View
231
Download
0
Category
Preview:
Citation preview
8/8/2019 Swine Flu - Kamal
1/118
SWINE FLU
8/8/2019 Swine Flu - Kamal
2/118
DEFINITIONy It can be defined as a respiratory disease of pigs
caused by type A influenza viruses that causes
regular outbreaks in pigs.
y Human infections can and do happen.
y Swine flu, Hog flu, and Pig flu
8/8/2019 Swine Flu - Kamal
3/118
HISTORYy The influenza virus, known to be circulating as
a pathogen in the human population since at
least the 16th centuryis notable for its uniqueability to cause recurrent epidemics and global
pandemics.
y Each century has seen some pandemics rapidlyprogressing to all parts of the world due to emergenceof a novel virus to which the overall population holdsno immunity.
8/8/2019 Swine Flu - Kamal
4/118
Antigenic Shifts and Pandemicsy
Year Designation ResultingPandemic
Death Toll
1892 H3N2 Moderate NotAvailable
1918 H1N1(Spanish)
Devastating 50-100million
1957 H2N2(Asian)
Moderate 1-4 million
1968 H3N2(Hong Kong)
Mild 1-4 million
8/8/2019 Swine Flu - Kamal
5/118
ETIOLOGYy The name infuenza was given by Italians in the 1743
malevolent infuence of heavenly bodies or of
inclement weather
y 1933 - Influenza virus was isolated by Smith ,Andrews & Laidlaw
y Influenza Virus Orthomyxovirus
8/8/2019 Swine Flu - Kamal
6/118
y Divided into three serotypes; type A, type B or type C.
on the basis of antigenic nature of the internal orribonucleoprotein and the matrix (M) proteins
y Nonhuman isolates - type A
y Type B , C exclusively human
y Type C subclinical disease
8/8/2019 Swine Flu - Kamal
7/118
RES
IS
TANCE PATTERN
y Killed by heat (56C for 3 hrs or 60 C for 30 mins) andwith common disinfectants such as formalin, iodine
compounds, ether, phenol, heavy metal salts
y Indefinite survival in frozen material at -70C
y viable in fomites such as blankets for about 2 weeks
8/8/2019 Swine Flu - Kamal
8/118
SURVIVAL OF THE VIRUSTEMPERATURE SURVIVAL TIME
Contaminatedmanure Cool 3 months
Water 22C 4 days
0c 30 days
8/8/2019 Swine Flu - Kamal
9/118
MORPHOLOGYy Spherical Virus 80 to 120 nm diameter
y pleomorphism, filamentous form
y Core - Ribonucleoprotein in helical symmetry
y Negative Sense single stranded RNA genome
ySegmented 8 pieces
y Viral RNA-dependentRNA polymerase which is essentialfor transcription of the viral RNA in infected host cells
8/8/2019 Swine Flu - Kamal
10/118
y The nucleocapsid is surrounded by an envelope
which has an inner membrane protein layer and anouter lipid layer
y The membrane protein is also known as matrix or M
Protein composed of 2 components , M1 & M2
y The protein part Virus Coded
y The lipid layer is derived from the modified host cellmembrane during the process of replication bybudding
8/8/2019 Swine Flu - Kamal
11/118
y Projecting from the envelope are two types ofspikes
(peplomers) :
y HaemagglutininSpikes Triangular in cross section
y Neuraminidase Peplomers mushroom shaped ,less numerous
y subtypes based on their hemagglutinin (H) &
neuraminidases (N)
y 16 hemaglutinins (H) and 9 neuramindases (N)identified in humans, animals and birds
8/8/2019 Swine Flu - Kamal
12/118
8/8/2019 Swine Flu - Kamal
13/118
y HAEMAGGLUTININ
Glycoprotein 2 polypeptides HA 1 and HA 2
enables virus to attach to respiratory epithelial cells
y NEURAMINIDASEGlycoprotein destroys receptor cells by hydrolyticcleavage
Internal RNP antigen and M protein antigen are stable
8/8/2019 Swine Flu - Kamal
14/118
8/8/2019 Swine Flu - Kamal
15/118
ANTIGENIC DRIFT
y gradual sequential change in antigenic structureoccuring regularly at frequent intervals
y The new antigens though different from the previousantigens , are yet related to them, so that they react
with the antisera to the predecessor virus strains, tovarying degrees
y mutation and selection
y Periodical epidemics
8/8/2019 Swine Flu - Kamal
16/118
ANTIGENIC SHIFT
y Abrupt Drastic discontinuous variation in antigenicstructure, resulting in a novel virus strain unrelatedantigenically to the predecessor strain
y involves haemagglutinin, neuraminidase or both
y antibodies to the previous viruses do not neutralise
the new variants ( not accounted by mutations)y major epidemics and pandemics
8/8/2019 Swine Flu - Kamal
17/118
8/8/2019 Swine Flu - Kamal
18/118
y genetic reassortment ( coinfection with influenza
virus from diverse animal species)
y pigs Mixing Vessels avian & human viruses
8/8/2019 Swine Flu - Kamal
19/118
SWINE FLU IN PIGS
y Swine flu viruses cause high levels of illness and low
death rates in pigs.
