swine flu: a comprehensive presentation

1. SWINE FLU:SWINE FLU:
EPIDEMIOLOGY,EPIDEMIOLOGY,
PREVENTION, CONTROLPREVENTION, CONTROL
&&
TREATMENTTREATMENT
Dr. R. S. MatoriaDr. R. S. Matoria
MBBS, MD (Psychiatry), MD (community Medicine)MBBS, MD (Psychiatry), MD (community Medicine)
Sr. Consultant: Psychiatry & Sr. Public Health ExpertSr. Consultant: Psychiatry & Sr. Public Health Expert
Central Hospital, NWR, Jaipur (India)Central Hospital, NWR, Jaipur (India)
drmatoria@gmail.comdrmatoria@gmail.com

2. • Can we pick them early before they turn
sick?
• Testing in few center’s-takes 4 days to get
results
• Do we start Tamiflu in all suspected cases?
• All flu…Tamiflu?
• Deterioration is occurring on 4th
day and
death on 7th
or 8th
day
Challenges We Face

3. • Swine flu negative cases are dying with similar
phenomenology?
• What is ILI??
• Swine flu or any other virus??
• To prevent epidemic or pandemic: “Prevention is
better than cure.” Are we able to practice same?
• Where do we stand?
Challenges We Face

4. Challenges We Face
• Whom to test?
• Recognition of disease
• Difficulty in Confirmation of disease
• Self protection
• Protection of people around us
• Vaccine for whom?
• Notification
• To know more : Are we facing the pandemic?

5. Scenario Questions
Challenges We Face

6. Subsequent challenges
• Recognising in OPD- identify flu symptoms,
travel history, clinical signs of hemodynamic
derangement &pneumonia/ALI/ARDS
• Proper referral to institutions handling cases
• Isolation rooms, Use of masks Hand wash
• Ventilatory management

7. Influenza At A Glance
• Influenza, commonly called "the flu," is caused by
viruses that infect the respiratory tract.
• Influenza viruses are divided into three types,
designated A, B, and C.
• Swine influenza is a respiratory disease of pigs.

8.  In 2009, North American swine influenza, North
American avian influenza, human influenza, and swine
influenza virus typically found in Asia and Europe
reassorted and formed a new subtype called H1N1.
 Influenza-like illness (ILI) is defined as fever
(temperature of 100ºF [37.8ºC] or greater) with cough or
sore throat in the absence of a known cause other than
influenza
 Sometimes the existing strains of virus combine to form
a new subtype. ( Antigenic Shift).
Influenza At A Glance

9. VARIATION
• Antigenic drift
• minor antigenic changes of HA and NA due to
point mutations.
• cause annual epidemics of influenza viruses
(seasonal influenza).
• Antigenic shift
• major antigenic changes of HA and NA due to
genetic reassortment between human and animal
influenza viruses.
• may cause periodic pandemics.

10. PIG: THE CREATOR
TYPES
•Susceptible pig cells possess receptors for both avian (alpha 2-3-linked
sialic acids) and human influenza strains (alpha 2-6-linked sialic acids),
which allow for the reassortment of influenza virus genes from different
species if a pig cell is infected with more than one strain.

11. QUADRUPLE REASSORTMENT GENETICS
• Human swine
• Avian swine
H1N1
H1N2
H3N1
H3N2
H1N1
(pandemics)
H3N2 (rare)
H5N1

12. PATHOGENESISPATHOGENESIS
TRANSMISSION
AEROSOLS
INFECTECT THE
RESPIRATORY
EPITHELIAL CELLS
Replication cycle
4 –6 h
Cell death
Necrosis,
apoptosis
Incubation
Period 1-4 days
SYMPTOMS

13. EPIDEMIOLOGY

14. PANDEMICSPANDEMICS
• New strains of influenza (people have no
immunity).
• Appears periodically.
• At irregular intervals.
• Affects vast number of people within short time
spans.
• Antigenic shift (genetic reassortment).
• Four pandemics in last 100 years.
• Current pandemic H1N1 started in 2009 in mexico.

