Swine Flu - Copy

8/8/2019 Swine Flu - Copy

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CURRENT PANDEMICCURRENT PANDEMIC

SWINE FLUSWINE FLU

20092009 -- ??????

ByBy

Dr. IndiraDr. Indira

Dept of O&GDept of O&G

Public health centrePublic health centreWest mambalam.West mambalam.





20th century flu pandemics20th century flu pandemics

Pandemic Year

Influenza A

virus

subtype

People

infected

(approx)

Deaths

(est.)

Case

fatality rate

1918 flu

pandemic191819 H1N1

0.5 to 1

billion

(near 50%)

20 to 100

million>2.5%

Asian flu 195658 H2N2 2 million <0.1% ?

Hong Kong

flu196869 H3N2 1 million <0.1%

Seasonal

fluEvery year

mainlyA/H3N2,

A/H1N1,

and B

515% (340

million 1

billion)

250,000

500,000 per

year

<0.05%



MicrobiologyMicrobiology

TypesTypes ± ± Influenza A, B,CInfluenza A, B,C

A A ± ± commonestcommonest

In human, birds & pigIn human, birds & pig

Mostly responsible for pandemicMostly responsible for pandemic

BB -- Exclusive in human but rareExclusive in human but rare

CC ± ± both human & pigsboth human & pigs

Won't cause pandemicWon't cause pandemic




Influenza A:Influenza A:

GlycoproteinesGlycoproteines ± ± H & NH & N

Common in HumanCommon in Human ± ± HH ± ±1,2,31,2,3

-- NN -- 1,21,2Contains 8 genomesContains 8 genomes

RNARNA ± ± 8 segments in genomes8 segments in genomes

-- Possible to swap genesPossible to swap genes

-- combination of 8combination of 8

88

possiblepossible




Antigenic drift Antigenic drift

Antigenic shift Antigenic shift

Genetic ReassortmentGenetic ReassortmentIf 2 types infect a single cellIf 2 types infect a single cell ± ± newnew

strain developesstrain developes

Pigs act as mixing vesselPigs act as mixing vessel






Current virus combination of Current virus combination of

North American swineNorth American swine

North American AvianNorth American AvianHuman InfluenzaHuman Influenza

Eurasian SwineEurasian Swine



EpidemiologyEpidemiology Agent Agent

New subtype In flu H1N1New subtype In flu H1N1

virusvirus

Needs dry & cold climateNeeds dry & cold climate

Host factorsHost factorsHealthy young adultsHealthy young adults

55 ± ± 24 yr ; more in males24 yr ; more in males

TransmissionTransmission

Droplet infection &Droplet infection &

fomitesfomites

Incubation periodIncubation period

11 ± ± 7 days7 days

live up to 2live up to 2 ± ± 8 hr outside8 hr outside

CommunicabilityCommunicability

From 1 day beforeFrom 1 day before ± ± 7 days7 daysafter onset of symptomsafter onset of symptoms

If symptoms persist > 7 daysIf symptoms persist > 7 days

± ± till resolution of illnesstill resolution of illness

Children up to 10Children up to 10 ± ± 14 days14 days

Infection can travel up toInfection can travel up to3mt.3mt.



Clinical FeaturesClinical FeaturesCommon Symptoms :Common Symptoms :

Fever( > 37.9Fever( > 37.900 c) with chillsc) with chills

Non productive CoughNon productive Cough

Runny or stuffy nose Runny or stuffy nose

Sore throatSore throat

Body ache / Headache Body ache / Headache

Nausea/diarrhoeaNausea/diarrhoea

Fatigue/tiredness that can be extremeFatigue/tiredness that can be extreme

Signs of a more serious swine flu inf ection mightSigns of a more serious swine flu inf ection might

include pneumonia and respirator y failureinclude pneumonia and respirator y failure

If > 2 symptomsIf > 2 symptoms ² ² suspect swine flususpect swine flu





Groups at higher riskGroups at higher risk

Children less than 5 years old;Children less than 5 years old;

Persons aged 65 years or older;Persons aged 65 years or older;

Children and adolescents (less than 18 years) who are receivingChildren and adolescents (less than 18 years) who are receiving

longlong--term aspirin therapy and who might be at risk for term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection;experiencing Reye syndrome after influenza virus infection;

Pregnant women;Pregnant women;

Adults and children who have chronic pulmonary,Adults and children who have chronic pulmonary,

cardiovascular, hepatic, hematological, neurologic,cardiovascular, hepatic, hematological, neurologic,

neuromuscular, or metabolic disorders;neuromuscular, or metabolic disorders; Adults and children who have immuno suppression (includingAdults and children who have immuno suppression (including

immuno suppression caused by medications or by HIV);immuno suppression caused by medications or by HIV);

