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ORIENTATION WORKSHOP PPT ORIENTATION WORKSHOP PPT
FOR SWINE FLUFOR SWINE FLU
DR. LOKENDRA DAVE DR. LOKENDRA DAVE M.DM.D
Professor and Head , Dept Of TB Chest,Professor and Head , Dept Of TB Chest,
GMC & HH,GMC & HH,
BhopalBhopal
DEFINITIONS DEFINITIONS
: ILI/ ARI: ILI/ ARI
InfluenzaInfluenza--like illness (ILI) or flu is defined as like illness (ILI) or flu is defined as
fever (temperature of fever (temperature of 100100ºF [ºF [3737..88ºC] or ºC] or
greater) with cough or sore throat in thegreater) with cough or sore throat in the
absenceabsence of a known cause other than influenzaof a known cause other than influenza
Sequence of cold, Sequence of cold, coryzacoryza, sore throat, , sore throat,
bodyachebodyache, headache, reddening of eyes, , headache, reddening of eyes,
cough, chest tightness, breathlessness.cough, chest tightness, breathlessness.
Rapidly progressive, no response to Rapidly progressive, no response to
symptomatic treatmentsymptomatic treatment
Cases in clusters. Cases in clusters.
CLINICAL FEATURESCLINICAL FEATURES Cat A & B1 or B2Cat A & B1 or B2
Vomiting or diarrhea (not typical for
influenza but reported by recent cases of
swine influenza infection)
Risk factors with even mild illnessRisk factors with even mild illness
Cat BCat B22
Age Age ---- <5 yr, >65 yrs. <5 yr, >65 yrs.
COPDCOPD-- AsthmaAsthma
ImmunocompromisedImmunocompromised statestate-- HIV,CancersHIV,Cancers
DMDM
PregnancyPregnancy
Cardiac disease/ HTNCardiac disease/ HTN
ObesityObesity
Active or healed PTBActive or healed PTB
COMPLICATIONSCOMPLICATIONS
Seriously illSeriously ill-- Cat B2Cat B2
Similar to those of seasonal influenzaSimilar to those of seasonal influenza
Exacerbation of underlying chronic medical Exacerbation of underlying chronic medical
conditions conditions
Upper respiratory tract disease (sinusitis, Upper respiratory tract disease (sinusitis, otitisotitis
media, croup) media, croup)
Lower respiratory tract disease ( clinical Lower respiratory tract disease ( clinical
pneumonia with normal spO2 , pneumonia with normal spO2 , bronchiolitisbronchiolitis, ,
status status asthmaticusasthmaticus) )
Other Manifestations:Other Manifestations: Seriously illSeriously ill-- Cat CCat C
TachycardiaTachycardia
TachypnoeaTachypnoea
LowLow OO22 satsat..
HypotensionHypotension
CyanosisCyanosis
ConfusionalConfusional statestate
AcuteAcute myocarditismyocarditis
CardiopulmonaryCardiopulmonary arrestarrest
Cardiac (myocarditis, pericarditis) Cardiac (myocarditis, pericarditis)
Neurologic (Acute and postNeurologic (Acute and post--infectious infectious
encephalopathy, encephalitis, febrile seizures, encephalopathy, encephalitis, febrile seizures,
status epilepticus) status epilepticus)
Toxic shock syndrome Toxic shock syndrome
Secondary bacterial pneumonia with or Secondary bacterial pneumonia with or
without sepsis without sepsis
Adults Need attention if Present withAdults Need attention if Present with
Difficulty breathing or shortness of breath Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen Pain or pressure in the chest or abdomen
Sudden dizziness Sudden dizziness
Confusion Confusion
Severe or persistent vomiting Severe or persistent vomiting
Seek emergency medical care.Seek emergency medical care.
