swine flu

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swine flu

  1. 1. SWINE FLU PANDEMIC (H1N1)
  2. 2. NOMENCLATURE - <ul><li>Some authorities object to calling the flu outbreak &quot;swine flu&quot;. </li></ul><ul><li>H1N1 influenza virus </li></ul><ul><li>CDC - &quot;Novel influenza A (H1N1)“ </li></ul><ul><li>Pig Flu </li></ul><ul><li>Mexican flu </li></ul><ul><li>Mexican virus </li></ul><ul><li>SI, short for &quot;swine influenza&quot;. </li></ul><ul><li>H1N1 Flu </li></ul><ul><li>New Flu </li></ul>
  3. 3. NOMENCLATURE - <ul><li>North American influenza </li></ul><ul><li>WHO -&quot;Influenza A (H1N1) virus, human </li></ul><ul><li>In July 2009 WHO - pandemic H1N1/09 virus to distinguish it from the current seasonal H1N1 viruses </li></ul>
  4. 4. Historical context - <ul><li>Annual influenza epidemics -5–15% of the global population. </li></ul><ul><li>Most cases are mild </li></ul><ul><li>Severe illness in 3–5 million people </li></ul><ul><li>250,000–500,000 deaths worldwide </li></ul>
  5. 5. Historical context - Pandemic Year Influenza A virus subtype People infected (approx) Deaths (est.) Case fatality rate Seasonal flu Every year mainly A/H3N2, A/H1N1, and B 5–15% (340 million – 1 billion) 250,000–500,000 per year <0.05%
  6. 6. 20th century flu pandemics - Pandemic Year Influenza A virus subtype People infected (approx) Deaths (est.) Case fatality rate 1918 flu pandemic 1918–19 H1N1 0.5 to 1 billion (near 50%) 20 to 100 million [ >2.5% Asian flu 1956–58 H2N2 2 million <0.1% ? Hong Kong flu 1968–69 H3N2 1 million <0.1%
  7. 7. 1918 - 1919 Pandemic - <ul><li>Thought to have originated in China </li></ul><ul><li>Most devastating epidemic in recorded world history </li></ul><ul><li>Known as &quot;Spanish Flu“ </li></ul><ul><li>Killed more people than the Great War </li></ul><ul><li>Most deadly for people ages 20 to 40 </li></ul>
  8. 8. 1918 - 1919 Pandemic - <ul><li>Infected 28% of all Americans </li></ul><ul><li>675,000 Americans died-ten times as many as in the world war </li></ul><ul><li>Mortality rate at 2.5% </li></ul><ul><li>In India the mortality rate was extremely high at around 50 deaths from influenza per 1,000 people </li></ul>
  9. 9. 1918 - 1919 Pandemic -
  10. 10. Pandemic H1N1/09 virus - <ul><li>Novel strain of influenza A </li></ul><ul><li>The strain contained genes from four different flu viruses: </li></ul><ul><li>North American swine influenza, </li></ul><ul><li>North American avian influenza, </li></ul><ul><li>Human influenza, </li></ul><ul><li>Two swine influenza viruses typically found in Asia and Europe. </li></ul><ul><li>The first full genetic sequencing of the virus on 6 May </li></ul>
  11. 11.
