1. SWINE FLU AWARENESS BY
Dr. Mohit Bhutani
Dr. D. Himanshu M.D

2. Influenza pandemics & emerging new pandemic threats exist since 1900!
Pandemic outbreaks
Recent outbreaks of influenza
1918
1957
1977
2000
2008
>50 million deaths
H1N1
1918 Spanish
Asian
~2 million deaths
H2N2
1968
Hong Kong
~1 million deaths
H3N2
<1 million deaths
Russian
H9N2
1999
2 cases
H5N1
1997
18 cases
Six deaths
H7N7
82 cases
One death
Global
387 cases
245 deaths
2003
Dutch
2009
~30,000 cases
145 deaths
Pandemic
The emergence of H1N1 has demonstrated the difficulty in predicting pandemics
Nicholson KG, Wood JM, Zambon M. Lancet 2003; 362: ; WHO, Cumulative number of confirmed human cases of avian influenza A/(H5N1), available at: (accessed 5 November 2008); CDC, Avian Influenza, available at: (accessed 5 November 2008).

3. The guiding principles are:*
Early implementation of infection control precautions to minimize nosocomical / household spread of disease
Prompt treatment to prevent severe illness & death.
Early identification and follow up of persons at risk.
*Pandemic Influenza A H1N1 Clinical management Protocol and Infection Control Guidelines Directorate

4. Infrastructure / manpower / material support *
Isolation facilities: if dedicated isolation room is not available then patients can be cohorted in a well ventilated isolation ward with beds kept one meter apart.
Manpower: Dedicated doctors, nurses, paramedical workers.
Equipment: Portable X Ray machine, ventilators, large oxygen cylinders, pulse oxymeters
Supplies: Adequate quantities of Personal Protection Equipments (PPE), disinfectants and medications (Oseltamivir, antibiotics and other medicines)
*Pandemic Influenza A H1N1 Clinical management Protocol and Infection Control Guidelines Directorate

5. Standard Operating Procedures *
Reinforce standard infection control precautions
all those entering the room must use high efficiency N95 masks, gowns, goggles, gloves, cap and shoe cover.
Restrict number of visitors and provide them with PPE.
Provide antiviral prophylaxis to health care personnel managing the case and ask them to monitor their own health twice a day.
Dispose waste properly by placing it in sealed impermeable bags labeled as Bio- Hazard
*Pandemic Influenza A H1N1 Clinical management Protocol and Infection Control Guidelines Directorate

6. MANAGEMENT

7. The first thing is to differentiate between a flu and a cold

8. CATEGORISATION OF CASES*
MILD OR UNCOMPLICATED ILLNESS
PROGRESSIVE ILLNESS
SEVERE OR COMPLICATED ILLNESS
*Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the Season

9. Mild or Uncomplicated illness
Fever
Cough
Sore throat
Rhinorrhea
Muscle pain
Headache
Chills
Malaise
Diarrhea and vomiting
These patients do not require treatment with anti-viral drugs as they do not need hospitalization.

10. TREATMENT ALGORITHM FOR MILD DISEASE

11. HIGH RISK GROUP* Children younger than 2 years old
Adults 65 years of age or older
Pregnant women and women up to 2 weeks postpartum (regardless of how the pregnancy ended)
Persons with certain medical conditions: asthma, chronic lung disease, heart disease, blood disorders, kidney and liver disease, diabetes mellitus, immunocompromised and obese
*Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the Season

12. Progressive illness Typical symptoms plus Chest pain
Tachypnea i.e. respiratory rate > 30
Hypoxia i.e. SpO2 < 94% at room air
Labored breathing in children
Low blood pressure i.e. SBP < 90mmHg
Confusion
Severe dehydration
Exacerbations of chronic conditions
These patients require urgent hospitalization and treatment.

13. Severe or Complicated Illness
Abnormal CXR
Requiring mechanical ventilation
Encephalitis
Encephalopathy
Organ failure
Myocarditis
Rhabdomyolysis
Invasive secondary bacterial infection based on laboratory testing or clinical signs (e.g. persistent high fever and other symptoms beyond three days)
These patients require prompt admission and treatment with anti-viral drugs.

14. Whom to test
The following people should receive influenza diagnostic testing
people who are hospitalized with suspected flu i.e. patients with progressive or severe/complicated disease
Symptomatic patients in high risk group
Additional people may be recommended for testing based on the clinical judgment of their health care provider
During 2009 H1N1 CDC considered that most people with flu symptoms would not require testing because the test results usually do not change the way one is treated.
*Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the Season

15. How to treat !!!
Antiviral drugs: oseltamivir (oral), zanamivir (inhaled)
Initiate treatment as early as possible after onset of symptoms
Treat empirically before diagnostic test results are reported
*Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the Season

16. OSELTAMIVIR : oral (cap/suspension)
Oseltamivir is the recommended drug both for prophylaxis and treatment.
Neuraminidase inhibitor
Pregnancy category ‘c’

17. SCHEDULE

18. ADVERSE EFFECTS(oseltamivir)
>10%- gastrointestinal- vomiting, nausea , pain abdomen
1%- conjuctivitis
1%- epistaxis
<1%- anaphylactic reaction, pseudomembranous colitis, SJS/TEN, abnormal LFT, neuropsychiatric events

19. Zanamivir – inhalational .(Relenza®)
FDA-approved for the treatment of influenza in patients 7 years of age and older
Caution
Bronchospasm in asthma patients

20. SINGLE DOSE Peramivir
A third neuraminidase inhibitor formulated for intravenous (IV) administration for 18yrs and older pt.
Treatment approved only if: 
(1) the patient has not responded to either oral or inhaled antiviral therapy;
(2) drug delivery by a route other than IV is not expected to be dependable or is not feasible

