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Swine Flu

Swine Flu



Information for health personnel and masses

Information for health personnel and masses



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    Swine Flu Swine Flu Presentation Transcript

    • Influenza A (H1N1) Swine Flu
      Dr Muhammad Khurram
      FCPS, FRCP
      Assistant Professor- Medicine
      Rawalpindi Medical College, Rawalpindi
      • RNA, enveloped
      • Viral family: Orthomyxoviridae
      • Size:
      80-200nm or .08 – 0.12 μm (micron) in diameter
      • Three types
      • A, B, C
      • Surface antigens
      • H (haemaglutinin)
      • N (neuraminidase)
      Credit: L. Stammard, 1995
    • InfluenzaVirus - Types
    • Influenza: Normal Burden of Disease
      Seasonal Influenza
      Globally: 250,000 to 500,000 deaths per year
      In the US (per year)
      ~35,000 deaths (mainly among people 65 years or older)
      >200,000 Hospitalizations
      $37.5 billion in economic cost (influenza & pneumonia)
      >$10 billion in lost productivity
      Pandemic Influenza
      An ever present threat
    • Definitions
      Epidemic – a located cluster of cases
      Pandemic – worldwide epidemic
      Antigenic drift
      Changes in proteins by genetic point mutation & selection
      Ongoing and basis for change in vaccine each year
      Antigenic shift
      Changes in proteins through genetic reassortment
      Produces different viruses not covered by annual vaccine
    • Swine Flu
      Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs
    • Human Virus
      Avian Virus
      Reassorted Virus
      Swine Virus
      Transmission Through Species
      Reassortment in Pigs
    • Transmission to Humans
      Through contact with infected pigs or environments contaminated with swine flu viruses
      Through contact with a person with swine flu
      Human-to-human spread of swine flu has been documented also and is thought to occur in the same way as seasonal flu, through coughing or sneezing of infected people
    • Status Update
      GLOBALLY: March 1-December 06
      At least 9,596 Deaths
      Africa Region (AFRO): 109
      Americas Region (AMRO):
      Eastern Mediterranean Region (EMRO): 452
      Europe Region (EURO) :
      South-East Asia Region (SEARO): 814
      Western Pacific Region (WPRO) : 848
      Source: WHO
    • Swine Influenza A(H1N1)Global Confirmed Deaths, by Week
      As of December 18, 2009
      * Increase in number of deaths in week 43 due to aggregate reporting of fatal cases from Brazil (week 37-40) & due to batch report of US fatal cases since August 1, 2009
      Source: ECDC
    • North-East & South Asia Confirmed Deaths
      As of December 18, 2009
      Source: ECDC
    • Level of Threat
      The WHO raises the alert level to Phase 6
      WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3
      In Late April 2009 WHO announced the emergence of a novel influenza A virus
      April 27, 2009: Alert Level raised to Phase 4
      April 29, 2009: Alert Level raised to Phase 5
      June 11, 2008: Alert Level raised to Phase 6
      Source: WHO
    • Pathogenesis
    • Features
      Short incubation period, usually 1-4 days.
      Spread by respiratory droplets
      Person to person,
      Direct contact, rare aerosol
      Highly contagious
      infectious period:
      • Adults: 1 day prior to symptoms & 5 days post illness
      • Children: >10 days
      • Immune compromised shed virus for weeks to months
      Virus is detectable just before symptom onset.
      Usually not detectable after 5-10 days
    • The illness
    • Symptoms
      Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm
    • Signs and Complications
    • Signs of progressive illness
      • Persistent high fever beyond 3 days
      • Dyspnea, cyanosis
      • Bloody or coloured sputum, chest pain or low blood pressure
      • Dyspnea, tachypnea in children
      • Drowsiness, confusion or severe weakness
      • Dehydration, which can cause dizziness, decreased urine output or lethargy.
      • Diagnostic testing to confirm the pandemic virus should be prioritized for patients at higher risk for severe illness.
    • Attention
      Children younger than 2 years
      Persons aged 65 years or older
      Pregnant females
      Persons of any age with chronic medical or immunosuppressive conditions
      Persons younger than 19 years who are on chronic aspirin therapy.
    • Radiological Findings in Severe Disease
    • Indications for H1N1 Testing
      a. Radiographically confirmed pneumonia, acute respiratory distress syndrome, or other severe respiratory illness for which an alternate diagnosis has not been established,
