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Swine flu

This document discusses swine flu, also known as influenza A subtype H1N1. It provides information on the virus classification, structure, replication stages, and types including seasonal influenza, pandemic influenza, antigenic drift, and antigenic shift. It also summarizes data on swine flu cases and deaths globally and in specific regions. Clinical features, pathogenesis, and definitions of swine flu cases are outlined.

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SWINE FLU Influenza virus H1N1.
Under the guidance of: Dr. S M Mangalkar Asso. Professor Microbiology GMC Latur.
Credit: L. Stammard, 1995 o Viral family: Orthomyxoviridae o Negative sense o Single stranded o Segmented RNA genome. o 5 different genera in this family. o Influenza A o Influenza B o Influenza C o Thogoto virus o ISAvirus VIRUS CLASSIFICATION
CLASSIFICATION…  Different influenza virus strains are named according to their:  Genus (type)  The species from which the virus was isolated. (omitted if human)  The location of the isloate  The number of the isolate  The year of isolate  In case of the Influenza A virus  The hemagglutinnin H subtype  The neuraminidase N subtype.  For example, the 220th isolate of an H5N1 subtype virus isolated from Hong Kong in chickens in 1997 is designated as:  Influenza A/chicken/Hong Kong/97 (H5N1)
Influenza Virus - Types Type A Type B Type C Causes significant disease Causes significant disease Does not cause significant disease Infects humans and other species ! Limited to humans Limited to humans
VIRION STRUCTURE.. The virus has a complex structure and possess: • A lipid bilayer membrane • Surface proteins: • Hemaglutinnin H • Neuraminidase N • M2 protien. • Matrix protein • M1 lies just beneath the envelope • Ribonecleoprotiens: • Polymerase basic 1 PB1 • Polymerase basic 2 PB2 • Polymerase acid PA • Nuclear export protien/ Nonstructural protien. NEP/NS2. • Viral RNA segments. The viral RNA segments are as follows: • PB2 • PB1 • PA • HA • NP • NA • M • NS1
Segmented RNA Function PB2 Component of RNA polymerase Cap recognition. PB1 PB1-F2: Pro apoptotic activity PB1: component of RNA polymerase endonuclease activity elongation. PA Component of RNA polymerase: protease HA Major antigen Surface glycoprotein, receptor binding Fusion activity NP RNA binding RNA synthesis RNA nuclear import NA Surface glycoprotien Neuraminidase activity M M1:Matrix protien Interaction with vRNPs and surface glycoprotiens, nuclear export M2: budding membrane protein ion channel activity. NS1 NS1: multifunctional protein viral INF antagonist NEP/NSP2: nuclear export of vRNPs
H1 N1 H2 N2 H3 N3 H4 N4 H5 N5 H6 N6 H7 N7 H8 N8 H9 N9 H10 H11 H12 H13 H14 H15 H16 Haemagglutinin subtype Neuraminidase subtype
Stages of replication  Attatchment  HA  Sialic acid receptors.  Preferentially binds to the N-acetylneuraminic acid attatched to the penultimate glucose sugar by α 2,6 linkage. (2,3 linkage for avian flu)  Entry and intracellular trafikking  Endocytosis : 4 different mechanisms.  Acidification of the vescile  Fusion of virus and host membranes
 Transcription and Translation and post translational processing  RNPs.  Replication of genomic nucleic acid  vRNA Promoter.  Formation of the ‘Pan handle,RNA fork and Corkscrew ’ structure  Antigenomic RNA to genomic RNA  Assembly and release  Apical plasma membrane of polarised cells  Packaging of 8 RNA segments :  non coding segments  Budding process :M1 protien
Influenza: Normal Burden of Disease  Seasonal Influenza  Globally: 250,000 to 500,000 deaths per year  In the US (per year)  ~35,000 deaths (mainly among people 65 years or older)  >200,000 Hospitalizations  $37.5 billion in economic cost (influenza & pneumonia)  >$10 billion in lost productivity  Pandemic Influenza  An ever present threat
Pathophysiology
 Little is know about what constitutes a typical infectious dose, but is believed to be 127- 320 TCID50.  High affinity for the tracheal cells with sialic acid receptors.  the virus multiplies in bronchial epithelium within 16 hr of infection and causes  focal necrosis of the bronchial epithelium,  focal atelectasis, and gross hyperemia of the lungs.  Epithelial cell damage  Airway plugging  Peribronchial and perivascular mononuclear infiltrates.
Pathogenesis
 Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area.  Pandemic – worldwide epidemic  Antigenic drift  Changes in proteins by genetic point mutation & selection  Ongoing and basis for change in vaccine each year  Antigenic shift  Changes in proteins through genetic reassortment  Produces different viruses not covered by annual vaccine Definitions
Anitgenic Drift  Causes changes in hemagglutinin and neuraminidase of influenza virus due to point mutations  This involves no change in serotype; there is merely an alteration in amino acid sequence of HA or NA leading to change in antigenicity.  Results from positive selection of spontaneous mutants by neutralising antibodies.  Cannot be neutralised by antibodies to parents strain.  Drift variants can cause epidemics and lasts for 2 to 5 years, before being replaced by a different strain.