Residents of nursing homes and other chronicResidents of nursing homes and other chronic--care facilitiescare facilities





Sample CollectionSample Collection

Trained personalTrained personal

Within 24Within 24--72 hr; not later then 5 days72 hr; not later then 5 days

Before starting antiviralBefore starting antiviral At least nasopharyngeal swab At least nasopharyngeal swab

Bronchoalveolar lavage idealBronchoalveolar lavage ideal

Oropharyngeal swabOropharyngeal swab ± ± not adequatenot adequate



Sample CollectionSample Collection

Dacron / polyester tipped swabDacron / polyester tipped swab

Aluminium / plastic shaft Aluminium / plastic shaft

In 2In 2--3ml viral transport media3ml viral transport media At 4 At 400 C ; maintain cold chainC ; maintain cold chain

Transported within 24 hr Transported within 24 hr

If can¶tIf can¶t ± ± store atstore at ± ±707000 CC





LaboratoriesLaboratories

King Institute , GuindyKing Institute , Guindy

CMC, VelloreCMC, Vellore

Bharat scans, RoyapettahBharat scans, RoyapettahHiHi--Tech Diag. Centre, T.Nagar Tech Diag. Centre, T.Nagar

Diagnostic Services, T.Nagar Diagnostic Services, T.Nagar

Micro Labs, R.S puram ,CoimbatoreMicro Labs, R.S puram ,Coimbatore

Dr.Rath¶s Lab, Thillai nagar, TrichyDr.Rath¶s Lab, Thillai nagar, Trichy



PrecautionsPrecautions

Stay at home and avoid traveling to public places like schoolStay at home and avoid traveling to public places like schooland offices; seek medical care IMMEDIATELY.and offices; seek medical care IMMEDIATELY.

Wash your hands frequently: Wash them often, for at leastWash your hands frequently: Wash them often, for at least15 seconds and rinse with running water.15 seconds and rinse with running water.

Get enough sleep: Try to get 8 hours of good sleep everyGet enough sleep: Try to get 8 hours of good sleep everynight to keep your immune system in top flunight to keep your immune system in top flu--fighting shape.fighting shape.

Drink sufficient water: Drink 8 to10 glasses of water eachDrink sufficient water: Drink 8 to10 glasses of water eachday to flush toxins from your system and maintain goodday to flush toxins from your system and maintain goodmoisture and mucous production in your sinuses.moisture and mucous production in your sinuses.

Always try to cover your nose and mouth with a tissue while Always try to cover your nose and mouth with a tissue whilecoughing or sneezing to avoid passing on infection of anycoughing or sneezing to avoid passing on infection of anykind to others around you.kind to others around you.

Avoid touching your eyes, nose and mouth to prevent the Avoid touching your eyes, nose and mouth to prevent thespread of the virus.spread of the virus.



6 WAYS TO IMPROVE UR6 WAYS TO IMPROVE UR

IMMUNITYIMMUNITY

Lose WeightLose Weight

ExerciseExercise

Eliminate Sugar From your DietEliminate Sugar From your Diet Stop Junk FoodStop Junk Food

Get Plenty of SleepGet Plenty of Sleep..

RelaxRelax

Last but not least, keep washing your handsLast but not least, keep washing your hands

frequently.frequently.



TREATMENTTREATMENT



Guiding principlesGuiding principles

Early implementation of infection controlEarly implementation of infection control

measuresmeasures

Prompt treatment to prevent severePrompt treatment to prevent severeillness and deathillness and death

Early identification and follow up of Early identification and follow up of

persons at riskpersons at risk



INFRASTRUCTUREINFRASTRUCTURE

Isolation facilities : if separate rooms notIsolation facilities : if separate rooms not

available, patients can be cohorted in wellavailable, patients can be cohorted in well

ventilated ward with beds kept 1 meter apartventilated ward with beds kept 1 meter apart

Dedicated doctors, nurses and paramedicalDedicated doctors, nurses and paramedicalworker.worker.

Portable Xray machine, ventilators, O2 cylinders,Portable Xray machine, ventilators, O2 cylinders,

pulse oximeter and morepulse oximeter and more

Adequate PPE , disinfectants and medications Adequate PPE , disinfectants and medications..







