What’s Influenza?

An acute RTI, caused by

Influenza virus, characterized Fever
by sudden onset of:
• Fever/ chills Running Nose,
Lack of Appetite,
• Headache, myalgia
Sore Throat
Headache
• Sore throat
• Cough
• Coryza
• Prostration
Coughing Nausea,
• Range of symptoms differs by age Vomiting

– Vomiting & diarrhea in children/

elderly
– Fever alone in infants
– May be atypical in elderly Diarrhea
• Serious complications can
occur among high-risk groups
 Influenza Virus: 3 Types
RNA virus (8-12 micron)
Antigenically distinct
No cross-immunity

Type A
Type A Type B
B Type C
Causes significant Causes significant Does not cause
disease: epidemics; disease: milder significant disease
pandemics epidemics
Infects both humans Limited to humans Limited to humans
and other species !
Frequent antigenic Infrequent antigenic Antigenically stable
variations variations
 Influenza A: Important Feature
2 surface antigens:
Influenza Virus
• Haemagglutinin (HA)
– Initiates infection following
attachment of virus to
susceptible cells
• Neuraminidase (NA)
– Release of virus from
infected cell
• 16 ‘H’ antigens (1-16)
• 9 ‘N’ antigens (1-9) HA NA
• Different combinations
 Influenza A: Antigenic Variations
Antigenic drift: gradual antigenic change over a period;
• Involves ‘point mutations’ in genes owing to selection pressure
by immunity in host population
• Responsible for frequent influenza epidemics; necessitates
reformulations of influenza vaccines.
Antigenic shift: sudden complete or major change;
• Results from genetic recombination of human with animal/
avian virus;
• Leads to a novel subtype different from both parent viruses;
• If ‘novel subtype’ has sufficient genes from HI viruses which
make it readily transmissible from person to person, it may
cause pandemics;
• Evidence suggests HI viruses responsible for last 3 pandemics
contained gene segments closely related to avian influenza
viruses.
 Species Infected by Influenza A
Subtypes
H1 N1
H2 N2

H3 N3
H4 N4
H5 N5
H6 N6
H7
? N7
H8 N8
H9 N9
H10
All 16 H subtypes infect
H11
H12 birds;
H13 most widespread epidemics
H14 & all pandemics: H1N1,
H15,16 H2N2, H3N2
 Influenza Terminology - 1

• Seasonal influenza
• Avian Influenza
• Pandemic Influenza
 Influenza Terminology - 2
Seasonal influenza:
influenza
• occurs every year with gradual variations in
previous year’s virus surface proteins (antigenic
drift); may give rise to epidemics every 2-3
years.
• spreads around the world in seasonal
epidemics, affecting 10 - 20% of total population
in general and >50% on close community;
• annual epidemics thought to result in 3-5 million
cases of severe illness and 2.5 - 5 lakh deaths

Avian Influenza

Pandemic Influenza
 Influenza Terminology - 3
Seasonal influenza

Avian Influenza:
Influenza
• Primarily a disease of birds due to large group
of different influenza viruses;
• Rarely jumps species and infects humans;
• An influenza pandemic happens when a new
subtype emerges that has not previously
circulated in humans and is adapted to human
to human transmission.
• Ultimately, is the source of new viruses in
humans causing pandemics.
Pandemic Influenza
 Influenza Terminology - 4
Seasonal influenza

Avian Influenza

Pandemic Influenza:
Influenza

• a worldwide surge in cases caused by the

introduction of a new type A surface protein
(antigenic shift).
 Influenza Pandemics so far

1918: “Spanish 1957: “Asian 1968: “Hong Kong 2004- 09:Current

Flu” Flu” Flu” outbreak
50 million 1- 4 million 421 cases,257 deaths
1- 4 million
deaths deaths Azerbaijan, China,
deaths
Cambodia, Djibouti,
A(H1N1) A(H2N2) A(H3N2) Egypt, Indonesia,
Iraq, Lao’s PDR,
Myanmar, Nigeria,
Pakistan, Thailand,
Turkey, Vietnam &
B’desh ; till Apr. 2009
A(H5N1)
 Pre-requisites to Start Influenza
Pandemics

(i) Emergence of a novel virus to which all

are susceptible
(ii) New virus is able to replicate and cause
disease in humans
(iii) New virus is transmitted efficiently
from human-to-human.

