Flu swine

Status in Odisha
• According to the Govt. of Odisha H&FW Department, death
toll has risen to 13 in the state, as of 18th August.
• The total number of patients in the state has crossed 200 mark.
• In 2009, when H1N1 was first discovered in humans, experts
regarded it as pandemic.
• Since then, the virus has been known as a regular human flu
virus. At present, it continues to spread during the flu season
like other strains of flu.
• Apart from Orissa, other states such as Gujarat, Maharashtra,
Karnataka, Rajasthan and Telangana also reported H1N1.
Therefore, the health experts here are pointing out that the
floating population or migrant workers could be the sources of
H1N1.
• Swine Flu may be amosnomer.

The Virus
Single stranded RNA Virus (Orthomixovirus)

Influenza
What is it
• A contagious viral
respiratory infection
• typically, although not
always, causes fever (100-
102° F for several days),
• severe aches and pains,
exhaustion, coughing, sore
throat, congestion and a
runny nose.
• much more intense than cold
• Sudden onset of symptoms
What it is not
• A cold – Cold symptoms
are similar, such as:
• congestion, runny nose
and cough,
• but rarely include fever
(very mild, if so),
• aches and pains;
• almost never exhaustion

Spread of Virus
• Transmitted primarily by droplets or
respiratory secretions of infected persons. Also,
spread through air-borne transmission.
• An annual global attack rate estimated at 5 –
10% in adults and 20 – 30% in children.
• Secondary bacterial pneumonia is a frequent
complication of influenza infection, particularly
in elderly people and individuals with certain
chronic diseases, resulting in a significant level
of morbidity and mortality. An influenza
pandemic is a rare but recurrent event.

Droplet from Cough
• It can travel from 3 to 6 feet distance. Larger droplets
are ≥ 5 micron and smaller are ≤ 5 micron. In a study,
it was found out that smaller droplets contain large
number of virus.

Spread of Virus
• Direct Contact: oral and nasal secretion
• Indirect Contact: Door knobs, door handles, beds, chairs,
Washroom surfaces, Cups, dishes, Medical instruments
• Large Droplet Contact: (droplets produced by breathing,
talking, sneezing, coughing) include various cells types (e.g.
epithelial cells and cells of the immune system), physiological
electrolytes contained in mucous and saliva (e.g. Na+, K+, Cl-),
as well as the viruses. Typically travels 1-2 meter.
• Air-borne transmission: droplet nuclei (residue from
evaporated droplets) or dust particles containing
microorganisms can remain suspended in air for long periods
of time.
• Aerosol generation procedures: Ventilation (BiPAP and CPAP),
endotracheal intubation, airway suction, tracheostomy, chest
physiotherapy, nebulizer treatment and bronchoscopy

Survival of Virus H1N1
The Pandemic H1N1 influenza virus can survive
on different items for different periods.
• Hard and nonporous surfaces: 24-48 Hours.
• On plastic & stainless steel: it is recoverable up
to 24 hours and can be transferred to hands up
to 24 hours.
• On cloth, paper and tissue: the virus is
recoverable for 8-12 hours and transferable to
hands up to 15 minutes.
The virus can survive at humidity of 35-40% and
a temperature of 280C (820 F).

Incubation and Infective Period
• The typical incubation period for influenza is
1—4 days (average: 2 days).
• Most healthy adults may be able to infect
others beginning 1 day before symptoms
develop and up to 5 to 7 days after becoming
sick.
• Some people, especially young children and
people with weakened immune systems, might
be able to infect others for an even longer time.

The Virus
• Human: Influenza (Flu)
• Birds: Avian Flu
• Pigs: Swine Flu
• Horse: Horse Flu etc.
Types of Influenza Virus
• Type A (warm-blooded animals (birds and
mammals) can affect human
• Type B (Predominantly Human)
• Type C (Predominantly Human) Milder
• Type D (cattle; not known to infect human)

The Virus
•Type A, B, C are
classified
according to the
core proteins.
• Can be further
classified
according to the
surface proteins
1. HA (18 types)
(Hemagglutinin)
and
2. NA (11 types)
(Neuraminidase)

Influenza
Seasonal
• Happens annually and
usually peaks between
December and February
• Usually some immunity
from previous exposures and
influenza vaccination
• Certain people are at high-
risk for serious complications
(infants, elderly, pregnant
women, extreme obesity and
persons with certain chronic
medical conditions)
Pandemic
• Emergence of a novel virus
to which all are susceptible
• New virus is able to replicate
and cause disease in humans
• New virus is transmitted
efficiently from human-to-
human.
• Community level outbreaks
in at least one other country
in a different WHO region.

