dr. r v s n sarma., md., msc. (canada), fimsa consultant physician & chest specialist

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Dr. R V S N Sarma., Dr. R V S N Sarma., MD., MSc. MD., MSc. (Canada), FIMSA (Canada), FIMSA Consultant Physician & Chest Consultant Physician & Chest Specialist Specialist www.drsarma. in

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Page 1: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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

Consultant Physician & Chest SpecialistConsultant Physician & Chest Specialist

www.drsarma.in

Page 2: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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• To compile this comprehensive presentation many resources on To compile this comprehensive presentation many resources on the internet are reviewed and relevant material like text, pictures, the internet are reviewed and relevant material like text, pictures, images, diagrams etc., are incorporated.images, diagrams etc., are incorporated.

• The main objective is to share the wide knowledge, at this hour of The main objective is to share the wide knowledge, at this hour of need, with all the physicians I come across and in turn help the need, with all the physicians I come across and in turn help the patients and the community at large.patients and the community at large.

• Scientific information from CDC, WHO, NIH, ECDC, BMJ, NEJM, Scientific information from CDC, WHO, NIH, ECDC, BMJ, NEJM, Flu watch, SEARO, MOHFW, NCDC (NICD) is invaluable. Flu watch, SEARO, MOHFW, NCDC (NICD) is invaluable.

• I record my sincere thanks and acknowledge using these I record my sincere thanks and acknowledge using these resources. The references are listed at the end. resources. The references are listed at the end.

Page 3: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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Essential – Positive – Constructive ApproachEssential – Positive – Constructive Approach• Adequate awareness in general public – preventive measuresAdequate awareness in general public – preventive measures• Comprehensive knowledge for the healthcare providersComprehensive knowledge for the healthcare providers• Appropriate planning and responsibility of all involvedAppropriate planning and responsibility of all involved

Unwarranted – Misleading – Dangerous – Negative reactionsUnwarranted – Misleading – Dangerous – Negative reactions• Fear, minute to minute monitoring of deaths, rumorsFear, minute to minute monitoring of deaths, rumors• Media hype, Anxiety about infection and death by this fluMedia hype, Anxiety about infection and death by this flu• Panic, mania of mask use by one and all, and worry Panic, mania of mask use by one and all, and worry

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• Influenza AInfluenza A– Common, More Severe, Several Sub-typesCommon, More Severe, Several Sub-types– Epidemics, Pandemics, Epidemics, Pandemics, Mortality, High Mutagenicity Mortality, High Mutagenicity

• Influenza BInfluenza B– Less Severe, Less Frequent, No Sub types, Faithfully HumanLess Severe, Less Frequent, No Sub types, Faithfully Human

• Influenza CInfluenza C– Mild, Rare, No Sub types, Non fatal, Mild Illness in ChildrenMild, Rare, No Sub types, Non fatal, Mild Illness in Children

• Common Cold Common Cold – Coryza & Other Viruses – Not Flu– Coryza & Other Viruses – Not Flu

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Symptoms Influenza Common Cold

Fever Usually high grade; 3-4 d Unusual

Head ache Yes Unusual

Fatigue May last up to 2-3 weeks Mild

Myalgia Usual and often severe Slight

Exhaustion Early and sometimes severe Never

Stuffy nose Sometimes Common

Sore throat Sometimes Common

Cough Yes Unusual

Chest pain Common / may be severe Mild

Complications Bronchitis, Viral or Bacterial pneumonia Sinus congestion

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Neuraminidase (N) For Detachment

Hemagglutinin (H)for Attachment

• Orthomyxoviridae FamilyOrthomyxoviridae Family• Single stranded RNA virus Single stranded RNA virus • High mutagenicity, 8 proteinsHigh mutagenicity, 8 proteins• H Ag types are 16H Ag types are 16• N Ag types are 09N Ag types are 09• So, 16 x 9 = 144 types possibleSo, 16 x 9 = 144 types possible• But only 3 types infect HumansBut only 3 types infect Humans• H1N1, H2N2 and H3N2H1N1, H2N2 and H3N2• Avian Flu Virus is H5N1Avian Flu Virus is H5N1• Virus H1N1 - Virus H1N1 - ‘Swine Flu’ Misnomer‘Swine Flu’ Misnomer• Present Pandemic – (H1N1)vPresent Pandemic – (H1N1)v

