CURRENT PANDEMIC

SWINE FLU
2009 - ???

By
Dr. Indira
Dept of O&G
Public health centre
West mambalam.
 Introduction
Influenza A ( H1N1) virus
Swine Flu – misnomer
Pandemic level phase 6 (WHO)
Started in Mexico on 18th March, 2009
As of now around 170 countries involved
30 – 35% global population involved
In India 150 new cases reported daily
Total in Chennai – 154 cases
90% doesn’t require testing / treatment
Mortality – 1-2%
20th century flu pandemics
Influenza A People
virus Deaths
Pandemic Year infected Case fatalit
(est.) y rate
(approx)
subtype
0.5 to 1
20 to 100
1918 flu pa 1918–19 H1N1 billion >2.5%
ndemic million
(near 50%)

Asian flu 1956–58 H2N2 2 million <0.1% ?

Hong Kong 1968–69 H3N2 1 million <0.1%

flu
mainly
5–15% (340 250,000–
A/H3N2,
Seasonal fl Every year million – 1 500,000 per <0.05%
u A/H1N1,
billion) year
and B
 Microbiology
Types – Influenza A, B,C
A – commonest
In human, birds & pig
Mostly responsible for pandemic
B - Exclusive in human but rare
C – both human & pigs
Won't cause pandemic
 Microbiology
Influenza A:
Glycoproteines – H & N
Common in Human – H –1,2,3
- N - 1,2
Contains 8 genomes
RNA – 8 segments in genomes
- Possible to swap genes
- combination of 88 possible
 Microbiology
Antigenic drift
Antigenic shift
Genetic Reassortment
If 2 types infect a single cell – new
strain developes
Pigs act as mixing vessel
 Microbiology
Current virus combination of
 North American swine
 North American Avian
 Human Influenza
 Eurasian Swine
 Epidemiology
 Agent  Incubation period
New subtype In flu H1N1 1 – 7 days
virus live up to 2 – 8 hr outside
Needs dry & cold climate  Communicability
 Host factors From 1 day before – 7 days
Healthy young adults after onset of symptoms
5 – 24 yr ; more in males If symptoms persist > 7 days
 Transmission – till resolution of illness
Droplet infection & Children up to 10 – 14 days
fomites Infection can travel up to
3mt.
 Clinical Features
 Common Symptoms : 

 Fever( > 37.90 c) with chills

 Non productive Cough
 Runny or stuffy nose
 Sore throat
 Body ache / Headache
 Nausea/diarrhoea
 Fatigue/tiredness that can be extreme
 Signs of a more serious swine flu infection might
include pneumonia and respiratory failure
 If > 2 symptoms – suspect swine flu
 Complications
 Similar to seasonal influenza
 Sinusitis / Otitis media
 Croup / Pneumonia / bronchiolitis
 Status asthmatics
 Myocarditis / Pericarditis
 Myositis / Rhabdomyositis
 Encephalitis / seizures
 TSS
 Secondary bact. Pneumonia
 Groups at higher risk
 Children less than 5 years old;
 Persons aged 65 years or older;
 Children and adolescents (less than 18 years) who are receiving
long-term aspirin therapy and who might be at risk for
experiencing Reye syndrome after influenza virus infection;
 Pregnant women;
 Adults and children who have chronic pulmonary,
cardiovascular, hepatic, hematological, neurologic,
neuromuscular, or metabolic disorders;
 Adults and children who have immuno suppression (including
immuno suppression caused by medications or by HIV);
 Residents of nursing homes and other chronic-care facilities
 Investigations
Real time PCR - takes 3 hr to complete

