SEASONAL INFLUENZA

DR. URVASHI

PG RESIDENT

DEPARTMENT OF COMMUNITY MEDICINE

DAYANAND MEDICAL COLLEGE & HOSPITAL, LUDHIANA

PANDEMICS OF THE 20TH CENTURY

• 1918-19 “Spanish flu”. H1N1

• 1957 “Asian flu”. H2N2

• 1968 “Hong Kong flu”. H3N2

• 1976 “Swine flu” episode. H1N1

• 1977 “Russian flu”. H1N1

• 1997 “Bird flu” in HK. H5N1

• 1999 “Bird flu” in HK. H9N2

• 2003 “Bird flu” in Netherlands. H7N7

• 2004 “Bird flu” in SE Asia. H5N1

• 2009 “Swine flu” in Mexico. H1N1

.

2

50 to 100 million total

deaths

Spanish flu hospital, 1918

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PROBLEM STATEMENT- WORLD

WHO estimates (2009)

2 billion cases

2 - 7.4 million deaths

WHO predicts worse economic disruption than past

pandemics (absenteeism may go up to 70%.)

Globally, this year influenza activity remained elevated

in the northern hemisphere with influenza A(H3N2)

viruses predominating, although some countries in Asia,

Europe and North Africa reported high levels of activity

associated with influenza A(H1N1)pdm09 viruses.

2015 SWINE FLU EPIDEMIC IN INDIA

2015 Indian swine flu outbreak refers to a outbreak of

the 2009 pandemic H1N1 virus in India, which is still ongoing

as of March 2015. The states of Gujarat and Rajasthan are the

worst effected.

India had reported 937 cases and 218 deaths from swine flu in

the year 2014.

By mid-February 2015, the reported cases and deaths in 2015

had surpassed the previous numbers.

The total number of laboratory confirmed cases crossed

33000 mark with death of more than 2000 people.

CASUALITIES

2,035 dead (as of 30 March 2015)

33,761 infected (as of 30 March 2015)

REPORTED CASES BY STATES (MOHFW AS

ON MARCH 30,2015)

Sate Cases Deaths

Rajasthan 6,559 415

Gujarat 6,495 428

Delhi 4,137 12

Maharashtra 4000+ 394

Madhya Pradesh 2,185 299

Telangana 2,140+ 75

Tamil Nadu 320 14

Karnataka 2,733 82

Punjab 227 53

Andhra Pradesh 72 22

Uttar Pradesh 165 36

Chhatisgarh 17

Cases Deaths

Goa 7 1

Jammu and Kashmir 109 16

Himachal Pradesh 20

Kerala 25 12

Uttarakhand 11

Odisha 22 5

West Bengal 58 24

Assam 10 1

Manipur 5 2

Mizoram 4

Nagaland 1

Total 33,761 2,035

DMC LUDHIANA

No. of cases in DMC = 71

No. of deaths =11

Month Cases Deaths

Jan 09

Feb 35

March 27

Total 71 11

WHY ARE WE CONCERNED?

(H1N1 V/S SEASONAL INFLUENZA)

Short incubation period

Subclinical and mild cases

Short duration of immunity

H1N1 - High Transmission Risk (20-30%)

Seasonal Influenza ( 5-15%)

H1N1 - young & healthy adults (20-60 yrs)

Seasonal flu (≥65 years)

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World Health Organization

(11th June 2009)

Upgraded the phasing of pandemic influenza from Phase 5 to Phase 6

“A public health emergency” of international concern12

H1N1: SEGMENTED AND ENVELOPED , SPHERICAL

RNA VIRUS

TAXONOMY

FAMILY Orthomyxoviridae

GENUS Influenza virus

TYPES Type A Type B Type C

SUB TYPES

Sero types

(based on

hemagglutinin

(H) and the

neuraminidase

(N)

17 H and 10 N

H 1-17

N 1-10

The subtypes based

on the combination of

H and N proteins

:H1N1, H1N2, H2N2,

H3N1, H3N2, H3N8,

H5N1, H5N2, H5N3,

H5N8, H5N9, H7N1,

H7N2, H7N3, H9N2,

H10N7

Infect multiple

species; Human,

Avian, Swine, equine

etc.

