emerging diseases have taken a toll of human life and existance by doubling our ways of treating and re-treating them

1. Dr. Meely Panda
MBBS, MD
Community Medicine
SWINE FLU

2. CONTENTS
 Burden of the disease
 Natural history of disease
 Lifecycle
 Pathogenesis
 Management (Diagnosis & treatment)
 Future prospects
 Summary

3. BURDEN
 Soon after the outbreak of H1N1 virus in the United States
and Mexico in March 2009, the Government of India started
screening people coming from the affected countries at
airports for swine flu symptoms.
 The first case of the flu in India was found on the
Hyderabad airport on 13 May, when a man traveling from
US to India was found H1N1 positive.
 Subsequently, more confirmed cases were reported and as
the rate of transmission of the flu increased in the beginning
of August, with the first death due to swine flu in India in
Pune panic began to spread.
 As of 24 Aug 2010, 10193 cases of swine flu have been
confirmed with 1835 deaths

4. Influenza Laboratory Surveillance - Information generated on 29/03/2013 06:27:13 by the Global
Influenza Surveillance and Response System (GISRS)

5. Influenza Laboratory Surveillance - Information generated on 29/03/2013 06:27:13 by the Global
Influenza Surveillance and Response System (GISRS)

6. BURDEN
States of India per confirmed deaths
0 deaths
1+ deaths
10+ deaths
100+ deaths
200+ deaths
States of India per confirmed cases
4000+ cases
2000+ cases
1000+ cases
500+ cases
100+ cases
1+ cases

7. BURDEN
At least 30 people have died from swine flu
in Haryana this year with 49 people —diagnosed positive
with H1N1 virus —being quarantined at their homes across
the state. Since January 1, a total of 455 suspected
cases have been tested, out...
http://www.who.int/influenza/gisrs_laboratory/flune
t/charts/en/

8. MAJOR PANDEMICS
observe
d that
pigs
could
also
catch
the
flu..1918
1930 - The virus was isolated
in pigs by Dr. Shoppe - H1N1
- close to the
humanH1N1….North America
1976 - Also circulated in
pigs from Europe and
Asia through a
contamination in Italy
1997 - the swine virus gained
genes from an avian influenza and
another from humans. This triple
rearrangement circulates until
today and it was one of the two
viruses in pigs that gave origin to
the Influenza A (H1N1) in 2009.
The Greek physician
Hippocrates, the "Father of
Medicine", first described
influenza in 412 BC. First
influenza pandemic - 1580
and since then influenza
pandemics occurred every
10 to 30 years.

9. ANTIGENIC VARIATION
Types of Antigenic shift

10. MORPHOLOGY

11. MORPHOLOGY

12. COMPARISON
TYPE A TYPE B TYPE C
Severity of illness ++++ ++ +
Animal reservoir
yes no no
Human pandemics yes no no
Human epidemics yes yes no (sporadic)
Antigenic changes shift, drift drift drift
Segmented genome yes yes yes
Amantadine, rimantidine sensitive no effect no effect
Zanamivir (Relenza) sensitive sensitive No effect

13.  Type A influenza - classified into subtypes depending
on which versions of two different proteins are present
on the surface of the virus.
 For example:
A virus with version 1 of the HA protein and version 2
of the NA protein would be called influenza A subtype
H1N2
= A H1N2
 The influenza A - further classified into strains
 Therefore, an H1N1 strain isolated in California in 2009
is referred to as
= A/California/07/2009 (H1N1).

14. LIFECYCLE

15. Incubation period - 1-7 days.
Communicability - From 1 day before to 7 days after the onset of
symptoms.

16. WHY PIGS???

17. PATHOGENESIS

20. Symptoms Cold Flu
Fever Rare or mild Characteristic, high(100-
102 F); lasts 3-4 days
Headache Rare Prominent
General Aches, Pains Slight Usual; often severe
Fatigue, Weakness Quite mild Can last up to2-3weeks
Extreme Exhaustion Never Early and prominent
Stuffy Nose Common Sometimes
Sneezing Usual Sometimes
Sore Throat Common Sometimes
Chest Discomfort,
Cough
Mild to moderate;
hacking cough
Common; can become
severe
Complications Sinus congestion
or earache
Bronchitis, pneumonia;
can be life-threatening

22. PHASES OF PANDEMIC
Phase 1
No influenza viruses circulating in animals reported to cause
infections in humans
Phase 2
Influenza virus circulating in animals reported to cause
infection in humans
Phase 3
Small clusters of infections in humans, but no human-to-
human transmission
Phase 4
Human-to-human transmission resulting in community-wide
outbreaks
Phase 5
Human-to-human transmission in at least two countries within
one WHO region
Phase 6
Community level outbreaks in at least one other country in a

31. CASE DEFINITION
A suspected case of swine influenza A (H1N1) virus
infection is defined as a person with acute febrile
respiratory illness (fever ≥ 38 0 C) with onset.:
• within 7 days of close contact with a person who is a
confirmed case of swine influenza A (H1N1) virus
infection, or
• within 7 days of travel to community where there are one
or more confirmed swine influenza A(H1N1) cases, or
• resides in a community where there are one or more
confirmed swine influenza cases.