  12. 12. Virus source and name - <ul><li>Derived originally from a strain that lived in pigs </li></ul><ul><li>This origin gave rise to the common name of &quot;swine flu“ </li></ul><ul><li>Not a food-borne illness </li></ul><ul><li>There is no risk in eating pork </li></ul>
  13. 13. Virus origins - <ul><li>New York Times </li></ul><ul><li>Most likely emerged in pigs in Asia, but then traveled to North America in a human </li></ul><ul><li>Oxford University's Department of Zoology- </li></ul><ul><li>This strain has been circulating among pigs, possibly among multiple continents, for many years prior to its transmission to humans </li></ul>
  14. 14. Virus origins - <ul><li>Consensus is </li></ul><ul><li>Movement of live pigs between Eurasia and North America seems to have facilitated the mixing of diverse swine influenza viruses, </li></ul><ul><li>Leading to the multiple re assortment events associated with the genesis of the (new H1N1) strain </li></ul>
  15. 15. Virulence - <ul><li>Most infections continue to be mild </li></ul><ul><li>Deaths so far are &quot;a tiny fraction&quot; of people who die every year from seasonal flu </li></ul><ul><li>Medical journalists suggest that the news media may be overreacting </li></ul>
  16. 16. Mutation potential - <ul><li>Both H1N1 and H5N1 are unstable so the chances of them exchanging genetic material are higher </li></ul><ul><li>Hybrid of: </li></ul><ul><li>More virulent Asian-lineage HPAI (highly pathogenic avian influenza) A/H5N1 strain (media labeled &quot;bird flu&quot;) </li></ul><ul><li>More human-transmissible Influenza A strains such as this novel 2009 swine-origin A/H1N1 strain </li></ul>
  17. 17. Initial outbreaks - <ul><li>Virus first evolved around September 2008 </li></ul><ul><li>Circulated in the human population for several months before the first cases were identified </li></ul>
  18. 18. Role Of Mexico - <ul><li>Outbreak was first detected in Mexico City on March 18, 2009 </li></ul><ul><li>Within days of the outbreak, Mexico City was &quot;effectively shut down,&quot; </li></ul><ul><li>Scientists tried to understand why there were so many deaths in Mexico while infections in the United States and Canada were relatively mild </li></ul>
  19. 19. Spread - <ul><li>New strain has spread widely beyond North America </li></ul><ul><li>Initially, most cases outside North America were following recent travel to Mexico or the U.S. </li></ul>
  20. 20. Spread - <ul><li>By May 15 in-country transmission had been reported </li></ul><ul><li>As of June 17 most countries within the European Union had documented in-country transmission </li></ul>
  21. 21. India - <ul><li>Saturday , May 16 </li></ul><ul><li>A 23 year old passenger </li></ul><ul><li>Arrived at Hyderabad from US </li></ul>
  22. 22. India -
  23. 23. Gujarat - <ul><li>Ahmedabad </li></ul><ul><li>July 6 2009, Saturday </li></ul><ul><li>Thai national </li></ul>
  24. 24. Pandemic declared - <ul><li>On June 11, 2009, the WHO 's Chan declared the outbreak had become a pandemic </li></ul><ul><li>Declared a Pandemic Alert Level of six </li></ul><ul><li>A move to phase 6 means that &quot;emergency plans are instantly triggered around the globe” </li></ul>
  25. 25. By July 2009 - <ul><li>Northern Hemisphere- </li></ul><ul><li>The flu has been reported in more than 100 countries </li></ul><ul><li>Southern Hemisphere </li></ul><ul><li>There is a mixed picture </li></ul>
  26. 26. By August 2009 - <ul><li>Areas of tropical Asia are reporting increasing rates of illness as they enter their monsoon season </li></ul><ul><li>In the northern temperate zones, overall rates are declining in both North America and Europe </li></ul><ul><li>The cases are bout to rise again with the fall of winter (WHO) </li></ul>
  27. 27.
  28. 28.
  29. 29.
  30. 30.
  31. 31. Epidemiological factors - <ul><li>Host Factors- </li></ul><ul><li>Majority of cases in healthy young adults </li></ul>
  32. 32. Epidemiological factors - <ul><li>Transmission- </li></ul><ul><li>The transmission is by droplet infection (coughs and sneezes) and fomites </li></ul><ul><li>Communicability- </li></ul><ul><li>From 1 day before to 7 days after the onset of symptoms. </li></ul><ul><li>Children may spread the virus for a longer period. </li></ul>
