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H1 n1 swine flu

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H1 n1 swine flu

  1. 1. SWINE FLU By Dr. Ashish kumar Santosh Hospital , Chest and T.B dept.
  2. 2. SWINE FLU  Introduction  Epidemiology  Sign and symptom  Diagnosis  Prevention  Treatment  Vaccination  Guidelines on Infection control Measures
  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. 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.
  5. 5. COUNTRIES AFFECTED TILL NOW
  6. 6. SEASONAL INFLUENZA COMPARED TO PANDEMIC — PROPORTIONS OF TYPES OF CASES 7 Asymptomatic Clinical symptoms Deaths Requiring hospitalisation Seasonal influenza Pandemic Asymptomatic Clinical symptomsDeaths Requiring hospitalisation
  7. 7. 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 %
  8. 8. 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.)
  9. 9. 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.
  10. 10. 13 SUBTYPE VIRAL STRUCTURE/CARRIERS http://www-ermm.cbcu.cam.ac.uk/01002460a.pdf  Humans  Swine  Birds  Horses  Seals Type A  Humans Type C Type B  Humans  Swine
  11. 11. ORTHOMYXOVIRUSES 80-200nm M1 protein helical nucleocapsid (RNA plus NP protein) HA - hemagglutinin –attaches to sialic Acid receptor polymerase complex lipid bilayer membrane NA – neuraminidase-helps in Budding out of infected cell type A, B, C : NP, M1 protein sub-types: HA or NA protein
  12. 12. INFLUENZA -A  Two proteins on the surface of the virus  Hemagglutinin (H)  16 subtypes  Neuraminidase (N)  09 subtypes
  13. 13. GENETIC CHANGES IN THE FLU VIRUS – WHAT THIS MEANS Changes in the surface antigens (H and N) result in the flu virus constantly changing • antigenic drift: minor changes (natural mutations) in the genes of flu viruses that occur gradually over time  antigenic shift: when two or more different strains combine. This abrupt major change results in a new subtype. Immunity from previous flu infections/vaccinations may not protect against the new subtype, potentially leading to a widespread epidemic or pandemic Because of the changing nature of flu viruses, WHO monitors their epidemiology throughout the world. Each year WHO makes recommendations about the strains of influenza A and B which are predicted to be circulating in the forthcoming winter. These strains are then included in the flu vaccine developed each year 18
  14. 14. ANTIGENIC DRIFT  Gradual sequential change in antigenic structure  At regular intervals  New antigens react with Antisera to the precursor virus strains Occurs due to mutation and selection due to the presence of antibodies to previous infection.
  15. 15. ANTIGENIC SHIFT  It is abrupt and Drastic  Discontinuous variation in structure in antigens  Results in novel virus and unrelated to previous strains causing infections  Involves – Hemagglutinins, Neuraminidase or both  Subtypes depends only on antigenic shifts, occurs on Hemagglutinins
  16. 16. ANTIGENIC SHIFT INITIATES PANDEMICS
  17. 17. MECHANISM OF ANTIGENIC SHIFT
  18. 18. 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
  19. 19. 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.
  20. 20. 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.
  21. 21. 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
  22. 22. 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  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 http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm,Influenza Antiviral Medications: Summary for Clinicians (Current for the 2012-2013 Influenza Season)
  23. 23. CLINICAL PRESENTATION AND COMPLICATIONS OF FLU Ghebrehewet S et al. BMJ. 2016 Dec 7;355:i6258.
  24. 24. SYMPTOMS  Mild or uncomplicated illness
  25. 25. PROGRESSIVE ILLNESS  typical symptoms  chest pain  poor oxygenation (eg, tachypnea)  cardiopulmonary insufficiency  central nervous system (CNS) impairment (eg, confusion, altered mental status)  severe dehydration
  26. 26. 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.
  27. 27. LABORATORY FINDINGS  Elevated SGOT/SGPT  Anemia  Leukopenia  Thrombocytopenia /Thrombocytosis  Elevated total bilirubin  Elevations of CPK ,LDH
  28. 28. PATHOLOGY  Pandemic H1N1 influenza A infection included both upper and lower respiratory tract abnormalities  Histopathologic findings in the trachea and bronchi included  inflammation and edema  necrosis  hemorrhage  Diffuse alveolar damage was present in the lungs of all cases.  Specific histopathologic findings in the lungs  Edema  hyaline membranes  Hemorrhage  type II pneumocyte hyperplasia  The primary cells infected with influenza virus were alveolar lining cells, including type I and type II pneumocytes.
