1. Influenza A (H1N1)

2. Influenza A (H1N1) (Swine flu) Swine flu is a respiratory disease of pigs caused by Type A Influenza virus that causes regular outbreaks in pigs Swine flu viruses have been reported to spread from person-to-person, however transmission was limited The current pandemic started in Mexico in 2009 and now declared as seasonal influenza

3. 3 Pandemics of influenza H7 H5 H9 * 1980 1997 Recorded new avian influenzas 19962002 1999 2003 195519651975198519952005 H1N1 H2N2 1889 Russian influenza H2N2 1957 Asian influenza H2N2 H3N2 1968 Hong Kong influenza H3N2 H3N8 1900 Old Hong Kong influenza H3N8 1918 Spanish influenza H1N1 19151925195519651975198519952005 18951905 2010 2015 2009 Pandemic influenza H1N1 Recorded human pandemic influenza (early sub-types inferred) Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research, National Institute of Infectious Diseases (NIID), Japan. Animated slide: Press space bar H1N1 Pandemic H1N1

4. Phases of Pandemic Influenza

5. Influenza A (H1N1) (Swine flu) Swine flu is a respiratory disease of pigs caused by Type A Influenza virus that causes regular outbreaks in pigs Swine flu viruses have been reported to spread from person-to-person, however transmission was limited During pandemic and post pandemic situation widespread human to human infection occurs

6. What is Influenza A (H1N1) ? Viral infection. Genetic mixing of three different viruses Highly susceptible to oseltamivir

7. Current Situation Global – First case reported on 18 th March 2009 – WHO declared Post Pandemic – June 2010 India Pandemic Phase – May 2009 to Dec 2010 Post Pandemic Phase – Jan 2011 – Dec 2014 Circulate as Seasonal Influenza Tamil Nadu First case : 1 st May 2009 & Declined in 2011 Cases continue to report sporadically

8. Tamil Nadu

9. YearSamplesPositives Positivity Rate DeathsCFR 200923625304712.9100.33 20109630140514.6241.71 2011786344.3411.76 2012505875014.8405.33 20132528371.5616.22 20141363584.3813.79 2015*1963618.4411.11 *Up to 20.01.2015

10. Place Distribution S.noHUD 20142015 CasesDeathsCasesDeaths 1Chennai18171 2Coimbatore8281 3Vellore6 -5 - 4Erode3131 5Kancheepuram3 - - - 6Thiruppathur3 - - - 7Thiruvallur321 - 8Salem2 -2 - 9Thiruvannamalai2 - - - 10Villupuram2 -1 -

11. Place Distribution S.noHUD 20142015 CasesDeathsCasesDeaths 11Cuddalore1 - - - 12Kanniyakumari111 - 13Krishnagiri1 - - - 14Namakkal11 - - 15Ramnad10 - - 16Saidapet1 -3 - 17The Nilgiris1 -1 - 18Thiruppur1021 19Dharmapuri - -1 - 20Madurai - -1 - Total588364

14. (Up to 20-01-2015)

16. Laboratories Identified for Testing

17. Sl. NoName of the Laboratory Government 1King Institute of Preventive Medicine, Guindy Chennai 2Madras Medical College and Research Institute, Chennai 3Coimbatore Medical College, Coimbatore 4Tirunelveli Medical College, Tirunelveli 5KAP Vishwanathan Medical College, Tiruchirapalli 6Madurai Medical College, Madurai 7JIPMER, Pondycherry Private 1Bharat Specialities Lab, Chennai 2Hitech Diagnostics Centre, Chennai 3Lister Metropolis Laboratory and Research Centre(P) Ltd 4Sri Ramachandra Medical College, Porur Chennai 5Diagnostic services, T Nagar, Chennai 6Immuno Ancillary Clinical Services, Coimbatore 7Microbiology Laboratory, Coimbatore 8Vivek Laboratory, Nagercoil 9Doctor’s Doagnostic centre, Tiruchirapalli 10Premier Health centre, Chennai 11Star biotech solution, Chennai 12Christian Medical College, Vellore 13Narayana Hiruthayala Hospital, Kartanaka

18. Epidemiology of AH1N1

19. Case Definition* A suspected case Acute febrile respiratory illness who Develops symptoms within seven days of close contact with a person who is a confirmed case of H1N1 influenza A virus infection or Develops symptoms within seven days of travel or resides in a community where there are one or more confirmed A H1N1 influenza cases * CDC definition

20. Case Definition A probable case: Acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by RT-PCR A confirmed case A cute febrile respiratory illness with laboratory-confirmed H1N1 influenza A virus detection by real-time reverse transcriptase PCR (RT-PCR) or culture.

21. Mode of transmission People become infected by touching something with live flu viruses on it and then touching their mouth or nose (More than 80%) Viruses are spread from person to person by droplet through coughing or sneezing of people with influenza.