y Swine influenza viruses usually circulate among swinethroughout the year, but most outbreaks occur duringthe late fall and winter months similar to outbreaks inhumans.
y classical swine flu virus (an influenza type A H1N1virus) was first isolated from a pig in 1930.
8/8/2019 Swine Flu - Kamal
20/118
8/8/2019 Swine Flu - Kamal
21/118
8/8/2019 Swine Flu - Kamal
22/118
ANTIGENIC CHARACTERIZATION
y March 2009 pandemic -H1N1 influenza A virus .
y Quadruple reassortment of two swine strains, onehuman strain, and one avian strain of influenza .
y 30.6 percent from North American swine influenza strains,17.5 percent from Eurasian swine influenza strains,
y Followed by North American avian influenza strains (34.4percent) and
y Human influenza strains (17.5 percent)
8/8/2019 Swine Flu - Kamal
23/118
8/8/2019 Swine Flu - Kamal
24/118
8/8/2019 Swine Flu - Kamal
25/118
y
8/8/2019 Swine Flu - Kamal
26/118
CURRENT SCENARIOy A novel influenza A (H1N1) virus of swine origin emergedamong people in Mexico during the spring of2009(march18) and spread with travellers worldwide, resultingin the first influenza pandemic since 1968.
y On 11thJune, 2009, World Health Organizationdeclared this a pandemic
y As of October 2009, over 200 countries have reportedconfirmed human cases of pandemic (H1N1) 2009.
y While the majority of illnesses caused by pandemic (H1N1)2009 virus infection have been self-limited mild-to-moderate uncomplicated disease, severe complicationsincluding fatal outcomes have been reported.
8/8/2019 Swine Flu - Kamal
27/118
y After Mexico, subsequent confirmed cases in USA,
Canada , U.K., Australia, Brazil, France , Israel, NewZealand
y On April 26, 2009 Declared a National PublicHealth Emergency by the US Deptt of Health &Human Services
y
On April 27, 2009 Health services in Indiaw
ereput on high alert
8/8/2019 Swine Flu - Kamal
28/118
y The pandemic (H1N1) 2009 influenza virus differs in
its pathogenicity from seasonal influenza in two keyaspects.
y First, as the majority of human population has little or
no pre-existing immunity to the virus, the impactof the infection has been in a wider age range, inparticular among children and young adults.
y Secondly, the virus can infect the lower respiratorytract and cause rapidly progressive pneumoniaespecially in childrenand young to middle-aged adults.
y High morbidity, low mortality (1-4%)
8/8/2019 Swine Flu - Kamal
29/118
CDC (DEC 09)
SUMMARYOF STATISTICS - CDCOfficial US Total:
(According to CD
C)
44640 cases, 10837 deaths
Unofficial US Total:(Other Reliable Sources)
115431 cases, 10837 deaths
Worldwide Total:
(Various Reliable Sources)1483520 cases, 25174 deaths
Most Infected States:(According to CDC)
Wisconsin: 6222 casesTexas: 5151 casesIllinois: 3404 cases
Most Infected Countries:(Various Reliable Sources)
Germany: 222006 casesPortugal: 166922 casesChina (Mainland): 120940 cases
8/8/2019 Swine Flu - Kamal
30/118
WHO UPDATE - INFLUENZA
(13TH AUG 10)y Influenza H1N1 virus transmission remains locally
intense in parts of India and NewZealand
y India- The number of new H1N1 cases per week,including fatal cases, continued to increase since mid
June 2010 in several states
y Particularly in the western state of Maharashtra and toa lesser extent in Gujarat, Andhra Pradesh, and WestBengal.
