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SWINE FLU

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SWINE FLU. Marcus Zervos, MD ... Symptoms with surveillance (flu in community) has a 70% - 80% predictive power. ... Patients with flu like symptoms should be ... – PowerPoint PPT presentation

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Title: SWINE FLU


1
SWINE FLU
  • Marcus Zervos, MD
  • Division Head, Infectious Diseases, Medical
    Director, Infection Control
  • Henry Ford Health System
  • Clinical Professor of Medicine
  • Wayne State University, Detroit, MI
  • May 5, 2009

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Swine Influenza
  • Mexico reported increased number of cases of
    severe respiratory disease, pneumonia and deaths,
    beginning in March 2009.
  • Other countries Canada, Europe 13 countries
  • USA reported cases 21 states
  • CDC has been working closely with public health
    officials in Mexico, World Health Organization
    (WHO). 
  • The etiologic agent has been identified as Swine
    Origin Influenza A H1N1 (S-OIV) Swine
    influenza
  • It is known to have spread from pigs to humans
    and then widespread person to person transmission

05/1/2009
4
US Human Cases of H1N1 US Declares Public
Emergency
  •  

Arizona 4  California
24  Colorado 2 Connecticut
1  Delaware 4  Florida
2  Illinois 3  Indiana
3 Kansas 2 
Kentucky 1
  • Massachusetts 8 
  • Michigan 2
  • Minnesota 1 
  • Missouri 1 
  • Nevada 1
  • New Jersey 7
  • New York 50 
  • Ohio 1 
  • South Carolina 13
  • Texas 28 (1 death)
  • Virginia 2 

TOTAL (21) 160 cases 1 death
As of 5/1/09
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Swine Influenza
  • CDC public health officials cases of febrile
    respiratory illness caused by swine influenza
    (H1N1) viruses
  • Illness onsets occurred from March 28, 2009. 
  • Age range was 7-54 yo. Cases are 63 male.
  • Mexico 2000 patients affected and 149 deaths.
  • Other Countries 1 associated death- Austria,
    Canada, China, Hong Kong Special Administrative
    Region, Denmark, Germany, Israel, Netherlands,
    New Zealand, Spain, Switzerland, the United
    Kingdom

NOTE 4-27-09 WHO raises pandemic threat level
from 3 to 4 and 4-29-09 to level to 5 meaning
pandemic imminent
05/2/09
7
Knowing your foe. Seasonal flu
  • 5-20 infected by the flu each year
  • Mortality due to influenza and pneumonia is the
    6th leading cause of death in the United States
    after cancer, heart disease, Cardiovascular
    diseases, and COPD .
  • Estimated 36,000 deaths per year.
  • 200,000 hospital admissions per year.

8
Month of Peak Influenza Activity United States,
1976-2006
43
20
13
13
3
3
MMWR 200655(RR-10)22
9
Impact of Influenza
  • 90 of deaths among persons 65 years of age
  • Higher mortality during seasons when influenza
    type A viruses predominate
  • Highest rates of complications and
    hospitalization among young children and people
    65 years

05/2009
10
Influenza Virus Knowing Your Foe
  • Influenza Highly infectious viral illness
  • Virus was first isolated in 1933
  • Single-stranded RNA virus
  • Orthomyxoviridae family
  • 3 types A, B, C
  • Subtypes of type A determined by hemagglutinin
    (H) and neuraminidase (N)

11
Swine Influenza Type A Subtype H1N1
  • Type A - moderate to severe illness - all age
    groups, potential for epidemic - humans and
    other animal
  • Type B - milder disease - primarily affects
    children - humans only
  • Type C - rarely reported in humans - no
    epidemics
  • S-OIV contain a unique combination of gene
    segments that have not been reported previously
    among swine or human influenza viruses in the
    U.S. or elsewhere.
  • Mutations-mistakes made by the RNA Polymerase is
    just only surpassed by HIVHIGH RATE OF
    MUTATIONS, INABILITY TO PROOF READ AND SEGMENTED
    GENOME THAT ALLOWS GENETIC REASORTMENT

12
Influenza Virus Surface Proteins
haemagglutinin
neuraminidase
13
  • Influenza Virus

05/2009
14
Antigenic Drift
  • Gradual change in the virus with mutations and
    substitutions in the amino acid chain of the
    surface proteins
  • (neuraminidase and haemagglutinin).
  • A new strain can trigger a new epidemic
  • usually prevail for 2-5 years before next
    antigenic drift.

