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Our Experience with SWINE FLU

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Our Experience with SWINE FLU

  1. 1. SWINE FLUSWINE FLU Dr Nirmal B TapariaDr Nirmal B Taparia MD MedicineMD Medicine Physician & IntensivistPhysician & Intensivist Ashwini HospAshwini Hosp
  2. 2. What is Swine FluWhat is Swine Flu  Swine influenza virusSwine influenza virus (referred to as(referred to as SIVSIV) refers to influenza cases that are) refers to influenza cases that are caused by Orthomyxovirus endemic to pigcaused by Orthomyxovirus endemic to pig populations. SIV strains isolated to datepopulations. SIV strains isolated to date have been classified either ashave been classified either as Influenza(virus C or one of the variousInfluenza(virus C or one of the various subtypes of the genus Influenza virus A)subtypes of the genus Influenza virus A)
  3. 3. What is H1N1 Influenza A Virus (Swine Flu)?What is H1N1 Influenza A Virus (Swine Flu)?  H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people.  This new virus was first detected in people in April 2009 in the United States.  H1N1 Influenza A (swine flu) is transmitted by respiratory secretions  This virus was originally referred to asThis virus was originally referred to as “swine flu” because laboratory testing“swine flu” because laboratory testing showed that many of the genes in thisshowed that many of the genes in this
  4. 4. What are the Signs & Symptoms ofWhat are the Signs & Symptoms of H1N1 Influenza A in Humans?in Humans?  The symptoms of this new influenza A H1N1 virus in people are similar to the symptoms of regular human flu and include fever (greater than 100.0º F or 37.8 º C), cough, sore throat, body aches, headache, chills and fatigue.  A significant number of people who have been infected with this virus also have reported diarrhea and vomiting.    Also, like seasonal flu, severe illnesses and death has occurred as a result of illness associated with
  5. 5. Different Strains circulateDifferent Strains circulate PeriodicallyPeriodically  In the United States the H1N1 subtypeIn the United States the H1N1 subtype was exclusively prevalent among swinewas exclusively prevalent among swine populations before 1998; however, sincepopulations before 1998; however, since late August 1998, H3N2 subtypes havelate August 1998, H3N2 subtypes have been isolated from pigs. As of 2004, H3N2been isolated from pigs. As of 2004, H3N2 virus isolates in US swine and turkeyvirus isolates in US swine and turkey stocks were triple reassortants, containingstocks were triple reassortants, containing genes from human (HA, NA, and PB1),genes from human (HA, NA, and PB1), swine (NS, NP, and M), and avian (PB2swine (NS, NP, and M), and avian (PB2 and PA) lineages.and PA) lineages.
  6. 6. Swine Influenza (Flu)Swine Influenza (Flu)  Swine Influenza (swine flu) is a respiratorySwine Influenza (swine flu) is a respiratory disease of pigs caused by type Adisease of pigs caused by type A influenza that regularly cause outbreaks ofinfluenza that regularly cause outbreaks of influenza among pigs. Swine flu viruses doinfluenza among pigs. Swine flu viruses do not normally infect humans, however,not normally infect humans, however, human infections with swine flu do occur,human infections with swine flu do occur, and cases of human-to-human spread ofand cases of human-to-human spread of swine flu viruses has been documented.swine flu viruses has been documented.
