The excellent presentations can help you learn about the disease and take effective steps for its prevention.

1. REVIEW
H1N1
Maj SK Mishra
Dr Rajeev Gupta
Dr Prashant Malviya
Chair Person
Surg Cdr Anuj Singhal

2. Introduction
 Epidemiology
 Sign and symptom
 Diagnosis
 Treatment
 Prevention


3. WHAT IS SWINE FLU

Swine influenza
Refers to influenza cases that are caused by
Orthomyxovirus endemic to pig populations.
Is a respiratory disease of pigs caused by type A
influenza
Regularly cause outbreaks among pigs.
Swine flu viruses do not normally infect humans

4. VIRAL INFLUENZA A - HUMAN
HISTORY
1889-90
1900-03
1918-19
H2N8
H3N8
H1N1(HswN1)
Severe epidemic
Mod epidemic
Severe epidemic
1933-35
1946-47
1957-58
H1N1(HON1)
H1N1
H2N2
Mild epidemic
Mild epidemic
Severe epidemic
1968-69
1977-78
H3N2
H1N1
Mod epidemic
Mild epidemic

5. OR Y
H IS T
The H1N1 form of swine flu is one of the descendants of
the Spanish flu that caused a devastating pandemic in
humans in 1918–1919
In 1957, an Asian flu pandemic infected some 45 million
Americans and killed 70,000. It caused about 2 million
deaths globally
Eleven years later, lasting from 1968 to 1969, the Hong
Kong flu pandemic afflicted 50 million Americans and
caused 33,000 deaths
In 1976, about 500 soldiers became infected with swine
flu over a period of a few weeks.

6. COUNTRIES AFFECTED TILL NOW

7. PANDEMICS OF INFLUENZA
H2N2
H2N2
H1N1
H1N1
H3N8
1895 1905
1889
Russian
influenza
H2N2
7
1915
1900
Old Hong
Kong
influenza
H3N8
Pandemic
H1N1
H3N2
1925
1955
1918
Spanish
influenza
H1N1
Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research,
National Institute of Infectious Diseases (NIID), Japan.
1965
1957
Asian
influenza
H2N2
1975
1985
1968
Hong Kong
influenza
H3N2
1995
2005
2010
2009
Pandemic
influenza
H1N1
Animated slide: Press space bar
2015

8. SEASONAL INFLUENZA COMPARED
TO PANDEMIC — PROPORTIONS OF
TYPES OF CASES
Deaths
Requiring
hospitalisation
Deaths
Requiring
hospitalisation
Clinical
symptoms
Asymptomatic
Seasonal influenza
8
Clinical
symptoms
Asymptomatic
Pandemic

9. SOME OF THE 'KNOWN UNKNOWNS' IN
THE 20TH CENTURY PANDEMICS
Three pandemics (1918, 1957, 1968).
Each quite different in shape and waves.
Some differences in effective reproductive
number.
Different groups affected.
Different levels of severity including case
fatality ratio.
Imply different approaches to mitigation.






9

10. INDIAN SCENARIO- 2009

13. NO OF CASES 10 MAIN AFFECTED
CITIES-2009
CITIES
NO OF CASES
PUNE
574
MUMBAI
324
DELHI
316
BANGALORE
131
HYDERABAD
67
CHENNAI
82
GURGAON
39
AHEMDBAD
34
KOLKATA
25
CALICUT
23

14. 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
>1 %

15. INFLUENZA VIRUS

Three types of influenza viruses:
A, B and C.
 A and B  seasonal epidemics of disease
 C infections mild respiratory illness and are not
thought to cause epidemics.


17. ORTHOMYXOVIRUSES 80-200nm
HA - hemagglutinin –attaches to sialic
Acid receptor
NA – neuraminidase-helps in
Budding out of infected cell
helical nucleocapsid (RNA plus
NP protein)
lipid bilayer membrane
polymerase complex
M1 protein
type A, B, C : NP, M1 protein
sub-types: HA or NA protein

18. INFLUENZA -A

Two proteins on the surface of the virus
 Hemagglutinin

16 subtypes
 Neuraminidase

(H)
09 subtypes
(N)

19. CLASSIFICATION=
The antigenic type (e.g., A, B, C)
 The host of origin (e.g., swine, equine, chicken,
etc. For human-origin viruses, no host of origin
designation is given.)
 Geographical origin (e.g., Mexico, Taiwan, etc.)
 Strain number (e.g., 15, 7, etc.)
 Year of isolation (e.g., 57, 2009, etc.)