15
Antigenic Shift
  • A type A influenza virus with a completely novel
    haemagglutinin or neuraminidase formation moves
    into the human species from other host species
  • The primary source is birds, with recombination
    in swine or humans.

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Pandemic influenza
  • The fact is, that flu is one of the most
    formidable infections confronting humankind. The
    virus mutates constantly as it circulates among
    birds, pigs and humans. So each new flu season
    brings new challenges
  • First pandemic known in 15th century
  • In pandemic response and planning, prediction of
    the future is not possible. Thought is to hope
    for best, but plan for worst

18
Recent Pandemics
  • 1889-1890 first recorded pandemic
  • 1918 Spanish flu- 20-40 million deaths
  • 1957 Asian flu- 1 million deaths
  • 1968 Hong Kong flu- 1 million deaths
  • 1976 Swine flu unreported deaths

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21
Influenza Pathogenesis
  • Respiratory transmission of virus
  • Replication in respiratory epithelium with
    subsequent destruction of cells
  • Viremia rarely documented
  • Viral shedding in respiratory secretions for 5-10
    days

05/2009
22
Influenza Clinical Features
  • Incubation period 2-3 days (range 1-7 days)
  • Severity of illness depends on prior experience
    with related variants
  • Often abrupt onset symptoms

05/2009
23
Knowing your foe..
  • Symptoms of influenza include
  • Fever
  • Cough
  • Headache
  • Myalgia
  • Fatigue and weakness
  • Chest discomfort
  • Nausea, diarrhea with swine flu

24
Knowing your foe..
  • Risk factors for complications
  • Age 65 years
  • Residence of nursing homes and other chronic care
    facilities
  • Chronic cardiac or pulmonary disorders
  • Chronic conditions such as diabetes
  • Long term ASA therapy
  • Immunosuppression

25
Complications knowing your foe
  • Pneumonia
  • secondary bacterial
  • primary influenza viral
  • Reye syndrome
  • Myocarditis
  • Otitis media incidence up to 30
  • Febrile convulsion in children
  • Sinusitis and Bronchitis in all patient groups
  • Exacerbation of asthma and croup
  • Encephalopathy
  • ARDS
  • Death 0.5-1 per 1,000 cases
  • Treatment may decrease the length of the disease
    and the complications

05/2009
26
Diagnosis
  • Symptoms of cough and fever has a
  • 30 40 predictive power.
  • Symptoms with surveillance (flu in community) has
    a 70 - 80 predictive power.

27
Influenza Diagnosis by Specialty
of Diagnoses
Physician Specialty
Data from IMS America, National Disease and
Therapeutic Index, Diagnosis, volume 2, 4Q 1997.
28
Influenza vs Cold Symptoms
  • Signs Symptoms Influenza Cold
  • Onset Sudden Gradual
  • Fever Characteristic, high (over Rare 101?F)
    lasting 3 to 4 days
  • Cough Nonproductive can Hacking become severe
  • Headache Prominent Rare
  • Myalgia (aches and pains) Usual often
    severe Slight
  • Fatigue weakness Can last up to 2 to 3
    weeks Very mild
  • Extreme exhaustion Early and prominent Never
  • Chest discomfort Common Mild to moderate
  • Stuffy nose Sometimes Common
  • Sneezing Sometimes Usual
  • Sore throat Sometimes Common

Adapted from the National Institute of Allergy
and Infectious Diseases.
29
S-OIV Diagnosis
  • Clinicians should consider swine influenza
    infection in the DIFF DX of patients with febrile
    respiratory illness and who
  • 1) who traveled recently to Mexico or were in
    contact with persons who had febrile respiratory
    illness and were in one of the three U.S.
    counties or Mexico during the 7 days preceding
    their illness onset.
  • 2) 85 of current cases have not been linked to
    travel or to another confirmed case MMWR 4/2009
  • This information is dynamically changing.