Viral culture – MDCK cell lines

Neutralisation test - 4 fold increase

positive
Rapid test for virus - Not gold
standard
 Sample Collection
Trained personal
Within 24-72 hr; not later then 5 days
Before starting antiviral
At least nasopharyngeal swab
Bronchoalveolar lavage ideal
Oropharyngeal swab – not adequate
 Sample Collection
Dacron / polyester tipped swab
Aluminium / plastic shaft
In 2-3ml viral transport media
At 40 C ; maintain cold chain
Transported within 24 hr
If can’t – store at –700 C
 Sample Collection
Person should wear
Fit tested N-95 respirator
Goggles / Disp. gloves / Disp. Gowns
Collect in –ve pressure room
All work at BSL 2
Lab work at BSL 3
PPE collected in biohazard bag
Wash hand – Soap / at least 60% alcohol
solution
 Laboratories
King Institute , Guindy
CMC, Vellore
Bharat scans, Royapettah
Hi-Tech Diag. Centre, T.Nagar
Diagnostic Services, T.Nagar
Micro Labs, R.S puram ,Coimbatore
Dr.Rath’s Lab, Thillai nagar, Trichy
 Precautions
 Stay at home and avoid traveling to public places like school
and offices; seek medical care IMMEDIATELY.
 Wash your hands frequently: Wash them often, for at least
15 seconds and rinse with running water.
 Get enough sleep: Try to get 8 hours of good sleep every
night to keep your immune system in top flu-fighting shape.
 Drink sufficient water: Drink 8 to10 glasses of water each
day to flush toxins from your system and maintain good
moisture and mucous production in your sinuses.
 Always try to cover your nose and mouth with a tissue while
coughing or sneezing to avoid passing on infection of any
kind to others around you.
 Avoid touching your eyes, nose and mouth to prevent the
spread of the virus.
 6 WAYS TO IMPROVE UR
IMMUNITY
 Lose Weight
 Exercise
 Eliminate Sugar From your Diet

 Stop Junk Food

 Get Plenty of Sleep.

 Relax
 Last but not least, keep washing your hands

frequently.
TREATMENT
 Guiding principles
Early implementation of infection control
measures
Prompt treatment to prevent severe
illness and death
Early identification and follow up of
persons at risk
 INFRASTRUCTURE
Isolation facilities : if separate rooms not
available, patients can be cohorted in well
ventilated ward with beds kept 1 meter apart
Dedicated doctors, nurses and paramedical
worker.
Portable Xray machine, ventilators, O2 cylinders,
pulse oximeter and more
Adequate PPE , disinfectants and medications.
 STANDARD OPERATING
PROCEDURES
Reinforce standard infection control precautions
to all.
Restrict the number of visitors and provide them
PPE
Antiviral prophylaxis for health care
professionals and monitor them
Dispose infected waste in sealed impermeable
bags labelled BIOHAZARD.
Ensure personnel hygienic measures.
 Oseltamivir
Agent, group Treatment
75-mg capsule twice per day
Adults
for 5 days
60 mg per day divided into 2
15 kg or less
doses
90 mg per day divided into 2
16-23 kg
doses
Children ≥ 12 months
120 mg per day divided into
24-40 kg
2 doses
150 mg per day divided into
>40 kg
2 doses
Dosing recommendations for antiviral treatment of children younger than
1 year using oseltamivir.
Age Recommended treatment
<3 months dose for 5 days
12 mg twice daily
3-5 months
20 mg twice daily
6-11 months
25 mg twice daily
 Oseltamivir - ADR

Generally well tolerated

GI side effects common if > 300μg/day
May cause bronchitis, insomnia, vertigo
Epistaxis in children, most common vomiting
Rarely anaphylaxis and skin rashes
No change of dose in liver disease
Decrease if GFR is low
 CAUTION !!!

ONLY VIROSTATIC DRUG

Indiscriminate use cause resistance

Highly effective even if started after 48 hr of

infection
Never stop oseltamivir once started
Start as per guidelines
 Zanamivir

Agent, group Treatment Chemoprophylaxis

Two 5-mg inhalations Two 5-mg inhalations

Adults (10 mg total) twice per (10 mg total) once per
day day

Two 5-mg inhalations Two 5-mg inhalations

(10 mg total) twice per (10 mg total) once per
day (age, 7 years or day (age, 5 years or
older) older)
 Supportive treatment
Iv fluids Drink plenty of fluids
Parenteral treatment Avoid smoking
O2 therapy / ventilatory Topical
support decongestants,steam
Antibiotics inhalation
Vasopressors for shock Monitor LRTI & Hypoxia
Paractemol / ibuprofen Steroids
Salicylate / aspirin - CI high dose – harmful
Immunomodulatory low dose – septic shock
drugs- NO USE
 DISCHARGE POLICY

Adults : 7 days after symptoms subsides

Children : 14 days after
Family should be educated about
preventive measures
 CHEMOPROPHYLAXIS
DOC : Oseltamivir - Agent, group Chemoprophylaxis

