SWINE FLU

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Influenza A (H1N1) A/California/7/2009 (H1N1) DR. MUHAMMAD ALAUDDIN SARWAR Medical Officer, Sindh Government Qatar Hospital Karachi

Influenza A Viruses : 

Influenza A Viruses Influenza A viruses categorized by subtype Classified according to two surface proteins Hemagglutinin (H) – 16 known Site of attachment to host cells Antibody to HA is protective Neuraminidase (N) – 9 known Helps release virions from cells Antibody to NA can help modify disease severity National Center for Disease Prevention and Control, DOH

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SWINE FLU VIRUS A/California/7/2009 (H1N1)

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GENESIS OF SWINE FLU VIRUS

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SWINE FLU PANDEMIC

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WORLDWIDE SWINE FLU PANDEMIC

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WHO 9 jan 2010 WORLDWIDE SWINE FLU PANDEMIC

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WORLDWIDE SWINE FLU PANDEMIC http://www.flucount.org/ and Wikipedia 23/01/10

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219 cases of swine flu have so far been detected in the country. 14 casualties Health Minister Makhdoom Shahabuddin 12 january 2010. THE DAILY DAWN History of Swine Flu in Pakistan First case of swine flu was detected in August, 2009

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A Suspected Case of Influenza A / H1N1 virus infection is defined as an individual presenting with High fever >38°C, AND One or more of the following respiratory symptoms: cough, shortness of breath, body ache, difficulty in breathing, AND One or more of the following: close contact with a person diagnosed as Influenza A/H1N1 OR recent travel to an area reporting cases of confirmed Influenza A/H1N1 Case Definitions for Influenza A H1N1 Cases (Acute febrile respiratory illness (fever > 38 °C) with the spectrum of disease from influenza-like illness to pneumonia) WHO and The U.S. Centers for Disease Control and Prevention

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A Probable Case of Influenza A/H1N1 infection is defined as an individual that fulfill the criteria for a suspected case, with an influenza test that is positive for influenza A, but is unsubtypable by reagents used to detect seasonal influenza virus infection OR An individual with a clinically compatible illness or who died of an unexplained acute respiratory illness who is considered to be epidemiologically linked to a probable or confirmed case. Case Definitions for Influenza A H1N1 Cases WHO and The U.S. Centers for Disease Control and Prevention

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A Confirmed Case of Influenza A/H1N1 infection is defined as an individual with laboratory confirmed Influenza A/H1N1 virus infection by one or more of the following tests: real-time RT-PCR viral culture 4-fold rise in swine influenza A(H1N1) virus specific neutralizing antibodies Case Definitions for Influenza A H1N1 Cases WHO and The U.S. Centers for Disease Control and Prevention

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Clinical Signs & Symptoms of Influenza A (H1N1) WHO, Wikipedia and The U.S. Centers for Disease Control and Prevention

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DIFFERENCE B/W FLU, COLD & ALLERGY

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Close contact is defined as: within about 3 feet of an ill person who is a confirmed or suspected case of influenza A H1N1 virus infection during the case’s infectious period. Complications:viral and bacterial pneu monia, febrile seizures, cardiomyopathy, encephalopathy/encephalitis, worsening underlying chronic conditions WHO and The U.S. Centers for Disease Control and Prevention FEATURES OF H1N1 INFECTION

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Infectious period for a confirmed case of swine influenza A (H1N1) virus infection is defined as 1 day prior to the case’s illness onset to 7 days after onset. Incubation period Time from exposure to onset of symptoms 1 to 4 days (average = 2 days) Seasonality In temperate zones, sharp peaks in winter months In tropical zones, circulates year-round with seasonal increases. FEATURES OF H1N1 INFECTION WHO and The U.S. Centers for Disease Control and Prevention

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Through large-particle respiratory droplets which do not remain suspended in air & travel only short distances (<1m ). Contact with respiratory-droplet contaminated surfaces is another possible source of transmission.   As data from influenza viruses H1N1 are limited, potential for ocular, conjunctival, or GI infection is unknown. Being a novel influenza A virus, transmission from infected persons to close contacts maybe common. All respiratory secretions & bodily fluids (diarrheal stool) of H1N1 cases should be considered infectious. TRANSMISSION OF SWINE FLU VIRUS WHO and The U.S. Centers for Disease Control and Prevention