32. A probable case of swine influenza A (H1N1) virus
infection is defined as a person with an acute febrile
respiratory illness who:
• 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
• is positive for influenza A by an influenza rapid test or
an influenza immunofluorescence assay (IFA) plus
meets criteria for a suspected case
• individual with a clinically compatible illness who died
of an unexplained acute respiratory –illness who is
considered to be epidemiologically linked to a
probable or confirmed case.

33. A confirmed case of swine influenza A (H1N1) virus
infection is defined as:
A 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:
• Real Time PCR
• viral culture
• Four-fold rise in swine influenza A (H1N1) virus specific
neutralizing antibodies.

34. DIAGNOSIS
 For confirmation of diagnosis, clinical specimens
such as nasopharyngeal swab, throat swab, nasal
swab, and tracheal aspirate (for intubated patients)
are to be obtained.
 Keep specimens at 4°C in viral transport media until
transported for testing.
 Transported to designated laboratories with in 24
hours.
 If no - stored at -70°C.
 Repeat blood samples after 14 days.

35. Method Rapid
influenza
diagnostic
tests (RIDT)
Direct and
indirect
immunofluore
scence assays
(DFA and IFA)
Viral isolation
in tissue cell
culture
Nucleic acid
amplification
tests
(including rRT-
PCR)
Availability Antigen
detection
Wide
Antigen
detection
Wide
Virus isolation
Limited
RNA detection
Limited
Typical
Processing
Time2
0.5 hour 2 – 4 hours 2 -10 days 48 – 96 hours
Sensitivity3 for
2009 H1N1
influenza
10 – 70% 47–93% - 86 – 100%
Distinguishes
2009 H1N1
influenza from
No No Yes Yes

36. DIAGNOSIS
The samples are to be tested & at present the
following laboratories are the identified
laboratories for this purpose:
 (i) National Institute of Communicable Diseases,
22, Sham Nath Marg, Delhi [Tel. Nos. Influenza
Monitoring Cell: 011-23921401; Director: 011-
23913148]
 (ii) National Institute of Virology, 20-A, Dr.
Ambedkar Road, Pune-411001 [Tel.No. 020-2612

37. NATIONAL INFLUENZA CENTRE
 India - Kasauli Usha Soren Singh National
Influenza Center Central Research Institute
Kasauli (H.P.) India
Fax: +91 (1792) 72016
 India – Mumbai Ranjana Deshmukh Department
of Virology Acharya Donde Marg Parel, Mumbai
India
Fax: +91 (22) 416 1787
 India – Pune A.C. Mishra National Institute
of Virology 20-A Dr Ambedkar Road P.O. Box
11411001 Pune India Fax: +91 (20) 26122669

38. TREATMENT
The guiding principles are:
 Early implementation of infection control
precautions to minimize nosocomical /
household spread of disease
 Prompt treatment to prevent severe illness &
death
 Early identification and follow up of persons at
risk

39. Infrastructure / manpower / material support
 Isolation facilities: if dedicated isolation room is not
available then patients can be cohorted in a well
ventilated isolation ward with beds kept one metre
apart.
 Manpower: Dedicated doctors, nurses and
paramedical workers.
 Equipment: Portable X Ray machine, ventilators,
large oxygen cylinders, pulse oxymeter
 Supplies: Adequate PPE, disinfectants and
medications (Oseltamivir, antibiotics and other

40. Standard Operating Procedures
 Reinforce standard infection control precautions i.e.
all those entering the room must use high efficiency
masks, gowns, goggles, gloves, cap and shoe cover.
 Restrict number of visitors and provide them with
PPE.
 Provide antiviral prophylaxis to health care personnel
managing the case and ask them to monitor their
own health twice a day.
 Dispose waste properly by placing it in sealed
impermeable bags labeled as Bio- Hazard.

