Influenza AH 1N1

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					     Influenza A H1N1
             &
 Current Management of
Influenza Like Illness (ILI)



                       Dr Fatahul Laham
                 Influenza
- Normal Burden of Disease
a. Seasonal Influenza
   - Globally 250,000 to 500,000 death/year
   - In U.S (per year)
      - about 35,000 death
      - 200,000 hospitalisation
      - USD 37.5 billion in economic cost
      - USD 10 billion lost productivity
b. Pandemic Influenza
   - An ever present threat
  Pandemic Flu and Pandemic
     Threat Flu since 1900

• Probably happened during at least 4
  centuries
• 3 pandemic and several pandemic threat
  have occurred since 1900
  Pandemic Flu and Pandemic
     Threat Flu since 1900
Spanish Flu 1918
- The catastrophe against all modern
  pandemic are measured
- 20% to 40% worldwide population became
  ill.
- 0ver 50 million died
- Many people died very fast
- Sept 1918 – April 1919 – 675,000 death
  from flu in u.s
   Pandemic Flu and Pandemic
      Threat Flu since 1900
Asian Flu (1957)
 - First detected in the far east
 - 69,800 people in u.s died

Hong Kong Flu (1968)
 - First detected in Hong Kong early 1968
 - First detected in u.s in September 1968
 - Sept 1968 – March 1969 33,800 death in u.s
   Pandemic Flu and Pandemic
      Threat Flu since 1900
• 1976 – Swine flu threat
• 1977 – Russian flu threat
• 1997 – Avian Flu threat
            Influenza A Virus
• Found in many different animals
• Flu strains are name after their types of hemaglutinin
  and neuraminidase surface protein
• E.g H3N2 for type 3 haemaglutinin and type 2
  neuraminidase
• There are 16 different haemaglutinin subtypes (H1 –
  H16) and 9 neuraminidase subtypes (N1 – N9)
• If 2 different strains of influenza infect the same cells
  simultaneously, the host cell then forms new viruses that
  combine antigen
• E.g H3N2 and H5N1 can form H5N1
       H1N3 and H5N1 can form H1N1
            Influenza A H1N1
• New strain detected in California (24 April 2009)
• Mixed gene of human, avian and swine
  (Influenza A/California/04/09)
       - North American swine
       - North American avian
       - North American human
       - Eurasian swine
• Swine Flu A H1N1 was refer to Influenza A H1N1 since
  30 April 2009
• Efficient human to human transmission
• Everyone is at risk due to absence to immunity
    Global Influenza A H1N1
    Current status (29/7/09)

• 169,573 cases reported
• 1125 death
• 159 country
* Increased 6,083 cases and 100 death
   compare the day before
       Local Influenza A H1N1
       Current status (29/7/09)
• 1,266 confirmed cases reported with
  574(45%) were imported cases whereas 692
  (55%) were local transmission
• 47 new cases and all are local transmission
• 4 Death
• 1233 cases recovered
• 24 cases (2%) received anti-viral therapy at
  Hospital
• 9 cases (1%) received anti-viral therapy as out-
  patient
           PANDEMIC INFLUENZA PHASE


                                                    Phase 5 – 6
                                                  Pandemic Phase
                                     Phase                                Post
                                       4                                  Peak
           Phase 1 - 3                                                                 Post
Time                                                                                 Pandemic