No subtypes

Infect humans

No subtypes

Infect human and

pigs

TYPE A TYPE B TYPE C

GENETIC

PLASTICITY

Undergoes mutation that can take place

within the genome (Antigenic drift) / or

re-assortment among the genetic

materials of subtypes (Antigenic Shift )

resulting in a new virus.

Antigenic Drift is responsible for new

seasonal strains that makes necessary

surveillance to detect these strains and

to prepare new seasonal influenza

vaccine (yearly basis)

Antigenic Shift may result in a new

virus easily transmissible from man to

man for which the population has no

immunity : Results in Pandemics

Antigenic

variations

infrequent

Antigenically

stable

PUBLIC

HEALTH

IMPORTANCE

Causes Pandemics Causes

Epidemics

Seasonal

Influenza

Causes mild

respiratory

disease

Does not Cause

epidemic

IMAGES OF THE VIRUS

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NEW VIRUS A NEW COMBINATION

QUADRUPLE RE-ASSORTMENT

Genes from four different flu viruses

North American swine influenza,

North American avian influenza,

North American Human influenza,

Euresian swine influenza

----an unusual mix of genetic sequences. 17

North american

swine influenza.

North american avian

influenza.

North american human

influenza.

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EPIDEMIOLOGY:

AGENT FACTORS

Reservoir of Infection:

Humans primary reservoir for human

infections.

Major reservoir – animals & birds (swine,

horses, dogs, cats, domestic poultry, water

birds, wild birds etc.)

Source of Infection:

Usually a case or sub-clinical case.19

HOST FACTORS

Age & Sex:

All ages, both sexes.

Attack rates lower among adults.

High Case Fatality Ratio (CFR) during epidemic

in high risk cases.

Human Immunity

No long lasting immunity.

Antibodies to ‘H’: neutralise the virus.

Antibodies to ‘N’: modify the infection.

Antibodies appear in 7 days after an attack;

reach maximum level in 2 weeks; drops to pre-

infection level in 8-12 months.20

ENVIRONMENTAL FACTORS

Seasonality :

Temperate zones: epidemics occur in winter.

Tropics: epidemics occur in rainy season.

Sporadic cases: any month.

Overcrowding :

Enhances transmission.

Higher attack rates in closed population groups.

(schools, institutions etc.)21

DISEASE TRANSMISSION

Mainly airborne:

Droplet nuclei = 1,00,000 to 10,00,000 Virions per

droplet.

Through direct contact.

Transmission from objects possible.

22

SURVIVAL OF INFLUENZA VIRUS

SURFACES AND EFFECT OF HUMIDITY & TEMPERATURE

Hard non-porous surfaces 24-48 hours.

Plastic, stainless steel

Recoverable for > 24 hours

Transferable to hands up to 24 hours

Cloth, paper & tissue

Recoverable for 8-12 hours

Transferable to hands 15 minutes

Viable on hands <5 minutes only at high viral titers

Potential for indirect contact transmission

*Humidity 35-40%, Temperature 28 C (82F)23

CHARACTERISTICS

Virus is destroyed by:

o heat 75-100 degrees Celsius.

o chemical germicides: chlorine, hydrogen

peroxide, detergents (soap), iodophors (iodine-

based antiseptics), and alcohols.

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TRANSMISSION

Novel influenza A (H1N1) spreads in the same way as

regular seasonal influenza viruses;

coughs and sneezes and

Fomites

Does not spread by eating pork

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TRANSMISSION TO HUMAN

Direct Transmission

Pigs to Human

e.g. people at pigs farm or at a fairs

Person - Person

Human to Pigs

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INDIRECT TRANSMISSION

Human to Human:

respiratory secretions

contaminated inanimate

objects & then touching

nose or mouth

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INFECTIOUS PERIOD

The duration of shedding with swine flu A (H1N1) virus is unknown.

