Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.

1. Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495

2. WHAT DO WE DO?
• We have recorded 24 deaths
• We have no Medical guidelines of do’s
and don'ts
• Young people are dying-is their a pattern
• Can we pick them early before they turn
sick?
• Testing in few center’s-takes 4 days to get
results
• Do we start Tamiflu in all suspected
cases?
• Deterioration is occurring on 4 th day and
death on 7th or 8th day

3. CHALLENGES WE FACE
• Recognition of disease
• Not to forget chikungunya & dengue
• Difficulty in Confirmation of disease
• Self protection
• Protection of people around us
• Notification
• To know more ; Are we facing the
pandemic?

4. Scenario
• Admitted suspected Patient with
Patient (symptoms+ hemodynamic
travel history) compromise &
• Sample sent for PCR respiratory difficulty
• Reported positive Need for intubation-To
H1N1 proceed & then send
• What to do for patient sample for PCR
relatives& hosp staff What to do meanwhile
who are exposed Is it necessary to test
all doctors & staff

5. Enigmatic questions
• Should we close the hospital & fumigate?
• What to do for other patients next to the
case
• Should we send all suspected cases to
referral hospital

6. Subsequent challenges
• Recognising in OPD- identify flu symptoms,
travel history, clinical signs of hemodynamic
derangement &pneumonia/ALI/ARDS
• Proper referral to institutions handling cases
• Isolation rooms, Use of masks Hand wash
• Ventilatory management

7. Influenza At A Glance
• Influenza, commonly called "the flu," is caused
by viruses that infect the respiratory tract.
• Influenza viruses are divided into three types,
designated A, B, and C.

8. INFLUENZA VIRUS

9. ELECTRON MICROSCOPY

10. TYPES

11. PIG THE CREATOR

12. VIRAL VARIANTS
• INFLUENZA A VIRUS
• Swine Human Avian
•
• H1N2 H1N1(pandemics) H5N1
• H3N1 H3N2 (rare)
• H3N2

13. QUADRUPLE
REASSORTMENT GENETICS
• Human swine
H1N1
• Avian swine

14. EARTH LIVING SPACE FOR
ALL
Epidemic: An increase in disease above what is normally expected
Pandemic: A worldwide epidemic
A pandemic begins when: there is person-to-person sustained
transmission on multiple continents

15. HISTORY
• In the 20th century there have been three
influenza pandemics in 1918, 1957 and
1968.

16. Emergency hospital, Camp Funston,
Kansas 1918

17. WHO
• April 24: H1N1 first disease outbreak notice.
• April 25: WHO Director General declares a formal
“Public health emergency of international concern”
• April 27: “containment of the outbreak is not feasible”
pandemic alert raised from phase 3 to phase 4.
• April 29: phase 4 to phase 5.
• June 11: phase 5 to phase 6.

18. • The World Health Organization uses a six
stage phase for alerting the general public to
an outbreak
• Phase 1 – animal to animal transmission.
• Phase 2 – an animal influenza virus is
capable of human infection.
• Phase 3 - small outbreaks among close
populations but not through human to
human contact.

19. • Phase 4 - Human to human transmission
• Phase 5 - spread across two countries or
more in one of the WHO regions
(continents).
• Phase 6 – spread across two countries or
more in one of the WHO regions plus
spread to another WHO region.

20. Global pandemic
• W.H.O. identifies the following six
epidemiological sub-regions.
• - African Region
• - Eastern Mediterranean Region
• - European Region
• - Region of the Americas
• - South-East Asian Region
• - Western Pacific Region

21. Global pandemic

22. EPIDEMIOLOGY
• Incubation period- 1-7 days
• Transmission
PRIMARY CASE –direct contact with pigs
SECONDARY CASES
sneezing, coughing
resp droplets
body fluids(diarroeal

23. Transmission

24. • This virus is not transmitted from eating
pork or pork products
• Contagiousness:
1 day onset of symptoms
7 days
Children are contagious for longer periods.
. Majority of pts were previously healthy.
Clinical course mild in PCR negative
influenza.

25. • Majority of pts were previously healthy.
• Clinical course mild in PCR negative
influenza.
• Pregnant women — Increased rates of
spontaneous abortion and preterm birth
• Patients with swine flu were found to have
increased incidence of cardiovascular &
cerebrovascular events.

