Swine Flu

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					A,B,C of Flu
Human FLU                               Deaths worldwide

 Seasonal flu: mainly A + B (C rare)     500,000 / yr


Influenza A virus pandemics:
 H1N1:          Spanish Flu 1918         50 million
 H2N2:          Asian Flu 1957           2 million
 H3N2:          Hong-Kong Flu 1968       1 million

 H5N1:         Bird Flu
Where does Swine Flu fit in?
Swine Flu
       New influenza A(H1N1) virus
       Unrelated to seasonal flu
       Respiratory disease of pigs,
        birds, poultry, horses &
        humans



      “Quadruple reassortant" virus
       Bird-Flu gene
       Pig-flu gene
          2 genes: Europe & Asia
       Human-gene
 Pandemic H1N1 2009
 Never before circulated in humans
 WHO Phase 6 = Pandemic
 > 300,000 cases in over 200 countries
Symptoms
 Fever (> 38°C / 100.4°F)

Plus 2 or more of:

   Tiredness
   Headache
   Runny nose
   Sore throat
   SOB /cough
   Loss of appetite
   Aching muscles
   D&V
Who Is At Risk?
Chronic Disease:
 Lung
 Heart
 Kidney
 Liver
 Neurological           Also:
 Immunosuppressed        Pregnant women
 Diabetes                Elderly ≥ 65 y
 Asthma (Rx past 3 y)
                          Children <5 y
               UK 2009 Timeline
 March:       first confirmed cases (US & Mexico)
 April:       confirmed in UK
 June:        first death in UK, Glasgow
 July:        1st death with no underlying medical probs

     Containment to Treatment Phase
              Diagnose on symptoms NOT testing
              All contact tracing stopped
              Exposure does not = antiviral drugs


 Sept:        Rising new cases
Predictions
              Infected = 18.3m

              Deaths
               18-64,050

              Hospital
               366,000

              Complications
               2.74m

              Mild
               15m
Public Messages
 Catch it, bin it, kill it
    Cover mouth / tissues / basic hygiene
    Hard surfaces e.g. Door handles, keyboards, phones


 Stay at Home
    If symptoms (5-7d)
    Flu friends


 Face mask unnecessary

 Contact
    GP / NHS 24
    National Pandemic Flu Service
DOH: General Advice
 Children
    Attend schools unless flu symptoms
    Avoid “flu-parties”
    See Doctor if < 1 yr

 Pregnant
      Routine avoidance measures
      Safe to breastfeed if anti-virals
      Teachers advised to attend school

 Travel:
    Unrestricted unless symptomatic
    Avoid Mecca Pilgrimages if high-risk group
                          Headlines
 “Swine flu jabs rushed through safety tests”
 “GPs demand more money for swine flu jabs” TIMES ONLINE
 “NHS staff don’t want swine flu jab”
    “Up to half of GPs and one in three nurses ... because of concerns
     over safety.” Telegraph
    “Vaccine risk outweighs risk of virus” Irish-Times
 “Swine flu over-diagnosed”
 “Swine-flu under-reported”
HCP Advice
 Triage suspected cases
 Avoid in surgery if possible
 Declutter waiting rooms


 Use of PPE
    Gloves
    Mask
    Glasses
    Gown
Antivirals
 May lessen severity by reducing:
   Length of illness (~ 1 day)
   Symptoms, and
   ? Serious complications risk


 Maximum benefit
   Adults: Within 48 hrs of symptoms onset
   Children: Within 36 hrs of symptoms onset


 Preparation:
    TAMIFLU (Oseltamivir) & RELENZA (Zanamivir)
    neuraminidase enzyme inhibitors
Action
 Block viral enzyme
 Prevent shedding


