Transcript - WordPress.com

SWINE FLU
DR REJI JOSE.MD.
CONSULTANT PHYSICIAN
TALUK HOSPITAL
THODUPUZHA
DEFINITION

SWINE FLU IS A HIGHLY CONTAGEOUS
ACUTE RESPIRATORY DISEASE OF PIGS
CAUSED BY INFLUENZA A VIRUS, CAN
CAUSE ILLNESS IN MAN ALSO
SWINE FLU IN MAN
SWINE FLU IN MAN

IN MAN THE DISEASE PRESENT AS AN
ABRUPT ONSET OF HIGH FEVER WITH
FEATURES OF ACUTE LOWER
PESPIRATORY INFECTION RAPIDLY
PROGRESSING, HIGHLY CONTAGEOUS
AND IF NOT TREATED IN TIME MAY LEAD
TO SERIOUS CMPLICATIONS OR DEATH
HISTORY OF FLU
PANDEMIC HISTORY

1918-SPANISH FLU-50 MILL
DEATHS.H1N1

1957-ASIAN FLU-1-4 MILL DEATHS.
1968-HONG KONG FLU-1-4 MILL DEATHS.
 NEXT????????????????????????

Iowa State gymnasium, converted into hospital,
1918 flu epidemic
Emergency hospital, Camp Funston, Kansas 1918
Courtesy of National Museum of Health and Medicine
IMPENDING FLU PANDEMIC

WE HAVE TO BE PREPARED TO MEET THE
CHALLENGE, WHICH CAN OCCUR AT ANY
TIME.
THE AGENT
SWINE INFLUENZA-THE AGENT
It is a RNA virus,
 Influenza A virus,
 Natural reservoir-pigs
 Can infect man,
 Shifted virus may cause pandemic

THE AGENT

IT IS INFLUENZA A VIRUS A
Influenza virus A- antigenic variations
ANTIGENIC DRIFT: Gradual antegenic
change over a period
 Involves “point mutations" in genes owing
to selection pressure by immunity in host
population
 Responsible for frequent influenza
epidemics;necessiates reformulation of
influenza vaccines
Influenza virus A- antigenic variations

ANTIGENIC SHIFT: Sudden complete or
major change;
 Results fro genetic recombination of human with
animal/avian virus
 Leads to a novel subtype different from both
parent viruses
 If novel subtype has sufficient genes from H1
viruses which make it readily transmissible from
person to person, it may cause pandemic
SWINE INFLUENZA-THE AGENT
2 surface antigens
HAEMAGGLUTININS(HA)-16 Nos
 Initiates infection following attachment of
virus to susceptible cells
NEURAMINIDASE(NA)-9 Nos
 Different combinations eg H1N1,N5N2 etc
SWINE INFLUENZA-THE AGENT
THE
VIRUS RESPONSIBLE
FOR CURRENT PANDEMIC
IS
H1N1
HOST FACTORS
SEASONAL INFLUENZA -HOST FACTORS
Age & sex
 All ages, both sexes
 Attack rates more among young adults
 High CFR during in high risk cases like old
and very young, DM cases and with other
diseases like COPD
SWINE INFLUENZA –HIGH RISK GROUPS
Infants and young children,
 Elderly,
 Persons of any age with chronic conditions
>COPD
>CVA,
>Renal diseases,
>Immunocompromised,
>Pregnant women.

