The document provides an overview of swine flu, including: 1) It defines suspected, probable, and confirmed cases of swine flu based on symptoms, exposure history, and test results. 2) The symptoms of swine flu in humans are similar to seasonal flu and include fever, cough, sore throat, and body aches. Complications can include pneumonia and worsening of chronic conditions. 3) As of July 2009, the WHO had confirmed over 94,000 cases in 122 countries with 429 deaths related to the new H1N1 virus.

1. Swine Flu & Overview
Dr.Sushmita Ghosh
Registrar Dept.of Pediatrics
Dr.S.K.Saha(moderator)
Senior Consultant
J.L.N.H. & R.C. Bhilai Steel Plant

2. Clinical Features & Complications

3. Case Definitions
 Suspected Case-
defined as a person with acute febrile
respiratory illness (fever≥38ºC) with onset:
Within 7 days of close contact with a person who
is a confirmed case of swine influenza(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

4. Probable Case-
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 immunoflourescence assay(IFA) plus meet
criteria for a suspected case.
► Individual with clinically compatible illness who died of an
unexplained acute respiratory illness who is considered
to be epidemiologically linked to a probable or confirmed
case

5. Confirmed Case:
defined as a person with an acute febrile 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 neutralising antibodies

6.  Close Contact:
defined as within 6 feet of an ill person who is a
confirmed or suspected case of swine influenza
A(H1N1) virus infection.
 Acute Respiratory Illness:
defined as recent onset of at least two of the
following:
-rhinorrhoea or nasal congestion
-sore throat
-cough(with or without fever or feverishness)

7. Ordinary flu and pandemic flu – the
differences
Pandemic Flu Ordinary Flu
Occurs during any season Occurs every yr during winter
Affects almost half of the Affects 10-15% of world
population population,
Is a more serious infection Most recover in 1-2 wks without
treatment
Vaccine not available(new strain) Virus identified & vaccine available
in advance(protective)
People of all ages at risk of
infection
Antiviral med.stockpiled to treat
people

9. Symptoms & Signs in Swine
 In pigs influenza infection produces
fever, lethargy, sneezing, coughing
, difficulty breathing and decreased
appetite.
 In some cases the infection can
cause abortion.
 Although mortality is usually low,
the virus can produce weight loss
and poor growth
 Infected pigs can loose up to 12
pounds of body weight over a
3 to 4 week period

10. Signs and symptoms
 Symptoms of novel H1N1 flu in
people are similar to those
associated with seasonal flu.
 Fever
 Cough
 Sore throat
 Runny or stuffy nose
 Body aches
 Headache
 Chills
 Fatigue
 In addition, vomiting(25%) and
diarrhea (25%) have been
reported. (Higher rate than for
seasonal flu.)

12. Watch for Emergency Warning Signs
Most people should be able to recover at home, but watch for
emergency warning signs that mean you should seek immediate
medical care.
In adults:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting
Flu-like symptoms improve but then
return
with fever and worse cough

13. Emergency warning signs in children
If a child gets sick and experiences any of these warning signs, seek
emergency medical care.
In children:
 Fast breathing or trouble breathing
 Bluish or gray skin color
 Not drinking enough fluids
 Severe or persistent vomiting
 Not waking up or not interacting
 Irritable, the child does not want to be held
 Flu-like symptoms improve but then return
with fever and worse cough

14. Transmission
Transmission between pigs
 The main route of transmission is through direct contact
between infected and uninfected animals.
 These close contacts are particularly common during
animal transport.
 The direct transfer of the virus probably occurs either by
pigs touching noses, or through dried mucus.
 Airborne transmission through the aerosols produced by
pigs coughing or sneezing are also an important means
of infection.

15. Transmission to humans
Through contact with infected pigs or
environments contaminated with swine flu
viruses(zoonosis)
Through contact with a person with swine flu

16. How does novel H1N1 Influenza
spread?
 This virus is thought to 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

17. Can you get novel H1N1 Influenza from
eating pork?
No. The novel H1N1 influenza virus
(formerly referred to as swine flu) virus is
not spread by food.
You cannot get novel H1N1 flu from
eating pork or pork products. Eating
properly handled and cooked pork
products is safe

18. High Risk Groups
Children younger than 5 years old. (more in <2 yrs old)
Adults 65 years of age and older.
Persons with the following conditions:
Chronic pulmonary (including asthma), cardiovascular
(except hypertension), renal, hepatic, hematological
(including sickle cell disease), neurologic,
neuromuscular, or metabolic disorders (including
diabetes mellitus);
Immunosuppression, including that caused by
medications or by HIV;
Pregnant women
Persons younger than 19 years of age who are receiving
long-term aspirin therapy
Residents of nursing homes and other chronic-care
facilities.

19. Complications
Bacterial Pneumonia
Ear infection(otitis media)
Sinus infection
Croup
Bronchiolitis
Status asthmaticus
Myocarditis
Pericarditis
Myositis
Rhabdomyolysis
contd.

