Transcript Slide 1

www.drsarma.in
Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA
Consultant Physician & Chest Specialist
• Treatment is largely supportive
– Bed rest; Patient should stay at home for 7 days
– Increased fluid consumption; Cough suppressants and
– Cough Etiquette, Hand washing, Use of Mask by patient
– Antipyretics and analgesics (Paracetamol, NSAIDs)
– Pt to avoid close contact with other persons, co-morbid
– May require intravenous hydration & supportive measures
– Home Isolation; One designated person to take care
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– Antibiotics for secondary bacterial infection
• Shortness of breath, with activity or while resting
• Difficulty in breathing, Chest pain on breathing
• Turning blue (cyanosis)
• Bloody or rust colored sputum
• Altered mental status, severe fatigue
• High fever that persists beyond 3 days
• Low blood pressure
• Refusal of feeds by children
• Tachypnea, No interest in play, Not getting up
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Category A
1.
Fever with cough and throat pain  body pain and headache,
diarrhea and vomiting.
2. No need to test for A(H1N1). No need to give Tamiflu.
3. Symptomatic Rx. and home isolation. Cough etiquette.
4. Avoid mixing with others – Use of Mask must
5. Under constant supervision for a three days.
6. Watch out for danger signs of progression.
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Category B
1. All signs and symptoms of category A, In addition if they have
2. High fever ( > 1010 F) and severe throat infection. Or
3. Children < 5 years, pregnant women, Adults 65 + age and or
4. With co-morbidities of the kidneys, heart and lungs, chronic liver
disease, Cancer, diabetics and HIV., long term steroid Rx.,
5. Give Tamiflu and other symptomatic measures + Infection control
6. But no test for A (H1N1). Watch out for serious signs.
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7. Home isolation, Mask, Avoid mixing for at least 10 days
Category C
1. Same signs and symptoms as Category B,
2. But have breathlessness, chest pain, fainting spells, low blood
pressure, blood in the phlegm, cyanosis, altered sensorium.
3. Irritability among small children, refusal to accept feeds.
4. Worsening of underlying chronic co-morbid conditions.
5. Must get Tamiflu and must be hospitalized immediately.
6. Must be tested for A (H1N1) and informed of the severity.
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A (90%)
• Home
• No Tamiflu
• No Test
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B (8%)
C (2%)
• Home
• Tamiflu
• No Test
• Hosp
• Tamiflu
• Test
• It is a neuraminidase inhibitor, decreases the release of
viruses from infected cells and, thus, viral spread.
• Must be administered within 48 hours of symptom onset
• Reduces the length of illness by an average of 1.5 to 2.5 days
• Duration of administration for treatment is 5 days – may be 10 days
• Post-exposure prophylaxis to be initiated within 7 days of exposure
and continued for at least 10 days
• Available as 30-mg, 45-mg, and 75-mg capsules and as a powder
for suspension containing 12 mg/mL after reconstitution
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• Adult Dose
– Acute illness: 75 mg PO (150 mg) bid for 5 days – up to 10 days
– Prophylaxis: 75 mg PO once a day for 10 days after exposure
• Pediatric dose
– Acute illness in children aged <1 year
• <3 months: 12 mg PO bid for 5 d; 3-5 months: 20 mg PO bid for 5 d
• 6-11 months: 25 mg PO bid for 5 d
– Acute illness and age >1 year
• <15 kg: 30 mg PO bid for 5 d; 15-23 kg: 45 mg PO bid for 5 d
• 23-40 kg: 60 mg PO bid for 5 d; >40 kg: Administer as in adults
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It is a neuraminidase inhibitor, decreases the release of viruses from infected
cells and, thus, viral spread. Must be administered within 48 hours
Adult Dose
Treatment for acute illness: 10 mg inhaled orally bid for 5 days
• Prophylaxis of household contact: 10 mg inhaled orally od for 10 d
• Prophylaxis for community outbreak: 10 mg inhaled orally od for 28 d
Pediatric Dose
Treatment for acute illness
• <7 years: Not established; >7 years: Administer as in adults
Both are ‘Pregnancy Category C’ – Not a contraindication – prefer Zanamivir
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Tamiflu – Some Issues
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• Nausea
• Cost – 10 caps 2000/-
• Vomiting
• Not available in private
• Diarrhea
• Misuse
• Bronchitis
• Hoarding
• Stomach pain
• Resistance
• Dizziness
• Spurious caps
• Headache
• Limited Pvt. availability
• Confusion, Hallucinations
• Private Hospitals - yes
• Most cases do not need Test, Tami Flu, Hospitalization
• Supportive treatment and home isolation will suffice
• Watch out for the high risk groups and Category B and C
• Early administration of Tami Flu if indicated; Reduces viremia
• Monitor O2 saturation and maintain 90-92% saturation - O2 Rx.
