seminar on Swine flu by Dr. Sreejith

1. SWINE FLU
Influenza virus
H1N1.

2. Under the guidance of:
Dr. S M Mangalkar
Asso. Professor
Microbiology
GMC Latur.

3. Credit: L. Stammard, 1995
o Viral family:
Orthomyxoviridae
o Negative sense
o Single stranded
o Segmented RNA
genome.
o 5 different genera in
this family.
o Influenza A
o Influenza B
o Influenza C
o Thogoto virus
o ISAvirus
VIRUS CLASSIFICATION

4. CLASSIFICATION…
 Different influenza virus strains are named according to their:
 Genus (type)
 The species from which the virus was isolated. (omitted if human)
 The location of the isloate
 The number of the isolate
 The year of isolate
 In case of the Influenza A virus
 The hemagglutinnin H subtype
 The neuraminidase N subtype.
 For example, the 220th isolate of an H5N1 subtype virus isolated from
Hong Kong in chickens in 1997 is designated as:
 Influenza A/chicken/Hong Kong/97 (H5N1)

5. Influenza Virus - Types
Type A Type B Type C
Causes significant
disease
Causes significant
disease
Does not cause
significant disease
Infects humans
and other
species !
Limited to humans Limited to humans

6. VIRION STRUCTURE..
The virus has a complex structure and
possess:
• A lipid bilayer membrane
• Surface proteins:
• Hemaglutinnin H
• Neuraminidase N
• M2 protien.
• Matrix protein
• M1 lies just beneath the
envelope
• Ribonecleoprotiens:
• Polymerase basic 1 PB1
• Polymerase basic 2 PB2
• Polymerase acid PA
• Nuclear export protien/
Nonstructural protien.
NEP/NS2.
• Viral RNA segments.
The viral RNA segments are as follows:
• PB2
• PB1
• PA
• HA
• NP
• NA
• M
• NS1

7. Segmented RNA Function
PB2 Component of RNA polymerase
Cap recognition.
PB1 PB1-F2: Pro apoptotic activity
PB1: component of RNA polymerase endonuclease
activity
elongation.
PA Component of RNA polymerase: protease
HA Major antigen
Surface glycoprotein, receptor binding
Fusion activity
NP RNA binding
RNA synthesis
RNA nuclear import
NA Surface glycoprotien
Neuraminidase activity
M M1:Matrix protien
Interaction with vRNPs and surface
glycoprotiens, nuclear export
M2: budding membrane protein
ion channel activity.
NS1 NS1: multifunctional protein
viral INF antagonist
NEP/NSP2: nuclear export of vRNPs

8. H1 N1
H2 N2
H3 N3
H4 N4
H5 N5
H6 N6
H7 N7
H8 N8
H9 N9
H10
H11
H12
H13
H14
H15
H16
Haemagglutinin subtype Neuraminidase subtype

9. Stages of replication
 Attatchment
 HA
 Sialic acid receptors.
 Preferentially binds to the N-acetylneuraminic acid attatched to the penultimate
glucose sugar by α 2,6 linkage. (2,3 linkage for avian flu)
 Entry and intracellular trafikking
 Endocytosis : 4 different mechanisms.
 Acidification of the vescile
 Fusion of virus and host membranes

10.  Transcription and Translation and post translational processing
 RNPs.
 Replication of genomic nucleic acid
 vRNA Promoter.
 Formation of the ‘Pan handle,RNA fork and Corkscrew ’ structure
 Antigenomic RNA to genomic RNA
 Assembly and release
 Apical plasma membrane of polarised cells
 Packaging of 8 RNA segments :
 non coding segments
 Budding process :M1 protien

11. Influenza: Normal Burden of Disease
 Seasonal Influenza
 Globally: 250,000 to 500,000 deaths per year
 In the US (per year)
 ~35,000 deaths (mainly among people 65 years or older)
 >200,000 Hospitalizations
 $37.5 billion in economic cost (influenza & pneumonia)
 >$10 billion in lost productivity
 Pandemic Influenza
 An ever present threat

12. Pathophysiology

13.  Little is know about what constitutes a typical infectious dose, but is believed to be 127-
320 TCID50.
 High affinity for the tracheal cells with sialic acid receptors.
 the virus multiplies in bronchial epithelium within 16 hr of infection and causes
 focal necrosis of the bronchial epithelium,
 focal atelectasis, and gross hyperemia of the lungs.
 Epithelial cell damage
 Airway plugging
 Peribronchial and perivascular mononuclear infiltrates.

