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REVIEW
H1N1
Maj SK Mishra
Dr Rajeev Gupta
Dr Prashant Malviya
Chair Person
Surg Cdr Anuj Singhal
Introduction
 Epidemiology
 Sign and symptom
 Diagnosis
 Treatment
 Prevention

WHAT IS SWINE FLU


Swine influenza
Refers to influenza cases that are caused by
Orthomyxovirus endemic to pig population...
VIRAL INFLUENZA A - HUMAN
HISTORY
1889-90
1900-03
1918-19

H2N8
H3N8
H1N1(HswN1)

Severe epidemic
Mod epidemic
Severe epid...
OR Y
H IS T
The H1N1 form of swine flu is one of the descendants of
the Spanish flu that caused a devastating pandemic in
...
COUNTRIES AFFECTED TILL NOW
PANDEMICS OF INFLUENZA
H2N2

H2N2

H1N1

H1N1

H3N8
1895 1905

1889
Russian
influenza
H2N2

7

1915

1900
Old Hong
Kong
in...
SEASONAL INFLUENZA COMPARED
TO PANDEMIC — PROPORTIONS OF
TYPES OF CASES

Deaths
Requiring
hospitalisation

Deaths

Requiri...
SOME OF THE 'KNOWN UNKNOWNS' IN
THE 20TH CENTURY PANDEMICS

Three pandemics (1918, 1957, 1968).
Each quite different in sh...
INDIAN SCENARIO- 2009
NO OF CASES 10 MAIN AFFECTED
CITIES-2009
CITIES

NO OF CASES

PUNE

574

MUMBAI

324

DELHI

316

BANGALORE

131

HYDERABA...
COMPARATIVE MORTALITY
Avian flu(H7N7) HK 07
Hantavirus PS China 06
SARS-CoV China 07
Swine flu(H1N1)
Dengue

60 %
30-40 %
...
INFLUENZA VIRUS


Three types of influenza viruses:
A, B and C.
 A and B  seasonal epidemics of disease
 C infections ...
ORTHOMYXOVIRUSES 80-200nm
HA - hemagglutinin –attaches to sialic
Acid receptor
NA – neuraminidase-helps in
Budding out of ...
INFLUENZA -A


Two proteins on the surface of the virus
 Hemagglutinin


16 subtypes

 Neuraminidase


(H)

09 subtyp...
CLASSIFICATION=
The antigenic type (e.g., A, B, C)
 The host of origin (e.g., swine, equine, chicken,
etc. For human-orig...
PATHOPHYSIOLOGY


Antigenic drift
 Mutations

within the virus antibody-binding sites
accumulate over time
 Circumvent ...
ANTIGENIC SHIFT

H1N1
NOVEL H1N1 INFLUENZA


The first cases of human infection with novel
H1N1 influenza virus were detected in April 2009
in ...
WHO CAN CATCH THE “FLU” ?
WHO CAN CATCH THE FLU ?
As in all epidemics
Children
Elderly
Pregnant women
Immuno-suppressed or Immuno-compromised
Chroni...
HOW DOES NOVEL H1N1 INFLUENZA
SPREAD?


spread the same way seasonal
flu spreads

 Primarily

through
respiratory drople...
CAN YOU GET NOVEL H1N1 INFLUENZA
FROM EATING PORK?

No
You cannot get novel H1N1 flu
from eating pork or pork products.
Ea...
DEFINITIONS- CDC
CDC INTERIM GUIDANCE REPORT
CONFIRMED CASE
is defined as a person with an acute febrile
respiratory infection and a confir...
SUSPECTED CASE
is defined as a person with an acute febrile
respiratory infection with onset
Within 7 days of close contac...
INFECTIOUS PERIOD for a confirmed case
of H1N1 is defined as 1 day prior to the
cases illness onset to 7 days after onset....
INFECTIVITY PERIOD
Should be considered potentially contagious as
long as they are symptomatic
and possible for up to 7 da...
INDIVIDUALS AT INCREASED
RISK
Elderly > 65 years
 Children less than two years
 Certain chronic diseases


 Heart

(ex...
Pregnant/postpartum (2 weeks after delivery)
 Hemoglobinopathies
 Aged younger than 19 years, receiving long term
Asprin...
SIGNS AND SYMPTOMS
SYMPTOMS


Mild or uncomplicated illness


Progressive illness 
 typical

symptoms
 chest pain
 poor oxygenation


(eg, tachypnea)

 cardiopulmonary

insuffi...


