Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
SWINE FLU:SWINE FLU:
EPIDEMIOLOGY,EPIDEMIOLOGY,
PREVENTION, CONTROLPREVENTION, CONTROL
&&
TREATMENTTREATMENT
Dr. R. S. Mat...
• Can we pick them early before they turn
sick?
• Testing in few center’s-takes 4 days to get
results
• Do we start Tamifl...
• Swine flu negative cases are dying with similar
phenomenology?
• What is ILI??
• Swine flu or any other virus??
• To pre...
Challenges We Face
• Whom to test?
• Recognition of disease
• Difficulty in Confirmation of disease
• Self protection
• Pr...
Scenario Questions
Challenges We Face
Subsequent challenges
• Recognising in OPD- identify flu symptoms,
travel history, clinical signs of hemodynamic
derangeme...
Influenza At A Glance
• Influenza, commonly called "the flu," is caused by
viruses that infect the respiratory tract.
• In...
 In 2009, North American swine influenza, North
American avian influenza, human influenza, and swine
influenza virus typi...
VARIATION
• Antigenic drift
• minor antigenic changes of HA and NA due to
point mutations.
• cause annual epidemics of inf...
PIG: THE CREATOR
TYPES
•Susceptible pig cells possess receptors for both avian (alpha 2-3-linked
sialic acids) and human i...
QUADRUPLE REASSORTMENT GENETICS
• Human swine
• Avian swine
H1N1
H1N2
H3N1
H3N2
H1N1
(pandemics)
H3N2 (rare)
H5N1
PATHOGENESISPATHOGENESIS
TRANSMISSION
AEROSOLS
INFECTECT THE
RESPIRATORY
EPITHELIAL CELLS
Replication cycle
4 –6 h
Cell de...
EPIDEMIOLOGY
PANDEMICSPANDEMICS
• New strains of influenza (people have no
immunity).
• Appears periodically.
• At irregular intervals....
EARTH LIVING SPACE FOR ALL
Epidemic: An increase in disease above what is normally expected
Pandemic: A worldwide epidemic...
WHO:- 6 phases for alerting the general public to
an outbreak
•Phase 1 – animal to animal transmission.
•Phase 2 – an anim...
• Phase 4 - Human to human transmission
• Phase 5 - spread across two countries or more
in one of the WHO regions (contine...
Transmission
COMMUNICABILITY: HOW LONG???
onset of
symptom
s
 The amount of virus shed is greatest in the first 2-3 days of illness an...
Transmission: Mode of pandemic???
 PRIMARY CASE
SECONDARY CASES
sneezing, coughing, respsneezing, coughing, resp
droplet...
Transmission: Environmental factors
• Tropics/ Sub tropics: epidemics
occur in
rainy season
• Overcrowding : Mostly affect...
Close contacts:???
• Having cared for or lived with a person
• setting where there was a high likelihood of contact
with r...
Risk factors
• Age <5 years & >65 years
• COPD
• Immunocompromised state
• DM
• Pregnancy
• Cardiac disease
• Obesity
• Po...
SEASONAL INFLUENZA H1N1 INFLUENZA
AGE <5 YRS >60 YRS YOUNG & MIDDLE AGE
SEVERITY LESS SEVERE PNEUMONIA ARDS
MORBIDITY LESS...
SEASONAL INFLUENZA H1N1 INFLUENZA
SYMPTOMS RESPIRATORY RESPIRATORY &
GASTROINTESTINAL
SECONDARY
ATTACK RATE
5-15 % 22-33 %...
How Does Human Flu & Animal Flu Spread?
HUMAN FLU(H1N1)
•Droplet transmission.
•Coughing or sneezing.
•Transmission can al...
Difference Between
HUMAN FLU (H1N1) & BIRD FLU(H5N1)
Management:
Strategies
CLINICAL FEATURES
 Influenza illness typically
resolves within 1 week.
 Cough and malaise can
persist for more than 2
we...
Other Manifestations
• Tachycardia
• Tachypnoea
• Low O2 sat.
• Hypotension
• Cyanosis
• Acute myocarditis
• Cardiopulmona...
Children Clinical Presentation
• Infants may present with fever and lethargy, and
may not have cough or other respiratory
...
Children Emergency Warning Signs
• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough f...
Adults Emergency Warning Signs
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• ...
Why Complications In young
(Cytokine storm)
• It is the systemic expression of a healthy and vigorous
immune system result...
SYMPTOMS OF THE CYTOKINE STORM
The final result, of cytokine storm or sepsis is multiple
organ dysfunction syndrome (MODS)...
Cytokine Storm Treatment
• Steroids
• ACE Inhibitors & ARBs
• Anti-CD28 Monoclonal Antibody
• TNF-alpha blockers
CLINICAL CASE DESCRIPTION
• Acute febrile respiratory illness (fever >38°C) with the
spectrum of disease from influenza-li...
2. A Probable case of pandemic influenza:
A(H1N1) virus infection is defined as an individual with an
influenza test that ...
LABORATORY FINDINGS
• CBC- leucocytosis/leucopenia
lymphopenia
• Elevated CPK, LDH
• Elevated UREA,CREATININE
• Elevated A...
DIAGNOSTIC TESTS
RT PCRRT PCR
QUIDELQUIDEL
CULTURECULTURE
DFA/IFADFA/IFA
Specimens & Sample Collection
 Before administration of anti viral drugs.
 Respiratory specimen should be collected with...
 Specimens should be placed in viral transport
media and placed on ice (4ºC) or refrigerated
immediately for transportati...
LAB TESTS
• Real time RT PCR (4 hours) -confirmatory
