Rtn Dr Niraj Shrestha,Rotary Club Swoyambhu
Kathmandu Model Hospital,Blue Cross Hospital
 Swine Influenza (swine flu) is a respiratory
disease of pigs caused by type A influenza
that regularly cause outbreaks of influenza
among pigs
 Most commonly, human cases of swine flu
happen in people who are around pigs
 Swine flu viruses do not normally infect
humans, however, human infections with
swine flu do occur, and cases of human-tohuman spread of swine flu viruses have
been documented
 The first cases of human infection with novel
H1N1 influenza virus were detected in April 2009
in San Diego and Imperial County, California and
in Guadalupe County, Texas.
 The virus has spread rapidly.
 The virus is widespread in the United States at
this time and has been detected internationally as
well.

In March and early April 2009, Mexico
experienced outbreaks of respiratory illness and
increased reports of patients with influenza-like
illness (ILI) in several areas of the country

April 12, the General Directorate of Epidemiology
(DGE) reported an outbreak of ILI in a small
community in the state of Veracruz to the Pan
American Health Organization (PAHO) in
accordance with International Health Regulations

April 17, a case of atypical pneumonia in Oaxaca
State prompted enhanced surveillance throughout
Mexico

April 23, several cases of severe respiratory illness
laboratory confirmed as influenza A(H1N1) virus
infection were communicated to the PAHO

Sequence analysis revealed that the patients were
infected with the same strain detected in 2 children
residing in California

Samples from the Mexico outbreak match swine
influenza isolates from patients in the United States
Source: CDC
the potential to be as serious as seasonal flu, if not more so,
especially given the fact that there currently is no vaccine
against this virus.
 new virus, most people will not have immunity to it, and
illness may be more severe and widespread as a result.
Swine flu is different from seasonal flu because:
 a new strain of the virus
Humans do not have an immunity from it
Immunizations received last fall or this winter
do not offer protection against the H1N1 swine
flu
• RNA, enveloped
• Viral family: Orthomyxoviridae
• Size:
80-200nm or .08 – 0.12 μm
(micron) in diameter
• Three types
• A, B, C
• Surface antigens
• H (haemaglutinin)
• N (neuraminidase)
Credit: L. Stammard, 1995
Haemagglutinin subtype
H1
H2
H3
H4
H5
H6
H7
H8
H9
H10
H11
H12
H13
H14
H15
H16
Neuraminidase subtype
N1
N2
N3
N4
N5
N6
N7
N8
N9
Timeline of Emergence
Influenza A Viruses in Humans
Reassorted Influenza virus
(Swine Flu)
1976 Swine Flu
Outbreak, Ft.
Dix
H1
Avian
Influenza
H9 H7
H5 H5
H1
H3
H2
H1
1918
Spanish
Influenza
H1N1
1957
Asian
Influenza
H2N2
1968
1977
Hong
Kong
Influenza
H3N2
Russian
Influenza
1997
2003
1998/9
2009
Definitions
General
 Epidemic – a located cluster of cases
 Pandemic – worldwide epidemic
 Antigenic drift
 Changes in proteins by genetic point mutation &
selection
 Ongoing and basis for change in vaccine each year
 Antigenic shift
 Changes in proteins through genetic reassortment
 Produces different viruses not covered by annual
vaccine
 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 28C (82F)
Source: Bean B, et al. JID 1982;146:47-51
Influenza
The Normal Burden of Disease
 Seasonal Influenza
 Globally: 250,000 to 500,000 deaths per year
 In the US (per year)
 ~35,000 deaths
 >200,000 Hospitalizations
 $37.5 billion in economic cost (influenza & pneumonia)
 >$10 billion in lost productivity
 Pandemic Influenza
 An ever present threat
 Through contact with infected pigs or
environments contaminated with
swine flu viruses
 Through contact with a person with
swine flu
 Human-to-human spread of swine flu
has been documented also and is
thought to occur in the same way as
seasonal flu, through coughing or
sneezing of infected people
Human Virus
Avian Virus
Avian/Human
Reassorted Virus
Swine Virus
Reassortment in Pigs