8/8/2019 Swine Flu - Kamal
31/118
Death Rate per Infection- DEC 09
Country Cases Deaths % Dead Frequency
India 29303 1302 4.44% 1 in 23
8/8/2019 Swine Flu - Kamal
32/118
yCURRENT STATUS IN INDIAy Total cases 6050
y deaths - 173
8/8/2019 Swine Flu - Kamal
33/118
PUNJABy 30 per cent rise in the number of H1N1 flu (swine flu)
patients due to change of season
y 24 confirmed cases of the pandemic
y More than 700 contacts of these 24 patients too havebeen administered prophylactic treatment
8/8/2019 Swine Flu - Kamal
34/118
LUDHIANA
y 45 year old Mura Kawa
y Nodal officerDr. Deepak Bhatia
8/8/2019 Swine Flu - Kamal
35/118
TRANSMISSION
y Influenza viruses can be directly transmitted from pigs topeople and from people to pigs.
y
Human infection with flu viruses from pigs are most likelyto occur when people are in close proximity to infectedpigs, such as in pig barns and livestock exhibits housingpigs at fairs.
Human-to-human transmission of swine flu can alsooccur. This is thought to occur in the same way as seasonalflu which is mainly person-to person transmission throughcoughing or sneezing by people infected with theinfluenza virus.
8/8/2019 Swine Flu - Kamal
36/118
y Cold and dry weather
y not transmitted by food.
y
Eating properly handled and cooked pork (at aninternal temperature of 160F) and pork products issafe.
8/8/2019 Swine Flu - Kamal
37/118
RISK FACTORS
y Persons of any age with chronic pulmonarydisease(e.g. asthma, COPD), chronic cardiac disease (e.g.congestive cardiac failure), metabolic disorders (e.g.diabetes), chronic renal disease, chronic hepatic
disease, certain neurological conditions (includingneuromuscular, neurocognitive, and seizuredisorders), hemoglobinopathies
y immunosuppression,whether due toprimaryimmunosuppressive conditions, such as HIVinfection, or secondary conditions,such asimmunosuppressive medication or malignancy
8/8/2019 Swine Flu - Kamal
38/118
y Infants and young children, in particular
8/8/2019 Swine Flu - Kamal
39/118
SUSPECTED CASE
A person with acute febrile respiratory illness (fever =38C) with onset
y within 7 days of close contact with a person who is a
confirmed case of swine influenza(H1N1 virusinfection)
y within 7 days of travel to areas where there are one ormore confirmed cases of swine influenza(H1N1 virusinfection)
y resides in a community where there are one or moreconfirmed cases of swine influenza.
8/8/2019 Swine Flu - Kamal
40/118
PROBABLE CASEy positive for influenza A, but unsubtypable for H1 and H3
by influenza RT-PCRor reagents used to detect seasonalinfluenza virus infection
y positive for influenza A by an influenza rapid test or aninfuenza immunofluorescence assay (IFA) plus meetscrieteria for a suspected case
y individual with a clinically compatible illness who died ofan unexplained acute respiratory illness who is consideredto be epidemiologically linked to a probable or confirmedcase
8/8/2019 Swine Flu - Kamal
41/118
CONFIRMED CASEA person with an acute febrile respiratory illness withlaboratory confirmed swine influenza A(H1N1) virusinfection at WHO appproved laboratories by one or moreof the following tests:
y Real Time PCR
y Viral culture
y Four-fold rise in swine influenza A(H1N1) virus specific
neutralising antibodies.
8/8/2019 Swine Flu - Kamal
42/118
8/8/2019 Swine Flu - Kamal
43/118
y Symptoms and signs suggesting oxygen
impairment or cardiopulmonary insufficiency:
y - Shortness of breath (with activity or at rest),difficulty in breathing, turning blue, bloody or
coloured sputum, chest pain, and low blood pressure
y In children, fast or laboured breathing; and
y Hypoxia, as indicated by pulse oximetry.
8/8/2019 Swine Flu - Kamal
44/118
y Symptoms and signs suggesting CNS
complications:
yAltered mental status, unconsciousness, drowsiness,or difficult to awaken and
y recurring or persistent convulsions (seizures),confusion, severe weakness, or
y paralysis.
