Transcript SWINE INFLUENZA

Fore More Lectures www.medicalppt.blogspot.com
What is it?
What can I do?
An Indian perspective!
Dr. T.R.Chandrashekar
Director critical care
Dr. N.K. RAGHURAM
Fellow in CCM
K.R HOSPITAL
Bengaluru, India
Fore More Lectures www.medicalppt.blogspot.com
What do we do?
• We have recorded 24 deaths
• We have no Medical guidelines of do’s and
don'ts
• Young people are dying-is their a pattern
• Can we pick them early before they turn sick?
• Testing in few center’s-takes 4 days to get
results
• Do we start Tamiflu in all suspected cases?
• Deterioration is occurring on 4th day and death
on 7th or 8th day
• Where do we stand?
Fore More Lectures www.medicalppt.blogspot.com
CHALLENGES WE FACE
•
•
•
•
•
•
•
Recognition of disease
Not to forget chikungunya & dengue
Difficulty in Confirmation of disease
Self protection
Protection of people around us
Notification
To know more ; Are we facing the
pandemic?
Fore More Lectures www.medicalppt.blogspot.com
Scenario
• Admitted suspected
Patient (symptoms+
travel history)
• Sample sent for PCR
• Reported positive
H1N1
• What to do for patient
relatives& hosp staff
who are exposed
Patient with
hemodynamic
compromise &
respiratory difficulty
Need for intubation-To
proceed & then send
sample for PCR
What to do meanwhile
Is it necessary to test
all doctors & staff
Fore More Lectures www.medicalppt.blogspot.com
Enigmatic questions
• Should we close the hospital & fumigate?
• What to do for other patients next to the
case
• Should we send all suspected cases to
referral hospital
Fore More Lectures www.medicalppt.blogspot.com
Subsequent challenges
• Recognising in OPD- identify flu symptoms,
travel history, clinical signs of hemodynamic
derangement &pneumonia/ALI/ARDS
• Proper referral to institutions handling cases
• Isolation rooms, Use of masks Hand wash
• Ventilatory management
Fore More Lectures www.medicalppt.blogspot.com
Influenza At A Glance
• Influenza, commonly called "the flu," is caused
by viruses that infect the respiratory tract.
• Influenza viruses are divided into three types,
designated A, B, and C.
Fore More Lectures www.medicalppt.blogspot.com
INFLUENZA VIRUS
Fore More Lectures www.medicalppt.blogspot.com
ELECTRON MICROSCOPY
Fore More Lectures www.medicalppt.blogspot.com
TYPES
Fore More Lectures www.medicalppt.blogspot.com
PIG
THE CREATOR
Fore More Lectures www.medicalppt.blogspot.com
VIRAL VARIANTS
•
•
•
•
•
•
INFLUENZA A VIRUS
Swine
Human
H1N2
H3N1
H3N2
H1N1(pandemics)
H3N2 (rare)
Avian
H5N1
Fore More Lectures www.medicalppt.blogspot.com
QUADRUPLE
REASSORTMENT GENETICS
• Human
swine
H1N1
• Avian
swine
Fore More Lectures www.medicalppt.blogspot.com
EARTH LIVING SPACE FOR
ALL

Epidemic: An increase in disease above what is normally expected

Pandemic: A worldwide epidemic
A pandemic begins when: there is person-to-person sustained
transmission on multiple continents
Fore More Lectures www.medicalppt.blogspot.com
HISTORY
• In the 20th century there have been three
influenza pandemics in 1918, 1957 and
1968.
Fore More Lectures www.medicalppt.blogspot.com
Emergency hospital, Camp Funston,
Kansas 1918
Fore More Lectures www.medicalppt.blogspot.com
WHO
• April 24: H1N1 first disease outbreak
notice.
• April 25: WHO Director General declares a formal
“Public health emergency of international concern”
• April 27: “containment of the outbreak is not feasible”
pandemic alert raised from phase 3 to phase 4.
• April 29: phase 4 to phase 5.
• June 11: phase 5 to phase 6.