       Predominantly animal          Sustained     Widespread human    Possibility    Disease
       Infection with few human   human-human          infection      of recurrent    activity at
       infection                   transmission                          events       seasonal
                                                                                        level
Lessons from past pandemic
Past pandemics were characterized by :
• a shift in virus subtype
• shifts of highest death rates to younger
  populations,
• higher transmissibility
• differences in impact in different
  geographic regions,
• successive pandemic waves
Assessment of Influenza A H1N1
  at early stage of pandemic
• Cases have been confirmed in all age group but
  – younger people more likely affected
• Most cases, the illness appear to be mild and
  self limiting.
• For minority of people, H1N1 has caused severe
  illness wt complication.
• In many of these cases underlying RISK
  FACTORS OR COMORBIDITIES have been
  identified to contribute to the severity of the
  condition.
 Infectiousness & Incubation
            period
• Estimated incubation period 1-7 days,
  [likely 1-4 days].
• H1N1 appears to be more contagious than
  seasonal influenza.
• Infectious period for a confirmed case of
  H1N1 virus infection is defined as 1 day
  prior to the case’s illness onset to 7 days
  after onset.
  Complications of influenza A
Respiratory                          Muscular
• Pneumonia: primary viral,          • Rhabdomyositis
  secondary bacterial, combined      • Rhabdomyolysis with
• Upper respiratory: otitis media,     myoglobinuria
  sinusitis, conjunctivitis            and renal failure
• Acute laryngotracheo-bronchitis    Neurological
  (croup)                            • Encephalitis
• Bronchiolitis                      • Reye’s syndrome
• Complication of pre-existing       • Guillain-Barré syndrome
  disease
                                     • Transverse myelitis
Cardiovascular
                                     Systemic
• Myocarditis, Pericarditis
                                     • Toxic shock syndrome
                                     • Sudden death
 Paradigm Shift
 Management of
Influenza A HINI
   in Malaysia
 Depending on phase of pandemic
As of 27th. April 09 until 24th June 2009
 (Containment Phase)
• In early phases; to prevent importation or to
  reduce viral transmission in the country
• Screening all the movement at entry point of
  country
• Those who had fever at the entry point and
  within 7 days off travel were taken throat swab
• There were separate area for management of
  case suspected influenza A H1N1 at all Health
  facilities
• Only 28 designated hospital were allowed to take
  throat swab and admission
As of 27th. April 09 until 24th June 09
(Containment Phase)
• All suspect influenza H1N1 cases will be
  admitted in designated hospitals and kept in
  isolation. There were given anti-viral therapy
• All close contact with positive Influenza A H1N1
  were aggressively identified, screen, quarantine
  and given prophylaxis anti-viral for 10 days.
• They were quarantine until the result of throat
  swab came back
• All the specimen must reach to IMR within 6hrs
As of 24th June 09 until 10th July 09
 (Containment Phase)
• Cases go beyond capacity of health facilities to
  cope, a policy of surveillance and treatment at
  home were modified
• All suspected case still taken the throat swab but
  were instructed to quarantine at home until
  result come back
• Hospital admissions were only be for
     • Positive H1N1
     • those with respiratory distress or
     • with assoc complications of influenza or those in
       high risk groups (ie.with co-morbidities).
As 10th July 09 until Now!
• Declared Mitigation Phase in Malaysia
• No more screening for suspected case
• Focused on all Influenza Like Illness (ILI)
  cases and identify their severity
• Only those admitted for moderate to
  severe ILI are given anti-viral treatment
• Identified clusters cases especially at
  institution premises
• If 20% of the sample taken positive that
  institution will close or qurantine
• Focused on education to public
   Containment vs mitigation
• Containment
  – Mostly imported cases
  – Clearly defined local cases (linked to imported cases)
    • Aim of control strategies : to delay spread of disease in our
      community.
• Mitigation
  – There is sustained community spread and and new
    cases have no defined epidemiological links with
    existing cases.
  – Aim of control of strategies:
    • To reduce morbidity and mortality of the disease.
    • To slow spread of disease
    • To minimize disruption of essential services.
               Definition
• Influenza-like-illness (ILI) is defined as
  – fever (esp. temperature > 38°C) and
  – cough and a sore throat in the absence of a
    KNOWN cause other than influenza.
• Close contact is defined as:
  – within about 3 feet of an ill person who is a
   confirmed or suspected case of influenza A
   H1N1 virus infection during the case’s
   infectious period.
            Education to Public
• Not all patients need to be seen by a health care provider.

• Pt wt ILI are advised to seek medical care should they develop:
• (Patient Home Assessment Tool)
   –   Respiratory Difficulties: Shortness of breath, rapid breathing or
   –   Purple or blue discoloration of lips
   –   Coughing out blood or blood streaked sputum
   –   Persistent chest pains
   –   Persistent diarrhea and / or vomiting
   –   Fever persisting beyond 3 days or recurring after 3 days
   –   Abnormal behavior , confusion, less responsive , convulsion
   –   Dizziness when standing and/or reduced urine production

• seek EARLY medical assessment (preferably within first 2 days of
  illness)
   In all Health Facilities
• Patient who fulfilled criteria for ILI:
  Should be assessed for :
     - Moderate to Severe Influenza
        – See Pt Home Assessment Tool
        – See Clinical assessment tools of moderate to severe
          disease
    - Co-morbidities (help to identifies
      patient with high risk)
• Consider admission.
    Clinical assessment tool for
    Moderate to Severe Influenza
•   Respiratory impairment: any of the following
     –   Tachypnoea, respiratory rate > 24/min
     –   Inability to complete sentence in one breath
     –   Use of accessory muscles of respiration, supraclavicular recession
     –   Oxygen saturation < 92% on pulse oximetry
     –   Decreased effort tolerance since onset of ILI
     –   Respiratory exhaustion
     –   Chest pains

•   Evidence of clinical dehydration or clinical shock
     – Systolic BP < 90mmHg and/or diastolic BP < 60mmHg
     – Capillary refill time > 2 seconds, reduced skin turgor

•   Altered Conscious level (esp. in extremes of age)
     – New confusion, striking agitation or seizures