41. Oseltamivir is the recommended drug both for
prophylaxis and treatment.
By Weight:
‐ <15kg 30 mg BD for 5 days
‐ 15-23kg 45 mg BD for 5 days
‐ 24-<40kg 60 mg BD for 5 days
‐ >40kg 75 mg BD for 5 days
• For infants:
‐ < 3 months 12 mg BD for 5 days
‐ 3-5 months 20 mg BD for 5 days
‐ 6-11 months 25 mg BD for 5 days
It is also available as syrup (12mg per ml )

42. • Gastrointestinal side effects - transient nausea, vomiting
• Less commonly angina, pseudo membranous colitis &
peritonsillar abscess.
• Rare reports of anaphylaxis and skin rashes.
• Abdominal pain, epistaxis, bronchitis, otitis media,
dermatitis and conjunctivitis have also been observed.
• Rare reporting of fatal neuro-psychiatiric illness in children
and adolescents have been linked, although there is no
scientific evidence for a causal relationship.
Ten tablets of Tamiflu - Rs
450
marketed in India by Cipla

43. Zanamav
ir
Oseltamavir

44. Discharge Policy
 Adult patients should be discharged 7 days after
symptoms have subsided.
 Children should be discharged 14 days after
symptoms have subsided.
 The family of patients discharged earlier should
be educated on personal hygiene and infection
control measures at home; children should not
attend school during this period.

45. Chemo Prophylaxis
 All close contacts of suspected, probable and confirmed
cases.
 Close contacts include household /social contacts, family
members, workplace or school contacts, fellow travelers etc.
 All health care personnels
 Prophylaxis should be provided till 10 days after last
exposure (maximum period of 6 weeks)
By Weight:
- <15kg 30 mg OD
‐ 15-23kg 45 mg OD
‐ 24-<40kg 60 mg OD
‐ >40kg 75 mg OD
For infants:
‐ < 3 months not recommended unless situation judged critical
due to limited data on use in this age group
‐ 3-5 months 20 mg OD
‐ 6-11 months 25 mg OD

46.  All suspected cases, clusters of ILI cases need to be notified
to the State Health Authorities and the Ministry of Health &
Family Welfare, Govt. of India (Director, NICD)
 Outbreak Monitoring Cell (Control Room, NICD): 011-
23921401
 EMR Control room (Ministry of Health and family Welfare: 011-
23061469
 The Nodal Officer in- charge: Dr. Dhruv Chowdhry.

47. VACCINES
 The World Health Organization (WHO)
monitors influenza viruses throughout the world
and recommends which strains are to be
included.
 Trivalent vaccines - 70-80% protection
 It takes 10-14 days to produce active antibody
levels.
 needs to be given annually to provide
protection from the antigenically changed
nature of the prevailing virus.
 In the event of a major antigenic shift liable to
cause a pandemic, a monovalent vaccine
would be prepared.
 Immunisation should be carried out between

48. VACCINE
 It is recommended that vaccines for use in the
2013-2014 influenza season will contain the
following:
 A/California/7/2009 (H1N1)pdm09
 A(H3N2) virus antigenically like the cell propagated
prototype
virus A/Victoria/361/2011.
 B/Massachusetts/2/2012.
 It is recommended that quadrivalent vaccines
containing two influenza B viruses contain the
above three viruses and a B/Brisbane/60/2008.
 Bharat Biotech, a biotechnology firm, announced the
launch of India's first indigenously developed cell

49. Vac
cine
Trade
name
Manufacturer Presentation Age
group
No. of
doses
Route
TIV Fluzone Sanofi Pasteur
0.25 mL prefilled syringe 6–35 m 1 or 2 IM
0.5 mL prefilled syringe ≥36 m 1 or 2 IM
0.5 mL vial ≥36 m 1 or 2 IM
5.0 mL multidose vial ≥6 m 1 or 2 IM
TIV Agriflu Novartis Vaccines 0.5 mL prefilled syringe ≥18 yrs 1 IM
TIV Fluvirin Novartis Vaccines
0.5 mL prefilled syringe
≥4 yrs 1 or 2 IM
5.0 mL multidose vial
TIV Fluarix GlaxoSmithKline 0.5 mL prefilled syringe ≥3 yrs 1 or 2 IM
TIV FluLaval GlaxoSmithKline 5.0 mL multidose vial ≥18 yrs 1 IM
TIV Afluria CSL Biotherapies
0.5 mL prefilled syringe
≥9 yrs 1 IM
5.0 mL multidose vial
TIV Fluzone Sanofi Pasteur
0.1 mL prefilled
microinjection system
18–64 yrs 1 ID
LAIV FluMist MedImmune
0.2 mL prefilled
intranasal sprayer
2–49 yrs 1 or 2 IN