14. Pathogenesis

15.  Epidemic refers to an increase, often sudden, in the number
of cases of a disease above what is normally expected in that
population in that area.
 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
Definitions

16. Anitgenic Drift
 Causes changes in hemagglutinin and neuraminidase of influenza virus due
to point mutations
 This involves no change in serotype; there is merely an alteration in amino
acid sequence of HA or NA leading to change in antigenicity.
 Results from positive selection of spontaneous mutants by neutralising
antibodies.
 Cannot be neutralised by antibodies to parents strain.
 Drift variants can cause epidemics and lasts for 2 to 5 years, before being
replaced by a different strain.

17. Antigenic Shift
 Involves major antigenic changes in which a new HA or NA subtype is introduced
into the human population.
 During the last century 4 antigenic shifts have occurred.
 1918 Spanish influenza (appearance of H1N1)
 1957 Asian Flu (H1N1--- H2N2)
 1968 HongKong ( H2N2 --- H3N2)
 1977 Russian Flu (Re emergence of H1N1)
.
• Caused by Reassortment, typically
between human and avian and
swine strains.
• Double reassortment
• Triple reassortment.
• Second mechanism is the direct
transmission of the avian or swine
influenza viruses to human and
their establishment in human
population

19. Swine Flu
 Swine Influenza (swine flu) is a respiratory
disease of pigs caused by type A influenza that
regularly cause outbreaks of influenza among
pigs

20. Transmission Through Species
Avian Virus
Human Virus
Swine Virus
Avian/Human
Reassorted Virus
Reassortment in Pigs

21. Transmission to Humans
 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

22. 19 7 5 6 1
23
170
85
110
146
207 212
261
436
396
461
422 405
235
485
190
212
181
129
1046
303
330
566 581
936
1231
1066
0
200
400
600
800
1000
1200
1400
18 19 20 21 22 23 25 26 27 28 29 30 32 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Week-2009
NoofConfirmedDeaths
Swine Influenza A(H1N1)
Global Confirmed Deaths, by Week
n=10,863
Source: ECDC
* Increase in number of deaths in week 43 due to aggregate reporting of fatal cases from Brazil (week 37-40) & due to batch report
of US fatal cases since August 1, 2009
As of December 18, 2009

23. 17 6
326
45
684
73
2 1
26
1
117
23 35
0
200
400
600
800
1000
Afghanistan
Bangladesh
China
(Minland)
HongKong
SARChina
India
Japan
MacaoSAR
China
Maldives
Mongolia
Pakistan
SouthKorea
SriLanka
Taiwan
Countries
ConfirmedDeaths
North-East & South Asia Confirmed Deaths
n=1,356
Source: ECDC
As of December 18, 2009

24. Level of Threat
 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

25. Pandemic Influenza
Viruses
Pandemic Subtype
1889 H2N?
1899 H3N8
1918 H1N1
1957 H2N2
1968 H3N2
1977 H1N1

26. Circulating Influenza Strains and
Pandemics in The 20th Century
1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”
H1N1 H2N2 H3N2
20-40 million deaths 1-4 million deaths 1-4 million deaths

27. Remergence of H1N1.
 Re-emerging infectious Diseases
 Diseases’ incidence in human has increased during the last 20 years or threatens to
increase in the near future
 Infectious agents that have been known for some time, had fallen to such low levels
that they were no longer considered public health problems & are now showing
upward trends in incidence or prevalence worldwide
 From Nov 1977 to mid 1978 young adults suffered from influenza in USSR and China.
 Morbidity was almost exclusively limited to persons younger than 25yr of age.
 This suggested that older individuals were being protected by pre existing immunity.
 This assumption was proven when the causative agent was found to be H1N1.
(A/USSR/77).

28. Swine flu in India
 Union Health Ministry data said 1,319 persons have perished due to the disease
while the number of persons affected across the states stood at 24,661 as on
March 6.
 The Ministry had said that 1,289 had died while the number of those affected
by it across the states was 23,922 as on March 5 2015.

29. Swine flu in Maharashtra
 As of 11th March 2015 2890 cases have been reported from various parts
of maharashtra
 235 deaths have been confirmed.