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Page 8: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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• Orthomyxoviridae FamilyOrthomyxoviridae Family• Single Stranded RNA virus Single Stranded RNA virus • High mutagenicityHigh mutagenicity• Two viruses co-infect the same cellTwo viruses co-infect the same cell• New virus with segments of bothNew virus with segments of both• A mix of Avian, Swine and HumanA mix of Avian, Swine and Human• This is genetic reassortmentThis is genetic reassortment• Doesn’t require pigs as intermediaryDoesn’t require pigs as intermediary• ‘‘Swine Flu’ is now named H1N1vSwine Flu’ is now named H1N1v• Present Pandemic – (H1N1)vPresent Pandemic – (H1N1)v• This is less virulent This is less virulent than H5N1than H5N1

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Page 11: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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Seasonal Epidemic Influenza Pandemic Influenza H1N1

A public health problem each year Rare and unpredictable in population

Some immunity from previous exposures No herd immunity, Virulence not linked

Infants and elderly are at utmost risk All age groups including healthy adults

This is result of Antigenic Drift This is result of Antigenic Shift

Vaccine available; Modified each year No vaccine available as it’s a novel virus

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Name of the Pandemic Year Deaths SubtypePandemic

Severity Index

Asiatic (Russian) Flu 1889 - 1890 I Million ? H2N2 NA

Spanish Flu 1918 Pandemic 1918 - 1920 50 Million H1N1 5

Asian Flu 1957 - 1958 4 Million H2N2 2

Hong Kong Flu 1968 - 1969 2 Million H3N3 2

2009 Flu Pandemic 2009 – Present 4, 735 H1N1v About 1.5

Seasonal Influenza Every Year 500, 000 H1N1 NA

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• We’re still learning about the severity of the novel H1N1 We’re still learning about the severity of the novel H1N1 • At this time, there is not enough information to predict At this time, there is not enough information to predict

how severe this novel H1N1 flu outbreak will be in terms how severe this novel H1N1 flu outbreak will be in terms of illness and death or of illness and death or

• It compares very similar to seasonal influenza. It compares very similar to seasonal influenza. • Luckily most cases have been mild. Only few fatal casesLuckily most cases have been mild. Only few fatal cases• Most people recover without hospitalization or Tamiflu Most people recover without hospitalization or Tamiflu • It may mutate eventually and become more / less serious.It may mutate eventually and become more / less serious.

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Page 15: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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Second Wave

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WHO - Region wiseAs of 8th Nov 09

Cases Deaths

WHO RO for Africa – AFRO 14,868 103

WHO RO for the Americas – AMRO 1,90,765 4,512

WHO RO for Eastern Mediterranean – EMRO 25,531 151

WHO RO for Europe - EURO > 78,000 300

WHO RO for South-East Asia – SEARO 44,661 678

WHO RO for Western Pacific – WPRO 1,49,711 516

Total > 5,03,536 6,260

CFR = (6260 ÷ 5,03,536) x 100 = 1.243%

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Page 18: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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As on 08th November 2009

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1,00,000

50,000

10,000

1,000

150

Mortality Rate = 150 ÷1,00,000 =

0.15%

CFR = 150 ÷ 10,000 or 1.5%CFR = 150 ÷

10,000 or 1.5%

Clinical Attack Rate = 10,000 ÷ 50,000 = 20%

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Influenza A H1N1 Status as on 11th November 09State Cumulative Cases Cumulative Death

