Swine Flu - A new disease

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Information about Swine Flu - A new disease

Published on August 19, 2009

Author: gir13

Source: authorstream.com

SWINE FLU – A new disease : SWINE FLU – A new disease Dr. Girish Vaswani Consulting physician Bhatia hospital Dalvi hospital Swine Flu – present position statement of CDC : Swine Flu – present position statement of CDC CDC expects that more cases, more hospitalizations and many more deaths from this outbreak will occur over the coming days and months. As it is a new virus and most people will not have immunity to it, in all likelihood it is poised to emerge as the pandemic “flu” of this century. Viral Influenza A - Human history : Viral Influenza A - Human history Comparative mortality : Comparative mortality Avian flu(H7N7) HK 07 Hantavirus PS China 06 SARS-CoV China 07 Swine flu(H1N1) Dengue 60 % 30-40 % 9.5 % <1 %(177457 and 1462) < 1 % Slide 5: ORTHOMYXOVIRUSES 80-200nm type A, B, C : NP, M1 protein sub-types: HA or NA protein 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. Cause by Reassortment of different strains : Cause by Reassortment of different 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 Swine Influenza : Swine Influenza HOWEVER Sporadically humans have been victims of swine flu ( not more than 2-3 persons) as an occupational hazard since 1931. Even in 1976, in the US,sporadic transmission and mild H1N1 epidemic occurred. It is only recently that it has assumed widespread human to human transmission. Novel H1N1 Influenza : Novel H1N1 Influenza The first cases of human infection with novel H1N1 influenza virus were detected in April 2009 in San Diego and Imperial County, California and in Guadalupe County, Texas. The virus has spread rapidly. The virus is widespread in the United States at this time and has been detected internationally as well. Swine Flu scare - worldwide : Swine Flu scare - worldwide Mexico shut down Swine flu arrived in India Pune and Mumbai shut down by SMS polling Who can catch the “Flu” ? : Who can catch the “Flu” ? Times of India : Times of India Indian cricket team well prepared to deal with any situation: Gary Kirsten “They never catch anything on the field so it is highly unlikely that they will ever catch the flu” Who can catch the Flu ? : Who can catch the Flu ? As in all epidemics children and the elderly are more prone as are pregnant women and those who are immuno-suppressed or immuno-compromised and have associated medical conditions like cardiac, renal, liver and other respiratory illnesses as well as DM How does novel H1N1 Influenza spread? : How does novel H1N1 Influenza spread? This virus is thought to spread the same way seasonal flu spreads Primarily through respiratory droplets Coughing Sneezing Touching respiratory droplets on yourself, another person, or an object, then touching mucus membranes (e.g., mouth, nose, eyes) without washing hands Can you get novel H1N1 Influenza from eating pork? : Can you get novel H1N1 Influenza from eating pork? No. The novel H1N1 influenza virus (formerly referred to as swine flu) virus is not spread by food. You cannot get novel H1N1 flu from eating pork or pork products. Eating properly handled and cooked pork products is safe. Signs and symptoms : Signs and symptoms Symptoms of novel H1N1 flu in people are similar to those associated with seasonal flu. Fever Cough Sore throat Runny or stuffy nose Body aches Headache Chills Fatigue In addition, vomiting (25%) and diarrhea (25%) have been reported. (Higher rate than for seasonal flu.) As the disease progresses-Urgent medical attention IF : As the disease progresses-Urgent medical attention IF Bovine or brassy cough of laryngo-tracheo-bronchitis(croup:commoner in children) Breathlessness or pleuritic chest pain of pneumonitis and pleuritis with increased respiratory rate and cyanosis. ABG may reveal hypoxia, respiratory alkalosis and ALI and ARDS with or without florid signs of pneumonia or few occassional creps with or without abnormal CXR As the disease progresses-Urgent medical attention IF : As the disease progresses-Urgent medical attention IF Giddiness due to shock and MOSF may supervene along-with altered sensorium and finally coma due to encephalopathy Severe persistent vomiting may be harbinger of a complicated course as it may signify Reye’s syndrome and its hepatic enceph Likewise return of a cough or dyspnoea may suggest a complicated course. As the disease progresses-Urgent medical attention IF : As the disease progresses-Urgent medical attention IF A pan-muscle weakness suggestive of myositis with myoglobinuria has also been reported. Myopathy or GBS like proximal muscle weakness syndrome due to peripheral neuropathy (demyelination) may develop Emergency warning signs in children : Emergency warning signs in children If a child gets sick and experiences any of these warning signs, seek emergency medical care. In children: Fast breathing or trouble breathing Bluish or gray skin color Not drinking enough fluids Severe or persistent vomiting Not waking up or not interacting Irritable, the child does not want to be held Flu-like symptoms improve but then return with fever and worse cough My way of remembering : My way of remembering H – Headache, hotness ( FEVER & CHILLS) A – Anorexia and ARDS(late cf) M – Malaise, Myalgia and MOSF(late cf) B – Bodyache and breathlessness U – Unclear thinking and unconsciousness(Late ) R – Rhinorrhea and Respiratory cough G – GI symptoms: N/V/D E – Enlarged tonsils and its draining nodes R – Rashes S – Sneezing and