8/8/2019 Swine Flu - Kamal
45/118
y Evidence of sustained virus replication or invasivesecondary bacterial infection based on laboratorytesting or clinical signs (e.g. persistent high feverand other symptoms beyond 3 days).
y Severe dehydration, manifested as decreasedactivity, dizziness, decreased urine output, andlethargy
8/8/2019 Swine Flu - Kamal
46/118
LABORATORY
DIAGNOSIS
8/8/2019 Swine Flu - Kamal
47/118
8/8/2019 Swine Flu - Kamal
48/118
y Hyderabad ( Andhra Pradesh)
1. Institute of Preventive Medicine Narayanaguda,2.Centre for DNA Fingerprinting & Diagnostics, Hyderabady Port Blair (Arunachal Pradesh )
Regional Medical Research Centre, Port Blairy Dibrugarh( Assam)Regional Medical Research Centre
y
Patna (Bihar)Rajendra Memorial Research Institute of Medical Sciences, Patnay Chattisgarh( NewDelhi)
National Centre for Disease Controly Goa
1.National Centre for Disease Control, New Delhi2.Kasturba Medical College, Manipal
y Ahmedabad (Gujarat)B. J. Medical College,Asarwa
y Madhya PradeshDefence Research Development Establishment,Gwalior
8/8/2019 Swine Flu - Kamal
49/118
y Haryana
y National Centre for Disease Control,NewDelhi
y PostGraduate Institute of Medical Education and Research,Chandigarhy Himachal Pradesh
y Central Research Institute,Kasauli Dist. Solan,Himachal Pradesh
y Indira Gandhi Medical College,Shimla
y
Jammu and KashmirNational Centre for Disease Control, NewDelhi
y Jharkhand
y National Institute of Cholera & Enteric Diseases,Kolkata
y Karnataka
y
National Institute of Mental Health and Neuro Sciences(NIMHANS) Bangalorey Kasturba Medical College,Manipal
y Kerala
y RajivGandhi Centre for Biotechnology, Thiruvananthapuram
y Kasturba Medical College,Manipal
8/8/2019 Swine Flu - Kamal
50/118
y Maharashtray Haffkine Institute,Mumbaiy
National Institute of Virology, Puney National Institute of Virology, Microbial Containment Puney Manipur
National Institute of Cholera & EntericDiseases, Kolkatay Meghalayay Regional Medical Research Centre,Dibrugarhy Mizoramy
National Institute of Cholera & EntericDiseases, Kolkatay Nagalandy Regional Medical Research Centre,Dibrugarhy Orissay Regional Medical Research Centre, Bhubaneswary Sikkim
y National Institute of Cholera & EntericDiseases, Kolkatay Rajasthany Vallabhbhai Patel Chest Institute University ofDelhi,
Delhi
8/8/2019 Swine Flu - Kamal
51/118
y Tamil Naduy King Institute of Preventive Medicine,Chennai
y Christian Medical College, Vellorey Hi-TechDiagnostic Centre Lab,Chennaiy Bharath Scan Lab, Chennaiy Diagnostic Services,Chennaiy Microbiology Lab Coimbatorey Dr. Rath Lab,Tiruchyy Tripuray National Institute of Cholera & EntericDiseases,Kolkatay Uttar Pradeshy SanjayGandhi PostGraduate Institute of Medical Sciences
Lucknowy
Uttarakhandy All India Institute of Medical Sciences,NewDelhiy West Bengaly National Institute of Cholera & EntericDiseases,Kolkata
8/8/2019 Swine Flu - Kamal
52/118
y Andaman and Nicobar
y
Regional Medical Research Centre,Port Blairy Dadra and Nagar Haveli
y B. J. Medical College,Ahmedabad
y Daman and Diu
y Haffkine Institute, Mumbai
y Lakshadweep
y RajivGandhi Centre for Biotechnology,Thiruvananthapuram
y Puducherry
y JIPMER
8/8/2019 Swine Flu - Kamal
53/118
y DELHIy National Centre forDisease Control
y Vallabhbhai Patel Chest Institute,
y University ofDelhiAll India Institute of Medical Sciences,
y Super Religare Laboratories (SRL)
y Dr. Lal's Path Lab
y Dr. Naveen Dang's Medical Diagnostic Centre,
y Auroprobe Laboratories,
8/8/2019 Swine Flu - Kamal
54/118
PUNJAB & CHANDIGARH
y PostGraduate Institute of Medical Education andResearchSector-12, Chandigarh-160012,
Phone: 0172-2746018, 2756565, 2747585,Fax: 0172-2744401, 2745078
8/8/2019 Swine Flu - Kamal
55/118
SPECIMENSy nasopharyngeal swab
y nasal aspirate
y
combined nasopharyngeal swabwithoropharyngeal swab.
y nasal swab
y oropharyngeal swab
y Intubated patients - an endotracheal aspirate .Bronchoalveolar lavage (BAL) and sputumspecimens also acceptable.
