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SWINE FLU What is it? What can I do? An Indian perspective! Dr. T.R.Chandrashekar Director critical care Dr. N.K. RAGHURAM Fellow in CCM K.R HOSPITAL Bengaluru, India

What do we do? : 

What do we do? We have recorded 24 deaths We have no Medical guidelines of do’s and don'ts Young people are dying-is their a pattern Can we pick them early before they turn sick? Testing in few center’s-takes 4 days to get results Do we start Tamiflu in all suspected cases? Deterioration is occurring on 4th day and death on 7th or 8th day Where do we stand?


CHALLENGES WE FACE Recognition of disease Not to forget chikungunya & dengue Difficulty in Confirmation of disease Self protection Protection of people around us Notification To know more ; Are we facing the pandemic?

Scenario : 

Scenario Admitted suspected Patient (symptoms+ travel history) Sample sent for PCR Reported positive H1N1 What to do for patient relatives& hosp staff who are exposed Patient with hemodynamic compromise & respiratory difficulty Need for intubation-To proceed & then send sample for PCR What to do meanwhile Is it necessary to test all doctors & staff

Enigmatic questions : 

Enigmatic questions Should we close the hospital & fumigate? What to do for other patients next to the case Should we send all suspected cases to referral hospital

Subsequent challenges : 

Subsequent challenges Recognising in OPD- identify flu symptoms, travel history, clinical signs of hemodynamic derangement &pneumonia/ALI/ARDS Proper referral to institutions handling cases Isolation rooms, Use of masks Hand wash Ventilatory management

Influenza At A Glance : 

Influenza At A Glance Influenza, commonly called "the flu," is caused by viruses that infect the respiratory tract. Influenza viruses are divided into three types, designated A, B, and C.










VIRAL VARIANTS INFLUENZA A VIRUS Swine Human Avian H1N2 H1N1(pandemics) H5N1 H3N1 H3N2 (rare) H3N2




EARTH LIVING SPACE FOR ALL Epidemic: An increase in disease above what is normally expected Pandemic: A worldwide epidemic A pandemic begins when: there is person-to-person sustained transmission on multiple continents


HISTORY In the 20th century there have been three influenza pandemics in 1918, 1957 and 1968.

Slide 16: 

Emergency hospital, Camp Funston, Kansas 1918

WHO : 

WHO April 24: H1N1 first disease outbreak notice. April 25: WHO Director General declares a formal “Public health emergency of international concern” April 27: “containment of the outbreak is not feasible” pandemic alert raised from phase 3 to phase 4. April 29: phase 4 to phase 5. June 11: phase 5 to phase 6.

Slide 18: 

The World Health Organization uses a six stage phase for alerting the general public to an outbreak Phase 1 – animal to animal transmission. Phase 2 – an animal influenza virus is capable of human infection. Phase 3 - small outbreaks among close populations but not through human to human contact.

Slide 19: 

Phase 4 - Human to human transmission Phase 5 - spread across two countries or more in one of the WHO regions (continents). Phase 6 – spread across two countries or more in one of the WHO regions plus spread to another WHO region.

Global pandemic : 

Global pandemic W.H.O. identifies the following six epidemiological sub-regions. - African Region - Eastern Mediterranean Region - European Region - Region of the Americas - South-East Asian Region - Western Pacific Region

Global pandemic : 

Global pandemic


EPIDEMIOLOGY Incubation period- 1-7 days Transmission PRIMARY CASE –direct contact with pigs SECONDARY CASES sneezing, coughing resp droplets body fluids(diarroeal stool) contact surfaces

Transmission : 


Slide 24: 

This virus is not transmitted from eating pork or pork products Contagiousness: 1 day onset of symptoms 7 days Children are contagious for longer periods. . Majority of pts were previously healthy. Clinical course mild in PCR negative influenza.

Slide 25: 

Majority of pts were previously healthy. Clinical course mild in PCR negative influenza. Pregnant women — Increased rates of spontaneous abortion and preterm birth Patients with swine flu were found to have increased incidence of cardiovascular & cerebrovascular events.

Can I get infected with this new H1N1 virus from eating or preparing pork? : 

Can I get infected with this new H1N1 virus from eating or preparing pork? No. H1N1 viruses are not spread by food. You cannot get this new HIN1 virus from eating pork or pork products. Eating properly handled and cooked pork products is safe.