15. EARTH LIVING SPACE FOR ALL
Epidemic: An increase in disease above what is normally expected
Pandemic: A worldwide epidemic
A pandemic begins when: there is person-to-person sustained
transmission on multiple continents
In the 20th century there have been three influenza pandemics in 1918,
1957 and 1968.

16. WHO:- 6 phases for alerting the general public to
an outbreak
•Phase 1 – animal to animal transmission.
•Phase 2 – an animal influenza virus is
capable of human infection.
•Phase 3 - small outbreaks among close
populations but not through human to human
contact.

17. • Phase 4 - Human to human transmission
• Phase 5 - spread across two countries or more
in one of the WHO regions (continents).
• Phase 6 – spread across two countries or more
in one of the WHO regions plus spread to
another WHO region.
• - African Region
• - Eastern Mediterranean Region
• - European Region
• - Region of the Americas
• - South-East Asian Region
• - Western Pacific Region

18. Transmission

19. COMMUNICABILITY: HOW LONG???
onset of
symptom
s
 The amount of virus shed is greatest in the first 2-3 days of illness and appears
to correlate with fever, with higher amounts of virus shed when temperatures
are highest.
 Children are contagious for longer periods.

20. Transmission: Mode of pandemic???
 PRIMARY CASE
SECONDARY CASES
sneezing, coughing, respsneezing, coughing, resp
droplets, body fluids (diarroealdroplets, body fluids (diarroeal
stool), contact surfacesstool), contact surfaces
direct contact with pigs
This virus is not transmitted from eating pork or pork products

21. Transmission: Environmental factors
• Tropics/ Sub tropics: epidemics
occur in
rainy season
• Overcrowding : Mostly affect urban
and peri-urban areas.
• Closed populations :High attack
rates may be witnessed in Army
Barracks, College hostels, Schools,
Residential hostels of schools,
aircrafts, ships etc

22. Close contacts:???
• Having cared for or lived with a person
• setting where there was a high likelihood of contact
with respiratory droplets and/or bodily fluids
• Having had close contact (kissing, embracing,
sharing eating or drinking utensils, physical
examination, or any other contact likely to result in
exposure to respiratory droplets)

23. Risk factors
• Age <5 years & >65 years
• COPD
• Immunocompromised state
• DM
• Pregnancy
• Cardiac disease
• Obesity
• Post transplant patients

24. SEASONAL INFLUENZA H1N1 INFLUENZA
AGE <5 YRS >60 YRS YOUNG & MIDDLE AGE
SEVERITY LESS SEVERE PNEUMONIA ARDS
MORBIDITY LESS MORE BUT >60 YRS LESS
LIKELY TO HAVE SEVERE
PNEUMONIA
SEASONAL INFLUENZA VS H1N1 INFLUENZA

25. SEASONAL INFLUENZA H1N1 INFLUENZA
SYMPTOMS RESPIRATORY RESPIRATORY &
GASTROINTESTINAL
SECONDARY
ATTACK RATE
5-15 % 22-33 %
VACCINE PROTECTIVE UNDER DEVELOPMENT
SEASONAL INFLUENZA VS H1N1 INFLUENZA

26. How Does Human Flu & Animal Flu Spread?
HUMAN FLU(H1N1)
•Droplet transmission.
•Coughing or sneezing.
•Transmission can also occur by
touching a surface contaminated with
respiratory secretions and then putting
the fingers in the mouth or nose or
near the eyes.
•The flu virus can live on a hard surface
for upto 24 hours and on a soft surface
for around 20 minutes.
ANIMAL FLU
•Avian influenza virus(H5N1)
and swine influenza virus.
•Distinct from human influenza
viruses.
•Do not easily transmit between
humans.
•Has passed to humans only via
direct contact with animals.

27. Difference Between
HUMAN FLU (H1N1) & BIRD FLU(H5N1)

28. Management:
Strategies

29. CLINICAL FEATURES
 Influenza illness typically
resolves within 1 week.
 Cough and malaise can
persist for more than 2
weeks.

