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CURRENT PANDEMIC SWINE FLU 2009 - ???

By Dr. Indira Dept of O&G Public health centre West mambalam.

Introduction
Influenza A ( H1N1) virus Swine Flu ± misnomer Pandemic level phase 6 (WHO) Started in Mexico on 18th March, 2009 As of now around 170 countries involved 30 ± 35% global population involved In India 150 new cases reported daily Total in Chennai ± 154 cases 90% doesn¶t require testing / treatment Mortality ± 1-2%

20th century flu pandemics
Pandemic Year Influenza A virus subtype H1N1 H2N2 H3N2 People infected (approx) 0.5 to 1 billion (near 50%) Deaths (est.) 20 to 100 million 2 million 1 million Case fatality rate 1918 flu pandemic Asian flu Hong Kong flu Seasonal flu

1918 19 1956 58 1968 69

>2.5% <0.1% ? <0.1%

Every year

mainly 5 15% (340 250,000 A/H3N2, million 1 500,000 per A/H1N1, billion) year and B

<0.05%

Microbiology
Types ± Influenza A, B,C A ± commonest In human, birds & pig Mostly responsible for pandemic B - Exclusive in human but rare C ± both human & pigs Won't cause pandemic

Microbiology
Influenza A: Glycoproteines ± H & N Common in Human ± H ±1,2,3 - N - 1,2 Contains 8 genomes RNA ± 8 segments in genomes - Possible to swap genes - combination of 88 possible

Microbiology Antigenic drift Antigenic shift Genetic Reassortment If 2 types infect a single cell ± new strain developes Pigs act as mixing vessel .

.

Microbiology Current virus combination of  North American swine  North American Avian  Human Influenza  Eurasian Swine .

more in males € Transmission Droplet infection & fomites 1 ± 7 days live up to 2 ± 8 hr outside € Communicability From 1 day before ± 7 days after onset of symptoms If symptoms persist > 7 days ± till resolution of illness Children up to 10 ± 14 days Infection can travel up to 3mt. .Epidemiology € Agent € Incubation period New subtype In flu H1N1 virus Needs dry & cold climate € Host factors Healthy young adults 5 ± 24 yr .

90 c) with chills € Non productive Cough € Runny or stuffy nose € Sore throat € Body ache / Headache € Nausea/diarrhoea € Fatigue/tiredness that can be extreme € Signs of a more serious swine flu infection might include pneumonia and respiratory failure € If > 2 symptoms ² suspect swine flu .Clinical Features Common Symptoms : € Fever( > 37.

Pneumonia .Complications € Similar to seasonal influenza € Sinusitis / Otitis media € Croup / Pneumonia / bronchiolitis € Status asthmatics € Myocarditis / Pericarditis € Myositis / Rhabdomyositis € Encephalitis / seizures € TSS € Secondary bact.

Adults and children who have immuno suppression (including immuno suppression caused by medications or by HIV). Residents of nursing homes and other chronic-care facilities chronic- . cardiovascular. or metabolic disorders. € Persons aged 65 years or older. hepatic.Groups at higher risk € Children less than 5 years old. neuromuscular. Adults and children who have chronic pulmonary. hematological. Pregnant women. neurologic. € Children and adolescents (less than 18 years) who are receiving € € € € longlong-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection.

Not gold standard .takes 3 hr to complete Viral culture ± MDCK cell lines Neutralisation test .Investigations Real time PCR .4 fold increase positive Rapid test for virus .

not later then 5 days 24Before starting antiviral At least nasopharyngeal swab Bronchoalveolar lavage ideal Oropharyngeal swab ± not adequate .Sample Collection Trained personal Within 24-72 hr.

maintain cold chain Transported within 24 hr If can¶t ± store at ±700 C .Sample Collection Dacron / polyester tipped swab Aluminium / plastic shaft In 2-3ml viral transport media 2At 40 C .

gloves / Disp.Sample Collection Person should wear Fit tested N-95 respirator NGoggles / Disp. Gowns Collect in ±ve pressure room All work at BSL 2 Lab work at BSL 3 PPE collected in biohazard bag Wash hand ± Soap / at least 60% alcohol solution .