20. Complications
Encephalitis
Seizures
Toxic Shock Syndrome
Dehydration
Worsening of chronic medical conditions
,such as CHF ,asthma & diabetes

21. Pneumonia
+
Respiratory Failure
SIRS
Hypotension
decreased oxygenation
& perfusion to brain,heart,kidneys

22. Cause of Death
The most common cause of death is
Respiratory Failure
Other causes-
-Pneumonia(leading to sepsis)
-High fever
-Dehydration
Fatalities are more likely in young children
and the elderly

24. INFLUENZA
What is Influenza(also called Flu)?
The flu is a contagious respiratory
illness caused by influenza viruses.It can
cause mild to severe illness, and at times
can cause death.

25. What is an epidemic, an endemic and a
pandemic?
An epidemic is a sudden outbreak of
disease that spreads through a single
population or region in a short amount of
time.
An endemic is when in a population
infection is maintained without the need for
external inputs.

26. A pandemic occurs when there is a
rapidly-spreading epidemic of a
disease that affects most
countries and regions of the
world.

27. History
 Greek physician Hippocrates“ Father of
medicine” first described influenza in 412 BC
 The first Influenza pandemic was recorded in
1580 and since then influenza pandemics
occurred every 10-30 years
 Influenza pandemics occurred in 1729-
1730,1732-1733,1781-1782,1830,1833-
1834,1847-1848.

28. SPANISH FLU 1918

29. SPANISH FLU 1918

30. Pandemics of 20th century

32. Inter epidemic phase
Phase 1 : No new subtype
human infection may be present
in animals
Phase 2 : No new subtype
circulating animal infection

33. Pandemic alert period
Phase 3 : Human infection with a new
subtype.
No human to human spread
Phase 4 : Small clusters with limited human
to human transmission.

34. Pandemic phase
Phase 5 : large clusters with human to
human transmission.
Phase 6: Increased & sustained
transmision with spread to
different continents.

36. Novel H1N1 Influenza
First identified in april 2009
Mutation of 4 known strains of influenza
virus
Outbreak began in Mexico
Transmission is human to human
Not transmitted by eating foods

38. Agent- genetic sequencing shows a new
subtype of influenza A(H1N1) virus with
segments from four influenza viruses:
-North American Swine
-North American Avian
-Human Influenza
-Eurasian Swine

39. Host factors- otherwise healthy young
adults
Transmission- Droplet infection and
fomites
Incubation Period - 1-7 days
Communicability- From day 1 before to 7
days after the onset of symptoms.

40. CDC expects that more cases, more hospitalizations, and
more deaths from this outbreak will occur over the coming
days and months.
 Influenza is always serious – each year in the United
States, seasonal influenza results, on average, in an
estimated 36,000 deaths and more than 200,000
hospitalizations from flu-related causes.
 This outbreak certainly poses the potential to be at least as
serious as seasonal flu, if not more so, especially given the
fact that there currently is no vaccine against this virus.
 Because this is a new virus, most people will not have
immunity to it, and illness may be more severe and
widespread as a result.

43. WHO Update
Last WHO update on july 6 ,2009
94,512 confirmed cases
122 countries
429 deaths
In U.S. as of july 17,2009
40,617 confirmed cases
263 deaths

44. Indian scenario until Monday
Total 1707 cases reported
New cases 152
Cured 694
230 positive cases in Pune
Total no.of deaths so far 24

45. Influenza Virus-Microbiological Aspect

47. Genomic Segments of Influenza A
Virus

48. Antigenic Variation
 Unique Feature: HA, NA undergo
independent antigenic variation
Antigenic Drift
Antigenic Shift
 Drift: gradual sequential change in
antigenic structure, occurring regularly
at freq. intervals.New ags though diff.
from the prev. ags are yet related to
them-cause periodical epidemics.

49.  Shift: Abrupt, drastic, discontinuous variation
in the antigenic structure resulting in a novel
virus strain unrelated antigenically to
predecessor strains-may involve both HA and
NA.
 Antibodies to predecessor viruses do not
neutralise the new variants, therefore spread
widely in the popn causing major epidemics
or pandemics.
 Present strain influenza 2009 A/ H1N1 is a
rare recombination of gene segments from
swine with avian and human influenza
strains.

51. Laboratory diagnosis
Demo of the virus antigen
• Direct detection
Microscopy
Ag detection
Nucleic Acid analysis
Nucleic Acid Act. Assay
Isolation
• Culture
Serological test

52. Direct Detection
Microscopy-EM
Ag Detection
NA activity assay-rarely used
NA analysis-RT-PCR

53. Isolation
 Culture-Cell culture, chick embryo
Identification and Typing
 HAI,Elisa
Serologic tests
 Four fold rise in ab titre

55. Principles of Management
1. Prevention of spread of disease from
patient to others,
2. Prompt treatment to prevent severe
illness and death,
3. Early identification and follow up of
suspected cases.

