H1 N1 (SWINE) INFLUENZA

1. H1 N1 (SWINE) INFLUENZA RBS Leumit Medical Group Dr Micha Halperin MBBS, MPH, FRACGP

3. INTRODUCTION • Influenza pandemics are caused by influenza viruses that have adapted to human beings. • Influenza virus can affect human, pigs, poultry, and horses.

4. LATEST INFLUENZA PANDEMICS

5. SWINE INFLUENZA • Swine influenza is a respiratory disease of pigs caused by type A influenza virus that regularly causes influenza outbreaks. • Illness was first recognised in 1930. • Current pandemic of influenza related to the spread of human cases of swine flu.

6. AGENT • Recent Swine influenza is being caused by Influenza type A H1N1 virus. • Like all influenza viruses, swine flu virus also changes constantly due to reassortment of genes and new novel strain can emerge for which human being have no immunity.

7. HOST • Swine influenza do not normally infect human. Sporadic human infection can occur. • Most commonly these cases occur in persons having direct exposure to pigs.

8. Transmission • The transmission is by droplet infection and fomites (infected surfaces) • Infected flu droplets can travel 1 meter with sneezing and coughing • Disease spread quickly in crowded places • Cold and dry weather enables the virus to survive longer outside the body • Virus is not transmitted by food

9. INCUBATION PERIOD 1-7 days. 1-4 days (most likely)

10. COMMUNICABILITY • From 1 day before to 7 days after the onset of symptoms. If illness persist for more than 7 days, chances of communicability may persist till resolution of illness. • Children may spread the virus for a longer period (14 days).

11. CLINICAL FEATURES • Fever • Not everyone with flu will have a fever • Upper respiratory symptoms such as cough and sore throat, running nose. • Headache, body aches and pain, lethargy, reduced appetite, diarrhea and vomiting

12. CLINICAL FEATURES • Fever • Not everyone with flu will have a fever • Upper respiratory symptoms such as cough and sore throat, running nose. • Headache, body aches and pain, lethargy, reduced appetite, diarrhea and vomiting

13. CLINICAL FEATURES • Fever • Not everyone with flu will have a fever • Upper respiratory symptoms such as cough and sore throat, running nose. • Headache, body aches and pain, lethargy, reduced appetite, diarrhea and vomiting

14. What to do if you get the flu? • Most people with seasonal flu or 2009 H1N1 flu have mild illness (hope this continues to be the case) • Most people can be managed at home without seeing a doctor or receiving antiviral medications.

15. What to do if you get the flu? • Rest • Drink plenty of fluids • Analgesia (acamol) or cold/flu meds (dexamol cold) • Stay away from others to avoid spread • Consider antiviral medication (tamiflu) if in high risk group (best to commence within first 48 hours)

16. High Risk Group • Elderly (65+) and very young patients (<5yrs) • Residents of institutions for elderly/disabled • Pregnancy • Chronic heart, lung, kidney, metabolic or immunodeficiency diseases • Diseases requiring long term aspirin treatment • Neuromuscular disorders, seizure disorders or cognitive dysfunction that may compromise the handling of respiratory secretions

17. Emergency signs • In adults: • Difficult breathing or shortness of breath • Pain of pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Healthy people can develop severe illness • See a doctor at the clinic or emergency room quickly

18. Emergency signs • In adults: • Difficult breathing or shortness of breath • Pain of pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Healthy people can develop severe illness • See a doctor at the clinic or emergency room quickly

19. Emergency signs • In children: • Fast or difficult breathing • Bluish skin color • Not drinking enough fluids • Not waking up or playing/interacting normally • Irritability • Ongoing fever or cough beyond 5 days • Fever with rash • See a doctor at the clinic or emergency room quickly.

20. INVESTIGATIONS Confirmation of influenza A(H1N1) infection is through: • Real time RT PCR or • Isolation of the virus in culture or • Four-fold rise in virus specific neutralizing antibodies.