26. Can I get infected with this new H1N1 virus
from eating or preparing pork?
• No. H1N1 viruses are not spread by food.
You cannot get this new HIN1 virus from
eating pork or pork products. Eating
properly handled and cooked pork
products is safe.

27. Is there a risk from drinking water?
• Recent studies have demonstrated that
free chlorine levels typically used in
drinking water treatment are adequate to
inactivate highly pathogenic H5N1 avian
influenza. It is likely that other influenza
viruses such as novel H1N1 would also be
similarly inactivated by chlorination.

28. What kills influenza virus?
• Influenza virus is destroyed by heat (167-
212°F [75-100°C]). In addition, several
chemical germicides, including chlorine,
hydrogen peroxide, detergents (soap),
iodophors (iodine-based antiseptics), and
alcohols

29. Risk factors
• COPD
• Immunocompromised state
• DM
• Pregnancy
• Cardiac disease
• Obesity

30. DEFINITIONS
• Influenza-like illness (ILI) is defined as
fever (temperature of 100ºF [37.8ºC] or
greater) with cough or sore throat in the
absence of a known cause other than
influenza

31. Case Definitions By CDC
• A confirmed case acute febrile
respiratory illness with laboratory-
confirmed H1N1 influenza A virus
detection by real-time reverse
transcriptase (RT)-PCR or culture.
• A probable case acute febrile respiratory
illness who is positive for influenza A, but
negative for H1 and H3 by RT-PCR

32. A suspected case acute febrile
respiratory illness who:
• - Develops symptoms within seven
days of close contact with a person who is
a confirmed case of H1N1 influenza A
virus infection or
• - Develops symptoms within seven
days of travel or resides in a community
where there are one or more confirmed
H1N1 influenza A cases

33. Close contacts
• Having cared for or lived with a person
• setting where there was a high likelihood
of contact with respiratory droplets and/or
bodily fluids
• Having had close contact (kissing,
embracing, sharing eating or drinking
utensils, physical examination, or any
other contact likely to result in exposure to
respiratory droplets)

34. COMPARISION
SEASONAL H1N1 INFLUENZA
INFLUENZA
AGE <5 YRS >60 YRS YOUNG & MIDDLE AGE
SEVERITY LESS SEVERE PNEUMONIA
ARDS
MORBIDITY LESS MORE BUT >60 YRS
LESS LIKELY TO HAVE
SEVERE PNEUMONIA

35. contd
SEASONAL H1N1 INFLUENZA
INFLUENZA
SYMPTOMS RESPIRATORY RESPIRATORY &
GASTROINTESTINAL
SECONDARY ATTACK 5-15 % 22-33 %
RATE
VACCINE PROTECTIVE UNDER
DEVELOPMENT

36. AGE SHIFTS IN MORTALITY
• Concept of “original antigenic sin,”by
Francis - immune response is greatest to
antigens to which first exposure occurred
in childhood.
• Persons born before 1957 who were
exposed in childhood to influenza A
(H1N1) viruses might be better protected
against this viral subtype than those who
were first exposed to other influenza A
subtypes, H2N2 and H3N2, at a later

37. • During the early phase of this epidemic,
the rapid identification of persons who are
likely to have severe disease, as
compared with those who are likely to
have mild disease, can guide epidemic or
pandemic response strategies.

38. Specimens
• Nasopharyngeal swab, nasal swab, throat
swab, combined oropharyngeal/
nasopharyngeal swab, or nasal aspirate
• Swabs with a synthetic tip (eg, polyester
or Dacron) and an aluminum or plastic
shaft should be used. Swabs with cotton
tips and wooden shafts are not
recommended.
• The collection vial in which the swab is
placed should contain 1 to 3 mL of viral

39. • Respiratory specimen should be collected
within 4 to 5 days of illness.
• Specimens should be placed in viral
transport media and placed on ice (4ºC) or
refrigerated immediately for transportation
to the laboratory

40. DIAGNOSTIC TESTS
QUIDEL
RT PCR
CULTURE
DFA/IFA

41. LAB TESTS
• Real time RT PCR-confirmatory
• culture is usually too slow to help guide
clinical management. A negative viral
culture does not exclude pandemic H1N1
influenza A infection.
• Rapid antigen tests — evaluation of
patients suspected of having influenza,
but results should be interpreted with
caution the QuickVue Influenza A+B
(Quidel) assay (sensitivity 51 percent
specificity 99 percent)

42. • Rapid influenza antigen tests & Direct or
indirect immunofluorescent antibody
testing (DFA or IFA) can distinguish
between influenza A and B but negative
test does not exclude infection.