in Children, if:in Children, if:
In children emergency warning signs that need urgent In children emergency warning signs that need urgent medical attention include : medical attention include :
Fast breathing or trouble breathing Bluish skin Fast breathing or trouble breathing Bluish skin color.Not drinking enough fluids color.Not drinking enough fluids
Not waking up or not interacting Not waking up or not interacting
Being so irritable that the child does not want to be Being so irritable that the child does not want to be held held
FluFlu--like symptoms improve but then return with fever like symptoms improve but then return with fever and worse cough and worse cough
Fever with a rash Fever with a rash
LABORATORY FINDINGSLABORATORY FINDINGS
CBCCBC-- leucocytosisleucocytosis/leucopenia/leucopenia
lymphopenialymphopenia
Elevated CPK, LDHElevated CPK, LDH
Elevated UREA,CREATININEElevated UREA,CREATININE
Elevated AST,ALTElevated AST,ALT
CHEST RADIOGRAPHCHEST RADIOGRAPH--bilateral patchy bilateral patchy
pneumonia but no specific pattern.pneumonia but no specific pattern.
Recommended test Recommended test for suspected cases is realfor suspected cases is real--
time reverse transcriptase (RT)time reverse transcriptase (RT)--PCR for PCR for
influenza A, B, Hinfluenza A, B, H11, and H, and H33
Priority for testing should be given to :Priority for testing should be given to :
Those who require hospitalization and Those who require hospitalization and
Those who are at high risk for severe Those who are at high risk for severe
complications complications ––CAT C and BCAT C and B22
No testing No testing if illness is mild and the person if illness is mild and the person
resides in an area with confirmed casesresides in an area with confirmed cases
CAT A & B CAT A & B
Should all such patients be isolated?Should all such patients be isolated?
DiagnosisDiagnosis
To diagnose swine influenza To diagnose swine influenza A infection, a respiratory A infection, a respiratory specimen would generally specimen would generally need to be need to be collected within collected within the first 2 to 3 days of the first 2 to 3 days of illnessillness (when an infected (when an infected person is most likely to be person is most likely to be shedding virus). shedding virus).
However, some persons, However, some persons, especially children, may especially children, may shed virus for 10 days or shed virus for 10 days or longer. longer.
SpecimensSpecimens
Nasopharyngeal swab, nasal swab, throat Nasopharyngeal swab, nasal swab, throat
swab, combined swab, combined oropharyngealoropharyngeal/ /
nasopharyngeal swab, or nasal aspiratenasopharyngeal swab, or nasal aspirate
A clinician has to obtain sample.A clinician has to obtain sample.
Swabs with a synthetic tip (Swabs with a synthetic tip (egeg, polyester or , polyester or
Dacron) and an aluminum or plastic shaft Dacron) and an aluminum or plastic shaft
should be used. Swabs with cotton tips and should be used. Swabs with cotton tips and
wooden shafts are not recommended.wooden shafts are not recommended.
The collection vial in which the swab is placed The collection vial in which the swab is placed
should contain 1 to 3 should contain 1 to 3 mLmL of viral transport of viral transport
media.media.
Respiratory specimen should be collected Respiratory specimen should be collected
earliest or within 4 to 5 days of illness.earliest or within 4 to 5 days of illness.
Specimens should be placed in viral transport Specimens should be placed in viral transport
media and placed on ice (4media and placed on ice (4--8ºC, 8ºC, uptoupto 48 hrs) 48 hrs)
or else refrigerated (or else refrigerated (--70ºC) till transportation 70ºC) till transportation
to the laboratoryto the laboratory
TREATMENTTREATMENT
Antiviral drugs TAMIFLU can be Antiviral drugs TAMIFLU can be
given to treat those who become given to treat those who become
moderately ill moderately ill CAT BCAT B11&B&B22
Severely ill with influenzaSeverely ill with influenza CAT CCAT C. .
