Recent advances in prevention and management of H1N1 epidemics. Focuses mainly on hospital protocols in dealing with H1N1 cases.

1. Recent advances inRecent advances in
H1N1H1N1
Dr. Vaibhav Yawalkar

2. What is Swine FluWhat is Swine Flu
Swine influenza virus (referred to as
SIV) refers to influenza cases that are
caused by Orthomyxovirus endemic to pig
populations. SIV strains isolated to date
have been classified either as
Influenza(virus C or one of the various
subtypes of the genus Influenza virus A)

3. Different Strains circulateDifferent Strains circulate
PeriodicallyiPeriodicallyi
In the United States the H1N1 subtype
was exclusively prevalent among swine
populations before 1998; however, since
late August 1998, H3N2 subtypes have
been isolated from pigs. As of 2004, H3N2
virus isolates in US swine and turkey
stocks were triple reassortants, containing
genes from human (HA, NA, and PB1),
swine (NS, NP, and M), and avian (PB2
and PA) lineages.

4. MAP of H1 N1 Swine FluMAP of H1 N1 Swine Flu

5. Swine Influenza (Flu)Swine Influenza (Flu)
Swine Influenza (swine flu) is a
respiratory disease of pigs caused by type
A influenza that regularly cause outbreaks
of influenza among pigs. Swine flu viruses
do not normally infect humans, however,
human infections with swine flu do occur,
and cases of human-to-human spread of
swine flu viruses has been documented.

6. Pigs can harbour influenza virusesPigs can harbour influenza viruses
can be adapted to Humanscan be adapted to Humans

7. Swine Flu 2009Swine Flu 2009
In late March and early April 2009, cases
of human infection with swine influenza A
(H1N1) viruses were first reported in
Southern California and near San Antonio,
Texas. Other U.S. states have reported
cases of swine flu infection in humans and
cases have been reported internationally
as well.

8. Swine flu in IndiaSwine flu in India
India reported its first case on 13th
May, 2008. Most of
the cases reported subsequently were travel related
cases among those traveling to India from affected
countries. Number of cases now being reported from
Maharashtra (Mumbai and Pune), Karnataka
(Bangalore) and Tamil Nadu (Chennai) are indigenous
cases.

9. There have been 132 deaths and 708
cases of swine flu across the country
during the current year. The worst hit
state has been Rajasthan with 236 cases
and 65 deaths, followed by Haryana.
Since 2009 there have been a reported
53,943 cases and 3,315 deaths due to the
virus.

10. Swine Flu and VirusSwine Flu and Virus
Swine Influenza (swine flu) is a respiratory
disease of pigs caused by type A influenza
virus that regularly causes outbreaks of
influenza in pigs. Swine flu viruses cause
high levels of illness and low death rates in
pigs. Swine influenza viruses may circulate
among swine throughout the year, but most
outbreaks occur during the late fall and
winter months similar to outbreaks in
humans. The classical swine flu virus (an
influenza type A H1N1 virus) was first
isolated from a pig in 1930.

11. Cause by Reassortment ofCause by Reassortment of
different strainsdifferent strains
 Like all influenza
viruses, swine flu
viruses change
constantly. Pigs can be
infected by avian
influenza and human
influenza viruses as well
as swine influenza
viruses. When influenza
viruses from different
species infect pigs, the
viruses can reassort (i.e.
swap genes) and new
viruses that are a mix of
swine, human and/or
avian influenza viruses
can emerge

12. Swine Flu differs from HumanSwine Flu differs from Human
FluFlu
The H1N1 swine flu
viruses are
antigenically very
different from
human H1N1 viruses
and, therefore,
vaccines for human
seasonal flu would
not provide
protection from
H1N1 swine flu
viruses

13. Out breaks among PigsOut breaks among Pigs
Outbreaks among pigs
normally occur in
colder weather months
(late fall and winter)
and sometimes with
the introduction of new
pigs into susceptible
herds. Studies have
shown that the swine
flu H1N1 is common
throughout pig
populations worldwide,
with 25 percent of
animals showing
antibody evidence of
infection.

14. Present Swine Flu strainsPresent Swine Flu strains
At this time, there are
four main influenza
type A virus subtypes
that have been
isolated in pigs: H1N1,
H1N2, H3N2, and
H3N1. However, most
of the recently
isolated influenza
viruses from pigs have
been H1N1 viruses.

15. How man is exposedHow man is exposed
Most commonly, these
cases occur in persons
with direct exposure
to pigs (e.g. children
near pigs at a fair or
workers in the swine
industry). In addition,
there have been
documented cases of
one person spreading
swine flu to others.