Virus described as a new subtype of
A/H1N1 not previously detected in swine
or humans

CDC determines that this virus is
contagious and is spreading from human
to human

The virus contains gene segments from
4 different influenza types:




North American swine
North American avian
North American human and
Eurasian swine

The WHO raises the alert level to Phase 6





WHO’s alert system was revised after Avian influenza began to spread in 2004 – Alert Level raised to Phase 3
In Late April 2009 WHO announced the emergence of a novel influenza A virus
April 27, 2009: Alert Level raised to Phase 4
April 29, 2009: Alert Level raised to Phase 5
June 11, 2008: Alert Level raised to Phase 6
Source: WHO
 Infectious period for a confirmed case of swine influenza A(H1N1)
virus infection is defined as 1 day prior to the case’s illness onset to 7
days after onset
 Close contact is defined as: within about 6 feet of an ill person who
is a confirmed or suspected case of swine influenza A(H1N1) virus
infection during the case’s infectious period
 Acute respiratory illness is defined as recent onset of at least two of
the following: rhinorrhea or nasal congestion, sore throat, cough (with
or without fever or feverishness)
 High-risk groups: A person who is at high-risk for complications of
swine influenza A(H1N1) virus infection is defined as the same for
seasonal influenza (see Reference)
Source: CDC
 May cause more serious symptoms in
individuals with chronic medical conditions
 Pneumonia, respiratory failure, and deaths
have been reported.
 in patients presenting with febrile respiratory illness
who
 Live or have traveled in areas where human cases of swine
influenza A(H1N1) have been identified or
 have been in contact with ill persons from these areas in the 7
days prior to their illness onset
 obtain a respiratory swab for swine influenza testing and
place it in a refrigerator (not a freezer)

transport and timely diagnosis at a state public health laboratory
Source: CDC
 Diagnostic work on clinical samples conducted in a BSL-2 laboratory
 Viral isolation performed in a BSL-2 laboratory with BSL-3 practices
(enhanced BSL-2 conditions)
 Additional precautions include:
 recommended personal protective equipment (based on site specific risk
assessment)
 respiratory protection - fit-tested N95 respirator or higher level of protection
 shoe covers
 closed-front gown
 double gloves
 eye protection (goggles or face shields)
Source: CDC
 People are contagious as long as they have symptoms,
and
 up to 7 days after they become sick
 Children, especially infants, may be contagious for
longer periods
 Viruses can live 2 hours or longer on surfaces like
tables, desks, and doorknobs.
 Covering nose and mouth with a
tissue when coughing or sneezing
 Dispose the tissue in the trash after use.
 Handwashing with soap and water
 Especially after coughing or sneezing.
 Cleaning hands with alcohol-based
hand cleaners
 Avoiding close contact with sick
people
 Avoiding touching eyes, nose or
mouth with unwashed hands
 If sick with influenza, staying home
from work or school and limit contact
with others to keep from infecting
them
 Stay home if you’re sick
for 7 days after your symptoms
begin or until you’ve been
symptom-free for 24 hours,
whichever is longer.
 If you are sick, limit your contact
with other people as much as possible. Practice
good health habits: get enough sleep, eat nutritious
food, keep physically active.If you smoke, quit.
Most people should be able to recover at home, but
watch for emergency warning signs that mean you
should seek immediate medical care.
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
If a child gets sick and experiences any of these
warning signs, seek emergency medical care.
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
 No vaccine available
 Antivirals for the treatment and/or prevention of infection:
 Oseltamivir (Tamiflu) or
 Zanamivir (Relenza)
 Use of anti-virals can make illness milder and recovery faster
 They may also prevent serious flu complications
 For treatment, antiviral drugs work best if started soon after getting sick
(within 2 days of symptoms)
 Warning! Do NOT give aspirin (acetylsalicylic acid) or aspirin-containing
products (e.g. bismuth subsalicylate – Pepto Bismol) to children or
teenagers (up to 18 years old) who are confirmed or suspected ill case
of swine influenza A (H1N1) virus infection; this can cause a rare but
serious illness called Reye’s syndrome. For relief of fever, other antipyretic medications are recommended such as acetaminophen or non
steroidal anti-inflammatory drugs.
Source: CDC
 People who can receive FREE vaccine are:







Anyone 65 years of age and over
All Indigenous people 15 years of age and over
All Anyone 65 years of age and over
All Indigenous people 15 years of age and over
All
pregnant women at any stage of pregnancy
Anyone over 6 months of age with medical conditions that increase their risk of
severe influenza*.
 People with medical conditions that increase their risk of severe influenza.

Medical conditions include:





Cardiac disease
Chronic respiratory conditions
Chronic illnesses
Chronic neurological condition
People with impaired immunity and
 Children aged 6 months to 10 years having long term aspirin therapy.
Q: How long does protection from the vaccine last?
A: The vaccine takes 2 weeks to work and will last for about 12 months. Low levels of
protection may persist for another year after. For ongoing protection a new vaccine is
required each year.
 Q: Can I catch influenza from having the vaccine?
A: No. The vaccine does not contain any live influenza virus. Some people have a sore
arm or a mild temperature after they have received the vaccine and this is a normal
reaction. However, it does take around 2 weeks before the body is fully protected
after vaccination. If you are exposed to someone with influenza infection during this
time you may still become sick because your body is not yet fully protected.
 Q: Does the 2015 seasonal influenza vaccine include protection against swine
flu?
A: Yes. The vaccine contains the 2009 Pandemic (H1N1) Influenza (swine flu) strain plus
2 other strains predicted to be the most commonly occurring this year. People who want
to protect themselves against the 3 strains should get the 2014 seasonal influenza vaccine.
 Q: If a person had flu (influenza) previously, do they still need the 2015 seasonal
influenza vaccine?
A: Yes. Having had flu offers protection against that flu strain but not the other strains
of flu. The 2014 seasonal influenza vaccine is recommended to protect against strains of
flu that are causing infections this yea

Oseltamivir (Tamiflu)
Treatment
Prophylaxis
Zanamivir (Relenza)
Treatment
Prophylaxis
Adults
75 mg capsule twice
per day for 5 days
75 mg capsule once
per day
Two 5 mg inhalations
(10 mg total) twice per
day
Two 5 mg inhalations
(10 mg total) once per
day
Children
15 kg or less: 60 mg
per day divided into 2
doses
30 mg once per day
Two 5 mg inhalations
(10 mg total) twice per
day (age, 7 years or
older)
Two 5 mg inhalations
(10 mg total) once per
day (age, 5 years or
older)
15–23 kg: 90 mg per
day divided into 2
doses
45 mg once per day
24–40 kg: 120 mg per
day divided into 2
doses
60 mg once per day
>40 kg: 150 mg per
day divided into 2
doses
75 mg once per day
Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. Recommended treatment
dose for 5 days. <3 months: 12 mg twice daily; 3-5 months: 20 mg twice daily; 6-11 months: 25 mg twice daily
Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. Recommended
prophylaxis dose for 10 days. <3 months: Not recommended unless situation judged critical due to limited data on use in this age
group; 3-5 months: 20 mg once daily; 6-11 months: 25 mg once daily
Source: CDC
 Isolation: Refers only to the sequestration of symptomatic
patents either in the home or hospital so that they will not infect
others
 Quarantine: Defined as the separation from circulation in the
community of asymptomatic persons that may have been
exposed to infection
 Social-Distancing: Has been used to refer to a range of non-
quarantine measures that might serve to reduce contact between
persons, such as, closing of schools or prohibiting large
gatherings
Source: CDC
Personnel Engaged in Aerosol Generating Activities
 CDC Interim recommendations:
 Personnel engaged in aerosol generating activities (e.g., collection of
clinical specimens, endotracheal intubation, nebulizer treatment,
bronchoscopy, and resuscitation involving emergency intubation or
cardiac pulmonary resuscitation) should wear a fit-tested disposable N95
respirator

