New Influenza A (H1N1)

1. New Influenza A (H1N1) Earlier called – Swine Flu India: 13th August 2009 Information source : WHO Websites

2. Influenza: A Viral infection • Acute respiratory infection caused by Influenza virus – Three types A, B and C • Currently viruses circulating in human population – Influenza A (H3N2), A (H1N1) and B Strains • All known pandemics (global outbreaks) were caused by Influenza A • Animal influenza viruses may affect humans in special circumstances – Bird Flu: A (H5N1)

3. Continues to evolve Two distinct surface antigens H – Total 16 (1 to 16) N – Total 9 (1 to 9) Antigen H (Haemagglutinin) initiates infection following attachment of virus to susceptible cells Antigen N (Neuraminidase) responsible for release of virus from the infected cell Antigenic changes less in B while C appears stable Influenza Virus

4. Major reservoir in wide variety of birds and animals including swine, horses, dogs, cats, domestic poultry Evidence is available that animal reservoirs provide new strains by recombination between influenza viruses of man, animals and birds Virus Reservoirs

5. Influenza in Past • 1918 – A (H1N1) • Spanish Flu : > 20 million deaths • 1957 – A (H2N2) • Asian Flu : > 2 million deaths • 1968 – A (H3N2) • Hong Kong Flu : > 2 million deaths • Antigenic shift only in H antigen • 2003 – Avian Influenza / Bird Flu A (H5N1) • First human case in 1997 • Human – to – Human transmission relatively inefficient and not sustained

6. Novel Influenza A (H1N1) 2009 Virus • New strain of A (H1N1) • Not previously detected in swine or humans • Unusual mix of genetic segments including of swine, avian and human influenza viruses • Originated from pigs and at some point of time transmitted to humans • Cases began to appear from 17th March’09 in Mexico with human – to – human transmission • No cases in swine population and no infections from pork. Pigs are responsible only for mutation of virus.

7. Global Scenario when 1 case in India

8. Pandemic Phases

9. Wash your hands. Get plenty of sleep. Be physically active. Manage your stress. Drink plenty of fluids. Eat nutritious food. Avoid touching your eyes, nose or mouth. Avoid close contact with people who are sick. Avoid crowding. Preventive Behaviors

10. CASE DEFINITION Suspected case : A person with acute febrile respiratory illness   (fever ≥ 38 0 C) with onset • within 7 days of close contact with a person who is a confirmed case of novel influenza A (H1N1) virus infection, or • within 7 days of travel to community where there are one or more confirmed novel influenza A(H1N1) cases, or • resides in a community where there are one or more confirmed novel influenza cases. • Probable case : A person with an acute febrile respiratory illness • who is positive for influenza A, but unsubtypable 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 immunofluorescence assay (IFA) plus meets criteria for a suspected case • individual 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.

11. Confirmed Case of A(H1N1) • A person with an acute febrile respiratory illness with laboratory confirmed novel influenza A (H1N1) virus infection at WHO approved laboratories by one or more of the following tests: • Real Time PCR • Viral culture • Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies

12. Clinical Features • Ranging from non-febrile, mild upper respiratory tract illness to severe or fatal pneumonia • The most common symptoms include cough, fever, sore throat, malaise and headache • Some cases have experienced gastrointestinal symptoms (nausea, vomiting and/or diarrhoea) • Secondary bacterial infections may occur • Rarely rhabdomyolysis with renal failure, myocarditis • Worsening of underlying conditions like asthma and cardiovascular disease

13. Confirmatory diagnostic tests of nasal or throat swab can be done by specialized Laboratories. Reverse transcriptase polymerase chain reaction (RTPCR) will provide the most timely and sensitive evidence of infection Clinical diagnosis based on the acute onset of fever and cough can be increasingly predictive as the prevalence of infections increase Specialized Labs in India Diagnosis

14. Treatment Considerations • Most cases of new influenza A (H1N1) virus infection have had uncomplicated illness of limited duration. • Hospitalization is being done more for isolation and for observation and treatment of seriously ill patients • Supportive care includes antipyretics, such as Paracetamol for fever or pain. • Fluid rehydration to be provided as needed. • Salicylates (such as aspirin) should not be used in children and young adults because of the risk of Reye’s syndrome.

15. Infection control at Individual level • Respiratory Hygiene / Cough Etiquette • Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing • Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use • Hand hygiene • Hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash after having contact with respiratory secretions and contaminated objects /materials • Use of mask • Three layered surgical mask • For cases and immediate family and social contacts.

16. USE OF MASK • Any person who is in close contact with someone who has influenza-like symptoms is at risk of being exposed to potentially infective respiratory droplets. • Correct use of mask • place mask carefully to cover mouth and nose and tie securely to minimise any gaps between the face and the mask • while in use, avoid touching the mask and whenever you touch a used mask (when removing or washing), clean hands by washing with soap and water or using an alcohol-based hand rub • replace masks with a new clean, dry mask as soon as they become damp/humid • do not re-use single-use masks. Discard single-use masks after each use and dispose of them immediately upon removing. • Using a mask incorrectly however, may actually increase the risk of transmission, rather than reduce it. • If masks are to be used, this measure should be combined with • other general measures to help prevent the human-to-human transmission of influenza, • Training on the correct use of masks and • consideration of cultural and personal values.