Evolution of Flu Virus: H1N1-2009

Past Pandemics
• 1918 pandemic:- Associated with Influenza A (H1N1).
• 1957: “Asian Flu”: Influenza A (H2N2); 1-2 million deaths
worldwide.
• 1968: “Hong Kong Flu”: Associated with Influenza A (H3N2)
and 700,000 deaths were reported worldwide.
• 2004-2009: Outbreak of H5N1 was reported in 2003 and has
affected poultry in 50 countries and caused human infections in
15 countries with 262 deaths.
• 2009: Novel Influenza A (H1N1) Virus of swine origin and
contained a unique combination of gene segments that has not
been identified in the past. The molecular analysis of the novel
H1N1 virus has re-assorted segments from American swine,
Eurasian swine, Avian and Human virus. It has not been
previously detected in pigs or humans.

Symptoms
• Fever,
• Cough, Sore throat,
• Malaise, and headache; Exhaustion
• vomiting and diarrhoea.
• Breathlessness/Cyanosis
• Altered mental status, and extreme irritability
Complications
• Pneumonia (primary viral or secondary
bactererial)
• Encephalopathy/Encephalitis

Risk Groups
• Children younger than 5 years old;
• Adults 65 years of age and older
• Chronic pulmonary condition (including asthma),
• Cardiovascular (except hypertension), renal, hepatic,
hematological (including sickle cell disease),
neurologic, neuromuscular, or metabolic disorders
(including diabetes mellitus);
• Immuno-suppression, including that caused by
medications or by HIV;
• Pregnant women;
• Residents of nursing homes/Hospitals
• Obesity.

A suspected case
• acute febrile respiratory illness (reported or
documented fever, and one of the following: cough,
sore throat, shortness of breath, difficulty in breathing
or chest pains) with onset:
1. within 7 days of close contact with a person who is a
probable or confirmed case of the new influenza
virus infection, or
2. within 7 days of travel to a community
internationally where there has been one or more
confirmed Pandemic influenza, or
3. resides in a community where there are one or more
confirmed new influenza cases.

A Probable case
• An individual with an influenza test that is
positive for influenza A (Novel), but is un-
subtypable by reagents used to detect seasonal
influenza virus infection;
OR
• An individual with a clinically compatible
illness or who died of an unexplained acute
respiratory illness, considered to be
epidemiologically linked to a probable or
confirmed case.

A Confirmed case
• An individual with laboratory confirmed new
influenza A (Novel) virus infection by one
or more of the following:
• Real-time RT-PCR,
• Viral culture
• Four-fold rise in new influenza A (Novel)
virus-specific neutralizing antibodies.

Treatment/Chemoprophylaxis
• Treatment with oseltamivir or zanamivir is
recommended for all people with suspected or
confirmed influenza who require
hospitalization.
• Should be initiated as soon as possible after the
onset of symptoms. Benefits are maximal when
treatment is started within 48 hours of illness.
• Recommended duration of treatment is five
days. However, hospitalized patients with
severe infection might require longer
treatment.

Broad Guidelines For Schools And Educational
Institutions
• Avoid any large gathering of students. If, unavoidable, at least
2 meter distance be maintained.
• All class teachers should begin their class with active screening
of each student
• Students, teachers and other employees working in
schools/educational institutions are advised to stay at home, if
they develop flu like symptoms. They should consult the
medical doctor and take treatment as advised including home
isolation and drugs for treatment.
• They should continue to stay at home for at least 7 days, if they
are advised by the doctor to take Oseltamivir treatment and
they should observe home isolation. If, symptoms deteriorate, it
should be reported to health authorities, immediately.

Institutions
• School authorities should not insist on production of
medical certificate from such absentees.
• All are advised to wash their hands frequently with
soap and water.
• Should observe strict cough/sneeze etiquette i.e. using
tissue while sneezing and coughing. The tissue paper
so used should be kept in a separate plastic bag, so
that it can be disposed of safely.
• Regular cleaning of the area with cleaner they
ordinarily use so that all the droplets and shredding
from any unnoticed mildly infected
students/employees are taken care of.

Institutions
• Closure of schools has not been recommended by
Centre for Disease Control, Atlanta, USA.
• School authority should monitor the health status of
students as well as the other ancillary staff in the
hostel on regular basis
• Authorized local medical authority should be called
for examination of suspected cases in the hostel
• School should discourage excursion of the students to
the affected countries.
• All the schools should display and circulate “DO’S
AND DON’TS” for the infection and frequently asked
questions (FAQ) to the students.