S puram .Nagar HiDiagnostic Services. T. T. Centre. Vellore Bharat scans.Coimbatore Dr. Guindy CMC.Rath¶s Lab.Laboratories King Institute . R. Trichy .Nagar Micro Labs. Royapettah Hi-Tech Diag. Thillai nagar.

seek medical care IMMEDIATELY. Avoid touching your eyes. . fluDrink sufficient water: Drink 8 to10 glasses of water each day to flush toxins from your system and maintain good moisture and mucous production in your sinuses.Precautions € Stay at home and avoid traveling to public places like school € € € € € and offices. Always try to cover your nose and mouth with a tissue while coughing or sneezing to avoid passing on infection of any kind to others around you. Get enough sleep: Try to get 8 hours of good sleep every night to keep your immune system in top flu-fighting shape. Wash your hands frequently: Wash them often. for at least 15 seconds and rinse with running water. nose and mouth to prevent the spread of the virus.

 Relax  Last but not least. Sleep.6 WAYS TO IMPROVE UR IMMUNITY  Lose Weight  Exercise  Eliminate Sugar From your Diet  Stop Junk Food  Get Plenty of Sleep. keep washing your hands frequently. .

TREATMENT .

Guiding principles Early implementation of infection control measures Prompt treatment to prevent severe illness and death Early identification and follow up of persons at risk .

ventilators. nurses and paramedical worker. Portable Xray machine. disinfectants and medications. pulse oximeter and more Adequate PPE . . patients can be cohorted in well ventilated ward with beds kept 1 meter apart Dedicated doctors. O2 cylinders.INFRASTRUCTURE Isolation facilities : if separate rooms not available.

STANDARD OPERATING PROCEDURES Reinforce standard infection control precautions to all. Ensure personnel hygienic measures. . Restrict the number of visitors and provide them PPE Antiviral prophylaxis for health care professionals and monitor them Dispose infected waste in sealed impermeable bags labelled BIOHAZARD.

Age <3 months 3-5 months 6-11 months Recommended treatment dose for 5 days 12 mg twice daily 20 mg twice daily 25 mg twice daily .Oseltamivir Agent. group Adults 15 kg or less 1616-23 kg Children • 12 months 2424-40 kg >40 kg Treatment 7575-mg capsule twice per day for 5 days 60 mg per day divided into 2 doses 90 mg per day divided into 2 doses 120 mg per day divided into 2 doses 150 mg per day divided into 2 doses Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir.

ADR Generally well tolerated GI side effects common if > 300 g/day May cause bronchitis.Oseltamivir . most common vomiting Rarely anaphylaxis and skin rashes No change of dose in liver disease Decrease if GFR is low . vertigo Epistaxis in children. insomnia.

CAUTION !!! ONLY VIROSTATIC DRUG Indiscriminate use cause resistance Highly effective even if started after 48 hr of infection Never stop oseltamivir once started Start as per guidelines .

Zanamivir Agent. 5 years or older) . 7 years or older) Two 5-mg inhalations (10 mg total) once per day (age. group Treatment Chemoprophylaxis Adults Two 5-mg inhalations Two 5-mg inhalations (10 mg total) twice per (10 mg total) once per day day Two 5-mg inhalations (10 mg total) twice per day (age.

steam inhalation Monitor LRTI & Hypoxia Steroids high dose ± harmful low dose ± septic shock .Supportive treatment Iv fluids Parenteral treatment O2 therapy / ventilatory support Antibiotics Vasopressors for shock Paractemol / ibuprofen Salicylate / aspirin .NO USE Drink plenty of fluids Avoid smoking Topical decongestants.CI Immunomodulatory drugsdrugs.

DISCHARGE POLICY Adults : 7 days after symptoms subsides Children : 14 days after Family should be educated about preventive measures .

