SWINE SWINE FLUFLU

DR REJI JOSE.MD.DR REJI JOSE.MD.CONSULTANT PHYSICIANCONSULTANT PHYSICIAN

TALUK HOSPITALTALUK HOSPITALTHODUPUZHATHODUPUZHA

DEFINITIONDEFINITION

SWINE FLU IS A HIGHLY CONTAGEOUS SWINE FLU IS A HIGHLY CONTAGEOUS ACUTE RESPIRATORY DISEASE OF ACUTE RESPIRATORY DISEASE OF PIGS CAUSED BY INFLUENZA A PIGS CAUSED BY INFLUENZA A VIRUS, CAN CAUSE ILLNESS IN MAN VIRUS, CAN CAUSE ILLNESS IN MAN ALSOALSO

SWINE FLU IN SWINE FLU IN MANMAN

SWINE FLU IN MANSWINE FLU IN MAN

IN MAN THE DISEASE PRESENT AS AN IN MAN THE DISEASE PRESENT AS AN ABRUPT ONSET OF HIGH FEVER WITH ABRUPT ONSET OF HIGH FEVER WITH FEATURES OF ACUTE LOWER FEATURES OF ACUTE LOWER PESPIRATORY INFECTION RAPIDLY PESPIRATORY INFECTION RAPIDLY PROGRESSING, HIGHLY CONTAGEOUS PROGRESSING, HIGHLY CONTAGEOUS AND IF NOT TREATED IN TIME MAY AND IF NOT TREATED IN TIME MAY LEAD TO SERIOUS CMPLICATIONS OR LEAD TO SERIOUS CMPLICATIONS OR DEATHDEATH

HISTORY OF FLUHISTORY OF FLU

PANDEMIC HISTORYPANDEMIC HISTORY

1918-SPANISH FLU-50 MILL 1918-SPANISH FLU-50 MILL DEATHS.H1N1DEATHS.H1N1

1957-ASIAN FLU-1-4 MILL DEATHS.1957-ASIAN FLU-1-4 MILL DEATHS.

1968-HONG KONG FLU-1-4 MILL 1968-HONG KONG FLU-1-4 MILL DEATHS.DEATHS.

NEXT????????????????????????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 IMPENDING FLU PANDEMICPANDEMIC

WE HAVE TO BE PREPARED TO MEET WE HAVE TO BE PREPARED TO MEET THE CHALLENGE, WHICH CAN OCCUR THE CHALLENGE, WHICH CAN OCCUR AT ANY TIME.AT ANY TIME.

THE AGENTTHE AGENT

SWINE INFLUENZA-THE SWINE INFLUENZA-THE AGENTAGENT

It is a RNA virus,It is a RNA virus, Influenza A virus,Influenza A virus,Natural reservoir-pigsNatural reservoir-pigsCan infect man,Can infect man,Shifted virus may cause pandemicShifted virus may cause pandemic

THE AGENTTHE AGENT

IT IS INFLUENZA A VIRUS IT IS INFLUENZA A VIRUS AA

Influenza virus A- antigenic variationsInfluenza virus A- antigenic variations

ANTIGENIC DRIFTANTIGENIC DRIFT: Gradual : Gradual antegenic change over a periodantegenic change over a period

Involves “point mutations" in genes Involves “point mutations" in genes owing to selection pressure by owing to selection pressure by immunity in host populationimmunity in host population

Responsible for frequent influenza Responsible for frequent influenza epidemics;necessiates reformulation epidemics;necessiates reformulation of influenza vaccinesof influenza vaccines

Influenza virus A- antigenic variationsInfluenza virus A- antigenic variations

ANTIGENIC SHIFTANTIGENIC SHIFT: Sudden complete : Sudden complete or major change;or major change;

Results fro genetic recombination of Results fro genetic recombination of human with animal/avian virushuman with animal/avian virus

Leads to a novel subtype different from Leads to a novel subtype different from both parent virusesboth parent viruses

If novel subtype has sufficient genes from If novel subtype has sufficient genes from H1 viruses which make it readily H1 viruses which make it readily transmissible from person to person, it transmissible from person to person, it may cause pandemicmay cause pandemic

SWINE INFLUENZA-THE SWINE INFLUENZA-THE AGENTAGENT

2 surface antigens2 surface antigens

HAEMAGGLUTININSHAEMAGGLUTININS(HA)-16 Nos(HA)-16 Nos Initiates infection following Initiates infection following

attachment of virus to susceptible attachment of virus to susceptible cellscells

NEURAMINIDASENEURAMINIDASE(NA)-9 Nos(NA)-9 NosDifferent combinations eg Different combinations eg