Severe illness 
 mechanical

ventilation
 CNS findings (encephalitis, encephalopathy)
 complications of hypotension ...
COMPLICATIONS 


Refractory respiratory failure
 Not

improving on mechanical ventilator
 Inhaled nitric oxide
 high-f...
COMPLICATIONS


Bacterial superinfection 
 Streptococcus

pneumoniae
 Streptococcus pyogenes
 Staphylococcus aureus,
...
BACTERIAL SUPERINFECTION


Clinical findings:
 Secondary

fever after a period of defervescence.
 Sputum Gm stain or cu...
COMPLICATIONS


Neurologic 
 Seizure
 Confusion






acute or postinfectious encephalopathy
quadriparesis
encepha...
COMPLICATIONS


Other 
 Myocarditis
 Renal

insufficiency
 Rhabdomyolysis
 Multisystem organ failure.
 Hypercoagulab...
LABORATORY FINDINGS 
Elevated SGOT/SGPT
 Anemia
 Leukopenia
 Thrombocytopenia /Thrombocytosis
 Elevated total bilirubi...
 
DIAGNOSTIC ASSAYS


Real-time reverse transcriptase
(rRT)-PCR
 most



sensitive and specific test

culture
 too

slow...
LIMITATIONS
Analysts should be trained and familiar with
testing procedures and interpretation of results
prior to perform...
DIAGNOSTIC ASSAYS
Combined nasopharyngeal
and throat swabs (CNTS)
 Nasopharyngeal
aspirates (NPA)

DIAGNOSTIC ASSAYS


Rapid antigen tests
 Distinguish

between influenza A and B viruses
 Cannot distinguish among diffe...
DIAGNOSTIC ASSAYS


Immunofluorescent antibody testing 
 Direct

or indirect immunofluorescent antibody
testing (DFA or ...
METHOD

Acceptable Specimens

Test Time

Viral cell culture

NP swab, throat swab, NP
,bronchial wash, nasal
endotracheal ...
Treatment of H1N1
Treatment
• Adamantane agents
– Amantadine
– Rimantadine

• Neuraminidase inhibitor
– Oseltamivir (oral)
– Zanamivir (aero...
CDC recommends
• Treatment and prevention of H1N1/seasonal
flu
• Neuraminidase inhibitor
– Oseltamivir (oral)
– Zanamivir ...
GUIDELINES ON CATEGORIZATION OF
INFLUENZA A H1N1 CASES DURING
SCREENING FOR HOME ISOLATION,
TESTING TREATMENT AND
HOSPITAL...
Category- A
• Patients with mild fever plus cough / sore throat with
or without body ache, headache, diarrhoea and
vomitin...
Category-B
i.
i.

•
•

Category-A + high grade fever & severe sore
throat

– Require home isolation and Oseltamivir

Categ...
Category-C
• Category-A and B
– Breathlessness, chest pain, drowsiness, fall in
blood pressure, sputum mixed with blood, b...
• Treatment should be started as soon as
possible after illness onset
– Ideally within 48 hrs
Chemoprophylaxis
• Drug approved
– Oseltamivir is approved for prophylaxis of
influenza in individual > 1 year of age
– Za...
Guidelines on chemoprophylaxis
• Healthy persons after community exposure
– No chemoprophylaxis

• If states qualify the c...
• States which does not qualify the criteria of
community spread
– Family contacts, school contacts and social
contacts

•...
OSELTAMIVIR (Cap.Tamiflu)
TREATMENT (5 DAYS)
75 mg BD

ADULTS

Chemoprophylaxis
(10 days)
75 mg OD

Body Weight (kg) TREAT...
ZANAMIVIR (Relenza Diskhaler)
ADULTS
and
Children >
5 years

TREATMENT
(5 DAYS)

Chemoprophylaxis
(10 days)

10 mg (two
in...
Adverse effect
• Oseltamivir
–
–
–
–
–
–

• Zanamivir

Nausea
GI discomfort
Vomiting
Vertigo
Insomnia
Neuropsychiatric eve...
INFLUENZA SEASONAL VACCINE

CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine
Vaccination
• Annually
• Trivalent
– 2 strain of influenza A & 1 strain of influenza B