  7. 7. Swine Flu in MexicoSwine Flu in Mexico  In the Federal District of Mexico,In the Federal District of Mexico, surveillance began picking up cases of ILIsurveillance began picking up cases of ILI starting 18 March. The number of casesstarting 18 March. The number of cases has risen steadily through April and as ofhas risen steadily through April and as of 23 April there are now more than 85423 April there are now more than 854 cases of pneumonia from the capital. Ofcases of pneumonia from the capital. Of those, 59 have died. In San Luis Potosi, inthose, 59 have died. In San Luis Potosi, in central Mexico, 24 cases of ILI, with threecentral Mexico, 24 cases of ILI, with three deaths, have been reported.deaths, have been reported.  (NEJM Aug. 2009)(NEJM Aug. 2009)
  8. 8. Swine Flu and VirusSwine Flu and Virus  Swine Influenza (swine flu) is a respiratorySwine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza virusdisease of pigs caused by type A influenza virus that regularly causes outbreaks of influenza inthat regularly causes outbreaks of influenza in pigs. Swine flu viruses cause high levels ofpigs. Swine flu viruses cause high levels of illness and low death rates in pigs. Swineillness and low death rates in pigs. Swine influenza viruses may circulate among swineinfluenza viruses may circulate among swine throughout the year, but most outbreaks occurthroughout the year, but most outbreaks occur during the late fall and winter months similar toduring the late fall and winter months similar to outbreaks in humans. The classical swine fluoutbreaks in humans. The classical swine flu virus (an influenza type A H1N1 virus) was firstvirus (an influenza type A H1N1 virus) was first isolated from a pig in 1930.isolated from a pig in 1930.
  9. 9. Cause by Reassortment ofCause by Reassortment of different strainsdifferent strains  Like all influenza viruses,Like all influenza viruses, swine flu viruses changeswine flu viruses change constantly. Pigs can beconstantly. Pigs can be infected by avianinfected by avian influenza and humaninfluenza and human influenza viruses as wellinfluenza viruses as well as swine influenzaas swine influenza viruses. When influenzaviruses. When influenza viruses from differentviruses from different species infect pigs, thespecies infect pigs, the viruses can reassort (i.e.viruses can reassort (i.e. swap genes) and newswap genes) and new viruses that are a mix ofviruses that are a mix of swine, human and/orswine, human and/or avian influenza virusesavian influenza viruses can emerge
  10. 10. Swine Flu differs from HumanSwine Flu differs from Human FluFlu  The H1N1 swine fluThe H1N1 swine flu viruses areviruses are antigenically veryantigenically very different from humandifferent from human H1N1 viruses and,H1N1 viruses and, therefore, vaccinestherefore, vaccines for human seasonalfor human seasonal flu would not provideflu would not provide protection from H1N1protection from H1N1 swine flu virusesswine flu viruses
  11. 11. Present Swine Flu strainsPresent Swine Flu strains  At this time, there are fourAt this time, there are four main influenza type Amain influenza type A virus subtypes that havevirus subtypes that have been isolated in pigs:been isolated in pigs: H1N1, H1N2, H3N2, andH1N1, H1N2, H3N2, and H3N1. However, most ofH3N1. However, most of the recently isolatedthe recently isolated influenza viruses frominfluenza viruses from pigs have been H1N1pigs have been H1N1 viruses.viruses.
  12. 12. Swine flu…Swine flu…  Influenza A is most virulent.Influenza A is most virulent.  It is known to cause pandemics.TheseIt is known to cause pandemics.These strains evolve and mutate thru severalstrains evolve and mutate thru several stages while infecting the humans.stages while infecting the humans.  Interpandemic influenza A is less virulentInterpandemic influenza A is less virulent as compared to pandemic strains.as compared to pandemic strains.  B is less virulent more localised.B is less virulent more localised.  C is least with good serum antibodyC is least with good serum antibody response in humans.response in humans.
  13. 13. Presentation…Presentation…   OurOur  Experience…Experience…
  14. 14. Our experience…Our experience…  Background :Background :  From mid January 2015 to March 8 2015,From mid January 2015 to March 8 2015, patients with similar pattern of illness werepatients with similar pattern of illness were admitted to our hospital later proved to beadmitted to our hospital later proved to be caused by Swine Flu.caused by Swine Flu.  Methods :Methods :  we used retrospective medical chartwe used retrospective medical chart reviews to collect data on the hospitalisedreviews to collect data on the hospitalised patients.patients. 
