Download SWINE INFLUENZA

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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
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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?
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CHALLENGES WE FACE
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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?
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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
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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
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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
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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.
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INFLUENZA VIRUS
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ELECTRON MICROSCOPY
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TYPES
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PIG
THE CREATOR
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VIRAL VARIANTS
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INFLUENZA A VIRUS
Swine
Human
H1N2
H3N1
H3N2
H1N1(pandemics)
H3N2 (rare)
Avian
H5N1
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QUADRUPLE
REASSORTMENT GENETICS
• Human
swine
H1N1
• Avian
swine
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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
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HISTORY
• In the 20th century there have been three
influenza pandemics in 1918, 1957 and
1968.
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Emergency hospital, Camp Funston,
Kansas 1918
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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.
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• 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.
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• 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.
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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
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Global pandemic
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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
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Transmission
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• 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.
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• 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.
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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.
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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.
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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
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Risk factors
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COPD
Immunocompromised state
DM
Pregnancy
Cardiac disease
Obesity
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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
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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
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A suspected case acute febrile
respiratory illness who:
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- Develops symptoms within seven
days of close contact with a person who is
a confirmed case of H1N1 influenza A
virus infection or
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- Develops symptoms within seven
days of travel or resides in a community
where there are one or more confirmed
H1N1 influenza A cases
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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)
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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
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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
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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
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contd
SEASONAL
INFLUENZA
H1N1 INFLUENZA
SYMPTOMS
RESPIRATORY
RESPIRATORY
&
GASTROINTESTINAL
SECONDARY ATTACK
RATE
5-15 %
22-33 %
VACCINE
PROTECTIVE
UNDER
DEVELOPMENT
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AGE SHIFTS IN MORTALITY
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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
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• 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.
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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.
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• 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
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DIAGNOSTIC TESTS
QUIDEL
RT PCR
CULTURE
DFA/IFA
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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)
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• 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.
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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
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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
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CLINICAL FEATURES
Vomiting or diarrhea (not typical for
influenza but reported by recent cases of
swine influenza infection)
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Mexican data in MV patients
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Mexican data in MV patients
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Younger people at risk
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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
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Can we make a broad clinical
check list
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History of contact
Younger age, sudden onset
Fever, cough, breathlessness
Leucopenia, raised LDH and CPK
Should all such patients be isolated and
given Tamiflu?
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Other Manifestations:
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Tachycardia
Tachypnoea
Low O2 sat.
Hypotension
Cyanosis
Acute myocarditis
Cardiopulmonary arrest
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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.
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Children Emergency Warning Signs
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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
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In adults, emergency warning
signs
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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
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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
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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
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Cytokine Storm Treatment
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Steroids
ACE Inhibitors & ARBs
Anti-CD28 Monoclonal Antibody
TNF-alpha blockers
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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).
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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
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LABORATORY FINDINGS
• CBC- leucocytosis/leucopenia
lymphopenia
• Elevated CPK, LDH
• Elevated UREA,CREATININE
• Elevated AST,ALT
• CHEST RADIOGRAPH-bilateral patchy
pneumonia.
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H1 N1 Pneumonia
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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)
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• Cardiac (myocarditis, pericarditis)
• Neurologic (Acute and post-infectious
encephalopathy, encephalitis, febrile
seizures, status epilepticus)
• Toxic shock syndrome
• Secondary bacterial pneumonia with or
without sepsis
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DD H1N1 PNEUMONIA
• OTHER VIRAL pneumonia
influenza A,B
adenovirus
RSV
para influenza rhinovirus
humanmetapneumonia
• Legionella,Chlamydia,Mycoplasma
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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.
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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
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Tamiflu
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Tamiflu
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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
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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
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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
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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
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Hospitalized pts:
• Antivirals
• Pneumonia management like avian
(antibiotics)
• Resp. Support: early detection
Correction of hypoxia with
supplemental O2 or mech. Vent as
necessary
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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
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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?
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prevention
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N95 Mask
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What should I do to keep from getting
the flu?
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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.
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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
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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
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Is Negative Pressure Room
Must ?
Place patients in a single-patient room with the door
kept closed & droplet and contact isolation
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Is BIA ready?
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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
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Dealing with the Deceased
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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.
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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
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