8/8/2019 Swine Flu - Kamal
56/118
TIME OF SPECIMEN COLLECTIONy Soon after symptoms begin
y Before administration of antiviral medications
y
Even if symptoms began more than oneweek agoy Multiple specimens on multiple days can be
collected
8/8/2019 Swine Flu - Kamal
57/118
y Swabswith a synthetic tip (eg, polyester orDacron) and an aluminium or plastic shaftpreferred
y Swabswith cotton tips and wooden shafts not
recommended.y Swabs made of calcium alginate not acceptable.
y Collection vial for swab should contain 1 to 3 ml ofviral transport media.
8/8/2019 Swine Flu - Kamal
58/118
BIOSAFETY MEASURES FOR
SPECIMEN COLLECTIONy Collection by trained hospital / lab staff
y N95 masks should be used while taking samples & ifthey are not available, triple layer well fitted surgicalfacemasks can be used
y disposable latex gloves
y lab coat / disposable apron
y Head cover
y Use of protective eyewear (goggles)/faceshields ifprocedure likely to generate aerosols, or splashes ofsecretions
8/8/2019 Swine Flu - Kamal
59/118
8/8/2019 Swine Flu - Kamal
60/118
y Intensive Care Unit & Laboratory personnel :
N 95 Respirators.y Mortuary:
Triple layer surgical mask.
8/8/2019 Swine Flu - Kamal
61/118
Methods OfSample Collection
8/8/2019 Swine Flu - Kamal
62/118
Nasopharyngeal Swab
y Insert a dry swab into the nostril and take it backto the nasopharynx
y Leave in place for a fewseconds
y Slowly remove itwhile slightly rotating it
y Newswab for other nostril
Nasal SwabCollected from the anterior turbinate
8/8/2019 Swine Flu - Kamal
63/118
8/8/2019 Swine Flu - Kamal
64/118
Nasopharyngeal aspirates
y 3 to 7 ml saline introduced through the nose andaspirated by a small tubing inserted into the othernostril
8/8/2019 Swine Flu - Kamal
65/118
8/8/2019 Swine Flu - Kamal
66/118
Throat Swab
y Patients mouth should be wide open
y Touch the swab at the back of the throat near thetonsils
8/8/2019 Swine Flu - Kamal
67/118
8/8/2019 Swine Flu - Kamal
68/118
8/8/2019 Swine Flu - Kamal
69/118
8/8/2019 Swine Flu - Kamal
70/118
Viral transportmediay protein stabilises the virus (serum ,albumin,gelatin)
y foetal calf serum less inhibitory factors, antibodies
y buffers- ph maintenance
y Antifungals, antibacterials y Penicillin(500units/ml)
y streptomycin(500 to 1000 units/ml)
y Vancomycin(20mcg/ml)
y gentamicin(50mcg/ml)
y amphotericin(10mcg/ml)
8/8/2019 Swine Flu - Kamal
71/118
8/8/2019 Swine Flu - Kamal
72/118
y stuarts medium, amies medium
y Leibovitz-Emory mediumy Hanks balanced salt solution
y Eagles tisue culture medium
8/8/2019 Swine Flu - Kamal
73/118
Labelling OfSpecimensy Pre-printed barcode labels to be used
y On the specimen container
y
On the field data collection formy On the log book
8/8/2019 Swine Flu - Kamal
74/118
Specimen Storagey Within 48 hours store at 4 C before and after
transport
y
Beyond 48
hours- -70 Cy Do not store in standard freezer- keep on ice or in
refrigerator
8/8/2019 Swine Flu - Kamal
75/118
TransportyAll specimens should be
transported after packagingusing the WHO triplepackaging system.
y While transportation coldchain should be maintained.
8/8/2019 Swine Flu - Kamal
76/118
Triple Packaging System1) Primary receptacle: a labelled primarywatertight,
leak-proof receptacle containing the specimen.