21. Vaccination • Seasonal flu vaccination is very important! • Don’t ignore risks of seasons flu • Available October • H1N1 flu vaccination • Vaccine available mid November • Immunization for people with high-risk conditions is highly recommended

22. TREATMENT: Guiding principles • Early implementation of infection control precautions to minimize spread of disease. • Prompt treatment (within 48 hours) to prevent severe illness and death. • Early identification and follow up of persons at risk.

23. Preventing spread

24. Preventing spread • Frequent hand washing • Covering mouth /nose for coughs and sneezes • Avoidance of crowded settings when possible • Sick persons to stay home (except to seek medical care) and minimize contact with others in household • Voluntary home quarantine of members of households with probable swine influenza cases

25. Face Masks • Not clear how effective face masks are at protecting against influenza • Not recommended in most situations • EXCEPTIONS: • High risk person caring for someone who has flu-like illness • High risk people in crowded setting where H1N1 is present • People with flu-like illness to use a mask to prevent spreading their illness to others

26. HAND HYGIENE • Hands should be washed frequently with soap and water / alcohol based hand rubs/ antiseptic hand wash and thoroughly dried preferably using disposable tissue or towel. After contact with respiratory secretions or such contaminated surfaces. Any activity that involves hand to face contact such as eating, normal grooming or smoking.

28. 1. Wash palms and fingers. 2. Wash back of hands. STEPS OF HAND WASHING

29. 3. Wash fingers and knuckles. 4. Wash thumbs. STEPS OF HAND WASHING

30. 5. Wash fingertips. 6. Wash wrists. STEPS OF HAND WASHING

31. TREATMENT • Oseltamivir (Tamiflu) is the recommended drug both for prophylaxis and treatment. • Dosing: • For weight <15kg 30 mg x2/day for 5 days • 15-23kg 45 mg x2/day for 5 days • 24-<40kg 60 mg x2/day for 5 days • >40kg 75 mg x2/day for 5 days • For infants: • < 3 months 12 mg x2/day for 5 days • 3-5 months 20 mg x2/day for 5 days • 6-11 months 25 mg x2/day for 5 days • Available as syrup (12mg per ml )

32. ADVERSE REACTION • Oseltamivir is generally well tolerated, gastrointestinal side effects (transient nausea, vomiting) may increase with increasing doses, particularly above 300 mg/day. • Occasionally it may cause bronchitis, insomnia and vertigo. Less commonly angina, pseudo membranous colitis and peritonsillar abscess have also been reported. • There have been rare reports of anaphylaxis and skin rashes.

33. INFECTION CONTROL MEASURES AT HOME • Get plenty of sleep, manage your stress, drink plenty of fluids and eat nutritious food. • People who are sick and their household members should wash their 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 face mask or handkerchief. • Sweeping and dusting to be done with wet cloth. Small amount of disinfectant may be mixed in water. • If any family member develop any symptoms: stay at home, rest, drink fluids, try analgesia and report to clinic if difficultly breathing, vomiting or in high risk category (very young, pregnant or other health problems) • Precautions to continue during the period of infectivity

34. CHEMO PROPHYLAXIS • Not currently recommended, but consider for: • Close contacts of confirmed cases. • Close contacts include household /social contacts, family members, workplace or school contacts, fellow travelers • All health care personnel coming in contact with probable or confirmed cases

35. PROPHYLAXIS • Tamiflu is the drug of choice. • Prophylaxis should be provided till 10 days after last exposure (maximum period of 6 weeks) • For weight <15kg 30 mg x1/day • 15-23kg 45 mg x1/day • 24-<40kg 60 mg x1/day • >40kg 75 mg x1/day • For infants: • < 3 months not recommended unless judged by MD to be critical • 3-5 months 20 mg x1/day • 6-11 months 25 mg x1/day

36. For more information: • Call the clinic: (02) 992 2727 • On-call night physician: 1700 507 507 • Dr Efraim Rosenbaum: 054 280 2823 Websites • www.flu.gov (English – CDC, US) • www.flublog.co.il (Hebrew – Leumit, Israel) • www.RBSMedical.com (English / Hebrew)