20. PATHOPHYSIOLOGY

Antigenic drift
 Mutations
within the virus antibody-binding sites
accumulate over time
 Circumvent the body's immune system
 A and B

Antigenic shift
 Sudden
change in antigenicity
 Recombination of the influenza genome
 Cell becomes simultaneously infected by two different
strains of type A influenza.
 Humans live in close proximity swine, that human
strains and bird strains, may readily infect a pig at
the same time, resulting in a unique virus.

22. ANTIGENIC SHIFT
H1N1

23. 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

Has been detected internationally as well.

24. WHO CAN CATCH THE “FLU” ?

25. WHO CAN CATCH THE FLU ?
As in all epidemics
Children
Elderly
Pregnant women
Immuno-suppressed or Immuno-compromised
Chronic medical conditions
Occupational exposure-paramedics, medics

26. HOW DOES NOVEL H1N1 INFLUENZA
SPREAD?

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

27. CAN YOU GET NOVEL H1N1 INFLUENZA
FROM EATING PORK?
No
You cannot get novel H1N1 flu
from eating pork or pork products.
Eating properly handled and
cooked pork products is safe.

28. DEFINITIONS- CDC

29. CDC INTERIM GUIDANCE REPORT
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.
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.

30. SUSPECTED CASE
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 SIV
infection.

31. 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

32. INFECTIVITY PERIOD
Should be considered potentially contagious as
long as they are symptomatic
and possible for up to 7 days following illness
onset.
Children - might potentially be contagious for
longer periods.

33. INDIVIDUALS AT INCREASED
RISK
Elderly > 65 years
 Children less than two years
 Certain chronic diseases

 Heart
(except HTN) or lung disease (including
asthma)
 Metabolic disease, including diabetes
 HIV/AIDS, other immuno-suppression (drugs
induced)
 Chronic renal disease
 chronic hepatic disease
http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm,Influenza Antiviral
Medications: Summary for Clinicians (Current for the 2012-2013 Influenza Season)

34. Pregnant/postpartum (2 weeks after delivery)
 Hemoglobinopathies
 Aged younger than 19 years, receiving long term
Asprin therapy
 Person who are morbidly obese (BMI >40)
 Residents of nursing homes and other chronic
care facilities


35. SIGNS AND SYMPTOMS

36. SYMPTOMS

Mild or uncomplicated illness

37. 
Progressive illness
 typical
symptoms
 chest pain
 poor oxygenation

(eg, tachypnea)
 cardiopulmonary
insufficiency
 central nervous system (CNS) impairment (eg,
confusion, altered mental status)
 severe dehydration

38. 
Severe illness
 mechanical
ventilation
 CNS findings (encephalitis, encephalopathy)
 complications of hypotension (shock, organ failure)
 myocarditis or rhabdomyolysis
 invasive secondary bacterial infection
 persistent high fever and other symptoms beyond
three days.

39. COMPLICATIONS

Refractory respiratory failure
 Not
improving on mechanical ventilator
 Inhaled nitric oxide
 high-frequency oscillatory ventilation
 extracorporeal membrane oxygenation (ECMO)

40. COMPLICATIONS

Bacterial superinfection
 Streptococcus
pneumoniae
 Streptococcus pyogenes
 Staphylococcus aureus,
 Streptococcus mitis
 Haemophilus influenzae
 Moraxella catarrhalis

41. BACTERIAL SUPERINFECTION

Clinical findings:
 Secondary
fever after a period of defervescence.
 Sputum Gm stain or culture
 Lobar consolidation on chest imaging (diffuse pattern
in normal viral pneumonia)
 Leukocytosis (normal or low white blood cell count)
 Onset of respiratory compromise occurring four to
seven days after initial symptoms

42. COMPLICATIONS

Neurologic
 Seizure
 Confusion





acute or postinfectious encephalopathy
quadriparesis
encephalitis
severe acute disseminated encephalomyelitis
stroke, and transient ischemic attack

43. COMPLICATIONS

Other
 Myocarditis
 Renal
insufficiency
 Rhabdomyolysis
 Multisystem organ failure.
 Hypercoagulability

44. LABORATORY FINDINGS
Elevated SGOT/SGPT
 Anemia
 Leukopenia
 Thrombocytopenia /Thrombocytosis
 Elevated total bilirubin
 Elevations of CPK ,LDH


46. DIAGNOSTIC ASSAYS

Real-time reverse transcriptase
(rRT)-PCR
 most

sensitive and specific test
culture
 too
slow
 A negative viral culture does not
exclude pandemic H1N1 influenza A infection.