Adults 75-mg capsule once per day

15 kg or less 30 mg once per day

16-23 kg 45 mg once per day

Children ≥ 12 months
24-40 kg 60 mg once per day

>40 kg 75 mg once per day

Dosing recommendations for antiviral chemoprophylaxis of children younger than 1
year using oseltamivir.
Age Recommended prophylaxis dose for 10 days
<3 months Not recommended unless situation judged
critical due to limited data on use in this age group
3-5 months
20 mg once daily
6-11 months
25 mg once daily
 PPE
Gloves Correct procedures
Mask N95/ 3 layered for applying PPE
surgical mask Correct procedures
Long sleeved cuffed for removing PPE
gown Should be employed
Protective eye wear in situations where
Cap unavoidable definite
direct exposure to
Plastic apron cases are present.
PPE
 PPE
Applying technique Removing technique
Remove gown(rubbish bin)
Thorough hand wash
Remove glove (peel from
Wear cover all hand)
Wear goggles/ shoe Use hand wash
cover/ head cover ( in Remove cap and face
that order) shield
Wear face mask Remove mask
Wear gloves Use hand wash
Mask should be changed Leave the room
every 6 to 8 hrs Once outside – hand wash
GUIDE LINES
 Guidelines – infection control
a) Individual level
Hand hygiene – most important
Respiratory hygiene
Staying away from source
Use of mask
- not as routine
- only symptomatic
- health personnel at risk
 Guidelines – infection control
b)For clinicians
Well ventilated rooms for consultations/separate
rooms
Pedestrial fans opposite to patients
Clean AC filters often
3 layered surgical mask
Wash hand
Avoid contact with mouth/ nose/ eye
 Guidelines – infection control
c) At health facility
Droplet precautions
Visual alerts
Use of PPE
Decontaminating the infective surface, things &
equipments (70% ethanol, 5% lysol, 10%
bleach)
Waste disposal as per waste management
protocols
 Guidelines – Pregnant women
Higher risk for complications from infection
Oseltamivir and zanamivir are "Pregnancy Category "
medications
No clinical studies have been conducted to assess the
safety of these medications
No relation between the use of these medications and
adverse events has been established.
Get an informed consent before USE OF DRUG
Because of its systemic activity, oseltamivir is
preferred for treatment of pregnant women. The drug
of choice for chemoprophylaxis is less clear.
 Guidelines – Pregnant women
Zanamivir may be preferable because of its limited
systemic absorption; however, respiratory
complications that may be associated with zanamivir
because of its inhaled route of administration need to be
considered, especially in women at risk for respiratory
problems
Amantadine and rimantadine have been demonstrated in
animal studies to be teratogenic and embryo toxic .
No adverse effects have been reported among women
who received oseltamivir or zanamivir during pregnancy
or among infants born to such women.
 Guidelines – Breast feeding
 Breast feeding is a must.
 Healthy Individuals should take care of the baby
 Through washing of hands, use mask.
 Use a cloth blanket between you and your baby
during feeding
 Try not to cough and sneeze in the baby’s face
 Express breast milk and feed in case of severe
infection
 Don’t stop breastfeeding while taking
medications
 Give as many feeds as possible if baby is sick
 Guidelines – Pediatricians
High risk
Early identification and monitor the cases
If flu like symptoms – keep her/his at home for 7
days/24hr after symptoms resolve, whichever is
longer
Avoid exposure to sick person
Use tissue or hanky or upper sleeve while sneezing
or coughing
Wash hands thoroughly
Avoid touching your eyes, nose, mouth before
washing your hands.
 Seek emergency in case of
Fast breathing Not waking up/
Trouble breathing interacting as usual
Bluish/gray skin color Being so irritable that
Not drinking enough the child doesn’t even
fluids want to be held
Not urinating as much Fever returns after
as usual being absent for a
day or a significant
Severe or persistent
change in fever
vomiting
pattern
 GUIDELINES FOR
SCHOOLS/COLLEGES/INSTITUTIONS ON
INFLUENZA A/H1N1

 Any student or staff member showing flu like symptoms such

as fever, cough, running nose and difficulty in breathing

should be allowed to stay at home for a period of 7 to 10
days.
 Educational institutions should not insist on production of

medical certificate by the student/staff.