16. From 1 day before to 7 days after the onset of
symptoms. If illness persist for more than 7 days,
chances of communicability may persist till
resolution of illness. Children may spread the virus
for a longer period.
Communicability

17. Is the eating Pork infects ?Is the eating Pork infects ?
No. Swine influenza
viruses are not
transmitted by food.
You can not get swine
influenza from eating
pork or pork products.
Eating properly
handled and cooked
pork and pork
products is safe.
Cooking pork to an
internal temperature
of 160°F kills the
swine flu virus as it
does other bacteria
and viruses

18. What are the signs and symptomsWhat are the signs and symptoms
of swine flu in people?of swine flu in people?
 Fever
 Cough
 Sore throat
 Body aches
 Headache
 Chills
 Fatigue
 Diarrhea
 Vomiting.
 Lack of appetite

19. 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
Childrens Need attention ifChildrens Need attention if
Present withPresent with

20. Adults Need attention ifAdults Need attention if
Present withPresent with
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting

21. Categorization of Influenza ACategorization of Influenza A
H1N1 casesH1N1 cases
Category- A
 Patients with mild fever plus cough / sore throatwith or
without body ache, headache, diarrhoea and vomiting will
be categorized as Category-A. They do not require
Oseltamivir and should be treated for the symptoms
mentioned above.
The patients should be monitored for their progress and
reassessed at 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 up with public and high risk members in the family.

22. Category-B
(i) In addition to all the signs and symptoms mentioned under
Category-A, if the patient has high grade fever and severe sore
throat, may require home isolation and Oseltamivir.
(ii) In addition to all the signs and symptoms mentioned under
Category-A, individuals having one or more of the following
high risk conditions shall be treated with Oseltamivir:
 Children with mild illness but with predisposing risk
factors.
 Pregnant women;
 Persons aged 65 years or older;
 Patients 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 tests for H1N1 is required for Category-B (i) and (ii).
 All patients of Category-B (i) and (ii) should confine
themselves at home and avoid mixing with public and high
risk members in the family

23. Category-C
In addition to the above signs and symptoms of Category-
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.
 Children with influenza like illness who had a severe
disease as manifested by the red flag signs (Somnolence,
high and persistent fever, inability to feed well,convulsions,
shortness of breath, difficulty in breathing, etc).
 Worsening of underlying chronic conditions.
All these patients mentioned above in Category-C require
testing, immediate hospitalization and treatment.

24. Complications:Complications:
Clinicians should expect complications to
be similar to seasonal influenza:
Sinusitis,otitis media, croup, pneumonia,
bronchiolitis, status asthamaticus, myocarditis,
pericarditis, myositis, rhabdomyolysis,
encephalitis, seizures, toxic shock syndrome and
secondary bacterial pneumonia with or without
sepsis.
Individuals at extremes of age and with preexisting
medical conditions are at higher risk of
complications and exacerbation of the underlying
conditions.

25. Investigations:Investigations:
Routine investigations required for evaluation and
management of a patient with symptoms as
described above will be required. These may include
haematological, biochemical, radiological and
microbiological tests as necessary.
Confirmation of Pandemic influenza A(H1N1) infection
is through:
 ” Real time RT PCR or
 ” Isolation of the virus in culture or
 ” Four-fold rise in virus specific neutralizing
antibodies.

26. 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. 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 be stored at
-70°C. Paired blood samples at an interval of 14days for
serological testing should also be collected.

27. The apex laboratories are:
National Institute of Communicable
Diseases, 22, Sham Nath Marg, Delhi
 National Institute of Virology, 20-A, Dr.
Ambedkar Road, Pune-411001
There is a network of 16 other laboratories
that can test for Influenza A H1N1. This
network is being expanded to include
private laboratories.

28.  An H1N1 detection kit developed by the Defence
Research and Development Organisation (DRDO)
that will give test reports in an hour and will come at
a low cost will be available in the market soon.
 At present, the real time polymerase chain reaction
kits approved by the WHO and recommended by
the Centre for Disease Control (CDC) take 24 hours
to get the result and the test costs Rs 4,500 for a
patient.
 The kit was developed in the Defence R&D
Establishment (DRDE) labs in Gwalior. The
technology has been transferred to a private
company, bigtec Labs', Bangalore.