Age <3 months 3-5 months 6-11 months 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 .CHEMOPROPHYLAXIS DOC : Oseltamivir . group Adults 15 kg or less 16-23 kg Children • 12 months 24-40 kg >40 kg 60 mg once per day 75 mg once per day Chemoprophylaxis 75-mg capsule once per day 30 mg once per day 45 mg once per day Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir.Agent.

.PPE Gloves Mask N95/ 3 layered surgical mask Long sleeved cuffed gown Protective eye wear Cap Plastic apron Correct procedures for applying PPE Correct procedures for removing PPE Should be employed in situations where unavoidable definite direct exposure to cases are present.

PPE .

PPE Appl i t i R i t i Thorough hand wash Wear cover all Wear goggles/ shoe cover/ head cover ( in that order) Wear face mask Wear gloves Mask should be changed every 6 to 8 hrs Remove gown(rubbish bin) Remove glove (peel from hand) Use hand wash Remove cap and face shield Remove mask Use hand wash Leave the room Once outside ± hand wash .

GUIDE LINES .

not as routine .Guidelines ± infection control a) Individual level Hand hygiene ± most important Respiratory hygiene Staying away from source Use of mask .only symptomatic .health personnel at risk .

Guidelines ± infection control b)For clinicians Well ventilated rooms for consultations/separate rooms Pedestrial fans opposite to patients Clean AC filters often 3 layered surgical mask Wash hand Avoid contact with mouth/ nose/ eye .

things & equipments (70% ethanol. 10% bleach) Waste disposal as per waste management protocols .Guidelines ± infection control c) At health facility Droplet precautions Visual alerts Use of PPE Decontaminating the infective surface. 5% lysol.

Guidelines ± Pregnant women Higher risk for complications from infection Oseltamivir and zanamivir are "Pregnancy Category " medications No clinical studies have been conducted to assess the safety of these medications No relation between the use of these medications and adverse events has been established. Get an informed consent before USE OF DRUG Because of its systemic activity. The drug of choice for chemoprophylaxis is less clear. oseltamivir is preferred for treatment of pregnant women. .

No adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to such women. . however. especially in women at risk for respiratory problems Amantadine and rimantadine have been demonstrated in animal studies to be teratogenic and embryo toxic .Guidelines ± Pregnant women Zanamivir may be preferable because of its limited systemic absorption. respiratory absorption. complications that may be associated with zanamivir because of its inhaled route of administration need to be considered.

use mask. € Use a cloth blanket between you and your baby during feeding € Try not to cough and sneeze in the baby¶s face € Express breast milk and feed in case of severe infection € Don¶t stop breastfeeding while taking medications € Give as many feeds as possible if baby is sick . € Healthy Individuals should take care of the baby € Through washing of hands.Guidelines ± Breast feeding € Breast feeding is a must.

whichever is longer Avoid exposure to sick person Use tissue or hanky or upper sleeve while sneezing or coughing Wash hands thoroughly Avoid touching your eyes. . nose.Guidelines ± Pediatricians High risk Early identification and monitor the cases If flu like symptoms ± keep her/his at home for 7 days/24hr after symptoms resolve. mouth before washing your hands.

Seek emergency in case of Fast breathing Trouble breathing Bluish/gray skin color Not drinking enough fluids Not urinating as much as usual Severe or persistent vomiting Not waking up/ interacting as usual Being so irritable that the child doesn¶t even want to be held Fever returns after being absent for a day or a significant change in fever pattern .

€ Educational institutions should not insist on production of medical certificate by the student/staff. . € Educational institutions should monitor the health status of such students/staff who might have come in contact with a suspected case of Influenza A H1N1. running nose and difficulty in breathing should be allowed to stay at home for a period of 7 to 10 days.GUIDELINES FOR SCHOOLS/COLLEGES/INSTITUTIONS ON INFLUENZA A/H1N1 € Any student or staff member showing flu like symptoms such as fever. cough.