shock(late cf) Case definition-CDC interim guidance report : Case definition-CDC interim guidance report A confirmed case is defined as a person with an acute febrile respiratory infection and a confirmed positive test for S-OIV by RT-PCR and/or viral culture. A probable case is defined as a person with an acute febrile respiratory infection who tests positive for influenza A but negative for H1 and H3 by viral RT-PCR. CDC case definition : CDC case definition A suspected case of S-OIV infection is defined as a person with an acute febrile respiratory infection with onset Within 7 days of close contact with a person who is a confirmed case of S-OIV infection. Within 7 days of travel to a community where there are one or more confirmed cases. Resides in a community where there are one or more confirmed cases of S-OIV infection. Slide 24: Infectious period for a confirmed case of H1N1 is defined as 1 day prior to the cases illness onset to 7 days after onset. Close contact is defined as being within 6 feet of a confirmed or suspected case of H1N1 during the case’s infectious period. Acute onset of a respiratory illness is defined as having at least 2 of the following: rhinorrhea, sore throat and cough with or without fever High Risk Groups : High Risk Groups Children Pregnant women, SMOKERS Those who are immunocompromised or immunosuppressed Those with other chronic medical conditions like renal, cardiac, hepatic and other respiratory illnesses Those with DM Occupational exposure-paramedics, medics Diagnosis : Diagnosis To diagnose swine influenza A infection, a respiratory specimen would generally need to be collected within 4-5 days of onset of illness(when an infected person is most likely to be shedding virus). However, some persons, especially children, may shed virus for 10 days or longer. Identification as a swine flu influenza A virus Slide 27: Preferred respiratory specimens The following should be collected as soon as possible after illness onset: nasopharyngeal swab, nasal aspirate or a combined nasopharyngeal swab with oropharyngeal swab. If these specimens cannot be collected, a nasal swab or oropharyngeal swab is acceptable. For patients who are intubated, an endotracheal aspirate should also be collected. Bronchoalveolar lavage (BAL) and sputum specimens are also acceptable. Slide 28: Swabs Ideally, swab specimens should be collected using swabs with a synthetic tip (e.g. polyester or Dacron®) and an aluminum or plastic shaft. Swabs with cotton tips and wooden shafts are not recommended. Specimens collected with swabs made of calcium alginate are not acceptable. The swab specimen collection vials should contain 1-3ml of viral transport medium (e.g. containing, protein stabilizer, antibiotics to discourage bacterial and fungal growth, and buffer solution). Storing clinical specimens All respiratory specimens should be kept at 4°C for no longer than 4 days.  Shipping clinical specimens Clinical specimens should be shipped on wet ice or cold packs in appropriate packaging. All specimens should be labeled clearly and include information requested by your state public health laboratory. Suspected case specimens shipped from the state public health laboratory to CDC should include all information required for seasonal influenza surveillance isolate or specimen submission. Tests for Swine Flu : Tests for Swine Flu RT-PCR. This is currently the most sensitive and specific. Results available within 4–6 h after specimen submission. RT-PCR shows greater sensitivity & may be used as a confirmatory test. Quickly differentiating between influenza types and subtypes. Also the preferred test for specimens obtained from persons with a history of exposure to animals with possible influenza illness (e.g., influenza A [H5N1] in poultry in Eurasia or Africa or swine influenza in any part of the world Other Tests for Swine flu : Other Tests for Swine flu Commercial rapid influenza diagnostic tests. Currently available antigen detection tests provide results in 10–30 min but exhibit decreased sensitivity (70%–90% in children and 40% to 60% in adults), compared with RT-PCR and with viral Performance of these assays depends heavily on patient age, duration of illness, sample type, and perhaps viral type. Given the lower sensitivity of immunofluorescence and commercial rapid tests, follow-up testing with RT-PCR and/or viral culture should be considered to confirm negative Other Tests for Swine flu : Other Tests for Swine flu Immunofloresence- direct and indirect. Low sensitivity with high specificity. Detects H antigen, N antigen or both. Requires confirmation by RT-PCR. Tests for Swine flu : Tests for Swine flu Viral isolation (in standard cell culture and shell vial culture) is not a screening test, but during periods of low influenza activity (late spring, summer, and early fall), it should be performed on respiratory specimens collected from persons with suspected influenza that present for medical care within 5 days after illness onset. It is diagnostic but results are delayed. A negative culture does not rule out disease. Other tests for detection : Other tests for detection These detect antibodies to influenza virus in the serum and hence may not be positive before 14 days and are of no clinical significance in the acute setting which is generally an emergency. Ideally paired sera and demonstration of rising or falling antibody titres are necessary along with clinical co-relation as in Widal testing. These tests include HI, ELISA, CFT. Therapy of Swine Flu : Therapy of Swine Flu WARNING : WARNING Do not use