H1N1 in Pune, H1N1 in 2017, Risk Stratification in H1N1 cases, Pune Karnataka and Kerala outbreak, approved and trial vaccines

1. Prevention and Management of H1N1
Capt Mohammed Ashraf Ali

3. MODES OF TRANSMISSION
1. Droplet transmission
• Large droplets- major route
(in community and HC settings)
• Small particle aerosols
(particularly in health care settings)
AEROSOL generating procedures
i. Endotracheal intubation
ii. Suctioning
iii. CPR
iv. Nebulizer treatment
v. Bronchosocopy
vi. Diagnostic sputum induction /
collection
vii. Positive pressure ventilation

4. Mode of transmission (cont…)
2. Contact transmission
 Skin-to-skin contact and physical transfer
(i) Direct
Patient-care activities requiring physical contact
Between two patients
(ii) Indirect
Contaminated intermediate objects (inanimate)
 Contaminated hands and fomites.

5. Reservoir – Humans
Source – Case / sub-clinical
Incubation period – 1 to 2 days
Infectious period – 1 day prior to
onset of illness to 7 days after
onset in a confirmed caseHost factors
High risk-
• Extremes of age
• Pregnant ladies
• HCW (occupational risk pyramid)
• Immunocompromised
• Co-morbid conditions
Environment factors
• Seasonality
• Overcrowding
• Closed populations
Agent factors

6. Case definitions
Suspected case: Acute febrile illness with onset
• within 7 days of close contact with a confirmed case of H1N1 inf
• within 7 days of travel to areas which has ≥1 confirmed case(s).
• Resides in a community which has ≥1 confirmed case(s).
Probable case: Patient of Acute febrile illness who is
• positive for influenza A, but un-subtypable for H1 and H3.
• positive for influenza A by a rapid test or an influenza immunofluorescence
assay + meets the criteria of susceptible case
• Death due to unexplained respiratory illness, epidemiologically linked to a
probable/confirmed case.

7. Confirmed case: Acute febrile respiratory illness
with lab confirmation (WHO approved laboratories) by
• RT-PCR
• Viral culture
• Four-fold rise in antibody titre (H1N1 specific)

8. CLASSIFICATION OF WORKERS EXPOSURE
TO INFLUENZA
Occupational Risk
Pyramid

9. VERY HIGH EXPOSURE RISK
Aerosol-generating procedures on known / suspected
patients
Collection/handling specimens from known/ suspected
patients

10. HIGH EXPOSURE RISK
Health care delivery & support staff exposed to known
or suspected patients
Medical transport of known / suspected patients in
enclosed vehicles
Performing autopsies on known / suspected patients

11. STANDARD PRECAUTIONS
&
TRANSMISSION-BASED
PRECAUTIONS

12. Standard precautions
Designed for the care of all patients, regardless of
their diagnosis or presumed infection status
Apply to
1) Blood.
2) All body fluids, secretions & excretions except
sweat, regardless of whether or not they
contain visible blood.
3) Non-intact skin.
4) Mucous membranes.

13. 1. Hand hygiene
Summary technique:
• Hand washing (40–60 sec): use
towel to turn off faucet.
• Hand rubbing (20–30sec):
cover all areas of the hands;
rub until dry.
• Use of PPE does not eliminate
the need for hand hygiene.

14. 2.Personnel protective equipment

15. TRANSMISSION-BASED
PRECAUTIONS

16. • Patient placement
– Single room
– Cohorting
– Negative pressure [airborne infection isolation room (AIIR)]
• Limited movement
• Particulate respirator
• Hand washing: sink, toilet, and bath facilities
• Patient care equipment: Dedicated

17. Guidelines for the usage of mask

18. Hospital setting Guidelines
Screening area TLSM (medical personnel)
Isolation ward • TLSM (medical personnel + all
patients)
• N95 (aerosol gen proced + sample
collection)
Critical care facility N 95 respirators (All HCW)
Laboratory N 95 respirators + PPE
Mortuary TLSM + PPE
Ambulance staff TLSM
Guidelines for the usage of mask

19. Fundamentals of infection prevention
strategies
• Categories of controls for preventing infection transmission in
health‐care settings have been organized hierarchically in
accordance with their effectiveness.
• The categories are:
1. Administrative Controls
2. Environmental/Engineering Controls
3. Personal Protective Equipment (PPE).