  29. 29. DIAGNOST IC APPROAC H  The criterion standard for confirming influenza virus infection is reverse transcription-polymerase chain reaction (RT-PCR) or viral culture of nasopharyngeal or throat secretions  Rapid diagnostic tests for influenza are available and are becoming more widely used. These tests have high specificity but only moderate sensitivity.  Findings of standard laboratory studies, such as a complete blood count (CBC) and electrolyte levels, are nonspecific but helpful in the workup of influenza  Leukopenia and relative lymphopenia are typical findings  Thrombocytopenia may be present.  In severe cases of influenza, the patient is likely to have hypoxemia, and the alveolar-arterial (A-a) gradient may be increased (>35 mm Hg). Patients with physical examination findings compatible with meningitis should undergo lumbar puncture.  CXR
  30. 30. 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.
  31. 31. DIAGNOSTIC ASSAYS  Combined nasopharyngeal and throat swabs (CNTS)  Nasopharyngeal aspirates (NPA)
  32. 32. 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
  33. 33. 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.
  34. 34. 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
  35. 35. HAND WASHING A TOP PRIORITY  Single most important measure to reduce the risk of transmitting infectious organism from one person to other
  36. 36. 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
  37. 37. TOUCHING FACE REGIONS CAN FASTER THE SPREAD  Avoiding touching your eyes, nose or mouth. Virus can spread this way in a faster way
  38. 38. STAYING HOME IF YOU ARE SICK
  39. 39. AVOID CROWDED PLACES MORE SO WITH YOUNG CHILDREN
  40. 40. 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) .
  41. 41. INFECTION CONTROL MEASURES AT HEALTH FACILITY  Droplet Precautions  Visual alerts  Use of PPE  Decontaminating contaminated surfaces, fomites and equipments  Guidelines for waste disposal
  42. 42. 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
  43. 43. 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
  44. 44. Treatment of H1N1
  45. 45. Treatment • Adamantane agents – Amantadine – Rimantadine • Neuraminidase inhibitor – Oseltamivir (oral) – Zanamivir (aerosolized) – Peramivir (intravenous)
  46. 46. CDC recommends • Treatment and prevention of H1N1/seasonal flu • Neuraminidase inhibitor – Oseltamivir (oral) – Zanamivir (aerosolized)
  47. 47. 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
  48. 48. 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
  49. 49. Category-B i. Category-A + high grade fever & severe sore throat – Require home isolation and Oseltamivir ii. Category-A + one or more of high risk conditions – Shell be treated with Oseltamivir • No tests required for Category-B (i) and (ii) • All patients of Category-B (i) and (ii) – should confine themselves at home – Avoid mixing with public and high risk members in the family
  50. 50. 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
  51. 51. • Treatment should be started as soon as possible after illness onset – Ideally within 48 hrs
  52. 52. 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
  53. 53. 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
  54. 54. • 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
  55. 55. It is also available as syrup (12mg per ml ) OSELTAMIVIR (Cap.Tamiflu) ADULTS TREATMENT (5 DAYS) Chemoprophylaxis (10 days) 75 mg BD 75 mg OD Children ≥ 12 months Body Weight (kg) TREATMENT (5 DAYS) Chemoprophylaxis (10 days) ≤15 kg 30 mg twice daily 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 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 WHO and The U.S. Centers for Disease Control and Prevention http://www.cdc.gov/H1N1flu/recommendations.htm
  56. 56. 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
  57. 57. Adverse effect • Oseltamivir – Nausea – GI discomfort – Vomiting – Vertigo – Insomnia – Neuropsychiatric events • Delirium • Self-injury • Zanamivir – 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
  58. 58. COPD & INFLUENZA
  59. 59. COPD Assesment: Co-morbidities COPD patients are at increased risk for: • Cardiovascular diseases • Osteoporosis • Respiratory infections • Anxiety and Depression • Diabetes • Lung cancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.