Is there a risk from drinking water? : 

Is there a risk from drinking water? Recent studies have demonstrated that free chlorine levels typically used in drinking water treatment are adequate to inactivate highly pathogenic H5N1 avian influenza. It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination.

What kills influenza virus? : 

What kills influenza virus? Influenza virus is destroyed by heat (167-212°F [75-100°C]). In addition, several chemical germicides, including chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols

Risk factors : 

Risk factors COPD Immunocompromised state DM Pregnancy Cardiac disease Obesity


DEFINITIONS Influenza-like illness (ILI) is defined as fever (temperature of 100ºF [37.8ºC] or greater) with cough or sore throat in the absence of a known cause other than influenza

Case Definitions By CDC : 

Case Definitions By CDC A confirmed case acute febrile respiratory illness with laboratory-confirmed H1N1 influenza A virus detection by real-time reverse transcriptase (RT)-PCR or culture. A probable case acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by RT-PCR

Slide 32: 

A suspected case acute febrile respiratory illness who:       - Develops symptoms within seven days of close contact with a person who is a confirmed case of H1N1 influenza A virus infection or       - Develops symptoms within seven days of travel or resides in a community where there are one or more confirmed H1N1 influenza A cases

Close contacts : 

Close contacts Having cared for or lived with a person setting where there was a high likelihood of contact with respiratory droplets and/or bodily fluids Having had close contact (kissing, embracing, sharing eating or drinking utensils, physical examination, or any other contact likely to result in exposure to respiratory droplets)

Mexican data : 

Mexican data Influenza-like illness or respiratory symptoms developed in 22 of 190 health care workers These 22 workers received oseltamivir for 5 days and were sent home for 3 to 7 days. They had mild-to-moderate disease, and none required hospitalization nejm.org august 13, 2009

Preventive measures taken in Mexican hospitals : 

Preventive measures taken in Mexican hospitals After infection-control measures were strictly enforced — with patients confined and isolated in three hospital areas and N95 masks Separate respirators used in addition to goggles, gowns, and gloves, as well as liberal use of gel-alcohol hand sanitizer — no more health care workers had influenza-like illness, nejm.org august 13, 2009



contd : 



AGE SHIFTS IN MORTALITY Concept of “original antigenic sin,”by Francis - immune response is greatest to antigens to which first exposure occurred in childhood. Persons born before 1957 who were exposed in childhood to influenza A (H1N1) viruses might be better protected against this viral subtype than those who were first exposed to other influenza A subtypes, H2N2 and H3N2, at a later date .

Slide 39: 

During the early phase of this epidemic, the rapid identification of persons who are likely to have severe disease, as compared with those who are likely to have mild disease, can guide epidemic or pandemic response strategies.

Specimens : 

Specimens Nasopharyngeal swab, nasal swab, throat swab, combined oropharyngeal/ nasopharyngeal swab, or nasal aspirate Swabs with a synthetic tip (eg, polyester or Dacron) and an aluminum or plastic shaft should be used. Swabs with cotton tips and wooden shafts are not recommended. The collection vial in which the swab is placed should contain 1 to 3 mL of viral transport media.

Slide 41: 

Respiratory specimen should be collected within 4 to 5 days of illness. Specimens should be placed in viral transport media and placed on ice (4ºC) or refrigerated immediately for transportation to the laboratory




LAB TESTS Real time RT PCR-confirmatory culture is usually too slow to help guide clinical management. A negative viral culture does not exclude pandemic H1N1 influenza A infection. Rapid antigen tests — evaluation of patients suspected of having influenza, but results should be interpreted with caution the QuickVue Influenza A+B (Quidel) assay (sensitivity 51 percent specificity 99 percent)

Slide 44: 

Rapid influenza antigen tests & Direct or indirect immunofluorescent antibody testing (DFA or IFA) can distinguish between influenza A and B but negative test does not exclude infection.