Mild CasesMild Cases
Supportive: Supportive: ParacetamolParacetamol, decongestants, , decongestants,
antihistaminicsantihistaminics fluids…fluids…
*NO SALICYLATES IN CHILDREN/ *NO SALICYLATES IN CHILDREN/
YOUNG ADULTS: REYE'S SYNDROME YOUNG ADULTS: REYE'S SYNDROME
AntiviralsAntivirals : *best within first 48 hours: *best within first 48 hours
*Early administration in at*Early administration in at--risk pts risk pts ieie those those
with with comorbiditiescomorbidities/ pregnancy… / pregnancy…
control precautions: cough etiquettecontrol precautions: cough etiquette
Hand hygiene & Natural ventilationHand hygiene & Natural ventilation
Hospitalized pts:Hospitalized pts:
AntiviralsAntivirals
Pneumonia management (antibiotics, if Pneumonia management (antibiotics, if
necessary)necessary)
Resp. Support: Resp. Support: early detection of hypoxiaearly detection of hypoxia
Correction of hypoxia with supplemental O2 Correction of hypoxia with supplemental O2
Mechanical Ventilator as necessary Mechanical Ventilator as necessary
1. Screen patients1. Screen patients
WHO?WHO?
Assign a staff Assign a staff
member to screen member to screen
patientspatients
WHAT?WHAT?
Acute febrile Acute febrile
respiratory illnessrespiratory illness
Symptom of cough, Symptom of cough,
cold, coryza.cold, coryza.
1. Screen patients1. Screen patients
WHEN? WHEN?
Immediately after patients arriveImmediately after patients arrive at facilityat facility
HOW? HOW?
Screening criteria will vary depending on the local Screening criteria will vary depending on the local
setting and patient populationsetting and patient population
Establish a screening checklist for rapid Establish a screening checklist for rapid
identification of patients with ARD of potential identification of patients with ARD of potential
concernconcern
If screening is positive, then we should control the source
of infection, educate, separate and provide priority service
Educate patientsEducate patients
Educate patients on Educate patients on respiratory hygienerespiratory hygiene and and cough etiquettecough etiquette::
Cover nose and mouth with Cover nose and mouth with cloth /tissue when sneezingcloth /tissue when sneezing (provide (provide if necessary)if necessary)
Wash hands after contact with Wash hands after contact with respiratory secretionsrespiratory secretions
Place posters emphasizing Place posters emphasizing cough etiquette in waiting cough etiquette in waiting areasareas
Patient placement and Patient placement and
cohorting of patientscohorting of patients
In order of preference the best configurations In order of preference the best configurations
are:are:
1.1. Single roomSingle room for a patientfor a patient
2.2. CohortCohort patients with same known or suspected patients with same known or suspected
diagnosis.diagnosis.
3.3. Maintain spatial separationMaintain spatial separation of at least 1.5 meter of at least 1.5 meter
between patients between patients
During admission of patients During admission of patients
with respiratory infectionswith respiratory infections
Educate patients on cough etiquette and Educate patients on cough etiquette and
respiratory hygienerespiratory hygiene
Ensure adequate disposal of sputum Ensure adequate disposal of sputum
Reduce number of visitorsReduce number of visitors
Review periodicallyReview periodically
Discharge promptlyDischarge promptly--do not prolong stay do not prolong stay
Limit access to visitorsLimit access to visitors
Inpatient transport of patients Inpatient transport of patients
with ARDs of potential concernwith ARDs of potential concern
Avoid patient movement outside of the room Avoid patient movement outside of the room
unless essentialunless essential
Alert health care workers receiving the patient in Alert health care workers receiving the patient in
advance about the patient’s diagnosis and advance about the patient’s diagnosis and
relevant infection control measuresrelevant infection control measures
Clean and disinfect surfaces that may have come Clean and disinfect surfaces that may have come
in contact with the patient or patient’s secretionsin contact with the patient or patient’s secretions
Inpatient transport of patients Inpatient transport of patients
with ARDswith ARDs Place a Place a medical maskmedical mask on the patient while on the patient while
moving or caring for them outside their roommoving or caring for them outside their room
If masks are not available, instruct the patient to If masks are not available, instruct the patient to
cover their mouth/nose when coughing or cover their mouth/nose when coughing or
sneezingsneezing
Antiseptic (alcohol) handrubAntiseptic (alcohol) handrub
You can make an alcohol/glycerin solution:You can make an alcohol/glycerin solution:
Use 2Use 2--5 ml of solution for each application5 ml of solution for each application
Rub the solution vigorously into hands until Rub the solution vigorously into hands until
drydry
Always use standard precautions Always use standard precautions
when providing care, even when when providing care, even when
patient looks well !!patient looks well !!