      b. Stay or history of travel within 10 days of symptom onset to a place with documented influenza in animal and/or humans
    • Case Definitions
      A Case under Investigation
      Individual presenting with
      • A). High fever >38°C,
      • B). One or more of the respiratory symptoms
      • C). 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
    • Case Definitions (cont)
      Probable Case
      Defined as a suspected case, with an influenza test that is
      positive for influenza A
      Confirmed Case
      Laboratory confirmed Influenza A/H1N1 virus infection by
      • Real-time RT-PCR
      • Viral culture
      • 4-fold rise in H1N1 virus specific neutralizing antibodies
    • Available Diagnostic Tests1
      Source: CDC
    • How Severe It is…..????
      Initial estimates of mortality rates from H1N1 infection in Mexico ranged as high as 8%. This is a remarkably high mortality rate when viewed in the context of the 2% mortality rate during the 1918 Spanish Flu pandemic.
      Subsequent data from the United States and WHO indicated that the mortality rate from H1N1 infection was probably even lower than the mortality rate expected from seasonal flu.
      Data over the ensuing months have confirmed that overall mortality from H1N1 infection is less than 1% and may be less than 0.1%
    • Management
      Don’t get panic….Treat as simple RTI
      Bed rest, hydration, analgesic, cough suppressants
      Neuraminidase inhibitors
      Oseltamivir (Tamiflu)
      Zanamivir (Relenza)
      Adamantanes (Not used because of resistance)
    • Antiviral Treatment
      There are two flu antiviral drugs recommended
      Oseltamivir or Zanamivir
      Use of anti-virals can make illness milder and recovery faster
      They may also prevent serious flu complications
      For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms)
      Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing products (e.g. bismuth subsalicylate – Bismol) to children or teenagers (up to 18 years old) who are confirmed or suspected ill case of swine influenza A (H1N1) virus infection; this can cause a rare but serious Reye’s syndrome. For relief of fever, other anti-pyretic medicationsare recommended such as acetaminophen or non steroidal anti-inflammatory drugs.
      Treatment is recommended for:
      All hospitalized patients with confirmed, probable or suspected H1N1 cases.
      Patients who are at higher risk for seasonal influenza complications
      If patient is not in a high-risk group or is not hospitalized, healthcare providers should use clinical judgment to guide treatment decisions
      Source: CDC
    • Treatment Priority Groups
      Treatment is recommended for all outpatients with confirmed or
      suspected influenza if they belong to groups known to be at higher
      risk. These groups include:
      Children younger than 2 years;
      Persons aged 65 years or older;
      Pregnant females;
      Persons of any age with chronic medical or immunosuppressive conditions; and
      Persons younger than 19 years who are on chronic aspirin therapy.
    • Chemoprophylaxis
      • Antiviral Chemoprophylaxis
      • Post-exposure: can be considered in:
      • Close contacts of cases (confirmed, probable, or suspected)
      • Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person (confirmed, probable, or suspected) during that person’s infectious period.
      • Pre-exposure: Antivirals should only be used in limited circumstances, and in consultation with local medical or public health authorities.
      Source: CDC
    • Antiviral Protection
      Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatment dose for 5 days. <3 months: 12 mg twice daily; 3-5 months: 20 mg twice daily; 6-11 months: 25 mg twice daily
      Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. Recommended prophylaxis dose for 10 days. <3 months: Not recommended unless situation judged critical due to limited data on use in this age group; 3-5 months: 20 mg once daily; 6-11 months: 25 mg once daily
      Source: CDC
    • Management Issues
      ICU care
      Oseltamivir resistance has been an issue with seasonal influenza A infection and is beginning to emerge in pandemic H1N1.
      Zanamivir and asthma
      In Extracorporeal membrane oxygenation (ECMO) the patient's large vessels are cannulated, blood pumped through the a membrane that removes CO2 and adds O2, and then returned to the patient. ECMO has traditionally been used in neonates.
    • Vaccine Protection
      H1N1 vaccine available for since Mid-September
      H1N1 vaccine is not intended to replace the seasonal flu vaccine – it is intended to be used along-side seasonal flu vaccine
      Inactivated influenza virus vaccines
      CSL Ltd. of Australia
      Novartis Vaccines of Switzerland
