Dr. R V S N Sarma., MD., MSc. (Canada),Consultant Physician & Chest Specialist

Land line: 044 3760 9993 Mobile 91 9380521221

email: sarma.rvsn@gmail.com

web site: www.drsarma.in

What Should be Our Approach?Essential – Positive – Constructive Approach Adequate awareness in general public – adopting the

preventive measures Comprehensive knowledge for the healthcare

providers Appropriate planning and responsibility of all involved

Unwarranted – Misleading – Dangerous – Negative Fear, minute to minute monitoring of deaths, rumors Media hype , Anxiety about infection and death by

this flu Panic, mania of mask use by one and all, and worry

Types of Human Flu (Influenza) Influenza A

Common, More Severe, Several Sub-types Epidemics, Pandemics, Mortality, High

Mutagenicity Influenza B

Less Severe, Less Frequent, No Sub types, Faithfully Human

Influenza C Mild, Rare, No Sub types, Non fatal, Mild

Illness in Children Common Cold – Coryza Virus – It is not

‘Flu’

Influenza A Virus Types

Orthomyxoviridae Family

Single stranded RNA virus

High mutagenicity, 8 proteins

H Ag types are 16 N Ag types are 09 So, 16 x 9 = 144 types

possible But only 3 types infect

Humans H1N1, H2N2 and H3N2 Avian Flu Virus is H5N1 ‘Swine Flu’ Virus H1N1

Misnomer Present Pandemic –

(H1N1)v

Neuraminidase (N) For Detachment

Hemagglutinin (H)for Attachment

Seasonal v/s Pandemic Flu

Influenza Pandemics

Name of the Pandemic

YearDeath

sSubtype

Pandemic Severity

Index

Asiatic (Russian) Flu

1889 - 1890

I Million

? H2N2

NA

Spanish Flu 1918 Pandemic

1918 - 1920

50 Million

H1N1 5

Asian Flu1957 - 1958

4 Million

H2N2 2

Hong Kong Flu1968 - 1969

2 Million

H3N3 2

2009 Flu Pandemic

2009 – Present

1,500

H1N1v

About 1.5

Seasonal Influenza

Every Year

500, 000

H1N1 NA

Global Picture of the Pandemic

Cumulative Confirmed Cases In India

Natural History of H1N1v

1,00,000

50,000

10,000

1,000

15

Mortality Rate = 15/1,00,000 =

0.015%

Symptoms of H1N1 Pandemic Flu Very Similar to the Seasonal Flu and Not like

Common Cold Moderate to high fever aches, muscle and joint pains chills and fatigue sore throat, head ache cough sneezing and running nose shortness of breath, chest pain on breathing diarrheas and vomiting (possible), loss of

appetite

When to Suspect H1N1 ?

Onset of acute febrile respiratory illness within 7 days of close contact with a person who has a confirmed case of H1N1 influenza A virus infection, or

Onset of acute febrile respiratory illness within 7 days of travel to a community (within the United States or internationally) where one or more H1N1 influenza A cases have been confirmed, or

Acute febrile respiratory illness in a person who resides in a community where at least one H1N1 influenza case has been confirmed.

Fever or H/o Fever

87%

Head ache 41%

Myalgia 38%

Arthralgia 23%

Dry cough 49%

Productive cough

17%

Sore throat 49%

Running nose 33%

Sneezing 21%

Shortness of Breath

10%

Diarrhea 12%

Vomiting 16%

Nausea 17%

Conjunctivitis 7%

Nose bleed 2%

Altered Sensorium

0.5%

Others 22%

Seasonal v/s Pandemic Influenza

Age and Gender Distribution

Global Experience of the Pandemic Secondary attack rate in household contacts: 12 %. Overall proportion of hospitalizations: 8 %. Overall case fatality: 0.15 % or 1.5 per every 1000

cases Most cases (58 %) highest incidence in 5–24 years

age group, Second highest incidence in children < 5 years Most hospitalizations (34 %) in 5–24 years age group, Highest age-specific hospitalization rate in children <

5 years Most deaths in 5–24 years age group The old are generally spared > 65

The Current H1N1 Virus

Cocktail mix of Porcine, Avian and Human Influenza A Virus

Direct Fine droplets expelled during coughing and

sneezing Expectorated sputum and the dried secretion

Indirect All items that have been in contact with a

patient (Fomite) Incubation Period (IP)