43. Whom to test
• Testing for pandemic H1N1 influenza A
should be considered in individuals with
an acute febrile respiratory illness
( temperature of 100ºF or higher and
recent onset of at least one of the
following: rhinorrhea, nasal congestion,
sore throat, or cough) or
sepsis-like syndrome

44. Priority for testing should be given to :
Those who require hospitalization and
Those who are at high risk for severe
complications
No testing if illness is mild or the person
resides in an area with confirmed cases
Recommended test for suspected cases is
real-time reverse transcriptase (RT)-PCR
for influenza A, B, H1, and H3

45. CLINICAL FEATURES
Vomiting or diarrhea (not typical for
influenza but reported by recent cases of
swine influenza infection)

46. Can we make a broad clinical
check list
• History of contact
• Younger age, sudden onset
• Fever, cough, breathlessness
• Leucopenia, raised LDH and CPK
• Should all such patients be isolated and
given Tamiflu?

47. Other Manifestations:
• Tachycardia
• Tachypnoea
• Low O2 sat.
• Hypotension
• Cyanosis
• Acute myocarditis
• Cardiopulmonary arrest

48. Children Clinical Presentation
• Infants may present with fever and
lethargy, and may not have cough or other
respiratory symptoms.
• Apnea, tachypnea, dyspnea, cyanosis,
dehydration, altered mental status, and
extreme irritability.

49. Children Emergency Warning Signs
• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• 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

50. In adults, emergency warning
signs
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return
with fever and worse cough

51. Why Complications In young
(Cytokine storm)
• It is the systemic expression of a healthy and vigorous
immune system resulting in the release of more than 150
inflammatory mediators . Both pro and anti-inflammatory
cytokines are elevated in serum with lethal interplay of
these cytokines is referred to as a "Cytokine Storm".
• The primary contributors to the cytokine storm are TNF-a
and IL-6 .
• It is inappropriate (exaggerated) immune response that
is caused by rapidly proliferating and highly activated T-
cells or natural killer (NK) cells.
• Bird flu patients die from acute respiratory distress
syndrome (ARDS) caused by the cytokine storm, and not
directly from the virus

52. SYMPTOMS OF THE
CYTOKINE STORM
The final result, of cytokine storm (SIRS) or
sepsis is multiple organ dysfunction
syndrome (MODS)
• hypotension ( Myocarditis)
• tachycardia
• ARDS acute respiratory failure
• Ischemia, or insufficient tissue perfusion
• uncontrollable haemorrhage
• Multisystem organ failure

53. Cytokine Storm Treatment
• Steroids
• ACE Inhibitors & ARBs
• Anti-CD28 Monoclonal Antibody
• TNF-alpha blockers

54. HISTOPATHOLOGY
LUNG FINDINGS
• . The specimen shows
necrosis of bronchiolar
walls (top arrow),
• a neutrophilic infiltrate
(middle arrow), and
diffuse
• alveolar damage with
prominent hyaline
membranes (bottom
arrow).

55. Diagnosis
• Laboratory Tests
– Viral culture
• Presence of virus confirmed by
– ELISA( 4 fold rise )
– RT-PCR
• Rapid antigen tests (distinguish between influenza A
and B

56. LABORATORY FINDINGS
• CBC- leucocytosis/leucopenia
lymphopenia
• Elevated CPK, LDH
• Elevated UREA,CREATININE
• Elevated AST,ALT
• CHEST RADIOGRAPH-bilateral patchy
pneumonia.

57. H1 N1 Pneumonia

58. COMPLICATIONS
Similar to those of seasonal influenza
• Exacerbation of underlying chronic
medical conditions
• Upper respiratory tract disease (sinusitis,
otitis media, croup)
• Lower respiratory tract disease
(pneumonia, bronchiolitis, status
asthmaticus)

59. • Cardiac (myocarditis, pericarditis)
• Neurologic (Acute and post-infectious
encephalopathy, encephalitis, febrile
seizures, status epilepticus)
• Toxic shock syndrome
• Secondary bacterial pneumonia with or
without sepsis

60. DD H1N1 PNEUMONIA
• OTHER VIRAL pneumonia
influenza A,B adenovirus RSV
para influenza rhinovirus
humanmetapneumonia
• Legionella,Chlamydia,Mycoplasma

61. TREATMENT
• Only neuraminidase inhibitors
ORALTamiflu (oseltamivir) and
Relenza( zanamivir) are approved to
cure the viral infection.
• H1N1 is resistant to Amantadine
Rimantadine
• Antiviral drugs can be given to treat
those who become severely ill with
influenza.

