Download ACTIVE AND PASSIVE MANAGEMENT OF H1N1 FLU

SWINE FLU AWARENESS
BY
Dr. Mohit Bhutani
Dr. D. Himanshu M.D
Influenza pandemics & emerging
new pandemic threats exist since
1900!
1918
Spanish
1957
Asian
1968
Hong
Kong
1977
Russian
1997
Hong
Kong
1999
Hong
Kong
2003
Dutch
20032008
Global
2009
Global
H1N1
H2N2
H3N2
H1N1
H5N1
H9N2
H7N7
H5N1
H1N1
18
cases
2
cases
82
cases
387
cases
~30,000
cases
One
death
245
deaths
145
deaths
2008
2009
>50
million
deaths
~2
million
deaths
~1
million
deaths
<1
million
deaths
1918
1957
1968
1977
Pandemic outbreaks
Six
deaths
2000
Recent outbreaks of influenza
The emergence of H1N1 has demonstrated the difficulty in predicting
pandemics
Nicholson KG, Wood JM, Zambon M. Lancet 2003; 362:1733-1745; WHO, Cumulative number of confirmed human cases of avian influenza
A/(H5N1), available at: http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_09_10/en/index.html (accessed 5
November 2008); CDC, Avian Influenza, available at: http://www.cdc.gov/flu/avian/outbreak.htm (accessed 5 November 2008).
Pandemic
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
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
Standard Operating Procedures *
Reinforce standard infection control precautions
oall 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
MANAGEMENT
The first thing is to differentiate between a flu and a cold
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 2009-2010 Season
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.
TREATMENT ALGORITHM FOR
MILD DISEASE
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 2009-2010 Season
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.
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.
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 2009-2010 Season
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 2009-2010 Season
• OSELTAMIVIR : oral (cap/suspension)
 Oseltamivir is the recommended drug both for
prophylaxis and treatment.
 Neuraminidase inhibitor
 Pregnancy category ‘c’
SCHEDULE
ADVERSE EFFECTS(oseltamivir)
• >10%- gastrointestinal- vomiting, nausea , pain
abdomen
• 1%- conjuctivitis
• 1%- epistaxis
• <1%- anaphylactic reaction,
pseudomembranous colitis, SJS/TEN, abnormal
LFT, neuropsychiatric events
• Zanamivir – inhalational .(Relenza®)

FDA-approved for the treatment of influenza in patients
7 years of age and older
 Caution
 Bronchospasm in asthma patients
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
• AMANTADINE
• RIMANATADINE
Not recommended due to widespread
resistance in 2009 H1N1 strain
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 2009-2010 Season
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.
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
ACTIVE
PREVENTION
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.
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
Oseltamivir AND Zanamivir drug of
choice
• Prophylaxis should be provided till 10 days after last
exposure
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.
2.LIVE ATTENUATED
• administered by nasal spray.
• healthy individuals 2-49 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
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
o pregnant women
o aged above 6 months with one of several chronic medical
conditions,
o healthy adults of 65 years of age and above
PASSIVE
PREVENTION
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
N95 Respirator
• Filters 95% of airborne particulates
*NIOSH- National Institute for Occupational Safety
and Health. Agency under CDC.
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 .
o If splashing with blood or other body fluids is anticipated,
a water proof apron should be worn over the PPE
• 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
• 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.
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
THANK YOU