personnel providing direct patient care should wear a fit-tested
disposable N95 respirator when entering the patient room
Source: CDC
Infection Control of Ill Persons in a Healthcare Setting
 Patients with suspected or confirmed case-status should be placed
in a single-patient room with the door kept closed.
 If available, an airborne infection isolation room (AIIR) with negative
pressure air handling with 6 to 12 air changes per hour can be used.
 Air can be exhausted directly outside or be recirculated after filtration
by a high efficiency particulate air (HEPA) filter.
 The ill person should wear a surgical mask when outside of the
patient room, and should be encouraged to wash hands frequently
and follow respiratory hygiene practices. Cups and other utensils
washed with soap and water .
Source: CDC
Infection Control of Ill Persons in a Healthcare Setting
 Standard, Droplet and Contact precautions used for all patient care
activities, and maintained for 7 days after illness onset or until
symptoms have resolved.

hand hygiene by washing with soap and water or using hand
sanitizer immediately after removing gloves and other equipment and
after any contact with respiratory secretions.

should wear disposable non-sterile gloves, gowns, and eye
protection (e.g., goggles) to prevent conjunctival exposure.
Source: CDC
 Surgical masks
 Easily available and commonly used for routine surgical and examination
procedures
 High-filtration respiratory mask
 Special microstructure filter disc to flush out particles bigger than 0.3 micron.
These masks are further classified:
• oil proof
• oil resistant
• not resistant to oil

The masks have numbers beside them that indicate their filtration efficiency. For
example, a N95 mask has 95% efficiency in filtering out particles greater than 0.3
micron under normal rate of respiration.
 The next generation of masks use Nano-technology capable of blocking
particles as small as 0.027 micron.
Believed to have come from neighbouring India
2 death at 2010,14 death at 2014, no death in between years
In 2015, 43 suspected positive cases
1 death till now
Risk of being epidemic given crowded conditions and lack
of awareness and ill equipped hospitals
 Help desks at border towns like
birgunj,mahendranagar,sunauli
 Respiratory swabs being sent to National Health
Laboratory ,Teku from different hospitals inside valley and
outside hospitals






WHO raised the alert level to Phase 6 on June 11, 2009

The overall global case-fatality is 0.50%

Epidemiological Data




US
Median Age 16 years (range: 1-81 years)
Over 80% of the cases in <18 years
60% female; 40% Male



Mexico
Majority of the cases reported in health young adults
71.3% of the deaths were reported in healthy young adults, 20-54 years




EU
Majority of the cases reported in health young adults (20-29 years).
Nepal
43 suspected positive cases 1 death

No vaccine is available,just seasonal flu vaccine available

Anti-virals available
 First outbreaks March 1918 in Europe, USA
 Highly contagious, but not deadly
 Virus traveled between Europe/USA on troop
ships
 Land, sea travel to Africa, Asia
 Warning signal was missed
 August, 1918 simultaneous explosive
outbreaks in in France, Sierra Leone, USA


10-fold increase in death rate
Highest death rate ages 15-35 years

Cytokine Storm?
Deaths from primary viral pneumonia, secondary
bacterial pneumonia
 Deaths within 48 hours of illness
 Coincident severe disease in pigs

