<ul><li>Influenza Virus </li></ul><ul><li>Definitions </li></ul><ul><li>Introduction </li></ul><ul><li>History  </li></ul>...
Virus Credit: L. Stammard, 1995 <ul><li>ss RNA, enveloped </li></ul><ul><li>Viral family:  Orthomyxoviridae </li></ul><ul>...
 
<ul><li>Epidemic  –  a located cluster of cases </li></ul><ul><li>Pandemic  –  worldwide epidemic </li></ul><ul><li>Antige...
Survival of Influenza Virus  Surfaces and Affect of Humidity & Temperature* <ul><li>Hard non-porous surfaces 24-48 hours <...
<ul><li>Seasonal Influenza </li></ul><ul><ul><li>Globally:  250,000 to 500,000 deaths per year </li></ul></ul><ul><ul><li>...
Swine Influenza A(H1N1)   Introduction <ul><li>Outbreaks of influenza among pigs </li></ul><ul><li>Do not normally infect ...
Swine Influenza A(H1N1)  History in US <ul><li>New Jersey, USA 1976 –  </li></ul><ul><li>> 200 cases with serious illness ...
2009 Swine Influenza A(H1N1)  T ransmission Through Species Reassortment in Pigs <ul><li>NOT REPORTED IN PIGS </li></ul><u...
Swine Influenza A(H1N1)  US Response <ul><li>Congress asked for an additional $1.5 billion </li></ul><ul><li>April 27, 200...
Swine Influenza A(H1N1)  Global Response <ul><li>The WHO raises the alert level to Phase 6 </li></ul><ul><ul><li>WHO’s ale...
Pandemic  Phases Phase 1-3 Preparedness Phase 5-6 Pandemic
Swine Influenza A(H1N1) May 25, 2009 Status Update <ul><li>GLOBALLY: March 1-May 25 </li></ul><ul><ul><li>27,737 Laborator...
Swine Influenza A(H1N1)  Mexico Confirmed Case Distribution, by Age Total Number of Confirmed Cases = 6,241* As of June 09...
Swine Influenza A(H1N1)  Mexico Confirmed Cases & Death, by Age Groups Total Number of Confirmed Cases = 6,241* Deaths = 1...
Clinical features <ul><li>Fever </li></ul><ul><li>Myalgia </li></ul><ul><li>Headache </li></ul><ul><li>Cough; respiratory ...
Case Definitions <ul><li>Case under Investigation   </li></ul><ul><li>An individual after 17th of April 2009**, presenting...
Swine Influenza A(H1N1)  US   Case Definitions  <ul><li>A  confirmed case   - a person with an acute febrile respiratory i...
Other definitions <ul><li>Infectious period   1 day prior to the case’s illness onset to 7 days after onset.  </li></ul><u...
High risk groups /  Co-morbidities  <ul><li><5 yrs; Older age group   65 yr </li></ul><ul><li>pregnancy </li></ul><ul><li...
Swine Influenza A(H1N1)  <ul><li>Consider swine influenza virus infections in patients presenting with febrile respiratory...
Infectiousness & Incubation period <ul><li>From 1-7 days; more likely 1-4 days.  </li></ul><ul><li>More contagious than se...
Samples for diagnosis <ul><li>Respiratory specimens including: </li></ul><ul><li>bronchoalveolar lavage, tracheal aspirate...
When to collect samples <ul><li>As soon as possible after symptoms begin (preferably first 4-5 days; 10 days- children) </...
Personal Protective Equipment <ul><li>Before initiating collection of sample; a full </li></ul><ul><li>complement of PPE s...
<ul><li>Surgical masks  </li></ul><ul><li>High-filtration respiratory mask  </li></ul><ul><ul><li>Special microstructure f...
How to Store Specimens <ul><li>Store specimens at 4 °C before & during transportation within 48 hours </li></ul><ul><li>St...
 
Swine Influenza A (H1N1)  Guidelines for General Population <ul><li>Covering nose and mouth with a tissue when coughing or...
Treatment principles <ul><li>Early implementation of infection control </li></ul><ul><li>Precautions to minimize spread </...
Critical Measures <ul><li>Avoiding crowding patients together </li></ul><ul><li>Hand hygiene </li></ul><ul><li>PPE </li></...
