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A,B,C of Flu
Human FLU
Deaths worldwide
 Seasonal flu: mainly A + B (C rare)
500,000 / yr
Influenza A virus pandemics:
 H1N1:
Spanish Flu 1918
 H2N2:
Asian Flu 1957
 H3N2:
Hong-Kong Flu 1968
50 million
2 million
1 million
 H5N1:
Bird Flu
Where does Swine Flu fit in?
Swine Flu
 New influenza A(H1N1) virus
 Unrelated to seasonal flu
 Respiratory disease of pigs,
birds, poultry, horses &
humans
“Quadruple reassortant" virus
 Bird-Flu gene
 Pig-flu gene
 2 genes: Europe & Asia
 Human-gene
Pandemic H1N1 2009
 Never before circulated in humans
 WHO Phase 6 = Pandemic
 > 300,000 cases in over 200 countries
Symptoms
 Fever (> 38°C / 100.4°F)
Plus 2 or more of:
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
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Tiredness
Headache
Runny nose
Sore throat
SOB /cough
Loss of appetite
Aching muscles
D&V
Who Is At Risk?
Chronic Disease:
 Lung
 Heart
 Kidney
 Liver
 Neurological
 Immunosuppressed
 Diabetes
 Asthma (Rx past 3 y)
Also:
 Pregnant women
 Elderly ≥ 65 y
 Children <5 y
UK 2009 Timeline
 March:
 April:
 June:
 July:
first confirmed cases (US & Mexico)
confirmed in UK
first death in UK, Glasgow
1st death with no underlying medical probs
 Containment to Treatment Phase
 Diagnose on symptoms NOT testing
 All contact tracing stopped
 Exposure does not = antiviral drugs
 Sept:
Rising new cases
Predictions
Infected = 18.3m
Deaths
 18-64,050
Hospital
 366,000
Complications
 2.74m
Mild
 15m
Public Messages
 Catch it, bin it, kill it
 Cover mouth / tissues / basic hygiene
 Hard surfaces e.g. Door handles, keyboards, phones
 Stay at Home
 If symptoms (5-7d)
 Flu friends
 Face mask unnecessary
 Contact
 GP / NHS 24
 National Pandemic Flu Service
DOH: General Advice
 Children
 Attend schools unless flu symptoms
 Avoid “flu-parties”
 See Doctor if < 1 yr
 Pregnant



Routine avoidance measures
Safe to breastfeed if anti-virals
Teachers advised to attend school
 Travel:
 Unrestricted unless symptomatic
 Avoid Mecca Pilgrimages if high-risk group
Headlines
 “Swine flu jabs rushed through safety tests”
 “GPs demand more money for swine flu jabs” TIMES ONLINE
 “NHS staff don’t want swine flu jab”
 “Up to half of GPs and one in three nurses ... because of concerns
over safety.” Telegraph
 “Vaccine risk outweighs risk of virus” Irish-Times
 “Swine flu over-diagnosed”
 “Swine-flu under-reported”
HCP Advice
 Triage suspected cases
 Avoid in surgery if possible
 Declutter waiting rooms
 Use of PPE
 Gloves
 Mask
 Glasses
 Gown
Antivirals
 May lessen severity by reducing:
 Length of illness (~ 1 day)
 Symptoms, and
 ? Serious complications risk
 Maximum benefit
 Adults: Within 48 hrs of symptoms onset
 Children: Within 36 hrs of symptoms onset
 Preparation:
 TAMIFLU (Oseltamivir) & RELENZA (Zanamivir)
 neuraminidase enzyme inhibitors
Action
 Block viral enzyme
 Prevent shedding
Safety
 Relatively new
 report via the MHRA’s
‘Swine Flu ADR Portal’
Tamiflu
 Age 1 and over
 Caps: 30/45/75mg
 Susp: 12mg/ml solution
SEs
 676 suspected ADRs since April
 nausea, vomiting, diarrhoea, abdo pain,
headache, mild allergic
 ??seizures/delirium
Caution
 Severe renal impairment

AVOID dialysis (CrCl ≤ 10ml/min)
 ?methotrexate ?probenecid
 ?? warfarin
Dose:
 Age 1-12
 BW ≤ 15kg:
 BW ≤ 23kg:
 BW ≤ 40kg:
 Age 13+/>40kg:
30mg
45mg
60mg
75mg
Duration:
 Treat = bd for 5 days
 Prev = od for 10 days
NB
 Best with food
Relenza
 Age 5 and over
 Inhaled (Diskhaler): 5mg dose
 Use: pregnancy, renal disorders
SEs:
 22 suspected ADRs since April
 V rare: 1 in 10,000
 allergy, bronchospasm
Caution:
 persistent asthma/severe COPD
AVOID severe asthma
 Use bronchodilator before taking

AVOID:
 allergy to lactose/milk protein
Dose:
 2 inhalations (2 blisters) = 10mg
Duration:
 Treat = bd for 5 days
 Prev = od for 10 or 28 days*
* Longer duration if community outbreak
Vaccination
Vaccination
 First batches expected October
 Once licensed by European Medicines Agency (EMEA)
 Safety concerns (medical / case reports Guillain-Barre 1970’s)
 Prioritised by risk Grp
 2 doses, 3 weeks apart
 Annual flu vaccination also required
 “Previous Swine-flu” does not reduce risk
 Even if received anti-virals
 Exception is lab (swab) +ve cases
st
1
1.
2.
3.
4.
5.
Stage Contact
High Risk: age > 6m – 65 y
Pregnant
House contacts immunosuppr
High-Risk: age > 65 y
Frontline Health Professionals
TOTAL =
SCOTLAND
ENGLAND
640,700
60,000
53,000
428,250
250,000
_________
5m
0.5 m
0.5 m
3.5 m
2m
________
1.4 million
11 million
Complications
Complications
NEJM 2009
 Most common severe complications
 Respiratory Distress
 Pneumonia
 Youth Shift: Age 5-59
 87% of total Deaths (exp ~ 17%)
 71% of Severe pneumonia (exp~32%)
• Selective Antivirals (WHO Aug 2009)
• High risk groups
• Serious / deteriorating cases =
SOB / Resp distress / cyanosis / haemoptysis /
chest pain / fever >3d / confusion / low BP
Second Wave?
Is it coming back?
Week until 14/9/9: Sentinel GP practice data
 New cases in Scotland
 Higher now than start of August
 Past week
6181
 Prev week
3336
 Consultation rates
 Tayside > Scottish average
 Increasing
age < 65
 Decreasing
age > 65
 Complications
 Hospitalised
13 cases (1 ICU)
 Deaths
8 cases
 2nd wave likely coincide with seasonal flu
Summary
 High Risk
 “Young people”
 Pregnancy
 Chronic Disease / immuno-suppressed
 esp < 5y & >65y
 Course
 Most mild  self-care
 Mortality ~0.3% (= seasonal flu)
 Second-wave
 Anti-virals
 Best evidence severe cases / high-risk
 Treat based on risk groups
 ? Emerging resistance
 Vaccination
 Late-October
 Normal flu-risk group 6m – 65y
Extra:
 Frontline health-care workers
The End
 www.direct.gov.uk
 www.nhs24.com
 www.scotland.gov.uk
 www.rcgp.org.uk/pandemic
 www.hpa.org.uk
 www.bma.org.uk/health_promoti
on_ethics/influenza
 www.documents.hps.scot.nhs.uk/
respiratory/swineinfluenza/situation-
reports/weekly-h1n1v