aspirin You may cause Reye’s syndrome Drugs which are effective in Swine Flu : Drugs which are effective in Swine Flu There are four different antiviral drugs that are licensed for use in the US for the treatment of influenza: Amantidine, rimantadine, oseltamivir and zanamivir. While most swine influenza viruses have been susceptible to all four drugs Drugs proved resistant at Present : Drugs proved resistant at Present Most recent swine influenza viruses isolated from humans are resistant to Amantidine and Rimantadine Slide 39: Most of the strains in Norway show resistance to Oseltamivir inspite of the drug not being used suggests that it may be genetically resistant. Whereas in Japan 3 % resistance to oseltamivir has been reported inspite of everyone popping in the pill. Drug resistance may hence not be related to the exposure of the virus to oseltamivir. CDC recommends at Present : CDC recommends at Present CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with swine influenza viruses Adverse events of antivirals : Adverse events of antivirals Minimal and non-serious 10% nausea, vomiting and diarrhoea Sometimes neuropsychiatric Zanamivir is inhaled and may cause bronchospasm Antiviral therapy recommendations : Antiviral therapy recommendations All confirmed, probable and suspected cases of H1N1 infection Serious hospitalized patients are a top priority Start as early as possible within 48 hrs of illness onset Benefit not lost even if delay is reasonable Duration of treatment is 5 days. Adults - Treatment : Adults - Treatment Oseltamivir :75mg 1 tab two times daily x 5 d Zanamivir – 10mg 2 inhalations twice daily Adjust dose to 50 % less if eGFR is 30ml/min/1.72m2 or less Hepatic failure – no dose adjustment Child dose – Treatment with oseltamivir : Child dose – Treatment with oseltamivir Children > 13 yrs follow adult dose <15kgs 30mg bd 15-23kgs 45mg bd 24-40kgs 60mg bd >41kgs adult dose Zanamivir in children adult dose 7 yrs and over Antiviral chemoprophylaxis-pre/post exposure : Antiviral chemoprophylaxis-pre/post exposure Given to household contacts ( who are at high risk of complications) of a confirmed, probable or suspected case. School children with chronic medical conditions who had close (face-to-face) contact with a confirmed, probable or suspected case. Travelers to epidemic areas who are 65 yrs of age or older, children younger than 5 yrs of age or pregnant women or non high risk travelers Health care workers Slide 46: Zanamivir 10 mg (2 inhalations) once daily for adults and children ≥ 5 years old Oseltamivir orally adults and children ≥ 13 years old - 75 mg once daily children aged 1-12 years - dose based on weight ≤ 15 kg 30 mg once daily 15-23 kg 45 mg once daily 23-40 kg 60 mg once daily > 40 kg 75 mg once daily Dosing of Antivirals PREVENTION-SWINE FLU : PREVENTION-SWINE FLU CDC GUIDELINES How long can an infected person spread swine flu to others? : How long can an infected person spread swine flu to others? People with swine influenza virus infection should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children, especially younger children, might potentially be contagious for longer periods. How long can viruses live outside the body? : How long can viruses live outside the body? We know that some viruses and bacteria can live 2 hours or longer(probably upto 8 hrs) on surfaces like cafeteria tables, doorknobs, and desks. Frequent hand washing will help you reduce the chance of getting contamination from these common surfaces. STAY HOME WHEN SICK : STAY HOME WHEN SICK If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness. There’s no party tonight. Cover your mouth and nose. : Cover your mouth and nose. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick Avoid touching your eyes, nose or mouth. : Avoid touching your eyes, nose or mouth. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Slide 53: Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Avoid close contact : Avoid close contact Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too. Aerosols spread the virus in any environment Slide 55: * consider Facemasks (disposable, single use masks) for persons who enter crowded settings * consider Respirators (N95 or higher filtering facepiece respirator) for persons who have unavoidable close contact with infectious person No clear scientific evidence regarding the effectiveness of facemasks and respirators in protecting against influenza When contact is unavoidable Slide 56: Hand washing technique No Vaccines to HumansBut available to PIGS : No Vaccines to HumansBut available to PIGS Vaccines are available to be given to pigs to prevent swine influenza. There is no vaccine to protect humans from swine flu. The seasonal influenza vaccine will likely help provide partial protection against swine H3N2, but not swine H1N1 viruses. Summary-Are we prepared?-Check list : Summary-Are we prepared?-Check list S – Stay home (if ill) and sleep well W – Wine not to be consumed.Wash hands, wear masks I – Imbibe fluids N – No smoking E – Eat well F – Fear not ( deaths < 1 %) ,Fully treatable L – Lessen travel and visits to crowded places U – Uphold cleanliness and proper disposal of used masks HIV could not sell as many condoms as many masks are being sold by S-OIV : HIV could not sell as many condoms as many masks are being sold by S-OIV THANK YOU : THANK YOU Visit for UpdatesCDC : Visit for UpdatesCDC CDC ( Center of Disease) control updates the current information. The topic made as per guidelines of CDC THANK YOU

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