Anti Viral medications <ul><li>Resistant to Amanatidine and Rimanatidine </li></ul><ul><li>Neuraminidase inhibitors availa...
Swine Influenza A(H1N1)  Treatment <ul><li>No vaccine available  </li></ul><ul><li>Use of anti-virals  </li></ul><ul><ul><...
Indications of anti-virals <ul><li>Oseltamivir </li></ul><ul><li>To treat cases. </li></ul><ul><li>To be given to all susp...
Swine Influenza A(H1N1)  Treatment Source: CDC Dosing recommendations for antiviral treatment of children younger than 1 y...
Oseltamivir side effects <ul><li>Generally well tolerated </li></ul><ul><li>Gastrointestinal side effects (transient nause...
Discharge policy <ul><li>Adults </li></ul><ul><ul><li>7 days after symptoms subside </li></ul></ul><ul><li>Children </li><...
Managing close contacts <ul><li>Close Contacts (suspected, probable & confirmed </li></ul><ul><li>cases)  </li></ul><ul><l...
Infection Control Measures <ul><li>Prevention of pig to human transmission </li></ul><ul><li>Health facility measures for ...
Preventing Pig to Human transmission <ul><li>Farmers & Veterinarians </li></ul><ul><li>Encourage face masks </li></ul><ul>...
Managing Human Cases <ul><li>Pre Hospital Care </li></ul><ul><li>Patient </li></ul><ul><ul><li>3-layer surgical mask </li>...
<ul><li>Hospital care </li></ul><ul><li>Patient </li></ul><ul><ul><li>Isolation facility </li></ul></ul><ul><ul><li>3-laye...
Swine Influenza A(H1N1)  O ther Protective Measures <ul><ul><li>Isolation :  sequestration of  symptomatic  patents either...
<ul><li>New strain </li></ul><ul><ul><ul><li>No-one vaccinated or naturally immunised </li></ul></ul></ul><ul><li>Reassort...
MOHFW- Oseltamivir chemoprophylaxis <ul><li>Chemoprophylaxis for health care workers at high risk </li></ul><ul><li>Chemop...
MOHFW- Oseltamivir Mass Chemoprophylaxis <ul><ul><ul><li>The strategy of containment by geographic approach by giving osel...
Timeline of Emergence Influenza A Viruses in Humans 1918 1957 1968 1977 1997 1998/9 2003 H1 H1 H3 H2 H7 H5 H5 H9 Spanish I...
Conclusion/Recommendations <ul><li>At present most of the deaths due to H1N1 strain has been reported from Mexico.   </li>...
Conclusion/Recommendations <ul><li>“ Times-have-changed ”  </li></ul><ul><ul><li>We are much better prepared than 1918. </...
Identified isolation facilities  <ul><li>DELHI </li></ul><ul><li>Yellow Fever Quarantine Centre, Near AAI Residential Colo...
Delhi Nodal Officer <ul><li>DHS Office </li></ul><ul><li>Tel:22307145 </li></ul><ul><li>(24X7) </li></ul><ul><li>Dr.R.P.Va...
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H1N1

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  • The internal antigens (M1 and NP proteins) are the type-specific proteins (type-specific antigens) used to determine if a particular virus is A, B or C. The M1 proteins of all members of each type show cross reactivity. The NP proteins of all members of each type also show cross reactivity. The external antigens (HA and NA) show more variation and are the subtype and strain-specific antigens. These are used to determine the particular strain of influenza A responsible for an outbreak Flu strains are named after their types of hemagglutinin and neuraminidase surface proteins, so they will be called, for example, H3N2 for type-3 hemagglutinin and type-2 neuraminidase. If two different strains of influenza infect the same cell simultaneously, their protein capsids and lipid envelopes are removed, exposing their RNA, which is then transcribed to mRNA. The host cell then forms new viruses that combine antigens; for example, H3N2 and H5N1 can form H5N2 this way. Because the human immune system has difficulty recognizing the new influenza strain, it may be highly dangerous.
  • Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses, and seals. There are 16 different haemaglutinin subtypes and 9 different neuraminidase subtypes, all of which have been found among influenza A viruses in wild birds. Wild birds are the primary natural reservoir for all subtypes of influenza A viruses and are thought to be the source of influenza A viruses in all other animals. Most influenza viruses cause asymptomatic or mild infection in birds; however, the range of symptoms in birds varies greatly depending on the strain of virus. Infection with certain avian influenza A viruses (for example, some strains of H5 and H7 viruses) can cause widespread disease and death among some species of wild and especially domestic birds such as chickens and turkeys. Pigs can be infected with both human and avian influenza viruses in addition to swine influenza viruses. Infected pigs get symptoms similar to humans, such as cough, fever, and runny nose. Because pigs are susceptible to avian, human and swine influenza viruses, they potentially may be infected with influenza viruses from different species (e.g., ducks and humans) at the same time. If this happens, it is possible for the genes of these viruses to mix and create a new virus.
  • Reassortment, or Viral Subunit Reassortment, is the exchange of DNA between viruses inside a host cell. Two or more viruses of different strains (but usually the same species) infect a single cell and pool their genetic material creating numerous genetically diverse progeny viruses. It is a type of genetic recombination. Reassortment can lead to a viral shifts under some conditions.
  • WHO Definition of Phases Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion. Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short. Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way. During the post-peak period , pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave. Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature. In the post-pandemic period , influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required.
  • There seems to be a protective affect with increase in age, suggesting past exposure and immunity in people above the age of 60 years.
  • Highest % Case-Fatality (77.5%) was observed in the 20-54 year age group.
  • For more information about Reye’s syndrome, visit the National Institute of Health website at http://www.ninds.nih.gov/disorders/reyes_syndrome/reyes_syndrome.htm For information on homecare visit: http://www.cdc.gov/swineflu/guidance_homecare.htm
  • Pregnant Women Oseltamivir and zanamivir are &amp;quot;Pregnancy Category C&amp;quot; medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, oseltamivir or zanamivir should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus; the manufacturers&apos; package inserts should be consulted. However, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to women who have received oseltamivir or zanamivir. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Because of its systemic activity, oseltamivir is preferred for treatment of pregnant women.  The drug of choice for prophylaxis is less clear.  Zanamivir may be preferable because of its limited systemic absorption; however, respiratory complications that may be associated with zanamivir because of its inhaled route of administration need to be considered, especially in women at risk for respiratory problems. Adverse Events: http://www.cdc.gov/flu/professionals/antivirals/side-effects.htm
  • Two candidate vaccine the CDC is analyzing contain a mix of genes from the new swine flu virus with components of other viruses that allow them to grow better in the eggs that manufacturers use to produce vaccine. If one or both prove usable, manufacturers could begin producing pilot lots for testing this summer to see if the shots are safe, trigger immune protection and require one dose or two.
  • H1N1

