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Influenza A (H1N1)

A/California/7/2009 (H1N1)

SWINE FLU
DR. MUHAMMAD ALAUDDIN SARWAR
Medical Officer,
Sindh Government Qatar Hospital Karachi
Influenza A viruses categorized by subtype
• Classified according to two surface proteins
• Hemagglutinin (H) – 16 known
– Site of attachment to host cells
– Antibody to HA is protective
• Neuraminidase (N) – 9 known
– Helps release virions from cells
– Antibody to NA can help modify disease severity

National Center for Disease Prevention and Control, DOH


A/California/7/2009 (H1N1)
Confirmed Cases
Confirmed cases followed by death
Unconfirmed Cases
WHO 9 jan 2010
Deaths, World Deaths, Pakistan
14, 6%
16202,
1%

Cases,
1458472 Cases,
219, 94%
, 99%

Deaths,
10837, USA
20%

Germany: 215881 cases


Portugal: 166922 cases
Cases,
China (Mainland): 120940 cases 44640,
80%

http://www.flucount.org/ and Wikipedia


23/01/10
First case of swine
flu was detected in
August, 2009

 219 cases of
swine flu have
so far been
detected in the
country.
 14 casualties
Health Minister Makhdoom
Shahabuddin
12 january 2010.
THE DAILY DAWN
Case Definitions for Influenza A H1N1 Cases
A Suspected Case of Influenza A / H1N1 virus
infection is defined as an individual presenting with
• High fever >38°C, AND
• One or more of the following respiratory symptoms:
cough, shortness of breath, body ache, difficulty in
breathing, AND
• One or more of the following: close contact with a
person diagnosed as Influenza A/H1N1 OR recent
travel to an area reporting cases of confirmed
Influenza A/H1N1
(Acute febrile respiratory illness (fever > 38 °C) with the spectrum of
disease from influenza-like illness to pneumonia)
WHO and The U.S. Centers for Disease Control and Prevention
Case Definitions for Influenza A H1N1 Cases
A Probable Case of Influenza A/H1N1 infection is
defined as an individual that fulfill the criteria
for a suspected case,
• with an influenza test that is positive for
influenza A, but is unsubtypable by reagents
used to detect seasonal influenza virus infection
OR
• An individual with a clinically compatible illness
or who died of an unexplained acute respiratory
illness who is considered to be epidemiologically
linked to a probable or confirmed case.
WHO and The U.S. Centers for Disease Control and Prevention
Case Definitions for Influenza A H1N1 Cases

A Confirmed Case of Influenza A/H1N1


infection is defined as an individual with
laboratory confirmed Influenza A/H1N1 virus
infection by one or more of the following
tests:
real-time RT-PCR
viral culture
4-fold rise in swine influenza A(H1N1) virus
specific neutralizing antibodies

WHO and The U.S. Centers for Disease Control and Prevention
Clinical Signs & Symptoms of Influenza A (H1N1)

Symptom: sensitivity specificity


Fever 68-86% 25-73%
Cough 84-98% 7-29%
Nasal
68–91% 19–41%
congestion
All three findings, especially fever, were
less sensitive in patients over 60
years of age

WHO, Wikipedia and The U.S. Centers for Disease Control and Prevention
DIFFERENCE B/W FLU, COLD & ALLERGY
SYMPTOMS Flu or Influenza Common Cold Air Born Allergy

Usual, High (101-102 F)


Fever may be more in young Rare Never
children, lasts 3-5 days

Headache Common Rare Rare

General aches & pains Usual, often severe Slight Never

Usual, can last up to 3 Sometimes


Fatigue & Weakness weeks
Sometimes

Usual, at the beginning


Extreme exhaustion of the illness
Never Never

Stuffy or runny nose Sometime Common Common


Sometime
Sneezing Usual Usual

Sometime
Sore throat Common Sometimes

Common, usually non


Sometimes, dry (non
Cough productive, may Common, hacking
productive)
become severe

Chest discomfort Common Mild to Moderate Rare


FEATURES OF H1N1 INFECTION

Complications:viral and bacterial pneu monia,


febrile seizures, cardiomyopathy,
encephalopathy/encephalitis, worsening
underlying chronic conditions
Close contact is defined as: within about 3 feet
of an ill person who is a confirmed or suspected
case of influenza A H1N1 virus infection during
the case’s infectious period.

WHO and The U.S. Centers for Disease Control and Prevention
FEATURES OF H1N1 INFECTION
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.
Incubation period
– Time from exposure to onset of symptoms
– 1 to 4 days (average = 2 days)
Seasonality
– In temperate zones, sharp peaks in winter months
– In tropical zones, circulates year-round with
seasonal increases.