62. Tamiflu (Oseltamivir )
• Block the active site
of the influenza viral
enzyme
neuraminidase
• This effect results in
viral aggregation at
the host cell surface
and reduces the
number of viruses
released from the
infected cell

64. Tamiflu

65. Tamiflu

66. Tamiflu(contd)
• If one dose missed?
take as soon as you remember unless it
is within 2 hours of next dose
do not take two doses at a time
. With other medications?
minimal drug interaction
no intranasal flu vaccine(Flu Mist) within
2weeks before or 48 after taking tamiflu

67. Tamiflu (Contd)
• With kidney disease
Flu treatment :one 75mg dose OD for 5
days
Flu prevention:one 75 mg dose
alternate day or 30 mg dose OD
. Storage:
capsules- <25 degree C
liquid - 2 to 8 degree C

69. Zanamivir ( Relenza)
– It is not recommended for people with
underlying respiratory disease such as
asthma or chronic obstructive pulmonary
disease or lactose intolerance
– Treatment of 7 year & older patients 10mg
(2puffs)BID 5d
– Prophylaxis of 5 year & older patients 10mg
OD 10d-28 days

70. Mild Cases
• Supportive: Paracetamol, flds…
*NO SALICYLATES IN CHILDREN/
YOUNG ADULTS: REYE'S SYNDROME
• Antivirals : *best within first 48 hours
*Early administration in at-risk pts ie those
with comorbidities/ pregnancy…
• control precautions: cough etiquette
• Hand hygiene & Natural ventilation

71. Hospitalized pts:
• Antivirals
• Pneumonia management like avian
(antibiotics)
• Resp. Support: early detection
Correction of hypoxia with
supplemental O2 or mech. Vent as
necessary

72. Supportive care
• When Mech. vent is indicated:
low volume
low pressure
lung protective vent.
• Steroids:
• Avoid routine use, no benefit was reported
. Higher doses associated with serious
SE:
o evidence of increased viral replication in
SARS and other resp. viral infections.
o Increased mortality in Avian

73. It is highly contagious!
• Can we have separate wards ,ICU’s and
staffing
• We require separate OPD and testing
facilities for suspected cases
• Can we spare separate equipment
• Can we organise all this in a running
hospital?

74. prevention

75. Hand washing

76. N95 Mask

77. What should I do to keep from getting
the flu?
• First and most important: wash your hands
• Get plenty of sleep
• Drink plenty of fluids
• Try not to touch surfaces that may be
contaminated with the flu virus.
• Avoid close contact with people who are
sick.

78. Avoid close contact
• Avoid close contact
with people who are
sick. When you are
sick, keep your
distance ( > 1 meter )
from others to protect
them from getting sick
too.
• Aerosols spread the
virus in any
environment

79. N95 RESPIRATORS

80. Prevention
• management of the outbreak such as closure
of schools, advising avoidance of mass
gatherings and distribution of antivirals
• Avoiding close contact
• Staying home from work, school
• Covering mouth and nose with a tissue or
N95 mask (three layered) when coughing or
sneezing. Change the mask every 6 to 8
hours
• Washing your hands

81. Is Negative Pressure Room
Must ?
Place patients in a single-patient room with the door
kept closed & droplet and contact isolation

82. Why do we need vaccine
SEASONAL
RAPID GLOBAL
VACCINE
SPREAD
PROTECTION?
VACCINE
COST EFFECTIVE
WINTER SEASON
TARGET AT RISK
TO COME(LOW
PEOPLE
HUMIDITY,TEMP)

83. Dealing with the Deceased
• Transport of deceased persons in a transport bag.
• Hand hygiene should be performed after completing transport.
• For deceased persons with confirmed, probable, or suspect novel
influenza A (H1N1):
o limit contact with the body in health care settings to close family
members
o Direct contact with the body is discouraged
o Necessary contact may occur as long as hands are washed
immediately with soap and water.

84. Conclusion
• Be cautious but no need to panic
• Need for further guidelines beyond
diagnosis & management.
• Judicious use of diagnostic tests
• Early suspecting and treating cytokine
storm is very important
• Not to forget universal precautions