H1 N1 (SWINE) H1 N1 (SWINE) INFLUENZAINFLUENZARBS LeumitRBS Leumit

Medical GroupMedical Group

Dr Micha HalperinDr Micha HalperinMBBS, MPH, FRACGPMBBS, MPH, FRACGP

INTRODUCTIONINTRODUCTION

• Influenza pandemics are caused Influenza pandemics are caused by influenza viruses that have by influenza viruses that have adapted to human beings.adapted to human beings.

• Influenza virus can affect Influenza virus can affect human, pigs, poultry, and human, pigs, poultry, and horses.horses.

LATEST INFLUENZA PANDEMICSLATEST INFLUENZA PANDEMICSName of Name of pandemicpandemic

DateDate DeathsDeaths Subtype Subtype involvedinvolved

Asiatic Asiatic (Russian) (Russian) FluFlu

1889–1889–9090

1 1 millionmillion

possibly possibly H2N2 H2N2

Spanish FluSpanish Flu 1918–1918–2020

50 50 millionmillion

H1N1H1N1

Asian FluAsian Flu 1957–1957–5858

1.5 to 2 1.5 to 2 millionmillion

H2N2H2N2

Hong Kong Hong Kong FluFlu

1968–1968–6969

1 1 millionmillion

H3N2H3N2

Swine FluSwine Flu As of As of Nov Nov 8/098/09

6,2506,250 novel H1N1novel H1N1

SWINE INFLUENZASWINE INFLUENZA

• Swine influenza is a respiratory disease of Swine influenza is a respiratory disease of pigspigs caused by type A influenza virus that caused by type A influenza virus that regularly causes influenza outbreaks.regularly causes influenza outbreaks.

• Illness was first recognised in 1930.Illness was first recognised in 1930.

• Current pandemic of influenza related to Current pandemic of influenza related to the spread of human cases of swine flu.the spread of human cases of swine flu.

AGENTAGENT

• Recent Swine influenza is being caused by Recent Swine influenza is being caused by Influenza type A H1N1 virus. Influenza type A H1N1 virus.

• Like all influenza viruses, swine flu virus Like all influenza viruses, swine flu virus also changes constantly due to also changes constantly due to reassortment of genes and new novel strain reassortment of genes and new novel strain can emerge for which human being have no can emerge for which human being have no immunity.immunity.

HOSTHOST

• Swine influenza do not normally infect Swine influenza do not normally infect human. Sporadic human infection can human. Sporadic human infection can occur. occur.

• Most commonly these cases occur in Most commonly these cases occur in persons having direct exposure to persons having direct exposure to pigs.pigs.

TransmissionTransmission

• The transmission is by droplet infection The transmission is by droplet infection and fomites (infected surfaces)and fomites (infected surfaces)

• Infected flu droplets can travel 1 meter Infected flu droplets can travel 1 meter with sneezing and coughingwith sneezing and coughing

• Disease spread quickly in crowded Disease spread quickly in crowded placesplaces

• Cold and dry weather enables the virus Cold and dry weather enables the virus to survive longer outside the bodyto survive longer outside the body

• Virus is not transmitted by foodVirus is not transmitted by food

INCUBATION INCUBATION PERIODPERIOD

1-7 days.1-7 days.

1-4 days (most 1-4 days (most likely)likely)

COMMUNICABILITYCOMMUNICABILITY

• From 1 day From 1 day beforebefore to 7 days after the onset to 7 days after the onset of symptoms. If illness persist for more than of symptoms. If illness persist for more than 7 days, chances of communicability may 7 days, chances of communicability may persist till resolution of illness.persist till resolution of illness.

• Children may spread the virus for a longer Children may spread the virus for a longer period (14 days).period (14 days).

CLINICAL FEATURESCLINICAL FEATURES•FeverFever

– Not everyone with flu willNot everyone with flu willhave a feverhave a fever

• Upper respiratory symptoms such as Upper respiratory symptoms such as cough and sore throat, running nose. cough and sore throat, running nose.

• Headache, body aches and pain, lethargy, Headache, body aches and pain, lethargy, reduced appetite, diarrhea and vomitingreduced appetite, diarrhea and vomiting

CLINICAL FEATURESCLINICAL FEATURES•FeverFever

– Not everyone with flu willNot everyone with flu willhave a feverhave a fever

• Upper respiratory symptoms such as Upper respiratory symptoms such as cough and sore throat, running nose. cough and sore throat, running nose.