30. Swine flu: LATUR
 Swine flu isolation ward was formed in February 2015.
 Total no. of person tested:137
 No. of person tested positive:33
 No of deaths: 11

33. Case Definitions
A Case under Investigation
Individual presenting with
• A). High fever >38°C,
AND
• B). One or more of the respiratory symptoms
AND
• C). One or more of the following:
– Close contact with a person diagnosed as Influenza A/H1N1 OR
– Recent travel to an area reporting cases of confirmed Influenza
A/H1N1

34. Case Definitions (cont)
Probable Case
Defined as a suspected case, with an influenza test that is
positive for influenza A
Confirmed Case
Laboratory confirmed Influenza A/H1N1 virus infection by
•Real-time RT-PCR
•Viral culture
•4-fold rise in H1N1 virus specific neutralizing antibodies

35. Clinical Features
 Short incubation period, usually 1-4 days.
 Spread by respiratory droplets
 Person to person,
 Direct contact, rare aerosol
 Highly contagious
 infectious period:
Adults: 1 day prior to symptoms & 5 days post illness
Children: >10 days
Immune compromised shed virus for weeks to months
 Virus is detectable just before symptom onset.
 Usually not detectable after 5-10 days

36. The illness

37. Symptoms
Symptoms Number (n=268) %
Fever 249 93%
Cough 223 83%
Shortness of breath 145 54%
Fatigue/Weakness 180 40%
Chills 99 37%
Myalgias 96 36%
Rhinorrhea 96 36%
Sore throat 84 31%
Headache 83 31%
Vomiting 78 29%
Wheezing 64 24%
Diarrhea 64 24%
Source: CDC. http://www.cdc.gov/h1niflu/surveillanceqa.htm

39. Signs of progressive illness
• Persistent high fever beyond 3 days
• Dyspnea, cyanosis
• Bloody or coloured sputum, chest pain or low blood pressure
• Dyspnea, tachypnea in children
• Drowsiness, confusion or severe weakness
• Dehydration, which can cause dizziness, decreased urine
output or lethargy.
• Diagnostic testing to confirm the pandemic virus should be
prioritized for patients at higher risk for severe illness.

40. Complications.
 Pulmonary complications
 Primary viral pneumonia
 Combined viral bacterial pneumonia
 Secondary bacterial pneumonia.
 ARDS
 Extra pulmonary complications.
 Viremia
 Myositis
 Cardiac involvement
 Reye’s syndrome
 CNS involvement
 Toxic shock syndrome.

41. High Risk
 Children younger than 2 years
 Persons aged 65 years or older
 Pregnant females
 Persons of any age with chronic medical or immunosuppressive
conditions.

42. Radiological Findings in Severe Disease

43. Indications for H1N1 Testing
a. Radiographically confirmed pneumonia, acute respiratory
distress syndrome, or other severe respiratory illness for
which an alternate diagnosis has not been established,
AND
b. Stay or history of travel within 10 days of symptom onset to
a place with documented influenza in animal and/or humans

45. Available Diagnostic Tests1
Influenza
Diagnostic
Tests
Metho
d
Availabi
lity
Typical
Processing
Time
2
Sensitivity
3
for
H1N1
influenza
Distinguishes H1N1
influenza from other
influenza A viruses?
Rapid influenza
diagnostic
tests (RIDT)
4
Antigen
det
ecti
on
Wide 0.5 hour 10 – 70% No
Direct and indirect
Immunofluorescen
ce
assays (DFA and
IFA)
5
Antigen
det
ecti
on
Wide 2 – 4 hours 47–93% No
Viral isolation in
tissue cell
culture
Virus
isol
ati
on
Limited 2 -10 days - Yes
6
Nucleic acid
amplification
tests
(including rRT-
PCR)
7
RNA
det
ecti
on
Limited
8
48 – 96
hours
[6-8 hours to
perform test]
86 – 100% Yes

46. Sample collection.
 Respiratory specimens including:
 bronchoalveolar lavage,
 tracheal aspirates,
 nasopharyngeal or oropharyngeal aspirates as washes, and
 nasopharyngeal or oropharyngeal swabs.
 Swab specimens should be collected only on swabs with a synthetic tip (such as polyester
or Dacron) and aluminium or plastic shaft.
 Swabs with cotton and wooden shafts are not recommended. Specimens collected with
swabs made of calcium alginate are acceptable.