Oseltamivir Oseltamivir -- ADRADR

Generally well toleratedGenerally well tolerated

GI side effects common if > 300GI side effects common if > 300g/dayg/day

May cause bronchitis, insomnia, vertigoMay cause bronchitis, insomnia, vertigo

Epistaxis in children, most common vomitingEpistaxis in children, most common vomiting

Rarely anaphylaxis and skin rashesRarely anaphylaxis and skin rashes

No change of dose in liver diseaseNo change of dose in liver disease

Decrease if GFR is lowDecrease if GFR is low



CAUTION !!!CAUTION !!!

ONLY VIROSTATIC DRUGONLY VIROSTATIC DRUG

Indiscriminate use cause resistanceIndiscriminate use cause resistance

Highly effective even if started after 48 hr of Highly effective even if started after 48 hr of

infectioninfection

Never stop oseltamivir once startedNever stop oseltamivir once startedStart as per guidelinesStart as per guidelines





Supportive treatmentSupportive treatment

Iv fluidsIv fluids

Parenteral treatmentParenteral treatment

O2 therapy / ventilatoryO2 therapy / ventilatory

supportsupport Antibiotics Antibiotics

Vasopressors for shockVasopressors for shock

Paractemol / ibuprofenParactemol / ibuprofen

Salicylate / aspirinSalicylate / aspirin -- CICI

ImmunomodulatoryImmunomodulatory

drugsdrugs-- NO USENO USE

Drink plenty of fluidsDrink plenty of fluids

Avoid smoking Avoid smoking

TopicalTopical

decongestants,steamdecongestants,steaminhalationinhalation

Monitor LRTI & HypoxiaMonitor LRTI & Hypoxia

SteroidsSteroids

high dosehigh dose ± ± harmfulharmfullow doselow dose ± ± septic shockseptic shock



DISCHARGE POLICYDISCHARGE POLICY

Adults : 7 days after symptoms subsides Adults : 7 days after symptoms subsides

Children : 14 days after Children : 14 days after

Family should be educated aboutFamily should be educated about

preventive measurespreventive measures



CHEMOPROPHYLAXISCHEMOPROPHYLAXIS

DOC : Oseltamivir - Agent, group Chemoprophylaxis

Adults 75-mg capsule once per day

Children 12 months

15 kg or less 30 mg once per day

16-23 kg 45 mg once per day

24-40 kg 60 mg once per day

>40 kg 75 mg once per day

Dosing recommendations for antiviral chemoprophylaxis of children younger than 1

year using oseltamivir.

Age Recommended prophylaxis dose for 10 days Not recommended unless situation judged

critical due to limited data on use in this age group

20 mg once daily

25 mg once daily

<3 months

3-5 months

6-11 months





PPEPPE





GUIDE LINESGUIDE LINES



GuidelinesGuidelines ± ± infection controlinfection control

a)a) Individual levelIndividual level

Hand hygieneHand hygiene ± ± most importantmost important

Respiratory hygieneRespiratory hygiene

Staying away from sourceStaying away from source

Use of maskUse of mask

-- not as routinenot as routine

-- only symptomaticonly symptomatic

-- health personnel at riskhealth personnel at risk




b)For cliniciansb)For clinicians

Well ventilated rooms for consultations/separateWell ventilated rooms for consultations/separate

roomsrooms

Pedestrial fans opposite to patientsPedestrial fans opposite to patients

Clean AC filters oftenClean AC filters often

3 layered surgical mask3 layered surgical mask

Wash handWash hand Avoid contact with mouth/ nose/ eye Avoid contact with mouth/ nose/ eye




c)c) At health facilityAt health facility

Droplet precautionsDroplet precautions

Visual alertsVisual alerts

Use of PPEUse of PPE

Decontaminating the infective surface, things &Decontaminating the infective surface, things &

equipments (70% ethanol, 5% lysol, 10%equipments (70% ethanol, 5% lysol, 10%

bleach)bleach)Waste disposal as per waste managementWaste disposal as per waste management

protocolsprotocols



GuidelinesGuidelines ± ± Pregnant womenPregnant women

Higher risk for complications from infectionHigher risk for complications from infection

Oseltamivir and zanamivir are "Pregnancy Category "Oseltamivir and zanamivir are "Pregnancy Category "medicationsmedications

No clinical studies have been conducted to assess theNo clinical studies have been conducted to assess the

safety of these medicationssafety of these medicationsNo relation between the use of these medications andNo relation between the use of these medications andadverse events has been established.adverse events has been established.

Get an informed consent before USE OF DRUGGet an informed consent before USE OF DRUG

Because of its systemic activity, oseltamivir isB

ecause of its systemic activity, oseltamivir ispreferred for treatment of pregnant women.preferred for treatment of pregnant women. The drugThe drugof choice for chemoprophylaxis is less clear.of choice for chemoprophylaxis is less clear.