•   Other clinical concerns:
     – Rapidly progressive (esp. high fever > 3 days) or serious atypical illness
     – Severe & persistent vomiting and diarrhoea
ALL MODERATE TO SEVERE CASES
  OF INFLUENZA LIKE ILLNESS
             MUST
          REFER TO
 PHYCISIAN INCHARGE OF H1N1
        AT 019-4443394
        Co-morbidities / Risk
             factors
• Chronic respiratory conditions eg. asthma, COPD, sleep
  apnoea syndrome
• Pregnant women esp. 2nd & 3rd trimester
• Morbid obesity
• Cardiac disease eg. cardiac failure
  – (Hypertension by itself is not a risk factor)
• Chronic diseases eg. diabetes mellitus, renal failure
• Immunosuppression eg. cancer, HIV/AIDS, steroids
• Extreme Age groups:
  – those > 65 years esp those with chronic diseases
  – children < 5
          Triage Policy
• 1. G3 Room 5 for Influenza like Illness
  with no moderate to severe sign and
  symptoms.
• 2. Yellow Zone for Influenza like Illness
  with moderate to severe sign and
  symptoms but hemodynamically stable
• 3. Red Zone for Influenza like Illness with
  moderate to severe sign and symptoms
  and hemodynamically stable
    Admission Policy
• Patient fulfilling criteria of ILI
  – with any of the parameters listed in the
    clinical assessment tool for moderate to
    severe influenza (with or without co-
    morbidities).
            Ward Policy
•   Isolation Ward
•   Isolation Room
•   Influenza cubicle
•   ICU ( identify specific cubicle/room)

• Need not necessary be negative pressure
  room
     Management &Treatment
         Decision Policy
• Pt with mild illness should not be tested for
  H1N1 or given antiviral as a routine.
• Admission
  – Lab test (throat/NP swab or NP/tracheal
    aspirate) for H1N1 is indicated for those who
    are admitted (mod to severe disease).
• To arrange for earlier transport to IMR, if
  close contact is pregnant ( 2nd & 3rd
  trimester).
      Protective Garment Policy
Items           Entry to      Close contact Aerosol
                cohort area   < 3 feet      generated
                                            procedure

Gloves          No            Yes          Yes
Plastic Apron   No            Yes          Yes
Gown            No            No           Yes
Surgical mask   Yes           Yes          Yes
N95             No            No           Yes
Eye protection No             Risk assmt   Yes
Antiviral Treatment is recommended for:
 – All hospitalized pts (ie. those with moderate to
   severe disease) with confirmed or suspected
   novel influenza A H1N1.
 – Empirical therapy - if the turnaround time for
   H1N1 result >12 hour.
 – The antiviral treatment maybe stopped if the
   results are negative.
 – Evidence of best benefit is within 48H of illness
   onset.
            Oseltamivir (Tamiflu)
• Adults and adolescents:
   – The recommended oral dose is 75 mg bd for 5 days.
   – Those who are unable to swallow capsules may receive the
     appropriate dose of oseltamivir suspension.

• Paediatric patients:
   –   Recommended oral dose
   –   Body weight in kg. Recommended dose for 5 days
   –   < 15kg 30 mg twice daily
   –   15 - 23 kg 45 mg twice daily
   –   23 - 40 kg 60 mg twice daily
   –   > 40 kg 75 mg twice daily
               Zanamivir


• The recommended dose of zanamivir is 2
  puffs (2 x 5 mg) bd for 5 days providing a
• total daily inhaled dose of 20 mg.
           Algorithm ILI admission

                Pt wt ILI presented to
                    health facility

                  Moderate/severe
                      illness


    Yes                                      No


                                         Comorbidities
   Admit                                     needed
                                          intervention

                          Yes                            No

Develop sx as                             Discharge
   in PHAT                                Home Tx,
                                            PHAT
  Antiviral chemoprophylaxis
• RECOMMENDATION
• Close contacts of confirmed cases, who
  are pregnant (esp. in 2nd. & 3rd. trimester)
• Chemoprophylaxis is best given within 48
  hours of exposure.
• Dosage of antiviral prophylaxis is as
  follows:
  – Oseltamivir 75 mg daily for 10 days
  – Zanamivir 10 mg (2 puffs) daily for 10 days
          CONCLUSION
• We are now at early phase of mitigation
  Influenza A H1N1
• All health provider must be able to identify
  moderate to severe case of influenza like illness
• Cluster case must identified and manage
  accordingly
• Anti-viral therapy are given to:-
  - Moderate to severe confirm case of H1N1
  - Moderate to severe case of ILI where the result
  is not posibble to come back within 12 hrs
• Prophylaxis anti-viral are given only to close
  contact to confirm case who are pregnant

				
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