  15. 15. Our experience…Our experience…  Swine flu was confirmed with samplesSwine flu was confirmed with samples sent to NIV Pune by use of a real timesent to NIV Pune by use of a real time reverse transcriptase PCR.reverse transcriptase PCR.  Conclusions :Conclusions :  acute swine flu can cause severe illness,acute swine flu can cause severe illness, ARDS, and death in previously healthyARDS, and death in previously healthy persons who are young to middle age.persons who are young to middle age.
  16. 16. Analysis…Analysis…  A total of 28 pts were positive for swine fluA total of 28 pts were positive for swine flu during this period.during this period.  18 male & 10 female.18 male & 10 female.  Pts.admitted were from all over the districtPts.admitted were from all over the district and were suspected for swine flu.and were suspected for swine flu.  Data was gathered and analysedData was gathered and analysed retrospectively to study the disease.retrospectively to study the disease.
  17. 17. Tables…Tables… Statistics…Statistics…
  18. 18. Analysis…Analysis… variable value percentage Male sex 18/28 64 median 44.4 All patients 15 to 50 yrs 19/28 68 >50 yrs 9/28 32 Patients who died value percentage 15 to 50 yrs 7/19 37 > 50 yrs 2/9 22
  19. 19. Analysis…Analysis… Symptoms or outcome No. Of total percentage cough 26/28 93 rhinorrhea 17/28 61 wheezing 10/28 36 headache 6/28 21 myalgia 7/28 25 fever 25/28 89 Resp. distress 23/28 82 diarrhoea 3/28 10 hypotension 7/28 25 Mechanical ventilation 10/28 36 deaths 9/28 32
  20. 20. Analysis…Analysis… sex Total cases survived death male 18 13 5 female 10 6 4
  21. 21. Analysis…Analysis… variable median range SD Leukocyte count 6550 3200-16000 3239.28 Lymphocyte count Creatine kinase Mean– 95.5 34-186 53.52 LDH Mean– 740.2 322-1206 740.2 Apache score 9 1--30 7.1 Hypotension requiring inotrope 80 (6 of 9 pts who died) 60--180 --- Pts survived Pts died Odds ratio P value Opacity in ¾ 2/17 5/9 9.37 0.026 Quadrant in initial xray 1.29—67.65
  22. 22. Analysis…Median valuesAnalysis…Median values pH Paco2 Pao2 Fio2 Pao2: Fio2 APACH E survived 7.4 30 62 o.32 193.7 8.5 Median death 7.35 37.1 59 o.6 165.1 17
  23. 23. RESULTS (Observations)RESULTS (Observations)  Admissions for respiratory symptoms andAdmissions for respiratory symptoms and pneumonia increased during this period.pneumonia increased during this period.  Median age of pts was 44.4Median age of pts was 44.4  More than half were between 15 and 50More than half were between 15 and 50 yrs.yrs.  More than half (64%) were male.More than half (64%) were male.  None of the pts had a h/o pneumococcalNone of the pts had a h/o pneumococcal vaccination.vaccination.
  24. 24. Results…Results…  Time between onset of symptoms andTime between onset of symptoms and presentation to casualty was between 1 topresentation to casualty was between 1 to 8 days.(Median of 4.81)8 days.(Median of 4.81)  Symptoms of cough(93%), fever(89)% andSymptoms of cough(93%), fever(89)% and respiratory distress (82%) wererespiratory distress (82%) were predominant.predominant.  14 pts had associated comorbid14 pts had associated comorbid conditions like DM, HTN, IHD, COPD,conditions like DM, HTN, IHD, COPD,
  25. 25. Results…Results…  1 pt was pregnant and 2 were RVD +ve.1 pt was pregnant and 2 were RVD +ve.  14 pts needed ventilation in total14 pts needed ventilation in total (bipap+invasive)(bipap+invasive)  10 pts eventually went on mechanical10 pts eventually went on mechanical ventilation of which 1 survived.ventilation of which 1 survived.  In investigations Lymphopenia, raised CKIn investigations Lymphopenia, raised CK and LDH and ¾ quadrant opacities onand LDH and ¾ quadrant opacities on xray, hypotension, low Ph were importantxray, hypotension, low Ph were important features diagnostically.features diagnostically.