Fore More Lectures www.medicalppt.blogspot.com
• The World Health Organization uses a six
stage phase for alerting the general public to
an outbreak
• Phase 1 – animal to animal transmission.
• Phase 2 – an animal influenza virus is
capable of human infection.
• Phase 3 - small outbreaks among close
populations but not through human to
human contact.
Fore More Lectures www.medicalppt.blogspot.com
• Phase 4 - Human to human transmission
• Phase 5 - spread across two countries or
more in one of the WHO regions
(continents).
• Phase 6 – spread across two countries or
more in one of the WHO regions plus
spread to another WHO region.
Fore More Lectures www.medicalppt.blogspot.com
Global pandemic
• W.H.O. identifies the following six
epidemiological sub-regions.
• - African Region
• - Eastern Mediterranean Region
• - European Region
• - Region of the Americas
• - South-East Asian Region
• - Western Pacific Region
Fore More Lectures www.medicalppt.blogspot.com
Global pandemic
Fore More Lectures www.medicalppt.blogspot.com
EPIDEMIOLOGY
• Incubation period- 1-7 days
• Transmission
PRIMARY CASE –direct contact with pigs
SECONDARY CASES
sneezing, coughing
resp droplets
body fluids(diarroeal stool)
contact surfaces
Fore More Lectures www.medicalppt.blogspot.com
Transmission
Fore More Lectures www.medicalppt.blogspot.com
• This virus is not transmitted from eating
pork or pork products
• Contagiousness:
1 day
onset of symptoms
7 days
Children are contagious for longer periods.
. Majority of pts were previously healthy.
Clinical course mild in PCR negative
influenza.
Fore More Lectures www.medicalppt.blogspot.com
• Majority of pts were previously healthy.
• Clinical course mild in PCR negative
influenza.
• Pregnant women — Increased rates of
spontaneous abortion and preterm birth
• Patients with swine flu were found to have
increased incidence of cardiovascular &
cerebrovascular events.
Fore More Lectures www.medicalppt.blogspot.com
Can I get infected with this new H1N1 virus
from eating or preparing pork?
• No. H1N1 viruses are not spread by food.
You cannot get this new HIN1 virus from
eating pork or pork products. Eating
properly handled and cooked pork
products is safe.
Fore More Lectures www.medicalppt.blogspot.com
Is there a risk from drinking water?
• Recent studies have demonstrated that
free chlorine levels typically used in
drinking water treatment are adequate to
inactivate highly pathogenic H5N1 avian
influenza. It is likely that other influenza
viruses such as novel H1N1 would also be
similarly inactivated by chlorination.
Fore More Lectures www.medicalppt.blogspot.com
What kills influenza virus?
• Influenza virus is destroyed by heat (167212°F [75-100°C]). In addition, several
chemical germicides, including chlorine,
hydrogen peroxide, detergents (soap),
iodophors (iodine-based antiseptics), and
alcohols
Fore More Lectures www.medicalppt.blogspot.com
Risk factors
•
•
•
•
•
•
COPD
Immunocompromised state
DM
Pregnancy
Cardiac disease
Obesity
Fore More Lectures www.medicalppt.blogspot.com
DEFINITIONS
• Influenza-like illness (ILI) is defined as
fever (temperature of 100ºF [37.8ºC] or
greater) with cough or sore throat in the
absence of a known cause other than
influenza
Fore More Lectures www.medicalppt.blogspot.com
Case Definitions By CDC
• A confirmed case acute febrile
respiratory illness with laboratoryconfirmed H1N1 influenza A virus
detection by real-time reverse
transcriptase (RT)-PCR or culture.