47. LIMITATIONS
Analysts should be trained and familiar with
testing procedures and interpretation of results
prior to performing the assay.
 A false negative result may occur if inadequate
numbers of organisms are present in the
specimen due to improper collection, transport or
handling.


48. DIAGNOSTIC ASSAYS
Combined nasopharyngeal
and throat swabs (CNTS)
 Nasopharyngeal
aspirates (NPA)


52. DIAGNOSTIC ASSAYS

Rapid antigen tests
 Distinguish
between influenza A and B viruses
 Cannot distinguish among different subtypes of
influenza A
 sensitivity -10 to 70 percent
 specificity of rapid antigen testing was generally >95
percent

53. DIAGNOSTIC ASSAYS

Immunofluorescent antibody testing
 Direct
or indirect immunofluorescent antibody
testing (DFA or IFA)
 Distinguish between influenza A and B
 does not distinguish among different influenza A
subtypes
 Low sensitivity and specificity

54. METHOD
Acceptable Specimens
Test Time
Viral cell culture
NP swab, throat swab, NP
,bronchial wash, nasal
endotracheal aspirate,
sputum
3-10 days
Direct (DFA) or
Indirect
(IFA) Antibody
NP swab or wash, bronchial
wash, nasal or endotracheal
aspirate
1-4 hours
RT-PCR
NP swab, throat swab, NP
or bronchial wash, nasal or
endotracheal aspirate,
sputum
1- 6 hours
Rapid Influenza
Diagnostic Tests
NP swab, (throat swab),
nasal wash, nasal aspirate
<30 min.

55. Treatment of H1N1

56. Treatment
• Adamantane agents
– Amantadine
– Rimantadine
• Neuraminidase inhibitor
– Oseltamivir (oral)
– Zanamivir (aerosolized)
– Peramivir (intravenous)

57. CDC recommends
• Treatment and prevention of H1N1/seasonal
flu
• Neuraminidase inhibitor
– Oseltamivir (oral)
– Zanamivir (aerosolized)

58. GUIDELINES ON CATEGORIZATION OF
INFLUENZA A H1N1 CASES DURING
SCREENING FOR HOME ISOLATION,
TESTING TREATMENT AND
HOSPITALIZATION
Ministry of Health & Family Welfare Pandemic
Influenza A (H1N1) Govt of India

59. Category- A
• Patients with mild fever plus cough / sore throat with
or without body ache, headache, diarrhoea and
vomiting
• Do not require Oseltamivir
• Symptomatic treatment
• Monitored for their symptom progress and reassessed
at 24 to 48 hours by the doctor
• No testing of the patient for H1N1
• Confine themselves at home
• Avoid mixing up
– Public and high risk members in the family

60. Category-B
i.
i.
•
•
Category-A + high grade fever & severe sore
throat
– Require home isolation and Oseltamivir
Category-A + one or more of high risk conditions
i. Shell be treated with Oseltamivir
No tests required for Category-B (i) and (ii)
All patients of Category-B (i) and (ii)
i. should confine themselves at home
ii.Avoid mixing with public and high risk members in
the family

61. Category-C
• Category-A and B
– Breathlessness, chest pain, drowsiness, fall in
blood pressure, sputum mixed with blood, bluish
discoloration of nails
– Children with 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
• Require testing, immediate hospitalization
and treatment

62. • Treatment should be started as soon as
possible after illness onset
– Ideally within 48 hrs

63. Chemoprophylaxis
• Drug approved
– Oseltamivir is approved for prophylaxis of
influenza in individual > 1 year of age
– Zanamivir for > 5 years of age
• 84-89% efficacious against influenza A and B

64. Guidelines on chemoprophylaxis
• Healthy persons after community exposure
– No chemoprophylaxis
• If states qualify the criteria for community
spread
– Family contacts that are at high risk
– Co-morbid condition
• Irrespective of laboratory testing
Guidelines on chemoprophylaxis, Ministry of Health & Family Welfare
Pandemic Influenza A (H1N1) Govt of India