Health care workersHealth care workers
Before entering:Before entering: Assess the risk of any planned Assess the risk of any planned
clinical procedures and the clinical procedures and the expected level of contact with expected level of contact with the patientthe patient
Collect all equipment neededCollect all equipment needed
Perform hand hygiene Perform hand hygiene
Mask or particulate respirator Mask or particulate respirator before enteringbefore entering
Other PPE as needed either at Other PPE as needed either at door or inside roomdoor or inside room
PPE for standard precautionsPPE for standard precautions
Includes any or all of the Includes any or all of the
following:following:
GlovesGloves
GownsGowns
Eye protectionEye protection
Medical masks Medical masks
AerosolAerosol--generating procedures in suspected generating procedures in suspected
influenzainfluenza patients require a particulate patients require a particulate
respirator respirator plusplus other PPE as needed:other PPE as needed:
Sputum induction, sampling.Sputum induction, sampling.
Resuscitation, intubation, suctioning, and/orResuscitation, intubation, suctioning, and/or extubationextubation
BronchoscopyBronchoscopy
Aerosol-generating procedures that warrant airborne precautions
Particulate Respirator Particulate Respirator
To prevent To prevent inhalation of inhalation of airborneairborne--droplet nuclei by droplet nuclei by the health care worker the health care worker
Two examples: N95 EU FFP2
Visitors/family membersVisitors/family members
Recommendations for Recommendations for
patient’s visitor/family patient’s visitor/family
The patient's right to receive The patient's right to receive
visits should be guaranteedvisits should be guaranteed
Encourage parents/legal Encourage parents/legal
guardians of pediatric guardians of pediatric
patients to accompany the patients to accompany the
patient throughout the patient throughout the
hospitalizationhospitalization
What kills influenza virus?What kills influenza virus?
Influenza virus is destroyed by Influenza virus is destroyed by heatheat (167(167--
212212°°F [75F [75--100100°°C]). In addition, several C]). In addition, several
chemical germicides, including chemical germicides, including chlorine, chlorine,
hydrogen peroxide, detergents (soap),hydrogen peroxide, detergents (soap),
iodophorsiodophors (iodine(iodine--based antiseptics), and based antiseptics), and
alcohols alcohols
On inert surface, life is 2 hrs.On inert surface, life is 2 hrs.
Handling linen and wasteHandling linen and waste
The risk of being exposed to or acquiring an IRD The risk of being exposed to or acquiring an IRD
through handling waste or used linen is through handling waste or used linen is lowlow
ALLALL used linen & waste should be placed in used linen & waste should be placed in
bags/containers which can withstand transportationbags/containers which can withstand transportation
Double bagging is Double bagging is not needednot needed for used linen/wastefor used linen/waste
Important points to rememberImportant points to remember
Avoid aerosolizationAvoid aerosolization
whenever handling & whenever handling &
disposing waste especially disposing waste especially
faecesfaeces
WearWear gloves gloves whenever handling whenever handling wastewaste
Perform Perform hand hygienehand hygiene
immediately after removing the immediately after removing the glovesgloves
Keep bins closedKeep bins closed and bags tied and bags tied carefullycarefully
INCUBATION PERIODINCUBATION PERIOD
11--7 DAYS 7 DAYS
AFTER LAST DEFINITE AFTER LAST DEFINITE
EXPOSUREEXPOSURE
Contagiousness:Contagiousness:
1 day before onset of symptoms1 day before onset of symptoms
upto 7 days!upto 7 days!
Children are contagious for longer periods. May Children are contagious for longer periods. May
be upto 2be upto 2--3 weeks?3 weeks?
