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SWINE FLU DR REJI JOSE.MD. CONSULTANT PHYSICIAN TALUK HOSPITAL THODUPUZHA DEFINITION SWINE FLU IS A HIGHLY CONTAGEOUS ACUTE RESPIRATORY DISEASE OF PIGS CAUSED BY INFLUENZA A VIRUS, CAN CAUSE ILLNESS IN MAN ALSO SWINE FLU IN MAN SWINE FLU IN MAN IN MAN THE DISEASE PRESENT AS AN ABRUPT ONSET OF HIGH FEVER WITH FEATURES OF ACUTE LOWER PESPIRATORY INFECTION RAPIDLY PROGRESSING, HIGHLY CONTAGEOUS AND IF NOT TREATED IN TIME MAY LEAD TO SERIOUS CMPLICATIONS OR DEATH HISTORY OF FLU PANDEMIC HISTORY 1918-SPANISH FLU-50 MILL DEATHS.H1N1 1957-ASIAN FLU-1-4 MILL DEATHS. 1968-HONG KONG FLU-1-4 MILL DEATHS. 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 PANDEMIC WE HAVE TO BE PREPARED TO MEET THE CHALLENGE, WHICH CAN OCCUR AT ANY TIME. THE AGENT SWINE INFLUENZA-THE AGENT It is a RNA virus, Influenza A virus, Natural reservoir-pigs Can infect man, Shifted virus may cause pandemic THE AGENT IT IS INFLUENZA A VIRUS A Influenza virus A- antigenic variations ANTIGENIC DRIFT: Gradual antegenic change over a period Involves “point mutations" in genes owing to selection pressure by immunity in host population Responsible for frequent influenza epidemics;necessiates reformulation of influenza vaccines Influenza virus A- antigenic variations ANTIGENIC SHIFT: Sudden complete or major change; Results fro genetic recombination of human with animal/avian virus Leads to a novel subtype different from both parent viruses If novel subtype has sufficient genes from H1 viruses which make it readily transmissible from person to person, it may cause pandemic SWINE INFLUENZA-THE AGENT 2 surface antigens HAEMAGGLUTININS(HA)-16 Nos Initiates infection following attachment of virus to susceptible cells NEURAMINIDASE(NA)-9 Nos Different combinations eg H1N1,N5N2 etc SWINE INFLUENZA-THE AGENT THE VIRUS RESPONSIBLE FOR CURRENT PANDEMIC IS H1N1 HOST FACTORS SEASONAL INFLUENZA -HOST FACTORS Age & sex All ages, both sexes Attack rates more among young adults High CFR during in high risk cases like old and very young, DM cases and with other diseases like COPD SWINE INFLUENZA –HIGH RISK GROUPS Infants and young children, Elderly, Persons of any age with chronic conditions >COPD >CVA, >Renal diseases, >Immunocompromised, >Pregnant women. SEASONAL INFLUENZA -HOST FACTORS Immunity Antibody to H neutralizes the virus Antibody to N modifies the infection Antibody appear 7 days after the infection, max in 2 weeks, drops to pre infection level in 8-12 months THE ENVIORNMENT INFLUENZA -ENVIORNMENTAL FACTORS Seasonality Temperate zone: epidemics occur in winter Tropics: epidemics occur in rainy season Sporadic cases: any month Overcrowding Enhances transmission Higher attack rates in closed population SWINE INFLUENZA -TRANSMISSION Mainly airborne Droplet infection Droplet nuclei Through direct contact Fomites also PATHOGENESIS VIRUS INFECT WHOLE OF THE RESPIRATORY TRACT FROM NASAL MUCOSA TO ALVEOLI Local inflammatory reaction->nasal congestion, cough, breathlessness Systemic body reaction-> Fever,myalgia etc Features of ac lower respiratory infection, INCUBATION PERIOD 1 TO 7 DAYS MORE IN CHILDREN COMMUNICABILITY 1 DAY BEFORE TO 7 DAYS AFTER THE INFECTION, MORE IN CHILDREN CLINICAL FEATURES SYMPTOMS Abrupt onset of fever body aches,head ache and fatigue Cough, rhinitis, sore throat GI symptoms and myositis common in young, FEVER ABRUPT ONSET ABOVE 38° C ASSOCIATED BODY PAIN ALSO CONTINUE FOR FEW DAYS AND GRADUALLY DIMINISH CHILLS AND RIGOR ALSO HEAD ACHE COUGH TYPICAL OF LOWER RESPIRATORY INFECTION FEATURES OF UPPER RESPIRATORY INFECTION IN THE FORM OF NASAL CONGESTION,RHINORRHOEA, SORE THROAT. GIT SYMPTOMS USUALLY SEEN AS DIARRHOEA, NAUSEA AND VOMITING ASSOCITED SYMPTOMS FATIGUE, WEAKNESS, SIGNS Elevated temperature Tachycardia Tachypnoea Crepitations TEMPERATURE USUALLY ABOVE 38° C CHILLS AND RIGOR CAN OCCUR INCREASED RESPIRATORY RATE DUE TO LOWER RESPIRATORY INFECTION CREPITATIONS AND RONCHI ALSO SWINE INFLUENZA -COMPLICATIONS Sinus and ear infections, Pneumonia, bacterial and viral, Myocarditis, Pericarditis, Encephalitis, Febrile