  33. 33. Immunity - <ul><li>Pseudo-pandemic of 1947 </li></ul><ul><li>1976 swine flu outbreak by the </li></ul><ul><li>1977 Russian flu H1N1 </li></ul><ul><li>People who have contracted flu prior to 1957 may have some immunity </li></ul><ul><li>That does not mean that everyone over 52 is immune </li></ul>
  34. 34. Clinical Features – <ul><li>WHO guidelines, August 20 2009 </li></ul>
  35. 35. Clinical Features – Uncomplicated influenza <ul><li>Influenza‐like illness symptoms : </li></ul><ul><li>Fever </li></ul><ul><li>Cough </li></ul><ul><li>Sore throat </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Headache </li></ul><ul><li>Muscle pain </li></ul><ul><li>Malaise </li></ul><ul><li>No shortness of breath, No dyspnoea </li></ul>
  36. 36. Clinical Features – Uncomplicated influenza <ul><li>Gastrointestinal illness  may also be present </li></ul><ul><li>Diarrhoea  </li></ul><ul><li>Vomiting </li></ul><ul><li>  Especially in children, but without evidence of dehydration.  </li></ul>
  37. 37. Clinical Features – Complicated or Severe Influenza <ul><li>Clinically (shortness of breath, dyspnoea,  tachypnea, hypoxia)  </li></ul><ul><li>  </li></ul><ul><li>Radiological signs of lower respiratory tract  disease (e.g. pneumonia) </li></ul><ul><li>CNS findings (e.g. encephalopathy) </li></ul><ul><li>Severe dehydration </li></ul>
  38. 38. Clinical Features – Complicated or Severe Influenza <ul><li>Presenting secondary complications: </li></ul><ul><li>renal failure </li></ul><ul><li>multi‐organ failure </li></ul><ul><li>septic shock. </li></ul><ul><li>Other complications </li></ul><ul><li>musculoskeletal (rhabdomyolysis)  </li></ul><ul><li>cardiac (myocarditis).   </li></ul>
  39. 39. Clinical Features – Complicated or Severe Influenza <ul><li>Exacerbation of underlying chronic disease </li></ul><ul><li>Asthma </li></ul><ul><li>chronic obstructive pulmonary disease </li></ul><ul><li>chronic hepatic or renal failure </li></ul><ul><li>Diabetes  </li></ul><ul><li>other cardiovascular conditions.  </li></ul>
  40. 40. Clinical Features – Complicated or Severe Influenza <ul><li>Any other condition or clinical presentation requiring hospital admission for clinical  management.  </li></ul>
  41. 41. Clinical Features - Progressive disease <ul><li>Symptoms and signs suggesting oxygen impairment or cardiopulmonary insufficiency:  </li></ul><ul><li>Shortness of breath (with activity or at rest) </li></ul><ul><li>Turning blue </li></ul><ul><li>Bloody or coloured sputum </li></ul><ul><li>Chest pain </li></ul><ul><li>Low blood pressure </li></ul><ul><li>In children, fast or laboured breathing.  </li></ul><ul><li>Hypoxia as indicated by pulse oximetry  </li></ul>
  42. 42. Clinical Features - Progressive disease <ul><li>Symptoms and signs suggesting CNS complications: </li></ul><ul><li>Altered mental status </li></ul><ul><li>Unconscious </li></ul><ul><li>Drowsiness </li></ul><ul><li>Difficult to awaken </li></ul><ul><li>Recurring or persistent convulsions </li></ul><ul><li>Confusion </li></ul><ul><li>Severe weakness or paralysis.  </li></ul>
  43. 43. Clinical Features - Progressive disease <ul><li>Severe dehydration:  </li></ul><ul><li>decreased activity </li></ul><ul><li>Dizziness </li></ul><ul><li>decreased urine output </li></ul><ul><li>lethargy. </li></ul>
  44. 44. Clinical Features - Progressive disease <ul><li>Evidence of sustained virus replication or  invasive secondary bacterial infection:  </li></ul><ul><li>(based on laboratory testing or clinical signs) </li></ul><ul><li>e.g. persistent high fever and other  symptoms beyond three days </li></ul>
  45. 45. Pneumonia - <ul><li>Virus can cause pneumonia leading to death </li></ul><ul><li>Rapid onset, often within one day after infection </li></ul><ul><li>Attributed to &quot; cytokine storm “ </li></ul><ul><li>Deaths among healthy young people during the first weeks of the 2009 flu pandemic were attributed to this cause </li></ul>
