from the Secretary of Health and Human Services (HHS).

Of the five companies applying for FDA approval -- Novartis, sanofi pasteur, CSL Biotherapies, GlaxoSmithKline, and MedImmune -- only CSL has already started human trials. The Australian company, which provides seasonal flu vaccines to the U.S., inoculated its first human trial participant Wednesday. Meanwhile, the NIH announced it was set to begin clinical trials in the United States of vaccines made by sanofi-pasteur and CSL.

If the vaccine is ineffective at stimulating an immune response, the FDA might have to issue an "emergency use authorization" for an oil-in-water adjuvant that sparks a stronger reaction in the immune system, but causes more side effects. Two companies, GlaxoSmithKline and Novartis, are applying for approval for vaccines that contain oil-in-water adjuvants. The NIH is also conducting a trial of an adjuvant-enhanced vaccine. Adjuvanted flu vaccines have been used for a decade in Europe and have not been shown to harm vulnerable populations, such as children.(Theodore Eickhoff). The government has already purchased a supply of 120 million adjuvant doses that it will add to its antigen supply if it there is a shortage of the vaccine, or if the standard versions are shown to be ineffective.

Human infection with 2009 H1N1virus: clinical observations from Mexico and other affected countries, May 2009

Presenting Manifestations: Fever: may be absent in one out of six hospitalized patients. Dehydration Shortness of breath Myalgia Sever malaise Tachycardia Tachypnoea Low O2 sat. Hypotension Cyanosis Acute myocarditis Cardiopulmonary arrest *Diarrhoea,nausea,vomiting: uncommon in hospitalized pts (38% of US outpatients) *NO ENCEPHALITIS TO DATE

Hospitalization : 2-5% of confirmed cases in US and Canada 6% of confirmed cases in Mexico (in Mexico 33% of hospitalized patients required ventilation as compared to only 13% in California) Fatalities are mainly from rapid progression to: ARDS Renal failure Multiorgan failure The highest rates of hospitalization are actually in children under 5,  and the next highest rates are in those people 5 to 24. Preparing ICUs…

Comorbidities associated with complications: (71% of the hospitalized patients have occurred in people who have an underlying condition ) Pregnancy:2/5 developed complications: Spontaneous abortion Premature ruptured membrane Asthma and other lung disease Diabetes Morbid Obesity Autoimmune disorders Associated immunosuppressive therapy Neurological Cardiovascular disease

Lab: Leucocytosis/leucopenia Lymphopenia Elevated aminotransferases Elevated LDH was found (retrogradely) in 100% of 16 dead patients In some extremely elevated CPK 1/2 hospitalized pts showed some degree of Renal insufficiency ( 2ry to rhabdomyolysis and myoglobinuria) Co-infections with strept. pneumonia and adenovirus have been reported in some Mexican cases.

Pathology (postmortem) ARDS 2ry to 1ry viral pneumonia including : diffuse alveolar damage Peribronchial and perivascular lymphoctic infiltrates hyperplastic airway changes bronchiolitis obliterans Muscle biopsy: sk ms necrosis

WHO Guidance

Mild Cases: Supportive: Paracetamol, flds… *NO SALICYLATES IN CHILDREN/ YOUNG ADULTS: REYE'S SYNDROME Antivirals : *best within first 48 hours *Early administration in at-risk pts ie those with co-morbidities/pregnancy… *Neuraminidase inhibitors: oral Oseltamivir Inhaled Zanamivir (N H1N1 is resistant to M2 ion channel inhibitors: Amantadine Rimantadine ) Adequate control precautions: cough etiquette Hand hygiene Natural ventilation

Hospitalized pts: Antivirals Pneumonia management like avian (antibiotics) Resp. Support: early detection Correction of hypoxia with supplemental O2 or mech. Vent as necessary when mech. vent is indicated: low volume low pressure lung protective vent. Strategy for ARDS Steroids: Avoid routine use, no benefit was reported . Higher doses associated with serious SE: evidence of increased viral replication in SARS and other resp. viral infections. Increased mortality in Avian.

Who is prioritized for treatment with influenza antiviral drugs? Most people ill with influenza will recover without complications.  Some people are at increased risk of influenza complications and are prioritized for treatment with influenza antiviral drugs this season. They include: People hospitalized with suspected or confirmed influenza People with suspected or confirmed influenza who are at higher risk for complications: Children younger than 5 years old (children under 2 years old are at higher risk for complications than older children) Adults 65 years and older Pregnant women People with certain chronic medical or immunosuppressive conditions People younger than 19 years of age who are receiving long-term aspirin therapy Physicians may also decide not to treat some people in these groups and/or treat people who are not in these groups based on their clinical judgment.

Antiviral medication dosing recommendations for treatment or chemoprophylaxis of 2009 H1N1 infection

Dosing recommendations for antiviral treatment or chemoprophylaxis of children younger than 1 year using oseltamivir

Storage of Tamiflu At controlled room temperature; defined as temperature maintained thermostat between 20-25 degrees centigrade. Other temperature excursions that are outside of the labeled temperature storage conditions are permitted within the 90-day period provided they do not exceed 40 degrees centigrade.

Unanswered questions: Effect of: Smoking Air pollution Faeces and vomitus Role of flies?