• Above the age of 6 months
• Quad...
“Flu shot”
• The "flu shot"
– Killed vaccine
– Intramuscular
– Usually in the arm
– approved for use in
people older than ...
Nasal vaccination
• LAIV (Flumist)
– a vaccine made with
live, weakened flu
viruses that do not
cause the flu
– LAIV (FluM...
Seasonal influenza vaccine 2012-13
• Influenza vaccines for 2012–13 season
– A/California/7/2009 (H1N1)
– A/Victoria/361/2...
Available
Pandemic flu vaccine
• Monovalent vaccine
– CELVAPAN
– PANDEMRIX
Side effects
• Flu shot

• LAIV (Flumist)

– Soreness, redness, or
swelling where the shot
was given
– Fever (low grade)
–...
Who should get the swine flu shot?
• Pregnant women
• People who live with or care for children younger
than 6 months of a...
Who Should Not Be Vaccinated?
• People who have a severe allergy to chicken
eggs
• Severe reaction to an influenza vaccina...
GUIDELINES ON INFECTION
CONTROL MEASURES

Clinical management Protocol and Infection Control Guidelines; Directorate Gener...
Health facility managing the human
cases of Influenza A H1N1
• During Pre Hospital Care
– Three layer surgical mask
– Full...
Contd
• During hospital care
– Isolation ward and continue to wear a three layer
surgical mask
– Identified medical, nursi...
Contd
• Infection control precautions
– 7 days after resolution of symptoms for adult
– 14 days after resolution of sympto...
STANDARD OPERATING PROCEDURES
ON USE OF PERSONAL PROTECTION
EQUIPMENTS (PPE)

Clinical management Protocol and Infection C...
Personal Protection Equipments (PPE)
• Reduces the risk of infection. It includes:
– Gloves (nonsterile)
– Mask (high-effi...
Contd
• Correct procedure for applying PPE :
– Follow thorough hand wash
– Wear the coverall
– Wear the goggles/ shoe cove...
Remove PPE in the following order
• Remove gown (place in rubbish bin)
• Remove gloves (peel from hand and discard
into ru...
INFECTION CONTROL MEASURES AT
INDIVIDUAL LEVEL

Clinical management Protocol and Infection Control Guidelines; Directorate...
Hand washing a Top priority
• Single most important
measure to reduce the
risk of transmitting
infectious organism
from on...
Respiratory Hygiene/Cough Etiquette
• Covering your nose
and mouth with a
tissue when you
cough or sneeze.
Throw the tissu...
Touching face regions can faster
the Spread
• Avoiding touching
your eyes, nose or
mouth.
Virus
can spread this way
in a f...
Staying home if you are sick
Avoid crowded places more so
with young children
Mild cold like symptoms - Take
rest
Using N95 mask reduces the Risk
• You can cut your risk
of contracting the flu
or other respiratory
viruses by as much
as ...
Infection control measures at
health facility
•
•
•
•

Droplet Precautions
Visual alerts
Use of PPE
Decontaminating contam...
Discharge policy
• Asymptomatic pt after two to three days of
treatment
– Should be discharged after 5 days of treatment
–...
Discharge policy
• Symptomatic
– Even after 10 days of treatment or
– cases with respiratory distress
– Suspected secondar...
Check list
• S – Stay home (if ill) and sleep well
• W –Wash hands, wear masks. Wine not to be
consumed
• I – Imbibe fluid...
Panic and Fear are much dangerous than
Swine Flu
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Swine Flu