Whom to test : 

Whom to test Testing for pandemic H1N1 influenza A should be considered in individuals with an acute febrile respiratory illness ( temperature of 100ºF or higher and recent onset of at least one of the following: rhinorrhea, nasal congestion, sore throat, or cough) or sepsis-like syndrome

Slide 46: 

Priority for testing should be given to : Those who require hospitalization and Those who are at high risk for severe complications No testing if illness is mild or the person resides in an area with confirmed cases Recommended test for suspected cases is real-time reverse transcriptase (RT)-PCR for influenza A, B, H1, and H3


CLINICAL FEATURES Vomiting or diarrhea (not typical for influenza but reported by recent cases of swine influenza infection)

Mexican data in MV patients : 

Mexican data in MV patients

Mexican data in MV patients : 

Mexican data in MV patients

Younger people at risk : 

Younger people at risk

10-50 yrs : 

10-50 yrs Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza Gerardo Chowell, Ph.D., Stefano M. Bertozzi, M.D., Ph.D., NEJM August 2009

Can we make a broad clinical check list : 

Can we make a broad clinical check list History of contact Younger age, sudden onset Fever, cough, breathlessness Leucopenia, raised LDH and CPK Should all such patients be isolated and given Tamiflu?

Other Manifestations: : 

Other Manifestations: Tachycardia Tachypnoea Low O2 sat. Hypotension Cyanosis Acute myocarditis Cardiopulmonary arrest

Children Clinical Presentation : 

Children Clinical Presentation Infants may present with fever and lethargy, and may not have cough or other respiratory symptoms. Apnea, tachypnea, dyspnea, cyanosis, dehydration, altered mental status, and extreme irritability.

Children Emergency Warning Signs : 

Children Emergency Warning Signs Fast breathing or trouble breathing Bluish or gray skin color Not drinking enough fluids Severe or persistent vomiting Not waking up or not interacting Being so irritable that the child does not want to be held Flu-like symptoms improve but then return with fever and worse cough

In adults, emergency warning signs : 

In adults, emergency warning signs Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting Flu-like symptoms improve but then return with fever and worse cough

Why Complications In young (Cytokine storm) : 

Why Complications In young (Cytokine storm) It is the systemic expression of a healthy and vigorous immune system resulting in the release of more than 150 inflammatory mediators . Both pro and anti-inflammatory cytokines are elevated in serum with lethal interplay of these cytokines is referred to as a "Cytokine Storm". The primary contributors to the cytokine storm are TNF-a and IL-6 . It is inappropriate (exaggerated) immune response that is caused by rapidly proliferating and highly activated T-cells or natural killer (NK) cells. Bird flu patients die from acute respiratory distress syndrome (ARDS) caused by the cytokine storm, and not directly from the virus


SYMPTOMS OF THE CYTOKINE STORM The final result, of cytokine storm (SIRS) or sepsis is multiple organ dysfunction syndrome (MODS) hypotension ( Myocarditis) tachycardia ARDS acute respiratory failure Ischemia, or insufficient tissue perfusion uncontrollable haemorrhage Multisystem organ failure

Cytokine Storm Treatment : 

Cytokine Storm Treatment Steroids ACE Inhibitors & ARBs Anti-CD28 Monoclonal Antibody TNF-alpha blockers


HISTOPATHOLOGY LUNG FINDINGS . The specimen shows necrosis of bronchiolar walls (top arrow), a neutrophilic infiltrate (middle arrow), and diffuse alveolar damage with prominent hyaline membranes (bottom arrow).

Diagnosis : 

Diagnosis Laboratory Tests Viral culture Presence of virus confirmed by ELISA( 4 fold rise ) RT-PCR Rapid antigen tests  (distinguish between influenza A and B


LABORATORY FINDINGS CBC- leucocytosis/leucopenia lymphopenia Elevated CPK, LDH Elevated UREA,CREATININE Elevated AST,ALT CHEST RADIOGRAPH-bilateral patchy pneumonia.

H1 N1 Pneumonia : 

H1 N1 Pneumonia


COMPLICATIONS Similar to those of seasonal influenza Exacerbation of underlying chronic medical conditions Upper respiratory tract disease (sinusitis, otitis media, croup) Lower respiratory tract disease (pneumonia, bronchiolitis, status asthmaticus)

Slide 65: 

Cardiac (myocarditis, pericarditis) Neurologic (Acute and post-infectious encephalopathy, encephalitis, febrile seizures, status epilepticus) Toxic shock syndrome Secondary bacterial pneumonia with or without sepsis


DD H1N1 PNEUMONIA OTHER VIRAL pneumonia influenza A,B adenovirus RSV para influenza rhinovirus humanmetapneumonia Legionella,Chlamydia,Mycoplasma


TREATMENT Only neuraminidase inhibitors ORALTamiflu (oseltamivir) and Relenza( zanamivir) are approved to cure the viral infection. H1N1 is resistant to Amantadine Rimantadine Antiviral drugs can be given to treat those who become severely ill with influenza.