H1N1,N5N2 etcH1N1,N5N2 etc

SWINE INFLUENZA-THE SWINE INFLUENZA-THE AGENTAGENT

THE VIRUS THE VIRUS RESPONSIBLE FOR RESPONSIBLE FOR CURRENT PANDEMIC IS CURRENT PANDEMIC IS

H1N1H1N1

HOST HOST FACTORSFACTORS

SEASONAL INFLUENZA -HOST FACTORSSEASONAL INFLUENZA -HOST FACTORS

Age & sexAge & sex All ages, both sexesAll ages, both sexesAttack rates more among young Attack rates more among young

adultsadultsHigh CFR during in high risk cases High CFR during in high risk cases

like old and very young, DM cases like old and very young, DM cases and with other diseases like COPDand with other diseases like COPD

SWINE INFLUENZA –HIGH RISK SWINE INFLUENZA –HIGH RISK GROUPSGROUPS

Infants and young children,Infants and young children,Elderly,Elderly,Persons of any age with chronic Persons of any age with chronic

conditionsconditions >COPD>COPD >CVA,>CVA, >Renal diseases,>Renal diseases, >Immunocompromised,>Immunocompromised, >Pregnant women.>Pregnant women.

SEASONAL INFLUENZA -HOST FACTORSSEASONAL INFLUENZA -HOST FACTORS

ImmunityImmunityAntibody to H neutralizes the virus Antibody to H neutralizes the virus Antibody to N modifies the infectionAntibody to N modifies the infectionAntibody appear 7 days after the Antibody appear 7 days after the

infection, max in 2 weeks, drops to infection, max in 2 weeks, drops to pre infection level in 8-12 months pre infection level in 8-12 months

THE ENVIORNMENTTHE ENVIORNMENT

INFLUENZA -ENVIORNMENTAL INFLUENZA -ENVIORNMENTAL FACTORSFACTORS

SeasonalitySeasonalityTemperate zone: epidemics occur in Temperate zone: epidemics occur in

winterwinterTropics: epidemics occur in rainy Tropics: epidemics occur in rainy

seasonseasonSporadic cases: any monthSporadic cases: any month OvercrowdingOvercrowdingEnhances transmissionEnhances transmissionHigher attack rates in closed populationHigher attack rates in closed population

SWINE INFLUENZA -TRANSMISSIONSWINE INFLUENZA -TRANSMISSION

Mainly airborneMainly airborneDroplet infectionDroplet infectionDroplet nucleiDroplet nuclei

Through direct contactThrough direct contactFomites alsoFomites also

PATHOGENESISPATHOGENESIS

VIRUS INFECT WHOLE OF THE VIRUS INFECT WHOLE OF THE RESPIRATORY TRACT FROM NASAL RESPIRATORY TRACT FROM NASAL MUCOSA TO ALVEOLIMUCOSA TO ALVEOLI

Local inflammatory reaction->nasal Local inflammatory reaction->nasal congestion, cough, breathlessnesscongestion, cough, breathlessness

Systemic body reaction-> Systemic body reaction-> Fever,myalgia etcFever,myalgia etc

Features of ac lower respiratory Features of ac lower respiratory infection,infection,

INCUBATION PERIODINCUBATION PERIOD

1 TO 7 DAYS1 TO 7 DAYSMORE IN CHILDRENMORE IN CHILDREN

COMMUNICABILITYCOMMUNICABILITY

1 DAY BEFORE TO 7 DAYS AFTER THE 1 DAY BEFORE TO 7 DAYS AFTER THE INFECTION, MORE IN CHILDRENINFECTION, MORE IN CHILDREN

CLINICAL CLINICAL FEATURESFEATURES

SYMPTOMSSYMPTOMSAbrupt onset of fever body Abrupt onset of fever body

aches,head ache and fatigueaches,head ache and fatigueCough, rhinitis, sore throatCough, rhinitis, sore throatGI symptoms and myositis common GI symptoms and myositis common

in young,in young,

FEVERFEVERABRUPT ONSETABRUPT ONSETABOVE 38° CABOVE 38° CASSOCIATED BODY PAIN ALSOASSOCIATED BODY PAIN ALSOCONTINUE FOR FEW DAYS AND CONTINUE FOR FEW DAYS AND

GRADUALLY DIMINISHGRADUALLY DIMINISHCHILLS AND RIGOR ALSOCHILLS AND RIGOR ALSOHEAD ACHE HEAD ACHE

COUGHCOUGHTYPICAL OF LOWER RESPIRATORY TYPICAL OF LOWER RESPIRATORY

INFECTIONINFECTIONFEATURES OF UPPER RESPIRATORY FEATURES OF UPPER RESPIRATORY

INFECTION IN THE FORM OF NASAL INFECTION IN THE FORM OF NASAL CONGESTION,RHINORRHOEA, SORE CONGESTION,RHINORRHOEA, SORE THROAT. THROAT.