  1. 1. REVIEW H1N1 Maj SK Mishra Dr Rajeev Gupta Dr Prashant Malviya Chair Person Surg Cdr Anuj Singhal
  2. 2. Introduction  Epidemiology  Sign and symptom  Diagnosis  Treatment  Prevention 
  3. 3. WHAT IS SWINE FLU  Swine influenza Refers to influenza cases that are caused by Orthomyxovirus endemic to pig populations. Is a respiratory disease of pigs caused by type A influenza Regularly cause outbreaks among pigs. Swine flu viruses do not normally infect humans
  4. 4. VIRAL INFLUENZA A - HUMAN HISTORY 1889-90 1900-03 1918-19 H2N8 H3N8 H1N1(HswN1) Severe epidemic Mod epidemic Severe epidemic 1933-35 1946-47 1957-58 H1N1(HON1) H1N1 H2N2 Mild epidemic Mild epidemic Severe epidemic 1968-69 1977-78 H3N2 H1N1 Mod epidemic Mild epidemic
  5. 5. OR Y H IS T The H1N1 form of swine flu is one of the descendants of the Spanish flu that caused a devastating pandemic in humans in 1918–1919 In 1957, an Asian flu pandemic infected some 45 million Americans and killed 70,000. It caused about 2 million deaths globally Eleven years later, lasting from 1968 to 1969, the Hong Kong flu pandemic afflicted 50 million Americans and caused 33,000 deaths In 1976, about 500 soldiers became infected with swine flu over a period of a few weeks.
  6. 6. COUNTRIES AFFECTED TILL NOW
  7. 7. PANDEMICS OF INFLUENZA H2N2 H2N2 H1N1 H1N1 H3N8 1895 1905 1889 Russian influenza H2N2 7 1915 1900 Old Hong Kong influenza H3N8 Pandemic H1N1 H3N2 1925 1955 1918 Spanish influenza H1N1 Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research, National Institute of Infectious Diseases (NIID), Japan. 1965 1957 Asian influenza H2N2 1975 1985 1968 Hong Kong influenza H3N2 1995 2005 2010 2009 Pandemic influenza H1N1 Animated slide: Press space bar 2015
  8. 8. SEASONAL INFLUENZA COMPARED TO PANDEMIC — PROPORTIONS OF TYPES OF CASES Deaths Requiring hospitalisation Deaths Requiring hospitalisation Clinical symptoms Asymptomatic Seasonal influenza 8 Clinical symptoms Asymptomatic Pandemic
  9. 9. SOME OF THE 'KNOWN UNKNOWNS' IN THE 20TH CENTURY PANDEMICS Three pandemics (1918, 1957, 1968). Each quite different in shape and waves. Some differences in effective reproductive number. Different groups affected. Different levels of severity including case fatality ratio. Imply different approaches to mitigation.       9
  10. 10. INDIAN SCENARIO- 2009
  11. 11. NO OF CASES 10 MAIN AFFECTED CITIES-2009 CITIES NO OF CASES PUNE 574 MUMBAI 324 DELHI 316 BANGALORE 131 HYDERABAD 67 CHENNAI 82 GURGAON 39 AHEMDBAD 34 KOLKATA 25 CALICUT 23
  12. 12. COMPARATIVE MORTALITY Avian flu(H7N7) HK 07 Hantavirus PS China 06 SARS-CoV China 07 Swine flu(H1N1) Dengue 60 % 30-40 % 9.5 % <1 %(177457 and 1462) <1 >1 %
  13. 13. INFLUENZA VIRUS  Three types of influenza viruses: A, B and C.  A and B  seasonal epidemics of disease  C infections mild respiratory illness and are not thought to cause epidemics. 
  14. 14. ORTHOMYXOVIRUSES 80-200nm HA - hemagglutinin –attaches to sialic Acid receptor NA – neuraminidase-helps in Budding out of infected cell helical nucleocapsid (RNA plus NP protein) lipid bilayer membrane polymerase complex M1 protein type A, B, C : NP, M1 protein sub-types: HA or NA protein
  15. 15. INFLUENZA -A  Two proteins on the surface of the virus  Hemagglutinin  16 subtypes  Neuraminidase  (H) 09 subtypes (N)
  16. 16. CLASSIFICATION= The antigenic type (e.g., A, B, C)  The host of origin (e.g., swine, equine, chicken, etc. For human-origin viruses, no host of origin designation is given.)  Geographical origin (e.g., Mexico, Taiwan, etc.)  Strain number (e.g., 15, 7, etc.)  Year of isolation (e.g., 57, 2009, etc.) 
  17. 17. PATHOPHYSIOLOGY  Antigenic drift  Mutations within the virus antibody-binding sites accumulate over time  Circumvent the body's immune system  A and B  Antigenic shift  Sudden change in antigenicity  Recombination of the influenza genome  Cell becomes simultaneously infected by two different strains of type A influenza.  Humans live in close proximity swine, that human strains and bird strains, may readily infect a pig at the same time, resulting in a unique virus.
  18. 18. ANTIGENIC SHIFT H1N1
  19. 19. NOVEL H1N1 INFLUENZA  The first cases of human infection with novel H1N1 influenza virus were detected in April 2009 in San Diego and Imperial County, California and in Guadalupe County, Texas.  The virus has spread rapidly.  The virus is widespread in the United States  Has been detected internationally as well.