SEASONAL INFLUENZA -HOST FACTORS
Immunity
 Antibody to H neutralizes the virus
 Antibody to N modifies the infection
 Antibody appear 7 days after the infection,
max in 2 weeks, drops to pre infection
level in 8-12 months
THE ENVIORNMENT
INFLUENZA -ENVIORNMENTAL
FACTORS
Seasonality
 Temperate zone: epidemics occur in winter
 Tropics: epidemics occur in rainy season
 Sporadic cases: any month
Overcrowding
 Enhances transmission
 Higher attack rates in closed population
SWINE INFLUENZA -TRANSMISSION
Mainly airborne
 Droplet infection
 Droplet nuclei
Through direct contact
 Fomites also
PATHOGENESIS
VIRUS INFECT WHOLE OF THE
RESPIRATORY TRACT FROM NASAL
MUCOSA TO ALVEOLI
 Local inflammatory reaction->nasal
congestion, cough, breathlessness
 Systemic body reaction-> Fever,myalgia
etc
 Features of ac lower respiratory infection,

INCUBATION PERIOD
1 TO 7 DAYS
 MORE IN CHILDREN

COMMUNICABILITY

1 DAY BEFORE TO 7 DAYS AFTER THE
INFECTION, MORE IN CHILDREN
CLINICAL FEATURES
SYMPTOMS
Abrupt onset of fever body aches,head
ache and fatigue
 Cough, rhinitis, sore throat
 GI symptoms and myositis common in
young,

FEVER
ABRUPT ONSET
 ABOVE 38° C
 ASSOCIATED BODY PAIN ALSO
 CONTINUE FOR FEW DAYS AND
GRADUALLY DIMINISH
 CHILLS AND RIGOR ALSO
 HEAD ACHE

COUGH
TYPICAL OF LOWER RESPIRATORY
INFECTION
 FEATURES OF UPPER RESPIRATORY
INFECTION IN THE FORM OF NASAL
CONGESTION,RHINORRHOEA, SORE
THROAT.

GIT SYMPTOMS

USUALLY SEEN AS DIARRHOEA, NAUSEA
AND VOMITING
ASSOCITED SYMPTOMS

FATIGUE, WEAKNESS,
SIGNS
Elevated temperature
 Tachycardia
 Tachypnoea
 Crepitations

TEMPERATURE
USUALLY ABOVE 38° C
 CHILLS AND RIGOR CAN OCCUR

INCREASED RESPIRATORY RATE
DUE TO LOWER RESPIRATORY
INFECTION
 CREPITATIONS AND RONCHI ALSO

SWINE INFLUENZA -COMPLICATIONS
Sinus and ear infections,
 Pneumonia, bacterial and viral,
 Myocarditis,
 Pericarditis,
 Encephalitis,
 Febrile seizures in young,
 Worsening of underlying chronic disease

SWINE INFLUENZA –HIGH RISK GROUPS
Infants and young children,
 Elderly,
 Persons of any age with chronic conditions
>COPD
>CVA,
>Renal diseases,
>Immunocompromised,
>Pregnant women.

PROVISIONAL DIAGNOSIS
HISTORY OF CONTACT
 COMING FROM AN ENDEMIC AREA
 SYMPTOMS AND SIGNS OF ACUTE
RESPIRATORY INFECTION WITH HIGH
GRADE FEVER

INVESTIGATIONS
INVESTIGATIONS TO EXCLUDE OTHER
CAUSES OF FEVER WITH SIMILAR
CLINICAL PICTURE
 CONFIRMATION
>REAL TIME PCR
>ISOLATION OF VIRUS IN CULTURE
>FOUR FOLD RISE IN VIRUS SPECIFIC
NEUTRILISING ANTEBODIES

CONFIRMATORY TESTS


The samples are to be tested in BSL-3
laboratory. At present the following
laboratories are the identified
laboratories for this purpose:
National Institute of Communicable
Diseases, 22, Sham Nath Marg, Delhi
[Tel. Nos. Influenza Monitoring Cell:
011-23921401; Director: 011-23913148]
CONFIRMATORY TESTS(CONT)

National Institute of Virology, 20-A, Dr.
Ambedkar Road, Pune-411001 [Tel.No.
020-26124386]
SPECIMEN COLLECTION
For confirmation of diagnosis, clinical
specimens such as nasopharyngeal swab,
throat swab, nasal swab, wash or aspirate,
and tracheal aspirate (for intubated
patients) are to be obtained.
 The sample should be collected by a
trained physician / microbiologist
preferably before administration of the
anti-viral drug

STORAGE AND TRANSPORT
Keep specimens at 4°C in viral transport
media until transported for testing. The
samples should be transported to
designated laboratories with in 24 hours
 If they cannot be transported then it
needs to b stored at -70°C. Paired blood
samples at an interval of 14 days for
serological testing should also be
collected.