22. Communicability From one day before to 7 days after the onset of symptoms. If illness persists for more than 7 days, communicability may persist. Children, especially younger children, might potentially be contagious for longer periods.

23. Clinical features Vomiting or diarrhea (not typical for influenza but reported by recent cases of swine influenza infection)

24. Other Manifestations Tachycardia Tachypnoea Low O2 sat. Hypotension Cyanosis Acute myocarditis Cardiopulmonary arrest

25. High Risk Group Asthma Pregnancy Age above 65 Years Children under five years Chronic lung disease Chronic heart disease Chronic kidney disease Chronic liver disease Chronic neurological disease Immunosuppressant (whether caused by disease or treatment) Diabetes mellitus Obesity

26. Investigations Routine investigations for evaluation and management of symptoms – Hematological, bio chemical, radiological and micro biological tests Confirmation of influenza – Real Time RT – PCR – Isolation of virus in culture – Four fold rise in virus specific neutralizing antibodies

27. Case Management Prompt treatment to prevent severe illness and death  Supportive treatment (Antipyretics, antibiotics, IV fluids, Oxygen therapy, nutrition, saline gorgling, mucolytics etc)  Specific anti viral treatment (Oseltamivir)

28. Antiviral treatment Oseltamivir (Tami flu) is the drug of choice for treatment and chemoprophylaxis. Available in capsule (75 mg, 45 mg and 30 mg) and syrup form (60 ml bottle= 12 mg per ml) For treatment, antiviral drugs work best if started soon after getting sick Reduces the duration of virus excretion and the severity of illness

29. Antiviral treatment for cases Duration of treatment: 5 days BD Dosage schedule WeightDosage <15 kg30 mg BD 5Days 15-23 kg45 mg BD 5Days 24 to <40kg60 mg BD 5Days >40 kg75 mg BD 5Days

30. Antiviral treatment for cases- Infants Duration of treatment: 5 days BD Available as oral suspension Dosage schedule MonthsDosage <3 months12mg BD 5Days 3-5 months20mg BD 5Days 6-11 months25mg BD 5Days

31. Contact tracing and chemoprophylaxis Powerful public health intervention to interrupt the transmission All contacts of confirmed cases are to be administered with Oseltamivir (Tami flu) irrespective of whether they have symptoms or not

32. Antiviral dosage for chemoprophylaxis Duration of treatment: 10 days OD Dosage schedule WeightDosage <15 kg30 mg OD 10 Days 15-23kg45mg OD 10 Days 24to<40kg60mg OD 10 Days >40 kg75mg OD 10 Days

33. Antiviral dosage for chemoprophylaxis -infants Duration of treatment: 10 days OD Chemoprophylaxis not recommended for children below 3 months generally Dosage schedule MonthsDosage 3-5 months20 mg OD 10 Days 6-11 months25 mg OD 10 Days

34. Guidelines for hand washing in Health Care Settings Use surgical spirit (70% alcohol or more) Wash hands before and after seeing every patient Discard basins with antiseptic lotions for handwashing

35. HAND HYGIENE

37. Disinfectants 1 to 10% Sodium or Calcium hypochlorite solution – for disinfecting instruments and infected body fluids 5% lysol – Decontamination of floor by mopping Surgical spirit with minimum of 70% alcohol – For disinfecting Hands

38. Guidelines for schools Daily screening Students/ teacher with flu like condition should be sent to a doctor Home isolation/ admission in isolation ward as per category Disinfect the class rooms before the commencement of next class (Floor with 5% lysol and other surfaces including desk with surgical spirit)

39. Guidelines for cinema theatres Disinfect the theatre before the commencement of next show - Floor with 5% lysol or 1% hypochlorite solution - Seats, ticket counters and other surfaces with surgical spirit

40. Guidelines for marriage halls and other community halls Disinfect the hall before the commencement of next function - Floor with 5% lysol or 1% hypochlorite solution - Seats and other surfaces with surgical spirit

41. Guidelines for lodging houses Disinfect the room before allotting to the next guest - Floor with 5% lysol or hypochlorite solution - Seats, teapoy, TV remote, door handles and other surfaces with surgical spirit

42. Guidelines for Public Transport Disinfect the vehicle particularly the areas touched by hands at the end of every trip - Floor with 5% lysol - Seats and other surfaces with surgical spirit

43. Guidelines for Public Places Improve general cleanliness -Floor with 5% lysol or hypochlorite solution -Seats and other surfaces with surgical spirit Liberal use of disinfectants

44. What should I do? First and most important: wash your hands Practice cough etiquette Avoid touching surfaces that may be contaminated with the flu virus. Avoid close contact with people having flu like illness

45. What should I do? Staying at home if you have flu like symptoms Educating school children and staff, advising avoidance of mass gatherings Avoid crowded places, avoid hand shaking Avoid picnics