• A probable case acute febrile respiratory
illness who is positive for influenza A, but
negative for H1 and H3 by RT-PCR
Fore More Lectures www.medicalppt.blogspot.com
A suspected case acute febrile
respiratory illness who:
•
- Develops symptoms within seven
days of close contact with a person who is
a confirmed case of H1N1 influenza A
virus infection or
•
- Develops symptoms within seven
days of travel or resides in a community
where there are one or more confirmed
H1N1 influenza A cases
Fore More Lectures www.medicalppt.blogspot.com
Close contacts
• Having cared for or lived with a person
• setting where there was a high likelihood
of contact with respiratory droplets and/or
bodily fluids
• Having had close contact (kissing,
embracing, sharing eating or drinking
utensils, physical examination, or any
other contact likely to result in exposure to
respiratory droplets)
Fore More Lectures www.medicalppt.blogspot.com
Mexican data
• Influenza-like illness or respiratory
symptoms developed in 22 of 190 health
care workers
• These 22 workers received oseltamivir
• for 5 days and were sent home for 3 to 7
days. They had mild-to-moderate disease,
and none required hospitalization
nejm.org august 13, 2009
Fore More Lectures www.medicalppt.blogspot.com
Preventive measures taken in
Mexican hospitals
• After infection-control measures were
strictly enforced — with patients confined
and isolated in three hospital areas and
N95 masks
• Separate respirators used in addition to
goggles, gowns, and gloves, as well as
liberal use of gel-alcohol hand sanitizer —
no more health care workers had
influenza-like illness,
nejm.org august 13, 2009
Fore More Lectures www.medicalppt.blogspot.com
COMPARISION
SEASONAL
INFLUENZA
H1N1 INFLUENZA
AGE
<5 YRS
YOUNG & MIDDLE AGE
SEVERITY
LESS
SEVERE PNEUMONIA
ARDS
MORBIDITY
LESS
MORE BUT >60 YRS
LESS LIKELY TO HAVE
SEVERE PNEUMONIA
>60 YRS
Fore More Lectures www.medicalppt.blogspot.com
contd
SEASONAL
INFLUENZA
H1N1 INFLUENZA
SYMPTOMS
RESPIRATORY
RESPIRATORY
&
GASTROINTESTINAL
SECONDARY ATTACK
RATE
5-15 %
22-33 %
VACCINE
PROTECTIVE
UNDER
DEVELOPMENT
Fore More Lectures www.medicalppt.blogspot.com
AGE SHIFTS IN MORTALITY
•
Concept of “original antigenic sin,”by
Francis - immune response is greatest to
antigens to which first exposure occurred
in childhood.
• Persons born before 1957 who were
exposed in childhood to influenza A
(H1N1) viruses might be better protected
against this viral subtype than those who
were first exposed to other influenza A
subtypes, H2N2 and H3N2, at a later date
Fore More Lectures www.medicalppt.blogspot.com
• During the early phase of this epidemic,
the rapid identification of persons who are
likely to have severe disease, as
compared with those who are likely to
have mild disease, can guide epidemic or
pandemic response strategies.
Fore More Lectures www.medicalppt.blogspot.com
Specimens
• Nasopharyngeal swab, nasal swab, throat
swab, combined oropharyngeal/
nasopharyngeal swab, or nasal aspirate
• Swabs with a synthetic tip (eg, polyester or
Dacron) and an aluminum or plastic shaft
should be used. Swabs with cotton tips
and wooden shafts are not recommended.
• The collection vial in which the swab is
placed should contain 1 to 3 mL of viral
transport media.
Fore More Lectures www.medicalppt.blogspot.com
• Respiratory specimen should be collected
within 4 to 5 days of illness.
• Specimens should be placed in viral
transport media and placed on ice (4ºC) or
refrigerated immediately for transportation
to the laboratory
Fore More Lectures www.medicalppt.blogspot.com
DIAGNOSTIC TESTS
QUIDEL
RT PCR
CULTURE
DFA/IFA
Fore More Lectures www.medicalppt.blogspot.com
LAB TESTS
• Real time RT PCR-confirmatory
• culture is usually too slow to help guide
clinical management. A negative viral
culture does not exclude pandemic H1N1
influenza A infection.