Considered potentially contagious for up to 7 days following illness

onset.

Children, especially younger children, might be contagious for longer

periods.

The estimated incubation period is unknown and could range from 1-

7 days, and more likely 1-4 days.

Antibodies appear in 7 days after an attack; reach maximum level in

2 weeks; drops to pre-infection level in 8-12 months28

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SYMPTOMS INFLUENZA (H1N1) COLD

Onset Suddenly Slowly

Fever Characteristically high > 38oC Rare

Headache Prominent Rare

General aches & pains Usual, often severe Rare

Fatigue, weakness Can be prolonged for wks Usually mild

Extreme exhaustion Early and prominent Never

Stuffy nose Sometimes Common

Sneezing Sometimes Usual

Sore throat Sometimes Common

Chest discomfort, cough Common, can be severe Mild to

moderate,

hacking cough

Diarrhoea, vomiting Reported Not associated30

WATCH FOR EMERGENCY WARNING

SIGNS

In adults:

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.

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In children:

Fast breathing or trouble breathing

Bluish or gray skin color

Not drinking enough fluids

Severe or persistent vomiting

Not waking up or not interacting

Irritable, the child does not want to be held

Flu-like symptoms improve but then return

with fever and worse cough

WATCH FOR EMERGENCY WARNING SIGNS

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CASE DEFINITIONS :

INFLUENZA LIKE ILLNESS ( I L I)

Sudden onset of a fever over 38° C

AND

Cough or sore throat

AND

Absence of other differential diagnoses.

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PANDEMIC INFLUENZA A (H1N1)SUSPECTED HUMAN CASE

A person having acute febrile (fever ≥ 38oC) respiratory illness with:

onset within 7 days of close contact with a person who is a

confirmed case of novel influenza A (H1N1) virus infection, or

onset within 7 days of travel to a community where there are one

or more confirmed novel influenza

A (H1N1) cases, or

residence in a community where there are one or more

confirmed novel influenza A (H1N1) cases.

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PANDEMIC INFLUENZA A (H1N1)PROBABLE HUMAN CASE

A person with acute febrile (fever ≥ 38oC) respiratory illness meeting the

criteria for a suspected case:

who is positive for influenza A, but un-subtypable for H1 and H3 by

influenza RT-PCR or reagents used to detect seasonal influenza virus

infection, or

who is positive for influenza A by an influenza rapid test or an Influenza

Immuno-fluorescence Assay (IFA), or

with a clinically compatible illness who died of an unexplained acute

respiratory illness & who is considered to be epidemiologically linked

to a probable or confirmed case 35

PANDEMIC INFLUENZA A (H1N1)CONFIRMED HUMAN CASE

A person with acute febrile (fever ≥ 38oC) respiratory illness meeting

the criteria for a suspected or probable case with positive test result

for novel influenza A (H1N1) virus infection at WHO approved

laboratories by one or more of the following tests:

Real time RT-PCR

Viral culture

Four-fold rise in novel influenza A(H1N1) virus specific

neutralising antibodies between acute and convalescent serum

samples36

GRADING OF SEVERITY

CDC classifies :

MILD: fever with malaise, sore throat, myalgia, rhinorrhea, but NO

breathlessness/ worsening of underlying illness.

PROGRESSIVE ILLNESS:

Above symptoms plus evidence of:

-poor oxygenation (hypoxia, tachypnoea, laboured breathing)

-chest pain

-low blood pressure

-altered mental status

-worsening of underlying medical condition.