  46. 46. Deaths – India <ul><li>Till August 21, 2009 (52) </li></ul><ul><li>Till August 24, 2009 (61) </li></ul><ul><li>The first death was a 14-year-old girl </li></ul><ul><li>First death in Ahmedabad was a 43-year-old man </li></ul>
  47. 47. Cases As of August 21 – Gujarat <ul><li>512 suspected cases- 82 have tested positive </li></ul><ul><li>51 cases have been reported from Ahmedabad </li></ul><ul><li>13 from Surat </li></ul><ul><li>8 from Vadodara </li></ul><ul><li>5 from Rajkot </li></ul><ul><li>2 each from Gandhinagar and Bhavnagar </li></ul><ul><li>1 from Daman and Jamnagar </li></ul>
  48. 48. Cases As of August 24 – Gujarat <ul><li>91(593) patients have tested positive </li></ul><ul><li>6 casualties. </li></ul><ul><li>56 cases was reported from Ahmedabad </li></ul><ul><li>Surat 14 </li></ul><ul><li>Vadodara 9 </li></ul><ul><li>Rajkot 6 </li></ul><ul><li>Bhavnagar 2 </li></ul><ul><li>one each from Kandla, Gandhinagar, Daman and Jamnagar,&quot; </li></ul>
  49. 49. Infection among animals - <ul><li>Swine: </li></ul><ul><li>Before being transmitted to humans, the viruses have circulated in swine </li></ul><ul><li>which has allowed for the undetected persistence and evolution of this potentially pandemic strain for many years. </li></ul><ul><li>Birds: </li></ul><ul><li>In late August, the government of Chile discovered that the swine flu virus had jumped to birds </li></ul>
  50. 50. Laboratory Diagnosis – <ul><li>(WHO guidelines 21 August 2009) </li></ul>
  51. 51. Laboratory Diagnosis – <ul><li>All un-subtypable influenza A specimens are strongly recommended to be sent </li></ul><ul><li>immediately to one of the five WHO collaborating Centres for influenza for </li></ul><ul><li>diagnosis and further characterization. </li></ul>
  52. 52. Specimens - <ul><li>Samples should be taken from </li></ul><ul><li>deep nostrils (nasal swab) </li></ul><ul><li>nasopharynx(nasopharyngeal swab) </li></ul><ul><li>Nasopharyngeal aspirate </li></ul><ul><li>throat or bronchial aspirate </li></ul><ul><li>It is not yet known which clinical specimen gives the best diagnostic yield. </li></ul>
  53. 53. Specimens - <ul><li>There is, as yet, no information on the diagnostic value of non-respiratory specimens, e.g., stool samples. </li></ul><ul><li>Acute and convalescent serum specimens should be used for the detection of rising antibody titres </li></ul>
  54. 54. Molecular diagnostics - <ul><li>Method of choice for influenza A (H1N1) </li></ul><ul><li>The following gene targets are important: </li></ul><ul><li>Type A influenza matrix gene </li></ul><ul><li>Haemagglutinin gene specific for influenza A (H1N1)swl virus </li></ul><ul><li>Haemagglutinin gene specific for seasonal </li></ul><ul><li>influenza A H1/H3 and other subtypes. </li></ul>
  55. 55. Molecular diagnostics - <ul><li>Basis </li></ul><ul><li>Extract viral RNA from clinical specimen </li></ul><ul><li>protocols </li></ul><ul><li>type-specific conventional and realtime PCR </li></ul><ul><li>CDC realtime RT-PCR (rRT-PCR) </li></ul><ul><li>positive </li></ul><ul><li>if results from tests using two different PCR targets </li></ul>
  56. 56. Molecular diagnostics - <ul><li>Conventional PCR - QIAamp Viral RNA Mini Kit </li></ul><ul><li>Real-time PCR - TaqMan® probe </li></ul>
  57. 57. Virus isolation - <ul><li>MDCK cells and egg inoculation can be used </li></ul>
  58. 58. Rapid tests or immunofluorescence - <ul><li>Sensitivity and specificity of immunofluorescence tests are currently unknown </li></ul><ul><li>These tests will not differentiate seasonal influenza from influenza A (H1N1)swl virus. </li></ul>
  59. 59. Serology - <ul><li>HAI </li></ul><ul><li>Microneutralization tests </li></ul><ul><li>Four-fold or greater rise in specific influenza A (H1N1)swl virus antibody titres indicates recent infection with the virus. </li></ul><ul><li>Results obtained using the H1 monoclonal antibodies in the WHO kit should not be taken as conclusive (the kit used for detection of seasonal H1 virus) </li></ul>
  60. 60. Biosafety - <ul><li>Diagnostic laboratory work on clinical specimens from patients who are suspected cases of influenza A (H1N1)swl virus infection should be conducted in: </li></ul><ul><li>BSL-2 </li></ul>
  61. 61.