65. • States which does not qualify the criteria of
community spread
– Family contacts, school contacts and social
contacts
• Irrespective of community spread or not
– Medical personnel attending to influenza A H1N1
cases
Guidelines on chemoprophylaxis, Ministry of Health & Family Welfare Pandemic Influenza
A (H1N1) Govt of India

66. OSELTAMIVIR (Cap.Tamiflu)
TREATMENT (5 DAYS)
75 mg BD
ADULTS
Chemoprophylaxis
(10 days)
75 mg OD
Body Weight (kg) TREATMENT (5 DAYS)
Chemoprophylaxis
(10 days)
≤15 kg
30 mg once daily
> 15 kg to 23 kg
45 mg twice daily
45 mg once daily
>23 kg to 40 kg
60 mg twice daily
60 mg once daily
>40 kg
Children
≥ 12 months
30 mg twice daily
75 mg twice daily
75 mg once daily
Children 3 months to <
12 months2
TREATMENT (5 DAYS)
Chemoprophylaxis
(10 days)
3 mg/kg/dose twice
daily
3 mg/kg/dose once per
day
It is also available as syrup (12mg per ml )
WHO and The U.S. Centers for Disease Control and Prevention
http://www.cdc.gov/H1N1flu/recommendations.htm
http://www.cdc.gov/H1N1flu/recommendations.htm

67. ZANAMIVIR (Relenza Diskhaler)
ADULTS
and
Children >
5 years
TREATMENT
(5 DAYS)
Chemoprophylaxis
(10 days)
10 mg (two
inhalations)
BD
10 mg (two
inhalations) once
daily
WHO and The U.S. Centers for Disease Control and Prevention
http://www.cdc.gov/H1N1flu/recommendations.htm
http://www.cdc.gov/H1N1flu/recommendations.htm

68. Adverse effect
• Oseltamivir
–
–
–
–
–
–
• Zanamivir
Nausea
GI discomfort
Vomiting
Vertigo
Insomnia
Neuropsychiatric events
• Delirium
• Self-injury
–
–
–
–
–
Worsen asthma
Diarrhea
Nausea
Sinusitis
Nasal signs and
symptoms
– Bronchitis
– Headache & dizziness
– Ear, nose, and throat
infections
http://www.cdc.gov/flu/professionals/antivirals/antiviral-adverse-events.htm
Harrison’s 18th edition, page no.1442

69. INFLUENZA SEASONAL VACCINE
CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine

72. Vaccination
• Annually
• Trivalent
– 2 strain of influenza A & 1 strain of influenza B
• Above the age of 6 months
• Quadrivalent vaccine
CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine

73. “Flu shot”
• The "flu shot"
– Killed vaccine
– Intramuscular
– Usually in the arm
– approved for use in
people older than 6
months, including
healthy people and
people with chronic
medical conditions.
76

74. Nasal vaccination
• LAIV (Flumist)
– a vaccine made with
live, weakened flu
viruses that do not
cause the flu
– LAIV (FluMist) is
approved for use in
healthy people 2-49
years of age who are
not pregnant
77

75. Seasonal influenza vaccine 2012-13
• Influenza vaccines for 2012–13 season
– A/California/7/2009 (H1N1)
– A/Victoria/361/2011 (H3N2)
– B/Wisconsin/1/2010 (Yamagata lineage) antigens
• All individual above the age of 6 mths
• 6 months to 8 years
– 2 doses
– Month apart (4 weeks to 1 years)
CDC- Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)
—United States, 2012–13 Influenza Season, August 17, 2012 / 61(32);613-618

76. Available

77. Pandemic flu vaccine
• Monovalent vaccine
– CELVAPAN
– PANDEMRIX

79. Side effects
• Flu shot
• LAIV (Flumist)
– Soreness, redness, or
swelling where the shot
was given
– Fever (low grade)
– Aches
– Children
•
•
•
•
•
runny nose
wheezing
headache
muscle aches
Fever
– Adults
•
•
•
•
runny nose
headache
sore throat
cough
CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine

80. Who should get the swine flu shot?
• Pregnant women
• People who live with or care for children younger
than 6 months of age
• Children and young people between the ages of 6
months and 24 years
• Health care workers and emergency medical
service providers
• 25 and 64 years of age who have chronic medical
disorders or compromised immune systems.
CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine

81. Who Should Not Be Vaccinated?
• People who have a severe allergy to chicken
eggs
• Severe reaction to an influenza vaccination
• Children younger than 6 months of age
• People who have a moderate-to-severe illness
with a fever (they should wait until they
recover to get vaccinated)
• History of Guillain–Barré Syndrome
CDC - Seasonal Influenza (Flu) - Key Facts About Seasonal Flu Vaccine

82. GUIDELINES ON INFECTION
CONTROL MEASURES
Clinical management Protocol and Infection Control Guidelines; Directorate General of
Health Services, Ministry of Health and Family Welfare, Government of India

83. Health facility managing the human
cases of Influenza A H1N1
• During Pre Hospital Care
– Three layer surgical mask
– Full complement of PPE(Personal Protection
Equipments )
– No Aerosol generating procedures
– Three layered surgical mask for driver
– Ambulance equipment sanitized using sodium
hypochlorite / quaternary ammonium compounds

84. Contd
• During hospital care
– Isolation ward and continue to wear a three layer
surgical mask
– Identified medical, nursing and paramedical
personnel attending the pt should wear full
complement of PPE (Personal Protection Equipments)
– Aerosol-generating procedures
– Sample collection and packing
– Hand wash
• Before and after patient contact
• Following contact with contaminated items

85. Contd
• Infection control precautions
– 7 days after resolution of symptoms for adult
– 14 days after resolution of symptoms for children
• Contaminated surfaces and equipments
• Disinfectants
– 70% ethanol, 5% benzalkonium chloride (Lysol)
and 10% sodium hypochlorite

87. STANDARD OPERATING PROCEDURES
ON USE OF PERSONAL PROTECTION
EQUIPMENTS (PPE)
Clinical management Protocol and Infection Control Guidelines; Directorate General of
Health Services, Ministry of Health and Family Welfare, Government of India

88. Personal Protection Equipments (PPE)
• Reduces the risk of infection. It includes:
– Gloves (nonsterile)
– Mask (high-efficiency mask N95) / 3 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

89. Contd
• Correct procedure for applying PPE :
– Follow thorough hand wash
– Wear the coverall
– Wear the goggles/ shoe cover/and head cover
– Wear face mask
– Wear gloves
The masks should be changed after every six to
eight hours

90. Remove PPE in the following order
• Remove gown (place in rubbish bin)
• Remove gloves (peel from hand and discard
into rubbish bin)
– Alcohol -based hand-rub or wash hands with soap & 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 & water

91. INFECTION CONTROL MEASURES AT
INDIVIDUAL LEVEL
Clinical management Protocol and Infection Control Guidelines; Directorate General of
Health Services, Ministry of Health and Family Welfare, Government of India

92. Hand washing a Top priority
• Single most important
measure to reduce the
risk of transmitting
infectious organism
from one person to
other

94. Respiratory Hygiene/Cough Etiquette
• Covering your nose
and mouth with a
tissue when you
cough or sneeze.
Throw the tissue in
the trash after you
use
• Wash hand

95. Touching face regions can faster
the Spread
• Avoiding touching
your eyes, nose or
mouth.
Virus
can spread this way
in a faster way

96. Staying home if you are sick

97. Avoid crowded places more so
with young children

98. Mild cold like symptoms - Take
rest

100. Using N95 mask reduces the Risk
• You can cut your risk
of contracting the flu
or other respiratory
viruses by as much
as 80 percent by
wearing a mask over
your nose and
mouth
Emerging Infectious Diseases, the journal
of the Centres for Disease Control and
Prevention (CDC) .

101. Infection control measures at
health facility
•
•
•
•
Droplet Precautions
Visual alerts
Use of PPE
Decontaminating contaminated surfaces,
fomites and equipments
• Guidelines for waste disposal

102. Discharge policy
• Asymptomatic pt after two to three days of
treatment
– Should be discharged after 5 days of treatment
– Repeat test not required
• Continuation of symptoms of fever, sore throat
etc. even on the 5th day
– should continue treatment for 5 more days
– Asymptomatic  discharge
– No need to test further

103. Discharge policy
• Symptomatic
– Even after 10 days of treatment or
– cases with respiratory distress
– Suspected secondary infection
– if patient continue to shed virus
• Resistance of the patients to anti viral drug would be
tested
• Family should be educated on
– Personal hygiene
– Infection control measures at home

104. Check list
• S – Stay home (if ill) and sleep well
• W –Wash hands, wear masks. Wine not to be
consumed
• 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

105. Panic and Fear are much dangerous than
Swine Flu