SEVERE ILLNESS/COMPLICATED:

- Lower respiratory tract involvement: hypoxia requiring Oxygen

supplementation / mechanical ventilation, abnormal chest X- ray

- CNS findings: encephalopathy

- Shock

- Invasive secondary bacterial infections

- Myocarditis/ rhabdomyolysis

Category of

patient

Symptoms Treatment Place of

treatment

Mild Who does not

demonstrate signs &

symptoms of

moderate category

Symptomatic

treatment No

Tamiflu

All hospitals

Moderate Fever,sore throat,

running nose, body

ache, vomiting, loose

motion

Osaltamavir,

Therapeutic

dose Advice

home corintine

Screening

Centers

Severe High grade fever,

sore throat, Sever

pharingities,

breathlessness,

associated illness

kidney, heart, lung

Osaltamavir,

Therapeutic

dose throat

swabs for

testing

Admission in

IIWS

CATEGORIZATION OF PATIENTS

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GUIDELINES BY MINISTRY OF HEALTH

AND FAMILY WELFARE FOR PANDEMIC

INFLUENZA A

Individuals seeking consultation for Flu Like Illness to be screened by government and private practitioners

Categorised as :

Category A:

Fever plus cough and/or sore throat

With/without malaise, bodyache/headache

No Indication for oseltamivir/throat swab

Treat symptomatically

Follow up after 24-48 hrs

Home isolation, avoid public contact

Category B:

In addition to above symptoms:

Severe sore throat/ pharyngitis

High grade fever

Underlying co morbid conditions like-

COPD/ Asthma/ IHD/ LIVER/ KIDNEY diseases

Pregnant females

Children with MILD illness

Elderly >65 yrs

Give oseltamivir

No tests required for H1N1

Home isolation avoid public contact

Category C:

Above symptoms plus:

-breathlessness

-shock

-cyanosis

-altered sensorium

Children with severe illness

Worsening of underlying conditions

DO throat swab for H1N1

Hospitalisation

Treat with oseltamivir

Broad spectrum antibiotics

Other supportive care/ ICU management

Category of

patient

Symptoms Treatment Place of

treatment

Mild Who does not

demonstrate signs &

symptoms of

moderate category

Symptomatic

treatment No

Tamiflu

All hospitals

Moderate Fever,sore throat,

running nose, body

ache, vomiting, loose

motion

Osaltamavir,

Therapeutic

dose

Advice home

isolation

Screening

Centers

Severe High grade fever, sore

throat, Sever

pharingities,

breathlessness,

associated illness

kidney, heart, lung

Osaltamavir,

Therapeutic

dose

Throat swabs

for testing

Admission in

ICU

CATEGORIZATION OF PATIENTS

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ROUTINE INFLUENZA DIAGNOSTICS &

ANALYSIS

Rapid test*Directigen Flu A+BBinax Now A/BCapilia Flu A,B

Lab assayDirect IFART-PCRHI assay

Further analysisVirus Culture Extensive HI Sequence HA & NA

Patient sample: throat swab,

aspirate (nasopharyngeal

/bronchoalveolar lavage)

Patient clinical details:

Influenza like illness,

temperature, cough malaise

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LABORATORY DIAGNOSIS

Nucleic acid amplification

Virus isolation

Antigen detection

Serology

LABORATORY DIAGNOSIS

Antigen detection –

Rapid test (30 mins)

low sensitivity (50-70%)

specificity depends on circulating strain

Not recommended for detecting the pandemic strain

• Serology- for epidemiological and research studies

LABORATORY DIAGNOSIS

Nucleic acid amplification test (RT-PCR)

Currently recommended test

detects A H1N1 pdm09 strain

very high sensitivity and specificity

INDICATIONS FOR RT-PCR

Not needed for all patients

Cough, cold

Fever of 100-1010C

Severe body ache, sore throat

Complicated cases

SPECIMEN COLLECTION

Viral Transport Kit

[VTM and Sterile nylon

flocked swab]

Tongue depressor

Personal protection

- Full sleeved gown

- N 95 respirator (NIOSH approved)

- Gloves

- Alcoholic handrub solution

• Highest yield

• open mouth wide

• Inform the patient that he / she should

try to resist gagging and closing the

mouth while the swab touches the

back of the throat near the tonsils

• Rub vigorously

• Break applicator stick and put in viral

transport medium

COLLECTION – THROAT

SWAB

NASAL / NASOPHARYNGEAL SWAB

Insert dry swab into nostril and back to

nasopharynx.