• culture is usually too slow to help guide clinical management.
A ne...
Whom to test
• Testing for pandemic H1N1 influenza A should
be considered in individuals with an acute febrile
respiratory...
Priority for testing should be given to :
Those who require hospitalization and
Those who are at high risk for severe
comp...
Can we make a broad clinical check list???
• History of contact
• Younger age, sudden onset
• Fever, cough, breathlessness...
Cat. Features Management
A Mild fever + Cough or sorethroat
± bodyache, headache, diarrhea, vomiting
• No testing
• Does n...
TREATMENT
Age Group/Body weight Treatment
(5 days)
Chemoprophylaxis
(10 days)
Infants (below 12 months):
3 mg/kg/dose
Osel...
CDC RECOMMANDATIONS
 Oral oseltamivir is approved by the FDA for treatment of acute
uncomplicated influenza with twice-da...
Who should receive prophylaxis?
• Those prone to get severe influenza.
• Women who are pregnant or postpartum(within 2
wee...
 Recommended duration is 7 days (after last known
exposure).
 For control of outbreaks in institutional settings (e.g.
l...
OSELTAMIVIR
If one dose missed?
 Take as soon as you remember unless it is within 2 hours of next
dose
 Do not take two ...
Tamiflu (Contd)
With kidney disease:
 Flu treatment :one 75mg dose OD for 5 days
 Flu prevention:one 75 mg dose alternat...
Adverse reactions of Oseltamivir
 No recommendation for dose
reduction in hepatic disease.
 Dosage modification should b...
Zanamivir ( Relenza)
– Dry powder inhalation
– Not effective in children
– It is not recommended for people with
underlyin...
Other drugs…
• Peramivir (Rapivap, Rapiacta, Peramiflu) :
– Only Intravenous drug available for Swine flu
– FDA approved f...
Supportive Therapy
• IV fluids, Parenteral Nutrition
• O2 / Ventilatory support
• Antibiotics, Vasopressors (shock)
• PCM ...
Ventilator Protocol
• Pressure pre-set (controlled)
• Low tidal volume ventilator
support
• Tidal volume — 6 ml/kg ideal
b...
Complications
• Sinus / Ear infections
• Bacterial pneumonia (MRSA,MSSA,Group A strep)
• Bronchiolitis, Croup, Diarrhea
• ...
H1 N1 Pneumonia
Discharge Policy
• Adults – 7 days after symptoms have
subsided.
• Children – 14 days after symptoms have
subsided.
prevention
It is highly contagious!
• Can we have separate wards ,ICU’s and staffing
• We require separate OPD and testing facilities...
Infection control measures
• Frequent hand washing of
personnel and contacts.
• Cough etiquettes and maintain
arms length ...
Contd..
• Use of face masks
• Isolation room or beds one meter apart.
• All those entering room wear protective
gear.
• Pr...
Avoid close contact
• Avoid close contact
with people who are
sick. When you are
sick, keep your
distance ( > 1 meter )
fr...
What kills influenza virus?
• Influenza virus is destroyed by
– Heat (167-212°F [75-100°C]).
– In addition, several chemic...
Use of face mask
N95 Mask: HOW TO APPLY
For General Public…….
• No scientific evidence to show health
benefit of using triple layer masks for
members of public.
•...
SOME SIMPLE MEASURES
 The only portals of entry are the nostrils and
mouth/throat. In a global epidemic of this nature, i...
Don't underestimate these simple, inexpensive
and powerful preventative methods.
•1. Frequent hand-washing (well highlight...
• 3. * Gargle twice a day with warm salt water (use Listerine if
you don't trust salt)... * H1N1 takes 2-3 days after init...
• 5. * Boost your natural immunity with foods that are rich
in Vitamin C (Amla and other citrus fruits). * If you have
to ...
Preventive care for contacts
• OD dose of Oseltamivir according to body weight
till 10 days after last exposure ( Upto 6 w...
• Trivalent influenza vaccine lends protection against
swine flu, H3N2 and influenza B viruses
• Inactivated trivalent vac...
Vaccination(H3, H1, and B strains )Vaccination(H3, H1, and B strains )
• American ACIP-universal influenza vaccination abo...
Types of vaccinesTypes of vaccines
• Trivalant and quadravalant vaccines are
available.
• Two types of vaccines
• Inactiva...
SCHEDULE FOR VACCINATIONSCHEDULE FOR VACCINATION
• 6months to 9 years of age- 2 doses 1 month
apart.
• Above 9 years – 1 d...
• Vaccination should occur before onset of influenza activity in
the community
• We live in a tropical region, which sees ...
• Not everybody
• Prioritized groups:
 Heath Care Workers – Medical and paramedical staff in
Casualty, ICU, Isolation war...
Why do we need vaccine
COST EFFECTIVE
TARGET AT RISK
PEOPLE
VACCINE
WINTER SEASON
TO COME(LOW
HUMIDITY,TEMP)
RAPID GLOBAL
...
TAKE HOME MESSAGE:TAKE HOME MESSAGE:
PROTECTION AGAINST INFLUENZAPROTECTION AGAINST INFLUENZA
• AVOID CLOSE CONTACT WITH I...
CONCLUSION
• Be cautious but no need to panic
• Need for further guidelines beyond diagnosis &
management.
• Judicious use...
Upcoming SlideShare
Loading in …5
×