  26. 26. Higher risk of complications in…Higher risk of complications in…  Age <4 yrsAge <4 yrs  PregnancyPregnancy  Elderly >65 yrs oldElderly >65 yrs old  Pts. With chronic disorders of the CVSPts. With chronic disorders of the CVS and RS.and RS.  Pts. Who have chronic metabolicPts. Who have chronic metabolic diseases.diseases.  Health care workers.Health care workers.
  27. 27. Adults Need attention ifAdults Need attention if Present withPresent with  Difficulty breathing or shortness of breathDifficulty breathing or shortness of breath  Pain or pressure in the chest or abdomenPain or pressure in the chest or abdomen  Sudden dizzinessSudden dizziness  ConfusionConfusion  Severe or persistent vomitingSevere or persistent vomiting
  28. 28. Summing up…Summing up… Discussion…Discussion…
  29. 29. Discussion…Discussion…  We presented retrospective analysis o 28We presented retrospective analysis o 28 pts. Detected to have H1N1 in ourpts. Detected to have H1N1 in our hospital.hospital.  28 patients of which 18 were male and 1028 patients of which 18 were male and 10 female, were admitted from Jan to 8 Marfemale, were admitted from Jan to 8 Mar 2015.2015.  9 pts died during treatment i.e mortality of9 pts died during treatment i.e mortality of 32.14%.32.14%.
  30. 30. Pathogenesis & Immunity…Pathogenesis & Immunity…  Infection by a small particle aerosol<10umInfection by a small particle aerosol<10um is more efficient.is more efficient.  Initially virus infects the ciliated columnarInitially virus infects the ciliated columnar epithelial cells.epithelial cells.  Virus replicates by 4-6 hrs and released toVirus replicates by 4-6 hrs and released to infect nearby cells foll. By cytokine storm.infect nearby cells foll. By cytokine storm.  Infected cells desquamate and replacedInfected cells desquamate and replaced by flat metaplastic cells.by flat metaplastic cells.  Rare in extra-pul sites including blood.Rare in extra-pul sites including blood.
  31. 31. Complications…Complications…  Pulmonary:Pulmonary:  Primary influenza pneumonia:Primary influenza pneumonia:  Least common. Xray findings of diffuseLeast common. Xray findings of diffuse interstitial infiltrates and/or ARDS.interstitial infiltrates and/or ARDS.  ABG shows marked HypoxemiaABG shows marked Hypoxemia  Predilection in diseased pts andPredilection in diseased pts and pregnancypregnancy  Secondary bacterial pneumoniaSecondary bacterial pneumonia
  32. 32. Comp…Comp…  Reappearance of fever and s/s of bacterialReappearance of fever and s/s of bacterial pneumonia.pneumonia.  Commonly caused by streptococcus pneu.Commonly caused by streptococcus pneu. Staph. Aureus, H influenzae.Staph. Aureus, H influenzae.  Common in high risk individuals.Common in high risk individuals.  Mixed pneumonia :Mixed pneumonia :  Most common pneumonic complicationMost common pneumonic complication during outbreaks.during outbreaks.