  20. 20. WHO CAN CATCH THE “FLU” ?
  21. 21. WHO CAN CATCH THE FLU ? As in all epidemics Children Elderly Pregnant women Immuno-suppressed or Immuno-compromised Chronic medical conditions Occupational exposure-paramedics, medics
  22. 22. HOW DOES NOVEL H1N1 INFLUENZA SPREAD?  spread the same way seasonal flu spreads  Primarily through respiratory droplets  Coughing  Sneezing  Touching respiratory droplets on yourself, another person, or an object, then touching mucus membranes (e.g., mouth, nose, eyes) without washing hands
  23. 23. CAN YOU GET NOVEL H1N1 INFLUENZA FROM EATING PORK? No You cannot get novel H1N1 flu from eating pork or pork products. Eating properly handled and cooked pork products is safe.
  24. 24. DEFINITIONS- CDC
  25. 25. CDC INTERIM GUIDANCE REPORT CONFIRMED CASE is defined as a person with an acute febrile respiratory infection and a confirmed positive test for S-OIV by RT-PCR and/or viral culture. PROBABLE CASE is defined as a person with an acute febrile respiratory infection who tests positive for influenza A but negative for H1 and H3 by viral RT-PCR.
  26. 26. SUSPECTED CASE is defined as a person with an acute febrile respiratory infection with onset Within 7 days of close contact with a person who is a confirmed case of S-OIV infection. Within 7 days of travel to a community where there are one or more confirmed cases. Resides in a community where there are one or more confirmed cases of SIV infection.
  27. 27. INFECTIOUS PERIOD for a confirmed case of H1N1 is defined as 1 day prior to the cases illness onset to 7 days after onset. CLOSE CONTACT is defined as being within 6 feet of a confirmed or suspected case of H1N1 during the case’s infectious period. ACUTE ONSET OF A RESPIRATORY ILLNESS is defined as having at least 2 of the following: rhinorrhea, sore throat and cough with or without fever
  28. 28. INFECTIVITY PERIOD Should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children - might potentially be contagious for longer periods.
  29. 29. INDIVIDUALS AT INCREASED RISK Elderly > 65 years  Children less than two years  Certain chronic diseases   Heart (except HTN) or lung disease (including asthma)  Metabolic disease, including diabetes  HIV/AIDS, other immuno-suppression (drugs induced)  Chronic renal disease  chronic hepatic disease http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm,Influenza Antiviral Medications: Summary for Clinicians (Current for the 2012-2013 Influenza Season)
  30. 30. Pregnant/postpartum (2 weeks after delivery)  Hemoglobinopathies  Aged younger than 19 years, receiving long term Asprin therapy  Person who are morbidly obese (BMI >40)  Residents of nursing homes and other chronic care facilities 
  31. 31. SIGNS AND SYMPTOMS
  32. 32. SYMPTOMS  Mild or uncomplicated illness
  33. 33.  Progressive illness   typical symptoms  chest pain  poor oxygenation  (eg, tachypnea)  cardiopulmonary insufficiency  central nervous system (CNS) impairment (eg, confusion, altered mental status)  severe dehydration
  34. 34.  Severe illness   mechanical ventilation  CNS findings (encephalitis, encephalopathy)  complications of hypotension (shock, organ failure)  myocarditis or rhabdomyolysis  invasive secondary bacterial infection  persistent high fever and other symptoms beyond three days.
  35. 35. COMPLICATIONS   Refractory respiratory failure  Not improving on mechanical ventilator  Inhaled nitric oxide  high-frequency oscillatory ventilation  extracorporeal membrane oxygenation (ECMO)
  36. 36. COMPLICATIONS  Bacterial superinfection   Streptococcus pneumoniae  Streptococcus pyogenes  Staphylococcus aureus,  Streptococcus mitis  Haemophilus influenzae  Moraxella catarrhalis
  37. 37. BACTERIAL SUPERINFECTION  Clinical findings:  Secondary fever after a period of defervescence.  Sputum Gm stain or culture  Lobar consolidation on chest imaging (diffuse pattern in normal viral pneumonia)  Leukocytosis (normal or low white blood cell count)  Onset of respiratory compromise occurring four to seven days after initial symptoms
  38. 38. COMPLICATIONS  Neurologic   Seizure  Confusion      acute or postinfectious encephalopathy quadriparesis encephalitis severe acute disseminated encephalomyelitis stroke, and transient ischemic attack