20. 1. ADMINISTRATIVE
CONTROLS
1. Respiratory Hygiene/Cough
Etiquette
2. Specimen Collection & Transport
3. Patient Transport within Healthcare
Facilities
4. Staff Education and Training
5. Care of the Deceased
6. Patient Discharge
7. Visitor Policies

21. 2. ENGINEERING &
ENVIRONMENTAL CONTROLS
1. Airborne Infection Isolation Rooms
2. Diagnostic & Research Laboratories
3. Autopsy Rooms

22. Autopsy Rooms
• Death during infectious phase: Live viruses (Lungs)
• Procedures on lungs / Aerosol generating procedures
• Protective autopsy settings
– Air borne precautions
– Exhaust fans to direct air away from HCWs
– Use of containment devices (Biosafety cabinets)
– Use of AIIR

23. Postmortem Care & Laboratory
Specimens And Practices
• Standard facility practices
• Collection, handling, and processing of laboratory
specimens
• Airborne precautions
– Aerosol-generating procedures for specimen collection
(diagnostic sputum induction)

24. No need for panic! It is curable!!!
We all are
going to die
Gonna stay
away from all
the pts
Am staying
inside
Not a big
deal
FEAR
KNOWLEDGE

25. Antiviral treatment and
chemoprophylaxis

26. ANTIVIRAL TREATMENT
Drugs for specific antiviral treatment
• Oseltamivir 75 mg- DOC BD x 5 days
• Zanamavir 10mg – inhalational form
• Peramavir
Supportive therapy includes:
• IV Fluids.
• Oxygen therapy/ ventilatory support.
• Antibiotics for secondary infection.
• Vasopressors for shock.
• Suspected cases monitored for clinical / radiological
evidence of LRTI

27. Discharge
• Adult patients – 7 days after symptoms have
subsided.
• Children after 14 days

28. Chemoprophylaxis
Prophylaxis is given to: All close contacts of
suspected, probable and confirmed cases. Close
contacts include
• household /social contacts,
• workplace or school contacts,
• fellow travelers etc.
• All health care personnel coming in contact with
suspected, probable or confirmed cases

29. Duration till 10 days after last exposure (maximum
period of 6 weeks)
Dosage
For infants:
• < 3 months: NR
• 3-5 months: 20 mg OD
• 6-11 months: 25 mg OD
By Weight:
For weight <15kg: 30 mg OD
15-23kg: 45 mg OD
24-<40kg: 60 mg OD
≥40kg: 75 mg OD

30. Vaccination Strategies

32. Vaccines available
Vaccine strains: yearly prepared, include strains isolated in
prev. seasons.
Trivalent form: 1 or 2 type A viruses and a type B virus
• Inactivated vaccines
• Live attenuated cold adapted influenza vaccines
Inactivated vaccines
• Allantoic cavity of embryonated
chick eggs
• Inactivation- formalin or BPL
• Standardised – haemagglutinin
content (15µg of HA/dose
Live attenuated
• Reassortment between currently
circulating strains with
• cold-adapted attenuated master
strain can grow at 33ºC

33. Inactivated vaccines
• Dosage- single dose (i.m or s.c)
• Protective value: 50-80%
• Immunity lasts- max 1 year
• Indication
• High risk groups
• Contraindication
• h/o allergy
Live attenuated
• Intranasal administration
• Recommended to all healthy
individuals of 2-49 yrs age
The Chinese prescription
• Lianhuaqingwen capsule (LH-C) exerts anti-influenza activity
inhibition of viral propagation and impacts immune function
BMC Complementary and Alternative MedicineBMC series 2017

34. Trivalent vaccines in India

35. References
• Influenza Update No 284 06 Mar ch 2017, based on
data upto 19 February, 2017.
http://www.who.int/influenza/surveillance_monitoring/
updates/EN_GIP_Influenza_transmission_zones.pdf
• H1N1 Flu Clinical and Public Health Guidance
https://www.cdc.gov/h1n1flu
• Ministry of Health & Family Welfare. Seasonal
Influenza: Guidelines on categorization of Seasonal
Influenza cases during screening for home isolation,
testing, treatment and hospitalization (Revised on
18.10.2016)