Delhi 3659 17

Andhra Pradesh 765 49

Karnataka 1513 118

Tamil Nadu 1654 7

Maharashtra 3768 209

Kerala 1124 22

Punjab 45 2

Haryana 814 5

Chandigarh 74 0

Goa 54 4

West Bengal 127 0

Uttarakhand 74 3Himachal Pradesh 6 1Jammu & Kashmir 47 0

State Cumulative Cases Cumulative Death

Gujarat 256 40

Manipur 1 0

Meghalaya 8 0

Mizoram 4 1

Assam 45 0

Jharkhand 1 0

Rajasthan 230 19

Bihar 7 0

Uttar Pradesh 451 3Puducherry 54 6

Chattishgarh 16 1

Madhya Pradesh 7 0

Orissa 19 1

Total 14851 508

CFR = (508 ÷ 14851) x 100 = 3.42 %

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• Very Similar to the Seasonal Flu Very Similar to the Seasonal Flu and Not like Common Coldand Not like Common Cold– Moderate to Moderate to high feverhigh fever– aches, muscle and joint pains aches, muscle and joint pains – chills and fatiguechills and fatigue– sore throat, head ache sore throat, head ache – cough cough – sneezing and running nosesneezing and running nose– shortness of breath, chest pain on breathing shortness of breath, chest pain on breathing – diarrheas and vomiting (possible), loss of appetitediarrheas and vomiting (possible), loss of appetite

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• Onset of acute febrile respiratory illness within 7 days of close Onset of acute febrile respiratory illness within 7 days of close contact with a person who has a confirmed case of H1N1 contact with a person who has a confirmed case of H1N1 influenza A virus infection, orinfluenza A virus infection, or

• Onset of acute febrile respiratory illness within 7 days of travel Onset of acute febrile respiratory illness within 7 days of travel to a community (within the United States or internationally) to a community (within the United States or internationally) where one or more H1N1 influenza A cases have been where one or more H1N1 influenza A cases have been confirmed, orconfirmed, or

• Acute febrile respiratory illness in a person who resides in a Acute febrile respiratory illness in a person who resides in a community where at least one H1N1 influenza case has been community where at least one H1N1 influenza case has been confirmed.confirmed.

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Fever or H/o Fever 87%

Head ache 41%

Myalgia 38%

Arthralgia 23%

Dry cough 49%

Productive cough 17&

Sore throat 49%

Running nose 33%

Sneezing 21%

Shortness of Breath 10%

Diarrhea 12%

Vomiting 16%

Nausea 17%

Conjunctivitis 7%

Nose bleed 2%

Altered Sensorium 0.5%

Others 22%

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Page 25: Dr. R V S N Sarma., MD., MSc. (Canada), FIMSA Consultant Physician & Chest Specialist

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ParameterPresent

Pandemic1918

PandemicComment

Serial Interval - SI 1.9 2.6 Less severe

Basic Reproductive Rate – R0 1.2 1.8 Less severe

Heard Immunity – HI 17% NA Will build up

Serial Transmission Cycles ? 2 6 Less severe

Infected population % 20% >60% Less severe

Case fatality rate – CFR ? 1.5 /1000 25% Mild

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• Secondary attack rate in household contacts: 12 %.Secondary attack rate in household contacts: 12 %.• Overall proportion of hospitalizations: 8 %.Overall proportion of hospitalizations: 8 %.• Overall case fatality: 0.15 % or 1.5 per every 1000 casesOverall case fatality: 0.15 % or 1.5 per every 1000 cases• Most cases (58 %) highest incidence in 5–24 years age group, Most cases (58 %) highest incidence in 5–24 years age group, • Second highest incidence in children < 5 yearsSecond highest incidence in children < 5 years• Most hospitalizations (34 %) in 5–24 years age group, Most hospitalizations (34 %) in 5–24 years age group, • Highest age-specific hospitalization rate in children < 5 yearsHighest age-specific hospitalization rate in children < 5 years• Most deaths in 5–24 years age groupMost deaths in 5–24 years age group• The old are generally spared > 65The old are generally spared > 65

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• Cocktail mix of Cocktail mix of Porcine, Avian and Human Porcine, Avian and Human Influenza A VirusInfluenza A Virus• Direct Airborne, No other routes so farDirect Airborne, No other routes so far

– Fine droplets expelled during coughing and sneezing Fine droplets expelled during coughing and sneezing – Expectorated sputum and the dried secretion Expectorated sputum and the dried secretion