Antigenic Shift  Involves major antigenic changes in which a new HA or NA subtype is introduced into the human population.  During the last century 4 antigenic shifts have occurred.  1918 Spanish influenza (appearance of H1N1)  1957 Asian Flu (H1N1--- H2N2)  1968 HongKong ( H2N2 --- H3N2)  1977 Russian Flu (Re emergence of H1N1) . • Caused by Reassortment, typically between human and avian and swine strains. • Double reassortment • Triple reassortment. • Second mechanism is the direct transmission of the avian or swine influenza viruses to human and their establishment in human population
Swine Flu  Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs
Transmission Through Species Avian Virus Human Virus Swine Virus Avian/Human Reassorted Virus Reassortment in Pigs
Transmission to Humans  Through contact with infected pigs or environments contaminated with swine flu viruses  Through contact with a person with swine flu  Human-to-human spread of swine flu has been documented also and is thought to occur in the same way as seasonal flu, through coughing or sneezing of infected people
19 7 5 6 1 23 170 85 110 146 207 212 261 436 396 461 422 405 235 485 190 212 181 129 1046 303 330 566 581 936 1231 1066 0 200 400 600 800 1000 1200 1400 18 19 20 21 22 23 25 26 27 28 29 30 32 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Week-2009 NoofConfirmedDeaths Swine Influenza A(H1N1) Global Confirmed Deaths, by Week n=10,863 Source: ECDC * Increase in number of deaths in week 43 due to aggregate reporting of fatal cases from Brazil (week 37-40) & due to batch report of US fatal cases since August 1, 2009 As of December 18, 2009
17 6 326 45 684 73 2 1 26 1 117 23 35 0 200 400 600 800 1000 Afghanistan Bangladesh China (Minland) HongKong SARChina India Japan MacaoSAR China Maldives Mongolia Pakistan SouthKorea SriLanka Taiwan Countries ConfirmedDeaths North-East & South Asia Confirmed Deaths n=1,356 Source: ECDC As of December 18, 2009
Level of Threat  The WHO raises the alert level to Phase 6  WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3  In Late April 2009 WHO announced the emergence of a novel influenza A virus  April 27, 2009: Alert Level raised to Phase 4  April 29, 2009: Alert Level raised to Phase 5  June 11, 2008: Alert Level raised to Phase 6 Source: WHO
Pandemic Influenza Viruses Pandemic Subtype 1889 H2N? 1899 H3N8 1918 H1N1 1957 H2N2 1968 H3N2 1977 H1N1
Circulating Influenza Strains and Pandemics in The 20th Century 1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu” H1N1 H2N2 H3N2 20-40 million deaths 1-4 million deaths 1-4 million deaths
Remergence of H1N1.  Re-emerging infectious Diseases  Diseases’ incidence in human has increased during the last 20 years or threatens to increase in the near future  Infectious agents that have been known for some time, had fallen to such low levels that they were no longer considered public health problems & are now showing upward trends in incidence or prevalence worldwide  From Nov 1977 to mid 1978 young adults suffered from influenza in USSR and China.  Morbidity was almost exclusively limited to persons younger than 25yr of age.  This suggested that older individuals were being protected by pre existing immunity.  This assumption was proven when the causative agent was found to be H1N1. (A/USSR/77).
Swine flu in India  Union Health Ministry data said 1,319 persons have perished due to the disease while the number of persons affected across the states stood at 24,661 as on March 6.  The Ministry had said that 1,289 had died while the number of those affected by it across the states was 23,922 as on March 5 2015.
Swine flu in Maharashtra  As of 11th March 2015 2890 cases have been reported from various parts of maharashtra  235 deaths have been confirmed.
Swine flu: LATUR  Swine flu isolation ward was formed in February 2015.  Total no. of person tested:137  No. of person tested positive:33  No of deaths: 11
Case Definitions A Case under Investigation Individual presenting with • A). High fever >38°C, AND • B). One or more of the respiratory symptoms AND • C). One or more of the following: – Close contact with a person diagnosed as Influenza A/H1N1 OR – Recent travel to an area reporting cases of confirmed Influenza A/H1N1
Case Definitions (cont) Probable Case Defined as a suspected case, with an influenza test that is positive for influenza A Confirmed Case Laboratory confirmed Influenza A/H1N1 virus infection by •Real-time RT-PCR •Viral culture •4-fold rise in H1N1 virus specific neutralizing antibodies
Clinical Features  Short incubation period, usually 1-4 days.  Spread by respiratory droplets  Person to person,  Direct contact, rare aerosol  Highly contagious  infectious period: Adults: 1 day prior to symptoms & 5 days post illness Children: >10 days Immune compromised shed virus for weeks to months  Virus is detectable just before symptom onset.  Usually not detectable after 5-10 days
The illness
Symptoms Symptoms Number (n=268) % Fever 249 93% Cough 223 83% Shortness of breath 145 54% Fatigue/Weakness 180 40% Chills 99 37% Myalgias 96 36% Rhinorrhea 96 36% Sore throat 84 31% Headache 83 31% Vomiting 78 29% Wheezing 64 24% Diarrhea 64 24% Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm
Signs of progressive illness • Persistent high fever beyond 3 days • Dyspnea, cyanosis • Bloody or coloured sputum, chest pain or low blood pressure • Dyspnea, tachypnea in children • Drowsiness, confusion or severe weakness • Dehydration, which can cause dizziness, decreased urine output or lethargy. • Diagnostic testing to confirm the pandemic virus should be prioritized for patients at higher risk for severe illness.
Complications.  Pulmonary complications  Primary viral pneumonia  Combined viral bacterial pneumonia  Secondary bacterial pneumonia.  ARDS  Extra pulmonary complications.  Viremia  Myositis  Cardiac involvement  Reye’s syndrome  CNS involvement  Toxic shock syndrome.
High Risk  Children younger than 2 years  Persons aged 65 years or older  Pregnant females  Persons of any age with chronic medical or immunosuppressive conditions.
Radiological Findings in Severe Disease
Indications for H1N1 Testing a. Radiographically confirmed pneumonia, acute respiratory distress syndrome, or other severe respiratory illness for which an alternate diagnosis has not been established, AND b. Stay or history of travel within 10 days of symptom onset to a place with documented influenza in animal and/or humans
Available Diagnostic Tests1 Influenza Diagnostic Tests Metho d Availabi lity Typical Processing Time 2 Sensitivity 3 for H1N1 influenza Distinguishes H1N1 influenza from other influenza A viruses? Rapid influenza diagnostic tests (RIDT) 4 Antigen det ecti on Wide 0.5 hour 10 – 70% No Direct and indirect Immunofluorescen ce assays (DFA and IFA) 5 Antigen det ecti on Wide 2 – 4 hours 47–93% No Viral isolation in tissue cell culture Virus isol ati on Limited 2 -10 days - Yes 6 Nucleic acid amplification tests (including rRT- PCR) 7 RNA det ecti on Limited 8 48 – 96 hours [6-8 hours to perform test] 86 – 100% Yes
Sample collection.  Respiratory specimens including:  bronchoalveolar lavage,  tracheal aspirates,  nasopharyngeal or oropharyngeal aspirates as washes, and  nasopharyngeal or oropharyngeal swabs.  Swab specimens should be collected only on swabs with a synthetic tip (such as polyester or Dacron) and aluminium or plastic shaft.  Swabs with cotton and wooden shafts are not recommended. Specimens collected with swabs made of calcium alginate are acceptable.