47.  When to Collect Respiratory Specimens?
 As soon as possible after symptoms begin
 Before antiviral medications are administered even if symptoms began
more than one week ago
 Multiple specimens on multiple days could be collected if you have access to
patient
 Specimen: before initiating collection of sample a full complement of PPE
should be worn.
 Methods of Collection
 • Throat swab
 • Nasal / Nasopharyngeal swab

48. • Throat Swab
• Easy to do
• Highest yield in detecting H1N1 influenza in
suspected cases
• Have the patient open his/her mouth wide
open.
• The patient should try to resist gagging and
closing the mouth while the swab touches
the back of the throat near the tonsils.

49.  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’s stick.
 Nasal Swab is collected from
the anterior turbinate.

50.  The swabs are collected and put in a viral transport medium (VTM).
 How to Label Samples
 Label
 Specimen No. :
 Subject’s unique identification number
 Patient’s Name :
 Hospital Name :
 Use pre-printed barcode* labels:
 – On the specimen container
 – On the field data collection form
 – On the log book
 – Subject’s name
 – Subject’s unique identification number

51. Transport of specimen.
 All samples should be transported after proper packaging using
the standard triple packaging system (WHO) and it should
accompany with the clinical details
 While transportation cold chain should be maintained

52. Test centres in India.
 Laboratories under the IDSP (NCDC) and ICMR network with capacity of testing Influenza
virus
 IDSP Network of Laboratories
 S.No. Name of Lab
 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

53.  ICMR Influenza Surveillance Network
 1. Sher-e-Kashmir Institute of Medical Sciences, Srinagar
 2. All India Institute of Medical Sciences, New Delhi
 3. National Institute for Cholera & Enteric Diseases, Kolkata
 4. Regional Medical Research Centre, Dibrugarh
 5. Indira Gandhi Govt. Medical College, Nagpur
 6. National Institute of Virology, Pune
 7. National Institute of Virology, Allapuzha, Kerala
 8. King Institute of Preventive Medicine, Chennai
 9. King George Medical University, Lucknow

54. How Severe It is…..????
 Initial estimates of mortality rates from H1N1 infection in Mexico
ranged as high as 8%. This is a remarkably high mortality rate when
viewed in the context of the 2% mortality rate during the 1918 Spanish
Flu pandemic.
 Subsequent data from the United States and WHO indicated that the
mortality rate from H1N1 infection was probably even lower than the
mortality rate expected from seasonal flu.
 Data over the ensuing months have confirmed that overall mortality
from H1N1 infection is less than 1% and may be less than 0.1%

55. Management
Antivirals
 Neuraminidase inhibitors
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Peramivir
 Adamantanes (Not used because of resistance)
 Amantadine
 Rimantadine
Don’t get panic….Treat as simple RTI
Bed rest, hydration, analgesic, cough suppressants

57. Antiviral Treatment
 There are two flu antiviral drugs recommended
 Oseltamivir or Zanamivir
 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 – 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 Reye’s syndrome. For
relief of fever, other anti-pyretic medications are recommended such as
acetaminophen or non steroidal anti-inflammatory drugs.
Source: CDC

58.  Treatment is recommended for:
 All hospitalized patients with confirmed, probable or suspected
H1N1 cases.
 Patients who are at higher risk for seasonal influenza
complications
 If patient is not in a high-risk group or is not hospitalized,
healthcare providers should use clinical judgment to guide
treatment decisions

59. Treatment Priority Groups
Treatment is recommended for all outpatients with confirmed or
suspected influenza if they belong to groups known to be at higher
risk. These groups include:
 infants
 Persons aged 65 years or older;
 Pregnant females;
 Persons of any age with chronic medical or immunosuppressive
conditions.