  39. 39. COMPLICATIONS  Other   Myocarditis  Renal insufficiency  Rhabdomyolysis  Multisystem organ failure.  Hypercoagulability
  40. 40. LABORATORY FINDINGS  Elevated SGOT/SGPT  Anemia  Leukopenia  Thrombocytopenia /Thrombocytosis  Elevated total bilirubin  Elevations of CPK ,LDH 
  41. 41.  
  42. 42. DIAGNOSTIC ASSAYS  Real-time reverse transcriptase (rRT)-PCR  most  sensitive and specific test culture  too slow  A negative viral culture does not exclude pandemic H1N1 influenza A infection.
  43. 43. LIMITATIONS Analysts should be trained and familiar with testing procedures and interpretation of results prior to performing the assay.  A false negative result may occur if inadequate numbers of organisms are present in the specimen due to improper collection, transport or handling. 
  44. 44. DIAGNOSTIC ASSAYS Combined nasopharyngeal and throat swabs (CNTS)  Nasopharyngeal aspirates (NPA) 
  45. 45. DIAGNOSTIC ASSAYS  Rapid antigen tests  Distinguish between influenza A and B viruses  Cannot distinguish among different subtypes of influenza A  sensitivity -10 to 70 percent  specificity of rapid antigen testing was generally >95 percent
  46. 46. DIAGNOSTIC ASSAYS  Immunofluorescent antibody testing   Direct or indirect immunofluorescent antibody testing (DFA or IFA)  Distinguish between influenza A and B  does not distinguish among different influenza A subtypes  Low sensitivity and specificity
  47. 47. METHOD Acceptable Specimens Test Time Viral cell culture NP swab, throat swab, NP ,bronchial wash, nasal endotracheal aspirate, sputum 3-10 days Direct (DFA) or Indirect (IFA) Antibody NP swab or wash, bronchial wash, nasal or endotracheal aspirate 1-4 hours RT-PCR NP swab, throat swab, NP or bronchial wash, nasal or endotracheal aspirate, sputum 1- 6 hours Rapid Influenza Diagnostic Tests NP swab, (throat swab), nasal wash, nasal aspirate <30 min.
  48. 48. Treatment of H1N1
  49. 49. Treatment • Adamantane agents – Amantadine – Rimantadine • Neuraminidase inhibitor – Oseltamivir (oral) – Zanamivir (aerosolized) – Peramivir (intravenous)
  50. 50. CDC recommends • Treatment and prevention of H1N1/seasonal flu • Neuraminidase inhibitor – Oseltamivir (oral) – Zanamivir (aerosolized)
  51. 51. GUIDELINES ON CATEGORIZATION OF INFLUENZA A H1N1 CASES DURING SCREENING FOR HOME ISOLATION, TESTING TREATMENT AND HOSPITALIZATION Ministry of Health & Family Welfare Pandemic Influenza A (H1N1) Govt of India
  52. 52. Category- A • Patients with mild fever plus cough / sore throat with or without body ache, headache, diarrhoea and vomiting • Do not require Oseltamivir • Symptomatic treatment • Monitored for their symptom progress and reassessed at 24 to 48 hours by the doctor • No testing of the patient for H1N1 • Confine themselves at home • Avoid mixing up – Public and high risk members in the family
  53. 53. Category-B i. i. • • Category-A + high grade fever & severe sore throat – Require home isolation and Oseltamivir Category-A + one or more of high risk conditions i. Shell be treated with Oseltamivir No tests required for Category-B (i) and (ii) All patients of Category-B (i) and (ii) i. should confine themselves at home ii.Avoid mixing with public and high risk members in the family
  54. 54. Category-C • Category-A and B – Breathlessness, chest pain, drowsiness, fall in blood pressure, sputum mixed with blood, bluish discoloration of nails – Children with red flag signs (Somnolence, high and persistent fever, inability to feed well, convulsions, shortness of breath, difficulty in breathing etc) – Worsening of underlying chronic conditions • Require testing, immediate hospitalization and treatment
  55. 55. • Treatment should be started as soon as possible after illness onset – Ideally within 48 hrs
  56. 56. Chemoprophylaxis • Drug approved – Oseltamivir is approved for prophylaxis of influenza in individual > 1 year of age – Zanamivir for > 5 years of age • 84-89% efficacious against influenza A and B
  57. 57. Guidelines on chemoprophylaxis • Healthy persons after community exposure – No chemoprophylaxis • If states qualify the criteria for community spread – Family contacts that are at high risk – Co-morbid condition • Irrespective of laboratory testing Guidelines on chemoprophylaxis, Ministry of Health & Family Welfare Pandemic Influenza A (H1N1) Govt of India