    1. 2. <ul><li>Influenza Virus </li></ul><ul><li>Definitions </li></ul><ul><li>Introduction </li></ul><ul><li>History </li></ul><ul><li>Spread/Transmission </li></ul><ul><li>Timeline/Facts </li></ul><ul><li>Response </li></ul><ul><li>Status Update </li></ul><ul><li>Case-Definitions </li></ul><ul><li>Guidelines </li></ul><ul><li>Treatment </li></ul><ul><li>Other Protective Measures </li></ul><ul><li>Summary </li></ul><ul><li>Timeline of Emergence </li></ul><ul><li>Conclusion & Recommendations </li></ul>OUTLINE
    2. 3. Virus Credit: L. Stammard, 1995 <ul><li>ss RNA, enveloped </li></ul><ul><li>Viral family: Orthomyxoviridae </li></ul><ul><li>Size: </li></ul><ul><li>80-200nm or .08 – 0.12 μm (micron) in diameter </li></ul><ul><li>Three types </li></ul><ul><ul><li>A, B, C </li></ul></ul><ul><li>Surface antigens </li></ul><ul><ul><li>H (haemaglutinin) </li></ul></ul><ul><ul><li>N (neuraminidase) </li></ul></ul>
    3. 5. <ul><li>Epidemic – a located cluster of cases </li></ul><ul><li>Pandemic – worldwide epidemic </li></ul><ul><li>Antigenic drift </li></ul><ul><ul><li>Changes in proteins by genetic point mutation & selection </li></ul></ul><ul><ul><li>Ongoing and basis for change in vaccine each year </li></ul></ul><ul><li>Antigenic shift </li></ul><ul><ul><li>Changes in proteins through genetic reassortment </li></ul></ul><ul><ul><li>Produces viruses not covered by annual vaccine </li></ul></ul>Definitions Aaa a Aaa a
    4. 6. Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature* <ul><li>Hard non-porous surfaces 24-48 hours </li></ul><ul><ul><li>Plastic, stainless steel </li></ul></ul><ul><ul><ul><li>Recoverable for > 24 hours </li></ul></ul></ul><ul><ul><ul><li>Transferable to hands up to 24 hours </li></ul></ul></ul><ul><li>Cloth, paper & tissue </li></ul><ul><ul><li>Recoverable for 8-12 hours </li></ul></ul><ul><ul><li>Transferable to hands 15 minutes </li></ul></ul><ul><li>Viable on hands <5 minutes only at high viral titers </li></ul><ul><li>* Humidity 35-40%, Temperature 28 C (82 F) </li></ul><ul><li>Affects of humidity on infectivity influenza, Loosli et al, 1943 </li></ul>Source: Bean B, et al. JID 1982;146:47-51 Aaa aa Aaa aa
    5. 7. <ul><li>Seasonal Influenza </li></ul><ul><ul><li>Globally: 250,000 to 500,000 deaths per year </li></ul></ul><ul><ul><li>US (per year) </li></ul></ul><ul><ul><ul><li>~35,000 deaths </li></ul></ul></ul><ul><ul><ul><li>>200,000 Hospitalizations </li></ul></ul></ul><ul><ul><ul><li>$37.5 billion economic cost (influenza & pneumonia) </li></ul></ul></ul><ul><li>Pandemic Influenza </li></ul><ul><ul><li>An ever present threat </li></ul></ul>Influenza The Normal Burden of Disease
    6. 8. Swine Influenza A(H1N1) Introduction <ul><li>Outbreaks of influenza among pigs </li></ul><ul><li>Do not normally infect humans </li></ul><ul><li>Human cases of swine flu in people around pigs </li></ul><ul><li>Human-to-human spread documented </li></ul>
    7. 9. Swine Influenza A(H1N1) History in US <ul><li>New Jersey, USA 1976 – </li></ul><ul><li>> 200 cases with serious illness & one death </li></ul><ul><ul><li>>40 million vaccinated </li></ul></ul><ul><ul><li>Program stopped after 500 cases of Guillain-Barre syndrome </li></ul></ul><ul><ul><ul><li>30 people died as a direct result of the vaccination </li></ul></ul></ul><ul><li>1988- 1 female died </li></ul><ul><li>Dec 2005 – Feb 2009- 12 human cases </li></ul>
    8. 10. 2009 Swine Influenza A(H1N1) T ransmission Through Species Reassortment in Pigs <ul><li>NOT REPORTED IN PIGS </li></ul><ul><li>Contains gene segments from </li></ul><ul><li>4 different influenza types: </li></ul><ul><ul><li>North American swine </li></ul></ul><ul><ul><li>North American avian </li></ul></ul><ul><ul><li>North American human and </li></ul></ul><ul><ul><li>Eurasian swine </li></ul></ul>Avian Virus Human Virus Swine Virus Avian/Human Reassorted Virus
    9. 11. Swine Influenza A(H1N1) US Response <ul><li>Congress asked for an additional $1.5 billion </li></ul><ul><li>April 27, 2009- </li></ul><ul><ul><li>CDC travel advisory against all non-essential travel to Mexico </li></ul></ul>Source: CDC