€ Given the current magnitude of the spread of AH1N1 infection and the fact that the current virus is fairly mild. € Educational institutions are further encouraged to report such cases to local health officers for further monitoring. . as it would spread infection further. closure of educational institutions on account of any student/staff member falling ill with flu like symptoms is not recommended.GUIDELINES FOR SCHOOLS/COLLEGES/INSTITUTIONS ON INFLUENZA A/H1N1 € In case of students staying in Hostels. the educational institutions would not only monitor the health status of the students. but also that of care providers. It might not be advisable to send the boarders back to home.

the schools should discourage the excursions of the students to the affected countries. if some students show flu like symptoms of fever. then on their return.GUIDELINES FOR SCHOOLS/COLLEGES/INSTITUTIONS ON INFLUENZA A/H1N1 All school or childcare related gatherings should be cancelled and encourage parents and students to avoid congregating outside of the school. . difficulty breathing etc. body ache. In case if the students had proceeded to affected countries on unavoidable tours. sorerunning nose. sore. they should be advised to abstain from attending school and be allowed to stay at home for a period of 7 to 10 days. In the first place.throat . cough .

Patients should confine themselves at home and avoid mixing with the public and high risk members in the family. The patients should be monitored for their progress and re-assessed every 24 to 48 hours by the doctor. . reNo testing of the patient for H1N1 is required. diarrhoea and vomiting. They do not require Oseltamivir and should be treated for the symptoms mentioned above. headache.Revised Guidelines ± Govt of INDIA (14th August. 2009) Category A: Patients with mild fever plus cough/sore throat with or without body ache.

neurologi l disorders. regn nt o en. In ddition to ll the signs nd s to s of tegor A. di etes. those ove e rs. u h tients should onfine the selves t ho e nd void i ing ith u li nd high-ris highe ers in the f il . tients on long ter ortisone ther . he rt dise se.Revised Guidelines ± Govt of INDIA (14th August. lood disorders. he/she re uire ho e isol tion nd selt ivir. individu ls h ving one or ore of the follo ing high ris onditions sh ll e tre ted ith selt ivir: hildren under five. idne dise se. liver dise se. those ith lung dise ses.(i) nd (ii). if the tient h s high gr de fever nd severe sore thro t. No 1N1 tests re re uired for tegor . n er nd I /AID . 2009) Cat r B: In ddition to ll the signs nd s to s of tegor A. .

dro siness. i edi te hos it lis tion nd tre t ent. s utu i ed ith lood.Revised Guidelines ± Govt of INDIA (14th August. luish dis olour tion of n ils. . f ll in lood ressure.Irrit ilit ong s ll hildren. . 2009) r C: Cat In ddition to the s to s of tegories A nd . u h tients re uire 1N1 testing.orsening of underl ing hroni onditions. refus l to e t feed. if the tient h s one or ore of the follo ing: . . hest in.re thlessness.

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Not yet commercially available. . 2 doses spanning over 21 or more days Human trials at Emory university Hope clinic. Seasonal influenza vaccine won¶t prevent swine flu.Vaccines Inactivated subunit ± single dose/ multi dose vial Live attenuated vaccines ± inhaler sprays 15 g of antigen for 1dose.

Jagadeshan ± 9444113370 Email : idspchennai@gmail.04425912688 Dr. Kuganadhan .1913 Infection control surveillance 25912686/87/88 Dr. Director CDH .com . Lakshmi.9445190744 Dr.HELPLINES Chennai corporation .

Complications more in high risk group. Never use salicylates / aspirin. 1-2% mortality. Communicability ± 1 day prior to 7 days after onset of symptoms. . 90% recover without treatment . If no improvement seen after 48 hrs seek medical help. 1Transmission only by droplet infection. A H1N1 ± like any other seasonal flu. Fever (93%) with URI ± common presentations.TAKE HOME MESSAGE Inf. Improve general health.

E. l t t l il r t r il li it i f t r O lt i ir (T i fl ) O ( ti i ti j i i ll . ti ri t/ r rt t r ti . l . ATE G I E I ES O TE . r i li ).TAKE HOME MESSAGE H A E i l i . tr i i t . r . r r tf i t OTI . . ti i . l i .

THANK U .