What is swine flu?How swine flu presents?How to diagnose swine flu?How to treat swine flu? What are the vaccines for swine flu?How to prevent from getting swine flu?

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Dr.S.Sesha Sai ,PG, Pulmonary Medicine

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Swine influenza is a respiratory disease
of pigs.
Influenza A.
Sometimes the existing strains of virus
combine to form a new subtype. (
Antigenic Shift).
In 2009, North American swine influenza,
North American avian influenza, human
influenza, and swine influenza virus
typically found in Asia and Europe
reassorted and formed a new subtype

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In US, Between 7,070 and 13,930 deaths were
attributable to H1N1 flu from April to 14 November 2009.
CDC estimates that between about 8,870 and 18,300
2009 H1N1-related deaths occurred between April 2009
and 10 April 2010.
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.
Highest number of deaths are in Gujarat > Rajasthan.

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History of Virus[3]
Year of Origin Sub type
1890 H2N8
1900 H3N8
1918 H1N1 (Spanish)
1957 H2N2 (Asian)
1968 H3N2 (Hong Kong)
1977 H1N1 (Russian)
2009 H1N1 (Swine)
2013 H7N9 (Avian, China)

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Virus (Agent)
Orthomyxoviridae family
ssRNA
Spherical shape
80-120 nm
Host
All age groups
Young Children
>65 years
HCWs, Co – morbids, Immunocompromised.

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Environment
• Tropics/ Sub tropics: epidemics occur in
rainy season
• Overcrowding : Mostly affect urban and peri-urban
areas.
• Closed populations :High attack rates may be
witnessed in Army Barracks, College hostels,
Schools, Residential hostels of schools, aircrafts,
ships etc

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EM of Swine flu virus

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Mode of
Trans.
• Direct Airborne
• Indirect – Objects, fomites, close
contact.
Incubation
period
• 1-4 days
• Shedding before onset of symptoms.
• Peak on day 1 of symptoms.
Period of
Communi
• Adults – 4-6 days
• Children – for months.

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Clinical features
Symptoms
• Sudden, rapid
onset.
• Fever, Chills, Body
ache, Sorethroat,
Non – productive
cough, Runny –
nose, Headache.
• GI symptoms,
Muscle
inflammation.
Findings
• Fever (upto 1060 F)
• Lasts for 3 days
• Face : flushed
• Skin : Hot and
moist
• Eyes: Watery and
reddened
• Ear : Otitis
Findings
• Nose : Nasal
discharge
• Mucous
membranes :
Hyperemic
• Cervical LN
enlargement in
children

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Investigations
RT – PCR (4 hours) or
Isolation of virus in culture or
Fourfold rise in virus specific neutralising antibodies.
Sample Collection:
o Swabs (Nasopharyngeal, Throat, Nasal)
o Tracheal aspirate (intubated)
o Before administration of anti viral drugs
o 40 C in viral transport media within 24 hours.
o If not possible, Store at –700 C

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Categorization[4]

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Features Manageme
nt
A
Mild fever + Cough or sorethroat
± bodyache, headache, diarrhea, vomiting
• No testing
• Does not require
oseltamivir
• Monitor and reassess (24-
48hr)
B
CAT A + any of
1. High grade fever, Severe sore throat.
2. Children with predisposing factors,
Pregnant women , >65, Comorbids,
Immunocompromised.
• No testing
• Home isolation
• Oseltamivir
• Broad spectrum
antibiotics for CAP
C
CAT A + CAT B + one or more of
1. Breathlessness, chest pain,
drowsiness, hypotension,
hemoptysis, cyanosis
2. Children with Somnolence, high and
persistent fever, inability to feed well,
• Testing
• Immediate
hospitalization and
treatment.

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Infection control
measuresFrequent hand washing of
personnel and contacts.
Cough etiquettes and maintain
arms length distance from others.
Dedicated doctors, nurses and
paramedical workers.
Portable X Ray machine,
ventilators, large oxygen
cylinders, pulse oxymeter and
other supportive equipments
Adequate disinfectants and
medications

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Contd..
Use of face masks
Isolation room or beds one meter
apart.
All those entering room wear
protective gear.
Prophylaxis to health care
personnel.
Waste disposal in biohazard
labeled bags.

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Use of face mask [5]
Triplelayerfacemask
• Screening area
• Isolation ward
• Mortuary
• Ambulance
• Community
surveillance,Contact
tracing
• Security personnel
• ≯ 6 hours
• Not reuse
N95Respirator
• Isolation ward -
aerosol generating
procedures like
suction, intubation,
nebulization
• ICU
• Laboratory personnel
• ± Expiration valve

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For General Public
No scientific evidence to show health
benefit of using triple layer masks for
members of public.
Erroneous use of masks or continuous
use of a disposable mask for longer than 6
hours or repeated use of same mask may
actually increase risk of infection further.