Collection & Transportation of Samples for
Testing
To establish the diagnosis of pandemic influenza A
• an upper respiratory sample (nasopharyngeal swab, nasal
swab, throat swab, combined oropharyngeal/ nasopharyngeal
swab, or nasal aspirate) should be collected.
• In intubated patients, an endotracheal aspirate should also be
obtained.
• Specimens should be placed in viral transport media and
placed on ice (4ºC) or refrigerated immediately for
transportation to the laboratory.
• Once the samples arrive in the laboratory, they should be
stored either in a refrigerator at 4ºC or in a -70ºC freezer.
• If a -70ºC freezer is not available, they should be kept
refrigerated, preferably for <1 week.

Guidance for Hospital Treatment
• Standard Precautions to be followed at all patient care areas:
hand hygiene, Gloves and use of personal protective
equipment (PPE) to avoid direct contact with patient’s blood,
body fluids, secretions and non-intact skin, prevention of
needle stick/sharp injury and cleaning and disinfection of the
environment and equipment.
• Droplet precautions to be followed when caring for patients
with influenza A (masks, respirators and eye shield) in isolation
facilities.
• Airborne and Contact Precautions should complement
Standard Precautions while managing case of Pandemic
influenza in critical care facilities.
• Hospitals should follow the hospital waste management
protocols as per the hospital waste management rules.
• Dead body should be handled using full cover of PPE.

Guidance for Hospital Treatment
• Hospitals to have advanced life support ambulance with
designated paramedic and driver.
• The ambulance staff should follow standard precautions while
handling the patient and airborne precautions, if, aerosol
generating procedures are done.
• Triple layer surgical masks should be available and worn
during transport.
• During transport, optimize the vehicle’s ventilation to increase
the volume of air exchange (e.g. opening the windows). When
possible, use vehicles that have separate driver and patient
compartments.
• Disinfect the ambulance after shifting patient.
• Notify the receiving facility as soon as possible.

Disposal of used masks
Used mask should be considered as potentially infected
medical waste:
• In the hospital setting it should be disposed off in the
identified infectious waste disposal bag/container.
• In community settings where medical waste
management protocol cannot be practiced, it may be
disposed off either by burning or deep burial.
• During home care, patients and contacts using triple
layer mask should first disinfect used mask with
ordinary bleach solution or sodium hypochlorite
solution and/or quaternary ammonium household
disinfectant and then dispose off either by burning or
deep burial.

Face Masks
Triple Layer Mask
Prevents larger particle
N 95 Mask
Filters 0.3 micron particle size
95% filtering

Categorization & Treatment
Category- A
Mild fever plus cough / sore throat with or
without body ache, headache, diarrhoea and
vomiting.
• Do not require Oseltamivir and symptomatic
treatment
• Monitored for their progress and reassessed at 24 to 48
hours by the doctor.
• No testing of the patient for H1N1 is required.
• Confine themselves at home and avoid mixing up
with public and high risk membersin the family.

Category-B
(i) In addition to symptoms of Category-A, if the patient
has high grade fever and severe sore throat, he/she
may require home isolation and Oseltamivir; OR
(ii) shall be treated with Oseltamivir, if, one or more of
the following high risk conditions exist
• Children less than 5 years old;
• Pregnant women;
• Persons aged 65 years or older;
• Patients with lung diseases, heart disease, liver disease, kidney
disease, blood disorders, diabetes, neurological disorders,
cancer and HIV/AIDS;
• Patients on long term cortisone therapy

Category-C
Category-A and B patients with one or more of
the following:
• Breathlessness, chest pain, drowsiness, fall in
blood pressure, sputum mixed with blood,
bluish discolouration of nails
• Irritability among small children, refusal to
accept feed
• Worsening of underlying chronic conditions
Require testing, immediate hospitalization and
treatment including Oseltamivir

Home Care Treatment
• Check with their health care provider about any special care they might
need and Whether to take antiviral medications
• Keep away from others as much as possible
• Do not go to work or school while ill. Stay home for at least 24 hours after
fever subsides, except to seek medical care or for other necessities. (Fever
should subside without the use of a fever-reducing medicine).
• Get plenty of rest.
• Drink clear fluids (such as water, broth, sports drinks, electrolyte beverages
for infants) to prevent dehydration.
• Cover coughs and sneezes. Clean hands with soap and water or an alcohol-
based hand rub
• Wear a facemask – if available and tolerable –when sharing common spaces
with other household members. This is especially important if other
household members are at high risk for complications from influenza.
• Be watchful for emergency warning signs that might indicate need to seek
medical attention

Vaccination
The seasonal flu vaccine is not expected to
protect against pandemic Influenza
However, seasonal vaccines mostly contains the
viral particle of last pandemic
• It has been recommended that certain groups of the population
receive the 2009 H1N1 vaccine.
• It includes pregnant women, people who live with or care for
children younger than 6 months of age, healthcare and
emergency medical services personnel, persons between the
ages of 6 months and 24 years old, and people ages of 25
through 64 years of age who are at higher risk for 2009 H1N1
because of chronic health disorders or compromised immune
systems.