  58. 58. • States which does not qualify the criteria of community spread – Family contacts, school contacts and social contacts • Irrespective of community spread or not – Medical personnel attending to influenza A H1N1 cases Guidelines on chemoprophylaxis, Ministry of Health & Family Welfare Pandemic Influenza A (H1N1) Govt of India
  59. 59. OSELTAMIVIR (Cap.Tamiflu) TREATMENT (5 DAYS) 75 mg BD ADULTS Chemoprophylaxis (10 days) 75 mg OD Body Weight (kg) TREATMENT (5 DAYS) Chemoprophylaxis (10 days) ≤15 kg 30 mg once daily > 15 kg to 23 kg 45 mg twice daily 45 mg once daily >23 kg to 40 kg 60 mg twice daily 60 mg once daily >40 kg Children ≥ 12 months 30 mg twice daily 75 mg twice daily 75 mg once daily Children 3 months to < 12 months2 TREATMENT (5 DAYS) Chemoprophylaxis (10 days) 3 mg/kg/dose twice daily 3 mg/kg/dose once 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 http://www.cdc.gov/H1N1flu/recommendations.htm
  60. 60. ZANAMIVIR (Relenza Diskhaler) ADULTS and Children > 5 years TREATMENT (5 DAYS) Chemoprophylaxis (10 days) 10 mg (two inhalations) BD 10 mg (two inhalations) once daily WHO and The U.S. Centers for Disease Control and Prevention http://www.cdc.gov/H1N1flu/recommendations.htm http://www.cdc.gov/H1N1flu/recommendations.htm
  61. 61. Adverse effect • Oseltamivir – – – – – – • Zanamivir Nausea GI discomfort Vomiting Vertigo Insomnia Neuropsychiatric events • Delirium • Self-injury – – – – – Worsen asthma Diarrhea Nausea Sinusitis Nasal signs and symptoms – Bronchitis – Headache & dizziness – Ear, nose, and throat infections http://www.cdc.gov/flu/professionals/antivirals/antiviral-adverse-events.htm Harrison’s 18th edition, page no.1442
  62. 62. INFLUENZA SEASONAL VACCINE CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine
  63. 63. Vaccination • Annually • Trivalent – 2 strain of influenza A & 1 strain of influenza B • Above the age of 6 months • Quadrivalent vaccine CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine
  64. 64. “Flu shot” • The "flu shot" – Killed vaccine – Intramuscular – Usually in the arm – approved for use in people older than 6 months, including healthy people and people with chronic medical conditions. 76
  65. 65. Nasal vaccination • LAIV (Flumist) – a vaccine made with live, weakened flu viruses that do not cause the flu – LAIV (FluMist) is approved for use in healthy people 2-49 years of age who are not pregnant 77
  66. 66. Seasonal influenza vaccine 2012-13 • Influenza vaccines for 2012–13 season – A/California/7/2009 (H1N1) – A/Victoria/361/2011 (H3N2) – B/Wisconsin/1/2010 (Yamagata lineage) antigens • All individual above the age of 6 mths • 6 months to 8 years – 2 doses – Month apart (4 weeks to 1 years) CDC- Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) —United States, 2012–13 Influenza Season, August 17, 2012 / 61(32);613-618
  67. 67. Available
  68. 68. Pandemic flu vaccine • Monovalent vaccine – CELVAPAN – PANDEMRIX
  69. 69. Side effects • Flu shot • LAIV (Flumist) – Soreness, redness, or swelling where the shot was given – Fever (low grade) – Aches – Children • • • • • runny nose wheezing headache muscle aches Fever – Adults • • • • runny nose headache sore throat cough CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine
  70. 70. Who should get the swine flu shot? • Pregnant women • People who live with or care for children younger than 6 months of age • Children and young people between the ages of 6 months and 24 years • Health care workers and emergency medical service providers • 25 and 64 years of age who have chronic medical disorders or compromised immune systems. CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine
  71. 71. Who Should Not Be Vaccinated? • People who have a severe allergy to chicken eggs • Severe reaction to an influenza vaccination • Children younger than 6 months of age • People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated) • History of Guillain–Barré Syndrome CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine
  72. 72. GUIDELINES ON INFECTION CONTROL MEASURES Clinical management Protocol and Infection Control Guidelines; Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India
  73. 73. Health facility managing the human cases of Influenza A H1N1 • During Pre Hospital Care – Three layer surgical mask – Full complement of PPE(Personal Protection Equipments ) – No Aerosol generating procedures – Three layered surgical mask for driver – Ambulance equipment sanitized using sodium hypochlorite / quaternary ammonium compounds