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Elderly > 65 years Children less than two years Certain chronic diseases Heart or lung disease, including asthma Metabolic disease, including diabetes HIV/AIDs, other immuno-suppression Conditions that can compromise respiratory function or the handling of respiratory secretions Pregnant women Individuals at Increased Risk for Hospitalizations and Death WHO and The U.S. Centers for Disease Control and Prevention

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Oseltamivir & zanamivir can be given for suspected, probable & confirmed H1N1 cases Current approach : Use for probable & confirmed cases In suspected cases: -Empirical treatment if patients present with complications of influenza eg. Pneumonia, mental confusion, metabolic derangement, etc - If patient is clinically comfortable (no complications), treatment deferred till virology results Duration of treatment: 5 days Antiviral Therapy WHO and The U.S. Centers for Disease Control and Prevention

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It is also available as syrup (12mg per ml ) OSELTAMIVIR (Cap.Tamiflu) WHO and The U.S. Centers for Disease Control and Prevention http://www.cdc.gov/H1N1flu/recommendations.htm

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ZANAMIVIR (Relenza Diskhaler) WHO and The U.S. Centers for Disease Control and Prevention http://www.cdc.gov/H1N1flu/recommendations.htm

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The patients can be discharged with the following criteria: Suspected cases: When PCR results are negative If patient is still unwell, he can be transferred out of isolation ward Probable & Confirmed cases: At least 7 days from onset of illness and Completed at least 5 days of antiviral therapy and Well / asymptomatic If the patient has fulfilled the first 2 criteria but is still recovering, he can be transferred out of isolation ward DISCHARGE OF PATIENTS WHO and The U.S. Centers for Disease Control and Prevention

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ALGORITHM FOR MANAGEMENT (H1N1) The University of North Carolina, 23 September 2009 Updates at http://intranet.unchealthcare.org/intranet_news/empnews/fluYesNoNo

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Vaccines are available. (CELVAPAN & PANDEMRIX) They are made just like seasonal flu vaccines. They are expected to be as safe and effective as seasonal flu vaccines. They will not prevent “influenza-like” illnesses caused by other viruses. They will not prevent seasonal flu. You should also get seasonal influenza vaccine, if you want to be protected against seasonal flu. PANDEMIC FLU VACCINATION Contraindication: Severe (life-threatening) allergy to eggs, or to any other substance in the vaccine. The U.S. Centers for Disease Control and Prevention, 10/2/09

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PANDEMIC FLU VACCINATION Groups recommended to receive 2009 H1N1 vaccine first are: Pregnant women. People who live with or care for infants younger than 6 months of age. Health care and emergency medical personnel. Anyone from 6 months through 24 years of age. Anyone from 25 through 64 years of age with certain chronic medical conditions or a weakened immune system. As more vaccine becomes available, these groups should also be vaccinated: Healthy 25 through 64 year olds Adults 65 years and older Children through 9 years of age should get two doses of vaccine, about a month apart. Older children and adults need only one dose. The U.S. Centers for Disease Control and Prevention, 10/2/09

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SEASONAL FLU VACCINATION Influenza vaccine is the best prevention for seasonal influenza. Inactivated viruses in the vaccine developed from three circulating strains (generally 2 Type A and 1 Type B strain) Therefore, seasonal “flu shot” only works for 3 influenza subtypes and will not work on pandemic strains (H1N1).

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Pakistan Vs Australia Series PANDEMIC FLU VACCINATION

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Frequent hand washing Covering coughs and sneezes Avoidance of crowded settings when possible advising ill persons to stay home (except to seek medical care) and minimize contact with others in household voluntary home quarantine of members of households with confirmed or probable swine influenza cases GENERAL PRECAUTIONS

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* 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

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Serious Public Health Impact Unusual or Unexpected International disease spread Interference with inter- national travel or trade **WHO Recommends intensifying and enhancing national surveillance systems for Influenza-like Illnesses and atypical pneumonia National Center for Disease Prevention and Control, DOH WHO Raise the Pandemic Alert level to 5-6 Influenza A (H1N1) is a Public Health Emergency of International Concern (PHEIC) ??

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Unusual combination of genetic material from pigs (of North America and Euroasia), birds & humans which have re-assorted??? Only fewer companies has the permission to produce vaccine??? Mortality is far less not only from previous Pandemics but also from yearly seasonal flu !!!!!!! Is it an attempt to control World population ??? Or just an experimentation ???? Influenza A (H1N1) is a Public Health Emergency of International Concern (PHEIC) ??

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alauddinsarwar@gmail.com

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