 When to Collect Respiratory Specimens?  As soon as possible after symptoms begin  Before antiviral medications are administered even if symptoms began more than one week ago  Multiple specimens on multiple days could be collected if you have access to patient  Specimen: before initiating collection of sample a full complement of PPE should be worn.  Methods of Collection  • Throat swab  • Nasal / Nasopharyngeal swab
• Throat Swab • Easy to do • Highest yield in detecting H1N1 influenza in suspected cases • Have the patient open his/her mouth wide open. • The patient should try to resist gagging and closing the mouth while the swab touches the back of the throat near the tonsils.
 Nasal / Nasopharyngeal Swab: Insert dry swab into nostril and back to nasopharynx. Leave in place for a few seconds. Slowly remove swab while slightly rotating it. Use a different swab for the other nostril. Put tip of swab into vial containing VTM, breaking applicator’s stick.  Nasal Swab is collected from the anterior turbinate.
 The swabs are collected and put in a viral transport medium (VTM).  How to Label Samples  Label  Specimen No. :  Subject’s unique identification number  Patient’s Name :  Hospital Name :  Use pre-printed barcode* labels:  – On the specimen container  – On the field data collection form  – On the log book  – Subject’s name  – Subject’s unique identification number
Transport of specimen.  All samples should be transported after proper packaging using the standard triple packaging system (WHO) and it should accompany with the clinical details  While transportation cold chain should be maintained
Test centres in India.  Laboratories under the IDSP (NCDC) and ICMR network with capacity of testing Influenza virus  IDSP Network of Laboratories  S.No. Name of Lab  1 Sanjay Gandhi Post Graduate Institute, Lucknow ,U.P  2 Indira Gandhi Medical College, Shimla  3 Haffkines Institute, Mumbai  4 Institute of Preventive Medicine, Hyderabad  5 Kasturaba Medical College, Manipal  6 North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong  7 NIMHANS, Bangalore  8 JIPMER, Puducherry  9 Central Research Institute, Kasauli  10 B.J. Medical College, Ahmedabad  11 National Centre of Disease Control, Delhi.  12 Post Graduate Institute of Medical Education & Research, Chandigarh
 ICMR Influenza Surveillance Network  1. Sher-e-Kashmir Institute of Medical Sciences, Srinagar  2. All India Institute of Medical Sciences, New Delhi  3. National Institute for Cholera & Enteric Diseases, Kolkata  4. Regional Medical Research Centre, Dibrugarh  5. Indira Gandhi Govt. Medical College, Nagpur  6. National Institute of Virology, Pune  7. National Institute of Virology, Allapuzha, Kerala  8. King Institute of Preventive Medicine, Chennai  9. King George Medical University, Lucknow
How Severe It is…..????  Initial estimates of mortality rates from H1N1 infection in Mexico ranged as high as 8%. This is a remarkably high mortality rate when viewed in the context of the 2% mortality rate during the 1918 Spanish Flu pandemic.  Subsequent data from the United States and WHO indicated that the mortality rate from H1N1 infection was probably even lower than the mortality rate expected from seasonal flu.  Data over the ensuing months have confirmed that overall mortality from H1N1 infection is less than 1% and may be less than 0.1%
Management Antivirals  Neuraminidase inhibitors  Oseltamivir (Tamiflu)  Zanamivir (Relenza)  Peramivir  Adamantanes (Not used because of resistance)  Amantadine  Rimantadine Don’t get panic….Treat as simple RTI Bed rest, hydration, analgesic, cough suppressants
Antiviral Treatment  There are two flu antiviral drugs recommended  Oseltamivir or Zanamivir  Use of anti-virals can make illness milder and recovery faster  They may also prevent serious flu complications  For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms)  Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing products (e.g. bismuth subsalicylate – Bismol) to children or teenagers (up to 18 years old) who are confirmed or suspected ill case of swine influenza A (H1N1) virus infection; this can cause a rare but serious Reye’s syndrome. For relief of fever, other anti-pyretic medications are recommended such as acetaminophen or non steroidal anti-inflammatory drugs. Source: CDC
 Treatment is recommended for:  All hospitalized patients with confirmed, probable or suspected H1N1 cases.  Patients who are at higher risk for seasonal influenza complications  If patient is not in a high-risk group or is not hospitalized, healthcare providers should use clinical judgment to guide treatment decisions
Treatment Priority Groups Treatment is recommended for all outpatients with confirmed or suspected influenza if they belong to groups known to be at higher risk. These groups include:  infants  Persons aged 65 years or older;  Pregnant females;  Persons of any age with chronic medical or immunosuppressive conditions.
Importance of the Early Treatment
Chemoprophylaxis • Antiviral Chemoprophylaxis – Post-exposure: can be considered in: • Close contacts of cases (confirmed, probable, or suspected) • Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person (confirmed, probable, or suspected) during that person’s infectious period. – Pre-exposure: Antivirals should only be used in limited circumstances, and in consultation with local medical or public health authorities. Source: CDC
Source: CDC 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 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 Antiviral Protection
Management Issues  ICU care and non availability of ventilatory support systems.  Oseltamivir resistance has been an issue with seasonal influenza A infection and is beginning to emerge in pandemic H1N1.  Zanamivir and asthma  In Extracorporeal membrane oxygenation (ECMO) the patient's large vessels are cannulated, blood pumped through the a membrane that removes CO2 and adds O2, and then returned to the patient. ECMO has traditionally been used in neonates.