05/2009
30
S-OIV Testing
  • Patients with flu like symptoms should be tested
    for influenza.
  • The currently available Influenza A tests can be
    used for screening INFLUENZA A () should be
    sent to public health laboratories for further
    characterization. (Microbiology Lab)
  • Clinicians who suspect it should
  • obtain a nasopharyngeal swab (NPS) (NP wash or
    aspirate could also be done)
  • place it in a viral transport medium,
  • refrigerate it (2 hs) and
  • then contact their state or local health
    department

05/2009
31
S-OIVTesting
  • CDC requests that state public health
    laboratories promptly send all influenza A
    specimens that cannot be subtyped to the CDC,
    Influenza Division, Virus Surveillance and
    Diagnostics Branch Laboratory.
  • Michigan
  • The current recommendation for laboratory testing
    for detection of swine influenza as per the
    Michigan Department of Community Health (MDCH) is
    to perform the influenza rapid antigen test.
  • HFH Patients with positive rapid antigen test
    for Influenza A will have their samples forwarded
    to MDCH for confirmatory testing for swine
    influenza.

05/2009
32
S-OIV Testing
  • Current data indicates that the rapid antigen
    will test positive for Influenza A in patients
    with swine influenza although the test is not
    100 sensitive.
  • Not Culture
  • The recommendations are to NOT perform virus
    culture on samples from patients with suspected
    swine influenza.
  • The only test to be performed is the influenza
    rapid antigen test.
  • The recommended sample for collection is the
    nasopharyngeal swab in viral transport media
    (white capped tube (Starswab).

05/2009
33
Influenza Antigen
34
Influenza Rapid Test
White Capped Starswab Flocked NP Swab
35
If White Capped Flocked Swab is Not Available
  • You can use Blue Capped Starswab media, but dont
    use the hard swab that comes with it.
  • Use an orange capped nasopharyngeal swab instead
  • Put the orange cap swab into the media from the
    blue capped kit

36
Nasopharyngeal Swab
37
Influenza Testing
  • Point of care testing is not suggested poor
    sensitivity (57-81 for seasonal flu)
  • Sensitivity for S-OIV not known
  • Biohazard potential, needs BSL2, culture by
    clinical microbiology laboratories should not be
    done

38
Management of Influenza
39
SWINE FLU TREATMENT
  • Sensitive to Oseltamivir (tamiflu) and Zanamivir
    (relenza) can be used for treatment if treatment
    is started early in illness (less than 3 days).
  • Resistant to The H1N1 viruses are resistant to
    amantadine and rimantadine but not to oseltamivir
    or zanamivir.
  • Flu Vaccine It is not anticipated that the
    current seasonal influenza vaccine will provide
    protection against the swine flu H1N1 viruses.

05/2009
40
SWINE FLU TREATMENT
  • Antiviral Treatment for confirmed, suspected, or
    probable cases
  • Antiviral treatment may include either Tamiflu
    or Relenza, with no preference given at this
    time.
  • Recommendations for use of antivirals may change
    as more data on antiviral susceptibilities become
    available.
  • Initiate treatment as soon as possible after the
    onset of symptoms (within 72 hours).
  • Tamiflu dose for treatment 75 mg po bid for 5
    days

05/2009
41
SWINE FLU TREATMENT
  • Antiviral chemoprophylaxis (pre-exposure or
    post-exposure) can be considered for close
    contacts of a highly confirmed or highly
    suspected case.
  • Tamiflu dose for prophylaxis 75 mg po daily for
    10 days after last known exposure
  • Oseltamavir and zanamavir are non-formulary
    agents for HFH inpatients. A limited quantity of
    Oseltamavir is available and may be obtained with
    approval by ID staff and completion of a
    non-formulary request form.

05/2009
42
Therapy for Influenza
  • The therapy for influenza is generally
    supportive.
  • Antivirals have been shown to reduce viral
    shedding by 3 days, and has a 1.3 day reduction
    in the median time to improvement. can be
    considered in individuals with an established
    diagnosis of influenza that are at high risk for
    complications, or with severe disease.
  • Antibiotics are not indicated for influenza.