GIT SYMPTOMSGIT SYMPTOMS

USUALLY SEEN AS DIARRHOEA, USUALLY SEEN AS DIARRHOEA, NAUSEA AND VOMITINGNAUSEA AND VOMITING

ASSOCITED SYMPTOMSASSOCITED SYMPTOMS

FATIGUE, WEAKNESS, FATIGUE, WEAKNESS,

SIGNSSIGNS

Elevated temperatureElevated temperatureTachycardiaTachycardiaTachypnoeaTachypnoeaCrepitations Crepitations

TEMPERATURETEMPERATURE

USUALLY ABOVE 38° CUSUALLY ABOVE 38° CCHILLS AND RIGOR CAN OCCURCHILLS AND RIGOR CAN OCCUR

INCREASED RESPIRATORY INCREASED RESPIRATORY RATERATE

DUE TO LOWER RESPIRATORY DUE TO LOWER RESPIRATORY INFECTIONINFECTION

CREPITATIONS AND RONCHI ALSOCREPITATIONS AND RONCHI ALSO

SWINE INFLUENZA -SWINE INFLUENZA -COMPLICATIONSCOMPLICATIONS

Sinus and ear infections,Sinus and ear infections,Pneumonia, bacterial and viral,Pneumonia, bacterial and viral,Myocarditis,Myocarditis,Pericarditis,Pericarditis,Encephalitis,Encephalitis,Febrile seizures in young,Febrile seizures in young,Worsening of underlying chronic Worsening of underlying chronic

diseasedisease

SWINE INFLUENZA –HIGH RISK SWINE INFLUENZA –HIGH RISK GROUPSGROUPS

Infants and young children,Infants and young children,Elderly,Elderly,Persons of any age with chronic Persons of any age with chronic

conditionsconditions >COPD>COPD >CVA,>CVA, >Renal diseases,>Renal diseases, >Immunocompromised,>Immunocompromised, >Pregnant women.>Pregnant women.

PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS

HISTORY OF CONTACTHISTORY OF CONTACTCOMING FROM AN ENDEMIC AREACOMING FROM AN ENDEMIC AREASYMPTOMS AND SIGNS OF ACUTE SYMPTOMS AND SIGNS OF ACUTE

RESPIRATORY INFECTION WITH HIGH RESPIRATORY INFECTION WITH HIGH GRADE FEVERGRADE FEVER

INVESTIGATIONSINVESTIGATIONS

INVESTIGATIONS TO EXCLUDE OTHER INVESTIGATIONS TO EXCLUDE OTHER CAUSES OF FEVER WITH SIMILAR CAUSES OF FEVER WITH SIMILAR CLINICAL PICTURECLINICAL PICTURE

CONFIRMATIONCONFIRMATION

>REAL TIME PCR>REAL TIME PCR

>ISOLATION OF VIRUS IN CULTURE>ISOLATION OF VIRUS IN CULTURE

>FOUR FOLD RISE IN VIRUS SPECIFIC >FOUR FOLD RISE IN VIRUS SPECIFIC NEUTRILISING ANTEBODIESNEUTRILISING ANTEBODIES

CONFIRMATORY TESTSCONFIRMATORY TESTS

The samples are to be tested in BSL-The samples are to be tested in BSL-3 laboratory. At present the following 3 laboratory. At present the following laboratories are the identified laboratories are the identified laboratories for this purpose:laboratories for this purpose:

National Institute of Communicable National Institute of Communicable Diseases, 22, Sham Nath Marg, Delhi Diseases, 22, Sham Nath Marg, Delhi [Tel. Nos. Influenza Monitoring Cell: [Tel. Nos. Influenza Monitoring Cell: 011-23921401; Director: 011-011-23921401; Director: 011-23913148] 23913148]

CONFIRMATORY CONFIRMATORY TESTS(CONT)TESTS(CONT)

National Institute of Virology, 20-A, National Institute of Virology, 20-A, Dr. Ambedkar Road, Pune-411001 Dr. Ambedkar Road, Pune-411001 [Tel.No. 020-26124386][Tel.No. 020-26124386]

SPECIMEN COLLECTIONSPECIMEN COLLECTION

For confirmation of diagnosis, clinical For confirmation of diagnosis, clinical specimens such as nasopharyngeal specimens such as nasopharyngeal swab, throat swab, nasal swab, wash swab, throat swab, nasal swab, wash or aspirate, and tracheal aspirate (for or aspirate, and tracheal aspirate (for intubated patients) are to be intubated patients) are to be obtained. obtained.