30. Other Manifestations
• Tachycardia
• Tachypnoea
• Low O2 sat.
• Hypotension
• Cyanosis
• Acute myocarditis
• Cardiopulmonary arrest

31. Children Clinical Presentation
• Infants may present with fever and lethargy, and
may not have cough or other respiratory
symptoms.
• Apnea, tachypnea, dyspnea, cyanosis,
dehydration, altered mental status, and extreme
irritability.

32. Children Emergency Warning Signs
• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be
held
• Flu-like symptoms improve but then return with
fever and worse cough

33. Adults Emergency Warning Signs
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with
fever and worse cough

34. Why Complications In young
(Cytokine storm)
• It is the systemic expression of a healthy and vigorous
immune system resulting in the release of more than
150 inflammatory mediators .
• Both pro and anti-inflammatory cytokines are elevated
in serum with lethal interplay of these cytokines is
referred to as a "Cytokine Storm".
• The primary contributors to the cytokine storm are
TNF-a and IL-6 .
• It is inappropriate (exaggerated) immune response
that is caused by rapidly proliferating and highly
activated T-cells or natural killer (NK) cells.
• Bird flu patients die from acute respiratory distress
syndrome (ARDS) caused by the cytokine storm, and
not directly from the virus

35. SYMPTOMS OF THE CYTOKINE STORM
The final result, of cytokine storm or sepsis is multiple
organ dysfunction syndrome (MODS):
• hypotension ( Myocarditis)
• tachycardia
• ARDS acute respiratory failure
• Ischemia, or insufficient tissue perfusion
• uncontrollable haemorrhage
• Multisystem organ failure

36. Cytokine Storm Treatment
• Steroids
• ACE Inhibitors & ARBs
• Anti-CD28 Monoclonal Antibody
• TNF-alpha blockers

37. CLINICAL CASE DESCRIPTION
• Acute febrile respiratory illness (fever >38°C) with the
spectrum of disease from influenza-like illness to pneumonia.
1. Suspected case of Pandemic Influenza:
Individuals presenting with acute febrile respiratory illness (fever >38 °C)
with the spectrum of disease from influenza-like illness (cough, sore
throat, shortness of breath) to pneumonia With or Without One of the
following-
Epidemiological risk factors:
• Close contact* to a suspected case of pandemic influenza A(H1N1)
virus infection while the case was ill
• Recent travel to an area where there are confirmed cases of pandemic
influenza A (H1N1)
*Close contact: having cared for, lived with, or had direct contact with respiratory
secretions or body fluids of a probable or confirmed case of pandemic influenza
A(H1N1).

38. 2. A Probable case of pandemic influenza:
A(H1N1) virus infection is defined as an individual with an
influenza test that is positive for influenza A, but is
unsubtypable by reagents used to detect seasonal influenza
virus infection
3. A Confirmed case of pandemic influenza:
A(H1N1) virus infection is defined as an individual with
laboratory confirmed pandemic influenza A(H1N1) virus
infection by one or more of the following tests:
• real-time (RT) – PCR
• viral culture
• four-fold rise in novel influenza A(H1N1) virus specific neutralizing
antibodies
CLINICAL CASE DESCRIPTIONS

39. LABORATORY FINDINGS
• CBC- leucocytosis/leucopenia
lymphopenia
• Elevated CPK, LDH
• Elevated UREA,CREATININE
• Elevated AST,ALT
• CHEST RADIOGRAPH-bilateral patchy
pneumonia.

40. DIAGNOSTIC TESTS
RT PCRRT PCR
QUIDELQUIDEL
CULTURECULTURE
DFA/IFADFA/IFA

41. Specimens & Sample Collection
 Before administration of anti viral drugs.
 Respiratory specimen should be collected within 4 to 5
days of illness.
 Nasopharyngeal swab, nasal swab, throat swab,
combined oropharyngeal/ nasopharyngeal swab, or
nasal aspirate (intubated)
 Swabs with a synthetic tip (eg, polyester or Dacron) and
an aluminum or plastic shaft should be used. Swabs with
cotton tips and wooden shafts are not recommended.
 The collection vial in which the swab is placed should
contain 1 to 3 mL of viral transport media.