43
Antiviral use and misuse
  • Public health authorities strongly discourage
    healthcare providers from prescribing and the
    public from requesting antivirals for private
    stockpiling purposes.
  • The indiscriminate use of Tamiflu may promote
  • the development and spread of resistance
  • may impact the ability for public health to
    adequately respond to a pandemic
  • There are limited supplies of oseltamivir in the
    U.S. and hoarding of this drug becomes a concern
    because it will be unavailable for those who need
    it most.

44
Influenza Management
  • Most patients with influenza can be managed out
    of the hospital
  • Major cause of morbidity and mortality post
    influenza is pneumonia WATCH OUT FOR CA-MRSA

45
SWINE FLU
  • Henry Ford Hospital Pandemic Flu Plan can be
    found in the HFH Emergency Operations Plan
    policies Appendix H Pandemic Flu Plan
  • http//henry.hfhs.org/body.cfm?id41actionlistpo
    licycacheck5baca1412D2ca42D45712Da75b2De1d74
    7b29fcf5FOF5F0nPPP50
  • For more information about swine flu
    http//www.cdc.gov/swineflu
  •  
  • Additional information is also available by
    calling 1-800-CDC-INFO (1-800-232-4636)

05/2009
46
Institutional pandemic flu planning
  • Availability of testing, patient care
  • Infection control
  • Surge planning, facility needs
  • Occupational health, staffing levels, prophylaxis
  • Availability of supplies, distribution plans
  • What to do with visitors, elective procedures
  • Antivirals, vaccines
  • Communication and education plan, hotlines
  • Command structure

47
Infection Control
  • Febrile Respiratory Illness
  • Do you have a new/worse cough, muscle aches or
    shortness of breath? and Are you feeling feverish?

Yes to both questions Initiate Droplet
Precautions and Prompts further questions
No to both questions Initiate Standard
Precautions
48
Infection Control for Ambulatory Settings
  • For acute respiratory illness, maintain
    respiratory isolation procedures.
  • The ill person should wear a surgical mask when
    outside of the patient room, wash hands follow
    respiratory hygiene practices.
  • Cohort or place in private room.
  • Hand hygiene wash or sanitizer.
  • Utensils Water and soap.
  • Routine cleaning and disinfection strategies used
    during influenza seasons can be applied to the
    environmental management of swine influenza.

05/2009
49
Infection Control for Hospitalized Patients
  • Standard, Airborne and Contact precautions for 7d
    after illness onset or until symptoms have
    resolved.
  • Personnel should wear N95s when entering the
    patient room
  • Use an airborne infection isolation room with
    negative pressure air handling, if available
    otherwise use a single patient room with the door
    kept closed. If a non-negative pressure room is
    used, one hour for proper air exchange is needed
    before the room can be opened.
  • For suctioning, bronchoscopy, or intubation, use
    a procedure room with negative pressure air
    handling.

05/2009
50
S-OIV Decrease the Transmission
  • Voluntary Isolation (Non-hospitalized patients)
    7d
  • Hand hygiene
  • Avoid unnecessary travel to affected areas
  • Contagiousness Persons with swine influenza A
    (H1N1) virus infection should be considered
    potentially contagious for up to 7 days following
    illness onset.
  • Persons who continue to be ill longer than 7 days
    after illness onset should be considered
    potentially contagious until symptoms have
    resolved ( in children)

05/2009
51
Infection Control
  • Survival of virus outside the human body
  • 24-48 hrs on hard nonporous surface
  • 8-12 minutes on cloth, paper, tissue.
  • 5 minutes on hands
  • Virus survives longer with low humidity and
    cooler weather.
  • Routine cleaning agents sufficient
  • Hand hygiene most important measure for control

52
Vaccine Management
  • Goal is to provide a safe and effective vaccine
    as soon as possible.
  • To allocate, distribute, and administer vaccine
    to identified priority groups.
  • Vaccine not likely to be available until closer
    to the second wave

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Questions and Thank You
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