• Rapid antigen tests — evaluation of
patients suspected of having influenza, but
results should be interpreted with caution
the QuickVue Influenza A+B (Quidel)
assay (sensitivity 51 percent specificity
99 percent)
Fore More Lectures www.medicalppt.blogspot.com
• Rapid influenza antigen tests & Direct or
indirect immunofluorescent antibody
testing (DFA or IFA) can distinguish
between influenza A and B but negative
test does not exclude infection.
Fore More Lectures www.medicalppt.blogspot.com
Whom to test
• Testing for pandemic H1N1 influenza A
should be considered in individuals with an
acute febrile respiratory illness
( temperature of 100ºF or higher and
recent onset of at least one of the
following: rhinorrhea, nasal congestion,
sore throat, or cough) or
sepsis-like syndrome
Fore More Lectures www.medicalppt.blogspot.com
Priority for testing should be given to :
Those who require hospitalization and
Those who are at high risk for severe
complications
No testing if illness is mild or the person
resides in an area with confirmed cases
Recommended test for suspected cases is
real-time reverse transcriptase (RT)-PCR
for influenza A, B, H1, and H3
Fore More Lectures www.medicalppt.blogspot.com
CLINICAL FEATURES
Vomiting or diarrhea (not typical for
influenza but reported by recent cases of
swine influenza infection)
Fore More Lectures www.medicalppt.blogspot.com
Mexican data in MV patients
Fore More Lectures www.medicalppt.blogspot.com
Mexican data in MV patients
Fore More Lectures www.medicalppt.blogspot.com
Younger people at risk
Fore More Lectures www.medicalppt.blogspot.com
10-50 yrs
Severe Respiratory Disease Concurrent
with the Circulation of H1N1 Influenza
Gerardo Chowell, Ph.D., Stefano M. Bertozzi, M.D.,
Ph.D., NEJM August 2009
Fore More Lectures www.medicalppt.blogspot.com
Can we make a broad clinical
check list
•
•
•
•
•
History of contact
Younger age, sudden onset
Fever, cough, breathlessness
Leucopenia, raised LDH and CPK
Should all such patients be isolated and
given Tamiflu?
Fore More Lectures www.medicalppt.blogspot.com
Other Manifestations:
•
•
•
•
•
•
•
Tachycardia
Tachypnoea
Low O2 sat.
Hypotension
Cyanosis
Acute myocarditis
Cardiopulmonary arrest
Fore More Lectures www.medicalppt.blogspot.com
Children Clinical Presentation
• Infants may present with fever and
lethargy, and may not have cough or other
respiratory symptoms.
• Apnea, tachypnea, dyspnea, cyanosis,
dehydration, altered mental status, and
extreme irritability.
Fore More Lectures www.medicalppt.blogspot.com
Children Emergency Warning Signs
•
•
•
•
•
•
Fast breathing or trouble breathing
Bluish or gray skin color
Not drinking enough fluids
Severe or persistent vomiting
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
Fore More Lectures www.medicalppt.blogspot.com
In adults, emergency warning
signs
•
•
•
•
•
•
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
Fore More Lectures www.medicalppt.blogspot.com
Why Complications In young
(Cytokine storm)
• It is the systemic expression of a healthy and vigorous
immune system resulting in the release of more than 150
inflammatory mediators . Both pro and anti-inflammatory
cytokines are elevated in serum with lethal interplay of
these cytokines is referred to as a "Cytokine Storm".
• The primary contributors to the cytokine storm are TNF-a
and IL-6 .
• It is inappropriate (exaggerated) immune response that
is caused by rapidly proliferating and highly activated Tcells or natural killer (NK) cells.
• Bird flu patients die from acute respiratory distress
syndrome (ARDS) caused by the cytokine storm, and not
directly from the virus
Fore More Lectures www.medicalppt.blogspot.com
SYMPTOMS OF THE
CYTOKINE STORM
The final result, of cytokine storm (SIRS) or
sepsis is multiple organ dysfunction
syndrome (MODS)
• hypotension ( Myocarditis)
• tachycardia
• ARDS acute respiratory failure
• Ischemia, or insufficient tissue perfusion
• uncontrollable haemorrhage
• Multisystem organ failure
Fore More Lectures www.medicalppt.blogspot.com
Cytokine Storm Treatment
•
•
•
•
Steroids
ACE Inhibitors & ARBs
Anti-CD28 Monoclonal Antibody
TNF-alpha blockers
Fore More Lectures www.medicalppt.blogspot.com
HISTOPATHOLOGY
LUNG
FINDINGS
• . The specimen shows
necrosis of bronchiolar
walls (top arrow),
• a neutrophilic infiltrate
(middle arrow), and
diffuse
• alveolar damage with
prominent hyaline
membranes (bottom
arrow).