WHO and The U.S. Centers for Disease Control and Prevention
TRANSMISSION OF SWINE FLU VIRUS
 Through large-particle respiratory droplets which do
not remain suspended in air & travel only short
distances (<1m ).
 Contact with respiratory-droplet contaminated
surfaces is another possible source of transmission.
 As data from influenza viruses H1N1 are limited,
potential for ocular, conjunctival, or GI infection is
unknown.
 Being a novel influenza A virus, transmission from
infected persons to close contacts maybe common. All
respiratory secretions & bodily fluids (diarrheal
stool) of H1N1 cases should be considered infectious.
WHO and The U.S. Centers for Disease Control and Prevention
Individuals at Increased Risk for
Hospitalizations and Death

• Elderly > 65 years


• Children less than two years
• Certain chronic diseases
– Heart or lung disease, including asthma
– Metabolic disease, including diabetes
– HIV/AIDs, other immuno-suppression
– Conditions that can compromise respiratory
function or the handling of respiratory
secretions
• Pregnant women
WHO and The U.S. Centers for Disease Control and Prevention
Antiviral Therapy
• Oseltamivir & zanamivir can be given for
suspected, probable & confirmed H1N1 cases
• Current approach :
 Use for probable & confirmed cases
 In suspected cases:
-Empirical treatment if patients present with
complications of influenza eg. Pneumonia, mental
confusion, metabolic derangement, etc
- If patient is clinically comfortable (no
complications), treatment deferred till virology
results
• Duration of treatment: 5 days
WHO and The U.S. Centers for Disease Control and Prevention
OSELTAMIVIR (Cap.Tamiflu)
Chemoprophylaxis
TREATMENT (5 DAYS)
ADULTS (10 days)
75 mg BD 75 mg OD
Chemoprophylaxis
Body Weight (kg) TREATMENT (5 DAYS)
(10 days)

≤15 kg 30 mg twice daily 30 mg once daily


Children
> 15 kg to 23 kg 45 mg twice daily 45 mg once daily
≥ 12 months
>23 kg to 40 kg 60 mg twice daily 60 mg once daily

>40 kg 75 mg twice daily 75 mg once daily

Chemoprophylaxis
Children 3 months to TREATMENT (5 DAYS)
(10 days)
< 12 months2
3 mg/kg/dose twice 3 mg/kg/dose once
daily per day
It is also available as syrup (12mg per ml )
WHO and The U.S. Centers for Disease Control and Prevention http://www.cdc.gov/H1N1flu/recommendations.htm
ZANAMIVIR (Relenza Diskhaler)
TREATMENT Chemoprophylaxis
ADULTS (5 DAYS) (10 days)
and 10 mg (two
Children > 10 mg (two inhalations) once
7 years inhalations) daily
BD Can be given up to
5 years old child

WHO and The U.S. Centers for Disease Control and Prevention http://www.cdc.gov/H1N1flu/recommendations.htm
DISCHARGE OF PATIENTS
The patients can be discharged with the following
criteria:
• Suspected cases:
o When PCR results are negative
o If patient is still unwell, he can be transferred out of
isolation ward

• Probable & Confirmed cases:


o At least 7 days from onset of illness and
o Completed at least 5 days of antiviral therapy and
o Well / asymptomatic
o If the patient has fulfilled the first 2 criteria but is still
recovering, he can be transferred out of isolation ward
WHO and The U.S. Centers for Disease Control and Prevention
ALGORITHM FOR MANAGEMENT (H1N1)
Acute Febrile Respiratory Illness of <7 days Duration With Fever AND >1 Of The Following
● Cough ● Sore throat
Vomiting and diarrhea do NOT exclude the diagnosis of influenza H1N1

NO
YES

No influenza testing Do patient’s symptoms indicate need


recommended. for hospitalization OR
Additional evaluation and Is the patient in a high risk group for
follow-up as clinically complications of influenza
indicated.

NO
YES
Discharge
Obtain NP swab for influenza PCR.
Patient should stay home until 24 afebrile
off antipyreticsUse proper hand and Additional clinical evaluation as indicated
respiratory hygiene.

NO
YES
Discharged
Hospitalized
Consider empiric anti viral therapy
begin empiric therapy with oseltamivir.
only if patient at “high risk” for
complications of influenza Use Droplet Precautions. For cough inducing
procedures use an N95 respirator plus eye
Antivirals most effective if inititiated
protection (face shield or goggles)
<48 after onset of symptoms.