  74. 74. Contd • During hospital care – Isolation ward and continue to wear a three layer surgical mask – Identified medical, nursing and paramedical personnel attending the pt should wear full complement of PPE (Personal Protection Equipments) – Aerosol-generating procedures – Sample collection and packing – Hand wash • Before and after patient contact • Following contact with contaminated items
  75. 75. Contd • Infection control precautions – 7 days after resolution of symptoms for adult – 14 days after resolution of symptoms for children • Contaminated surfaces and equipments • Disinfectants – 70% ethanol, 5% benzalkonium chloride (Lysol) and 10% sodium hypochlorite
  76. 76. STANDARD OPERATING PROCEDURES ON USE OF PERSONAL PROTECTION EQUIPMENTS (PPE) Clinical management Protocol and Infection Control Guidelines; Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India
  77. 77. Personal Protection Equipments (PPE) • Reduces the risk of infection. It includes: – Gloves (nonsterile) – Mask (high-efficiency mask N95) / 3 layered surgical mask – Long-sleeved cuffed gown – Protective eyewear (goggles/visors/face shields) – Cap (may be used in high risk situations where there may be increased aerosols) – Plastic apron if splashing of blood, body fluids, excretions and secretions is anticipated
  78. 78. Contd • Correct procedure for applying PPE : – Follow thorough hand wash – Wear the coverall – Wear the goggles/ shoe cover/and head cover – Wear face mask – Wear gloves The masks should be changed after every six to eight hours
  79. 79. Remove PPE in the following order • Remove gown (place in rubbish bin) • Remove gloves (peel from hand and discard into rubbish bin) – Alcohol -based hand-rub or wash hands with soap & water • Remove cap and face shield (place cap in bin and if reusable place face shield in container for decontamination) • Remove mask - by grasping elastic behind ears – do not touch front of mask – Use alcohol-based hand-rub or wash hands with soap & water
  80. 80. INFECTION CONTROL MEASURES AT INDIVIDUAL LEVEL Clinical management Protocol and Infection Control Guidelines; Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India
  81. 81. Hand washing a Top priority • Single most important measure to reduce the risk of transmitting infectious organism from one person to other
  82. 82. Respiratory Hygiene/Cough Etiquette • Covering your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use • Wash hand
  83. 83. Touching face regions can faster the Spread • Avoiding touching your eyes, nose or mouth. Virus can spread this way in a faster way
  84. 84. Staying home if you are sick
  85. 85. Avoid crowded places more so with young children
  86. 86. Mild cold like symptoms - Take rest
  87. 87. Using N95 mask reduces the Risk • You can cut your risk of contracting the flu or other respiratory viruses by as much as 80 percent by wearing a mask over your nose and mouth Emerging Infectious Diseases, the journal of the Centres for Disease Control and Prevention (CDC) .
  88. 88. Infection control measures at health facility • • • • Droplet Precautions Visual alerts Use of PPE Decontaminating contaminated surfaces, fomites and equipments • Guidelines for waste disposal
  89. 89. Discharge policy • Asymptomatic pt after two to three days of treatment – Should be discharged after 5 days of treatment – Repeat test not required • Continuation of symptoms of fever, sore throat etc. even on the 5th day – should continue treatment for 5 more days – Asymptomatic  discharge – No need to test further
  90. 90. Discharge policy • Symptomatic – Even after 10 days of treatment or – cases with respiratory distress – Suspected secondary infection – if patient continue to shed virus • Resistance of the patients to anti viral drug would be tested • Family should be educated on – Personal hygiene – Infection control measures at home
  91. 91. Check list • S – Stay home (if ill) and sleep well • W –Wash hands, wear masks. Wine not to be consumed • I – Imbibe fluids • N – No smoking • E – Eat well • F – Fear not ( deaths < 1 %) ,Fully treatable • L – Lessen travel and visits to crowded places • U – Uphold cleanliness and proper disposal of used masks
  92. 92. Panic and Fear are much dangerous than Swine Flu

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