The sample should be collected by a The sample should be collected by a trained physician / microbiologist trained physician / microbiologist preferably before administration of preferably before administration of the anti-viral drug the anti-viral drug

STORAGE AND STORAGE AND TRANSPORTTRANSPORT

Keep specimens at 4°C in viral Keep specimens at 4°C in viral transport media until transported for transport media until transported for testing. The samples should be testing. The samples should be transported to designated transported to designated laboratories with in 24 hours laboratories with in 24 hours

If they cannot be transported then it If they cannot be transported then it needs to b stored at -70°C. Paired needs to b stored at -70°C. Paired blood samples at an interval of 14 blood samples at an interval of 14 days for serological testing should days for serological testing should also be collected. also be collected.

DIFERENTIAL DIAGNOSISDIFERENTIAL DIAGNOSIS

OTHER EFVERS LIKE TYPHOID, OTHER EFVERS LIKE TYPHOID, COMMON RESPIRATORY INFECTIONS COMMON RESPIRATORY INFECTIONS LIKE AC BRONCHITIS, CAP, LIKE AC BRONCHITIS, CAP, LEPTOSPIROSIS ETCLEPTOSPIROSIS ETC

COMMON COLDCOMMON COLDAVIAN FLUAVIAN FLUSEASONAL INFLUENZASEASONAL INFLUENZA

SWINE INFLUENZA V/S COMMON COLDSWINE INFLUENZA V/S COMMON COLD

SYMPTOMSSYMPTOMS

FeverFever

Head acheHead ache

FatigueFatigue

Stuffy noseStuffy nose

CoughCough

Chest Chest discomfortdiscomfort

ComlicationsComlications

INFLUENZAINFLUENZA

High 3-4 daysHigh 3-4 days

YesYes

2-3 weeks 2-3 weeks

SometimesSometimes

YesYes

Yes, may be Yes, may be severe severe

CommonCommon

COLDCOLD

UnusualUnusual

UnusualUnusual

MildMild

CommonCommon

UnusualUnusual

MildMild

RareRare

SWINE INFLUENZA V/S SWINE INFLUENZA V/S INFLUENZA A INFLUENZA A

SYMPTOMSSYMPTOMS SWINE INFLUENZASWINE INFLUENZA INFLUENZA AINFLUENZA A

FEVERFEVER

HEAD ACHEHEAD ACHE

FATIGUEFATIGUE

COUGHCOUGH

GIT SYMPTOMGIT SYMPTOMCOMPLICATIONCOMPLICATIONSS

HIGHHIGH

SEVERESEVERE

>2 WEEKS>2 WEEKS

YESYES

MOREMORE

MORE CHANCEMORE CHANCE

LESSERLESSER

MILDERMILDER

2 WEEKS2 WEEKS

YESYES

NONO

LESSLESS

SWINE INFLEUNZA VS AVIANSWINE INFLEUNZA VS AVIAN

CLINICAL PICTURE SIMILAR BUT CLINICAL PICTURE SIMILAR BUT MORE SEVERE IN AVIAN INFLEUNZAMORE SEVERE IN AVIAN INFLEUNZA

TREATMENTTREATMENT

EARLY IMPLEMENTATION OF EARLY IMPLEMENTATION OF INFECTION CONTROLINFECTION CONTROL

PROMPT DRUG TREATMENT TO PROMPT DRUG TREATMENT TO PREVENT SEVERITY AND DEATHPREVENT SEVERITY AND DEATH

EARLY IDENTIFICATION OF PERSONS EARLY IDENTIFICATION OF PERSONS AT RISK AND PROTECT THEMAT RISK AND PROTECT THEM

INFECTION INFECTION CONTROLCONTROL

INFECTION CONTROL INFECTION CONTROL INFRASTRUCTUREINFRASTRUCTURE

ISOLATION FACILITIESISOLATION FACILITIESMANPOWER,MEDICAL, NURSING & MANPOWER,MEDICAL, NURSING &

PARAMEDICAL STAFFPARAMEDICAL STAFFEQUIPMENTS- VENTELATORS ETCEQUIPMENTS- VENTELATORS ETCSUPPLIES-PPE, DRUGSSUPPLIES-PPE, DRUGS

INFECTION CONTROLINFECTION CONTROL

Effective Infection Control Effective Infection Control Prevents Transmission Prevents Transmission From.From.