Vaccine Protection  H1N1 vaccine available for since Mid-September 2009  H1N1 vaccine is not intended to replace the seasonal flu vaccine – it is intended to be used along-side seasonal flu vaccine  Vaccines:  Inactivated influenza virus vaccines  CSL Ltd. of Australia  Novartis Vaccines of Switzerland  Sanofi Pasteur of France GlaxoSmithKline (GSK) of UK  Sinovac Biotech of China  Live-attenuated virus vaccine  MedImmune LLC of US (nasal-spray)
Vaccine Protection  Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;  Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated.  Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;  All people from 6 months through 24 years of age Source: CDC
 Children from 6 months through 18 years of age because many cases of H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and  Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,  Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
Source: Bean B, et al. JID 1982;146:47-51 Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature*  Hard non-porous surfaces 24-48 hours  Plastic, stainless steel  Recoverable for > 24 hours  Transferable to hands up to 24 hours  Cloth, paper & tissue  Recoverable for 8-12 hours  Transferable to hands 15 minutes  Viable on hands <5 minutes only at high viral titers  Potential for indirect contact transmission *Humidity 35-40%, Temperature 28C (82F)
Biosafety Guidelines  General Biosafety Measures  Clinical samples should be collected by hospital staff and not by the laboratory staff.  All clinical samples have to be collected wearing complete complement of PPE.  While taking samples always use N95 mask.  Use Latex disposable gloves.  Wear laboratory coat/disposable apron.  Always cover your hairs with head cover.  Source: CDC
 Use protective eye wear (goggles)/face shields  The clinical samples should be processed only in designated laboratory having the appropriate containment facilities.  All technical procedures should be performed in a way that minimizes the formation of aerosols and droplets.  Adequate and conveniently located biohazard containers should be available for disposal of contaminated materials.  Work surfaces must be decontaminated after any spill of potentially dangerous material and at the end of the working day. Generally, 5% bleach solutions are appropriate for dealing with biohazard us spillage. More information on disinfections and sterilization is provided in the WHO laboratory biosafety manual.  Personnel must wash their hands often – especially after handling infectious materials and , before leaving the laboratory working areas, and before eating.  Personal protective equipment must be removed before leaving the laboratory.   Appropriate disinfectants  70 per cent ethanol  5 per cent Lysol  10 per cent bleach  .
N95 Mask is effective but must be tight-fitting
 All personnel should self monitor for fever and any symptoms. Symptoms of swine influenza infection include diarrhea, headache, runny nose, and muscle aches  Any illness should be reported immediately  For personnel who had unprotected exposure or a known breach in personal protective equipment to clinical material or live virus from a confirmed case of swine influenza A (H1N1), antiviral chemoprophylaxis with zanamivir or oseltamivir for 7 days after exposure can be considered
 Patients with suspected or confirmed case-status should be placed in a single-patient room with the door kept closed. If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling.  The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Infection Control in ill admitted Persons Source: CDC
 Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Maintain adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions.  Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure. Infection Control in ill admitted Persons Source: CDC
Guidelines for General Population  Covering nose and mouth with a tissue when coughing or sneezing  Dispose the tissue in the trash after use.  Handwashing with soap and water  Especially after coughing or sneezing.  Cleaning hands with alcohol-based hand cleaners  Avoiding close contact with sick people  Avoiding touching eyes, nose or mouth with unwashed hands  If sick with influenza, staying home from work or school and limit contact with others to keep from infecting them
Prevention Respiratory etiquette Cover nose / mouth when coughing or sneezing Hand washing!
Hand Washing  Wet hands with clean (not hot) water  Apply soap  Rub hands together for at least 20 seconds  Rinse with clean water  Dry with disposable towel or air dry  Use towel to turn off faucet
Effective Hand washing
Droplet precautions Surgical Masks N-95 Filtering Masks
Household Cleaning, Laundry, and Waste Disposal • Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste. • Keep surfaces (esp bedside tables, surfaces in the bathroom, children’s toys, phone handles, doorknobs) clean by wiping them down with a household disinfectant . • Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first. • Wash linens (such as bed sheets and towels) by using household laundry soap and tumble dry on a hot setting. Avoid “hugging” laundry prior to washing it to prevent contaminating yourself. Clean your hands with soap and water or alcohol-based hand rub right after handling dirty laundry. • Eating utensils should be washed either in a dishwasher or by hand with water and soap.
Seasonal Influenza A H1N1 (as on 24.02.2015) Action Taken by Ministry of Health and Family Welfare  MOHFW deputed senior level Public Health Teams to highly affected states like gujrat, maharastra, madhya pradesh, karnataka , J&K, west bengal.  Integrated Disease Surveillance Programme (IDSP) and its State units have enhanced the surveillance for Influenza Like Illness (ILI) and Severe Acute Respiratory Infections (SARI)  IDSP assisted lab network of 12 Laboratories are providing laboratory support in terms of testing, quality assurance, guidance, providing viral transport mediums and diagnostic reagents.  The States have been asked to follow the risk categorization followed during the Pandemic.  Rapid Response Teams up to District level and Clinicians from all the States / UTs underwent training during the Pandemic (2009).
In a letter dated 27.02.15. DMER has issued new orders regarding the change in swine flu testing policy. Regular advertisements for do’s and don’ts for Influenza A H1N1are being issued by MOHFW in national and local newspapers. The Outbreak Monitoring Cell of NCDC is functioning round the clock to attend to public queries. The call number is 011-23921401.
Summary • WHO raised the alert level to Phase 6 on June 11, 2009 • Influenza transmission remains active in much of western and central Asia and there is evidence of pandemic virus circulation in most regions of Africa • The overall global case-fatality is ~1% • Symptoms mimic seasonal flu • 1:1 Male:Female Ratio • Globally – Number of deaths being reported is rising • Vaccine – Total Adverse Events: 5.4% (0.3% fatal) – Sanofi Pasteur vaccine recalled due to potency issues • Anti-virals (oseltamivir and zanamivir) – Oseltamivir resistance reported recently in immunocompromised patents
Panic and Fear are much dangerous than Swine Flu
Prevention is better than cure
Thank you
References  http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/flu.htm  http://www.who.int/mediacentre/factsheets/fs103/en/  http://mohfw.gov.in  www.osha.gov  Wright et. al. orthomyxoviridae: the viruses and their replication. Fields texbook of virology. 1409-1448.  Hampton, Tracy. Vaccines Against influenza viruses Viruses Show Promise in Primates Studies. Maedical News and Perspectives. JAMA. Vol. 294 No. 2 July 2005.  Jones, Steven. Live attenuated recombinant vaccine protects nonhuman primates against influenza viruses. Nature Medicine. Vol. 11 No. 7 July 2005.

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Swine flu

  • 1.
  • 2.
    Under the guidanceof: Dr. S M Mangalkar Asso. Professor Microbiology GMC Latur.
  • 3.
    Credit: L. Stammard,1995 o Viral family: Orthomyxoviridae o Negative sense o Single stranded o Segmented RNA genome. o 5 different genera in this family. o Influenza A o Influenza B o Influenza C o Thogoto virus o ISAvirus VIRUS CLASSIFICATION
  • 4.