  33. 33. Comp…Comp…  Xrays show less widespread involvementXrays show less widespread involvement of the lung compared to primaryof the lung compared to primary pneumonia.pneumonia.  Extra pulmonary complications:Extra pulmonary complications:  Myositis, rhabdomyolysis, myoglobinuria.Myositis, rhabdomyolysis, myoglobinuria.  Myocarditis, pericarditis.Myocarditis, pericarditis.  CNS: encephalitis, GBS, transverse-CNS: encephalitis, GBS, transverse- myelitismyelitis
  34. 34. DiagnosisDiagnosis  To diagnose swineTo diagnose swine influenza A infection, ainfluenza A infection, a respiratory specimenrespiratory specimen would generally need towould generally need to bebe collected withincollected within the first 4 to 5 daysthe first 4 to 5 days of illnessof illness (when an(when an infected person is mostinfected person is most likely to be sheddinglikely to be shedding virus). However, somevirus). However, some persons, especiallypersons, especially children, may shed viruschildren, may shed virus for 10 days or longer.for 10 days or longer. Identification as a swineIdentification as a swine flu influenza A virusflu influenza A virus
  35. 35. Drugs which are effective inDrugs which are effective in Swine FluSwine Flu  There are four differentThere are four different antiviral drugs that areantiviral drugs that are licensed for use in the USlicensed for use in the US for the treatment offor the treatment of influenza:influenza: Amantidine,Amantidine, rimantadine,rimantadine, oseltamivir andoseltamivir and zanamivirzanamivir. While most. While most swine influenza virusesswine influenza viruses have been susceptible tohave been susceptible to all four drugsall four drugs
  36. 36. DRUG TREATMENTDRUG TREATMENT  Oseltamivir:Oseltamivir:  Treatment :75 mg bd for 5 daysTreatment :75 mg bd for 5 days  Prophylaxis :75 mg qday for10 days.Prophylaxis :75 mg qday for10 days.  (S/E: nausea, dizziness, headache,(S/E: nausea, dizziness, headache, insomnia)insomnia)  Zanamivir :Zanamivir :  Treatment :10 mg inhalation bd for 5 daysTreatment :10 mg inhalation bd for 5 days  Prophylaxis :10 mg inh. Qday for 10 days.Prophylaxis :10 mg inh. Qday for 10 days. 
  37. 37. Drugs…Drugs…  Amantadine & Rimantadine also can beAmantadine & Rimantadine also can be used for t/t though less effective.used for t/t though less effective.  Doses :200mg/day for 3-7 days.Doses :200mg/day for 3-7 days.  Their use for prophylaxis is beingTheir use for prophylaxis is being evaluated but amantadine hasevaluated but amantadine has considerable CNS toxicity.considerable CNS toxicity.  Drugs decrease s/s of uncomplicated fluDrugs decrease s/s of uncomplicated flu by 1.5 to 2 days if started within 48 hrs ofby 1.5 to 2 days if started within 48 hrs of onset.onset.
  38. 38. Newer Drugs…Newer Drugs…  Iv zanamivir is been developedIv zanamivir is been developed  Peramivir :iv & im preparations are underPeramivir :iv & im preparations are under development. Its a neuraminidasedevelopment. Its a neuraminidase inhibitor.inhibitor.  Fludase 181DAS :cleaves the influenzaFludase 181DAS :cleaves the influenza receptors and removes them fromreceptors and removes them from epithelial cells.epithelial cells.  Cyanovirin N :a hemagluttinin receptorCyanovirin N :a hemagluttinin receptor inhibitor that blocks viral entry.inhibitor that blocks viral entry.
  39. 39. Newer drugs…Newer drugs…  T 705 :active against N-inhibitor resistant,T 705 :active against N-inhibitor resistant, amantadine resistant virus.amantadine resistant virus.  (nejm:aug 13 2009)(nejm:aug 13 2009)  Also global transmission of oseltamivirAlso global transmission of oseltamivir resistant influenza is also on the rise.resistant influenza is also on the rise.