Roooooar! ……. Nobody’s scared of me nomore! Round and round she goes, where it stops , nobody knows…

Hey, who said that?

swine flu in humans can vary in severity from mild to severe. Severe disease with pneumonia, respiratory failure and even death

How Flu Spreads, Droplet infection Respiratory droplets of coughs and sneezes propelled through the air and deposited on the mouth or nose or eyes of people nearby. when a person touches respiratory droplets on another person or an object and then touches their own mouth or nose or eyes (or someone else’s mouth or nose or eyes) before washing their hands.

People with 2009 NH1N1 who are cared for at home should: I wish everyone could have a home like this

Check with their health care provider about any special care they might need and about antivirals if they are pregnant or have a health condition such as diabetes, heart disease, asthma, or emphysema. stay home for 7 days after the start of their symptoms or until they have been symptom-free for 24 hours, whichever is longer get plenty of rest.

drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to keep from being dehydrated cover coughs and sneezes. Clean hands with soap and water or an alcohol-based hand rub often and especially after using tissues and after coughing or sneezing into hands. avoid close contact with others – do not go to work or school while ill be watchful for emergency warning signs that might indicate the need to seek medical attention

When to Seek Emergency Medical Care Emergency Warning Signs

Get medical care right away if the sick person at home: has difficulty breathing, or chest pain. has purple or blue discoloration of the lips. is vomiting and unable to keep liquids down . has signs of dehydration such as dizziness when standing (hypovolemia), absence of urination, or in infants, a lack of tears when they cry. has seizures (for example, uncontrolled convulsions) . is less responsive than normal or becomes confused . Irritable child who doesn’t want to be held. Flu-like symptoms improve but then return with fever and worse cough.

Medications to Help Lessen Symptoms of the Flu (fever and aches)

Acetaminophen , Ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDS). However: These medications will not lessen how infectious a person is. Could result in self-intoxication ,check the ingredients on the package label before taking additional doses. Need consultation with healthcare provider if receipient has kidney or stomach problems .

Aspirin Not to be given to children or teenagers who have the flu ( or any viral infection); as it can cause Reye’s syndrome. Should be checked for on ingredient labels on over-the-counter cold and flu medications to avoid accidental ingestion. cool-mist humidifier and a suction bulb The safest care for flu symptoms in children younger than 2 years of age . Used to clear away mucus.

Steps to Lessen the Spread of Flu in the Home

Stay informed. Follow the cough etiquette and teach and model it to your children: Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it. Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective. Avoid touching your eyes, nose or mouth. Germs spread this way. Try to avoid close contact with sick people.

Stay home for 7 days after your symptoms begin or until you have been symptom-free for 24 hours, whichever is longer. Keep away from other household members as much as possible. This is to keep you from infecting others and spreading the virus further. Provide each family member with their own hygienic necessaties eg towels…

Placement of the sick person

Keep the sick person in a room separate from the common areas of the house. For example, a spare bedroom with its own bathroom,to be cleaned daily with household disinfectant. Keep the sickroom door closed. Have the sick person wear a surgical mask if they need to be in a common area of the house near other persons. Stay away from the alien virus invasion!

Protect other persons in the home

The sick person should not have visitors other than caregivers. A phone call is safer than a visit. If possible, have only one adult in the home take care of the sick person. Avoid having pregnant women care for the sick person. Maintain good ventilation in shared household areas (e.g., keeping windows open in restrooms, kitchen, bathroom, etc.).

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. I didn’t believe them when they said that smoking was bad for my health… a risk factor for novel H1N1!

Avoid close contact (less than about 6 feet away) with the sick person as much as possible. Spend the least amount of time possible in close contact and try to wear a facemask (for example, surgical mask) or N95 disposable respirator(it is harder to breathe through an N95 mask for long periods of time) Get in, get out…

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. Talk to your health care provider about taking antiviral medication to prevent the caregiver from getting the flu. Monitor yourself and household members for flu symptoms and contact a telephone hotline or health care provider if symptoms occur.

Using Facemasks or Respirators

Facemasks and respirators may be purchased at a pharmacy, building supply or hardware store (not off the street). Used facemasks and N95 respirators should be taken off and placed immediately in the regular trash so they don’t touch anything else. Avoid re-using disposable facemasks and N95 respirators if possible. If a reusable fabric facemask is used, it should be laundered with normal laundry detergent and tumble-dried in a hot dryer. After you take off a facemask or N95 respirator, clean your hands with soap and water or an alcohol-based hand sanitizer.

Household Cleaning, Laundry, and Waste Disposal

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. Eating utensils should be washed either in a dishwasher or by hand with water and soap.

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.

Pandemic Flu Planning Checklist for Individuals and Families

To plan for a pandemic: Store a two week supply of water and food. Periodically check your regular prescription drugs Have any nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, fluids with electrolytes, and vitamins. Volunteer with local groups to prepare and assist with emergency response.

Ready-to-eat canned meats, fish, fruits, vegetables, beans, and soups Canned juices Fluids with electrolytes Bottled water Canned or jarred baby food and formula Pet food Protein or fruit bars Dry cereal or granola Dried fruit Peanut butter or nuts Crackers Cleansing agent/soap Soap and water, or alcohol-based (60-95%) hand wash Flashlight Batteries Other non-perishable items Portable radio Manual can opener Garbage bags  Tissues, toilet paper, disposable diapers Examples of food and non-perishables Examples of medical, health, and emergency supplies: Thermometer Prescribed medical supplies such as glucose and blood-pressure monitoring equipment Vitamins Medicines for fever, such as acetaminophen or ibuprofen Anti-diarrheal medication Be prepared for Power failure, water shortage….

Looks to me like he’s conquered his matador , and has every right to fly……….