DIFERENTIAL DIAGNOSIS
OTHER EFVERS LIKE TYPHOID, COMMON
RESPIRATORY INFECTIONS LIKE AC
BRONCHITIS, CAP, LEPTOSPIROSIS ETC
 COMMON COLD
 AVIAN FLU
 SEASONAL INFLUENZA

SWINE INFLUENZA V/S COMMON COLD
SYMPTOMS
Fever
Head ache
Fatigue
Stuffy nose
Cough
Chest
discomfort
Comlications
INFLUENZA
High 3-4 days
Yes
2-3 weeks
Sometimes
Yes
Yes, may be
severe
Common
COLD
Unusual
Unusual
Mild
Common
Unusual
Mild
Rare
SWINE INFLUENZA V/S INFLUENZA A
SYMPTOMS
SWINE INFLUENZA
INFLUENZA A
FEVER
HEAD ACHE
FATIGUE
COUGH
GIT SYMPTOM
HIGH
SEVERE
>2 WEEKS
YES
MORE
MORE CHANCE
LESSER
MILDER
2 WEEKS
YES
NO
LESS
COMPLICATIONS
SWINE INFLEUNZA VS AVIAN

CLINICAL PICTURE SIMILAR BUT MORE
SEVERE IN AVIAN INFLEUNZA
TREATMENT
EARLY IMPLEMENTATION OF INFECTION
CONTROL
 PROMPT DRUG TREATMENT TO PREVENT
SEVERITY AND DEATH
 EARLY IDENTIFICATION OF PERSONS AT
RISK AND PROTECT THEM

INFECTION CONTROL
INFECTION CONTROL
INFRASTRUCTURE
ISOLATION FACILITIES
 MANPOWER,MEDICAL, NURSING &
PARAMEDICAL STAFF
 EQUIPMENTS- VENTELATORS ETC
 SUPPLIES-PPE, DRUGS

INFECTION CONTROL
Effective Infection Control
Prevents Transmission From.

Patients to health care workers

Patients to patients

Patients to family members
providing care
Swine Influenza Precautions
Contact precautions
Droplet precautions
Airborne Precautions
Precautions for Suspected or
Confirmed Cases

Place patient in a negative air pressure room

To create a negative air pressure room:
 Install exhaust fan and direct air from inside to
an outside area with no person movement

If no air conditioning, open windows in isolation
areas but keep doors closed

Place patients in rooms alone
 Alternative: cohort patients away from other
patient care areas with beds > 1 meter apart
Precautions for Suspected or
Confirmed Cases

Limit number of health care workers,
family members and visitors

Designate experienced staff to provide
care

Limit designated staff to swine influenza
patient care

Teach family and visitors to use PPE
PERONAL PROTECTION
EQUIPMENTS(PPE)

THOSE ENTERING ROOM SHOULD WEAR
PPE
Use of PPE
The medical, nurses and paramedics attending
the suspect/ probable / confirmed case should
wear full complement of PPE .
 Use N-95 masks during aerosol-generating
procedures.
 Perform hand hygiene before and after patient
contact and following contact with contaminated
items, whether or not gloves are worn.
 Sample collection and packing should be done
under full cover of PPE.