Transport of deceased persons with precautionsTransport of deceased persons with precautions
Hand hygiene should be performed after completing Hand hygiene should be performed after completing
transport. transport.
For deceased persons with confirmed, probable, or suspect For deceased persons with confirmed, probable, or suspect
novel influenza A (H1N1):novel influenza A (H1N1):
oo limit contactlimit contact with the body in health care settings to with the body in health care settings to
close family membersclose family members
oo Direct contact with the body is discouragedDirect contact with the body is discouraged
oo Necessary contact may occur, as long as hands are Necessary contact may occur, as long as hands are
washed immediately with soap and water.washed immediately with soap and water.
Dealing with the DeceasedDealing with the Deceased
Avoid close contactAvoid close contact
Avoid close contact Avoid close contact
with people who are with people who are
sick. When you are sick, sick. When you are sick,
keep your distance from keep your distance from
others to protect them others to protect them
from getting sick too.from getting sick too.
Aerosols spread the Aerosols spread the
virus in any virus in any
environment environment
Stay home when you are sickStay home when you are sick..
If possible, stay home If possible, stay home
from work, school, and from work, school, and
errands when you are errands when you are
sick. You will help sick. You will help
prevent others from prevent others from
catching your illness. catching your illness.
Cover your mouth and nose.Cover your mouth and nose.
Cover your mouth and Cover your mouth and
nose with a tissue when nose with a tissue when
coughing or sneezing. It coughing or sneezing. It
may prevent those may prevent those
around you from getting around you from getting
sick sick
Avoid touching your eyes, nose or mouth.Avoid touching your eyes, nose or mouth.
Germs are often spread Germs are often spread
when a person touches when a person touches
something that is something that is
contaminated with contaminated with
germs and then touches germs and then touches
his or her eyes, nose, or his or her eyes, nose, or
mouth. mouth.
Clean your hands.Clean your hands.
Washing your hands Washing your hands
often will help protect often will help protect
you from germs.you from germs.
Hand washing proved to Hand washing proved to
be best procedure in be best procedure in
prevention of Majority prevention of Majority
of Communicable of Communicable
diseases. diseases.
Screening, Screening, councellingcouncelling, , followupfollowup of contacts of contacts
Early recognitionEarly recognition and reporting of patients with and reporting of patients with suspected or confirmed diseasesuspected or confirmed disease
Instruction in cough hygieneInstruction in cough hygiene: Reducing or : Reducing or eliminating the source of infectioneliminating the source of infection
CohortingCohorting of patients to a separate wellof patients to a separate well--ventilated waiting areaventilated waiting area
Adequate provision of Adequate provision of services withinservices within the the isolation areasisolation areas
Rapid diagnosisRapid diagnosis for disease confirmationfor disease confirmation
Administrative control measures
VACCINATIONVACCINATION
Annual repetitionAnnual repetition-- boosterbooster
Effect starts after 2Effect starts after 2--3 weeks3 weeks
Efficacy 60Efficacy 60--70%70%
High risk groupHigh risk group
Health workersHealth workers
InjectablesInjectables/ nasal ????/ nasal ????
TAKE HOME MESSAGETAKE HOME MESSAGE
Proper screening/triage, preferably in wellProper screening/triage, preferably in well--ventilated areaventilated area
For suspects/patients For suspects/patients –– ensure safe placement and ensure safe placement and inin--patient transportpatient transport
Separate designated isolation area (single room or Separate designated isolation area (single room or cohortedcohorted with same diagnosis)with same diagnosis)
Maintain Maintain >>1.5 meter distance between patient 1.5 meter distance between patient bedsbeds
Do not forget infection control measures Do not forget infection control measures including cough including cough hyigenehyigene, hand , hand hyigenehyigene, , appropriate level of precaution, use of appropriate appropriate level of precaution, use of appropriate PPE as applicable, for staff and visitors.PPE as applicable, for staff and visitors.
Vaccination, if possible and available.Vaccination, if possible and available.