    10. 12. Swine Influenza A(H1N1) Global Response <ul><li>The WHO raises the alert level to Phase 6 </li></ul><ul><ul><li>WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3 </li></ul></ul><ul><ul><li>April 27, 2009: Alert Level raised to Phase 4 </li></ul></ul><ul><ul><li>April 29, 2009: Alert Level raised to Phase 5 </li></ul></ul><ul><ul><li>June 11, 2008: Alert Level raised to Phase 6 (Pandemic Phase) </li></ul></ul>Source: WHO
    11. 13. Pandemic Phases Phase 1-3 Preparedness Phase 5-6 Pandemic
    12. 14. Swine Influenza A(H1N1) May 25, 2009 Status Update <ul><li>GLOBALLY: March 1-May 25 </li></ul><ul><ul><li>27,737 Laboratory confirmed cases, from 74 countries </li></ul></ul><ul><ul><li>144 Deaths among laboratory confirmed cases from 7 countries </li></ul></ul><ul><ul><ul><li>Mexico: 108 deaths </li></ul></ul></ul><ul><ul><ul><li>US: 27 deaths </li></ul></ul></ul><ul><ul><ul><li>Canada: 04 death </li></ul></ul></ul><ul><ul><ul><li>Chile: 02 deaths </li></ul></ul></ul><ul><ul><ul><li>Costa Rica: 01 death </li></ul></ul></ul><ul><ul><ul><li>Columbia: 01 death </li></ul></ul></ul><ul><ul><ul><li>Dominican R: 01 death </li></ul></ul></ul>Source: Secretaria de Salud, Mexico, CDC, Public Health Agency of Canada, European CDC, WHO
    13. 15. Swine Influenza A(H1N1) Mexico Confirmed Case Distribution, by Age Total Number of Confirmed Cases = 6,241* As of June 09, 2009 Source: Secretaria de Salud, Mexico *NOTE: 54 confirmed cases not included
    14. 16. Swine Influenza A(H1N1) Mexico Confirmed Cases & Death, by Age Groups Total Number of Confirmed Cases = 6,241* Deaths = 108 As of June 09, 2009 Source: Secretaria de Salud, Mexico *NOTE: 43 confirmed cases not included 71.3% Deaths
    15. 17. Clinical features <ul><li>Fever </li></ul><ul><li>Myalgia </li></ul><ul><li>Headache </li></ul><ul><li>Cough; respiratory symptoms progress with disease </li></ul><ul><li>Complications </li></ul><ul><ul><li>Primary viral pneumonia </li></ul></ul><ul><ul><li>Secondary bacterial pneumonia </li></ul></ul><ul><ul><li>Exacerbation of bronchial asthma </li></ul></ul>
    16. 18. Case Definitions <ul><li>Case under Investigation </li></ul><ul><li>An individual after 17th of April 2009**, presenting with </li></ul><ul><li>a. high fever >38°C, AND </li></ul><ul><li>b. One or more of the following respiratory symptoms: cough, shortness of breath, body ache, difficulty in breathing, AND </li></ul><ul><li>c. One or more of the following: close contact with a person diagnosed as Influenza A/H1N1 OR </li></ul><ul><li>recent travel to an area reporting cases of confirmed Influenza A/H1N1 </li></ul>
    17. 19. Swine Influenza A(H1N1) US Case Definitions <ul><li>A confirmed case - a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection by one or more of the following tests: </li></ul><ul><ul><li>real-time RT-PCR </li></ul></ul><ul><ul><li>viral culture </li></ul></ul><ul><ul><li>4-fold rise in titers </li></ul></ul><ul><li>A probable case - a person with an acute febrile respiratory illness who is: </li></ul><ul><ul><li>positive for influenza A, but negative for H1 and H3 by influenza RT-PCR, or </li></ul></ul><ul><ul><li>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><ul><li>A suspected case - a person with acute febrile respiratory illness with onset </li></ul><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><ul><ul><li>within 7 days of travel to community either within the United States or internationally where there are one or more confirmed swine influenza A(H1N1) cases, or </li></ul></ul><ul><ul><li>resides in a community where there are one or more confirmed swine influenza cases. </li></ul></ul>Source: CDC
    18. 20. Other definitions <ul><li>Infectious period 1 day prior to the case’s illness onset to 7 days after onset. </li></ul><ul><li>Close contact within about 6 feet of an ill person who is a confirmed or suspected case of influenza A H1N1 virus infection during the case’s infectious period. </li></ul><ul><li>Acute respiratory illness recent onset of at least two of the following: rhinorrhea, sore throat, cough (with or without fever / feverishness) </li></ul><ul><li>High-risk groups : the same for seasonal influenza </li></ul>