• Indirect - Indirect - All items that have been in contact with a patient (Fomite)All items that have been in contact with a patient (Fomite)• Incubation Period (IP) – Incubation Period (IP) – 3 to 7 days – Median 2-3 days3 to 7 days – Median 2-3 days• Contagious period – Contagious period – One day before symptoms to 7 daysOne day before symptoms to 7 days• Asymptomatic carrier state – Asymptomatic carrier state – NoneNone• Immunity – Immunity – Life time for this type; No protection by seasonal fluLife time for this type; No protection by seasonal flu

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IsolationIsolation• Separation and restricted movement of Separation and restricted movement of ill persons ill persons with with

contagious disease, often in a hospital settingcontagious disease, often in a hospital setting• Primarily individual level; Can be voluntary or mandatedPrimarily individual level; Can be voluntary or mandatedQuarantineQuarantine• Separation and restriction of movement or activities Separation and restriction of movement or activities

of persons who are, of persons who are, not yet illnot yet ill, have been exposed , have been exposed • Often at home, or residential facility or hospital Individual Often at home, or residential facility or hospital Individual

or community level; Can be voluntary or legally mandatedor community level; Can be voluntary or legally mandated

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• DiabetesDiabetes• PregnancyPregnancy• Chronic Respiratory Illnesses , Neuromuscular disordersChronic Respiratory Illnesses , Neuromuscular disorders• Chronic cardio-vascular disease (? hypertension)Chronic cardio-vascular disease (? hypertension)• Seizure disorder and other neurodegenerative diseaseSeizure disorder and other neurodegenerative disease• Chronic renal disease stages III and IVChronic renal disease stages III and IV• Cancer and immuno suppression including HIVCancer and immuno suppression including HIV• Morbid ObesityMorbid Obesity• More deaths in people <18 years of ageMore deaths in people <18 years of age

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• Children < 5 years old; Persons aged 65 years or older Children < 5 years old; Persons aged 65 years or older • Children and adolescents (< 18 years) who are receiving Children and adolescents (< 18 years) who are receiving

long-term aspirin therapy and at risk for Reye syndrome long-term aspirin therapy and at risk for Reye syndrome• Pregnant women Pregnant women • Adults and children who have asthma, chronic pulmonary, Adults and children who have asthma, chronic pulmonary,

cardiovascular, hepatic, hematological, neurologic, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders such as diabetes; neuromuscular, or metabolic disorders such as diabetes;

• Adults and children who have immuno-suppression Adults and children who have immuno-suppression (either due to medications or by HIV) (either due to medications or by HIV)

• Residents of nursing homes and other chronic-care facilities. Residents of nursing homes and other chronic-care facilities.

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• rRT-PCR Swine Flu assay– reverse transcriptase real time PCRrRT-PCR Swine Flu assay– reverse transcriptase real time PCR– Highly specific test, 24 to 48 hours, costly Rs. 4,000, detects viral Highly specific test, 24 to 48 hours, costly Rs. 4,000, detects viral

multiplication, can identify the novel H1N1 correctlymultiplication, can identify the novel H1N1 correctly– Confirmatory test, sensitivity is also quite high 85%, Quantitative Confirmatory test, sensitivity is also quite high 85%, Quantitative

• RIDT (Rapid Influenza Diagnostic Test) – RIDT (Rapid Influenza Diagnostic Test) – Not Recommended Not Recommended – point of care, 1 hour, less cost (Rs 700), card test, detects viral proteinpoint of care, 1 hour, less cost (Rs 700), card test, detects viral protein– Sensitivity low 10 to 70% - A negative result can’t exclude InfluenzaSensitivity low 10 to 70% - A negative result can’t exclude Influenza– Can not distinguish between Influenza B or A or A sub typesCan not distinguish between Influenza B or A or A sub types– Specificity – 80% - can confirm Influenza infection – not the type Specificity – 80% - can confirm Influenza infection – not the type – If positive – needs a confirmatory test to identify the typeIf positive – needs a confirmatory test to identify the type

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