      Sanofi Pasteur of France GlaxoSmithKline (GSK) of UK
      Sinovac Biotech of China
      Live-attenuated virus vaccine
      MedImmune LLC of US (nasal-spray)
    • Vaccine Protection
      Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
      Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus;
      Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
      All people from 6 months through 24 years of age
      Children from 6 months through 18 years of age because many cases of H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
      Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,
      Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
      Source: CDC
    • Other Preventive Steps
    • Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature*
      Hard non-porous surfaces 24-48 hours
      Plastic, stainless steel
      Recoverable for > 24 hours
      Transferable to hands up to 24 hours
      Cloth, paper & tissue
      Recoverable for 8-12 hours
      Transferable to hands 15 minutes
      Viable on hands <5 minutes only at high viral titers
      Potential for indirect contact transmission
      *Humidity 35-40%, Temperature 28C (82F)
      Source: Bean B, et al. JID 1982;146:47-51
    • Biosafety Guidelines
      Precautions include:
      Respiratory protection - fit-tested N95 respirator or higher level of protection
      Shoe covers
      Closed-front gown
      Double gloves
      Eye protection (goggles or face shields)
      All waste disposal procedures should be followed as outlined
      in your facility standard laboratory operating procedures
      Appropriate disinfectants
      70 per cent ethanol
      5 per cent Lysol
      10 per cent bleach
      Source: CDC
    • N95 Mask is effective but must be tight-fitting
    • All personnel should self monitor for fever and any symptoms. Symptoms of swine influenza infection include diarrhea, headache, runny nose, and muscle aches
      Any illness should be reported immediately
      For personnel who had unprotected exposure or a known breach in personal protective equipment to clinical material or live virus from a confirmed case of swine influenza A (H1N1), antiviral chemoprophylaxis with zanamivir or oseltamivir for 7 days after exposure can be considered
    • Infection Control in ill admitted Persons
      Patients with suspected or confirmed case-status should be placed in a single-patient room with the door kept closed.  If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling.
      The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons.
      Source: CDC
    • Infection Control in ill admitted Persons
      Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved.  Maintain adherence to hand hygiene by washing with soap and water or using hand sanitizerimmediately after removing gloves and other equipment and after any contact with respiratory secretions.
      Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure.
      Source: CDC
    • Guidelines for General Population
      Covering nose and mouth with a tissue when coughing or sneezing
      Dispose the tissue in the trash after use.
      Handwashing with soap and water
      Especially after coughing or sneezing.
      Cleaning hands with alcohol-based hand cleaners
      Avoiding close contact with sick people
      Avoiding touching eyes, nose or mouth with unwashed hands
      If sick with influenza, staying home from work or school and limit contact with others to keep from infecting them
    • Household Cleaning, Laundry, and Waste Disposal
      • 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 (esp bedside tables, surfaces in the bathroom, children’s toys, phone handles, doorknobs) clean by wiping them down with a household disinfectant .
      • 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.
      • Eating utensils should be washed either in a dishwasher or by hand with water and soap.
    • Summary
      • WHO raised the alert level to Phase 6 on June 11, 2009
      • As of December 6, 2009, worldwide more than 208 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including at least 9,596 deaths
      • Influenza transmission remains active in much of western and central Asia and there is evidence of pandemic virus circulation in most regions of Africa
      • The overall global case-fatality is ~1%
      • Symptoms mimic seasonal flu
      • 1:1 Male:Female Ratio
      • Globally
      • Number of deaths being reported is rising
      • Vaccine
      • Total Adverse Events: 5.4% (0.3% fatal)
      • Sanofi Pasteur vaccine recalled due to potency issues
      • Anti-virals (oseltamivir and zanamivir)
      • Oseltamivir resistance reported recently in immunocompromised patents
    • Panic and Fear are much dangerous than Swine Flu