Swine Flu , Mexican ? 2009 Novel H1N1 Pa

Category: Education

Presentation Description

what we know so far... from WHO CDC and Rhiza labs


By: monayoussef (118 month(s) ago)

cardiologists please join me at: http://www.cardiologylinks.webs.com/ (place it in the address bar, not the search bar)

By: sonali_sona (123 month(s) ago)

thaks for responding. sonali198113@gmail.com

By: sonali_sona (123 month(s) ago)

please i want to down load this presentation

By: mohammadalistella (123 month(s) ago)

please i want to download this ppt

By: monayoussef (123 month(s) ago)

I'm glad u like it...I don't know why u can't download it, I'm not blocking downloads...Send me ur email & I'll be happy to send u its update: 2009 H1N1 July 25th update


By: mohammadalistella (123 month(s) ago)

please i want to download this ppt

Presentation Transcript

Slide 1: 

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. : 

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?

Slide 3: 

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 : 

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) : 

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? : 

Drinking water? No completed research for novel H1N1 virus. Free chlorine levels typically used in drinking water treatment are adequate to inactivate highly pathogenic H5N1 avian influenza. It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination.

Swimming Pools : 

Swimming Pools No completed research for novel H1N1 virus. Free chlorine levels recommended by CDC (1–3 parts per million [ppm or mg/L] for pools and 2–5 ppm for spas) are adequate to disinfect avian influenza A (H5N1) virus. It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination.

Dealing with the Deceased : 

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….

Slide 9: 

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.

Slide 10: 

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

Slide 11: 


MidMarch: La Gloria,Veracruz, 60% of the town's population is sickened by a respiratory illness of unknown provenance. : 

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 : 

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

Slide 14: 

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

Slide 15: 

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.

Slide 16: 

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

Slide 17: 

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.

Slide 18: 

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

Slide 22: 

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

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.) : 

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

Slide 31: 

19/6/2009 19/6/2009

Slide 32: 

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%)

Slide 33: 

And then Fate has it that the first detected viral strains resistant to tamiflu would show up in China! NOT Australia, and Not Chilli

Slide 34: 

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 would be expected to make an announcement to specify whether manufacturers should switch from making seasonal to pandemic flu vaccines.

Slide 35: 

June 5 CDC Report: Testing CDC has developed a PCR diagnostic test kit Distributed test kits throughout U.S. nation as well as internationally. Vaccine CDC has isolated the new H1N1 virus, made a candidate vaccine virus that can be used to create vaccine. (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.

Slide 36: 

Previous Global Pandemics

Slide 37: 

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. Soldiers whose immunity was weakened by war. Many of the victims who have died in Mexico have been young and otherwise healthy. society's healthiest demographic

Slide 38: 

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

Slide 39: 

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 Reappeared…!!! Seasonal influenza normally claims app. ¼ to ½ a million lives yearly.

Slide 40: 

What we do know

Slide 41: 

Disease spectrum ranges from very mild self-limited disease to Death. Novel H1N1 virus tends to affect younger people just like the seasonal H1N1. Novel H1N1 spreads just as easily as regular winter flu.

Slide 42: 

The southern hemisphere is about to enter winter, when seasonal flu cases normally spike. We have to be prepared for changes in: The amount of illness The severity of illness The characteristics of the virus The reactions of our communities Early evidence in the southern hemisphere points to novel H1N1 potentially crowding out the seasonal flu viruses which is something that's been seen in previous pandemics.

Slide 43: 

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. Simultaneous circulation of the seasonal flu strains with the Novel H1N1 raises the possibility of mixing of the strains. Seasonal H1N1 virus that we've had this past year is resistant to Tamiflu.

Slide 44: 

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

Slide 45: 

There are several important limitations about the data that must be considered: countries are using different surveillance methods and case definitions most countries are at an early stage of disease spread ,a complete picture of the epidemiological and clinical characteristics of the H1N1 virus is unattainable. 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. the early estimates of important epidemiological parameters such as incubation period and attack rate have been derived from a limited number of settings such as households and schools and may not be broadly applicable. although Mexico and the United States have reported deaths among persons with confirmed H1N1 infection, it is too early to get a reliable estimate of the case fatality ratio. Additional studies are needed to assess risk factors for infection with the H1N1 virus as well as the severity of illness.

Slide 46: 


Slide 47: 

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: : 

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

Slide 49: 

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,

Slide 50: 

two doses of vaccine may be needed to induce adequate protection, as the global population is immunologically naïve to the new virus. (Older adults were shown to possess serum neutralizing antibodies to the new virus, most likely due to cross-immunity with human H1N1 viruses. ) The combination of A (H1N1) vaccine with trivalent seasonal vaccine would have significant regulatory implications.Therefore, production of a monovalent A (H1N1) vaccine to be used in addition to trivalent seasonal vaccine is the preferred option at this stage. 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. Manufacturers consistently observed yields less than 50% of those usually obtained with seasonal vaccine viruses. 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.

Slide 51: 

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.

Slide 52: 

(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

Influenza is unpredictable. : 

Influenza is unpredictable.

Slide 54: 

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

Slide 55: 

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

Slide 56: 

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…

Slide 57: 

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

Slide 58: 

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.

Slide 59: 

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

Slide 60: 

WHO Guidance

Slide 61: 

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

Slide 62: 

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.

Slide 63: 

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

Slide 64: 

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

Slide 65: 

Hey, who said that?

Slide 66: 

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

How Flu Spreads : 

How Flu Spreads 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 swine flu who are cared for at home should: : 

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

Slide 69: 

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

Slide 70: 

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

Slide 71: 

When to Seek Emergency Medical Care Emergency Warning Signs

Slide 72: 

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 : 

Medications to Help Lessen Symptoms of the Flu

Slide 74: 

Fevers and aches can be treated with acetaminophen or ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDS). These medications will not lessen how infectious a person is. Check the ingredients on the package label before taking additional doses. Patients with kidney or stomach problems should consult their health care provider before taking any NSAIDS.

Slide 75: 

Warning! Do not give aspirin (acetylsalicylic acid) to children or teenagers who have the flu; this can cause a rare but serious illness called Reye’s syndrome. Check ingredient labels on over-the-counter cold and flu medications to see if they contain aspirin. The safest care for flu symptoms in children younger than 2 years of age is using a cool-mist humidifier and a suction bulb to help clear away mucus.

Steps to Lessen the Spread of Flu in the Home : 

Steps to Lessen the Spread of Flu in the Home

Slide 77: 

Stay informed. Follow the cough etiquette: 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.

Slide 78: 

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. develop a family emergency plan as a precaution.

Slide 79: 

limit the spread of germs and prevent infection by teaching and modelling correct behavior to your children: to wash hands frequently with soap and water. Each person should have their own personal towel. cover coughs and sneezes with tissues. stay away from others as much as possible if they are sick. Stay home from work and school if sick.

Placement of the sick person : 

Placement of the sick person

Slide 81: 

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 : 

Protect other persons in the home

Slide 83: 

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 : 

If you are the caregiver

Slide 85: 

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!

Slide 86: 

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.

Slide 87: 

Avoid close contact (less than about 6 feet away) with the sick person as much as possible. If you must have close contact with the sick person (for example, hold a sick infant), 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…

Using Facemasks or Respirators : 

Using Facemasks or Respirators

Slide 89: 

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 : 

Household Cleaning, Laundry, and Waste Disposal

Slide 91: 

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.

Slide 92: 

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 : 

Pandemic Flu Planning Checklist for Individuals and Families

Slide 94: 

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.

Slide 95: 

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 Power failure, water shortage….

Slide 96: 

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

authorStream Live Help