Leave in place for a few seconds.

Slowly remove swab while slightly

rotating it.

Use a different swab for the other nostril.

Put tip of swab into vial

containing VTM, breaking

applicator stick.

COLLECTION OF SWABS - PEDIATRIC

patient is < 1 year old Collect nasal swab from both

nostrils

patient is > 1 year old and

having predominant

symptoms of nasal

discharge

( running nose)

Collect nasal swab from both

the nostrils

patient is > 1 year old and

NO NASAL DISCHARGE

collect throat swab

(two swabs )

Both Nasal and Throat swabs can be collected into the same

VTM to increase the viral yield.

LOWER RESPIRATORY TRACT

If the patient is intubated, take a tracheal aspirate

Broncho alveolar lavage

TRANSPORT 1.

• Triple packaging system

• Self sealing plastic envelopes

• Ice and Ice box

• Requisition form 2.

Kasturba Hospital /

Haffkine Institute

[8.00 a.m – 4.00 p.m] 3.

STORING SPECIMENS

Store at 4 °C before and during transportation

Not in door, freezer and chiller tray

After 48 hours:

Store at -20 °C

IDSP NETWORK OF LABS

1 Sanjay Gandhi Post Graduate Institute, Lucknow ,U.P

2 Indira Gandhi Medical College, Shimla

3 Haffkines Institute, Mumbai

4 Institute of Preventive Medicine, Hyderabad

5 Kasturaba Medical College, Manipal

6 North Eastern Indira Gandhi Regional Institute of Healthand Medical Sciences, Shillong

7 NIMHANS, Bangalore

8 JIPMER, Puducherry

9 Central Research Institute, Kasauli

10 B.J. Medical College, Ahmedabad

11 National Centre of Disease Control, Delhi.

12 Post Graduate Institute of Medical Education & Research,Chandigarh

DRUGS : TAMIFLU

1 Antiflu Cipla Limited Capsule75mg

2 Fluvir Hetero Healthcare Ltd.Capsule75mg

The companies include

Ranbaxy,

Cipla,

Metco,

Hetero,

Strides and

Roche.

AVAILABILITY OF TAMIFLU

Of the total 8 lakh drug outlets in India, 2,500 are

licensed to stock Oseltamivir.

In Ludhiana, it is available at DMC Emergency

pharmacy & Gurmail Medicos opposite DMC @ Rs. 45

per tablet.

DOSING GUIDELINES

Agent, Group Treatment Chemoprophylaxis

Oseltamivir

Adults 75 mg capsule twice

per day for 7 days

75 mg capsule once

per day

Children (≥12 months) 60-150 mg divided in 2

doses acc to body

weight for 7 days

30-75 mg capsule acc

to body weight once

per day

2-3 mg/kg twice daily

for 5 days

Zanamivir

Adults Two 5 mg inhalations

twice per day for 5

days

Two 5 mg inhalations

one per day

Children Two 5 mg inhalations

twice per day for 5

days

Two 5 mg inhalations

one per day

SIDE EFFECTS OF TAMIFLU

Nausea , vomiting

Gastritis

Insomnia

Hyper somnia

Malena

Hypertension

Suicidal tendencies

VACCINES

1. Inactivated Vaccine ( Tradename : Vaxigrip)

Dose: 0.5 ml

Route: Intra Muscular

Schedule: Single dose

2. Live Attenuated Vaccine (Tradename : Nosovac)

Dose: 1 puff /nostril

Route: Nasal spray

Schedule: Single dose

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Manufacturer :Serum Institute of India Ltd.