Safety
 Relatively new
 report via the MHRA’s
  ‘Swine Flu ADR Portal’
Tamiflu
 Age 1 and over
 Caps: 30/45/75mg
 Susp: 12mg/ml solution                    Dose:
                                             Age 1-12
SEs                                             BW ≤ 15kg:    30mg
 676 suspected ADRs since April                BW ≤ 23kg:    45mg
 nausea, vomiting, diarrhoea, abdo pain,       BW ≤ 40kg:    60mg
   headache, mild allergic
                                             Age 13+/>40kg:   75mg
 ??seizures/delirium

                                            Duration:
Caution
                                             Treat = bd for 5 days
 Severe renal impairment
                                             Prev = od for 10 days
       AVOID dialysis (CrCl ≤ 10ml/min)
 ?methotrexate ?probenecid
                                            NB
 ?? warfarin
                                             Best with food
Relenza
 Age 5 and over
 Inhaled (Diskhaler): 5mg dose
 Use: pregnancy, renal disorders


SEs:
 22 suspected ADRs since April
 V rare: 1 in 10,000
                                         Dose:
 allergy, bronchospasm
                                          2 inhalations (2 blisters) = 10mg

Caution:
                                         Duration:
 persistent asthma/severe COPD
     AVOID severe asthma                 Treat = bd for 5 days
     Use bronchodilator before taking    Prev = od for 10 or 28 days*
AVOID:
 allergy to lactose/milk protein        * Longer duration if community outbreak
Vaccination
                       Vaccination
 First batches expected October
    Once licensed by European Medicines Agency (EMEA)
    Safety concerns (medical / case reports Guillain-Barre 1970’s)


 Prioritised by risk Grp
    2 doses, 3 weeks apart
    Annual flu vaccination also required


 “Previous Swine-flu” does not reduce risk
    Even if received anti-virals
    Exception is lab (swab) +ve cases
1 st   Stage Contact

                                      SCOTLAND      ENGLAND

1.   High Risk: age > 6m – 65 y       640,700       5m
2.   Pregnant                         60,000        0.5 m
3.   House contacts immunosuppr       53,000        0.5 m
4.   High-Risk: age > 65 y            428,250       3.5 m
5.   Frontline Health Professionals   250,000       2m
                                      _______ __    ________
                         TOTAL =      1.4 million   11 million
Complications
                               Complications
                                                     NEJM 2009
 Most common severe complications
    Respiratory Distress
    Pneumonia


 Youth Shift: Age 5-59
    87% of total Deaths (exp ~ 17%)
    71% of Severe pneumonia (exp~32%)


• Selective Antivirals (WHO Aug 2009)
    • High risk groups
    • Serious / deteriorating cases =
    SOB / Resp distress / cyanosis / haemoptysis /
      chest pain / fever >3d / confusion / low BP
Second Wave?
                Is it coming back?
                              Week until 14/9/9: Sentinel GP practice data
 New cases in Scotland
    Higher now than start of August
    Past week          6181
    Prev week          3336

 Consultation rates
    Tayside > Scottish average
    Increasing           age < 65
    Decreasing           age > 65

 Complications
    Hospitalised         13 cases (1 ICU)
    Deaths               8 cases
    2nd wave likely coincide with seasonal flu
Summary    High Risk
               “Young people”
               Pregnancy
               Chronic Disease / immuno-suppressed
               esp < 5y & >65y

           Course
               Most mild  self-care
               Mortality ~0.3% (= seasonal flu)
               Second-wave


           Anti-virals
               Best evidence severe cases / high-risk
               Treat based on risk groups
               ? Emerging resistance


           Vaccination
               Late-October
               Normal flu-risk group 6m – 65y
              Extra:
               Frontline health-care workers
The End
 www.direct.gov.uk
 www.nhs24.com
 www.scotland.gov.uk
 www.rcgp.org.uk/pandemic
 www.hpa.org.uk
 www.bma.org.uk/health_promoti
  on_ethics/influenza
 www.documents.hps.scot.nhs.uk/
  respiratory/swine-
  influenza/situation-
  reports/weekly-h1n1v

				
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