2) Secondary receptacle: a second durable,watertight, leak-proof receptacle to enclose andprotect the primary receptacle(s).
3) Outer package: the package around the secondaryreceptaclewhich protects the receptacle and itscontents from outside influences such as physicaldamagewhile in transit.
8/8/2019 Swine Flu - Kamal
77/118
DiagnosticTests
8/8/2019 Swine Flu - Kamal
78/118
Test Method Infuenza VirusTypes Detected
Time For Results
Virus Culture A and B 5 10 days
FluorescentImmunoasssay
A and B 2 4 hrs
RT - PCR A and B 1 -2 days
Serological Tests A and B > 2weeks
EnzymeImmunoassay(EIA)
A and B 2 hours
Rapid AntigenDetection
A ; A and B < 30 mins
8/8/2019 Swine Flu - Kamal
79/118
y Diagnostic Tests
y Demonstration of virus antigen (IF , PCR)
y Isolation of virus
y Serology
y Other tests
8/8/2019 Swine Flu - Kamal
80/118
Immunofluorescence (DFAor IFA)y done using fluorescent tagged influenza antiserum
y distinguishes between influenza A and B .
y positive for influenza A by immunofluorescence maymeet criteria for a suspected case.
y not possible to differentiate from seasonal influenzaA viruses
y A negative DFA or IFA does not exclude H1N1 influenza
A infection .y should not be assumed a final diagnostic test for
novel influenza A(H1N1) virus infection.
8/8/2019 Swine Flu - Kamal
81/118
8/8/2019 Swine Flu - Kamal
82/118
PCRseveral PCR assays for detection of:
y highly conserved parts of the influenza genome
(matrix M gene) to confirm the presence of influenzaA;
y detect current human influenza virus H1 and H3genes;
y When the result of PCR assay on M gene is negative,the diagnosis of Influenza could be ruled out. Whenthe PCR M gene is positive together with either PCRH1/H3 is positive, human influenza is diagnosed
8/8/2019 Swine Flu - Kamal
83/118
y
Real-time RT-PCR is the recommended test forconfirmation of novel influenza A(H1N)1 cases.
y Currently, novel influenza A(H1N1) virus will testpositive for influenza A and negative for H1 and
H3 by real-time RT-PCR.y If reactivity of real-time RT-PCR for influenza A is
strong it is more suggestive of a novel influenza A(H1N1) virus
8/8/2019 Swine Flu - Kamal
84/118
Cell Culturey Done in monkey kidney cells or human embryo
kidney cells
y Isolation of H1N1 influenza A virus using cultureis diagnostic
y culture is usually too slowto help guide clinicalmanagement.
y
A negative viral culture does not exclude H1N1influenza A infection.
8/8/2019 Swine Flu - Kamal
85/118
y
more chance of isolation in 1st
2 or 3 days of illnessy Egg inoculation
y amniotic cavity 11 to 13 day old eggs( six eggs perspecimen)
y Incubation at 35C for 3 daysy Chilling, Harvesting of Amniotic and alllantoic fluid
separately
y Tested for haemaggglutination with guinea pig and
fowl RBCs in parallel, at room temperature & at 4C
8/8/2019 Swine Flu - Kamal
86/118
y Influenza A agglutinate only guinea pigs
y Influenza B both guinea pig & fowly Influenza C - only fowl cells
y Inhibition of haemagg specific viral antiserum
y Haemadsoption addition of fresh guinea pig RBC tocell culture
y Adv no damage to the culture
8/8/2019 Swine Flu - Kamal
87/118
y MonkeyKidney or Baboon Kidney Cell cultures:
y incubated without serum in presence of trypsin whichincreases isolation
y Incubation at roller drums
y No cytopathic effects or focal enlarged granular cells
followed by sloughing,rapid progression
8/8/2019 Swine Flu - Kamal
88/118
y Shell vial culture
y Detection within 1 to 2 daysy 15*45mm vial having coverslip in the bottom covered
with growth medium and appropriate cell monolayer
y specimen inoculated by low speed inoculation
y Coverslips are stained using virus specificimmunofluorescent conjugates
8/8/2019 Swine Flu - Kamal
89/118
8/8/2019 Swine Flu - Kamal
90/118
Rapid Influenza Antigen Testy can distinguish between influenza A and B
viruses.
y Can detect the HSI Influenza A(H1N1) virus
y not possible to differentiate from seasonalinfluenza A viruses.
y suboptimal sensitivity to detect seasonalinfluenza viruses
y negative rapid test could be a false negativey should not be assumed a final diagnostic test for
novel influenza A(H1N1) virus infection.