29. Chest X-Ray Features:Chest X-Ray Features:

32. CDC helps in DiagnosisCDC helps in Diagnosis
Requires sending
the specimen to
CDC for laboratory
testing as many
laboratories in
Developing world
do not have
facilities

33. Guidelines on Infection controlGuidelines on Infection control
MeasuresMeasures
During Pre Hospital Care
o Standard precautions are to be followed while transporting patient to a
health-care facility. The patient should also wear a three layer surgical
mask.
o Aerosol generating procedures should be avoided during transportation as
far as possible.
o The personnel in the patient’s cabin of the ambulance should wear full
complement of PPE including N95 masks, the driver should wear three
layered surgical mask.
o Once the patient is admitted to the hospital, the interior and exterior of
the ambulance and reusable patient care equipment needs to be sanitized
using sodium hypochlorite / quaternary ammonium compounds.
o Recommended procedures for disposal of waste (including PPE used by
personnel) generated in the ambulance while transporting the patient should
be followed.

34. 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 . If splashing with blood or other body fluids is anticipated, a
water proof apron should be worn over the PPE.
o Aerosol-generating procedures such as endotracheal intubation,
nebulized medication administration, induction and aspiration of
sputum or other respiratory secretions, airway suction, chest
physiotherapy and positive pressure ventilation should be performed
by the treating physician/ nurse wearing full complement of PPE with
N95 respirator on.
o Sample collection and packing should be done under full cover of PPE
with N-95 respirator .
o Perform hand hygiene before and after patient contact and following
contact with contaminated items, whether or not gloves are worn.

35. o Until further evidence is available, infection control precautions
should continue in an adult patient for 7 days after resolution of
symptoms and 14 days after resolution of symptoms for children
younger than 12 years because of longer period of viral shedding
expected in children.
o The virus can survive in the environment for variable periods of time
(hours to days). Survival period of virus outside the host varies with
temperature, at 40
C it survives for about 200 days and with temperature
around 350
C it survives for 24 hours. Hence outbreaks occur during winter
seasons.
o The virus is inactivated by a number of disinfectants such as 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. In addition to daily cleaning of floors
and other horizontal surfaces, special attention should be given to
cleaning and disinfecting frequently touched surfaces.

36. Personal Protection EquipmentsPersonal Protection Equipments
(PPE)(PPE)
PPE reduces the risk of infection if used correctly.
It includes:
• 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.

38. Correct procedure for applying PPE in the
following order:
1. Follow thorough hand wash
2. Wear the coverall.
3. Wear the goggles/ shoe cover/and head
cover in that order.
4. Wear face mask
5. Wear gloves
The masks should be changed after every
six to eight hours.

39. 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.

40. Guidelines for waste DisposalGuidelines 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.
• Waste like used gloves, face masks and disposable
syringes etc are to be discarded in Blue/White autoclavable
biosafety bags which should be autocalaved/microwaved
before disposal.
• All hospitals and laboratory personnel should follow the
standard guidelines (Biomedical waste management and
handling rules, 1998) for waste management.

41. Treatment:Treatment:
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.

42. Oseltamavir Medication:Oseltamavir Medication:
Oseltamivir is the recommended drug both for prophylaxis
and treatment.
In the current phase, if a person conforms to the case
definition of suspect case, then he would be provided
Oseltamivir.
for treatment is as follows:
Dose By Weight:
‐ For weight <15kg 30 mg BD for 5 days
‐ 15-23kg 45 mg BD for 5 days
‐ 24-<40kg 60 mg BD for 5 days
‐ >40kg 75 mg BD for 5 days
• 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
‐
It is also available as syrup (12mg per ml )

43. Adverse Reactions of Oseltamavir:Adverse Reactions of Oseltamavir:
 Gastrointestinal side effects (transient
nausea, vomiting) may increase with increasing
doses, particularly above 300 mg/day.
 Bronchitis, insomnia and vertigo.
 Less commonly angina, pseudo membranous colitis
and peritonsillar abscess have also been reported.
 Rare reports of anaphylaxis and skin rashes.
 In children, most frequentlyreported side effect is
vomiting.
 There is no recommendation for dose reduction in
patients with hepatic disease.

44. Important points to consider:Important points to consider:
 Patients with severe pneumonia and acute
respiratory failure (SpO2 < 90% and PaO2 <60
mmHg with oxygen therapy) must be supported with
mechanical ventilation. Invasive mechanical
ventilation is preferred choice.
 If the laboratory reports are negative, the patient
would be discharged after giving full course of
oseltamivir. Even if the test results are negative, all
cases with strong epidemiological criteria need to be
followed up.
 Immunomodulating drugs has not been found to be
beneficial in treatment of ARDS or sepsis associated
multi organ failure. 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).

45. Discharge Policy:Discharge Policy:
 Patients who responded to treatment after two to three
days and become totally asymptomatic should be
discharged after 5 days of treatment. There is 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 the patient become asymptomatic
during the course of treatment there is no need to test
further.
 For patients who continue to be symptomatic even after 10
days of treatment or those cases with respiratory distress
and in whomsecondary infection is taken care of, and if
patient continue to shed virus, then resistance of the
patients to anti viral would be tested. The dose of anti viral
may be adjusted on case to case basis.

