About the 2015 Indian Seasonal flu epidemic

1. SEASONAL INFLUENZA
DR. URVASHI
PG RESIDENT
DEPARTMENT OF COMMUNITY MEDICINE
DAYANAND MEDICAL COLLEGE & HOSPITAL,
LUDHIANA

2. 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

3. 50 to 100 million total
deaths
Spanish flu hospital, 1918
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4. 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.

6. 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.

7. CASUALITIES
 2,035 dead (as of 30 March 2015)
 33,761 infected (as of 30 March 2015)

8. 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

9. 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

10. DMC LUDHIANA
 No. of cases in DMC = 71
 No. of deaths =11
Month Cases Deaths
Jan 09
Feb 35
March 27
Total 71 11

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)
11

12. World Health Organization
(11th June 2009)
Upgraded the phasing of pandemic influenza from Phase 5 to Phase 6
“A public health emergency” of international concern
12

13. H1N1: SEGMENTED AND ENVELOPED , SPHERICAL
RNA VIRUS

14. 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

15. 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

16. IMAGES OF THE VIRUS
4/7/2015 16

17. 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

18. North american
swine influenza.
North american avian
influenza.
North american human
influenza.
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19. 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

20. 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.
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21. 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

22. DISEASE TRANSMISSION
Mainly airborne:
Droplet nuclei = 1,00,000 to 10,00,000 Virions per
droplet.
Through direct contact.
Transmission from objects possible.
22

23. 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

24. 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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24

25. 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
25

26. TRANSMISSION TO HUMAN
Direct Transmission
 Pigs to Human
e.g. people at pigs farm or at a fairs
 Person - Person
 Human to Pigs
26
26

27. INDIRECT TRANSMISSION
Human to Human:
 respiratory secretions
 contaminated inanimate
objects & then touching
nose or mouth
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28. 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 months
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29. 29

30. 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

31. 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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32. 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
32

33. 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.
33
33

34. 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.
34

35. 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

36. 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
samples 36

37. 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.

38.  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

39. 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
39

40. 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

41.  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

42.  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

43. 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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45. ROUTINE INFLUENZA DIAGNOSTICS &
ANALYSIS
Rapid test*
Directigen Flu
A+B
Binax Now A/B
Capilia Flu A,B
Lab assay
Direct IFA
RT-PCR
HI assay
Further analysis
Virus 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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46. LABORATORY DIAGNOSIS
 Nucleic acid amplification
 Virus isolation
 Antigen detection
 Serology

47. 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

48. LABORATORY DIAGNOSIS
 Nucleic acid amplification test (RT-PCR)
 Currently recommended test
 detects A H1N1 pdm09 strain
 very high sensitivity and specificity

49. INDICATIONS FOR RT-PCR
 Not needed for all patients
 Cough, cold
 Fever of 100-1010C
 Severe body ache, sore throat
 Complicated cases

50. 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

51. • 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

52. 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.

53. 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.

54. LOWER RESPIRATORY TRACT
 If the patient is intubated, take a tracheal aspirate
 Broncho alveolar lavage

55. 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.

56. STORING SPECIMENS
 Store at 4 °C before and during transportation
 Not in door, freezer and chiller tray
 After 48 hours:
 Store at -20 °C

57. 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 Health
and 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

58. DRUGS : TAMIFLU
 1 Antiflu Cipla Limited Capsule75mg
 2 Fluvir Hetero Healthcare Ltd.Capsule75mg
 The companies include
Ranbaxy,
Cipla,
Metco,
Hetero,
Strides and
Roche.

60. 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.

61. 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

62. SIDE EFFECTS OF TAMIFLU
 Nausea , vomiting
 Gastritis
 Insomnia
 Hyper somnia
 Malena
 Hypertension
 Suicidal tendencies

63. 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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64.  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

65. 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

66. CONTROL STRATEGY
• Surveillance and early detection
• Pharmaceutical intervention
• Non-Pharmaceutical intervention
• Clinical management and
• Risk communication.
66

67. COMPONENTS OF SURVEILLANCE
Collection of data
Compilation of data
Analysis of data
Interpretation
Action/Intervention
Feedback
67

68. CONTACT TRACING
Cases
Family contacts
Social contacts
- Workplace
- School
- Others
Symptomatic contacts
-Isolation
-Treatment
Asymptomatic
contacts
-Quarantine
-Health Monitoring
Travel contacts
- Train
-Flight

69. CONTACTS MANAGEMENT
All the contacts to be treated with tami-flu one
B.D. for 5 days even when they are not
symptomatic.
69

70. 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 indicates
70

71. 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
71

72. PPE
72
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73. • 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
73
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74. 74
74

75. PUT ON !
PERFORM HAND HYGIENE !
1.
2.
3.
4.
75

76. REMOVE !
4.
EXIT
1. 2.
3.
5.6.
7.
76

77.  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

78. CONTACT WITH PEOPLE FROM THE
AFFECTED AREAS SHOULD BE
CAUTIONARY
78

79. INFECTION CONTROLRECOMMENDATIONS:
COMMUNITY

81. Any Questions ?Thank You!