Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA

1
Case Management (H1N1)v Pandemic
www.drsarma.in
H1N1v

• Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA
• Consultant Physician Chest Specialist

2
General Treatment

• Treatment is largely supportive
• Bed rest Patient should stay at home for 7 days
• Increased fluid consumption Cough suppressants
  and
• Cough Etiquette, Hand washing, Use of Mask by
  patient
• Antipyretics and analgesics (Paracetamol, NSAIDs)
• Pt to avoid close contact with other persons,
  co-morbid
• May require intravenous hydration supportive
  measures
• Home Isolation One designated person to take
  care
• Antibiotics for secondary bacterial infection

3
Danger Signs of Pandemic Flu

• Shortness of breath, with activity or while
  resting
• Difficulty in breathing, Chest pain on breathing
• Turning blue (cyanosis)
• Bloody or rust colored sputum
• Altered mental status, severe fatigue
• High fever that persists beyond 3 days
• Low blood pressure
• Refusal of feeds by children
• Tachypnea, No interest in play, Not getting up

Watch Out !!
4
Categories of H1N1 cases as per Govt. India

• Category A
• Fever with cough and throat pain ? body pain and
  headache, diarrhea and vomiting.
• No need to test for A(H1N1). No need to give
  Tamiflu.
• Symptomatic Rx. and home isolation. Cough
  etiquette.
• Avoid mixing with others Use of Mask must
• Under constant supervision for a three days.
• Watch out for danger signs of progression.

5
Categories of H1N1 cases as per Govt. India

• Category B
• All signs and symptoms of category A, In addition
  if they have
• High fever ( gt 1010 F) and severe throat
  infection. Or
• Children lt 5 years, pregnant women, Adults 65
  age and or
• With co-morbidities of the kidneys, heart and
  lungs, chronic liver disease, Cancer, diabetics
  and HIV., long term steroid Rx.,
• Give Tamiflu and other symptomatic measures
  Infection control
• But no test for A (H1N1). Watch out for serious
  signs.
• Home isolation, Mask, Avoid mixing for at least
  10 days

6
Categories of H1N1 cases as per Govt. India

• Category C
• Same signs and symptoms as Category B,
• But have breathlessness, chest pain, fainting
  spells, low blood pressure, blood in the phlegm,
  cyanosis, altered sensorium.
• Irritability among small children, refusal to
  accept feeds.
• Worsening of underlying chronic co-morbid
  conditions.
• Must get Tamiflu and must be hospitalized
  immediately.
• Must be tested for A (H1N1) and informed of the
  severity.

7
Categories of H1N1 cases as per Govt. India
8
Oseltamivir (Tamiflu)

• It is a neuraminidase inhibitor, decreases the
  release of viruses from infected cells and, thus,
  viral spread.
• Must be administered within 48 hours of symptom
  onset
• Reduces the length of illness by an average of
  1.5 to 2.5 days
• Duration of administration for treatment is 5
  days may be 10 days
• Post-exposure prophylaxis to be initiated within
  7 days of exposure and continued for at least 10
  days
• Available as 30-mg, 45-mg, and 75-mg capsules and
  as a powder for suspension containing 12 mg/mL
  after reconstitution

9
Oseltamivir (Tamiflu)

• Adult Dose
• Acute illness 75 mg PO (150 mg) bid for 5 days
  up to 10 days
• Prophylaxis 75 mg PO once a day for 10 days
  after exposure
• Pediatric dose
• Acute illness in children aged lt1 year
• lt3 months 12 mg PO bid for 5 d 3-5 months 20
  mg PO bid for 5 d
• 6-11 months 25 mg PO bid for 5 d
• Acute illness and age gt1 year
• lt15 kg 30 mg PO bid for 5 d 15-23 kg 45 mg PO
  bid for 5 d
• 23-40 kg 60 mg PO bid for 5 d gt40 kg
  Administer as in adults

10
Zanamivir (Relenza)

• It is a neuraminidase inhibitor, decreases the
  release of viruses from infected
• cells and, thus, viral spread. Must be
  administered within 48 hours
• Adult Dose
• Treatment for acute illness 10 mg inhaled orally
  bid for 5 days
• Prophylaxis of household contact 10 mg inhaled
  orally od for 10 d
• Prophylaxis for community outbreak 10 mg inhaled
  orally od for 28 d
• Pediatric Dose
• Treatment for acute illness
• lt7 years Not established gt7 years Administer
  as in adults
• Both are Pregnancy Category C Not a
  contraindication prefer Zanamivir

11
Anti Viral Formulations
12
Tamiflu Some Issues

• Nausea
• Vomiting
• Diarrhea
• Bronchitis
• Stomach pain
• Dizziness
• Headache
• Confusion, Hallucinations

• Cost 10 caps 2000/-
• Not available in private
• Misuse
• Hoarding
• Resistance
• Spurious caps
• Limited Pvt. availability
• Private Hospitals - yes