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Oseltamivir (Tamiflu)
Neuraminidase (NA) Inhibitor
The drug should be given as BD dose for 5 days.
Adults :
Infants :
It is also available as syrup – 12mg / ml
Weight Dose
< 15 kg 30 mg
15 – 23 kg 45 mg
24 – 40 kg 60 mg
> 40 kg 75 mg
Age Dose
< 3 months 12 mg
3 – 5 months 20 mg
6 – 11 months 25 mg

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Tamiflu should be given within 24-48 hrs.
Adverse reactions of Oseltamivir
 No recommendation for dose
reduction in hepatic disease.
 Dosage modification should be done
in renal impairment
Common Nausea, Vomiting
Occasionally Bronchitis, Insomnia, Vertigo
Less commonly Angina, Psuedomembranous colitis,
Peritonsillar abscess
Rare Anaphylaxis, Skin rashes

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Other drugs…[6]
Zanamivir (Relenza) :
Dry powder inhalation
Not effective in children, asthmatics
Peramivir (Rapivap, Rapiacta, Peramiflu) :
Only Intravenous drug available for Swine flu
FDA approved for adults
Single dose of 600 mg given.($ 950)
M2 Inhibitors – Amantadine, Rimantadine
Developed resistance.
No longer recommended by CDC.
Laninamivir[7] – Phase III trials, Approved in Japan (Inavir)

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Supportive Therapy
IV fluids, Parenteral Nutrition
O2 / Ventilatory support
Antibiotics, Vasopressors (shock)
PCM / Ibuprofen – fever, myalgia, headache
Plenty of fluids
If SpO2 < 90% and PaO2 < 60 mmHg – Mechanical Ventilation
Preferred – Invasive
High dose corticosteroids – No benefit, Potential harm
Low dose ( Hydrocortisone 200 – 400 mg / day) – in persistent
septic shock
SALICYLATES are CONTRAindicated – REYE syndrome

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Ventilator Protocol
Pressure pre-set (controlled)
Low tidal volume ventilator support
Tidal volume — 6 ml/kg ideal body weight (Respiratory rate to
a maximum of 30-
35 per minute).
Open lung strategy of ventilation
PEEP titration to keep the lung recruited to achieve an FIO2 of <
0.5 and a saturation of > 90% or a PaO2 of > 60 mmHg
Plateau (Pause) pressure not to exceed of > 30-35 mmHg.
APRV (Airway Pressure Release Ventilation), IRV (Inverse
Ratio Ventilation) in patients with persistent Hypoxemia.

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Discharge Policy
Adults – 7 days after symptoms have subsided.
Children – 14 days after symptoms have subsided.

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Complications
Sinus / Ear infections
Bacterial pneumonia (MRSA,MSSA,Group A strep)
Bronchiolitis, Croup, Diarrhea
Febrile seizures
Rhabdomyolysis
Encephalopathy / Encephalitis
Myocarditis, Pericarditis
Exacerbation of chronic illness (COPD, Diabetes, Coronary artery disease)
Reye syndrome
Toxic shock syndrome
Sudden death

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Preventive care
for contacts
OD dose of Oseltamivir
according to body
weight till 10 days after
last exposure ( Upto 6
weeks)
Not recommended for
infants < 3 months

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Vaccination[8]
Prioritized groups
1. Heath Care Workers – Medical and paramedical
staff in Casualty, ICU, Isolation ward, Screening
centers.
2. All pregnant women.
3. Chronic illnesses.
4. > 65 years, 6 months – 8 years.
Takes about 2 – 3 weeks to develop immunity.
Administered at least One month prior to
commencement of season.

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Currently available vaccine is
Northern Hemisphere Trivalent
Vaccine
Inactivated trivalent vaccine
(SC/IM) .
Vaccination should occur before
onset of influenza activity in the
community
Can be used till May 2017.
In India, Influgen (Lupin), Costs ₹
720.
Also Vaxigrip (Sanofi Pasteur),

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Strains in the vaccine [9]:
A/California/2009 (H1N1)–like virus
A/Hong Kong/2014 (H3N2)–like virus
B/Brisbane/2008–like virus
Quadrivalent vaccines will include an additional vaccine
virus strain ,
B/Phuket/2013–like virus
 Contraindicated in Egg allergy and GBS.

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References
1. Clinical Management Protocol for Seasonal Influenza H1N1, Ministry of Health and
Family Welfare, Directorate General of Health Sciences, October 21, 2016.
2. The 2009 H1N1 Pandemic: Summary Highlights , CDC.
3. Paul M.; “Origin of Human Diversity” , Vol 108, Feb 8, 2002 and Tokiko W.;
“Pathogenesis of 1918 Pandemic history of influenza virus”, Feb 6, 2009.
4. Guidelines on categorization of Seasonal Influenza cases during
screening for home isolation, testing, treatment and hospitalization, MOHFW, DGHS,
October 10, 2016.
5. Guidelines on use of masks for health care workers, patients and members of public,
MOHFW, DGHS.
6. Influenza Antiviral Medications: Summary for Clinicians, Jan 25, 2017. Centre for
Disease Control.
7. https://www.ncbi.nlm.nih.gov/pubmed/21973296. National Center for biotechnology
information.
8. Seasonal Influenza: Guidelines for Vaccination with Influenza Vaccine , MOHFW, DGHS,
October 21,2016.
9. Prevention and Control of Seasonal Influenza with Vaccines, Recommendations of
the Advisory Committee on Immunization Practices — United States, 2016–17
Influenza Season, Aug 26,2016. Lisa A. Grohskopf, MD1; Leslie Z. Sokolow, MSc,
MPH1,2; Karen R. Broder, MD3; Sonja J. Olsen, PhD1; Ruth A. Karron, MD4; Daniel B.

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Thank
You