    CLASSIFICATION…  Different influenzavirus strains are named according to their:  Genus (type)  The species from which the virus was isolated. (omitted if human)  The location of the isloate  The number of the isolate  The year of isolate  In case of the Influenza A virus  The hemagglutinnin H subtype  The neuraminidase N subtype.  For example, the 220th isolate of an H5N1 subtype virus isolated from Hong Kong in chickens in 1997 is designated as:  Influenza A/chicken/Hong Kong/97 (H5N1)
  • 5.
    Influenza Virus -Types Type A Type B Type C Causes significant disease Causes significant disease Does not cause significant disease Infects humans and other species ! Limited to humans Limited to humans
  • 6.
    VIRION STRUCTURE.. The virushas a complex structure and possess: • A lipid bilayer membrane • Surface proteins: • Hemaglutinnin H • Neuraminidase N • M2 protien. • Matrix protein • M1 lies just beneath the envelope • Ribonecleoprotiens: • Polymerase basic 1 PB1 • Polymerase basic 2 PB2 • Polymerase acid PA • Nuclear export protien/ Nonstructural protien. NEP/NS2. • Viral RNA segments. The viral RNA segments are as follows: • PB2 • PB1 • PA • HA • NP • NA • M • NS1
  • 7.
    Segmented RNA Function PB2Component of RNA polymerase Cap recognition. PB1 PB1-F2: Pro apoptotic activity PB1: component of RNA polymerase endonuclease activity elongation. PA Component of RNA polymerase: protease HA Major antigen Surface glycoprotein, receptor binding Fusion activity NP RNA binding RNA synthesis RNA nuclear import NA Surface glycoprotien Neuraminidase activity M M1:Matrix protien Interaction with vRNPs and surface glycoprotiens, nuclear export M2: budding membrane protein ion channel activity. NS1 NS1: multifunctional protein viral INF antagonist NEP/NSP2: nuclear export of vRNPs
  • 8.
    H1 N1 H2 N2 H3N3 H4 N4 H5 N5 H6 N6 H7 N7 H8 N8 H9 N9 H10 H11 H12 H13 H14 H15 H16 Haemagglutinin subtype Neuraminidase subtype
  • 9.
    Stages of replication Attatchment  HA  Sialic acid receptors.  Preferentially binds to the N-acetylneuraminic acid attatched to the penultimate glucose sugar by α 2,6 linkage. (2,3 linkage for avian flu)  Entry and intracellular trafikking  Endocytosis : 4 different mechanisms.  Acidification of the vescile  Fusion of virus and host membranes
  • 10.
     Transcription andTranslation and post translational processing  RNPs.  Replication of genomic nucleic acid  vRNA Promoter.  Formation of the ‘Pan handle,RNA fork and Corkscrew ’ structure  Antigenomic RNA to genomic RNA  Assembly and release  Apical plasma membrane of polarised cells  Packaging of 8 RNA segments :  non coding segments  Budding process :M1 protien
  • 11.
    Influenza: Normal Burdenof Disease  Seasonal Influenza  Globally: 250,000 to 500,000 deaths per year  In the US (per year)  ~35,000 deaths (mainly among people 65 years or older)  >200,000 Hospitalizations  $37.5 billion in economic cost (influenza & pneumonia)  >$10 billion in lost productivity  Pandemic Influenza  An ever present threat
  • 12.
  • 13.
     Little isknow about what constitutes a typical infectious dose, but is believed to be 127- 320 TCID50.  High affinity for the tracheal cells with sialic acid receptors.  the virus multiplies in bronchial epithelium within 16 hr of infection and causes  focal necrosis of the bronchial epithelium,  focal atelectasis, and gross hyperemia of the lungs.  Epithelial cell damage  Airway plugging  Peribronchial and perivascular mononuclear infiltrates.
  • 14.
  • 15.
     Epidemic refersto an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area.  Pandemic – worldwide epidemic  Antigenic drift  Changes in proteins by genetic point mutation & selection  Ongoing and basis for change in vaccine each year  Antigenic shift  Changes in proteins through genetic reassortment  Produces different viruses not covered by annual vaccine Definitions
  • 16.
    Anitgenic Drift  Causeschanges in hemagglutinin and neuraminidase of influenza virus due to point mutations  This involves no change in serotype; there is merely an alteration in amino acid sequence of HA or NA leading to change in antigenicity.  Results from positive selection of spontaneous mutants by neutralising antibodies.  Cannot be neutralised by antibodies to parents strain.  Drift variants can cause epidemics and lasts for 2 to 5 years, before being replaced by a different strain.
  • 17.
    Antigenic Shift  Involvesmajor antigenic changes in which a new HA or NA subtype is introduced into the human population.  During the last century 4 antigenic shifts have occurred.  1918 Spanish influenza (appearance of H1N1)  1957 Asian Flu (H1N1--- H2N2)  1968 HongKong ( H2N2 --- H3N2)  1977 Russian Flu (Re emergence of H1N1) . • Caused by Reassortment, typically between human and avian and swine strains. • Double reassortment • Triple reassortment. • Second mechanism is the direct transmission of the avian or swine influenza viruses to human and their establishment in human population
  • 19.
    Swine Flu  SwineInfluenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs
  • 20.
    Transmission Through Species AvianVirus Human Virus Swine Virus Avian/Human Reassorted Virus Reassortment in Pigs
  • 21.
    Transmission to Humans Through contact with infected pigs or environments contaminated with swine flu viruses  Through contact with a person with swine flu  Human-to-human spread of swine flu has been documented also and is thought to occur in the same way as seasonal flu, through coughing or sneezing of infected people
  • 22.
    19 7 56 1 23 170 85 110 146 207 212 261 436 396 461 422 405 235 485 190 212 181 129 1046 303 330 566 581 936 1231 1066 0 200 400 600 800 1000 1200 1400 18 19 20 21 22 23 25 26 27 28 29 30 32 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Week-2009 NoofConfirmedDeaths Swine Influenza A(H1N1) Global Confirmed Deaths, by Week n=10,863 Source: ECDC * Increase in number of deaths in week 43 due to aggregate reporting of fatal cases from Brazil (week 37-40) & due to batch report of US fatal cases since August 1, 2009 As of December 18, 2009
  • 23.