21. AMANTADINE
RIMANATADINE
Not recommended due to widespread resistance in 2009 H1N1 strain

22. Duration of antiviral therapy*
Recommended duration: 5 days
Hospitalized patients with severe infections might require longer treatment courses
Treatment is most effective when started in the first 48 hours of illness
Limited data from observational studies suggests, treatment started 48 hours after onset of illness also reduced mortality/ duration of hospitalization
*Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the Season

23. Supportive therapy IV Fluids. Oxygen therapy/ ventilatory support
Antibiotics for secondary infection
Vasopressors for shock
Paracetamol or ibuprofen for fever, myalgia and headache.
Avoid smoking.
For sore throat, short course of topical decongestants, saline nasal drops, throat lozenges and steam inhalation.
Salicylate / aspirin is strictly contra-indicated in any influenza patient due to its potential to cause Reye’s syndrome.

24. Discharge Policy
Patients responded within 2-3 days can be discharged after 5 days of treatment. No need for a repeat test.
Patients who continue to have symptoms of fever, sore throat etc. even on the 5th day should continue treatment for 5 more days.
If symptomatic even after 10th day of treatment in the absence of secondary infection, retest
If positive, do check for resistance
While discharging, educate family on personal hygiene and infection control measures at home

25. ACTIVE PREVENTION

26. Antiviral Chemoprophylaxis of exposed individuals
INFECTIOUS PERIOD
One day before fever begins until 24 hours after fever ends or 7 days after onset of symptoms.
Children may spread the virus for a longer period
Mode of exposure
Droplet exposure of mucosal surfaces (e.g. nose, mouth, and eyes) by respiratory secretions from coughing or sneezing
Contact, usually of hands, with an infectious patient or fomites followed by self-inoculation of virus onto mucosal surfaces such as those of the nose, mouth, and eyes
Small particle aerosols in the vicinity of the infectious individual.

27. Who may be considered for antiviral chemoprophylaxis
The following persons who are a close contact of a person with suspected or confirmed H1N1 influenza during the infectious period:
Persons at high risk for complications of influenza;
Health care workers and emergency medical personnel;
Pregnant women.
Whom not to treat chemoprophylactically
Groups of healthy children or adults based on potential exposures in the community, workplace, school, camp or other settings;
If  >48 hours have elapsed since the last close contact
The close contact did not occur during the infectious period

28. Oseltamivir AND Zanamivir drug of choice
Prophylaxis should be provided till 10 days after last exposure

29. Use of the Pandemic (H1N1) 2009 vaccines
1. Inactivated – killed
Produced by growing virus in chicken eggs
Given by injection into the upper arm. In infants and younger children the thigh is the preferred site for the vaccine shot.
TYPES:
Trivalent VAXIGRIP (flu shot: A/H1N1, A/H3N2, and B)
50-80% protection
Can be given in pregnancy
Single dose in adults
Immunosuppressed and in children < 10 yr two doses 4 wks
apart
S/E: fever ; GBS 1 in 1 lac . C/I – ALLERGIC pts.

30. administered by nasal spray. healthy individuals 2-49 yr of age
2.LIVE ATTENUATED
administered by nasal spray.
healthy individuals yr of age
Contraindicated in
pregnancy
immunosuppresed
90% protection rate
Not advised for health care professionals
Influenza vaccines only become effective about 14 days after vaccination

31. Who will receive priority for vaccination?
WHO recommend that health workers be given first priority for early vaccination to protect themselves and their patients
Those caring for high risk individuals who cannot receive vaccination
Other groups at higher risk for severe illness
pregnant women
aged above 6 months with one of several chronic medical conditions,
healthy adults of 65 years of age and above

32. PASSIVE PREVENTION

33. Guidelines on Infection control Measures
FOR HEALTH CARE INDIVIDUALS
Personal Protection Equipments reduces the risk of infection if used correctly
• Gloves (nonsterile),
• Mask (high-efficiency mask) / Three layered surgical mask,
• Long-sleeved cuffed gown,
• Protective eyewear (goggles/visors/face shields),
• Cap (may be used in high risk situations where there may be increased aerosols),
• Plastic apron if splashing of blood, body fluids, excretions and secretions is anticipated

34. N95 Respirator Filters 95% of airborne particulates
*NIOSH- National Institute for Occupational Safety and Health. Agency under CDC.

35. During Hospital Care
o The patient should be admitted directly to the isolation facility and continue to wear a three layer surgical mask
O The identified medical, nursing and paramedical personnel attending the suspect/ probable / confirmed case should wear full complement of PPE .
If splashing with blood or other body fluids is anticipated, a water proof apron should be worn over the PPE

36. Perform hand hygiene before and after patient contact and following contact with contaminated items, whether or not gloves are worn. Hand washing and Hand rub

37. The virus is inactivated by
70% ethanol,
5% benzalkonium chloride (Lysol) and 10% sodium hypochlorite.
Patient rooms/areas should be cleaned at least daily and finally after discharge of patient. To avoid possible aerosolization of the virus, damp sweeping should be performed.
Recommended bed to bed distance should be at least 1m
All waste generated from influenza patients is infectious clinical waste and should be treated and disposed in accordance with national regulations.

38. Guidelines on Infection control Measures
FOR GENERAL POPULATION IN COMMUNITY
Wash hands frequently with soap and water. If soap and water are not available, use an alcohol-based hand rub
Cover your mouth and nose with a tissue when coughing or sneezing
Avoid touching your eyes, nose and mouth
People who are sick with an influenza-like illness should stay home for at least 24 hours after fever is gone except to get medical care or for other necessities
Avoid close contact (i.e. being within about 6 feet) with persons with Influenza like illness

40. THANK YOU