O slideshow foi denunciado.
8 de fev de 2017
What is swine flu?How swine flu presents?How to diagnose swine flu?How to treat swine flu? What are the vaccines for swine flu?How to prevent from getting swine flu?
Dr.S.Sesha Sai ,PG, Pulmonary Medicine
Swine influenza is a respiratory disease
Sometimes the existing strains of virus
combine to form a new subtype. (
In 2009, North American swine influenza,
North American avian influenza, human
influenza, and swine influenza virus
typically found in Asia and Europe
reassorted and formed a new subtype
In US, Between 7,070 and 13,930 deaths were
attributable to H1N1 flu from April to 14 November 2009.
CDC estimates that between about 8,870 and 18,300
2009 H1N1-related deaths occurred between April 2009
and 10 April 2010.
India had reported 937 cases and 218 deaths from swine
flu in the year 2014.
By mid-February 2015, the reported cases and deaths in
2015 had surpassed the previous numbers.
The total number of laboratory confirmed cases crossed
33000 mark with death of more than 2000 people.
Highest number of deaths are in Gujarat > Rajasthan.
History of Virus
Year of Origin Sub type
1918 H1N1 (Spanish)
1957 H2N2 (Asian)
1968 H3N2 (Hong Kong)
1977 H1N1 (Russian)
2009 H1N1 (Swine)
2013 H7N9 (Avian, China)
All age groups
HCWs, Co – morbids, Immunocompromised.
• Tropics/ Sub tropics: epidemics occur in
• Overcrowding : Mostly affect urban and peri-urban
• Closed populations :High attack rates may be
witnessed in Army Barracks, College hostels,
Schools, Residential hostels of schools, aircrafts,
EM of Swine flu virus
• Direct Airborne
• Indirect – Objects, fomites, close
• 1-4 days
• Shedding before onset of symptoms.
• Peak on day 1 of symptoms.
• Adults – 4-6 days
• Children – for months.
• Sudden, rapid
• Fever, Chills, Body
Non – productive
cough, Runny –
• GI symptoms,
• Fever (upto 1060 F)
• Lasts for 3 days
• Face : flushed
• Skin : Hot and
• Eyes: Watery and
• Ear : Otitis
• Nose : Nasal
• Cervical LN
RT – PCR (4 hours) or
Isolation of virus in culture or
Fourfold rise in virus specific neutralising antibodies.
o Swabs (Nasopharyngeal, Throat, Nasal)
o Tracheal aspirate (intubated)
o Before administration of anti viral drugs
o 40 C in viral transport media within 24 hours.
o If not possible, Store at –700 C
Mild fever + Cough or sorethroat
± bodyache, headache, diarrhea, vomiting
• No testing
• Does not require
• Monitor and reassess (24-
CAT A + any of
1. High grade fever, Severe sore throat.
2. Children with predisposing factors,
Pregnant women , >65, Comorbids,
• No testing
• Home isolation
• Broad spectrum
antibiotics for CAP
CAT A + CAT B + one or more of
1. Breathlessness, chest pain,
2. Children with Somnolence, high and
persistent fever, inability to feed well,
measuresFrequent hand washing of
personnel and contacts.
Cough etiquettes and maintain
arms length distance from others.
Dedicated doctors, nurses and
Portable X Ray machine,
ventilators, large oxygen
cylinders, pulse oxymeter and
other supportive equipments
Adequate disinfectants and
Use of face masks
Isolation room or beds one meter
All those entering room wear
Prophylaxis to health care
Waste disposal in biohazard
Use of face mask 
• Screening area
• Isolation ward
• Security personnel
• ≯ 6 hours
• Not reuse
• Isolation ward -
• Laboratory personnel
• ± Expiration valve
For General Public
No scientific evidence to show health
benefit of using triple layer masks for
members of public.
Erroneous use of masks or continuous
use of a disposable mask for longer than 6
hours or repeated use of same mask may
actually increase risk of infection further.
Neuraminidase (NA) Inhibitor
The drug should be given as BD dose for 5 days.
It is also available as syrup – 12mg / ml
< 15 kg 30 mg
15 – 23 kg 45 mg
24 – 40 kg 60 mg
> 40 kg 75 mg
< 3 months 12 mg
3 – 5 months 20 mg
6 – 11 months 25 mg
Tamiflu should be given within 24-48 hrs.
Adverse reactions of Oseltamivir
No recommendation for dose
reduction in hepatic disease.