Patients to health care Patients to health care workersworkers

Patients to patientsPatients to patients

Patients to family members Patients to family members providing careproviding care

Droplet Droplet precautionsprecautions

Swine Influenza Swine Influenza PrecautionsPrecautions

Contact Contact precautionsprecautions

Airborne PrecautionsAirborne Precautions

Precautions for Suspected or Precautions for Suspected or Confirmed CasesConfirmed Cases

Place patient in a negative air pressure room Place patient in a negative air pressure room

To create a negative air pressure room:To create a negative air pressure room: Install exhaust fan and direct air from Install exhaust fan and direct air from

inside to an outside area with no person inside to an outside area with no person movementmovement

If no air conditioning, open windows in If no air conditioning, open windows in isolation areas but keep doors closedisolation areas but keep doors closed

Place patients in rooms alonePlace patients in rooms alone Alternative: cohort patients away from Alternative: cohort patients away from

other patient care areas with beds > 1 other patient care areas with beds > 1 meter apartmeter apart

Precautions for Suspected or Precautions for Suspected or Confirmed CasesConfirmed Cases

Limit number of health care workers, Limit number of health care workers, family members and visitorsfamily members and visitors

Designate experienced staff to Designate experienced staff to provide careprovide care

Limit designated staff to swine Limit designated staff to swine influenza patient careinfluenza patient care

Teach family and visitors to use PPE Teach family and visitors to use PPE

PERONAL PROTECTION PERONAL PROTECTION EQUIPMENTS(PPE)EQUIPMENTS(PPE)

THOSE ENTERING ROOM SHOULD THOSE ENTERING ROOM SHOULD WEAR PPEWEAR PPE

Use of PPEUse of PPE

The medical, nurses and paramedics The medical, nurses and paramedics attending the suspect/ probable / confirmed attending the suspect/ probable / confirmed case should wear full complement of PPE . case should wear full complement of PPE .

Use N-95 masks during aerosol-generating Use N-95 masks during aerosol-generating procedures. procedures.

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

Sample collection and packing should be Sample collection and packing should be done under full cover of PPE.done under full cover of PPE.

PERSONAL PROTECTIVE PERSONAL PROTECTIVE EQUIPMENTSEQUIPMENTS

INCLUDEINCLUDEHIGH EFFICIENCY MASKHIGH EFFICIENCY MASKGOWNGOWNGOGGLESGOGGLESGLOVESGLOVESCAP ANDCAP ANDSHOE COVERSHOE COVER

Personal Protective Personal Protective EquipmentEquipment

Personal Protection Personal Protection EquipmentsEquipments

GogglesGoggles

Personal Protection Personal Protection EquipmentsEquipments

MaskMask

Personal Protection Personal Protection EquipmentsEquipmentsN95 MaskN95 Mask

Personal Protection Personal Protection EquipmentsEquipments Gown Gown

Protection Equipments Protection Equipments PersonalPersonal

Shoe CoverShoe Cover

Personal Protection Personal Protection EquipmentsEquipments

GlovesGloves

Correct procedure for Correct procedure for applyingapplying

Follow thorough hand washFollow thorough hand wash Wear the coverall.Wear the coverall. Wear the goggles/ shoe cover/and Wear the goggles/ shoe cover/and

head cover in that order.head cover in that order. Wear face maskWear face mask Wear glovesWear gloves The masks should be changed after The masks should be changed after

every six to eight hours.every six to eight hours.

Remove PPE in the following Remove PPE in the following order:order:

• • Remove gown (place in rubbish bin).Remove gown (place in rubbish bin). • • Remove gloves (peel from hand and discard into rubbish Remove gloves (peel from hand and discard into rubbish

bin).bin). • • Use alcohol-based hand-rub or wash hands with soap and Use alcohol-based hand-rub or wash hands with soap and

water.water. • • Remove cap and face shield (place cap in bin and if Remove cap and face shield (place cap in bin and if

reusable place face shield in container for decontamination).reusable place face shield in container for decontamination). • • Remove mask - Remove mask - by grasping elastic behind ears – do by grasping elastic behind ears – do

not touch front of mask not touch front of mask • • Use alcohol-based hand-rub or wash hands with soap and Use alcohol-based hand-rub or wash hands with soap and

water.water. • • Leave the room.Leave the room. • • Once outside room use alcohol hand-rub again or wash Once outside room use alcohol hand-rub again or wash

hands with soap and water hands with soap and water UUsed PPE should be handled as waste as per waste sed PPE should be handled as waste as per waste

management protocol management protocol

DRUG THERAPYDRUG THERAPY

Neuraminidase InhibitorsNeuraminidase InhibitorsOseltamivir and Zanamivir Oseltamivir and Zanamivir

belongs to this group.belongs to this group.