seizures in young, Worsening of underlying chronic disease SWINE INFLUENZA –HIGH RISK GROUPS Infants and young children, Elderly, Persons of any age with chronic conditions >COPD >CVA, >Renal diseases, >Immunocompromised, >Pregnant women. PROVISIONAL DIAGNOSIS HISTORY OF CONTACT COMING FROM AN ENDEMIC AREA SYMPTOMS AND SIGNS OF ACUTE RESPIRATORY INFECTION WITH HIGH GRADE FEVER INVESTIGATIONS INVESTIGATIONS TO EXCLUDE OTHER CAUSES OF FEVER WITH SIMILAR CLINICAL PICTURE CONFIRMATION >REAL TIME PCR >ISOLATION OF VIRUS IN CULTURE >FOUR FOLD RISE IN VIRUS SPECIFIC NEUTRILISING ANTEBODIES CONFIRMATORY TESTS The samples are to be tested in BSL-3 laboratory. At present the following laboratories are the identified laboratories for this purpose: National Institute of Communicable Diseases, 22, Sham Nath Marg, Delhi [Tel. Nos. Influenza Monitoring Cell: 011-23921401; Director: 011-23913148] CONFIRMATORY TESTS(CONT) National Institute of Virology, 20-A, Dr. Ambedkar Road, Pune-411001 [Tel.No. 020-26124386] SPECIMEN COLLECTION For confirmation of diagnosis, clinical specimens such as nasopharyngeal swab, throat swab, nasal swab, wash or aspirate, and tracheal aspirate (for intubated patients) are to be obtained. The sample should be collected by a trained physician / microbiologist preferably before administration of the anti-viral drug STORAGE AND TRANSPORT Keep specimens at 4°C in viral transport media until transported for testing. The samples should be transported to designated laboratories with in 24 hours If they cannot be transported then it needs to b stored at -70°C. Paired blood samples at an interval of 14 days for serological testing should also be collected. DIFERENTIAL DIAGNOSIS OTHER EFVERS LIKE TYPHOID, COMMON RESPIRATORY INFECTIONS LIKE AC BRONCHITIS, CAP, LEPTOSPIROSIS ETC COMMON COLD AVIAN FLU SEASONAL INFLUENZA SWINE INFLUENZA V/S COMMON COLD SYMPTOMS Fever Head ache Fatigue Stuffy nose Cough Chest discomfort Comlications INFLUENZA High 3-4 days Yes 2-3 weeks Sometimes Yes Yes, may be severe Common COLD Unusual Unusual Mild Common Unusual Mild Rare SWINE INFLUENZA V/S INFLUENZA A SYMPTOMS SWINE INFLUENZA INFLUENZA A FEVER HEAD ACHE FATIGUE COUGH GIT SYMPTOM HIGH SEVERE >2 WEEKS YES MORE MORE CHANCE LESSER MILDER 2 WEEKS YES NO LESS COMPLICATIONS SWINE INFLEUNZA VS AVIAN CLINICAL PICTURE SIMILAR BUT MORE SEVERE IN AVIAN INFLEUNZA TREATMENT EARLY IMPLEMENTATION OF INFECTION CONTROL PROMPT DRUG TREATMENT TO PREVENT SEVERITY AND DEATH EARLY IDENTIFICATION OF PERSONS AT RISK AND PROTECT THEM INFECTION CONTROL INFECTION CONTROL INFRASTRUCTURE ISOLATION FACILITIES MANPOWER,MEDICAL, NURSING & PARAMEDICAL STAFF EQUIPMENTS- VENTELATORS ETC SUPPLIES-PPE, DRUGS INFECTION CONTROL Effective Infection Control Prevents Transmission From. Patients to health care workers Patients to patients Patients to family members providing care Swine Influenza Precautions Contact precautions Droplet precautions Airborne Precautions Precautions for Suspected or Confirmed Cases Place patient in a negative air pressure room To create a negative air pressure room: Install exhaust fan and direct air from inside to an outside area with no person movement If no air conditioning, open windows in isolation areas but keep doors closed Place patients in rooms alone Alternative: cohort patients away from other patient care areas with beds > 1 meter apart Precautions for Suspected or Confirmed Cases Limit number of health care workers, family members and visitors Designate experienced staff to provide care Limit designated staff to swine influenza patient care Teach family and visitors to use PPE PERONAL PROTECTION EQUIPMENTS(PPE) THOSE ENTERING ROOM SHOULD WEAR PPE Use of PPE The medical, nurses and paramedics attending the suspect/ probable / confirmed case should wear full complement of PPE . Use N-95 masks during aerosol-generating procedures. Perform hand hygiene before and after patient contact and following contact with contaminated items, whether or not gloves are worn. Sample collection and packing should be done