• Headache, body aches and pain, lethargy, Headache, body aches and pain, lethargy, reduced appetite, diarrhea and vomitingreduced appetite, diarrhea and vomiting

CLINICAL FEATURESCLINICAL FEATURES•FeverFever

– Not everyone with flu willNot everyone with flu willhave a feverhave a fever

• Upper respiratory symptoms such as Upper respiratory symptoms such as cough and sore throat, running nose. cough and sore throat, running nose.

• Headache, body aches and pain, lethargy, Headache, body aches and pain, lethargy, reduced appetite, diarrhea and vomitingreduced appetite, diarrhea and vomiting

What to do if you get the flu?What to do if you get the flu?

• Most people with seasonal flu or 2009 Most people with seasonal flu or 2009 H1N1 flu have mild illness (H1N1 flu have mild illness (hope this hope this continues to be the casecontinues to be the case))

• Most people can be managed at home Most people can be managed at home without seeing a doctor or receiving without seeing a doctor or receiving antiviral medicationsantiviral medications..

What to do if you get the flu?What to do if you get the flu?

• RestRest

• Drink plenty of fluidsDrink plenty of fluids

• Analgesia (acamol) or cold/flu meds Analgesia (acamol) or cold/flu meds (dexamol cold)(dexamol cold)

• Stay away from others to avoid spreadStay away from others to avoid spread

• Consider antiviral medication (tamiflu) if Consider antiviral medication (tamiflu) if in in high riskhigh risk group (best to commence group (best to commence within first 48 hours) within first 48 hours)

High Risk GroupHigh Risk Group• Elderly (65+) and very young patients (<5yrs)Elderly (65+) and very young patients (<5yrs)• Residents of institutions for elderly/disabledResidents of institutions for elderly/disabled• PregnancyPregnancy• Chronic heart, lung, kidney, metabolic or Chronic heart, lung, kidney, metabolic or

immunodeficiency diseasesimmunodeficiency diseases• Diseases requiring long term aspirin treatmentDiseases requiring long term aspirin treatment• Neuromuscular disorders, seizure disorders or Neuromuscular disorders, seizure disorders or

cognitive dysfunction that may compromise the cognitive dysfunction that may compromise the handling of respiratory secretionshandling of respiratory secretions

Emergency signsEmergency signs

• In adults:In adults:– Difficult breathing or shortness of breathDifficult breathing or shortness of breath– Pain of pressure in the chest or abdomenPain of pressure in the chest or abdomen– Sudden dizzinessSudden dizziness– ConfusionConfusion– Severe or persistent vomitingSevere or persistent vomiting

• Healthy people can develop Healthy people can develop severe illnesssevere illness

• See a doctor at the clinic or emergency room See a doctor at the clinic or emergency room quicklyquickly

Emergency signsEmergency signs

• In adults:In adults:– Difficult breathing or shortness of breathDifficult breathing or shortness of breath– Pain of pressure in the chest or abdomenPain of pressure in the chest or abdomen– Sudden dizzinessSudden dizziness– ConfusionConfusion– Severe or persistent vomitingSevere or persistent vomiting

• Healthy people can develop Healthy people can develop severe illnesssevere illness

• See a doctor at the clinic or emergency room See a doctor at the clinic or emergency room quicklyquickly

Emergency signsEmergency signs• In children:In children:

– Fast or difficult breathingFast or difficult breathing– Bluish skin colorBluish skin color– Not drinking enough fluidsNot drinking enough fluids– Not waking up or playing/interacting normallyNot waking up or playing/interacting normally– IrritabilityIrritability– Ongoing fever or cough beyond 5 daysOngoing fever or cough beyond 5 days– Fever with rashFever with rash

• See a doctor at the clinic or emergency room See a doctor at the clinic or emergency room quickly. quickly.

INVESTIGATIONSINVESTIGATIONS

Confirmation of influenza A(H1N1) infection is Confirmation of influenza A(H1N1) infection is through:through:

• Real time RT PCR orReal time RT PCR or

• Isolation of the virus in culture or Isolation of the virus in culture or

• Four-fold rise in virus specific neutralizing Four-fold rise in virus specific neutralizing antibodies.antibodies.

