ORIENTATION WORKSHOP PPT FOR SWINE FLU Flu H1N1.pdf · ORIENTATION WORKSHOP PPT FOR SWINE FLU DR. LOKENDRA DAVE M.D Professor and Head , Dept Of TB Chest, GMC & HH, Bhopal

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.

H1 N1 PneumoniaH1 N1 Pneumonia

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

Entering and Exiting

Isolation Rooms or Cohort

Areas

Health Care Workers and Visitors

Remember! Use clean water to Remember! Use clean water to

wash and rinse handswash and rinse hands

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

Check for SealCheck for Seal

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.

PPE, including rubber apron, must be worn during cleaning and disinfection

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

preventionprevention

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.

SOAP & WATER BEST!SOAP & WATER BEST!

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.

Thanks Thanks

Created for Created for AwarnessAwarness on Swine Fluon Swine Flu

By By

Dr Dr LokendraLokendra Dave,Dave, M.D.M.D.

Mob 9893155531, 8966079204Mob 9893155531, 8966079204