    17 6 326 45 684 73 2 1 26 1 117 2335 0 200 400 600 800 1000 Afghanistan Bangladesh China (Minland) HongKong SARChina India Japan MacaoSAR China Maldives Mongolia Pakistan SouthKorea SriLanka Taiwan Countries ConfirmedDeaths North-East & South Asia Confirmed Deaths n=1,356 Source: ECDC As of December 18, 2009
  • 24.
    Level of Threat The WHO raises the alert level to Phase 6  WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3  In Late April 2009 WHO announced the emergence of a novel influenza A virus  April 27, 2009: Alert Level raised to Phase 4  April 29, 2009: Alert Level raised to Phase 5  June 11, 2008: Alert Level raised to Phase 6 Source: WHO
  • 25.
    Pandemic Influenza Viruses Pandemic Subtype 1889H2N? 1899 H3N8 1918 H1N1 1957 H2N2 1968 H3N2 1977 H1N1
  • 26.
    Circulating Influenza Strainsand Pandemics in The 20th Century 1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu” H1N1 H2N2 H3N2 20-40 million deaths 1-4 million deaths 1-4 million deaths
  • 27.
    Remergence of H1N1. Re-emerging infectious Diseases  Diseases’ incidence in human has increased during the last 20 years or threatens to increase in the near future  Infectious agents that have been known for some time, had fallen to such low levels that they were no longer considered public health problems & are now showing upward trends in incidence or prevalence worldwide  From Nov 1977 to mid 1978 young adults suffered from influenza in USSR and China.  Morbidity was almost exclusively limited to persons younger than 25yr of age.  This suggested that older individuals were being protected by pre existing immunity.  This assumption was proven when the causative agent was found to be H1N1. (A/USSR/77).
  • 28.
    Swine flu inIndia  Union Health Ministry data said 1,319 persons have perished due to the disease while the number of persons affected across the states stood at 24,661 as on March 6.  The Ministry had said that 1,289 had died while the number of those affected by it across the states was 23,922 as on March 5 2015.
  • 29.
    Swine flu inMaharashtra  As of 11th March 2015 2890 cases have been reported from various parts of maharashtra  235 deaths have been confirmed.
  • 30.
    Swine flu: LATUR Swine flu isolation ward was formed in February 2015.  Total no. of person tested:137  No. of person tested positive:33  No of deaths: 11
  • 33.
    Case Definitions A Caseunder Investigation Individual presenting with • A). High fever >38°C, AND • B). One or more of the respiratory symptoms AND • C). One or more of the following: – Close contact with a person diagnosed as Influenza A/H1N1 OR – Recent travel to an area reporting cases of confirmed Influenza A/H1N1
  • 34.
    Case Definitions (cont) ProbableCase Defined as a suspected case, with an influenza test that is positive for influenza A Confirmed Case Laboratory confirmed Influenza A/H1N1 virus infection by •Real-time RT-PCR •Viral culture •4-fold rise in H1N1 virus specific neutralizing antibodies
  • 35.
    Clinical Features  Shortincubation period, usually 1-4 days.  Spread by respiratory droplets  Person to person,  Direct contact, rare aerosol  Highly contagious  infectious period: Adults: 1 day prior to symptoms & 5 days post illness Children: >10 days Immune compromised shed virus for weeks to months  Virus is detectable just before symptom onset.  Usually not detectable after 5-10 days
  • 36.
  • 37.
    Symptoms Symptoms Number (n=268)% Fever 249 93% Cough 223 83% Shortness of breath 145 54% Fatigue/Weakness 180 40% Chills 99 37% Myalgias 96 36% Rhinorrhea 96 36% Sore throat 84 31% Headache 83 31% Vomiting 78 29% Wheezing 64 24% Diarrhea 64 24% Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm
  • 39.
    Signs of progressiveillness • Persistent high fever beyond 3 days • Dyspnea, cyanosis • Bloody or coloured sputum, chest pain or low blood pressure • Dyspnea, tachypnea in children • Drowsiness, confusion or severe weakness • Dehydration, which can cause dizziness, decreased urine output or lethargy. • Diagnostic testing to confirm the pandemic virus should be prioritized for patients at higher risk for severe illness.
  • 40.
    Complications.  Pulmonary complications Primary viral pneumonia  Combined viral bacterial pneumonia  Secondary bacterial pneumonia.  ARDS  Extra pulmonary complications.  Viremia  Myositis  Cardiac involvement  Reye’s syndrome  CNS involvement  Toxic shock syndrome.
  • 41.
    High Risk  Childrenyounger than 2 years  Persons aged 65 years or older  Pregnant females  Persons of any age with chronic medical or immunosuppressive conditions.
  • 42.
  • 43.
    Indications for H1N1Testing a. Radiographically confirmed pneumonia, acute respiratory distress syndrome, or other severe respiratory illness for which an alternate diagnosis has not been established, AND b. Stay or history of travel within 10 days of symptom onset to a place with documented influenza in animal and/or humans
  • 45.
    Available Diagnostic Tests1 Influenza Diagnostic Tests Metho d Availabi lity Typical Processing Time 2 Sensitivity 3 for H1N1 influenza DistinguishesH1N1 influenza from other influenza A viruses? Rapid influenza diagnostic tests (RIDT) 4 Antigen det ecti on Wide 0.5 hour 10 – 70% No Direct and indirect Immunofluorescen ce assays (DFA and IFA) 5 Antigen det ecti on Wide 2 – 4 hours 47–93% No Viral isolation in tissue cell culture Virus isol ati on Limited 2 -10 days - Yes 6 Nucleic acid amplification tests (including rRT- PCR) 7 RNA det ecti on Limited 8 48 – 96 hours [6-8 hours to perform test] 86 – 100% Yes
  • 46.
    Sample collection.  Respiratoryspecimens including:  bronchoalveolar lavage,  tracheal aspirates,  nasopharyngeal or oropharyngeal aspirates as washes, and  nasopharyngeal or oropharyngeal swabs.  Swab specimens should be collected only on swabs with a synthetic tip (such as polyester or Dacron) and aluminium or plastic shaft.  Swabs with cotton and wooden shafts are not recommended. Specimens collected with swabs made of calcium alginate are acceptable.
  • 47.