  60. 60. Comorbidity and Mortality in COPD Related Hospitalizations Mortaliyty(%) Holguin et al. CHEST 2005; 128:2005 COPD Non-COPD 40 30 20 10 0 RF Pneum HF IHD Hypert TM Diabetes PVD
  61. 61. Adapted from Wedzicha et al. Lancet 2007; 370:786-796; Donaldson et al. Thorax 2006; 61:164-168; Donaldson et al. Chest 2010; 137:1091-1097; Decramer et al. Am J Respir Crit Care Med 2010; 181:A1526. Poorer HRQoL Increased inflammation Faster decline in lung function Higher hospital readmission More recurrent exacerbations Increased mortality Frequent exacerbators Patients with ≥2 exacerbations/year Higher myocardial infarction rate Worse Prognosis in Frequent Exacerbators 71
  62. 62. Group A Patients with no acute exacerbations Group B Patients with 1–2 acute exacerbations of COPD requiring hospital management Group C Patients with ≥3 acute exacerbations of COPD requiring hospital management Time (months) 0 10 20 30 40 50 60 0.2 0.4 0.6 0.8 1.0 Probabilityof surviving p<0.0001 A B C p=0.069 p<0.0002 Soler-Cataluña et al. Thorax 2005; 60:925-931. ≥3 acute exacerbations requiring hospitalisation is associated with a risk of death 4.30 times greater than for those patients not requiring hospitalization Worse Prognosis in Frequent Exacerbators
  63. 63. Should Patients With COPD Be Vaccinated? RESPIRATORY CARE • FEBRUARY 2015 VOL 60 NO 2
  64. 64. Prevention of COPD Exacerbations Smoking cessation Self-management education Pulmonary rehabilitation Accesstopatients Influenza vaccination Annually Pneumococcal vaccination Every 5–10 years Roflumilast1 Combination therapy Mucolytics Optimize maintenance bronchodilator therapy Chronic productive cough Moderate to severe COPD with >1 exacerbation/yr
  65. 65. The NHLBI/WHO guidelines-GOLD Guidelines 2017 VACCINATION RECOMMENDATIONS IN COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ►Influenza vaccination can reduce serious illness (such as lower respiratory tract infections requiring hospitalization)24 and death in COPD patients. ►Pneumococcal vaccinations, PCV13 and PPSV23, are recommended for all patients ≥ 65 years of age
  66. 66. Vaccination in Immunocompetent Patients With COPD SAFETY There was no significant difference between the 2 groups with regard to the probability of not acquiring total ARI (influenza-related and/or non- influenza-related), Sehatzadeh S. Influenza and pneumococcal vaccinations for patients with chronic obstructive pulmonary disease (COPD): an evidence-based analysis. Ont Health Technol Assess Ser [Internet]. 2012 Mar; 12(3) 1-64. Available from: www.hqontario.ca/en/mas/tech/pdfs/2012/rev_COPD_Vaccinations_March.pdf.
  67. 67. INFLUENZA VACCINATION
  68. 68. Vaccination- Key to prevent influenza and reduce its impact • Its more challenging to control and treat influenza due to highly variable nature of virus – Every flu season is different • Antibodies develop within 2 weeks of vaccination • Influenza vaccine is best protection against influenza – ↓ flu illness severity – ↓ doctor/clinic visits – ↓ hospitalizations/death Source: 1. HHS.gov 2. CDC key facts influenza ; 3. WHO Influenza vaccines ; 4. CDC Flu vaccine benefits
  69. 69. VRBPAC: vaccines and related Biological products advisory Committee, part of FDA
  70. 70. Influenza Vaccine Manufacturing Cycle
  71. 71. Vaccine types – By strain count: Trivalent or quadrivalent – By vaccine virus preparation method: Inactivated, live attenuated, adjuvanated, cell culture based or recombinant – By composition of vaccine: whole virus (no longer used), surface proteins , nucleocapsid, matrix proteins, virosomes and/or adjuvant – By route: intramuscular, intradermal or nasal
  72. 72. Yearly influenza vaccination is safe and effective immunogenic • Reduces morbidity and mortality • Mimics natural infection – Expected to induce faster response • May induce local immunity, if nasal vaccine – Antibodies present in nasal mucosa helps to prevent entry of virus inside lungs – Additionally its painless • Reduces complications in high risk individuals (people with chronic condition, geriatric population) Source: 1. HHS.gov 2. CDC key facts influenza ; 3. WHO Influenza vaccines ; 4. CDC Flu vaccine benefits
  73. 73. INFLUENZA VACCINE EFFECTIVEN ESS DEPENDS ON  How you decide if someone has influenza  What population you study-most vaccines work less well in the very young and very old  What you mean by effective:  Prevents death  Prevents hospitalization  Prevents a visit to the doctor or emergency rom  Prevents any symptoms
  74. 74. WHAT IS EFFECTIVENESS? The same vaccine could be: 100% effective at preventing death 80% effective at preventing hospitalization 60% effective at preventing you from having symptoms and a positive test for influenza 40% effective at preventing an illness that looks like influenza 20% effective at preventing transmission