42.  Specimens should be placed in viral transport
media and placed on ice (4ºC) or refrigerated
immediately for transportation to the laboratory
within 24 hours.
 If not possible, Store at –700
C

43. LAB TESTS
• Real time RT PCR (4 hours) -confirmatory
• culture is usually too slow to help guide clinical management.
A negative viral culture does not exclude pandemic H1N1
influenza A infection.
• Rapid antigen tests — evaluation of patients suspected of
having influenza, but results should be interpreted with
caution (sensitivity 51 percent specificity 99 percent)
• Rapid influenza antigen tests & Direct or indirect
immunofluorescent antibody testing (DFA or IFA) can
distinguish between influenza A and B but negative test
does not exclude infection.

44. Whom to test
• Testing for pandemic H1N1 influenza A should
be considered in individuals with an acute febrile
respiratory illness ( temperature of 100ºF or
higher and recent onset of at least one of the
following:
• Rhinorrhea,
• Nasal congestion,
• Sore throat, or cough
• or sepsis-like syndrome

45. Priority for testing should be given to :
Those who require hospitalization and
Those who are at high risk for severe
complications
No testing if illness is mild or the person resides
in an area with confirmed cases
Recommended test for suspected cases is real-
time reverse transcriptase (RT)-PCR for
influenza A, B, H1, and H3
Whom to test

46. Can we make a broad clinical check list???
• History of contact
• Younger age, sudden onset
• Fever, cough, breathlessness
• Leucopenia, raised LDH and CPK
• Should all such patients be isolated and
given Tamiflu?
Whom to test

47. Cat. Features Management
A Mild fever + Cough or sorethroat
± bodyache, headache, diarrhea, vomiting
• No testing
• Does not require oseltamivir
• Monitor and reassess (24-
48hr)
B CAT A + any of
B1-High grade fever, Severe sore throat.
B2-Children with predisposing factors,
Pregnant women , >65, Comorbids,
Immunocompromised.
• No testing
• Home isolation
• Oseltamivir
• Broad spectrum antibiotics
for CAP
C CAT A + CAT B + one or more of
1.Breathlessness, chest pain, drowsiness,
hypotension, hemoptysis, cyanosis
2.Children with Somnolence, high and
persistent fever, inability to feed well,
convulsions, dyspnea.
3.Worsening of underlying chronic
conditions.
•Testing
• Immediate
hospitalization &
treatment.
CATEGORIZATION: MANAGEMENT

48. TREATMENT
Age Group/Body weight Treatment
(5 days)
Chemoprophylaxis
(10 days)
Infants (below 12 months):
3 mg/kg/dose
Oseltamivir-tablet or syrup (6mg /
ml)
Dose
Oseltamivir-tablet or syrup (6mg /
ml)
Dose
< 3 months 12 mg two times daily 12 mg once daily
3 – 5 months 20 mg two times daily 20 mg once daily
6 – 11 months 25 mg two times daily 25 mg once daily
Children: 12 months & above age
group
< 15 kg 30 mg two times daily 30 mg once daily
15 – 23 kg 45 mg two times daily 45 mg once daily
24 – 40 kg 60 mg two times daily 60 mg once daily
> 40 kg 75 mg two times daily 75 mg once daily
Adult: 75 mg two times daily 75 mg once daily
Oseltamivir should be given within 24-48 hrs.

49. CDC RECOMMANDATIONS
 Oral oseltamivir is approved by the FDA for treatment of acute
uncomplicated influenza with twice-daily dosing in persons 14 days and
older, and for chemoprophylaxis with once-daily dosing in persons 1
year and older.
 Although not part of the FDA approved indications, use of oral
oseltamivir for treatment of influenza in infants less than 14 days old,
and for chemoprophylaxis in infants 3 months to 1 year of age, is
recommended by the CDC and the American Academy of Pediatrics
(Committee on Infectious Diseases, 2014)

50. Who should receive prophylaxis?
• Those prone to get severe influenza.
• Women who are pregnant or postpartum(within 2
weeks after delivery)
• Persons aged younger than 19 years who are
receiving long term aspirin therapy
• All hospitalized patients with influenza.