    19. 21. High risk groups / Co-morbidities <ul><li><5 yrs; Older age group  65 yr </li></ul><ul><li>pregnancy </li></ul><ul><li>chronic lung disease (eg., COPD, cystic fibrosis,asthma) </li></ul><ul><li>congestive heart failure </li></ul><ul><li>renal failure </li></ul><ul><li>immunosuppression (due to underlying disease or therapy) </li></ul><ul><li>haematological abnormalities (anemia, haemaglobinopathies) </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Chronic hepatic disease </li></ul>
    20. 22. Swine Influenza A(H1N1) <ul><li>Consider swine influenza virus infections in patients presenting with febrile respiratory illness who </li></ul><ul><ul><li>live in areas where human cases of swine influenza A(H1N1) have been identified OR </li></ul></ul><ul><ul><li>have traveled to an area where human cases of swine influenza A(H1N1) has been identified OR </li></ul></ul><ul><ul><li>have been in contact with ill persons from these areas in the 7 days prior to their illness onset </li></ul></ul>Source: CDC
    21. 23. Infectiousness & Incubation period <ul><li>From 1-7 days; more likely 1-4 days. </li></ul><ul><li>More contagious than seasonal influenza. </li></ul><ul><li>2° attack rate of seasonal influenza 5- 15%. </li></ul><ul><li>2° attack rate of H1N1 22- 33%. </li></ul>
    22. 24. Samples for diagnosis <ul><li>Respiratory specimens including: </li></ul><ul><li>bronchoalveolar lavage, tracheal aspirates, </li></ul><ul><li>nasopharyngeal or oropharyngeal aspirates as washes, and </li></ul><ul><li>nasopharyngeal or oropharyngeal swabs </li></ul>
    23. 25. When to collect samples <ul><li>As soon as possible after symptoms begin (preferably first 4-5 days; 10 days- children) </li></ul><ul><li>Before antiviral medications administration </li></ul><ul><li>Even if symptoms began more than 1 wk ago </li></ul><ul><li>Multiple specimens on multiple days could be collected if patient access available </li></ul>
    24. 26. Personal Protective Equipment <ul><li>Before initiating collection of sample; a full </li></ul><ul><li>complement of PPE should be worn </li></ul><ul><li>PPE </li></ul><ul><li>Masks (N-95) </li></ul><ul><li>Gloves </li></ul><ul><li>Protective eye wear (goggles) </li></ul><ul><li>Hair covers </li></ul><ul><li>Boot or shoe covers </li></ul><ul><li>Protective clothing (gown or apron ) </li></ul>
    25. 27. <ul><li>Surgical masks </li></ul><ul><li>High-filtration respiratory mask </li></ul><ul><ul><li>Special microstructure filter disc to flush out particles bigger than 0.3 micron. • oil proof • oil resistant • not resistant to oil </li></ul></ul><ul><ul><li>The more a mask is resistant to oil, the better it is </li></ul></ul><ul><ul><li>N95 mask has 95% efficiency in filtering out particles greater than 0.3 micron under normal rate of respiration. </li></ul></ul><ul><li>Next generation of masks use Nano-technology (blocking particles as small as 0.027 micron) </li></ul>Types of Protective Masks
    26. 28. How to Store Specimens <ul><li>Store specimens at 4 °C before & during transportation within 48 hours </li></ul><ul><li>Store specimens at -70 °C beyond 48 hours </li></ul><ul><li>Do not store in standard freezer – keep on ice or in refrigerator </li></ul><ul><li>Avoid freeze-thaw cycles </li></ul><ul><li>Better to keep on ice for a week than to have repeat freeze and thaw </li></ul>
    27. 30. Swine Influenza A (H1N1) Guidelines for General Population <ul><li>Covering nose and mouth with a tissue when coughing or sneezing </li></ul><ul><ul><li>Dispose the tissue in the trash after use. </li></ul></ul><ul><li>Hand washing with soap and water </li></ul><ul><ul><li>Especially after coughing or sneezing. </li></ul></ul><ul><li>Cleaning hands with alcohol-based hand cleaners </li></ul><ul><li>Avoiding close contact with sick people </li></ul><ul><li>Avoiding touching eyes, nose or mouth with unwashed hands </li></ul>