Dosage modification should be done
in renal impairment
Common Nausea, Vomiting
Occasionally Bronchitis, Insomnia, Vertigo
Less commonly Angina, Psuedomembranous colitis,
Rare Anaphylaxis, Skin rashes
Zanamivir (Relenza) :
Dry powder inhalation
Not effective in children, asthmatics
Peramivir (Rapivap, Rapiacta, Peramiflu) :
Only Intravenous drug available for Swine flu
FDA approved for adults
Single dose of 600 mg given.($ 950)
M2 Inhibitors – Amantadine, Rimantadine
No longer recommended by CDC.
Laninamivir – Phase III trials, Approved in Japan (Inavir)
IV fluids, Parenteral Nutrition
O2 / Ventilatory support
Antibiotics, Vasopressors (shock)
PCM / Ibuprofen – fever, myalgia, headache
Plenty of fluids
If SpO2 < 90% and PaO2 < 60 mmHg – Mechanical Ventilation
Preferred – Invasive
High dose corticosteroids – No benefit, Potential harm
Low dose ( Hydrocortisone 200 – 400 mg / day) – in persistent
SALICYLATES are CONTRAindicated – REYE syndrome
Pressure pre-set (controlled)
Low tidal volume ventilator support
Tidal volume — 6 ml/kg ideal body weight (Respiratory rate to
a maximum of 30-
35 per minute).
Open lung strategy of ventilation
PEEP titration to keep the lung recruited to achieve an FIO2 of <
0.5 and a saturation of > 90% or a PaO2 of > 60 mmHg
Plateau (Pause) pressure not to exceed of > 30-35 mmHg.
APRV (Airway Pressure Release Ventilation), IRV (Inverse
Ratio Ventilation) in patients with persistent Hypoxemia.
Adults – 7 days after symptoms have subsided.
Children – 14 days after symptoms have subsided.
Sinus / Ear infections
Bacterial pneumonia (MRSA,MSSA,Group A strep)
Bronchiolitis, Croup, Diarrhea
Encephalopathy / Encephalitis
Exacerbation of chronic illness (COPD, Diabetes, Coronary artery disease)
Toxic shock syndrome
OD dose of Oseltamivir
according to body
weight till 10 days after
last exposure ( Upto 6
Not recommended for
infants < 3 months
1. Heath Care Workers – Medical and paramedical
staff in Casualty, ICU, Isolation ward, Screening
2. All pregnant women.
3. Chronic illnesses.
4. > 65 years, 6 months – 8 years.
Takes about 2 – 3 weeks to develop immunity.
Administered at least One month prior to
commencement of season.
Currently available vaccine is
Northern Hemisphere Trivalent
Inactivated trivalent vaccine
Vaccination should occur before
onset of influenza activity in the
Can be used till May 2017.
In India, Influgen (Lupin), Costs ₹
Also Vaxigrip (Sanofi Pasteur),
Strains in the vaccine :
A/California/2009 (H1N1)–like virus
A/Hong Kong/2014 (H3N2)–like virus
Quadrivalent vaccines will include an additional vaccine
virus strain ,
Contraindicated in Egg allergy and GBS.
1. Clinical Management Protocol for Seasonal Influenza H1N1, Ministry of Health and
Family Welfare, Directorate General of Health Sciences, October 21, 2016.
2. The 2009 H1N1 Pandemic: Summary Highlights , CDC.
3. Paul M.; “Origin of Human Diversity” , Vol 108, Feb 8, 2002 and Tokiko W.;
“Pathogenesis of 1918 Pandemic history of influenza virus”, Feb 6, 2009.
4. Guidelines on categorization of Seasonal Influenza cases during
screening for home isolation, testing, treatment and hospitalization, MOHFW, DGHS,
October 10, 2016.
5. Guidelines on use of masks for health care workers, patients and members of public,
6. Influenza Antiviral Medications: Summary for Clinicians, Jan 25, 2017. Centre for
7. https://www.ncbi.nlm.nih.gov/pubmed/21973296. National Center for biotechnology
8. Seasonal Influenza: Guidelines for Vaccination with Influenza Vaccine , MOHFW, DGHS,
9. Prevention and Control of Seasonal Influenza with Vaccines, Recommendations of
the Advisory Committee on Immunization Practices — United States, 2016–17
Influenza Season, Aug 26,2016. Lisa A. Grohskopf, MD1; Leslie Z. Sokolow, MSc,
MPH1,2; Karen R. Broder, MD3; Sonja J. Olsen, PhD1; Ruth A. Karron, MD4; Daniel B.