Types of Vaccines
Vaccines for the seasonal flu, specific for a year are developed as
per the recommendation of the WHO
• Egg-based flu vaccine
• Cell-based flu vaccine
• Recombinant flu vaccine
It can be
• An inactivated (killed) preparation that is injected
• An live attenuated influenza vaccine; normally delivered
nasally
• Trivalent or Quadrivalent
Inactivated vaccines can be
• Whole virus vaccines
• Split virus vaccines
• Subunit vaccines

Inactivated vaccines
• Whole Virus: a suspension of whole virus particles
inactivated by a suitable method
• Split Virus: a suspension treated such that the virus
particles have been partially or completely disrupted
by physicochemical means
• Sub-unit: a suspension treated so that the preparation
consists predominantly of haemagglutinin and
neuraminidase antigens
• Vaccine with adjuvant: a suspension of whole virus
particles, split or subunit components formulated with
an adjuvant.

Recommended Vaccine Virus for 2017-18
Recommended composition of influenza virus vaccines
for use in the 2017-2018 northern hemisphere
influenza season
Trivalent
• an A/Michigan/45/2015(H1N1)pdm09-like virus
• an A/Hong Kong/4801/2014 (H3N2)-like virus and
• a B/Brisbane/60/2008 like virus.
quadrivalent vaccines containing two influenza B
viruses contain the
• above three viruses and a B/Phuket/3073/2013-like
virus

Illness Resembling Influenza
1. Influenza-like illness (ILI) is defined (according to
WHO criteria) as:
• Sudden onset of a fever over 38°C, AND
• Cough or sore throat, AND
• An absence of other diagnoses.
2. Severe Acute Respiratory Infections (SARI): For
persons ≥ 5 years the definition for SARI is adapted
from the WHO protocol on rapid response:
• Sudden onset of fever over 38°C, AND
• Cough or sore throat, AND
• Shortness of breath or difficulty in breathing, AND
• Requiring hospital admission

Vaccination Contraindicated
• If you have any severe, life-threatening
allergies.
Most, but not all, types of flu vaccine contain a
small amount of egg protein.
• If you ever had Guillain-Barré Syndrome
(also called GBS).
• If you are not feeling well.
It is usually okay to get flu vaccine when you
have a mild illness, but you might be asked to
come back when you feel better

Risks of Minor Vaccine Reactions
• soreness, redness, or swelling where the shot was
given
• hoarseness
• sore, red or itchy eyes
• cough
• fever
• aches
• headache
• itching
• fatigue

Risks of Serious Vaccine Reaction
• There may be a small increased risk of Guillain-
Barré Syndrome (GBS) after inactivated flu
vaccine. This risk has been estimated at 1 or 2
additional cases per million people vaccinated.
This is much lower than the risk of severe
complications from flu, which can be prevented
by flu vaccine.
• Young children who get the flu shot along with
pneumococcal vaccine (PCV13) and/or DTaP
vaccine at the same time might be slightly more
likely to have a seizure caused by fever.

Information related to Odisha
• The Regional Medical Research Centre
(RMRC), Bhubaneswar has been
recommended for testing of throat swabs
for H1N1 free of cost.
• Joint director public health Bikash patnaik
is I/C of control of Swine Flu

Popular Brands in India
• Agripal Influenza Vaccine (A&B), H1N1 Vaccine
(Swine Flu) Chiron Panacea (Panacea Biotec Ltd)
• Fiuarix Influenza Vaccine (A&B), H1N1 Vaccine
(Swine Flu) Glaxo Smithkline Pharmaceuticals Ltd.
• Influgen Influenza Vaccine (A&B), H1N1 Vaccine
(Swine Flu) Lupin Laboratories Ltd.
• Influvac Influenza Vaccine (A&B), H1N1 Vaccine
(Swine Flu) Solvay Pharma India Pvt Ltd
• Nasovac Influenza Vaccine (A&B), H1N1 Vaccine
(Swine Flu) Serum Institute of India Ltd.
• Vaxigrip Influenza Vaccine (A&B), H1N1 Vaccine
(Swine Flu) Sanofi Pasteur

Dosages
• Children: 6 months through 35 months of age - The
first time last season with only one dose, should
receive two 0.25 mL doses: one on day 1 followed by
another approximately 4 weeks later.
• 36 months through 8 years of age- The first time last
season with only one dose, should receive two 0.5 mL
doses: one on day 1 followed by another
approximately 4 weeks later.
• 9 years of age and older should receive a single 0.5 mL
intramuscular dose.1
• Adults-It should be administered as a single 0.5 mL
intramuscular injection.

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