Download DIAGNOSIS OF SWINE FLU

Influenza A H1N1
(Swine flu)
DIAGNOSIS OF SWINE FLU
For diagnosis of swine influenza A infection,
respiratory specimen would generally need to
be collected within the first 4 to 5 days of
illness. However, some persons, especially
children, may shed virus for 10 days or longer.
 The following clinical samples need to be collected
preferably within 72 hours of illness and sent to the
laboratory with in 24 hours of collection.
 Nasopharyngeal Wash/Aspirate.
 Nasopharyngeal (NP) swab/ Oropharyngeal (OP)
swab/Throat swab (TS)
 Swab specimens should be collected only on swabs
with a synthetic tip (such as polyester or Dacron) and
aluminium or plastic shaft. Swabs with cotton and
wooden shafts are not recommended.
Throat Swab
Nasopharyngeal Swab
• Storage of Samples: all samples should be kept at 2-
8C until they can be placed at-70C.
• Transportation of Samples: Clinical samples should be
transported on dry ice in triple packaging. All samples
should be labeled clearly and include patient’s
complete information and should be sent to NIV, Pune
or NICD, Delhi within 24 hours for further
investigations.
Available Laboratory tests
 Rapid Antigen Tests
 RT-PCR
 Virus isolation
 Virus Genome Sequencing
 Four-fold rise in swine influenza A (H1N1) virus
specific neutralizing antibodies.
Biosafety for Laboratory Workers
 Respiratory protection – fit-tested N95 respirator or
higher level of protection.
 Shoe covers
 Closed-front gown
 Double gloves
 Eye protection (goggles or face shields)
 Appropriate disinfectants
70% Ethanol
5% Lysol
10% Bleach
Antiviral Treatment
 Oseltamivir (TAMIFLU) is the recommended drug
both for prophylaxis and treatment.
 Other drug: Zanamivir (RELENZA)
 Both are nuraminidase inhibitors.
Oseltamivir
Body weight Treatment Prophylaxis
< 15 kg
30mg twice a 30mg once a
day for 5 days day for 10 days
15-23 kg
45 mg twice a 45 mg once a
day for 5 days day for 10 days
24 - < 40 kg
60 mg twice a 60 mg once a
day for 5 days day for 10 days
> 40 kg
75 mg twice a 75 mg once a day
day for 5 days for 10 days
Infants less than 1 year
Age in months/
Dosage (Syrup Treatment
12mg/ml)
< 3 months
3-5 months
6-11 months
Prophylaxis
12 mg twice a Not recommended unless
day for 5 days situation judged
critical
20 mg twice a 20 mg once a day for 10
day for 5 days days after last
exposure
25 mg twice a 25 mg once a day for 10
day for 5 days days after last
exposure
Antiviral Chemoprophylaxis
 All close contacts of suspected, probable and
confirmed cases. Close contacts include household
/social contacts, workplace or school contacts, fellow
travelers etc.
 All health care personnel coming in contact with
suspected, probable or confirmed cases.
Oseltamivir and Zanamivir
Oseltamivir and Zanamivir are inhibitors of the
influenza viral neuraminidase enzyme, which is
essential for release of the virus from infected cells.
The enzyme cleaves terminal sialic acid residues and
thus destroys the cellular receptors to which the viral
hemagglutinin attaches. Both are sialicacid transitionstate analogues and are highly active and specific
inhibitors of the neuraminidases of influenza A.
Conti…
Both act through competitive and reversible
inhibition of the active site of influenza A viral
neuraminidases and have relatively little effect on
mammalian cell enzymes.
Oseltamivir phosphate is an ethyl ester prodrug that is
converted to oseltamivir carboxylate by esterases in
the liver. Orally administered oseltamivir has a
bioavailability of >60% and a plasma half-life of 7–9
h. The drug is excreted unmetabolized, primarily by
the kidneys.
Conti…
The toxicities most frequently encountered with
orally administered oseltamivir are nausea,
gastrointestinal discomfort, and (less commonly)
vomiting. Gastrointestinal discomfort is usually
transient and is less likely if the drug is administered
with food. Recently, neuropsychiatric events
(delirium, self-injury) have been reported in children
who have been taking oseltamivir, primarily in Japan.
Supportive therapy
 IV Fluids.
 Oxygen therapy/ ventilatory support.
 Antibiotics for secondary infection.
 Vasopressors for shock.
 Paracetamol or Ibuprofen
 Salicylate / aspirin is strictly contra-indicated in
any influenza patient due to its potential to cause
Reye’s syndrome.
Vaccines
 Currently, most of the world's flu vaccines use an
injection of "killed virus "
 The vaccine is administered by SC or IM route.
 A single inoculation (0.5ml for >3 yrs and 0.25 ml for
<3 yrs) is given.
 Protective value 70-90%.
 Immunity lasts for only 6-12 months.
Preparedness at National Level (GOI)
 Inter Ministerial Task Force monitoring the
situation.
 Travel advisory issued to defer non-essential
travel to the affected countries.
 Health screening of passengers from affected
countries in 21 International airports.
 191 doctors and 101 paramedics have been
deployed to man 76 counters at the above airports.
Conti…
 Guidelines issued on clinical management, infection
control practices and Lab support; and intensified
Surveillance in partnership with WHO.
 Stockpile of Tamiflu increased to 10 million doses.
 Stockpile of PPE increased to 1 million.
 IEC activities initiated in partnership with UNICEF.
Laboratory Support
1. National Institute of Communicable Diseases, New
2.
3.
4.
5.
6.
7.
8.
Delhi.
National Institute of Virology, Pune.
National Institute of Cholera & Other Enteric
Diseases, Kolkata.
Department of Microbiology, AIIMS.