Swineflu dr rs matoria

656 views

Published on

swine flu: a comprehensive presentation

Published in: Health & Medicine
  • Login to see the comments

Swineflu dr rs matoria

  1. 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. 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. 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. 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. 5. Scenario Questions Challenges We Face
  6. 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. 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. 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. 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. 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. 11. QUADRUPLE REASSORTMENT GENETICS • Human swine • Avian swine H1N1 H1N2 H3N1 H3N2 H1N1 (pandemics) H3N2 (rare) H5N1
  12. 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. 13. EPIDEMIOLOGY
  14. 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. 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. 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. 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. 18. Transmission
  19. 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. 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. 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. 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. 23. Risk factors • Age <5 years & >65 years • COPD • Immunocompromised state • DM • Pregnancy • Cardiac disease • Obesity • Post transplant patients
  24. 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. 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. 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. 27. Difference Between HUMAN FLU (H1N1) & BIRD FLU(H5N1)
  28. 28. Management: Strategies
  29. 29. CLINICAL FEATURES  Influenza illness typically resolves within 1 week.  Cough and malaise can persist for more than 2 weeks.
  30. 30. Other Manifestations • Tachycardia • Tachypnoea • Low O2 sat. • Hypotension • Cyanosis • Acute myocarditis • Cardiopulmonary arrest
  31. 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. 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. 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. 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. 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. 36. Cytokine Storm Treatment • Steroids • ACE Inhibitors & ARBs • Anti-CD28 Monoclonal Antibody • TNF-alpha blockers
  37. 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. 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. 39. LABORATORY FINDINGS • CBC- leucocytosis/leucopenia lymphopenia • Elevated CPK, LDH • Elevated UREA,CREATININE • Elevated AST,ALT • CHEST RADIOGRAPH-bilateral patchy pneumonia.
  40. 40. DIAGNOSTIC TESTS RT PCRRT PCR QUIDELQUIDEL CULTURECULTURE DFA/IFADFA/IFA
  41. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 60. H1 N1 Pneumonia
  61. 61. Discharge Policy • Adults – 7 days after symptoms have subsided. • Children – 14 days after symptoms have subsided.
  62. 62. prevention
  63. 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. 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. 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. 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. 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. 68. Use of face mask
  69. 69. N95 Mask: HOW TO APPLY
  70. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

×