swine flu, treatment , vaccination, vaccination in copd

1. SWINE FLU
By Dr. Ashish kumar
Santosh Hospital , Chest and T.B dept.

2. SWINE FLU
 Introduction
 Epidemiology
 Sign and symptom
 Diagnosis
 Prevention
 Treatment
 Vaccination
 Guidelines on Infection control Measures

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

5. 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.

6. COUNTRIES AFFECTED TILL NOW

7. 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

10. 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 %

11. 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.)

12. 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.

13. 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

15. 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

16. INFLUENZA -A
 Two proteins on the surface of the virus
 Hemagglutinin (H)
 16 subtypes
 Neuraminidase (N)
 09 subtypes

18. 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

19. 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.

20. 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

21. ANTIGENIC SHIFT INITIATES
PANDEMICS

22. MECHANISM OF ANTIGENIC SHIFT

23. 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

24. 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.

25. 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.

26. 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

27. 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)

28. CLINICAL
PRESENTATION
AND
COMPLICATIONS
OF FLU
Ghebrehewet S et al. BMJ. 2016 Dec 7;355:i6258.

29. SYMPTOMS
 Mild or uncomplicated illness

30. PROGRESSIVE ILLNESS
 typical symptoms
 chest pain
 poor oxygenation
(eg, tachypnea)
 cardiopulmonary insufficiency
 central nervous system (CNS) impairment (eg,
confusion, altered mental status)
 severe dehydration

31. 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.

32. LABORATORY FINDINGS
 Elevated SGOT/SGPT
 Anemia
 Leukopenia
 Thrombocytopenia /Thrombocytosis
 Elevated total bilirubin
 Elevations of CPK ,LDH

34. 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.

35. 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

36. 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.

37. DIAGNOSTIC ASSAYS
 Combined nasopharyngeal
and throat swabs (CNTS)
 Nasopharyngeal
aspirates (NPA)

40. 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

41. 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.

42. 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

43. HAND WASHING A TOP PRIORITY
 Single most important
measure to reduce the
risk of transmitting
infectious organism
from one person to
other

44. 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

45. TOUCHING FACE REGIONS CAN FASTER THE
SPREAD
 Avoiding touching your
eyes, nose or mouth.
Virus can spread this way
in a faster way

46. STAYING HOME IF YOU ARE SICK

47. AVOID CROWDED PLACES MORE SO WITH
YOUNG CHILDREN

48. 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) .

49. INFECTION CONTROL MEASURES AT HEALTH
FACILITY
 Droplet Precautions
 Visual alerts
 Use of PPE
 Decontaminating contaminated surfaces, fomites and
equipments
 Guidelines for waste disposal

50. 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

51. 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

52. Treatment of H1N1

53. Treatment
• Adamantane agents
– Amantadine
– Rimantadine
• Neuraminidase inhibitor
– Oseltamivir (oral)
– Zanamivir (aerosolized)
– Peramivir (intravenous)

54. CDC recommends
• Treatment and prevention of H1N1/seasonal flu
• Neuraminidase inhibitor
– Oseltamivir (oral)
– Zanamivir (aerosolized)

55. 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

56. 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

57. 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

58. 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

59. • Treatment should be started as soon as possible
after illness onset
– Ideally within 48 hrs

60. 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

61. 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

62. • 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

63. 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

64. 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

65. 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

66. COPD & INFLUENZA

67. 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.

68. 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

69. 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

70. 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

71. Should Patients With COPD Be
Vaccinated?
RESPIRATORY CARE • FEBRUARY 2015 VOL 60 NO 2

72. 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

73. 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

74. 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.

75. INFLUENZA VACCINATION

76. 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

77. VRBPAC: vaccines and related
Biological products advisory
Committee, part of FDA

78. Influenza Vaccine Manufacturing
Cycle

79. 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

80. 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

81. 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

82. 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

84. 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

85. 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

86. 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

87. 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

88. 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

89. 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

90. Need of a Quadrivalent vaccine

91. • 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

92. Influenza vaccines effectiveness decreases when
antigens in the vaccine do not match, those of
circulating strains

93. 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

94. 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

95. 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

97. 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

98. 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

99. 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

100. 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

101. 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

102. 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

103. 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

104. 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

105. 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

106. 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

107. Panic and Fear are much dangerous than
Swine Flu