46. Chemoprophylaxis:Chemoprophylaxis:
 Oseltamivir is the drug of choice.
 Prophylaxis should be provided till 10 days after last
exposure (maximum period of 6 weeks)
 By Weight:
‐ <15kg 30 mg OD
‐ 15-23kg 45 mg OD
‐ 24-<40kg 60 mg OD
‐ >40kg 75 mg OD
 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

47. Swine flu in Pregnancy:Swine flu in Pregnancy:
Pregnant women are at greater risk from swine
flu because their immune system is suppressed
during pregnancy.
The Committee for Medicinal Products for Human
Use (CHMP) of the European Medicines Agency
has given a clear recommendation that the
GlaxoSmithKline vaccine Pandemrix can be given
safely to all pregnant women.
Zanamavir is recommended as a first choice.
Zanamavir is inhaled using a disk-shaped inhaler.
It is recommended for pregnant women because
it easily reaches the throat and lungs, where it is
needed, and does not reach significant levels in
the blood or placenta.

48. Is there a vaccine for Pandemic Flu?Is there a vaccine for Pandemic Flu?
 Seasonal flu vaccine or past flu
immunization will not provide
protection.

51. ‘‘Made in India’ H1N1 vaccineMade in India’ H1N1 vaccine
 Swine flu vaccine in India was launched
by Health minister Gulam Nabi Azad.
 Given by I/M or intranasal route.
 Vaccines manufactured by
 Zydus Cadila
 Serum institute of india
 Panacea biotech
 Bharat biotech

52. The flu vaccine is available by shot or
nasal spray.
Sr. Type of H1N1
Vaccine
Manufacturer Date of
Result
Cost Per
Vial INR
1 Whole Virion
Inactivated
Serum institute
of India
18/1/2010 Not Decided
2 Human live
attenuated and
freeze dried
Serum institute
of India
(Nasovac)
17/12/2009 790
3 Whole virion
inactivated
Zydus Cadila
Health Care
Ltd.
(Vaxiflu S)
17/11/2009 3910

53.  There are two different types of flu vaccines, trivalent and
quadrivalent.
 Trivalent vaccines protect against 3 strains of the flu, A/H3N2,
A/H1N1, and influenza B.
Trivalent vaccines are available in:
 Traditional flu shots, approved for anyone 6 months and older
 Intradermal shots, which use a shorter needle, approved for
anyone 18-64
 High dose shots approved for people over 65
 Cell based shots created using viruses grown in animal cells and
approved for anyone over 18
 Recombinant shots created using DNA technology, approved for
people 18-49 with severe egg allergies
 Quadrivalent vaccines protect against 4 strains of the flu,
A/H3N2, A/H1N1, and 2 strains of influenza B.
Quadrivalent vaccines are available in:
 Traditional flu shots, approved for anyone 6 months and older
 Nasal spray, approved for healthy people from 2-49,
except pregnant women.

54. Side effects:Side effects:
 Mild side effects usually begin soon after you get the
vaccine and last one to two days.
Possible mild side effects of the flu shot include:
 Soreness, redness, and swelling at the injection site
 Fainting, mainly in adolescents
 Headaches
 Fever
 Nausea
Possible mild side effects of the nasal spray include:
 Runny nose
 Wheezing
 Headache
 Vomiting
 Muscle aches
 Fever

55. Serious side effects:Serious side effects:
Serious side effects usually begin within a few
minutes to a few hours after receiving the shot.
Possible serious side effects of vaccination
include:
Difficulty breathing
Hoarseness
Swelling around the eyes or lips
Hives
Paleness
Weakness
Racing heart
Dizziness
Behavior changes
High fever

56. Contraindications:Contraindications:
A severe allergy to chicken eggs
A history of severe reaction to a flu
vaccination
A moderate-to-severe illness with a fever
(you should wait until you are better to
get the vaccine)
A history of Guillain Barre Syndrome (a
severe paralytic illness, also called GBS)

57. IV Medication for swine flu:IV Medication for swine flu:
Peramivir is an investigational
neuraminidase inhibitor medication that
has variable activity against influenza A
and B viruses as reported in human and
animal studies with small sample sizes.
In October 2009, the FDA issued an
Emergency Use Authorization (EUA) for
the use of peramivir based on safety data
from Phase 1, Phase 2, and limited Phase
3 trial data. The emergency use
authorisation for peramivir expired in June
2010.