     When toCollect Respiratory Specimens?  As soon as possible after symptoms begin  Before antiviral medications are administered even if symptoms began more than one week ago  Multiple specimens on multiple days could be collected if you have access to patient  Specimen: before initiating collection of sample a full complement of PPE should be worn.  Methods of Collection  • Throat swab  • Nasal / Nasopharyngeal swab
  • 48.
    • Throat Swab •Easy to do • Highest yield in detecting H1N1 influenza in suspected cases • Have the patient open his/her mouth wide open. • The patient should try to resist gagging and closing the mouth while the swab touches the back of the throat near the tonsils.
  • 49.
     Nasal /Nasopharyngeal Swab: Insert dry swab into nostril and back to nasopharynx. Leave in place for a few seconds. Slowly remove swab while slightly rotating it. Use a different swab for the other nostril. Put tip of swab into vial containing VTM, breaking applicator’s stick.  Nasal Swab is collected from the anterior turbinate.
  • 50.
     The swabsare collected and put in a viral transport medium (VTM).  How to Label Samples  Label  Specimen No. :  Subject’s unique identification number  Patient’s Name :  Hospital Name :  Use pre-printed barcode* labels:  – On the specimen container  – On the field data collection form  – On the log book  – Subject’s name  – Subject’s unique identification number
  • 51.
    Transport of specimen. All samples should be transported after proper packaging using the standard triple packaging system (WHO) and it should accompany with the clinical details  While transportation cold chain should be maintained
  • 52.
    Test centres inIndia.  Laboratories under the IDSP (NCDC) and ICMR network with capacity of testing Influenza virus  IDSP Network of Laboratories  S.No. Name of Lab  1 Sanjay Gandhi Post Graduate Institute, Lucknow ,U.P  2 Indira Gandhi Medical College, Shimla  3 Haffkines Institute, Mumbai  4 Institute of Preventive Medicine, Hyderabad  5 Kasturaba Medical College, Manipal  6 North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong  7 NIMHANS, Bangalore  8 JIPMER, Puducherry  9 Central Research Institute, Kasauli  10 B.J. Medical College, Ahmedabad  11 National Centre of Disease Control, Delhi.  12 Post Graduate Institute of Medical Education & Research, Chandigarh
  • 53.
     ICMR InfluenzaSurveillance Network  1. Sher-e-Kashmir Institute of Medical Sciences, Srinagar  2. All India Institute of Medical Sciences, New Delhi  3. National Institute for Cholera & Enteric Diseases, Kolkata  4. Regional Medical Research Centre, Dibrugarh  5. Indira Gandhi Govt. Medical College, Nagpur  6. National Institute of Virology, Pune  7. National Institute of Virology, Allapuzha, Kerala  8. King Institute of Preventive Medicine, Chennai  9. King George Medical University, Lucknow
  • 54.
    How Severe Itis…..????  Initial estimates of mortality rates from H1N1 infection in Mexico ranged as high as 8%. This is a remarkably high mortality rate when viewed in the context of the 2% mortality rate during the 1918 Spanish Flu pandemic.  Subsequent data from the United States and WHO indicated that the mortality rate from H1N1 infection was probably even lower than the mortality rate expected from seasonal flu.  Data over the ensuing months have confirmed that overall mortality from H1N1 infection is less than 1% and may be less than 0.1%
  • 55.
    Management Antivirals  Neuraminidase inhibitors Oseltamivir (Tamiflu)  Zanamivir (Relenza)  Peramivir  Adamantanes (Not used because of resistance)  Amantadine  Rimantadine Don’t get panic….Treat as simple RTI Bed rest, hydration, analgesic, cough suppressants
  • 57.
    Antiviral Treatment  Thereare two flu antiviral drugs recommended  Oseltamivir or Zanamivir  Use of anti-virals can make illness milder and recovery faster  They may also prevent serious flu complications  For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms)  Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing products (e.g. bismuth subsalicylate – Bismol) to children or teenagers (up to 18 years old) who are confirmed or suspected ill case of swine influenza A (H1N1) virus infection; this can cause a rare but serious Reye’s syndrome. For relief of fever, other anti-pyretic medications are recommended such as acetaminophen or non steroidal anti-inflammatory drugs. Source: CDC
  • 58.
     Treatment isrecommended for:  All hospitalized patients with confirmed, probable or suspected H1N1 cases.  Patients who are at higher risk for seasonal influenza complications  If patient is not in a high-risk group or is not hospitalized, healthcare providers should use clinical judgment to guide treatment decisions
  • 59.
    Treatment Priority Groups Treatmentis recommended for all outpatients with confirmed or suspected influenza if they belong to groups known to be at higher risk. These groups include:  infants  Persons aged 65 years or older;  Pregnant females;  Persons of any age with chronic medical or immunosuppressive conditions.
  • 60.
    Importance of theEarly Treatment
  • 61.
    Chemoprophylaxis • Antiviral Chemoprophylaxis –Post-exposure: can be considered in: • Close contacts of cases (confirmed, probable, or suspected) • Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person (confirmed, probable, or suspected) during that person’s infectious period. – Pre-exposure: Antivirals should only be used in limited circumstances, and in consultation with local medical or public health authorities. Source: CDC
  • 62.
    Source: CDC 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 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 Antiviral Protection
  • 63.
    Management Issues  ICUcare and non availability of ventilatory support systems.  Oseltamivir resistance has been an issue with seasonal influenza A infection and is beginning to emerge in pandemic H1N1.  Zanamivir and asthma  In Extracorporeal membrane oxygenation (ECMO) the patient's large vessels are cannulated, blood pumped through the a membrane that removes CO2 and adds O2, and then returned to the patient. ECMO has traditionally been used in neonates.
  • 64.
    Vaccine Protection  H1N1vaccine available for since Mid-September 2009  H1N1 vaccine is not intended to replace the seasonal flu vaccine – it is intended to be used along-side seasonal flu vaccine  Vaccines:  Inactivated influenza virus vaccines  CSL Ltd. of Australia  Novartis Vaccines of Switzerland  Sanofi Pasteur of France GlaxoSmithKline (GSK) of UK  Sinovac Biotech of China  Live-attenuated virus vaccine  MedImmune LLC of US (nasal-spray)
  • 65.
    Vaccine Protection  Pregnantwomen because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;  Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated.  Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;  All people from 6 months through 24 years of age Source: CDC
  • 66.
     Children from6 months through 18 years of age because many cases of H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and  Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,  Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
  • 68.