51.  Recommended duration is 7 days (after last known
exposure).
 For control of outbreaks in institutional settings (e.g.
long-term care facilities for elderly persons and children)
and hospitals.
 CDC recommends antiviral chemoprophylaxis for a
minimum of 2 weeks, and continuing up to 1 week after
the last known case was identified.
 Antiviral chemoprophylaxis is recommended for all
residents, including those who have received influenza
vaccination, and for unvaccinated institutional
employees
Who should receive prophylaxis?

52. OSELTAMIVIR
If one dose missed?
 Take as soon as you remember unless it is within 2 hours of next
dose
 Do not take two doses at a time
With other medications?
minimal drug interaction
No intranasal flu vaccine(Flu Mist) within 2weeks before or 48
after taking tamiflu

53. Tamiflu (Contd)
With kidney disease:
 Flu treatment :one 75mg dose OD for 5 days
 Flu prevention:one 75 mg dose alternate day or 30 mg
dose OD
If child is younger than 3 months old, use of
oseltamivir for chemoprophylaxis is not
recommended unless situation is judged critical due
to limited data in this age group
Storage:
capsules- <25 degree C
liquid - 2 to 8 degree C

54. Adverse reactions of Oseltamivir
 No recommendation for dose
reduction in hepatic disease.
 Dosage modification should be done
in renal impairment
Common Nausea, Vomiting
Occasionally Bronchitis, Insomnia, Vertigo
Less commonly Angina, Psuedomembranous colitis,
Peritonsillar abscess
Rare Anaphylaxis, Skin rashes

55. Zanamivir ( Relenza)
– Dry powder inhalation
– Not effective in children
– It is not recommended for people with
underlying respiratory disease such as asthma
or chronic obstructive pulmonary disease or
lactose intolerance
– Treatment of 7 year & older patients 10mg
(2puffs)BID 5d
– Prophylaxis of 5 year & older patients 10mg OD
10d-28 days

56. Other drugs…
• Peramivir (Rapivap, Rapiacta, Peramiflu) :
– Only Intravenous drug available for Swine flu
– FDA approved for adults
– Single dose of 600 mg given.($ 950)
• M2 Inhibitors – Amantadine, Rimantadine
– Developed resistance.
– No longer recommended by CDC.
• Laninamivir– Phase III trials, Approved in Japan (Inavir)

57. Supportive Therapy
• IV fluids, Parenteral Nutrition
• O2 / Ventilatory support
• Antibiotics, Vasopressors (shock)
• PCM – fever, myalgia, headache
• Plenty of fluids
• If SpO2
< 90% and PaO2
< 60 mmHg – Mechanical
Ventilation
Preferred – Invasive
• High dose corticosteroids – No benefit, Potential harm
• Low dose ( Hydrocortisone 200 – 400 mg / day) – in
persistent septic shock
• SALICYLATES are CONTRAindicated – REYE syndrome

58. Ventilator Protocol
• Pressure pre-set (controlled)
• Low tidal volume ventilator
support
• Tidal volume — 6 ml/kg ideal
body weight (Respiratory rate to
a maximum of 30-
35 per minute).
• Open lung strategy of ventilation
– PEEP titration to keep the lung
recruited to achieve an FIO2 of <
0.5 and a saturation of > 90% or a
PaO2 of > 60 mmHg
• Plateau (Pause) pressure not to
exceed of > 30-35 mmHg.
• APRV (Airway Pressure Release
Ventilation), IRV (Inverse Ratio
Ventilation) in patients with
persistent Hypoxemia.