    28. 31. Treatment principles <ul><li>Early implementation of infection control </li></ul><ul><li>Precautions to minimize spread </li></ul><ul><li>Early identification & </li></ul><ul><li>Prompt treatment to prevent severe disease </li></ul>
    29. 32. Critical Measures <ul><li>Avoiding crowding patients together </li></ul><ul><li>Hand hygiene </li></ul><ul><li>PPE </li></ul><ul><li>Isolation for patient & close contacts </li></ul>
    30. 33. Anti Viral medications <ul><li>Resistant to Amanatidine and Rimanatidine </li></ul><ul><li>Neuraminidase inhibitors available </li></ul><ul><ul><li>Oseltamivir (Tamiflu) </li></ul></ul><ul><ul><ul><li>[ Rs 2250 for ten tablets] </li></ul></ul></ul><ul><ul><li>Zanamivir (Relenza) </li></ul></ul>
    31. 34. Swine Influenza A(H1N1) Treatment <ul><li>No vaccine available </li></ul><ul><li>Use of anti-virals </li></ul><ul><ul><li>illness milder and recovery faster </li></ul></ul><ul><ul><li>Prevent serious flu complications </li></ul></ul><ul><ul><li>Work best if started soon after getting sick (within 2 days of symptoms) </li></ul></ul><ul><li>Warning! Do NOT give aspirin or aspirin-containing products to children or teenagers (up to 18 years old) -- Reye’s syndrome. </li></ul>Source: CDC
    32. 35. Indications of anti-virals <ul><li>Oseltamivir </li></ul><ul><li>To treat cases. </li></ul><ul><li>To be given to all suspect cases and to provide chemoprophylaxis to immediate family and social contacts .   </li></ul>
    33. 36. Swine Influenza A(H1N1) Treatment Source: CDC Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatment dose for 5 days. <3 months: 12 mg twice daily; 3-5 months: 20 mg twice daily; 6-11 months: 25 mg twice daily Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. Recommended prophylaxis dose for 10 days. <3 months: Not recommended unless situation judged critical due to limited data on use in this age group; 3-5 months: 20 mg once daily; 6-11 months: 25 mg once daily Oseltamivir (Tamiflu) Zanamivir (Relenza) Treatment Prophylaxis Treatment Prophylaxis Adults 75 mg capsule twice per day for 5 days 75 mg capsule once per day Two 5 mg inhalations (10 mg total) twice per day Two 5 mg inhalations (10 mg total) once per day Children 15 kg or less: 60 mg per day divided into 2 doses 30 mg once per day Two 5 mg inhalations (10 mg total) twice per day (age, 7 years or older) Two 5 mg inhalations (10 mg total) once per day (age, 5 years or older) 15–23 kg: 90 mg per day divided into 2 doses 45 mg once per day 24–40 kg: 120 mg per day divided into 2 doses 60 mg once per day >40 kg: 150 mg per day divided into 2 doses 75 mg once per day
    34. 37. Oseltamivir side effects <ul><li>Generally well tolerated </li></ul><ul><li>Gastrointestinal side effects (transient nausea, vomiting) with above 300 mg/day. </li></ul><ul><li>Bronchitis, insomnia & vertigo. </li></ul><ul><li>Children- most frequently vomiting. </li></ul><ul><li>Infrequently, abdominal pain, epistaxis, bronchitis, otitis media, dermatitis and conjunctivitis </li></ul><ul><li>No recommendation for dose reduction in patients with hepatic disease. </li></ul><ul><li>Rare - fatal neuro-psychiatric illness in children & adolescents but no scientific evidence </li></ul>
    35. 38. Discharge policy <ul><li>Adults </li></ul><ul><ul><li>7 days after symptoms subside </li></ul></ul><ul><li>Children </li></ul><ul><ul><li>14 days after symptoms subside </li></ul></ul>
    36. 39. Managing close contacts <ul><li>Close Contacts (suspected, probable & confirmed </li></ul><ul><li>cases) </li></ul><ul><li>Advise to remain home (voluntary home quarantine) for at least 7 days after the last contact with the case. </li></ul><ul><li>Monitor fever for at least 7 days. </li></ul><ul><li>Prompt testing and hospitalization when symptoms reported. </li></ul>
    37. 40. Infection Control Measures <ul><li>Prevention of pig to human transmission </li></ul><ul><li>Health facility measures for human cases </li></ul>
    38. 41. Preventing Pig to Human transmission <ul><li>Farmers & Veterinarians </li></ul><ul><li>Encourage face masks </li></ul><ul><li>Major risk factor </li></ul><ul><ul><li>Not using gloves when dealing with sick animals </li></ul></ul>