PERSONAL PROTECTIVE
EQUIPMENTS
INCLUDE
 HIGH EFFICIENCY MASK
 GOWN
 GOGGLES
 GLOVES
 CAP AND
 SHOE COVER
Personal Protective Equipment
Personal Protection Equipments
Goggles
Personal Protection Equipments
Mask
Personal Protection Equipments
N95 Mask
Personal Protection Equipments
Gown
Protection Equipments Personal
Shoe Cover
Personal Protection Equipments
Gloves
Correct procedure for applying






Follow thorough hand wash
Wear the coverall.
Wear the goggles/ shoe cover/and head
cover in that order.
Wear face mask
Wear gloves
The masks should be changed after
every six to eight hours.
Remove PPE in the following
order:









• Remove gown (place in rubbish bin).
• Remove gloves (peel from hand and discard into rubbish bin).
• Use alcohol-based hand-rub or wash hands with soap and water.
• Remove cap and face shield (place cap in bin and if reusable place
face shield in container for decontamination).
• Remove mask - by grasping elastic behind ears – do not
touch front of mask
• Use alcohol-based hand-rub or wash hands with soap and water.
• Leave the room.
• Once outside room use alcohol hand-rub again or wash hands with
soap and water
Used PPE should be handled as waste as per waste management
protocol
DRUG THERAPY
Neuraminidase Inhibitors
 Oseltamivir
and Zanamivir belongs to
this group.
Mode of action:
These drugs block release of newly
formed virus particles by inhibiting
neuraminidase of virus.
Cont…
Oseltamivir:
 It is given by oral route.
 The drug is excreted unchanged by
kidney. Therefore dose needs to be
reduced if creatin clearance is less
than 30 ml per minute.
 No specific drug interaction has been
reported, although probenecid
reduces its excretion by 50%.
DOSAGE

Dose for treatment is as follows:
 By
Weight:
For weight <15kg
days
 15-23kg
days
 24-<40kg
days
 >40kg
days

30 mg BD for 5
45 mg BD for 5
60 mg BD for 5
75 mg BD for 5
DOSAGE
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

ADVERSE REACTIONS
gastrointestinal side effects (transient
nausea, vomiting) may increase with
increasing doses
 cause bronchitis, insomnia and vertigo.
Less commonly angina, pseudo
membranous colitis and peritonsillar
abscess have also been reported. There
have been rare reports of anaphylaxis and
skin rashes.

ADVERSE REACTIONS
Infrequently, abdominal pain, epistaxis,
bronchitis, otitis media, dermatitis and
conjunctivitis have also been observed.
 Though rare reporting of fatal neuropsychiatiric illness in children and
adolescents have been linked to
oseltamivir

Other Drugs under Evaluation




Peramivir and other cyclopentane derivatives:
A Single injection in mice strongly suppreses
influenza virus.
Dimeric Neuraminidase Inhibitors:
100 times more potent than Zanamivir, opens
possibility of once a week dose possibility.
Ribavarine and Interferon alpha.
Sialidase fusion proteins & siRNAs.
Supportive therapy
IV Fluids.
 Parentral nutrition.
 Oxygen therapy/ ventilatory support.
 Antibiotics for secondary infection.
 Vasopressors for shock

Supportive therapy

Paracetamol or ibuprofen is prescribed for
fever, myalgia and headache. Patient is
advised to drink plenty of fluids. Smokers
should avoid smoking. For sore throat,
short course of topical decongestants,
saline nasal drops, throat lozenges and
steam inhalation may be beneficial.
Supportive therapy
Salicylate / aspirin is strictly contraindicated in any influenza patient due to
its potential to cause Reye’s syndrome.
 The suspected cases would be constantly
monitored for clinical / radiological
evidence of lower respiratory tract
infection and for hypoxia (respiratory rate,
oxygen saturation, level of consciousness).

Supportive therapy
oxygen therapy
 Patients with signs of tachypnea,
dyspnea, respiratory distress and
oxygen saturation less than 90 per
cent should be supplemented with
oxygen therapy.