All criteria met

 
                                                                                                                                                       

two or
more
countries
in one
WHO
region
• Highly contagious acute
respiratory disease of pigs,
caused by one of several
swine influenza A viruses:
– Morbidity tends to be high
– Low mortality (1-4%)
• Although swine influenza
viruses (SIV) are normally
species specific, sometimes
cross species barrier to cause
disease in humans
 Swine influenza – Present virus
• Sometimes pigs can be infected with more than one virus
type at a time, which can allow the genes from these
viruses to mix
• This can result in an influenza virus containing genes
from a number of sources, called a "reassortant" virus
• The present virus: H1N1 virus with re-assorted
segments from:
– American swine,
– Eurasian swine,
– Avian and
– Human virus
• Influenza A/H1N1 virus characterized in this outbreak
has not been previously detected in pigs/humans.
How swine flu spread to human
Re-assortment and Direct Transmission Human to
human spread

Non-human
Human
virus virus

Pigs
Reassortant not involved
virus in
transmission
Cases started around 18th March
And in short interval reached to epidemic form
Evolution of Swine Influenza Pandemic
18th March 2009
Evolution of Swine Influenza Pandemic
13th April 2009
Evolution of Swine Influenza Pandemic

22 May

India-1

28 June

India 89
 10000
20000
30000
40000
50000
60000

50

0
0

100
150
200
250
5 /1 /2 0 0 9 5 /1 /2 0 0 9

DEATHS
CASES
5 /8 /2 0 0 9 5 /8 /2 0 0 9

5 /1 5 /2 0 0 9 5 /1 5 /2 0 0 9

5 /2 2 /2 0 0 9 5 /2 2 /2 0 0 9

5 /2 9 /2 0 0 9 5 /2 9 /2 0 0 9

6 /5 /2 0 0 9 6 /5 /2 0 0 9

6 /1 2 /2 0 0 9 6 /1 2 /2 0 0 9

6 /1 9 /2 0 0 9 6 /1 9 /2 0 0 9
Series1

Series1
 New Cases reported since last reporting period

9000
8000
7000
6000
5000
Series1
4000
3000
2000
1000
0
5/1/2009

5/15/2009

5/22/2009

5/29/2009

6/12/2009

6/19/2009
5/8/2009

6/5/2009
 Public Health Concern
• Number of affected countries with Influenza
H1N1 increasing
• Number of human cases of influenza H1N1
increasing
• The majority of the human population has no
immunity
• Potential to further mutate to a lethal novel
influenza virus
 WHO Alert
• Current situation constitutes a PHEIC (public
health emergency of international concern).
• WHO has declared H1N1 Pandemic, i.e, Phase 6
implying widespread human transmission.
• Containment of the outbreak is not feasible.
• The current focus should be on mitigation
measures.
• Not to close borders and not to restrict
international travel ???
 Disease Transmission
• H-2-H transmission mainly occurs
through direct droplet transmission
(usually within 6 feet).
• Same way as seasonal flu - mainly
through coughing or sneezing
• People may be infected by touching
something with flu viruses on it and
then touching their mouth, nose or
eyes (moist mucous membranes)
before washing their hands.
• Infected people can infect others
beginning 1 day before and up to
7 or more days after symptoms
develop.
 Symptoms and signs of H1N1 in humans?