under full cover of PPE. PERSONAL PROTECTIVE EQUIPMENTS INCLUDE HIGH EFFICIENCY MASK GOWN GOGGLES GLOVES CAP AND SHOE COVER Personal Protective Equipment Personal Protection Equipments Goggles Personal Protection Equipments Mask Personal Protection Equipments N95 Mask Personal Protection Equipments Gown Protection Equipments Personal Shoe Cover Personal Protection Equipments Gloves Correct procedure for applying Follow thorough hand wash Wear the coverall. Wear the goggles/ shoe cover/and head cover in that order. Wear face mask Wear gloves The masks should be changed after every six to eight hours. Remove PPE in the following order: • Remove gown (place in rubbish bin). • Remove gloves (peel from hand and discard into rubbish bin). • Use alcohol-based hand-rub or wash hands with soap and water. • Remove cap and face shield (place cap in bin and if reusable place face shield in container for decontamination). • Remove mask - by grasping elastic behind ears – do not touch front of mask • Use alcohol-based hand-rub or wash hands with soap and water. • Leave the room. • Once outside room use alcohol hand-rub again or wash hands with soap and water Used PPE should be handled as waste as per waste management protocol DRUG THERAPY Neuraminidase Inhibitors Oseltamivir and Zanamivir belongs to this group. Mode of action: These drugs block release of newly formed virus particles by inhibiting neuraminidase of virus. Cont… Oseltamivir: It is given by oral route. The drug is excreted unchanged by kidney. Therefore dose needs to be reduced if creatin clearance is less than 30 ml per minute. No specific drug interaction has been reported, although probenecid reduces its excretion by 50%. DOSAGE Dose for treatment is as follows: By Weight: For weight <15kg days 15-23kg days 24-<40kg days >40kg days 30 mg BD for 5 45 mg BD for 5 60 mg BD for 5 75 mg BD for 5 DOSAGE For infants: < 3 months 12 mg BD for 5 days 3-5 months 20 mg BD for 5 days 6-11 months 25 mg BD for 5 days ADVERSE REACTIONS gastrointestinal side effects (transient nausea, vomiting) may increase with increasing doses cause bronchitis, insomnia and vertigo. Less commonly angina, pseudo membranous colitis and peritonsillar abscess have also been reported. There have been rare reports of anaphylaxis and skin rashes. ADVERSE REACTIONS Infrequently, abdominal pain, epistaxis, bronchitis, otitis media, dermatitis and conjunctivitis have also been observed. Though rare reporting of fatal neuropsychiatiric illness in children and adolescents have been linked to oseltamivir Other Drugs under Evaluation Peramivir and other cyclopentane derivatives: A Single injection in mice strongly suppreses influenza virus. Dimeric Neuraminidase Inhibitors: 100 times more potent than Zanamivir, opens possibility of once a week dose possibility. Ribavarine and Interferon alpha. Sialidase fusion proteins & siRNAs. Supportive therapy IV Fluids. Parentral nutrition. Oxygen therapy/ ventilatory support. Antibiotics for secondary infection. Vasopressors for shock Supportive therapy Paracetamol or ibuprofen is prescribed for fever, myalgia and headache. Patient is advised to drink plenty of fluids. Smokers should avoid smoking. For sore throat, short course of topical decongestants, saline nasal drops, throat lozenges and steam inhalation may be beneficial. Supportive therapy Salicylate / aspirin is strictly contraindicated in any influenza patient due to its potential to cause Reye’s syndrome. The suspected cases would be constantly monitored for clinical / radiological evidence of lower respiratory tract infection and for hypoxia (respiratory rate, oxygen saturation, level of consciousness). Supportive therapy oxygen therapy Patients with signs of tachypnea, dyspnea, respiratory distress and oxygen saturation less than 90 per cent should be supplemented with oxygen therapy. Supportive therapy mechanical ventilation Patients with severe pneumonia and acute respiratory failure (SpO2 < 90% and PaO2 <60 mmHg with oxygen therapy) must be supported with mechanical ventilation Supportive therapy ABC, Maintain