VaccinationVaccination

• Seasonal flu vaccination is very Seasonal flu vaccination is very important!important!– Don’t ignore risks of seasons fluDon’t ignore risks of seasons flu– Available OctoberAvailable October

• H1N1 flu vaccinationH1N1 flu vaccination– Vaccine available mid NovemberVaccine available mid November– Immunization for people with high-risk Immunization for people with high-risk

conditions is highly recommendedconditions is highly recommended

TREATMENT: Guiding TREATMENT: Guiding principlesprinciples

• Early implementation of infection control Early implementation of infection control precautions to minimize spread of precautions to minimize spread of disease.disease.

• Prompt treatment (within 48 hours) to Prompt treatment (within 48 hours) to prevent severe illness and death.prevent severe illness and death.

• Early identification and follow up of Early identification and follow up of persons at risk.persons at risk.

Preventing spreadPreventing spread

Preventing spreadPreventing spread• Frequent hand washingFrequent hand washing

• Covering mouth /nose for coughs and sneezesCovering mouth /nose for coughs and sneezes

• Avoidance of crowded settings when possibleAvoidance of crowded settings when possible

• Sick persons to stay home (except to seek medical Sick persons to stay home (except to seek medical care) and minimize contact with others in householdcare) and minimize contact with others in household

• Voluntary home quarantine of members of Voluntary home quarantine of members of households with probable swine influenza caseshouseholds with probable swine influenza cases

Face MasksFace Masks• Not clear how effective face masks are Not clear how effective face masks are

at protecting against influenzaat protecting against influenza• Not recommended in most situations Not recommended in most situations • EXCEPTIONS:EXCEPTIONS:

– High risk person caring for someone who has High risk person caring for someone who has flu-like illnessflu-like illness

– High risk people in crowded setting where High risk people in crowded setting where H1N1 is presentH1N1 is present

– People with flu-like illness to use a mask to People with flu-like illness to use a mask to prevent spreading their illness to othersprevent spreading their illness to others

HAND HYGIENEHAND HYGIENE

• Hands should be washed Hands should be washed frequentlyfrequently with soap with soap and water / alcohol based hand rubs/ antiseptic and water / alcohol based hand rubs/ antiseptic hand wash and thoroughly dried preferably using hand wash and thoroughly dried preferably using disposable tissue or towel.disposable tissue or towel.

After contact with respiratory secretions or such After contact with respiratory secretions or such contaminated surfaces.contaminated surfaces.

Any activity that involves hand to face contact Any activity that involves hand to face contact such as eating, normal grooming or smoking.such as eating, normal grooming or smoking.

STEPS OF HAND WASHINGSTEPS OF HAND WASHING1. Wash palms and 1. Wash palms and

fingers.fingers. 2. Wash back of 2. Wash back of

hands.hands.

STEPS OF HAND WASHINGSTEPS OF HAND WASHING3. Wash fingers 3. Wash fingers

and knuckles.and knuckles. 4. 4. Wash thumbsWash thumbs. .

STEPS OF HAND WASHINGSTEPS OF HAND WASHING5. Wash fingertips.5. Wash fingertips. • 6. Wash wrists.6. Wash wrists.

TREATMENTTREATMENT• Oseltamivir (Tamiflu)Oseltamivir (Tamiflu) is the recommended drug both is the recommended drug both

for prophylaxis and treatment.for prophylaxis and treatment.

• DosingDosing::• For weight <15kg 30 mg x2/day for 5 daysFor weight <15kg 30 mg x2/day for 5 days• 15-23kg 45 mg x2/day for 5 days15-23kg 45 mg x2/day for 5 days• 24-<40kg 60 mg x2/day for 5 days24-<40kg 60 mg x2/day for 5 days• >40kg 75 mg x2/day for 5 days>40kg 75 mg x2/day for 5 days• For infants:For infants:• < 3 months< 3 months 12 mg x2/day for 5 days12 mg x2/day for 5 days• 3-5 months3-5 months 20 mg x2/day for 5 days20 mg x2/day for 5 days• 6-11 months6-11 months 25 mg x2/day for 5 days25 mg x2/day for 5 days

• Available as syrup Available as syrup (12mg per ml )(12mg per ml )

ADVERSE REACTIONADVERSE REACTION• Oseltamivir is generally well tolerated, Oseltamivir is generally well tolerated,

gastrointestinal side effects (transient nausea, gastrointestinal side effects (transient nausea, vomiting) may increase with increasing doses, vomiting) may increase with increasing doses, particularly above 300 mg/day. particularly above 300 mg/day.