Seek emergency in case of Seek emergency in case of

Fast breathingFast breathing

Trouble breathingTrouble breathing

Bluish/gray skin color Bluish/gray skin color

Not drinking enoughNot drinking enoughfluidsfluids

Not urinating as muchNot urinating as muchas usualas usual

Severe or persistentSevere or persistentvomitingvomiting

Not waking up/Not waking up/interacting as usualinteracting as usual

Being so irritable thatBeing so irritable that

the child doesn¶t eventhe child doesn¶t evenwant to be heldwant to be held

Fever returns after Fever returns after being absent for abeing absent for aday or a significantday or a significantchange in fever change in fever patternpattern



GUIDELINES FOR GUIDELINES FOR

SCHOOLS/COLLEGES/INSTITUTIONS ONSCHOOLS/COLLEGES/INSTITUTIONS ON

INFLUENZA A/H1N1INFLUENZA A/H1N1

Any student or staff member showing flu like symptoms such Any student or staff member showing flu like symptoms such

as fever, cough, running nose and difficulty in breathingas fever, cough, running nose and difficulty in breathing

should be allowed to stay at home for a period of 7 to 10should be allowed to stay at home for a period of 7 to 10

days.days.

Educational institutions should not insist on production of Educational institutions should not insist on production of

medical certificate by the student/staff.medical certificate by the student/staff.

Educational institutions should monitor the health status of Educational institutions should monitor the health status of such students/staff who might have come in contact with asuch students/staff who might have come in contact with a

suspected case of Influenza A H1N1.suspected case of Influenza A H1N1.



GUIDELINES FOR GUIDELINES FOR

SCHOOLS/COLLEGES/INSTITUTIONS ONSCHOOLS/COLLEGES/INSTITUTIONS ON

INFLUENZA A/H1N1INFLUENZA A/H1N1 In case of students staying in Hostels, the educationalIn case of students staying in Hostels, the educational

institutions would not only monitor the health status of institutions would not only monitor the health status of

the students, but also that of care providers. It might notthe students, but also that of care providers. It might not

be advisable to send the boarders back to home, as it be advisable to send the boarders back to home, as it

would spread infection further.would spread infection further. Educational institutions are further encouraged to reportEducational institutions are further encouraged to report

such cases to local health officers for further monitoring.such cases to local health officers for further monitoring.

Given the current magnitude of the spread of AH1N1Given the current magnitude of the spread of AH1N1

infection and the fact that the current virus is fairly mild,infection and the fact that the current virus is fairly mild,

closure of educational institutions on account of anyclosure of educational institutions on account of any

student/staff member falling ill with flu like symptomsstudent/staff member falling ill with flu like symptoms

is not recommended.is not recommended.





Revised GuidelinesRevised Guidelines ± ± Govt of INDIAGovt of INDIA

((1414thth August, 2009) August, 2009)

Category A:Category A:

Patients with mild fever plus cough/sore throat with or Patients with mild fever plus cough/sore throat with or

without body ache, headache, diarrhoea and vomiting.without body ache, headache, diarrhoea and vomiting.

They do not require Oseltamivir and should be treatedThey do not require Oseltamivir and should be treatedfor the symptoms mentioned above.for the symptoms mentioned above.

The patients should be monitored for their progress andThe patients should be monitored for their progress and

rere--assessed every 24 to 48 hours by the doctor.assessed every 24 to 48 hours by the doctor.

No testing of the patient for H1N1 is required. PatientsNo testing of the patient for H1N1 is required. Patients

should confine themselves at home and avoid mixingshould confine themselves at home and avoid mixing

with the public and high risk members in the family.with the public and high risk members in the family.













TAKE HOME MESSAGETAKE HOME MESSAGE

Inf. A H1N1Inf. A H1N1 ± ± like any other seasonal flu.like any other seasonal flu.

90% recover without treatment ; 190% recover without treatment ; 1--2% mortality.2% mortality.

Transmission only by droplet infection.Transmission only by droplet infection.

CommunicabilityCommunicability ± ± 1 day prior to 7 days after onset of 1 day prior to 7 days after onset of symptoms.symptoms.

Fever (93%) with URIFever (93%) with URI ± ± common presentations.common presentations.

If no improvement seen after 48 hrs seek medicalIf no improvement seen after 48 hrs seek medicalhelp.help.

Complications more in high risk group.Complications more in high risk group.Never use salicylates / aspirin.Never use salicylates / aspirin.

Improve general health.Improve general health.





THANK UTHANK U

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