Enterovirus Research Centre, Mumbai.
Vector Control and Research Centre, Pondicherry.
Centre for Research in Medical Entomology,
Madurai.
Defence Research Development Establishment,
Gwalior.
Standard Operating Procedure for
Entry Screening and Exit Screening
 The health desks would be set up before the
immigration area. A space of 1sq m would be required
for the desk and at least five metre in front of it for
maintaining que. The desks would be separated by at
least a meter. An approximate bench mark would be
one desk per 1000 passenger.
 In addition there would be an examination room, a
small space for storage of equipments and
consumables and a space of 5m x 3m for isolating a
suspect case.
At the Health Desk
 Ask for any history of travel to affected area/country.
 The body temperature would be recorded.
 If already febrile, then duty Nurse would put the face
mask on suspect ill traveler. He/she would be
subjected to detail clinical examination.
 Query of the passenger, if any, would be entertained.
 Use alcoholic hand rub / sanitizer / soap and water for
frequent hand wash.
The District Level
District Collector/ District Magistrate to assume over
all coordination of the operations at the District level.
Important functionaries in the district, particularly the
CDHO, Superintendent of the Police, Chief Executive
of the Panchayat Raj and Urban Local bodies will be
members of the committee.
Role of District Collector / Magistrate
 Hold meetings with District functionaries
 Develop district action plan. This would include:
 Details of RRT along with Contact numbers Number
of RRTs that can be set up in the District.
 Lab linkages to be established.
 Listing of health facilities available in the District
with details.
 Details human resource other than the existing work
force.
Conti…
 Police force available in the District.
 Availability of medicines and PPEs
 Availability of vehicles for transportation of RRTs,
drugs etc.
 Legislative provisions required for ordering
restricted movement, closure of schools, colleges,
markets, cinemas and other places of public
congregation.
 Test existing plan through Mock drill
Conti…
 Co-ordinate with the concerned officers of the State
Government and District Collectors of neighbouring
districts and keep them appraised of the situation.
 Preparing a media plan and IEC materials.
 Keeping a watch on the news reports as well as daily
briefing s of the MOHFW and if required scorching
all rumours relating to the disease or its spread.
 Plan for maintaining essential services and continuity
of operations.
 Assess budget requirements and identify the source.
Preventive Measures
 Avoid close contact with people who are having
respiratory illness. Sick persons should keep distance
from others.
 Cover your mouth and nose with a tissue or
handkerchief when coughing or sneezing.
 Washing your hands often with soap or alcohol based
hand wash will help protect from germs.
 Persons who develop influenza-like-illness (ILI)
should be strongly encouraged to selfisolate in their
home for 7 days after the onset of illness or at least 24
hours after symptoms have resolved, whichever is
longer.
 When the ill person is within 6 feet of others at home,
the ill person should wear a face mask, if available or
handkerchief or tissues.
 Get plenty of sleep, be physically active, manage your
stress, drink plenty of fluids, and eat nutritious food.
Precautions for School children
 Schools with a confirmed or a suspected case should
be considered for closure.
 All school or childcare related gatherings should be
cancelled and encourage parents and students to avoid
congregating outside of the school.
 If no additional confirmed or suspected cases are
identified among students (or school-based personnel)
for a period of 7days, schools may consider
reopening.
Social Distancing Interventions
 Mass gatherings such as festivals, sporting, religious,
political events need to be discouraged and cancelled.
Funeral gatherings, in particular, needs to be
discouraged. General public entry to airports and
railway stations etc would be restricted. Public
transportation may have to be restricted.
 Persons with underlying medical conditions who are
at high risk for complications of influenza may wish
to consider avoiding large gatherings.
Home based Preparedness during
pandemic phase
Stockpile for at least 6 weeks the following:
 Non perishable food items – ready to eat food, cereals,
pulses, sugar, salt, spices, oil, tea, coffee powder,
powdered milk, etc.
 Potable water, cooking fuel.
 Emergency medical kits.
 Prescribed medications for chronic patients.
 Soap/Alcoholic handrubs, tissues.
 Batteries.
Fundamentals of infection
prevention strategies
Administrative control are key components,
including: implementation of Standard and Droplet
Precautions; avoid crowding, promote distance
between patients (≥ 1 m); patient triage for early
detection, patient placement and reporting;
organization of services; policies on rational use of
available supplies; policies on patient procedures;
strengthening of infection control infrastructure.
Post-Peak Period
During this period, pandemic disease levels in most
countries with adequate surveillance will have
dropped below peak observed levels. The post-peak
period signifies that pandemic activity appears to be
decreasing; however, it is uncertain if additional
waves will occur and countries will need to be
prepared for a second wave.
Post-Pandemic Period
In this period, influenza disease activity will have
returned to levels normally seen for seasonal
influenza. It is expected that the pandemic virus will
behave as a seasonal influenza A virus. At this stage, it
is important to maintain surveillance and update
pandemic preparedness and response plans
accordingly. An intensive phase of recovery and
evaluation may be required.
Steps of Hand Washing
Personal Protective Equipments
Debate over name
 In the Netherland, it was originally called "pig flu",
but is now called "Mexican flu "
 South Korea and Israel briefly considered calling it
the "Mexican virus"
 Taiwan suggested the names "H1N1 flu" or "new flu"
 The World Organization for Animal Health has
proposed the name "North American influenza "
 The European Commission uses the term "novel flu
virus".
 The WHO announced they would refer to the new
influenza virus as influenza A (H1N1) or "Influenza A
(H1N1) virus, human"
THANK YOU
Issues to be answered on Vaccine?
“What happens if the virus mutates when the
vaccine is ready? How much should be
produced? How will it be distributed? Who
should get it?"