3 to 7 days – from the day of symptoms – Median 2-3 days

Transmission

Transmission

Transmission

The Aaa-chooh – (Sneezing)

High Risk Groups for H1N1

Diabetes Pregnancy Neuromuscular disorder Chronic cardio-vascular disease (excluding

hypertension) Seizure disorder and other neurodegenerative

disease Chronic renal disease stages III and IV Cancer and immuno suppression Obesity More deaths in people <18 years of age

Diagnostic Testing rRT-PCR Swine Flu assay– reverse transcriptase real time PCR

Highly specific test, 24 to 48 hours, costly Rs. 4,000, detects viral multiplication, can identify the novel H1N1 correctly

Confirmatory test, sensitivity is also quite high 85%, Quantitative

RIDT (Rapid Influenza Diagnostic Test) – Not Recommended point of care, 1 hour, less cost (Rs 700), card test, detects viral

protein Sensitivity low 10 to 70% - A negative result can’t exclude Influenza Can not distinguish between Influenza B or A or A sub types Specificity – 80% - can confirm Influenza infection – not the type If positive – needs a confirmatory test to identify the type

Testing Facilities in Chennai Government

King Institute, Guindy Private

Bharat Scans, Royapettah Hi-Tech Diagnostic Center, T. Nagar Diagnostic Services, T.Nagar Lister Metropolis Sri Rama Chandra University

General Hygiene1. Cover the mouth whenever you cough, then wash

hands

2. Cover the nose every time you sneeze, then wash hands

3. Wipe with disposable tissue paper, throw into a garbage can covered with a lid and then wash hands

4. Do spit in a disposable tissue paper, throw into a garbage can covered with a lid and then wash hands

5. Hand hygiene, is essential and imperative, either washing with soap or by clean by rubbing alcohol based sanitizer. It must be done carefully and repeated as often as possible

6. Use of surgical mask and personal protection equipment (PPE)

Face Masks, N95 Respirators

General Treatment Treatment is largely supportive

Bed rest; Patient should stay at home for 7 days

Increased fluid consumption; Cough suppressants and

Cough Etiquette, Hand washing Antipyretics and analgesics (Paracetamol,

NSAIDs) Avoid close contact with sick person May require intravenous hydration &

supportive measures Home Isolation; One designated person to

take care

Categories of H1N1 (Govt. India)1. Category A: Common fever with cough and throat pain

body pain and headache, diarrhea and vomiting. No need to test for A(H1N1). No Tamiflu. Under constant supervision for a three days. Cough etiquette.

2. Category B: High fever and severe throat infection. Children < 5 years, pregnant women, Adults 65 + age and with complications of the kidneys, heart and lungs, diabetics and HIV. Give Tamiflu, but no test for A (H1N1). Home isolation.

3. Category C: Same as Category B, but have breathlessness, chest pain, fainting spells, low blood pressure, blood in the phlegm, cyanosis, not taking feeds, altered sensorium. They need A (H1N1) test and be given Tamiflu and need hospitalization.

Categories of H1N1 cases as per Govt. India

Oseltamivir (Tamiflu) It is a neuraminidase inhibitor (NAI), decreases the

release of viruses from infected cells and, thus, viral spread.

Must be administered within 48 hours of symptom onset

Reduces the length of illness by an average of 1.5 to 2.5 days

Duration of administration for treatment is 5 days Post-exposure prophylaxis to be initiated within 7 days

of exposure and continued for at least 10 days Available as 30-mg, 45-mg, and 75-mg oral capsules

and as a powder for suspension containing 12 mg/mL after reconstitution

Oseltamivir (Tamiflu) Adult Dose

Acute illness: 75 mg PO bid for 5 days Prophylaxis: 75 mg PO once a day for 10 days