Tamiflu (Oseltamivir ) : 

Tamiflu (Oseltamivir ) Block the active site of the influenza viral enzyme neuraminidase This effect results in viral aggregation at the host cell surface and reduces the number of viruses released from the infected cell

Tamiflu : 


Tamiflu : 


Tamiflu(contd) : 

Tamiflu(contd) If one dose missed? take as soon as you remember unless it is within 2 hours of next dose do not take two doses at a time . With other medications? minimal drug interaction no intranasal flu vaccine(Flu Mist) within 2weeks before or 48 after taking tamiflu

Tamiflu (Contd) : 

Tamiflu (Contd) With kidney disease Flu treatment :one 75mg dose OD for 5 days Flu prevention:one 75 mg dose alternate day or 30 mg dose OD . Storage: capsules- <25 degree C liquid - 2 to 8 degree C

Zanamivir ( Relenza) : 

Zanamivir ( Relenza) It is not recommended for people with underlying respiratory disease such as asthma or chronic obstructive pulmonary disease or lactose intolerance Treatment of 7 year & older patients 10mg (2puffs)BID 5d Prophylaxis of 5 year & older patients 10mg OD 10d-28 days

Mild Cases : 

Mild Cases Supportive: Paracetamol, flds… *NO SALICYLATES IN CHILDREN/ YOUNG ADULTS: REYE'S SYNDROME Antivirals : *best within first 48 hours *Early administration in at-risk pts ie those with comorbidities/ pregnancy… control precautions: cough etiquette Hand hygiene & Natural ventilation

Hospitalized pts: : 

Hospitalized pts: Antivirals Pneumonia management like avian (antibiotics) Resp. Support: early detection Correction of hypoxia with supplemental O2 or mech. Vent as necessary

Supportive care : 

Supportive care When Mech. vent is indicated: low volume low pressure lung protective vent. Steroids: Avoid routine use, no benefit was reported . Higher doses associated with serious SE: evidence of increased viral replication in SARS and other resp. viral infections. Increased mortality in Avian

It is highly contagious! : 

It is highly contagious! Can we have separate wards ,ICU’s and staffing We require separate OPD and testing facilities for suspected cases Can we spare separate equipment Can we organise all this in a running hospital?

prevention : 


N95 Mask : 

N95 Mask

What should I do to keep from getting the flu? : 

What should I do to keep from getting the flu? First and most important: wash your hands Get plenty of sleep Drink plenty of fluids Try not to touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.

Avoid close contact : 

Avoid close contact Avoid close contact with people who are sick. When you are sick, keep your distance ( > 1 meter )from others to protect them from getting sick too. Aerosols spread the virus in any environment

Prevention : 

Prevention management of the outbreak such as closure of schools, advising avoidance of mass gatherings and distribution of antivirals Avoiding close contact Staying home from work, school Covering mouth and nose with a tissue or N95 mask (three layered) when coughing or sneezing. Change the mask every 6 to 8 hours Washing your hands

Is Negative Pressure Room Must ? : 

Is Negative Pressure Room Must ? Place patients in a single-patient room with the door kept closed & droplet and contact isolation

Is BIA ready? : 

Is BIA ready?

Why do we need vaccine : 

Why do we need vaccine

Dealing with the Deceased : 

Transport of deceased persons in a transport bag. Hand hygiene should be performed after completing transport. For deceased persons with confirmed, probable, or suspect novel influenza A (H1N1): limit contact with the body in health care settings to close family members Direct contact with the body is discouraged Necessary contact may occur as long as hands are washed immediately with soap and water. Dealing with the Deceased

Conclusion : 

Conclusion Be cautious but no need to panic Need for further guidelines beyond diagnosis & management. Judicious use of diagnostic tests Early suspecting and treating cytokine storm is very important Not to forget universal precautions


THANK YOU Department of critical care medicine

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