59. Complications
• Sinus / Ear infections
• Bacterial pneumonia (MRSA,MSSA,Group A strep)
• Bronchiolitis, Croup, Diarrhea
• Febrile seizures
• Rhabdomyolysis
• Encephalopathy / Encephalitis
• Myocarditis, Pericarditis
• Exacerbation of chronic illness (COPD, Diabetes,
Coronary artery disease)
• Reye syndrome
• Toxic shock syndrome
• Sudden death

60. H1 N1 Pneumonia

61. Discharge Policy
• Adults – 7 days after symptoms have
subsided.
• Children – 14 days after symptoms have
subsided.

62. prevention

63. It is highly contagious!
• Can we have separate wards ,ICU’s and staffing
• We require separate OPD and testing facilities
for suspected cases
• Can we spare separate equipment
• Can we organise all this in a running hospital?

64. Infection control measures
• Frequent hand washing of
personnel and contacts.
• Cough etiquettes and maintain
arms length distance from others.
• Dedicated doctors, nurses and
paramedical workers.
• Portable X Ray machine,
ventilators, large oxygen cylinders,
pulse oxymeter and other
supportive equipments
• Adequate disinfectants and
medications

65. Contd..
• Use of face masks
• Isolation room or beds one meter apart.
• All those entering room wear protective
gear.
• Prophylaxis to health care personnel.
• Waste disposal in biohazard labeled
bags.
• Contact surfaces – wipe with sodium
hypochlorite or 5% bleach

66. Avoid close contact
• Avoid close contact
with people who are
sick. When you are
sick, keep your
distance ( > 1 meter )
from others to protect
them from getting sick
too.
• Aerosols spread the
virus in any
environment

67. What kills influenza virus?
• Influenza virus is destroyed by
– Heat (167-212°F [75-100°C]).
– In addition, several chemical germicides,
including chlorine, hydrogen peroxide,
detergents (soap), iodophors (iodine-based
antiseptics), and alcohols

68. Use of face mask

69. N95 Mask: HOW TO APPLY

70. For General Public…….
• No scientific evidence to show health
benefit of using triple layer masks for
members of public.
• Erroneous use of masks or continuous use
of a disposable mask for longer than 6
hours or repeated use of same mask may
actually increase risk of infection further.

71. SOME SIMPLE MEASURES
 The only portals of entry are the nostrils and
mouth/throat. In a global epidemic of this nature, it's
almost impossible to avoid coming into contact with
H1N1 in spite of all precautions. Contact with H1N1 is
not so much of a problem as proliferation is.
 While you are still healthy and not showing any
symptoms of H1N1 infection, in order to prevent
proliferation, aggravation of symptoms and development
of secondary infections, some very simple steps, can be
practiced (instead of focusing on how to stock N95 or
Tamiflu):

72. Don't underestimate these simple, inexpensive
and powerful preventative methods.
•1. Frequent hand-washing (well highlighted in
all official communications).
•2. "Hands-off-the-face" approach. Resist all
temptations to touch any part of face (unless
you want to eat, bathe or slap).
SOME SIMPLE MEASURES

73. • 3. * Gargle twice a day with warm salt water (use Listerine if
you don't trust salt)... * H1N1 takes 2-3 days after initial
infection in the throat/ nasal cavity to proliferate and show
characteristic symptoms. Simple gargling prevents
proliferation. In a way, gargling with salt water has the same
effect on a healthy individual that Tamiflu has on an infected
one.
• 4. Similar to 3 above, * clean your nostrils at least once
every day with warm salt water. * Not everybody may be
good at Jala Neti or Sutra Neti (very good Yoga asanas to
clean nasal cavities), but * blowing the nose hard once a day
and swabbing both nostrils with cotton buds dipped in warm
salt water is very effective in bringing down viral population. *
SOME SIMPLE MEASURES

74. • 5. * Boost your natural immunity with foods that are rich
in Vitamin C (Amla and other citrus fruits). * If you have
to supplement with Vitamin C tablets, make sure that it
also has Zinc to boost absorption.
• 6. * Drink as much of warm liquids (tea, coffee, etc) as
you can. * Drinking warm liquids has the same effect as
gargling, but in the reverse direction. They wash off
proliferating viruses from the throat into the stomach
where they cannot survive, proliferate or do any harm.
SOME SIMPLE MEASURES