8/8/2019 Swine Flu - Kamal
91/118
Interpretation OfRapid Testy There are several possibilitieswhen a patient tests
positive for influenza A by rapid antigen test:
y The patient might have novel H1N1 virus infection
y The patient might have seasonal influenza A virusinfection or
y The patient might have a false positive test result
8/8/2019 Swine Flu - Kamal
92/118
y many new confirmed cases of novel H1N1 flu infection andwhere community spread of H1N1 is occurring- patients
who test positive on a rapid influenza diagnostic test can betreated empirically with antiviral medications if clinicallyindicated without further testing
8/8/2019 Swine Flu - Kamal
93/118
y Haemagglutination Inhibition tests
y Serial dilution of sera + Influenza virus suspensioncontaining 4 HA units + Fowl RBC
y Highest dilution of serum that inhibitsHaemagglutination - HI titre
y Disadv- Antihaemagglutinin antibodies are subtypespecific and hence it is necessary to use as antigen thestrain currently causing the infection
8/8/2019 Swine Flu - Kamal
94/118
y Paired Sample for SerologyStudy at an interval of14 days
y To demonstrate a four-fold or more rise in HSIinfluenza A(H1N1) virus specific antibodies
8/8/2019 Swine Flu - Kamal
95/118
8/8/2019 Swine Flu - Kamal
96/118
y Complement Fixation Test
yWith RNP antigeny Useful as antibodies formed only after infection not
immunisation with inactivated virus
y Enzyme Neutralisation tests estimation ofneuraminidase antibody
y Radioimmunodiffusion in agarose gel antibodies toRNP, haemagglutinin & neuraminidase
8/8/2019 Swine Flu - Kamal
97/118
TREATMENT
ANDPROPHYLAXIS
8/8/2019 Swine Flu - Kamal
98/118
y salicylate/aspirin is strictly c/i due to its potentialto cause reye s syndrome.
8/8/2019 Swine Flu - Kamal
99/118
y Oseltamivir (brand name Tamiflu )- to both treatand prevent influenza A and B virus infection inpeople one year of age and older.
y Zanamivir (brand name Relenza )- to treatinfluenza A and B virus infection in people 5 yearsand older and to prevent influenza A and B virusinfection in people 5 years and older.
8/8/2019 Swine Flu - Kamal
100/118
8/8/2019 Swine Flu - Kamal
101/118
y For adolescents (13 to17 years of age) and adults the
recommended oral dose is 75 mg oseltamivir twicedailyfor 5 days
y children 6 to 12 months of age is 3 mg per kg body
weight twice dailyfor 5 days for treatment
8/8/2019 Swine Flu - Kamal
102/118
y>3 months to 12 months - 3 mg/kg twice daily
y >1 month to 3 months - 2.5 mg/kg twice daily
y 0 to 1 month - 2 mg/kg twice daily
y 15 kg or less - 30 mg orally twice a day for 5 days
y 15-23 kg - 45 mg orally twice a day for 5 days
y 24-40 kg- 60 mg orally twice a day for 5 days
y>40 kg - 75 mg orally twice a day for 5 days
8/8/2019 Swine Flu - Kamal
103/118
y Zanamivir
y recommended dose for treatment of adults andchildren from the age of 5 years (based is twoinhalations (2 x 5mg) twice daily for 5 days.
8/8/2019 Swine Flu - Kamal
104/118
y SUPPORTIVETHERAPYINCLUDES-
y IV Fluids
y
Parenteral nutritiony Oxygen therapy/ventilatory support
yAntibiotics for secondary infection
yVasopressors for shock
y Paracetamol or ibuprofen is prescribed forfever,myalgia and headache.
8/8/2019 Swine Flu - Kamal
105/118
y Adult patients should be discharged 7 days after symptomshave subsided.
y Children should be discharged 14 days after symptoms havesubsided.
y The family of patients discharged earlier should beeducated on personal hygiene and infection control
measures at home.
y Children should not attend school during this period.