 Educational institutions should monitor the health status of

such students/staff who might have come in contact with a

suspected case of Influenza A H1N1. 
 GUIDELINES FOR
SCHOOLS/COLLEGES/INSTITUTIONS ON
INFLUENZA A/H1N1
 In case of students staying in Hostels, the educational
institutions would not only monitor the health status of
the students, but also that of care providers. It might not
be advisable to send the boarders back to home, as it
would spread infection further.
 Educational institutions are further encouraged to report
such cases to local health officers for further monitoring.
 Given the current magnitude of the spread of AH1N1
infection and the fact that the current virus is fairly mild,
closure of educational institutions on account of any
student/staff member falling ill with flu like symptoms is
not recommended.
 GUIDELINES FOR
SCHOOLS/COLLEGES/INSTITUTIONS ON
INFLUENZA A/H1N1
All school or childcare related gatherings should be
cancelled and encourage parents and students to
avoid congregating outside of the school.
In the first place, the schools should discourage the
excursions of the students to the affected countries.
In  case  if the students had proceeded to affected
countries on unavoidable tours, then on their  return, 
if  some  students  show flu like symptoms of fever,
sore- throat , cough , body ache, running nose,
difficulty breathing etc.  they should be advised to
abstain from attending school and be allowed to stay
at home for a period of 7 to 10 days.
 Revised Guidelines – Govt of INDIA
(14 August, 2009)
th

Category A:
Patients with mild fever plus cough/sore throat with or
without body ache, headache, diarrhoea and vomiting.
They do not require Oseltamivir and should be treated
for the symptoms mentioned above.
The patients should be monitored for their progress and
re-assessed every 24 to 48 hours by the doctor.
No testing of the patient for H1N1 is required. Patients
should confine themselves at home and avoid mixing
with the public and high risk members in the family.
 Revised Guidelines – Govt of INDIA
(14th August, 2009)
Category B:
In addition to all the signs and symptoms of Category A, if the
patient has high grade fever and severe sore throat, he/she may
require home isolation and Oseltamivir;
In addition to all the signs and symptoms of Category A,
individuals having one or more of the following high risk
conditions shall be treated with Oseltamivir: children under five,
pregnant women, those above 65 years, those with lung
diseases, heart disease, liver disease, kidney disease, blood
disorders, diabetes, neurological disorders, cancer and
HIV/AIDS; Patients on long term cortisone therapy.
No H1N1 tests are required for Category-B (i) and (ii).
Such patients should confine themselves at home and avoid
mixing with public and high-risk members in the family.
 Revised Guidelines – Govt of INDIA
(14th August, 2009)
Category C:
In addition to the symptoms of Categories A and B, if
the patient has one or more of the following:
- Breathlessness, chest pain, drowsiness, fall in
blood pressure, sputum mixed with blood, bluish
discolouration of nails;
- Irritability among small children, refusal to accept
feed;
- Worsening of underlying chronic conditions.
Such patients require H1N1 testing, immediate
hospitalisation and treatment.
 Vaccines
Inactivated subunit – single dose/ multi dose vial
Live attenuated vaccines – inhaler sprays
15μg of antigen for 1dose, 2 doses spanning
over 21 or more days
Human trials at Emory university Hope clinic.
Not yet commercially available.
Seasonal influenza vaccine won’t prevent swine
flu.
 HELPLINES
Chennai corporation - 1913
Infection control surveillance
-25912686/87/88
Dr. Lakshmi, Director CDH - 04425912688
Dr. Kuganadhan - 9445190744
Dr. Jagadeshan – 9444113370
Email : idspchennai@gmail.com
 TAKE HOME MESSAGE
Inf. A H1N1 – like any other seasonal flu.
90% recover without treatment ; 1-2% mortality.
Transmission only by droplet infection.
Communicability – 1 day prior to 7 days after onset of
symptoms.
Fever (93%) with URI – common presentations.
If no improvement seen after 48 hrs seek medical
help.
Complications more in high risk group.
Never use salicylates / aspirin.
Improve general health.
 TAKE HOME MESSAGE
Hand washing – single most important prevention.
Use mask, tissue, hanky during cough or sneeze.
Avoid close body contact / crowded places.
Educate school children about personnel hygiene.
While dealing with infected persons use PPE.
Oseltamivir (Tami flu) – DOC (use as per guidelines).
Use antibiotics judicially.
Pregnancy and breastfeeding not contraindicated.
NOTIFY.
UPDATE GUIDELINES OFTEN.
THANK U