    Source: Bean B,et al. JID 1982;146:47-51 Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature*  Hard non-porous surfaces 24-48 hours  Plastic, stainless steel  Recoverable for > 24 hours  Transferable to hands up to 24 hours  Cloth, paper & tissue  Recoverable for 8-12 hours  Transferable to hands 15 minutes  Viable on hands <5 minutes only at high viral titers  Potential for indirect contact transmission *Humidity 35-40%, Temperature 28C (82F)
  • 69.
    Biosafety Guidelines  GeneralBiosafety Measures  Clinical samples should be collected by hospital staff and not by the laboratory staff.  All clinical samples have to be collected wearing complete complement of PPE.  While taking samples always use N95 mask.  Use Latex disposable gloves.  Wear laboratory coat/disposable apron.  Always cover your hairs with head cover.  Source: CDC
  • 70.
     Use protectiveeye wear (goggles)/face shields  The clinical samples should be processed only in designated laboratory having the appropriate containment facilities.  All technical procedures should be performed in a way that minimizes the formation of aerosols and droplets.  Adequate and conveniently located biohazard containers should be available for disposal of contaminated materials.  Work surfaces must be decontaminated after any spill of potentially dangerous material and at the end of the working day. Generally, 5% bleach solutions are appropriate for dealing with biohazard us spillage. More information on disinfections and sterilization is provided in the WHO laboratory biosafety manual.  Personnel must wash their hands often – especially after handling infectious materials and , before leaving the laboratory working areas, and before eating.  Personal protective equipment must be removed before leaving the laboratory.   Appropriate disinfectants  70 per cent ethanol  5 per cent Lysol  10 per cent bleach  .
  • 71.
    N95 Mask iseffective but must be tight-fitting
  • 73.
     All personnelshould self monitor for fever and any symptoms. Symptoms of swine influenza infection include diarrhea, headache, runny nose, and muscle aches  Any illness should be reported immediately  For personnel who had unprotected exposure or a known breach in personal protective equipment to clinical material or live virus from a confirmed case of swine influenza A (H1N1), antiviral chemoprophylaxis with zanamivir or oseltamivir for 7 days after exposure can be considered
  • 74.
     Patients withsuspected or confirmed case-status should be placed in a single-patient room with the door kept closed. If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling.  The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Infection Control in ill admitted Persons Source: CDC
  • 75.
     Standard, Dropletand Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Maintain adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions.  Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure. Infection Control in ill admitted Persons Source: CDC
  • 76.
    Guidelines for GeneralPopulation  Covering nose and mouth with a tissue when coughing or sneezing  Dispose the tissue in the trash after use.  Handwashing with soap and water  Especially after coughing or sneezing.  Cleaning hands with alcohol-based hand cleaners  Avoiding close contact with sick people  Avoiding touching eyes, nose or mouth with unwashed hands  If sick with influenza, staying home from work or school and limit contact with others to keep from infecting them
  • 77.
    Prevention Respiratory etiquette Cover nose /mouth when coughing or sneezing Hand washing!
  • 78.
    Hand Washing  Wethands with clean (not hot) water  Apply soap  Rub hands together for at least 20 seconds  Rinse with clean water  Dry with disposable towel or air dry  Use towel to turn off faucet
  • 79.
  • 81.
  • 85.
    Household Cleaning, Laundry,and Waste Disposal • Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste. • Keep surfaces (esp bedside tables, surfaces in the bathroom, children’s toys, phone handles, doorknobs) clean by wiping them down with a household disinfectant . • Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first. • Wash linens (such as bed sheets and towels) by using household laundry soap and tumble dry on a hot setting. Avoid “hugging” laundry prior to washing it to prevent contaminating yourself. Clean your hands with soap and water or alcohol-based hand rub right after handling dirty laundry. • Eating utensils should be washed either in a dishwasher or by hand with water and soap.
  • 86.
    Seasonal Influenza AH1N1 (as on 24.02.2015) Action Taken by Ministry of Health and Family Welfare  MOHFW deputed senior level Public Health Teams to highly affected states like gujrat, maharastra, madhya pradesh, karnataka , J&K, west bengal.  Integrated Disease Surveillance Programme (IDSP) and its State units have enhanced the surveillance for Influenza Like Illness (ILI) and Severe Acute Respiratory Infections (SARI)  IDSP assisted lab network of 12 Laboratories are providing laboratory support in terms of testing, quality assurance, guidance, providing viral transport mediums and diagnostic reagents.  The States have been asked to follow the risk categorization followed during the Pandemic.  Rapid Response Teams up to District level and Clinicians from all the States / UTs underwent training during the Pandemic (2009).
  • 87.
    In a letterdated 27.02.15. DMER has issued new orders regarding the change in swine flu testing policy. Regular advertisements for do’s and don’ts for Influenza A H1N1are being issued by MOHFW in national and local newspapers. The Outbreak Monitoring Cell of NCDC is functioning round the clock to attend to public queries. The call number is 011-23921401.
  • 88.
    Summary • WHO raisedthe alert level to Phase 6 on June 11, 2009 • Influenza transmission remains active in much of western and central Asia and there is evidence of pandemic virus circulation in most regions of Africa • The overall global case-fatality is ~1% • Symptoms mimic seasonal flu • 1:1 Male:Female Ratio • Globally – Number of deaths being reported is rising • Vaccine – Total Adverse Events: 5.4% (0.3% fatal) – Sanofi Pasteur vaccine recalled due to potency issues • Anti-virals (oseltamivir and zanamivir) – Oseltamivir resistance reported recently in immunocompromised patents
  • 89.
    Panic and Fearare much dangerous than Swine Flu
  • 90.
  • 91.
  • 92.
    References  http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/flu.htm  http://www.who.int/mediacentre/factsheets/fs103/en/ http://mohfw.gov.in  www.osha.gov  Wright et. al. orthomyxoviridae: the viruses and their replication. Fields texbook of virology. 1409-1448.  Hampton, Tracy. Vaccines Against influenza viruses Viruses Show Promise in Primates Studies. Maedical News and Perspectives. JAMA. Vol. 294 No. 2 July 2005.  Jones, Steven. Live attenuated recombinant vaccine protects nonhuman primates against influenza viruses. Nature Medicine. Vol. 11 No. 7 July 2005.