60. Importance of the Early
Treatment

61. Chemoprophylaxis
• Antiviral Chemoprophylaxis
– Post-exposure: can be considered in:
• Close contacts of cases (confirmed, probable, or suspected)
• Health care personnel, public health workers, or first responders
who have had a recognized, unprotected close contact exposure to
a person (confirmed, probable, or suspected) during that person’s
infectious period.
– Pre-exposure: Antivirals should only be used in limited circumstances,
and in consultation with local medical or public health authorities.
Source: CDC

62. Source: CDC
Oseltamivir (Tamiflu) Zanamivir (Relenza)
Treatment Prophylaxis 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
Antiviral Protection

63. Management Issues
 ICU care and non availability of ventilatory support systems.
 Oseltamivir resistance has been an issue with seasonal influenza A
infection and is beginning to emerge in pandemic H1N1.
 Zanamivir and asthma
 In Extracorporeal membrane oxygenation (ECMO) the patient's large
vessels are cannulated, blood pumped through the a membrane that
removes CO2 and adds O2, and then returned to the patient. ECMO has
traditionally been used in neonates.

64. Vaccine Protection
 H1N1 vaccine available for since Mid-September 2009
 H1N1 vaccine is not intended to replace the seasonal flu vaccine – it is
intended to be used along-side seasonal flu vaccine
 Vaccines:
 Inactivated influenza virus vaccines
 CSL Ltd. of Australia
 Novartis Vaccines of Switzerland
 Sanofi Pasteur of France GlaxoSmithKline (GSK) of UK
 Sinovac Biotech of China
 Live-attenuated virus vaccine
 MedImmune LLC of US (nasal-spray)

65. Vaccine Protection
 Pregnant women because they are at higher risk of complications and can
potentially provide protection to infants who cannot be vaccinated;
 Household contacts and caregivers for children younger than 6 months of
age because younger infants are at higher risk of influenza-related
complications and cannot be vaccinated.
 Healthcare and emergency medical services personnel because infections
among healthcare workers have been reported and this can be a potential
source of infection for vulnerable patients. Also, increased absenteeism in
this population could reduce healthcare system capacity;
 All people from 6 months through 24 years of age
Source: CDC

66.  Children from 6 months through 18 years of age because many cases of H1N1
influenza in children and they are in close contact with each other in school and
day care settings, which increases the likelihood of disease spread, and
 Young adults 19 through 24 years of age because we have seen many cases of
novel H1N1 influenza in these healthy young adults and they often live, work, and
study in close proximity, and they are a frequently mobile population; and,
 Persons aged 25 through 64 years who have health conditions associated with
higher risk of medical complications from influenza.

68. Source: Bean B, et al. JID 1982;146:47-51
Survival of Influenza Virus Surfaces and Affect
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 28C (82F)

69. Biosafety Guidelines
 General Biosafety Measures
 Clinical samples should be collected by hospital staff and not by the
laboratory staff.
 All clinical samples have to be collected wearing complete
complement of PPE.
 While taking samples always use N95 mask.
 Use Latex disposable gloves.
 Wear laboratory coat/disposable apron.
 Always cover your hairs with head cover.

Source: CDC

70.  Use protective eye wear (goggles)/face shields
 The clinical samples should be processed only in designated laboratory having the
appropriate containment facilities.
 All technical procedures should be performed in a way that minimizes the formation of
aerosols and droplets.
 Adequate and conveniently located biohazard containers should be available for disposal
of contaminated materials.
 Work surfaces must be decontaminated after any spill of potentially dangerous material
and at the end of the working day. Generally, 5% bleach solutions are appropriate for
dealing with biohazard us spillage. More information on disinfections and sterilization is
provided in the WHO laboratory biosafety manual.
 Personnel must wash their hands often – especially after handling infectious materials and
, before leaving the laboratory working areas, and before eating.
 Personal protective equipment must be removed before leaving the laboratory.

 Appropriate disinfectants
 70 per cent ethanol
 5 per cent Lysol
 10 per cent bleach
 .

71. N95 Mask is effective but must be tight-fitting

73.  All personnel should self monitor for fever and any symptoms.
Symptoms of swine influenza infection include diarrhea, headache,
runny nose, and muscle aches
 Any illness should be reported immediately
 For personnel who had unprotected exposure or a known breach in
personal protective equipment to clinical material or live virus from a
confirmed case of swine influenza A (H1N1), antiviral
chemoprophylaxis with zanamivir or oseltamivir for 7 days after
exposure can be considered

74.  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. For suctioning, bronchoscopy,
or intubation, use a procedure room with negative pressure air
handling.
 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
used by the ill person should be washed with soap and water before
use by other persons.
Infection Control in ill admitted Persons
Source: CDC