75. Preventive care for contacts
• OD dose of Oseltamivir according to body weight
till 10 days after last exposure ( Upto 6 weeks)
• Not recommended for infants < 3 months

76. • Trivalent influenza vaccine lends protection against
swine flu, H3N2 and influenza B viruses
• Inactivated trivalent vaccine (SC/IM) .
• Takes about 2 – 3 weeks to develop immunity.
• The efficacy of swine flu vaccine is about 80%, but
even then it is advisable because it lends
protection to the vaccinated population from a
potentially fatal disease.“
• Contraindicated in Egg allergy and GBS.
• In India, Influgen (Lupin), Costs 720.₹
• Also Vaxigrip (Sanofi Pasteur), Costs 550₹
Vaccination

77. Vaccination(H3, H1, and B strains )Vaccination(H3, H1, and B strains )
• American ACIP-universal influenza vaccination above
the age 6 months.(<6months-vaccinte the care givers
and parents)
• IAP –High risk children.
• If there is an outbreak of influenza epidemic then in health
care workers and travelers.
• Can also be given to healthy children after discussion with
the doctor.
• All pregnant women- injectable influenza vaccine as
influenza in pregnancy leads to complications.
High risk children-
Immunocompromised, Asthmatics,Heart disease, Kidney
disease,Liver disease, Diabetes mellitus, Cerebral palsy.

78. Types of vaccinesTypes of vaccines
• Trivalant and quadravalant vaccines are
available.
• Two types of vaccines
• Inactivated vaccine(injection form).
• Live viral vaccine(nasal).
• The injectable vaccine is preferred in
high risk children, in pregnant
women, and in children less than 2
years of age.
VACCINE CHANGES EVERY YEAR

79. SCHEDULE FOR VACCINATIONSCHEDULE FOR VACCINATION
• 6months to 9 years of age- 2 doses 1 month
apart.
• Above 9 years – 1 dose.
• subsequent every year.
• From 6 months to 2 years of age- injectable
vaccine is preferred not the live nasal vaccine.

80. • Vaccination should occur before onset of influenza activity in
the community
• We live in a tropical region, which sees very irregular
influenza activity, so we cannot firmly say how long the
current outbreak situation will last.
• A vaccine-induced immunity lasts for eight to 12 months.
• Taking a flu shot in May is more advisable as it will cover two
periods of heightened influenza activity, which is seen in July-
August during monsoon and December-January during
winter.
WHEN TO VACCINATE???

81. • Not everybody
• Prioritized groups:
 Heath Care Workers – Medical and paramedical staff in
Casualty, ICU, Isolation ward, Screening centers.
 All pregnant women.
 Chronic illnesses- chronic respiratory, cardiovascular
problems, diabetes, kidney patients
 post-transplant patients
 > 65 years, 4 months – 5 years.
 pregnant and post-partum women
 * Foreign nationals planning to travel to the city
Vaccine for whom???

82. Why do we need vaccine
COST EFFECTIVE
TARGET AT RISK
PEOPLE
VACCINE
WINTER SEASON
TO COME(LOW
HUMIDITY,TEMP)
RAPID GLOBAL
SPREAD
SEASONAL
VACCINE
PROTECTION?

83. TAKE HOME MESSAGE:TAKE HOME MESSAGE:
PROTECTION AGAINST INFLUENZAPROTECTION AGAINST INFLUENZA
• AVOID CLOSE CONTACT WITH INFECTED
PERSONS.
• STAY HOME WHEN SICK.
• COVER YOUR MOUTH AND NOSE WITH A
TISSUE WHEN COUGHING OR SNEEZING.
• HAND WASHING.

84. CONCLUSION
• Be cautious but no need to panic
• Need for further guidelines beyond diagnosis &
management.
• Judicious use of diagnostic tests
• Early suspecting and treating cytokine storm is
very important
• Not to forget universal precautions