  62. 62. Case Definitions - <ul><li>Directorate General of Health Services </li></ul><ul><li>Ministry of Health and Family Welfare </li></ul><ul><li>Government of India </li></ul><ul><li>30.04.09 </li></ul>
  63. 63. Case Definition – suspected case <ul><li>Person with acute febrile respiratory illness (fever ≥ 38.0 C) with onset.: </li></ul><ul><li>Within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection, or </li></ul><ul><li>Within 7 days of travel to community where there are one or more confirmed swine influenza A(H1N1) cases, or </li></ul><ul><li>Resides in a community where there are one or more confirmed swine influenza cases. </li></ul>
  64. 64. Case Definition – probable case <ul><li>person with an acute febrile respiratory illness who: </li></ul><ul><li>Is positive for influenza A, but unsubtypable for H1 and H3 by influenza RT-PCR or reagents used to detect seasonal influenza virus infection, or </li></ul><ul><li>Is positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case </li></ul><ul><li>Individual with a clinically compatible illness who died of an unexplained acute respiratory –illness who is considered to be epidemiologically linked to a probable </li></ul>
  65. 65. Case Definition – confirmed case <ul><li>person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at WHO approved laboratories by one or more of the following tests: </li></ul><ul><li>Real Time PCR </li></ul><ul><li>viral culture </li></ul><ul><li>Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies. </li></ul>
  66. 66. Stratification of patients - <ul><li>Ministry of H&FW 14 th August 2009 </li></ul>
  67. 67. Stratification of patients - (Ministry of H&FW 14 th August 2009) <ul><li>Category A – </li></ul><ul><li>Mild fever plus cough / sore throat with or without bodyache, headche, diarrhoea and vomitting </li></ul><ul><li>No testing for H1N1 </li></ul><ul><li>No Oseltamivir </li></ul><ul><li>Only symptomatic treatment </li></ul><ul><li>Stay confine to home </li></ul>
  68. 68. Stratification of patients - (Ministry of H&FW 14 th August 2009) <ul><li>Category B – </li></ul><ul><li>i. Above signs and symptoms plus </li></ul><ul><li>High grade fever and severe sore throat </li></ul>
  69. 69. Stratification of patients - (Ministry of H&FW 14 th August 2009) <ul><li>Category B – </li></ul><ul><li>Addition of above sypmtoms and signs plus </li></ul><ul><li>one or more of the following conditions: </li></ul><ul><li>Children less than 5 years </li></ul><ul><li>Pregnant women </li></ul><ul><li>Age above 65 years </li></ul><ul><li>Having lung dz, heart dz, liver dz, kidney dz, blood disorders, diabetes, neurological disorders, cancer and HIV </li></ul><ul><li>Long term cortisone </li></ul>
  70. 70. Stratification of patients - (Ministry of H&FW 14 th August 2009) <ul><li>For i. and ii. Both….. </li></ul><ul><li>Home treatment </li></ul><ul><li>Oseltamivir given </li></ul><ul><li>No tests for H1N1 </li></ul><ul><li>Confine to home </li></ul>
  71. 71. Stratification of patients - (Ministry of H&FW 14 th August 2009) <ul><li>Category C – </li></ul><ul><li>In addition to symptoms and signs of A and B if patients have one or more of the following: </li></ul><ul><li>Breathlessness, chest pain, drowsiness, low BP, sputum mixed with blood, bluish discolouration </li></ul><ul><li>Irritability among small children, refusal to accept feeds </li></ul><ul><li>Worsening of underlying chronic conditions </li></ul>
  72. 72. Stratification of patients - (Ministry of H&FW 14 th August 2009) <ul><li>Immediate admission </li></ul><ul><li>Require testing for H1N1 </li></ul><ul><li>Oseltamivir treatment </li></ul>
  73. 73. Management of H1N1 – (Ministry of H&FW guidelines) <ul><li>Infrastructure support: </li></ul><ul><li>Isolation facilities </li></ul><ul><li>Beds kept one metre apart. </li></ul><ul><li>Dedicated doctors, nurses and paramedical workers. </li></ul><ul><li>Portable X Ray machine, ventilators, large oxygen cylinders, pulse oxymeter </li></ul><ul><li>Adequate quantities of PPE, disinfectants and medications </li></ul>
  74. 74.
  75. 75.