 20-40 million killed in less than 1 year

World War I –8.3 million military deaths over 4
years
 25-35% of the world infected
Swine Influenza A(H1N1)
Guidelines for Clinicians
FDA Issues Authorizations for Emergency Use (EUAs) of Antivirals
 On April 27, 2009, the U.S. Food and Drug Administration (FDA) issued
EUAs in response to requests by the Centers for Disease Control and
Prevention (CDC) for the swine flu outbreak
 One of the reasons the EUAs could be issued was because the U.S.
Department of Health and Human Services (HHS) declared a public health
emergency on April 26, 2009
 The swine influenza EUAs aid in the current response:
 Tamiflu: Allow for Tamiflu to be used to treat and prevent influenza in children
under 1 year of age, and to provide alternate dosing recommendations for children
older than 1 year. Tamiflu is currently approved by the FDA for the treatment and
prevention of influenza in patients 1 year and older.

Tamiflu and Relenza: Allow for both antivirals to be distributed to large segments
of the population without complying with federal label requirements that would
otherwise apply to dispensed drugs and to be accompanied by written information
about the emergency use of the medicines.
Source: FDA
 Thought to be spread in the same way that
seasonal flu spreads
 Mainly from person to person when an infected
person coughs or sneezes and spreads tiny
particles into the air
 Sometimes by touching something with flu
viruses on it, and then touching the mouth, nose
or eyes
If you have symptoms:
 Fever, body aches, runny nose, sore throat, nausea, or vomiting
or diarrhea
And you would typically see your health care provider, do
so.
If you have these symptoms but would not normally see
your health care provider, there is no need to do so
Stay home and avoid contact with others as much as
possible

Pandemics are unpredictable

Mortality, severity of illness, pattern of spread
A sudden, sharp increase in the need for medical care
will always occur
 Capacity to cause severe disease in nontraditional
groups is a major determinant of pandemic impact
 Epidemiology reveals waves of infection



Ages/areas not initially infected likely vulnerable in future
waves
Subsequent waves may be more severe



1918- virus mutated into more virulent form
1957 schoolchildren spread initial wave, elderly died in second
wave
Public health interventions delay, but do not stop
pandemic spread

Quarantine, travel restriction show little effect




Does not change population susceptibility
Delay spread in Australia— later milder strain causes infection
there
Temporary banning of public gatherings, closing schools
potentially effective in case of severe disease and high
mortality
Delaying spread is desirable

Fewer people ill at one time improve capacity to cope with
sharp increase in need for medical care
Prevention:
Vaccination
Shot or nasal spray
Hand washing –frequently and thoroughly
Alcohol based hand sanitizer
Avoid touching eyes, nose and mouth.
Germs spread this way
1. Past experience with pandemics have taught us that the second wave
is worse than the first causing more deaths due to:





Primary viral pneumonia, Acute Respiratory Distress Syndrome (ARDS), &
Secondary bacterial infections, particularly pneumonia
Fortunately compared to the past now we have anti-virals and antibiotics
(to treat secondary bacterial infections)
Though difficult, there is likelihood that there will be a vaccine for this
strain by the emergence of the second wave
In the US each year ~35,000 deaths are attributed to influenza resulting in
>200,000 hospitalizations, costing $37.5 billion in economic cost
(influenza & pneumonia) and >$10 billion in lost productivity
Based upon past experience and the way the current H1N1 pandemic is
acting (current wave is contagious, spreading rapidly and in
Mexico/Canada based upon preliminary data affecting the healthy), there
is a likelihood that come fall there might be a second wave which could be
more virulent
At present most of the deaths due to H1N1 strain has been reported
from Mexico.
2.
•
The disease, though spreading rapidly across the globe, is of a mild form
(exception Mexico)
Most people do not have immunity to this virus and, as it continues to
spread. More cases, more hospitalizations and some more deaths are
expected in the coming days and weeks
Disease seems to be affecting the healthy strata of the population based
upon epidemiological data from Mexico and EU
60 years and above age group seems to show some protection against
this strain suggesting past exposure and some immunity
Of concern is the disease spread in Australia
•
•
•
•
3.
Each locality/jurisdiction needs to