Supportive therapy
mechanical ventilation
 Patients with severe pneumonia and acute
respiratory failure (SpO2 < 90% and PaO2
<60 mmHg with oxygen therapy) must be
supported with mechanical ventilation

Supportive therapy
ABC, Maintain airway, breathing and
circulation
 Maintain hydration, electrolyte balance
and nutrition

Supportive therapy
mechanical ventilation
 Patients with severe pneumonia and acute
respiratory failure (SpO2 < 90% and PaO2
<60 mmHg with oxygen therapy) must be
supported with mechanical ventilation

STEROIDS
High dose corticosteroids in particular
have no evidence of benefit and there is
potential for harm.
 Low dose corticosteroids (Hydrocortisone
200-400 mg/ day) may be useful in
persisting septic shock (SBP < 90).

ANTEBIOTICS
Suspected case not having pneumonia do
not require antibiotic therapy. Antibacterial
agents should be administered, if
required, as per locally accepted clinical
practice guidelines
 Patient on mechanical ventilation should
be administered antibiotics prophylactically
to prevent hospital associated infections.

DANGER SIGNALS
Adults Need attention if Present
with
Difficulty breathing or shortness of breath
 Pain or pressure in the chest or abdomen
 Sudden dizziness
 Confusion
 Severe or persistent vomiting

Seek emergency medical care.
IF - in Children






In children emergency warning signs that need
urgent medical attention include:
Fast breathing or trouble breathing Bluish skin
color.Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to
be held
Flu-like symptoms improve but then return with
fever and worse cough
Fever with a rash
DISCHARGE
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

EARLY IDENTIFICATION OF
PERSONS AT RISK AND
PROTECTION OF THEM
CHEMOPROPHYLAXISINDICATIONS
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 personnel coming in
contact with suspected, probable or
confirmed cases

CHEMOPROPHYLAXISDURATION

Prophylaxis should be provided till 10 days
after last exposure (maximum period of 6
weeks
CHEMOPROPHYLAXIS- DRUG
Oseltamivir is the drug of choice.
 For weight <15kg
30 mg OD
 15-23kg
45 mg OD
 24-<40kg
60 mg OD
 >40kg
75 mg OD

Oseltamivir
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

Infection control measures at
Individual level
Hand Hygiene
 Hand hygiene is the single most important
measure to reduce the risk of transmitting
infectious organism from one person to other.
 Hands should be washed frequently with soap
and water / alcohol based hand rubs/ antiseptic
hand wash and thoroughly dried preferably
using disposable tissue/ paper/ towel.

Respiratory Hygiene/Cough
Etiquette
Cover the nose/mouth with a
handkerchief/ tissue paper when coughing
or sneezing;
 Use tissues to contain respiratory
secretions and dispose of them in the
nearest waste receptacle after use;

Cover your mouth and nose.

Cover your mouth
and nose with a
tissue when coughing
or sneezing. It may
prevent those around
you from getting sick
Simple measures carry get good
Benefits

Cover your mouth
and nose. Use a
tissue when you
cough or sneeze and
drop it in the trash. If
you don’t have a
tissue, cover your
mouth and nose as
best you can.
Staying away
Stay away from pigs. Keep them secure in
cages. Keep children out of reach.
 Wash hands if in contact with pig or pig
products.
 Stay at least one metre away from a
person having cough or sneeze

Stay home when you are sick.

If possible, stay home
from work, school,
and errands when you
are sick. You will help
prevent others from
catching your illness.
Use of mask

Persons under investigations / suspected
cases managed at home and there family
contacts are trained on using three
layered surgical masks.
Guidelines for waste disposal
All the waste has to be treated as
infectious waste and decontaminated as
per standard procedures
 Articles like swabs/gauges etc are to be
discarded in the Yellow coloured
autoclavable biosafety bags after use, the
bags are to be autoclaved followed by
incineration of the contents of the bag.

CARRY HOME MESSAGE
SWINE FLU IN MAN IS A HIGHLY
CONTAGEOUS DISEASE
 IF DIAGNOSED IN TIME, TREATED
PROPERLY, AND PROTECTING HEALTH
CARE STAFF AND CONTACTS, PANDEMIC
MAY BE CONTAINED

THANK YOU