  40. 40. Drugs proved resistant atDrugs proved resistant at PresentPresent  Most recent swineMost recent swine influenza virusesinfluenza viruses isolated from humansisolated from humans areare resistant toresistant to Amantidine andAmantidine and RimantadineRimantadine
  41. 41. VaccinationVaccination  The efficacy of influenza vaccine mayThe efficacy of influenza vaccine may differ from year to year.differ from year to year.  It differs in LIVE and INACTIVATEDIt differs in LIVE and INACTIVATED vaccines too.vaccines too.  The absolute efficacy against influenza AThe absolute efficacy against influenza A virus was 72% for INACTIVATED vaccinevirus was 72% for INACTIVATED vaccine and 29% for LIVE vaccine.and 29% for LIVE vaccine.  (nejm sep 2009)(nejm sep 2009)
  42. 42. Vaccination…Vaccination…  In elderly people study showed that HighIn elderly people study showed that High dose (60ug hemagluttinin per strain)dose (60ug hemagluttinin per strain) trivalent Inactivated influenza vaccinetrivalent Inactivated influenza vaccine improves antibody response to influenzaimproves antibody response to influenza as compared to standard dose (15ug ofas compared to standard dose (15ug of hemagluttinin)hemagluttinin)  (nejm aug 2014)(nejm aug 2014)
  43. 43. Vaccination…Vaccination…  Effective vaccination depends uponEffective vaccination depends upon development of HAI titers of >1:40 indevelopment of HAI titers of >1:40 in vaccinated individuals. This confers 50%vaccinated individuals. This confers 50% protection.protection.  The incidence of GBS in IM vaccinationThe incidence of GBS in IM vaccination was less than 0.1%(nejm feb 2011)was less than 0.1%(nejm feb 2011)  Recent study in Feb 2015 inRecent study in Feb 2015 in Eurosurveillance shows decreasedEurosurveillance shows decreased vaccine effectiveness (VE) because ofvaccine effectiveness (VE) because of genetic andgenetic and
  44. 44. Vaccination…Vaccination…  Antigenic mismatch between infecting andAntigenic mismatch between infecting and vaccine strains.vaccine strains.
  45. 45. Pregnancy and vaccination…Pregnancy and vaccination…  Pregnancy induces immune tolerance.Pregnancy induces immune tolerance.  Tri valent influenza vaccines producesTri valent influenza vaccines produces immunogenicity and HAI>1:40 andimmunogenicity and HAI>1:40 and protection to mothers.protection to mothers.  Studies in USA and Bangladesh haveStudies in USA and Bangladesh have confirmed this.confirmed this.  Antibodies from mothers crossing placentsAntibodies from mothers crossing placents and protecting fetus is not known but,and protecting fetus is not known but,  (nejm sep.2014)(nejm sep.2014)
  46. 46. Pregnancy and vaccination…Pregnancy and vaccination…  Decreased risk of infection in vaccinatedDecreased risk of infection in vaccinated mother decreases risk to fetus.mother decreases risk to fetus.  WHO safely recommends immunisation inWHO safely recommends immunisation in pregnancy,pregnancy, Adaptive changes occur during pregnancyAdaptive changes occur during pregnancy such as inc. HR & SV and dec.pulmonarysuch as inc. HR & SV and dec.pulmonary residual capacity,and inc. the risk ofresidual capacity,and inc. the risk of hypoxia & disease severity.hypoxia & disease severity. (NEJM Jan 2013)(NEJM Jan 2013)
  47. 47. How long can an infected personHow long can an infected person spread swine flu to othersspread swine flu to others??  People with swine influenza virus infectionPeople with swine influenza virus infection should be considered potentiallyshould be considered potentially contagious as long as they arecontagious as long as they are symptomatic and possible for up to 7 dayssymptomatic and possible for up to 7 days following illness onset. Children, especiallyfollowing illness onset. Children, especially younger children, might potentially beyounger children, might potentially be contagious for longer periods.contagious for longer periods.
  48. 48. How long can viruses liveHow long can viruses live outside the body?outside the body?  We know that some viruses and bacteriaWe know that some viruses and bacteria can live 2 hours or longer on surfaces likecan live 2 hours or longer on surfaces like cafeteria tables, doorknobs, and desks.cafeteria tables, doorknobs, and desks. Frequent hand washing will help youFrequent hand washing will help you reduce the chance of gettingreduce the chance of getting contamination from these commoncontamination from these common surfaces.surfaces.
  49. 49. Clean Hands saves youClean Hands saves you  Clean your hands often. Clean your hands every time you cough or sneeze. Hand washing stops germs. Alcohol-based gels and wipes also work well.
  50. 50. Cartoonists Imagination onCartoonists Imagination on Swine FluSwine Flu
  51. 51. Thank youThank you

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