Fore More Lectures www.medicalppt.blogspot.com
Diagnosis
• Laboratory Tests
– Viral culture
• Presence of virus confirmed by
– ELISA( 4 fold rise )
– RT-PCR
• Rapid antigen tests (distinguish between influenza A
and B
Fore More Lectures www.medicalppt.blogspot.com
LABORATORY FINDINGS
• CBC- leucocytosis/leucopenia
lymphopenia
• Elevated CPK, LDH
• Elevated UREA,CREATININE
• Elevated AST,ALT
• CHEST RADIOGRAPH-bilateral patchy
pneumonia.
Fore More Lectures www.medicalppt.blogspot.com
H1 N1 Pneumonia
Fore More Lectures www.medicalppt.blogspot.com
COMPLICATIONS
Similar to those of seasonal influenza
• Exacerbation of underlying chronic
medical conditions
• Upper respiratory tract disease (sinusitis,
otitis media, croup)
• Lower respiratory tract disease
(pneumonia, bronchiolitis, status
asthmaticus)
Fore More Lectures www.medicalppt.blogspot.com
• Cardiac (myocarditis, pericarditis)
• Neurologic (Acute and post-infectious
encephalopathy, encephalitis, febrile
seizures, status epilepticus)
• Toxic shock syndrome
• Secondary bacterial pneumonia with or
without sepsis
Fore More Lectures www.medicalppt.blogspot.com
DD H1N1 PNEUMONIA
• OTHER VIRAL pneumonia
influenza A,B
adenovirus
RSV
para influenza rhinovirus
humanmetapneumonia
• Legionella,Chlamydia,Mycoplasma
Fore More Lectures www.medicalppt.blogspot.com
TREATMENT
• Only neuraminidase inhibitors
ORALTamiflu (oseltamivir) and
Relenza( zanamivir) are approved to
cure the viral infection.
• H1N1 is resistant to Amantadine
Rimantadine
• Antiviral drugs can be given to treat
those who become severely ill with
influenza.
Fore More Lectures www.medicalppt.blogspot.com
Tamiflu (Oseltamivir )
• Block the active site
of the influenza viral
enzyme
neuraminidase
• This effect results in
viral aggregation at
the host cell surface
and reduces the
number of viruses
released from the
infected cell
Fore More Lectures www.medicalppt.blogspot.com
Fore More Lectures www.medicalppt.blogspot.com
Tamiflu
Fore More Lectures www.medicalppt.blogspot.com
Tamiflu
Fore More Lectures www.medicalppt.blogspot.com
Tamiflu(contd)
• If one dose missed?
take as soon as you remember unless it
is within 2 hours of next dose
do not take two doses at a time
. With other medications?