• Occasionally it may cause bronchitis, insomnia Occasionally it may cause bronchitis, insomnia and vertigo. Less commonly angina, pseudo and vertigo. Less commonly angina, pseudo membranous colitis and peritonsillar abscess membranous colitis and peritonsillar abscess have also been reported.have also been reported.

• There have been rare reports of anaphylaxis There have been rare reports of anaphylaxis and skin rashes.and skin rashes.

INFECTION CONTROL MEASURES AT INFECTION CONTROL MEASURES AT HOMEHOME

• Get plenty of sleep, manage your stress, drink plenty of fluids and eat Get plenty of sleep, manage your stress, drink plenty of fluids and eat nutritious food.nutritious food.

• People who are sick and their household members should wash their People who are sick and their household members should wash their hands with soap and water frequently; consider alcohol based hand gel.hands with soap and water frequently; consider alcohol based hand gel.

• When the patient is within 6 feet of other family member, he can wear a When the patient is within 6 feet of other family member, he can wear a face mask or handkerchief.face mask or handkerchief.

• Sweeping and dusting to be done with wet cloth. Small amount of Sweeping and dusting to be done with wet cloth. Small amount of disinfectant may be mixed in water.disinfectant may be mixed in water.

• If any family member develop any symptoms: stay at home, rest, drink If any family member develop any symptoms: stay at home, rest, drink fluids, try analgesia and report to clinic if difficultly breathing, vomiting or fluids, try analgesia and report to clinic if difficultly breathing, vomiting or in high risk category (very young, pregnant or other health problems)in high risk category (very young, pregnant or other health problems)

• Precautions to continue during the period of infectivityPrecautions to continue during the period of infectivity

CHEMO PROPHYLAXIS CHEMO PROPHYLAXIS • Not currently recommendedNot currently recommended, but consider , but consider

for:for:

• Close contacts of confirmed cases. Close contacts of confirmed cases. – Close contacts include household /social Close contacts include household /social

contacts, family members, workplace or school contacts, family members, workplace or school contacts, fellow travelerscontacts, fellow travelers

• All health care personnel coming in contact All health care personnel coming in contact with probable or confirmed cases with probable or confirmed cases

PROPHYLAXISPROPHYLAXIS• Tamiflu is the drug of choice.Tamiflu is the drug of choice.• Prophylaxis should be provided till 10 days after last Prophylaxis should be provided till 10 days after last

exposure (maximum period of 6 weeks) exposure (maximum period of 6 weeks)

• For weight <15kg 30 mg x1/dayFor weight <15kg 30 mg x1/day• 15-23kg 45 mg x1/day 15-23kg 45 mg x1/day • 24-<40kg 60 mg x1/day24-<40kg 60 mg x1/day• >40kg 75 mg x1/day>40kg 75 mg x1/day

• For infants:For infants:• < 3 months< 3 months not recommended unless judged by MD to be criticalnot recommended unless judged by MD to be critical

• 3-5 months3-5 months 20 mg x1/day20 mg x1/day• 6-11 months6-11 months 25 mg x1/day25 mg x1/day

For more information:For more information:• Call the clinic: (02) 992 2727Call the clinic: (02) 992 2727• On-call night physician: 1700 507 507On-call night physician: 1700 507 507• Dr Efraim Rosenbaum: 054 280 2823Dr Efraim Rosenbaum: 054 280 2823

WebsitesWebsites• www.flu.govwww.flu.gov (English – CDC, US) (English – CDC, US)• www.flublog.co.ilwww.flublog.co.il (Hebrew – Leumit, (Hebrew – Leumit,

Israel)Israel)• www.RBSMedical.comwww.RBSMedical.com (English / Hebrew) (English / Hebrew)