The University of North Carolina, 23 September 2009 Updates at http://intranet.unchealthcare.org/intranet_news/empnews/fluYesNoNo


PANDEMIC FLU VACCINATION
Vaccines are available. (CELVAPAN &
PANDEMRIX)
They are made just like seasonal flu
vaccines.
They are expected to be as safe and
effective as seasonal flu vaccines.
They will not prevent “influenza-like”
illnesses caused by other viruses.
They will not prevent seasonal flu.
You should also get seasonal
influenza vaccine, if you want to be
protected against seasonal flu.
Contraindication: Severe (life-threatening) allergy to eggs, or to any
other substance in the vaccine.
The U.S. Centers for Disease Control and Prevention, 10/2/09
PANDEMIC FLU VACCINATION
Groups recommended to receive 2009 H1N1 vaccine first are:
Pregnant women.
People who live with or care for infants younger than
6 months of age.
Health care and emergency medical personnel.
Anyone from 6 months through 24 years of age.
Anyone from 25 through 64 years of age with certain
chronic medical conditions or a weakened immune
system.
As more vaccine becomes available, these groups should also be
vaccinated:
Healthy 25 through 64 year olds
Adults 65 years and older
Children through 9 years of age should get two
doses of vaccine, about a month apart. Older
children and adults need only one dose.
The U.S. Centers for Disease Control and Prevention, 10/2/09
SEASONAL FLU VACCINATION
• Influenza vaccine is the best
prevention for seasonal
influenza.
• Inactivated viruses in the
vaccine developed from three
circulating strains (generally 2
Type A and 1 Type B strain)
– Therefore, seasonal “flu shot” only
works for 3 influenza subtypes and
will not work on pandemic strains
(H1N1).
PANDEMIC FLU VACCINATION

Wednesday, January 13, 2010

Wednesday, January 13, 2010


Pakistan Vs Australia Series

ISLAMABAD: Federal Health Minister Makhdoom


Shahabuddin told the National Assembly on
Tuesday that the swine flu vaccine would reach
Pakistan within a week. The health minister told the
House that Tammy Flu, a curative capsule has been
distributed across the country and 50,000 capsules
have been provided to Punjab, 30,000 to Sindh and
8,000 each to Balochistan and the NWFP. He said
the vaccine would reach Pakistan within one week,
as only 12 companies in the world were
manufacturing this preventive vaccine and supply it
only to governments through the World Health
Organisation, not any individual.
GENERAL PRECAUTIONS

• Frequent hand washing

• Covering coughs and sneezes

• Avoidance of crowded settings when possible

• advising ill persons to stay home (except to seek medical


care) and minimize contact with others in household

• voluntary home quarantine of members of households with


confirmed or probable swine influenza cases
WHEN CONTACT IS UNAVOIDABLE

* consider Facemasks (disposable,


single use masks) for persons who enter
crowded settings

* consider Respirators (N95 or higher


filtering facepiece respirator) for persons
who have unavoidable close contact with
infectious person

No clear scientific evidence regarding the effectiveness of


facemasks and respirators in protecting against influenza
Influenza A (H1N1) is a Public Health
Emergency of International Concern (PHEIC) ??

Serious Public Health Impact


Unusual or Unexpected
International disease spread
Interference with inter-
national travel or trade
WHO Raise the Pandemic Alert level to 5-6

**WHO Recommends intensifying and enhancing national surveillance


systems for Influenza-like Illnesses and atypical pneumonia

National Center for Disease Prevention and Control, DOH


20th century flu pandemics
Case
Influenza People infected Estimated deaths
Pandemic Year fatality
virus type (approximate) worldwide
rate

Spanish flu 1918–1919 A/H1N1 33% (500 million) 20–100 million >2.5%

Asian flu 1956–1958 A/H2N2 ? 2 million <0.1%

Hong Kong flu 1968–1969 A/H3N2 ? 1 million[ <0.1%

mainly A/H3N2, 5–15% (340 million – 250,000–500,000 per


Seasonal flu Every year <0.1%
A/H1N1, and B 1 billion) year

14,286 (lab-
Pandemic > 622,482 (lab- confirmed†; ECDC)
Swine flu 2009 0.03%
H1N1/09 confirmed) ≥8,768 (lab-
confirmed†; WHO)
Influenza A (H1N1) is a Public Health
Emergency of International Concern (PHEIC) ??
Unusual combination of genetic material from pigs (of North
America and Euroasia), birds & humans which have re-assorted???

Only fewer companies has the permission to produce vaccine???

Mortality is far less not only from previous Pandemics but also from
yearly seasonal flu !!!!!!!

Is it an attempt to control World population ??? Or just an


experimentation ????
alauddinsarwar@gmail.com