50.  Two doses of trivalent seasonal influenza vaccine are
required to achieve adequate antibody levels in
children under 13 years of age if they have never had
the influenza vaccination before (and all
immunocompromised children under 13 years of age):
 Immunocompetent patients
 Immunocompetent adults, including pregnant women,
and children aged 13 years and over should be given
a single dose of trivalent vaccine.
 Immunocompetent children aged 6 months to 13
years should be given one dose of trivalent seasonal
flu vaccine. They will also need a further dose of
trivalent seasonal influenza vaccine four weeks later if
they have never had seasonal flu vaccination before.

51. The 2011-2012 national policy is that influenza vaccine
should be offered to the following groups:
 All those aged 65 years
and over.
 All those aged 6 months
or over in a clinical risk
group
 Chronic respiratory
disease
 Chronic heart disease
 Chronic renal disease
 Chronic liver disease
 Chronic neurological
disease
 Diabetes
 Immunosuppression
 Pregnancy
 Clinicians, midwives
and nurses, paramedics
and ambulance drivers.
 Occupational therapists,
physiotherapists and
radiographers.
 Primary care providers
such as GPs & nurses.
 Staff who look after
older people in nursing
and care homes.

52.  Is it a good idea to take the flu shot that are being
developed?
 Yes.
 However, it will probably not do much as it may be
unable to generate an immune response in those with
high 25(OH)D levels.
 Two Russian studies, the only such studies in the
world, suggest higher vitamin D levels prevent the
immune response flu shots attempt to generate.
 Dr. Scott Dowell, at the CDC, has known about these
two studies for at least five years.

53. PREVENTION
Personal Protection Equipments
• Gloves
• Mask (high-efficiency mask) / Three layered surgical
mask,
• Long-sleeved gown,
• Protective eyewear (goggles/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.

54. Hand Hygiene
 Single most important measure to reduce the risk of
transmitting infectious organism from one person to other.
 Wash frequently with soap and water / alcohol based
hand rubs/ antiseptic hand wash and thoroughly dried
preferably using disposable tissue/ paper/ towel.
 After contact with respiratory secretions or such
contaminated surfaces.
 Any activity that involves hand to face contact such as
eating/ normal grooming / smoking etc.

56. Respiratory Hygiene/Cough Etiquette
 Cover the nose/mouth with a handkerchief when coughing or
sneezing.
 Perform hand hygiene (e.g., hand washing with non-
antimicrobial soap and water, alcohol-based hand rub, or
antiseptic hand wash) after having contact with respiratory
secretions and contaminated objects/materials.
Staying away
 Stay away from poultry. Keep them secure in cages. Children
out of reach.
 Wash hands if in contact with poultry or poultry products.

57. GISN
 Global influenza virological surveillance has been
conducted through WHO's Global Influenza
Surveillance and Response System (GISRS) for over
half a century.
 Formerly known as the Global Influenza Surveillance
Network (GISN), the new name came into effect
following the adoption of the Pandemic Influenza
Preparedness (PIP) Framework in May 2011.
 WHO GISRS monitors the evolution of influenza viruses
and provides recommendations in areas including
laboratory diagnostics, vaccines, antiviral susceptibility
and risk assessment.
 WHO GISRS also serves as a global alert mechanism
for the emergence of influenza viruses with pandemic
potential.

58. FLU NET----FLUID
 FluNet is a global tool for influenza virological surveillance.
 The virological data entered into FluNet, e.g. number of
influenza viruses detected by subtype, are critical for tracking
the movement of viruses globally and interpreting the
epidemiological data.
 The data is publically available.
 The results are presented in various formats including tables,
maps and graphs.
 The data are provided remotely by National Influenza Centres
(NICs) of the Global Influenza Surveillance and Response
System (GISRS) and other national influenza reference
laboratories collaborating actively with GISRS.
 FluID is a global platform for data sharing that links regional
influenza epidemiological data into a single global database.
 The platform provides connections between existing databases
and can also be used to directly enter data through a web-based
interface, if desired. It complements the existing virological data

59. CONCLUSION
 The 2009 pandemic has brought back attention to an
important question????
 Pigs are transported around the world, bred in locations
with a high density of animals, and in many less
developed places are in direct contact with poultry birds
and their owners.
 These animals have to be monitored and bred with
some control, if we wish to reduce the chances of the
appearance of new dangerous lineages.

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62. THANK YOU