• Similar symptoms as of human seasonal

influenza.
• Fever (≥ 38 º C), AND
• cough and sore throat
• Body aches, headache, chills, and fatigue or
lack of appetite.
• Some people with H1N1 have reported runny
nose, nausea, vomiting, and diarrhea.
 Case Definition: Influenza A
(H1N1) virus infection
• Suspected case is defined as a person
with acute febrile respiratory illness (fever ≥
380C) with onset:

• within 7 days of close contact with a person who

is a confirmed case of swine influenza A (H1N1)
virus infection, or
•  within 7 days of travel to community where
there are one or more confirmed swine influenza
A(H1N1) cases, or
• resides in a community where there are one or
more confirmed swine influenza cases.
 Case Definition: Influenza A
(H1N1) virus infection
Probable case: defined as a person with an acute febrile
respiratory illness who is:
• positive for influenza A, but unsubtypable for H1 by
influenza RT-PCR or reagents used to detect seasonal
influenza virus infection, or
• positive for influenza A by an influenza rapid test or an
influenza immuno-fluorescence assay (IFA) plus meets
criteria for a suspected case
• individual with a clinically compatible illness who died
of an unexplained acute respiratory illness who is
considered to be epidemiologically linked to a probable
or confirmed case.
 Case Definition: Influenza A
(H1N1) virus infection

Confirmed case: defined as a person with:

• An acute febrile respiratory illness with
laboratory confirmed swine influenza A (H1N1)
virus infection at WHO approved laboratories by
one or more of the following tests:
– Real Time PCR
– viral culture
– Four-fold rise in swine influenza A (H1N1) virus
specific neutralizing antibodies.
• If swine flu is suspected, clinicians should obtain a
Nasopharyngeal or throat swab for swine
influenza testing and place it in a refrigerator (not
a freezer) but transport within 24 hours if not then
store at –70 degree C.

– Once collected, the clinician should contact

their state or local health department to
facilitate transport and timely diagnosis at a
state public health laboratory
The guiding principles of treatment are:

•Early implementation of infection control precautions

to minimize nosocomical / household spread of disease.
•Prompt treatment to prevent severe illness & death.
•Early identification and follow up of persons at risk.
•Infrastructure / manpower / material support
Infrastructure & Manpower  
•Isolation facilities: if dedicated isolation room is not available then
patients can be cohorted in a well ventilated isolation ward with
beds kept one metre apart.
•Manpower: Dedicated doctors, nurses and paramedical workers.
•Equipment: Portable X Ray machine, ventilators, large oxygen
cylinders, pulse oxymeter
•Supplies: Adequate quantities of PPE, disinfectants and
medications (Oseltamivir, antibiotics and other medicines)
 Standard Operating Procedures

Reinforce standard infection control

precautions i.e. all those entering the room
must use high efficiency masks, gowns,
goggles, gloves, cap and shoe cover.

Restrict number of visitors and provide them

with PPE.

Provide antiviral prophylaxis to health care

personnel managing the case and ask them to
monitor their own health twice a day.

Dispose waste properly by placing it in sealed

impermeable bags labeled as Bio- Hazard.
Steps of Hand Washing Technique
 Clinical Management
Pharmaceutical Interventions
Viruses so far characterized have been sensitive to
oseltamivir & zanamivir; resistant to amantadine &
rimantadine
•Treatment:
• Oseltamivir 75 mg twice daily for 5 days

•Chemoprophylaxis:
– Close contacts of a confirmed case
– Health care personnel coming in contact with confirmed case
– Oseltamivir 75 mg once daily for 10 days
•Vaccine: Not available as of now; 4-6 mths later
Oseltamivir – Recommended doses
Body weight Recommended
Dose
< 15 kg (< 33 lb) 30 mg
> 15 kg – 23 kg (> 33 45 mg
lb – 51 lb)
> 23 kg – 40 kg (> 51 60 mg
lb – 88 lb)
> 40 kg (> 88 lb) 75 mg
 Supportive Therapy
• Fluid
• Parentral nutrition.
• Oxygen therapy/ ventilatory support.
• Antibiotics for secondary infection.
• Vasopressors for shock.
• Paracetamol or ibuprofen is prescribed for fever, myalgia and
headache. Patient is advised to drink plenty of fluids. For sore
throat, short course of topical decongestants, saline nasal drops,
throat lozenges and steam inhalation may be beneficial.
• Salicylate / aspirin is strictly contra-indicated (Reye’s syndrome).
• The suspected cases would be constantly monitored for clinical /
radiological evidence of lower respiratory tract infection and for
hypoxia (respiratory rate, oxygen saturation, level of
consciousness).
-  Maintain airway, breathing and circulation (ABC);
- Maintain hydration, electrolyte balance and nutrition.
- If the laboratory reports are negative, the patient would
be discharged after giving full course of oseltamivir.
-Immunomodulating drugs has not been found to be
beneficial in treatment of ARDS or sepsis associated
multi organ failure.
- Low dose corticosteroids (Hydrocortisone 200-400 mg/
day) may be useful in persisting septic shock (SBP < 90).
- No antibiotics if no pneumonia.