NASOVAC INJECTION

H1N1 Vaccine (Swine Flu)-15 mcg

Influenza Vaccine (A&B)-30 mcg

Manufacturer :Sanofi Pasteur

VAXIGRIP INJECTION

0.5 ml H1N1 Vaccine (Swine Flu)-15 mcg

Influenza Vaccine (A&B)-30 mcg

Manufacturer :Chiron Panacea (Panacea Biotec Ltd)

AGRIPAL INJECTION

Influenza Vaccine (A&B)-30 mcg

H1N1 Vaccine (Swine Flu)-15 mcg

Manufacturer :Glaxo Smithkline Pharmaceuticals Ltd.

FIUARIX INJECTION

Influenza Vaccine (A&B)-30 mcg

H1N1 Vaccine (Swine Flu)-15 mcg

Manufacturer :Lupin Laboratories Ltd.

INFLUGEN INJECTION

Influenza Vaccine (A&B)-30 mcg

H1N1 Vaccine (Swine Flu)-15 mcg

VACCINATION

Annual vaccination (single dose) is recommended for age ≥ 6

months

Antibodies develop in two weeks

Trivalent vaccine (A-H1N1, A-H3N2 and 1 B)

Quadrivalent vaccine (A-H1N1, A-H3N2 and 2 B)

Vaxigrip- inactivated injectable vaccine

CONTROL STRATEGY

• Surveillance and early detection

• Pharmaceutical intervention

• Non-Pharmaceutical intervention

• Clinical management and

• Risk communication.

66

COMPONENTS OF SURVEILLANCE

Collection of data

Compilation of data

Analysis of data

Interpretation

Action/Intervention

Feedback67

CONTACT TRACING

Cases

Family contacts

Social contacts

- Workplace

- School

- Others

Symptomatic contacts

-Isolation

-Treatment

Asymptomatic contacts

-Quarantine

-Health Monitoring

Travel contacts

- Train

-Flight

CONTACTS MANAGEMENT

All the contacts to be treated with tami-flu one

B.D. for 5 days even when they are not

symptomatic.

69

ADVISORY FOR ASYMPTOMATIC CONTACTS:

Remain at home (home quarantine) for at least 7 days after

the last exposure with a case.

Initiate self-health monitoring (regular temperature charting,

twice a day) or respiratory symptoms (cough, sore throat,

running nose, difficulty in breathing etc.) for 7 days after the

last exposure to the case patient.

Active monitoring (e.g. daily visits or telephone calls) for 7

days. All the contacts may be treated with tami-flu one B.D.

for 5 days, if risk assessment indicates70

HIGH RISK PERSONNEL IN HEALTH CARE

SETTINGS

Medical personnel involved in sample collection

RRT while transporting suspect case in the ambulance

Health staff involved in managing a suspect case at the

health facility

Medical and nursing staff involved in clinical

examination at airport and quarantine centre

Full complement of PPE and N 95

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PPE

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• Facemasks labelled as surgical, dental, medical

procedure, isolation, or laser masks.

• Single disposable high filtration mask

recommended

N95 -respirator (certified by National Institute

for Occupational Safety and Health (NIOSH). --

in preventing inhalation of small particles

fit-testing”

MASKS

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PUT ON !

PERFORM HAND HYGIENE !

1.

2.

3.4.

75

REMOVE !

4.

EXIT

1. 2.

3.

5.6.

7.

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Drink fluids

Cover coughs and sneezes.

Clean hands with soap and water or

an alcohol-based hand sanitizer

Avoid close contact with others – do not go to work or

school while ill

Be watchful for emergency warning signs that might

indicate the need to seek medical attention

Do not give aspirin (acetylsalicylic acid) : Reye’s

syndrome.

PERSONAL PREVENTIVE MEASURES

77

CONTACT WITH PEOPLE FROM THE

AFFECTED AREAS SHOULD BE

CAUTIONARY

78

INFECTION CONTROL RECOMMENDATIONS : COMMUNITY

Any Questions ?Thank You!