Presentation on theme: "SWINE FLU AWARENESS BY Dr. Mohit Bhutani Dr. D. Himanshu M.D."— Presentation transcript:
1SWINE FLU AWARENESSBYDr. Mohit BhutaniDr. D. Himanshu M.D
2Influenza pandemics & emerging new pandemic threats exist since 1900! Pandemic outbreaksRecent outbreaks of influenza19181957197720002008>50 million deathsH1N11918 SpanishAsian~2 million deathsH2N21968Hong Kong~1 million deathsH3N2<1 million deathsRussianH9N219992 casesH5N1199718 casesSix deathsH7N782 casesOne deathGlobal387 cases245 deaths2003Dutch2009~30,000 cases145 deathsPandemicThe emergence of H1N1 has demonstrated the difficulty in predicting pandemicsNicholson 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).
3The guiding principles are:* Early implementation of infection control precautions to minimize nosocomical / household spread of diseasePrompt 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
4Infrastructure / 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 oxymetersSupplies: 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
5Standard Operating Procedures * Reinforce standard infection control precautionsall 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
7The first thing is to differentiate between a flu and a cold
8CATEGORISATION OF CASES* MILD OR UNCOMPLICATED ILLNESSPROGRESSIVE ILLNESSSEVERE OR COMPLICATED ILLNESS*Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the Season
9Mild or Uncomplicated illness FeverCoughSore throatRhinorrheaMuscle painHeadacheChillsMalaiseDiarrhea and vomitingThese patients do not require treatment with anti-viral drugs as they do not need hospitalization.
11HIGH RISK GROUP* Children younger than 2 years old Adults 65 years of age or olderPregnant 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
12Progressive illness Typical symptoms plus Chest pain Tachypnea i.e. respiratory rate > 30Hypoxia i.e. SpO2 < 94% at room airLabored breathing in childrenLow blood pressure i.e. SBP < 90mmHgConfusionSevere dehydrationExacerbations of chronic conditionsThese patients require urgent hospitalization and treatment.
13Severe or Complicated Illness Abnormal CXRRequiring mechanical ventilationEncephalitisEncephalopathyOrgan failureMyocarditisRhabdomyolysisInvasive 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.
14Whom to testThe following people should receive influenza diagnostic testingpeople who are hospitalized with suspected flu i.e. patients with progressive or severe/complicated diseaseSymptomatic patients in high risk groupAdditional people may be recommended for testing based on the clinical judgment of their health care providerDuring 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
15How to treat !!!Antiviral drugs: oseltamivir (oral), zanamivir (inhaled)Initiate treatment as early as possible after onset of symptomsTreat 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
16OSELTAMIVIR : oral (cap/suspension) Oseltamivir is the recommended drug both for prophylaxis and treatment.Neuraminidase inhibitorPregnancy category ‘c’
19Zanamivir – inhalational .(Relenza®) FDA-approved for the treatment of influenza in patients 7 years of age and olderCautionBronchospasm in asthma patients
20SINGLE DOSE PeramivirA 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
21AMANTADINERIMANATADINENot recommended due to widespread resistance in 2009 H1N1 strain
22Duration of antiviral therapy* Recommended duration: 5 daysHospitalized patients with severe infections might require longer treatment coursesTreatment is most effective when started in the first 48 hours of illnessLimited 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
23Supportive therapy IV Fluids. Oxygen therapy/ ventilatory support Antibiotics for secondary infectionVasopressors for shockParacetamol 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.
24Discharge PolicyPatients 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, retestIf positive, do check for resistanceWhile discharging, educate family on personal hygiene and infection control measures at home
26Antiviral Chemoprophylaxis of exposed individuals INFECTIOUS PERIODOne 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 periodMode of exposureDroplet exposure of mucosal surfaces (e.g. nose, mouth, and eyes) by respiratory secretions from coughing or sneezingContact, 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 eyesSmall particle aerosols in the vicinity of the infectious individual.
27Who 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 chemoprophylacticallyGroups 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 contactThe close contact did not occur during the infectious period
28Oseltamivir AND Zanamivir drug of choice Prophylaxis should be provided till 10 days after last exposure
29Use of the Pandemic (H1N1) 2009 vaccines 1. Inactivated – killedProduced by growing virus in chicken eggsGiven 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% protectionCan be given in pregnancySingle dose in adultsImmunosuppressed and in children < 10 yr two doses 4 wksapartS/E: fever ; GBS 1 in 1 lac . C/I – ALLERGIC pts.
30administered by nasal spray. healthy individuals 2-49 yr of age 2.LIVE ATTENUATEDadministered by nasal spray.healthy individuals yr of ageContraindicated inpregnancyimmunosuppresed90% protection rateNot advised for health care professionalsInfluenza vaccines only become effective about 14 days after vaccination
31Who will receive priority for vaccination? WHO recommend that health workers be given first priority for early vaccination to protect themselves and their patientsThose caring for high risk individuals who cannot receive vaccinationOther groups at higher risk for severe illnesspregnant womenaged above 6 months with one of several chronic medical conditions,healthy adults of 65 years of age and above
33Guidelines on Infection control Measures FOR HEALTH CARE INDIVIDUALSPersonal 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
34N95 Respirator Filters 95% of airborne particulates *NIOSH- National Institute for Occupational Safety and Health. Agency under CDC.
35During Hospital Careo The patient should be admitted directly to the isolation facility and continue to wear a three layer surgical maskO 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
36Perform hand hygiene before and after patient contact and following contact with contaminated items, whether or not gloves are worn. Hand washing and Hand rub
37The 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 1mAll waste generated from influenza patients is infectious clinical waste and should be treated and disposed in accordance with national regulations.
38Guidelines on Infection control Measures FOR GENERAL POPULATION IN COMMUNITYWash hands frequently with soap and water. If soap and water are not available, use an alcohol-based hand rubCover your mouth and nose with a tissue when coughing or sneezingAvoid touching your eyes, nose and mouthPeople 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 necessitiesAvoid close contact (i.e. being within about 6 feet) with persons with Influenza like illness