Mode of action:Mode of action:

These drugs block release of These drugs block release of newly formed virus particles by newly formed virus particles by inhibiting neuraminidase of inhibiting neuraminidase of virus.virus.

Cont…Cont… Oseltamivir:Oseltamivir:It is given by oral route.It is given by oral route.The drug is excreted unchanged The drug is excreted unchanged

by kidney. Therefore dose needs by kidney. Therefore dose needs to be reduced if creatin clearance to be reduced if creatin clearance is less than 30 ml per minute.is less than 30 ml per minute.

No specific drug interaction has No specific drug interaction has been reported, although been reported, although probenecid reduces its excretion probenecid reduces its excretion by 50%. by 50%.

DOSAGEDOSAGE

Dose for treatment is as followsDose for treatment is as follows::By Weight: By Weight:

For weight <15kg 30 mg BD for 5 daysFor weight <15kg 30 mg BD for 5 days15-23kg 45 mg BD for 5 days15-23kg 45 mg BD for 5 days24-<40kg 60 mg BD for 5 days24-<40kg 60 mg BD for 5 days>40kg 75 mg BD for 5 days>40kg 75 mg BD for 5 days

DOSAGEDOSAGE

For infants:For infants:< 3 months< 3 months 12 mg BD for 5 days12 mg BD for 5 days3-5 months3-5 months 20 mg BD for 5 days20 mg BD for 5 days6-11 months6-11 months 25 mg BD for 5 days25 mg BD for 5 days

ADVERSE REACTIONSADVERSE REACTIONS

gastrointestinal side effects gastrointestinal side effects (transient nausea, vomiting) may (transient nausea, vomiting) may increase with increasing doses increase with increasing doses

cause bronchitis, insomnia and cause bronchitis, insomnia and vertigo. Less commonly angina, vertigo. Less commonly angina, pseudo membranous colitis and pseudo membranous colitis and peritonsillar abscess have also been peritonsillar abscess have also been reported. There have been rare reported. There have been rare reports of anaphylaxis and skin reports of anaphylaxis and skin rashes. rashes.

ADVERSE REACTIONSADVERSE REACTIONS

Infrequently, abdominal pain, Infrequently, abdominal pain, epistaxis, bronchitis, otitis media, epistaxis, bronchitis, otitis media, dermatitis and conjunctivitis have dermatitis and conjunctivitis have also been observed. also been observed.

Though rare reporting of fatal neuro-Though rare reporting of fatal neuro-psychiatiric illness in children and psychiatiric illness in children and adolescents have been linked to adolescents have been linked to oseltamivir oseltamivir

Other Drugs under Other Drugs under EvaluationEvaluation

Peramivir and other cyclopentane Peramivir and other cyclopentane derivatives:derivatives:A Single injection in mice strongly A Single injection in mice strongly suppreses influenza virus.suppreses influenza virus.

Dimeric Neuraminidase InhibitorsDimeric Neuraminidase Inhibitors:: 100 times more potent than Zanamivir, 100 times more potent than Zanamivir,

opens possibility of once a week dose opens possibility of once a week dose possibility.possibility.

Ribavarine and Interferon alpha.Ribavarine and Interferon alpha. Sialidase fusion proteins & siRNAs.Sialidase fusion proteins & siRNAs.

Supportive therapySupportive therapy

IV Fluids.IV Fluids.Parentral nutrition. Parentral nutrition. Oxygen therapy/ ventilatory support.Oxygen therapy/ ventilatory support.Antibiotics for secondary infection.Antibiotics for secondary infection.Vasopressors for shock Vasopressors for shock

Supportive therapySupportive therapy

Paracetamol or ibuprofen is Paracetamol or ibuprofen is prescribed for fever, myalgia and prescribed for fever, myalgia and headache. Patient is advised to drink headache. Patient is advised to drink plenty of fluids. Smokers should plenty of fluids. Smokers should avoid smoking. For sore throat, short avoid smoking. For sore throat, short course of topical decongestants, course of topical decongestants, saline nasal drops, throat lozenges saline nasal drops, throat lozenges and steam inhalation may be and steam inhalation may be beneficial. beneficial.

Supportive therapySupportive therapy

Salicylate / aspirin is strictly contra-Salicylate / aspirin is strictly contra-indicated in any influenza patient indicated in any influenza patient due to its potential to cause Reye’s due to its potential to cause Reye’s syndrome.syndrome.

The suspected cases would be The suspected cases would be constantly monitored for clinical / constantly monitored for clinical / radiological evidence of lower radiological evidence of lower respiratory tract infection and for respiratory tract infection and for hypoxia (respiratory rate, oxygen hypoxia (respiratory rate, oxygen saturation, level of consciousness). saturation, level of consciousness).