minimal drug interaction
no intranasal flu vaccine(Flu Mist) within
2weeks before or 48 after taking tamiflu
Fore More Lectures www.medicalppt.blogspot.com
Tamiflu (Contd)
• With kidney disease
Flu treatment :one 75mg dose OD for 5
days
Flu prevention:one 75 mg dose
alternate day or 30 mg dose OD
. Storage:
capsules- <25 degree C
liquid - 2 to 8 degree C
Fore More Lectures www.medicalppt.blogspot.com
Fore More Lectures www.medicalppt.blogspot.com
Zanamivir ( Relenza)
– It is not recommended for people with
underlying respiratory disease such as
asthma or chronic obstructive pulmonary
disease or lactose intolerance
– Treatment of 7 year & older patients 10mg
(2puffs)BID 5d
– Prophylaxis of 5 year & older patients 10mg
OD 10d-28 days
Fore More Lectures www.medicalppt.blogspot.com
Mild Cases
• Supportive: Paracetamol, flds…
*NO SALICYLATES IN CHILDREN/
YOUNG ADULTS: REYE'S SYNDROME
• Antivirals : *best within first 48 hours
*Early administration in at-risk pts ie those
with comorbidities/ pregnancy…
• control precautions: cough etiquette
• Hand hygiene & Natural ventilation
Fore More Lectures www.medicalppt.blogspot.com
Hospitalized pts:
• Antivirals
• Pneumonia management like avian
(antibiotics)
• Resp. Support: early detection
Correction of hypoxia with
supplemental O2 or mech. Vent as
necessary
Fore More Lectures www.medicalppt.blogspot.com
Supportive care
• When Mech. vent is indicated:
low volume
low pressure
lung protective vent.
• Steroids:
• Avoid routine use, no benefit was reported
. Higher doses associated with serious SE:
o evidence of increased viral replication in
SARS and other resp. viral infections.
o Increased mortality in Avian
Fore More Lectures www.medicalppt.blogspot.com
It is highly contagious!
• Can we have separate wards ,ICU’s and
staffing
• We require separate OPD and testing
facilities for suspected cases
• Can we spare separate equipment
• Can we organise all this in a running
hospital?
Fore More Lectures www.medicalppt.blogspot.com
prevention
Fore More Lectures www.medicalppt.blogspot.com
Fore More Lectures www.medicalppt.blogspot.com
N95 Mask
Fore More Lectures www.medicalppt.blogspot.com
What should I do to keep from getting
the flu?
•
•
•
•
First and most important: wash your hands
Get plenty of sleep
Drink plenty of fluids
Try not to touch surfaces that may be
contaminated with the flu virus.
• Avoid close contact with people who are
sick.
Fore More Lectures www.medicalppt.blogspot.com
Avoid close contact
• Avoid close contact
with people who are
sick. When you are
sick, keep your
distance ( > 1 meter
)from others to protect
them from getting sick
too.
• Aerosols spread the
virus in any
environment
Fore More Lectures www.medicalppt.blogspot.com
Fore More Lectures www.medicalppt.blogspot.com
Prevention
• management of the outbreak such as closure
of schools, advising avoidance of mass
gatherings and distribution of antivirals
• Avoiding close contact
• Staying home from work, school
• Covering mouth and nose with a tissue or
N95 mask (three layered) when coughing or
sneezing. Change the mask every 6 to 8
hours
• Washing your hands
Fore More Lectures www.medicalppt.blogspot.com
Is Negative Pressure Room
Must ?
Place patients in a single-patient room with the door
kept closed & droplet and contact isolation
Fore More Lectures www.medicalppt.blogspot.com
Is BIA ready?
Fore More Lectures www.medicalppt.blogspot.com
Why do we need vaccine
SEASONAL
VACCINE
PROTECTION?
RAPID GLOBAL
SPREAD
VACCINE
WINTER SEASON
TO COME(LOW
HUMIDITY,TEMP)
COST EFFECTIVE
TARGET AT RISK
PEOPLE
Fore More Lectures www.medicalppt.blogspot.com
Dealing with the Deceased
•
•
Transport of deceased persons in a transport bag.
Hand hygiene should be performed after completing transport.
•
For deceased persons with confirmed, probable, or suspect novel
influenza A (H1N1):
o limit contact with the body in health care settings to close family
members
o Direct contact with the body is discouraged
o Necessary contact may occur as long as hands are washed
immediately with soap and water.
Fore More Lectures www.medicalppt.blogspot.com
Conclusion
• Be cautious but no need to panic
• Need for further guidelines beyond
diagnosis & management.
• Judicious use of diagnostic tests
• Early suspecting and treating cytokine
storm is very important
• Not to forget universal precautions
Fore More Lectures www.medicalppt.blogspot.com
THANK YOU
PUBLISHED BY
www.medicalppt.blogspot.com