• Antibiotics for secondary bacterial pneumonia – as per CAP
• MRSA; Ventilator support in severely ill – VAP; Vasopressors
• No role for corticosteroids except in shock; Risk is increased
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• ARDS – Lung protective mechanical ventilation
• Prophylaxis with antiviral agents - Post-exposure
– Close household contacts of a confirmed or suspected case who are at high
risk for complications (chronic medical conditions, persons >65 y or <5 y,
pregnant women)
– School children at high risk for complications who have been in close contact
with a confirmed or suspected case
– Travelers to Mexico, USA who are at high risk for complications
– Health care providers or public health workers who were not using
appropriate personal protective equipment during close contact with a
confirmed or suspected case
• Prophylaxis with antiviral agents - Pre-exposure
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– Any health care provider who is at high risk for complications (persons with
chronic medical conditions, adults >65 y, pregnant women)
Vaccine is available in Europe and China
(H1N1)v
Virus
Isolation and
Characterization
Seed
Virus
Pilot lots
Scale up for
commercial
production
Vaccine is just becoming available.
Seasonal Flu Vaccine is not effective
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Clinical
Evaluation
–VTEUs
Commercial
production
Formulation,
Filling and
Delivery
1. Airborne transmission – No unusual routes – Food no risk
2. Cumulative clinical attack rate – 20 to 30%
3. Over 90% of the illness is mild and self limiting
4. Highest affected will be children and young adults
5. Adults > 60 years seem to be least affected
6. High risk groups discussed must be watched for fatality
7. Hospitalization rates will be 1 to 2% of clinical cases
8. The term ‘swine flu’ is inaccurate & confusing– A H1N1v 2009
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9. Case Fatality Rate will be around 0.1 to 0.2% (1-2 per 1000)
10. Fatality will be more in children and very old and high risk
11. Hospitalizations are for high risk groups, people < 5, > 60 yrs
12. H1N1v is sensitive to Oseltamivir and Zanamivir – NAIs
13. Seasonal flue vaccine is in effective; Vaccine in October
14. The virus can mutate at any time – Second wave aggressive
15. International co-operation and sharing of experience
16. All these rates & ratios are biased upwards – inapparent inf.
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Cough Etiquette
Hand washing
Social Distancing
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• This Flu is like any other ARI
• Cover your cough and sneeze
• Frequent hand washing
• Hand – face distancing
• Social distancing
• Fomite transmission – cell phones
• Home isolation; Discuss the need for Test and Tamiflu
• Only a small proportion need hospitalization
• Flu death is rare; No need to panic
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• Remember is similar in most respects like any other ARI
• Suspect the pandemic flu – particularly if temp is > 100
• Look for signs of serious illness – SOB, chest pain, blood etc
• Look for high risk profile, Be watchful about young kids
• Categorize the patient as A, B or C and write down the stage
• Take appropriate action as per the category
• Segregate patients at first contact in the waiting room
• Give priority to those with ARI and reduce contact time
• Protect yourself with mask while examining a suspect case
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• http://www.emedicinehealth.com/swine_flu/article_em.htm#history
• http://www.who.int/csr/disease/swineflu/en/index.html
• http://www.who.int/csr/disease/avian_influenza/phase/en/
• Journal of Applied Microbiology 91 (4): 572–579, 2001
• http://knol.google.com/k/salim-djelouat/swine-flu-pandemic-review
• http://emedicine.medscape.com/article/1673658-overview
• http://www.cdc.gov/h1n1flu/general_info.htm
• http://www.cdc.gov/h1n1flu/
• http://www.cdc.gov/h1n1flu/surveillanceqa.htm
• http://www.cdc.gov/h1n1flu/masks.htm
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• http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm
• http://www.cdc.gov/h1n1flu/recommendations.htm
• http://www.ecdc.europa.eu/en/Pages/home.aspx
• http://www.ecdc.europa.eu/en/healthtopics/PublishingImages/World_Map
• http://sis.nlm.nih.gov/enviro/swineflu.html#a3
• New England Journal of Medicine: H1N1 Influenza Center
• http://www.lancet.com/H1N1-flu
• http://www.healthmap.org/en
• http://pandemicflu.bmj.com/
• H1N1 Clinical Medical References & Guidelines @ MDConsult.com
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