Supportive therapySupportive therapy

oxygen therapyoxygen therapy Patients with signs of tachypnea, Patients with signs of tachypnea,

dyspnea, respiratory distress dyspnea, respiratory distress and oxygen saturation less than and oxygen saturation less than 90 per cent should be 90 per cent should be supplemented with oxygen supplemented with oxygen therapy.therapy.

Supportive therapySupportive therapy

mechanical ventilation mechanical ventilation Patients with severe pneumonia and Patients with severe pneumonia and

acute respiratory failure (SpO2 < acute respiratory failure (SpO2 < 90% and PaO2 <60 mmHg with 90% and PaO2 <60 mmHg with oxygen therapy) must be supported oxygen therapy) must be supported with mechanical ventilation with mechanical ventilation

Supportive therapySupportive therapy

ABC, Maintain airway, breathing and ABC, Maintain airway, breathing and circulation circulation

Maintain hydration, electrolyte Maintain hydration, electrolyte balance and nutrition balance and nutrition

Supportive therapySupportive therapy

mechanical ventilation mechanical ventilation Patients with severe pneumonia and Patients with severe pneumonia and

acute respiratory failure (SpO2 < acute respiratory failure (SpO2 < 90% and PaO2 <60 mmHg with 90% and PaO2 <60 mmHg with oxygen therapy) must be supported oxygen therapy) must be supported with mechanical ventilation with mechanical ventilation

STEROIDSSTEROIDS

High dose corticosteroids in High dose corticosteroids in particular have no evidence of particular have no evidence of benefit and there is potential for benefit and there is potential for harm. harm.

Low dose corticosteroids Low dose corticosteroids (Hydrocortisone 200-400 mg/ day) (Hydrocortisone 200-400 mg/ day) may be useful in persisting septic may be useful in persisting septic shock (SBP < 90). shock (SBP < 90).

ANTEBIOTICSANTEBIOTICS

Suspected case not having pneumonia Suspected case not having pneumonia do not require antibiotic therapy. do not require antibiotic therapy. Antibacterial agents should be Antibacterial agents should be administered, if required, as per locally administered, if required, as per locally accepted clinical practice guidelines accepted clinical practice guidelines

Patient on mechanical ventilation Patient on mechanical ventilation should be administered antibiotics should be administered antibiotics prophylactically to prevent hospital prophylactically to prevent hospital associated infections.associated infections.

DANGER SIGNALSDANGER SIGNALS

Adults Need attention if Adults Need attention if Present withPresent with

Difficulty breathing or shortness of Difficulty breathing or shortness of breath breath

Pain or pressure in the chest or Pain or pressure in the chest or abdomen abdomen

Sudden dizziness Sudden dizziness Confusion Confusion Severe or persistent vomiting Severe or persistent vomiting

Seek emergency medical care.Seek emergency medical care.IF -IF - in Childrenin Children

In children emergency warning signs that In children emergency warning signs that need urgent medical attention include: need urgent medical attention include:

Fast breathing or trouble breathing Bluish Fast breathing or trouble breathing Bluish skin color.Not drinking enough fluids skin color.Not drinking enough fluids

Not waking up or not interacting Not waking up or not interacting Being so irritable that the child does not Being so irritable that the child does not

want to be held want to be held Flu-like symptoms improve but then return Flu-like symptoms improve but then return

with fever and worse cough with fever and worse cough Fever with a rash Fever with a rash

DISCHARGEDISCHARGE

Adult patients should be discharged 7 Adult patients should be discharged 7 days after symptoms have subsided days after symptoms have subsided

Children should be discharged 14 days Children should be discharged 14 days after symptoms have subsided after symptoms have subsided

The family of patients discharged The family of patients discharged earlier should be educated on personal earlier should be educated on personal hygiene and infection control measures hygiene and infection control measures at home; children should not attend at home; children should not attend school during this period school during this period

EARLY IDENTIFICATION OF EARLY IDENTIFICATION OF PERSONS AT RISK AND PERSONS AT RISK AND PROTECTION OF THEMPROTECTION OF THEM

CHEMOPROPHYLAXIS-CHEMOPROPHYLAXIS-INDICATIONSINDICATIONS

All close contacts of suspected, All close contacts of suspected, probable and confirmed cases. Close probable and confirmed cases. Close contacts include household /social contacts include household /social contacts, family members, workplace contacts, family members, workplace or school contacts, fellow travelers or school contacts, fellow travelers etc.etc.