  76. 76. Pharmacological Management – <ul><li>WHO guidelines 20 August 2009 </li></ul>
  77. 77. Pharmacological Management – (WHO guidelines 20 August 2009) <ul><li>Work by deactivating an enzyme the virus needs to grow and spread </li></ul><ul><li>To be most useful, they must be taken within 2 days of showing symptoms </li></ul><ul><li>Be given to particularly vulnerable people </li></ul>
  78. 78. Pharmacological Management – (WHO guidelines 20 August 2009) <ul><li>Healthy people who catch mild to moderate cases of swine flu don't need the drug at all </li></ul><ul><li>CDC has warned that the indiscriminate use of antiviral medications to prevent and treat influenza could ease the way for drug-resistant strains to emerge </li></ul>
  79. 79. Antiviral susceptibilities of circulating  viruses ( June 2009 ) Oseltamivir  Zanamivir   M2 inhibitors Pandemic A(H1N1) 2009  S S R Seasonal A (H1N1)  R S S Seasonal A (H3N2)  S S R Influenza B  S S R Avian influenza (H5N1)  S S Variably resistant
  80. 80. Severe or Progressive symptoms <ul><li>confirmed or strongly suspected </li></ul><ul><li>severe or progressive </li></ul><ul><li>antivirals are available.  </li></ul><ul><li>Treatment should be initiated as soon as possible. </li></ul><ul><li>Treated with oseltamivir </li></ul><ul><li>treated with zanamivir if </li></ul><ul><li>oseltamivir is not available </li></ul><ul><li>resistant to oseltamivir </li></ul>
  81. 81. Uncomplicated - <ul><li>confirmed or strongly suspected </li></ul><ul><li>uncomplicated </li></ul><ul><li>antivirals are available.  </li></ul><ul><li>need not be treated with antivrals (Patients not in ”at risk” groups) </li></ul><ul><li>treated with oseltamivir or zanamivir </li></ul><ul><li>(Patients in ”at risk” groups) </li></ul>
  82. 82. Uncomplicated - <ul><li>“ at risk” means: </li></ul><ul><li>Infants and children aged less than 5 </li></ul><ul><li>elderly (>65 years) </li></ul><ul><li>nursing home residents </li></ul><ul><li>pregnant women </li></ul><ul><li>patients with chronic co‐morbid conditions </li></ul><ul><li>Immunosuppression  </li></ul>
  83. 83. Oseltamivir - <ul><li>Dose (75 mg capsules) – </li></ul><ul><li>Upto 12 years: </li></ul><ul><li>Weight‐adjusted doses:  </li></ul><ul><li>- 30 mg twice daily for ≤ 15 kg  </li></ul><ul><li>- 45 mg twice daily for >15 to 23 kg  </li></ul><ul><li>- 60 mg twice daily for >23 to 40 kg  </li></ul><ul><li>- 75 mg twice daily for >40 kg  </li></ul><ul><li>≥ 13 years: </li></ul><ul><li>- 75 mg twice daily </li></ul>
  84. 84. Oseltamivir - <ul><li>Reductions in risk of pneumonia, otitis media and hospitalization  </li></ul><ul><li>in pregnant women safe </li></ul><ul><li>Safe in children < 1 year of age </li></ul>
  85. 85. Oseltamivir - <ul><li>Gastrointestinal side effects </li></ul><ul><li>Bronchitis </li></ul><ul><li>Insomnia </li></ul><ul><li>Vertigo </li></ul><ul><li>Angina </li></ul><ul><li>pseudo membranous colitis </li></ul><ul><li>peritonsillar abscess </li></ul><ul><li>Rarely anaphylaxis and skin rashes </li></ul><ul><li>Rare reporting of fatal neuro-psychiatiric illness, there is no there is no </li></ul><ul><li>scientific evidence for a causal relationship </li></ul>
  86. 86. Oseltamivir - <ul><li>In children </li></ul><ul><li>Most frequently- vomiting </li></ul><ul><li>Infrequently- </li></ul><ul><li>abdominal pain </li></ul><ul><li>Epistaxis </li></ul><ul><li>Bronchitis </li></ul><ul><li>otitis media </li></ul><ul><li>Dermatitis </li></ul><ul><li>conjunctivitis </li></ul>
  87. 87. Zanamivir – (VIRENZA, Cipla) <ul><li>Dose (5 mg capsules) – </li></ul><ul><li>Upto 12 years: </li></ul><ul><li>( 5- 12 years, not licensed for use in younger age groups) </li></ul><ul><li>- 10 mg (2 inhalations) twice daily </li></ul><ul><li>≥ 13 years: </li></ul><ul><li>- 10 mg (2 inhalations) twice daily </li></ul>
  88. 88. Zanamivir – (VIRENZA, Cipla) <ul><li>Inhibition of influenza virus neuraminidase </li></ul><ul><li>Hepatic disorders </li></ul><ul><li>Renal disorders </li></ul><ul><li>Pregnant safety not </li></ul><ul><li>Children established </li></ul><ul><li>Geriatric </li></ul><ul><li>Contraindicated in patients with a known hypersensitivity </li></ul>