8/8/2019 Swine Flu - Kamal
106/118
ANTIVIRAL CHEMOPROPHYLAXISy given to
yAll close contacts of suspected,probable andconfirmed cases.
yAll health care personnel coming in contact withsuspected,probable or confirmed cases.
y Oseltamivir is the drug of choice.
y
Prophylaxis should be provided till 10 days after lastexposure(maximum period of 6 weeks).
8/8/2019 Swine Flu - Kamal
107/118
y Less than 15 kgs - 30mg OD
y 15-23 kg 45 mg OD
y 24- less than 40kg -60 mg OD
y More than or equal to 40kg -75 mg OD
8/8/2019 Swine Flu - Kamal
108/118
y DOSE FOR INFANTS-
y Less than 3 mnths-not recommended unless situationjudged critical due to limited data on use in this agegroup.
y3 5 mnths- 20mg OD
y 6 11 mnths-25mg OD
8/8/2019 Swine Flu - Kamal
109/118
y Close contacts of suspected , probable and confirmedcases should be advised to remain at home for at least7 days after the last contact with the case.
y Monitoring of fever should be done for at least 7 days.
y Prompt testing and hospitalization must be donewhen symptoms are reported.
8/8/2019 Swine Flu - Kamal
110/118
VACCINES
8/8/2019 Swine Flu - Kamal
111/118
y Egg based vaccines formalin inactivated
y
Subunit vaccines disrupted by detergents so thatthey have only immunogenic haemagglutinin andneuraminidase subunits
y no bulk preparation
y Recombinant vaccinesy ts mutants
8/8/2019 Swine Flu - Kamal
112/118
y 1.5 million doses of vaccine to vaccinate selected populationamong the high risk group.
y PANENZA, the pandemic vaccine procured from M/s SanofiPasteur, France, is a split virus inactivated, non-adjuvantedmonovalentvaccine against pandemic Influenza
y The active ingredient containing antigen equivalent to:
y A/California/7/2009(H1N1)v-like strain (NYMC X-179A) - 15
micrograms** per 0.5 ml dosey propagated in eggs
y ** expressed in microgram haemagglutinin
8/8/2019 Swine Flu - Kamal
113/118
y The other ingredients are: thiomersal (45 microgramsper 0.5 ml dose), sodium chloride, potassium chloride,disodium phosphate dihydrate, potassium dihydrogenphosphate, and water.
y
suspension for injection in a multidose vial (10doses of 0.5ml) - Pack of10 vials. The suspension isa colourless liquid, clear to opalescent
y
One dose (0.5 ml) intra muscular
8/8/2019 Swine Flu - Kamal
114/118
yVaxiFlu-S
y
Zydus Cadilay Drug ControllerGeneral of India (DCGI) has gave
approval to Zydus Cadila to market the H1N1 (swineflu) vaccine.
y The egg-based, inactivated vaccine based onconventional technology has been developed by thegroups researchers at its Vaccine Technology Centre(VTC) in Ahmedabad.
y Rs 350y unveiled with health minister Ghulam Nabi Azad.
8/8/2019 Swine Flu - Kamal
115/118
y It can only be used by people aged between 18-60 andcant be used on small children or pregnant women
who are believed to be at high risk of getting infected.
y The Swine Flu Vaccine, with a shelf life of a year from
date of manufacture, will provide protection only forone year
fi i di i l i l h d i
8/8/2019 Swine Flu - Kamal
116/118
y first indigenous intra-nasal vaccine was launched inMumbai (Nasovac)- Serum institute of India Pune
y Launched on 15 July 201o mumbaiy children over three years of age as well as for the
elderly
y donor virus' from WHO clinical trials on 380 people,
including children, the young and the elderlyRs 160/shot
y dose of 0.5ml directly to the nasal cavity
y Contraindicated -pregnant women, infants and
people with compromised immunity
8/8/2019 Swine Flu - Kamal
117/118
Hospital wastegeneratedy disposed off as per BIOMEDICAL WASTEGUIDELINES
8/8/2019 Swine Flu - Kamal
118/118
y Disposal of used masks
y In the hospital setting it should be disposed off in theidentified infectious waste disposal bag/container.
y In community settingswhere medical wastemanagement protocol cannot be practiced, it may be
disposed off either byburning or deep burial.
y During home care patients and contacts using Triplelayer mask should first disinfect used mask with
ordinary bleach solution or sodium hypochloritesolution or Quaternary Ammonium house holdDisinfectant and then dispose off either byburning ordeep burial
Recommended