- Antibacterial agents should be administered, if

required, as per locally accepted clinical practice
guidelines. Patient on mechanical ventilation should be
administered antibiotics prophylactically to prevent
hospital associated infections.
 Types of protective masks
• Surgical masks
– Easily available and commonly used for routine surgical and
examination procedures
• High-filtration respiratory mask
– Special microstructure filter disc to flush out particles bigger than 0.3
micron. These masks are further classified:
• oil proof
• oil resistant
• not resistant to oil
– The more a mask is resistant to oil, the better it is
– The masks have numbers beside them that indicate their filtration
efficiency. For example, a N95 mask has 95% efficiency in filtering out
particles greater than 0.3 micron under normal rate of respiration.
• The next generation of masks use Nano-technology which are
capable of blocking particles as small as 0.027 micron.
 Non-Pharmacological Measures

Complete Personal Protective Equipment for Infectious diseases

Non-Pharmacological Measures

Respiratory etiquettes
Non-Pharmacological Measures

Frequent Hand wash

Keeping distance

Isolation and Home quarantine

Self Monitoring of fever
•Community measures
•Social distancing
measures (at onset of
outbreak)
•Avoiding crowded
places
•Border/ Port / airport
Control
•Infection control
practices
•Risk communication
 Actions taken by Ministry of Health
• CoS, Inter Ministerial Task Force ( IMTF)
and Joint Monitoring Group (JMG)
monitoring the situation.
• Enhanced surveillance at all International
Airports to detect entry of disease into India at
the earliest and contain the same.
• Travel advisory issued to defer non-essential
travel to the affected countries.
• Tracking of persons travelled to India from
affected countries.
 Actions taken by Ministry of Health

• States alerted to heighten the level of

preparedness and action.
• IDSP focal points in States to look for and report
clusters of ILI and that of pneumonia
• Central and State RRTs alerted to investigate and
manage outbreaks.
• Identified labs at NICD, Delhi and NIV, Pune
beside all regional centers BSL2 Laboratories to
test clinical samples of the novel virus.
 Actions taken by Ministry of Health-3
• Guidance issued to States on clinical management,
infection control practices, laboratory support.
• Guidelines also available on MOHFW web site.
• Supply of Oseltamivir to states reporting cases.
• Supply of PPE to states reporting cases and other
potential states.
• Medical supplies are decentralized
• IEC activities initiated in print and visual media.
• 24X7 Control room
• Daily press briefing by identified authority.
 Actions by State Governments

•Travel advisory issued by Central Government be re-

emphasized.

•Assist MOHFW in tracking of persons travelled to India from

affected countries.

•Websites:
• www.mohfw.nic.in
• www.nicd.nic.in
 Actions by State Governments

• IEC activities has been initiated using print

and visual media.
• Messages suggesting Do’s & Dont’s to be re-
emphasised
• Nodal person for media briefing to be
identified and communicated to MOHFW. He
should be in constant touch with Director
(M&C), 99999-96104.
• Press briefing by designated authority only.
Dos and Don’t: Educating the Public
• 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
• Staying away: from poultry. Keep them secure in cages.
Keep children out of reach. Wash hands if in contact with
poultry or poultry products.
• Remain healthy by adequate sleep and balanced diet
 References
• CDC USA website
• Ministry of Health & Family Welfare, Govt. of India,
• National Institute of Communicable Diseases,
Government of India
• WHO website
• Kishore J A Dictionary of Public Health (2nd Ed).
New Delhi: Century Publications 2007