75.  Standard, Droplet and Contact precautions should be used for all
patient care activities, and maintained for 7 days after illness onset or
until symptoms have resolved. Maintain adherence to 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.
 Personnel providing care to or collecting clinical specimens from
suspected or confirmed cases should wear disposable non-sterile
gloves, gowns, and eye protection (e.g., goggles) to prevent
conjunctival exposure.
Infection Control in ill admitted Persons
Source: CDC

76. Guidelines for General Population
 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

77. Prevention
Respiratory
etiquette
Cover nose / mouth
when coughing or
sneezing
Hand washing!

78. Hand Washing
 Wet hands with clean (not hot)
water
 Apply soap
 Rub hands together for at least
20 seconds
 Rinse with clean water
 Dry with disposable towel or air
dry
 Use towel to turn off faucet

79. Effective Hand washing

81. Droplet precautions
Surgical Masks N-95 Filtering Masks

85. Household Cleaning, Laundry, and Waste
Disposal
• Throw away tissues and other disposable items used by the sick
person in the trash. Wash your hands after touching used tissues
and similar waste.
• Keep surfaces (esp bedside tables, surfaces in the bathroom,
children’s toys, phone handles, doorknobs) clean by wiping them
down with a household disinfectant .
• Linens, eating utensils, and dishes belonging to those who are sick
do not need to be cleaned separately, but importantly these items
should not be shared without washing thoroughly first.
• Wash linens (such as bed sheets and towels) by using household
laundry soap and tumble dry on a hot setting. Avoid “hugging”
laundry prior to washing it to prevent contaminating yourself. Clean
your hands with soap and water or alcohol-based hand rub right after
handling dirty laundry.
• Eating utensils should be washed either in a dishwasher or by hand
with water and soap.

86. Seasonal Influenza A H1N1
(as on 24.02.2015)
Action Taken by Ministry of Health and Family Welfare
 MOHFW deputed senior level Public Health Teams to highly affected states like gujrat,
maharastra, madhya pradesh, karnataka , J&K, west bengal.
 Integrated Disease Surveillance Programme (IDSP) and its State units have enhanced the
surveillance for Influenza Like Illness (ILI) and Severe Acute Respiratory Infections (SARI)
 IDSP assisted lab network of 12 Laboratories are providing laboratory support in terms of
testing, quality assurance, guidance, providing viral transport mediums and diagnostic
reagents.
 The States have been asked to follow the risk categorization followed during the Pandemic.
 Rapid Response Teams up to District level and Clinicians from all the States / UTs underwent
training during the Pandemic (2009).

87. In a letter dated 27.02.15. DMER has issued new orders
regarding the change in swine flu testing policy.
Regular advertisements for do’s and don’ts for Influenza A
H1N1are being issued by MOHFW in national and local
newspapers.
The Outbreak Monitoring Cell of NCDC is functioning
round the clock to attend to public queries. The call
number is 011-23921401.

88. Summary
• WHO raised the alert level to Phase 6 on June 11, 2009
• Influenza transmission remains active in much of western and central Asia and
there is evidence of pandemic virus circulation in most regions of Africa
• The overall global case-fatality is ~1%
• Symptoms mimic seasonal flu
• 1:1 Male:Female Ratio
• Globally
– Number of deaths being reported is rising
• Vaccine
– Total Adverse Events: 5.4% (0.3% fatal)
– Sanofi Pasteur vaccine recalled due to potency issues
• Anti-virals (oseltamivir and zanamivir)
– Oseltamivir resistance reported recently in immunocompromised patents

89. Panic and Fear are much dangerous than Swine
Flu

90. Prevention is better than cure

91. Thank you

92. References
 http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/flu.htm
 http://www.who.int/mediacentre/factsheets/fs103/en/
 http://mohfw.gov.in
 www.osha.gov
 Wright et. al. orthomyxoviridae: the viruses and their replication. Fields texbook of
virology. 1409-1448.
 Hampton, Tracy. Vaccines Against influenza viruses Viruses Show Promise in
Primates Studies. Maedical News and Perspectives. JAMA. Vol. 294 No. 2 July
2005.
 Jones, Steven. Live attenuated recombinant vaccine protects nonhuman primates
against influenza viruses. Nature Medicine. Vol. 11 No. 7 July 2005.