Have enhanced disease and virological surveillance capabilities
Develop a plan to house large number of severely sick and provide care
if needed to deal with mildly sick at home (voluntary quarantine)
Healthcare facilities/hospitals need to focus on increasing surge capacity
and stringent infection prevention/control
General population needs to follow basic precautions
4.
In the Northern Hemisphere influenza viral transmission traditionally
stops by the beginning of May but in pandemic years (1957) sporadic
outbreaks occurred during summer among young adults

Likelihood that



5.
This wave will fade in North America by the end of June or will cause disease
in a few cases (influenza virus cannot survive high humidity or temperature)
Will reappear in autumn in North America with the likelihood of being a highly
pathogenic second wave
Will continue to circulate and cause disease in the Southern Hemisphere
Border Closure and Travel Restrictions:

The disease has already crossed all borders and continents, thus, border
closure or travel restrictions will not change the course of the spread of
disease
•
•
•
•
Most recently, the 2003 experience with SARS demonstrated the
ineffectiveness of such measures
In China, 14 million people were screened for fever at the airport, train
stations, and roadside checkpoints, but only 12 were found to have probable
SARS
Singapore reported that after screening nearly 500,000 air passengers, none
were found to have SARS
Passive surveillance methods (in which symptomatic individuals report illness)
can be important tools
School Closures:
6.




Preemptive school closures will merely delay the spread of disease
Once schools reopen (as they cannot be closed indefinitely), the disease
will be transmitted and spread
Furthermore, this would put unbearable pressure on single-working
parents and would be devastating to the economy (as children cannot be
left alone)
Closure after identification of a large cluster would be appropriate as
absenteeism rate among students and teachers would be high enough to
justify this action
7.
High priority should be given to develop and include the present
“North American” (swine) influenza A(H1N1) virus in next years
vaccine. A critical look at manufacturing capacity is called for
8.
It is imperative to appreciate that “times-have-changed”
•
Though this strain has spread very quickly across the globe and seems to
be highly infectious, today we are much better prepared than 1918. There
is better surveillance, communication, understanding of infection control,
anti-virals, antibiotics and advancement in science and resources to
produce an affective vaccine
Complications:
Symptoms can sometimes
lead to life threatening
complications such as
pneumonia and respiratory
failure. And it can make
conditions like diabetes or
asthma worse.
If you have symptoms like
shortness of breath, severe
vomiting , abdominal pain,
dizziness or confusion along
with the symptoms of flu
please consult a physician
right away.
Complications:
Death usually occurs due to
secondary bacterial infection
of the lungs.
Swine flu?
Symptoms are very similar to
the less dangerous viral flu.
However, nausea and vomiting
the Epidemiology and Disease Control
Department (EDCD) has issued preventive
measures.
With the present rate of affliction, the
disease now threatens to take the shape of
an epidemic in crowded capital. According
to EDCD, if the number of people with
disease infection reaches 15 to 20 per day
then the disease can be termed as an
epidemic one.Given the lack of awareness
among the people regarding the severity of
the flu, the disease may cause real trouble
in the capital. The government is yet to
launch considerable awareness as well as
mobilise health institutions and health
workers for the preventive measures to
make the effect of the disease less severe for
the masses.
The swine flu (of which virus strain is
known, as A H1N1) is highly contagious
among the people as it spreads from person
to persons after coming into close contact
with the infect
 If your child has these symptoms, seek immediate medical
care:
Fast breathing or trouble breathing
Bluish skin color
Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse
cough
 Fever with a rash.






 Frequently wash your hands with soap and water for 15-20
seconds
 Alcohol-based hand cleaners are OK
 Cover your coughs and sneezes by coughing and sneezing
into your arm, not your hands. Or, sneeze into a tissue and
discard it
 Avoid touching your nose, eyes and mouth
 Try to avoid close contact with people who appear sick, and
have a fever and cough