  75. 75. Influenza immunizati on protective impact • Flu illness reduction by 50-60% • pediatric intensive care unit (PICU) admission reduction by 74% • Geriatric (50 years and older) hospitalization reduction by 57% • Reduced hospitalization in diabetics (79%) and COPD (52%) • Mortality reduction efficacy (80%) Source: 1. https://www.cdc.gov/flu/about/qa/vaccineeffect.htm 2. https://www.cdc.gov/flu/professionals/vaccination/effectivenessqa.htm 3. https://www.cdc.gov/vaccines/pubs/pinkbook/flu.html ; 3. https://www.ncbi.nlm.nih.gov/pubmed/27494630 4. Global news ; 5. https://www.ncbi.nlm.nih.gov/pubmed/19850275
  76. 76. Recommended composition of influenza virus vaccines for use in the 2017-2018 • TRIVALENT • A/Michigan/45/2015 (H1N1)pdm09-like virus • A/Hong Kong/4801/2014 (H3N2)- like virus and • B/Brisbane/60/2008-like virus • QUADRIVALENT • A/Michigan/45/2015 (H1N1)pdm09-like virus • A/Hong Kong/4801/2014 (H3N2)-like virus and • B/Brisbane/60/2008-like virus • B/Phuket/3073/2013-like virus http://www.who.int/influenza/vaccines/virus
  77. 77. Vaccination Schedules * 2 doses at least 1 month apart for children receiving vaccine for the first time Age group Dosage (im/sc) No. of doses 6-35 months 0.25 ml 1 or 2* 3-8 years 0.5 ml 1 or 2* > 9 years 0.5 ml 1
  78. 78. Commonly reported adverse reactions Following inactivated flu vaccine: • pain, swelling or redness at the injection site, low grade fever, malaise, shivering, fatigue, headache, myalgia and arthralgia • a small painless nodule (induration) may also form at the injection site • these symptoms usually disappear within one to two days without treatment Following live attenuated flu vaccine: • nasal congestion/rhinorrhoea, reduced appetite, weakness and headache Rarely, after live or inactivated vaccine, immediate reactions such as urticaria, angio-oedema, bronchospasm and anaphylaxis can occur 89
  79. 79. Vaccine viruses recommen dation 2017 vs Earlier recommen dations • The A(H1N1)pdm09 virus has been updated compared to the virus recommended for northern hemisphere 2016-2017 influenza season • This updated recommendation is as follows: – replacement of the A/California/7/2009 (H1N1)pdm09- like virus with an A/Michigan/45/2015 (H1N1)pdm09-like virus. http://www.who.int/influenza/vaccines/virus/candidates_reagents/201703_qanda_recommendation.pdf?ua=1
  80. 80. Influenza vaccination effectiveness varies from 7-53% Source: 1. http://www.drperlmutter.com/get-flu-shot/ ; 2. http://www.usatoday.com/story/news/2015/06/04/flu-shot-effective/28465601/ ; 3. http://www.pharmacytimes.com/publications/issue/2016/october2016/influenza-vaccination-formulations-recommendations-and-resources-for-the- pharmacist
  81. 81. Need of a Quadrivalent vaccine
  82. 82. • Trivalent vaccine reported to have high efficacy against well-matched B viruses (Victoria or Yamagata), but only 31% efficacy for opposite lineage • Antigenic divergence between 2 influenza B lineages is large, and leads to lack of cross-reactivity of vaccine Regardless of well-considered strain selection in trivalent vaccines, unsuccessful prediction leaves many individual un-protected from Influenza-B infection Hu JJ et al (2004) J Microbiol Immunol Infect, 37: 95, Belshe RB et al (2009) Vaccine,28: 2149, Fiore et al (2009) MMWR Recomm Rep 58: 1
  83. 83. Influenza vaccines effectiveness decreases when antigens in the vaccine do not match, those of circulating strains
  84. 84. Quadrivalent seasonal influenza vaccine Overall concept of development of Quadrivalent vaccine would provide extended coverage Food & Drug Administration Centre for Biologics & Research. Ad Committee meeting 18 Feb 2009 Food & Drug Administration Centre for Biologics & Research. Ad Committee meeting 21 Feb 2008
  85. 85. Impact of switching from Trivalent to Quadrivalent Significant reduction in no of cases, Hospitalizations & QALYs illness were seen with Quadrivalent vaccine Food & Drug Administration Centre for Biologics & Research. Ad Committee meeting 18 Feb 2009 Reed C et al (2009) Publich Health Impact including two inflz strains in seasonal influenzaUCM176699
  86. 86. 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 98
  87. 87. SIDE EFFECTS  Flu shot  Soreness, redness, or swelling where the shot was given  Fever (low grade)  Aches  LAIV (Flumist)  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
  88. 88. 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
  89. 89. 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
  90. 90. 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
  91. 91. 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
  92. 92. 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
  93. 93. 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
  94. 94. 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
  95. 95. 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
  96. 96. 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
  97. 97. Panic and Fear are much dangerous than Swine Flu

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