56. Infra structure/ Man power/ Material support
1. Isolation ward - Well ventilated
- Beds one meter apart
2. Man Power - Dedicated doctors
- Nurses
- Paramedical staff
1. Equipments - Portable X-Ray machine
- Oxygen
- Pulse Oxymeter
- Ventilator
1. Material - PPE, disinfectants, medicines

57. Standard Operating Procedures
1. Standard infection control precautions – PPE for all contacts
 High efficiency mask Three layer surgical mask
N- 95 mask
 Gowns
 Goggles
 Gloves
 Caps
 Shoe cover
2. Restrict number of visitors
3. Antiviral treatment and prophylaxis
4. Proper waste disposal

58. Anti Viral Treatment
 Oseltamivir (Tamiflu)
 Recommended by WHO
 For treatment and prophylaxis
 Adult dose -75 mg. BD
 Supervised govt. supply
 Other drug – Zanamivir (Relenza)

59. Doses Of Oseltamivir
By Weight:
 For 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 )
 If needed dose & duration can be modified as per clinical condition.

60. Chemoprophylaxis
 All close contacts of suspected , probable and
confirmed cases. Close contacts include
household/social contact , family members , work
place or school contacts, fellow travelers etc.
 All health care personnel coming in contact with
suspected , probable or confirmed case.
 Drug recommended - Oseltamivir
 Mass chemoprophylaxis

61. Doses of Oseltamivir for chemoprophylaxis
 Prophylaxis should be provided till 10 days after last exposure (maximum period
of 6 weeks)
By Weight:
 For 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

62. Side Effects of Oseltamivir
Generally well tolerated
Mild - Nausea , vomiting , pain in abdomen
- Vertigo , insomnia
- Bronchitis , epistaxis
Less common - Angina
- Pseudomembranous colitis
- Peritonsillar abscess
Rare - Anaphylaxis
Pregnancy - Risk benefit analysis

63. Supportive
 Plenty of oral fluids
 I . V. fluids
 Parenteral nutrition
 Oxygen
 Antibiotics for secondary bacterial infection
 Steam inhalation
 Paracetamol / ibuprofen
 Vasopressors for shock
 Mechanical ventilation

64. Avoid
 Aspirin
 Steroids
 Smoking
 Cough suppressants

65. Indication of Oxygen Therapy
Dyspnoea
Tachypnoea
SpO2 < 90%

66. Indication of Mechanical Ventilation
 Severe pneumonia
 Acute respiratory failure
 SpO2 < 90% with oxygen
 PaO2 < 60mm Hg with oxygen
 Invasive ventilator – Preferred
 Hepafilters on expiratory ports
 Prophylactic antibiotic

67. Admission Policy
 Severe - Admission
 Mild - Option of hospitalisation or isolation and
treatment at home
Home
 Well informed consent
 Guidelines to patient and household contact
 Treatment to patient
 Chemoprophylaxis to household contacts
 Strict home quarantine
 Children should not attend school
Not for passengers at the point of entry

68. CDC Guidelines for school
Inform students &parents about symptoms
Refer students with flu like symptoms
Use home isolation
Monitor closely
Consult with local authorities

69. Discharge Policy
 Adults – 7 days after symptoms have
subsided
 Children - 14 days

70. Management of close contacts
 Voluntary home quarantine x 7 days
 Monitor for fever
 Prompt testing and hospitalisation sos
when symptoms reported
 All suspected cases need to be notified to
the state health authorities

71. Every day steps
Cover your nose & mouth
Wash your hands often with soap & water
Avoid touching your nose,mouth & eyes
Avoid close contact with sick people
If sick with flu like symptome stay home for at
least 24 hrs after fever is gone.

72. SOP for Infection control
Pre-Hospital Care
 Three layer surgical mask for patient
 Avoid aerosol generating procedure
 Ambulance attendant – PPE
- N 95 mask
 Ambulance driver - Three layer mask
 Cleaning of ambulance interior by sodium
hypochlorite
 Proper waste disposal

73. During Hospital care
 Admit in isolation ward
 Three layer mask for patient
 Doctors , nurses , paramedical staff – PPE
- N-95 mask
 Aerosol generating procedures with PPE and N95 mask
 Hand hygiene
 Cleaning of patient’s room, contaminated surface and
equipments daily by 5% Lysol / 10% sodium hypochlorite
 Proper waste disposal

74. N-95 mask

75. Three layer surgical mask

76. How to prevent disease spread ?
 Home quarantine
 Defer nonessential travel
 Entry screening to all air ports / ports
 Air port / port quarantine
 Community quarantine
 Social distancing measure –closure of school , college ,
cinema hall , market , shopping mall
Avoid mass gathering like festivals , marriage , sports ,
religious , political & funeral

77. Quarentine
If flu like symptomes stay home for 24 hrs
after symptomes have subsided
Confirmed case on temiflu isolate for 3 days
Confirmed case without drug isolate for 7
days

78. Vaccine
Seasonal Influenza vaccine is not effective against H1 N1

79. State Control Room
State Surveillance Unit
Directorate Health Services
Old Nurses Hostel , D.K.S. Mantralaya Campus,
Raipur
0771-2220011 ( 24 x 7 )

80. Thank you