    39. 42. Managing Human Cases <ul><li>Pre Hospital Care </li></ul><ul><li>Patient </li></ul><ul><ul><li>3-layer surgical mask </li></ul></ul><ul><li>Personnel & Driver </li></ul><ul><ul><li>Full PPE & mask </li></ul></ul><ul><li>Ambulance </li></ul><ul><ul><li>Sanitise Sodium hypochlorite; Quaternary ammonium compounds </li></ul></ul><ul><li>Avoid aerosol generating procedures </li></ul>
    40. 43. <ul><li>Hospital care </li></ul><ul><li>Patient </li></ul><ul><ul><li>Isolation facility </li></ul></ul><ul><ul><li>3-layer surgical masks </li></ul></ul><ul><li>Personnel to use PPE </li></ul><ul><li>Aerosol generating procedures </li></ul><ul><ul><li>Nebulisation, ET, Sputum, suction </li></ul></ul><ul><ul><li>PPE </li></ul></ul><ul><li>Hand hygiene </li></ul><ul><li>Contaminated surfaces; equipments </li></ul><ul><ul><li>70% Ethanol; 5% Benzalkonium chloride; 10% sodium hypochlorite </li></ul></ul>Managing Human Cases
    41. 44. Swine Influenza A(H1N1) O ther Protective Measures <ul><ul><li>Isolation : sequestration of symptomatic patents either in the home or hospital so that they will not infect others </li></ul></ul><ul><ul><li>Quarantine : separation from circulation in the community of asymptomatic persons that may have been exposed to infection </li></ul></ul><ul><ul><li>Social-Distancing : range of non-quarantine measures that might serve to reduce contact between persons, such as, closing of schools or prohibiting large gatherings </li></ul></ul>Source: CDC
    42. 45. <ul><li>New strain </li></ul><ul><ul><ul><li>No-one vaccinated or naturally immunised </li></ul></ul></ul><ul><li>Reassortment virus </li></ul><ul><ul><li>Vaccine distant </li></ul></ul><ul><li>Human to human transmission known </li></ul><ul><ul><li>Unlike Bird Flu </li></ul></ul>Pandemic concerns
    43. 46. MOHFW- Oseltamivir chemoprophylaxis <ul><li>Chemoprophylaxis for health care workers at high risk </li></ul><ul><li>Chemoprophylaxis is advised for contacts with high risk </li></ul>
    44. 47. MOHFW- Oseltamivir Mass Chemoprophylaxis <ul><ul><ul><li>The strategy of containment by geographic approach by giving oseltamivir to every individual in a prescribed geographic limit of 5 km from the epicenter would be applied </li></ul></ul></ul><ul><ul><ul><li>If the virus is lethal and causing severe morbidity and high mortality and </li></ul></ul></ul><ul><ul><ul><li>If the cluster is limited by natural geographic boundaries </li></ul></ul></ul>
    45. 48. Timeline of Emergence Influenza A Viruses in Humans 1918 1957 1968 1977 1997 1998/9 2003 H1 H1 H3 H2 H7 H5 H5 H9 Spanish Influenza H1N1 Asian Influenza H2N2 Russian Influenza Avian Influenza Hong Kong Influenza H3N2 2009 H1 Reassorted Influenza virus (Swine Flu) 1976 Swine Flu Outbreak, Ft. Dix
    46. 49. Conclusion/Recommendations <ul><li>At present most of the deaths due to H1N1 strain has been reported from Mexico. </li></ul><ul><ul><li>The disease, though spreading rapidly across the globe, is of a mild form (exception Mexico) </li></ul></ul>
    47. 50. Conclusion/Recommendations <ul><li>“ Times-have-changed ” </li></ul><ul><ul><li>We are much better prepared than 1918. </li></ul></ul><ul><ul><li>Better surveillance, communication, understanding of infection control, anti-virals, antibiotics and </li></ul></ul><ul><ul><li>advancement in science & resources to produce an affective vaccine </li></ul></ul>
    48. 51. Identified isolation facilities <ul><li>DELHI </li></ul><ul><li>Yellow Fever Quarantine Centre, Near AAI Residential Colony, New Delhi [APHO- 25652129, Dr S.K Singh:09868252314] </li></ul><ul><li>  </li></ul><ul><li>Influenza Ward, Ward no 5, Second Floor, New Building, RML Hospital, Delhi-1 </li></ul>
    49. 52. Delhi Nodal Officer <ul><li>DHS Office </li></ul><ul><li>Tel:22307145 </li></ul><ul><li>(24X7) </li></ul><ul><li>Dr.R.P.Vashist </li></ul><ul><li>(09212222456) </li></ul>

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