Pediatric dose Acute illness in children aged <1 year

<3 months: 12 mg PO bid for 5 d; 3-5 months: 20 mg PO bid for 5 d

6-11 months: 25 mg PO bid for 5 d Acute illness and age >1 year

<15 kg: 30 mg PO bid for 5 d; 15-23 kg: 45 mg PO bid for 5 d

23-40 kg: 60 mg PO bid for 5 d; >40 kg: Administer as in adults

Zanamivir (Relenza)It is a neuraminidase inhibitor, decreases the release of

viruses from infected

cells and, thus, viral spread. Must be administered within 48 hours

Adult Dose

Treatment for acute illness: 10 mg inhaled orally bid for 5 days Prophylaxis of household contact: 10 mg inhaled orally od

for 10 d Prophylaxis for community outbreak: 10 mg inhaled orally

od for 28 d

Pediatric Dose

Treatment for acute illness <7 years: Not established; >7 years: Administer as in adults

Both are ‘Pregnancy Category C’ – Not a contraindication – prefer Zanamivir

Anti Viral Formulations

Management of Severe Disease Most cases do not need Test, Tamiflu, Hospitalization

Supportive treatment and home isolation will suffice Watch out for the high risk groups and Category B and C Early administration of Tamiflu if indicated; Reduces viremia

Monitor O2 saturation and maintain 90-92% saturation - O2

Rx. Antibiotics for secondary bacterial pneumonia – as per CAP MRSA; Ventilator support in severely ill – VAP; Vasopressors No role for corticosteroids except in shock; Risk is increased ARDS – Lung protective mechanical ventilation

Executive Summary1. Airborne transmission – No unusual routes – Food

no risk

2. Cumulative clinical attack rate – 20 to 30%

3. Over 90% of the illness is mild and self limiting

4. Highest affected will be children and young adults

5. Adults > 60 years seem to be least affected

6. High risk groups discussed must be watched for fatality

7. Hospitalization rates will be 1 to 2% of clinical cases

8. The term ‘swine flu’ is inaccurate & confusing– A H1N1v 2009

Executive Summary

9. Case Fatality Rate will be around 0.1 to 0.2% (1-2 per 1000)

10.Fatality will be more in children and very old and high risk

11.Hospitalizations are for high risk groups, people < 5, > 60 y

12.H1N1v is sensitive to Oseltamivir and Zanamivir – NAIs

13.Seasonal flu vaccine is ineffective; Vaccine in October

14.The virus can mutate at any time – Second wave aggressive

15.International co-operation and sharing of experience

16.All these rates & ratios are biased upwards – inapparent inf.

The Three Golden Principles

What We Know?

This Flu is like any other ARI Cover your cough and sneeze Frequent hand washing Hand – face distancing Social distancing Fomite transmission – cell phones Home isolation; Discuss the need for Test and

Tamiflu Only a small proportion need hospitalization Flu death is very rare; No need to panic

What Should We do? Remember is similar in most respects like any other ARI Suspect the pandemic flu – particularly if temp is > 100 Look for signs of serious illness – SOB, chest pain, blood

etc Look for high risk profile, Be watchful about young kids Categorize the patient as A, B or C and note the stage Take appropriate action as per the category Segregate patients at first contact in the waiting room Give priority to those with ARI and reduce contact time Protect yourself with mask while examining a suspect

case

Top Resources Consulted http://www.emedicinehealth.com/swine_flu/

article_em.htm#history http://www.who.int/csr/disease/swineflu/en/index.html http://www.who.int/csr/disease/avian_influenza/

phase/en/ Journal of Applied Microbiology 91 (4): 572–579, 2001 http://knol.google.com/k/salim-djelouat/swine-flu-

pandemic-review http://emedicine.medscape.com/article/1673658-

overview http://www.cdc.gov/h1n1flu/general_info.htm http://www.cdc.gov/h1n1flu/ http://www.cdc.gov/h1n1flu/surveillanceqa.htm http://www.cdc.gov/h1n1flu/masks.htm

Top Resources Consulted… contd http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm http://www.cdc.gov/h1n1flu/recommendations.htm http://www.ecdc.europa.eu/en/Pages/home.aspx http://www.ecdc.europa.eu/en/healthtopics/

PublishingImages/World_Map http://sis.nlm.nih.gov/enviro/swineflu.html#a3 New England Journal of Medicine: H1N1 Influenza

Center  http://www.lancet.com/H1N1-flu http://h1n1.nejm.org/?ssource=rthome http://pandemicflu.bmj.com/ H1N1 Clinical Medical References & Guidelines @

MDConsult.com

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