All health care personnel coming in All health care personnel coming in contact with suspected, probable or contact with suspected, probable or confirmed cases confirmed cases

CHEMOPROPHYLAXIS-CHEMOPROPHYLAXIS-DURATIONDURATION

Prophylaxis should be provided till 10 Prophylaxis should be provided till 10 days after last exposure (maximum days after last exposure (maximum period of 6 weeks period of 6 weeks

CHEMOPROPHYLAXIS- DRUGCHEMOPROPHYLAXIS- DRUG

Oseltamivir is the drug of choice.Oseltamivir is the drug of choice.For weight <15kg 30 mg OD For weight <15kg 30 mg OD 15-23kg 45 mg OD15-23kg 45 mg OD24-<40kg 60 mg OD24-<40kg 60 mg OD>40kg 75 mg OD>40kg 75 mg OD

OseltamivirOseltamivir

For infants:For infants:< 3 months< 3 months not recommended not recommended

unless situation judged critical due to unless situation judged critical due to limited data on use in this age grouplimited data on use in this age group

3-5 months3-5 months 20 mg OD20 mg OD6-11 months6-11 months 25 mg OD25 mg OD

Infection control measures Infection control measures at Individual levelat Individual level

Hand HygieneHand Hygiene Hand hygiene is the single most important Hand hygiene is the single most important

measure to reduce the risk of transmitting measure to reduce the risk of transmitting infectious organism from one person to infectious organism from one person to other.other.

Hands should be washed frequently with Hands should be washed frequently with soap and water / alcohol based hand rubs/ soap and water / alcohol based hand rubs/ antiseptic hand wash and thoroughly dried antiseptic hand wash and thoroughly dried preferably using disposable tissue/ paper/ preferably using disposable tissue/ paper/ towel.towel.

Respiratory Hygiene/Cough Respiratory Hygiene/Cough EtiquetteEtiquette

Cover the nose/mouth with a Cover the nose/mouth with a handkerchief/ tissue paper when handkerchief/ tissue paper when coughing or sneezing;coughing or sneezing;

Use tissues to contain respiratory Use tissues to contain respiratory secretions and dispose of them in the secretions and dispose of them in the nearest waste receptacle after use;nearest waste receptacle after use;

Cover your mouth and nose.Cover your mouth and nose.

Cover your mouth Cover your mouth and nose with a and nose with a tissue when tissue when coughing or coughing or sneezing. It may sneezing. It may prevent those prevent those around you from around you from getting sick getting sick

Simple measures carry get Simple measures carry get good Benefitsgood Benefits

Cover your Cover your mouth and nose. mouth and nose. Use a tissue when Use a tissue when you cough or you cough or sneeze and drop it sneeze and drop it in the trash. If you in the trash. If you don’t have a tissue, don’t have a tissue, cover your mouth cover your mouth and nose as best and nose as best you can.you can.

Staying awayStaying away

Stay away from pigs. Keep them Stay away from pigs. Keep them secure in cages. Keep children out of secure in cages. Keep children out of reach. reach.

Wash hands if in contact with pig or Wash hands if in contact with pig or pig products.pig products.

Stay at least one metre away from a Stay at least one metre away from a person having cough or sneeze person having cough or sneeze

Stay home when you are Stay home when you are sick.sick.

If possible, stay If possible, stay home from work, home from work, school, and errands school, and errands when you are sick. when you are sick. You will help You will help prevent others prevent others from catching your from catching your illness. illness.

Use of maskUse of mask

Persons under investigations / Persons under investigations / suspected cases managed at home suspected cases managed at home and there family contacts are trained and there family contacts are trained on using three layered surgical on using three layered surgical masks.masks.

Guidelines for waste Guidelines for waste disposaldisposal

All the waste has to be treated as All the waste has to be treated as infectious waste and decontaminated infectious waste and decontaminated as per standard proceduresas per standard procedures

Articles like swabs/gauges etc are to Articles like swabs/gauges etc are to be discarded in the Yellow coloured be discarded in the Yellow coloured autoclavable biosafety bags after autoclavable biosafety bags after use, the bags are to be autoclaved use, the bags are to be autoclaved followed by incineration of the followed by incineration of the contents of the bag.contents of the bag.

CARRY HOME MESSAGECARRY HOME MESSAGE

SWINE FLU IN MAN IS A HIGHLY SWINE FLU IN MAN IS A HIGHLY CONTAGEOUS DISEASECONTAGEOUS DISEASE

IF DIAGNOSED IN TIME, TREATED IF DIAGNOSED IN TIME, TREATED PROPERLY, AND PROTECTING HEALTH PROPERLY, AND PROTECTING HEALTH CARE STAFF AND CONTACTS, CARE STAFF AND CONTACTS, PANDEMIC MAY BE CONTAINEDPANDEMIC MAY BE CONTAINED

THANK YOUTHANK YOU