17. Seriously Ill Patients • Signs of clinical deterioration • Chest pain • Difficulty in breathing • Coughing up coloured sputum • Altered level of consciousness and confusion • Immediate hospitalization required • Take into account other associated illness such as immune-compromising conditions, pre-existing chronic lung or cardiovascular disease, diabetes etc.

18. Oxygen therapy • In seriously ill patients oxygen saturation should be monitored by pulse oximetry and supplemental oxygen should be provided to correct hypoxemia. • The WHO recommendations for pneumonia is to maintain oxygen saturations above 90%; however, this threshold may be increased to 92–95% in some clinical situations, for example during pregnancy. • Populations at altitude will require different thresholds for diagnosing hypoxemia but will also have increased susceptibility to severe hypoxemia in the presence of pneumonia or ARDS.

19. Use of Antibiotics • Antibiotic chemoprophylaxis should not be used. • Antibiotics should be used only if secondary bacterial infections occur. The microbiological test results, wherever possible, should be used to guide antibiotic usage. • Several patients in Mexico have developed ventilator-associated pneumonia or hospital-acquired pneumonia caused by typical nosocomial pathogens.

20. ANTIVIRAL THERAPY • The new influenza A (H1N1) viruses currently susceptible to the neuraminidase inhibitors (NAIs) Oseltamivir and Zanamivir • Early administration of NAIs • may reduce severity and duration of illness • may also contribute to prevent progression to severe disease and death • Antiviral therapy will be beneficial specially for • pregnant patients, in whom administration of antiviral medicines should be carefully evaluated taking possible benefits and risks into consideration • patients with progressing lower respiratory disease or pneumonia • patients with underlying medical conditions. • If used, antiviral treatment should ideally be started early, but it may also be used at any stage of active disease when ongoing viral replication is anticipated as it is possible that the virus may replicate for a prolonged period of time in some patients as a result of the lack of pre-existing protective immunity

21. Age Group : Above 1 Year Dosage by Weight < 15kg 30 mg BD for 5 days 15 - 23kg 45 mg BD for 5 days 24 - < 40kg 60 mg BD for 5 days > 40kg 75 mg BD for 5 days For infants: < 3 months 12 mg BD for 5 days 3-5 months 20 mg BD for 5 days 6-11 months 25 mg BD for 5 days It is also available as syrup (12mg per ml ) If needed dose & duration can be modified as per clinical condition. Oseltamivir : Drug of choice • Capsules of 75 mg each • Store at room temperature • Generally well tolerated • Side effects occur especially at higher dosages • Only 6 resistant cases reported so far of which 5 responded to Zanamivir

23. Vaccine for new virus • Making vaccine ready to immunize people generally takes five to six months after first identification (April 2009) of the virus. • The very first doses of influenza A (H1N1) vaccine usable to immunize people, from one or more manufacturers, are expected as early as September 2009. • Most of these vaccines will be produced using chicken eggs, while a few manufacturers are using cell culture technology for vaccine production. • When vaccine first becomes available, it is anticipated that the demand will be greater than the supply. This gap will narrow as more vaccine becomes available over time. • Three vaccine manufacturers in India have shown interest • Serum Institute of India • Panacea Biotech • Bharat Biotech

24. Mild Illness ! Why one should worry ? • A new virus will affect large number of people as there is no immunity. • Need to identify seriously ill patients early to prevent deaths. • Virus has a high potential for mutation and may develop into more lethal strain over the time. • Surveillance and preparedness needed. • Social and Economic impacts to occur.

25. Expected Social Impact • Rapid global spread of illness • All are susceptible as none are immune • Illness occurring in waves of variable period • Work absenteeism • Travel restrictions • Event cancellations • Institutional closures • Vaccine not likely to be available in first wave

26. Travel during pandemic • It is safe to travel. • Limiting travel and imposing travel restrictions would have very little effect on stopping the virus from spreading, but would be highly disruptive to the community. • Although identifying signs and symptoms of influenza in travellers can help track the path of the outbreak, it will not reduce the spread of influenza, as the virus can be transmitted from person to person before the onset of symptoms. • WHO do not believe that entry and exit screenings would work to reduce the spread of this disease. • People who are ill should delay travel plans. • Returning travellers who become ill should contact their health care provider. • Travellers can protect themselves and others by following simple prevention practices that apply while travelling and in daily life.

27. School Closure : CDC Guidelines • Schools should try to stay open. Decision-making up to local communities. • Weight the very real harm of school closings against the potential harms of increased flu spread. • Advice students • To stay home when sick, longer if needed. • Wash hands. Observe cough / sneeze etiquette • Separate ill students and staff. • Routine cleaning to be maintained. • Closure of the school to be considered • If there is excessive absenteeism among students or staff. • If large numbers of kids are ill and being sent home during the day. • If the school isn't able to keep sick people out. • If the flu becomes severe. • For other reasons that "decrease the ability to maintain school functioning.“ • Closed schools should also cancel school-related mass gatherings. • School should remain closed for five to seven calendar days and then consider whether to reopen.

30. Conclusion • Rapid spread as no immunity. • Mild illness in majority. • Remain cautious and prepared. Not to panic. • Flexibility in implementing control strategy. • Focus on evidence based practical and acceptable measures. • Vaccine will be soon available. • Watch for further mutation in virus is needed.