  89. 89. Zanamivir – (VIRENZA, Cipla) <ul><li>  No significant difference between zanamivir and placebo in the occurrence of complications or adverse events. </li></ul><ul><li>Avoided in pregnant, lactating and infant patients </li></ul><ul><li>Not effective in uncomplicated influenza patients without risk factors </li></ul>
  90. 90. Supportive therapy - <ul><li>-IV Fluids. </li></ul><ul><li>‐ Parentral nutrition. </li></ul><ul><li>‐ Oxygen therapy/ ventilatory support(PaO2 <60 mmHg with oxygen therapy) </li></ul><ul><li>‐ Antibiotics for secondary infection. </li></ul><ul><li>‐ Vasopressors for shock. </li></ul><ul><li>‐ Paracetamol or ibuprofen </li></ul><ul><li>-Plenty of oral fluids. </li></ul><ul><li>-topical decongestants, </li></ul><ul><li>-airway, breathing and circulation (ABC); </li></ul><ul><li>Salicylate / aspirin is strictly contra-indicated – REYE’s syndrome </li></ul>
  91. 91. Discharge Policy - <ul><li>Adult patients should be discharged 7 days after symptoms have subsided. </li></ul><ul><li>Children should be discharged 14 days after symptoms have subsided. </li></ul><ul><li>The family of patients discharged earlier should be educated on personal hygiene and infection control measures at home; </li></ul><ul><li>children should not attend school during this period. </li></ul>
  92. 92. Oseltamivir resistant virus - <ul><li>WHO has also been notified of 12 cases </li></ul><ul><li>8 have been associated with post exposure prophylaxis </li></ul><ul><li>two have been from immunocompromised </li></ul><ul><li>mutation in the Neuraminidase (referred to as H275Y) that confers resistance to oseltamivir, though the viruses remain sensitive to zanamivir </li></ul>
  93. 93. Prevention – Personal Protection Equipment <ul><li>• Gloves (nonsterile) </li></ul><ul><li>• Mask </li></ul><ul><li>• Long-sleeved cuffed gown </li></ul><ul><li>• Protective eyewear </li></ul><ul><li>• Cap </li></ul><ul><li>• Plastic apron </li></ul>
  94. 94.
  95. 95. Respiratory Hygiene/Cough Etiquette - <ul><li>Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing </li></ul><ul><li>Use tissues to contain respiratory secretions and dispose </li></ul><ul><li>Perform hand hygiene </li></ul>
  96. 96. Hand Hygiene - <ul><li>Step 1: wash palms and fingers </li></ul><ul><li>Step 2: Wash back of hands. </li></ul><ul><li>Step 3: Wash fingers and knuckles. </li></ul><ul><li>Step 4: Wash thumbs. </li></ul><ul><li>Step 5: Wash fingertips. </li></ul><ul><li>Step 6: Wash wrists. </li></ul>
  97. 97.
  98. 98. “ Close Contact&quot; <ul><li>World Health Organization : </li></ul><ul><li>1 m or less </li></ul><ul><li>Occupational Safety and Health Administration 6 feet or less </li></ul><ul><li>UK Health Protection Agency : </li></ul><ul><li>considers facial masks unnecessary for the general public and some experts feel it may lead to a false sense of security </li></ul>
  99. 99. Containment - <ul><li>Containment is not a feasible operation </li></ul><ul><li>Did not recommend closing borders or restricting travel </li></ul><ul><li>Number of countries also advised against travel to known affected regions </li></ul>
  100. 100. Quarantines - <ul><li>countries began quarantining foreign visitors suspected of having or being in contact </li></ul><ul><li>In India, after the travellers of a flight were detected positive asked the other passengers to stay home until further orders </li></ul><ul><li>Home quarantine: </li></ul><ul><li>people to be quarantined at home if they have been in close contact with someone who has swine flu </li></ul>
  101. 101.
  102. 102. Pre-screening advisories by some governments <ul><li>India 's Minister of State for Health, said </li></ul><ul><li>there should be &quot;some kind of screening&quot; for outbound travellers in the U.S., claiming that most people coming from that country have been tested positive for influenza </li></ul><ul><li>. &quot;The U.S. is the main source (of swine flu) as far as India is concerned,&quot; </li></ul>
  103. 103. Other measures - <ul><li>Schools are closed now (August 10, 2009) in many cities Like Pune , Mumbai , New Delhi </li></ul><ul><li>The CDC advised sick people to stay home from work, school, or social gatherings </li></ul><ul><li>Not known to be transmissible to people through eating processed pork </li></ul>
  104. 104.