airway, breathing and circulation Maintain hydration, electrolyte balance and nutrition Supportive therapy mechanical ventilation Patients with severe pneumonia and acute respiratory failure (SpO2 < 90% and PaO2 <60 mmHg with oxygen therapy) must be supported with mechanical ventilation STEROIDS High dose corticosteroids in particular have no evidence of benefit and there is potential for harm. Low dose corticosteroids (Hydrocortisone 200-400 mg/ day) may be useful in persisting septic shock (SBP < 90). ANTEBIOTICS Suspected case not having pneumonia do not require antibiotic therapy. Antibacterial agents should be administered, if required, as per locally accepted clinical practice guidelines Patient on mechanical ventilation should be administered antibiotics prophylactically to prevent hospital associated infections. DANGER SIGNALS Adults Need attention if Present with Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting Seek emergency medical care. IF - in Children In children emergency warning signs that need urgent medical attention include: Fast breathing or trouble breathing Bluish skin color.Not drinking enough fluids 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 Fever with a rash DISCHARGE Adult patients should be discharged 7 days after symptoms have subsided Children should be discharged 14 days after symptoms have subsided The family of patients discharged earlier should be educated on personal hygiene and infection control measures at home; children should not attend school during this period EARLY IDENTIFICATION OF PERSONS AT RISK AND PROTECTION OF THEM CHEMOPROPHYLAXISINDICATIONS All close contacts of suspected, probable and confirmed cases. Close contacts include household /social contacts, family members, workplace or school contacts, fellow travelers etc. All health care personnel coming in contact with suspected, probable or confirmed cases CHEMOPROPHYLAXISDURATION Prophylaxis should be provided till 10 days after last exposure (maximum period of 6 weeks CHEMOPROPHYLAXIS- DRUG Oseltamivir is the drug of choice. For weight <15kg 30 mg OD 15-23kg 45 mg OD 24-<40kg 60 mg OD >40kg 75 mg OD Oseltamivir For infants: < 3 months not recommended unless situation judged critical due to limited data on use in this age group 3-5 months 20 mg OD 6-11 months 25 mg OD Infection control measures at Individual level Hand Hygiene Hand hygiene is the single most important measure to reduce the risk of transmitting infectious organism from one person to other. Hands should be washed frequently with soap and water / alcohol based hand rubs/ antiseptic hand wash and thoroughly dried preferably using disposable tissue/ paper/ towel. Respiratory Hygiene/Cough Etiquette Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing; Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use; Cover your mouth and nose. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick Simple measures carry get good Benefits Cover your mouth and nose. Use a tissue when you cough or sneeze and drop it in the trash. If you don’t have a tissue, cover your mouth and nose as best you can. Staying away Stay away from pigs. Keep them secure in cages. Keep children out of reach. Wash hands if in contact with pig or pig products. Stay at least one metre away from a person having cough or sneeze Stay home when you are sick. If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness. Use of mask Persons under investigations / suspected cases managed at home and there family contacts are trained on using three layered surgical masks. Guidelines for waste disposal All the waste has to be treated as infectious waste and decontaminated as per standard procedures Articles like swabs/gauges etc are to be discarded in the Yellow coloured autoclavable biosafety bags after use, the bags are to be autoclaved followed by incineration of the contents of the bag. CARRY HOME MESSAGE SWINE FLU IN MAN IS A HIGHLY CONTAGEOUS DISEASE IF DIAGNOSED IN TIME, TREATED PROPERLY, AND PROTECTING HEALTH CARE STAFF AND CONTACTS, PANDEMIC MAY BE CONTAINED THANK YOU