13
Management of Severe Disease

• Most cases do not need Test, Tami Flu,
  Hospitalization
• Supportive treatment and home isolation will
  suffice
• Watch out for the high risk groups and Category B
  and C
• Early administration of Tami Flu if indicated
  Reduces viremia
• Monitor O2 saturation and maintain 90-92
  saturation - O2 Rx.
• Antibiotics for secondary bacterial pneumonia
  as per CAP
• MRSA Ventilator support in severely ill VAP
  Vasopressors
• No role for corticosteroids except in shock Risk
  is increased
• ARDS Lung protective mechanical ventilation

14
Chemo Prophylaxis

• Prophylaxis with antiviral agents - Post-exposure
• Close household contacts of a confirmed or
  suspected case who are at high risk for
  complications (chronic medical conditions,
  persons gt65 y or lt5 y, pregnant women)
• School children at high risk for complications
  who have been in close contact with a confirmed
  or suspected case
• Travelers to Mexico, USA who are at high risk for
  complications
• Health care providers or public health workers
  who were not using appropriate personal
  protective equipment during close contact with a
  confirmed or suspected case
• Prophylaxis with antiviral agents - Pre-exposure
• Any health care provider who is at high risk for
  complications (persons with chronic medical
  conditions, adults gt65 y, pregnant women)

15
Steps in Vaccine Development
Vaccine is available in Europe and China
Vaccine is just becoming available. Seasonal Flu
Vaccine is not effective
16
Executive Summary

1. Airborne transmission No unusual routes Food
   no risk
2. Cumulative clinical attack rate 20 to 30
3. Over 90 of the illness is mild and self limiting
   
4. Highest affected will be children and young
   adults
5. Adults gt 60 years seem to be least affected
6. High risk groups discussed must be watched for
   fatality
7. Hospitalization rates will be 1 to 2 of clinical
   cases
8. The term swine flu is inaccurate confusing A
   H1N1v 2009

17
Executive Summary

• Case Fatality Rate will be around 0.1 to 0.2
  (1-2 per 1000)
• Fatality will be more in children and very old
  and high risk
• Hospitalizations are for high risk groups, people
  lt 5, gt 60 yrs
• H1N1v is sensitive to Oseltamivir and Zanamivir
  NAIs
• Seasonal flue vaccine is in effective Vaccine in
  October
• The virus can mutate at any time Second wave
  aggressive
• International co-operation and sharing of
  experience
• All these rates ratios are biased upwards
  inapparent inf.

18
The Three Golden Issues
19
What Should We Tell Our Patient ?

• This Flu is like any other ARI
• Cover your cough and sneeze
• Frequent hand washing
• Hand face distancing
• Social distancing
• Fomite transmission cell phones
• Home isolation Discuss the need for Test and
  Tamiflu
• Only a small proportion need hospitalization
• Flu death is rare No need to panic

20
What Should We do?

• Remember is similar in most respects like any
  other ARI
• Suspect the pandemic flu particularly if temp
  is gt 100
• Look for signs of serious illness SOB, chest
  pain, blood etc
• Look for high risk profile, Be watchful about
  young kids
• Categorize the patient as A, B or C and write
  down the stage
• Take appropriate action as per the category
• Segregate patients at first contact in the
  waiting room
• Give priority to those with ARI and reduce
  contact time
• Protect yourself with mask while examining a
  suspect case

21
Top Resources Consulted

• http//www.emedicinehealth.com/swine_flu/article_e
  m.htmhistory
• http//www.who.int/csr/disease/swineflu/en/index.h
  tml
• http//www.who.int/csr/disease/avian_influenza/pha
  se/en/
• Journal of Applied Microbiology 91 (4) 572579,
  2001
• http//knol.google.com/k/salim-djelouat/swine-flu-
  pandemic-review
• http//emedicine.medscape.com/article/1673658-over
  view
• http//www.cdc.gov/h1n1flu/general_info.htm
• http//www.cdc.gov/h1n1flu/
• http//www.cdc.gov/h1n1flu/surveillanceqa.htm
• http//www.cdc.gov/h1n1flu/masks.htm

22
Top Resources Consulted contd

• http//www.cdc.gov/h1n1flu/guidance/rapid_testing.
  htm
• http//www.cdc.gov/h1n1flu/recommendations.htm
• http//www.ecdc.europa.eu/en/Pages/home.aspx
• http//www.ecdc.europa.eu/en/healthtopics/Publishi
  ngImages/World_Map
• http//sis.nlm.nih.gov/enviro/swineflu.htmla3
• New England Journal of Medicine H1N1 Influenza
  Center 
• http//www.lancet.com/H1N1-flu
• http//www.healthmap.org/en
• http//pandemicflu.bmj.com/
• H1N1 Clinical Medical References Guidelines _at_
  MDConsult.com

23
This is the best way to contain H1N1
Namaskaar