  105. 105. Chemo Prophylaxis - <ul><li>WHO guidelines 20 August 2009 </li></ul>
  106. 106. Chemo Prophylaxis - Indications <ul><li>Risk of human‐to‐human transmission is high or low but, </li></ul><ul><li>the likelihood of complications of infection is high  </li></ul><ul><li>Oseltamivir or Zanamivir might be used </li></ul>
  107. 107. Chemo Prophylaxis - Oseltamivir <ul><li>Begin as soon as exposure identified and continue for 5‐7 days after last known exposure (minimum of two weeks) </li></ul><ul><li>Weight adjusted doses (upto 12 years) </li></ul><ul><li>- 30 mg/day for ≤ 15 kg  </li></ul><ul><li>- 45 mg/day for >15 to 23 kg  </li></ul><ul><li>- 60 mg/day for >23 to 40 kg </li></ul><ul><li>-75 mg/day for >40 kg </li></ul><ul><li>≥ 13 years </li></ul><ul><li>75 mg/day   </li></ul><ul><li>  </li></ul>
  108. 108. Chemo Prophylaxis - Zanamivir <ul><li>Begin as soon as exposure identified and continue for 5‐7 days after last known exposure </li></ul><ul><li>(minimum of two weeks) </li></ul><ul><li>1‐4 yrs: not used </li></ul><ul><li>≥ 5 yrs: 10 mg (2 inhalations) once daily   </li></ul>
  109. 109. Chemo Prophylaxis - ContraIndications <ul><li>If the likelihood of complications of infection is low even if : </li></ul><ul><li>“ at risk” groups </li></ul><ul><li>health care workers </li></ul><ul><li>  This recommendation applies independent of  risk of human to human transmission </li></ul>
  110. 110. Vaccine - <ul><li>1957 and 1968: vaccines arrived too late </li></ul><ul><li>1918 without vaccine estimated 50 million people died. </li></ul><ul><li>It takes approximately five to six months for the first supplies of approved vaccine to become available once a new strain of influenza virus with pandemic potential is identified and isolated. </li></ul><ul><li>WHO does not expect the swine flu vaccine to be widely available until the end of 2009 </li></ul>
  111. 111. Vaccine - <ul><li>seasonal flu vaccine provides little or no protection against H1N1 swine flu </li></ul><ul><li>Reassortant vaccine virus (NIBRG‐121xp)  has been developed </li></ul><ul><li>originally developed from an A/California/7/2009(H1N1)v virus  </li></ul><ul><li>National Institute for Biological Standards and Control (NIBSC), United Kingdom. </li></ul>
  112. 112. Vaccine - <ul><li>Two injections will be required three weeks apart for the swine flu </li></ul><ul><li>A third will be needed for seasonal flu to provide maximum immunity. </li></ul>
  113. 113. Vaccine – safety?? <ul><li>Influenza vaccines have been used for more than 60 years and have an established record of safety in all age groups </li></ul><ul><li>Though some serious adverse reactions are seen, the incidence is very low. </li></ul><ul><li>WHO is aware of some media reports that have expressed concern about the safety of vaccines for pandemic influenza. </li></ul>
  114. 114. Vaccine - <ul><li>Time constraints mean that clinical data at the time when pandemic vaccines are first administered will inevitably be limited </li></ul><ul><li>For these reasons, WHO advises all countries administering pandemic vaccines to conduct intensive monitoring for safety and efficacy, </li></ul>
  115. 115. Global surveillance of pandemic – ( WHO guidelines) <ul><li>Early detection, investigation and risk  assessment   </li></ul><ul><li>After detection of the pandemic virus:  description of the epidemiology and assessment of the early cases  </li></ul><ul><li>Continuous epidemiological and virological monitoring of influenza activity  </li></ul><ul><li>Analysis and publication of surveillance data by WHO  </li></ul>
  116. 116. Estimates of total cases - <ul><li>Not possible: </li></ul><ul><li>Most people who have respiratory illnesses don't find out exactly what caused it. Even most people with influenza don't know exactly which type of influenza caused their illness.“ </li></ul><ul><li>12% to 24% of Americans might get swine flu this fall and winter </li></ul>
  117. 117. THANK YOU

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