Gasem MH Avian Influenza SPEED 2012
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Transcript of Gasem MH Avian Influenza SPEED 2012
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DIAGNOSIS & TATALAKSANA PASIEN
AVIAN INFLUENZA (A / H5N1)
Muhammad Hussein Gasem
PINERE Team
RSUP Dr. Kariadi, SemarangSPEED-1
SEMARANG, 26-27 MEI 2012
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SPEED-1
SEMARANG, 26-27 MEI 2012
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Date: Sat, 25 Feb 2012 19:53:14 +0700
ReplyTo: [email protected]
Subject: [Indozoone] Bali
Bird flu kills an Indonesian boy on Bali island
By Associated Press, Updated: Saturday, February 25, 2:46 PM
BALI, Indonesia — Indonesian health officials say a 12-year-old boy
has died of bird flu on the resort island of Bali, bringing the country’s death
toll from the virus to 154 since 2005.
Rita Kusriastuti, an official at the health ministry, said Saturday that the boy
died on Feb. 21 after suffering high fever and breathing difficulties for more
than a week. Tests showed the boy was infected with the H5N1 virus.
She said the boy is suspected to have had direct contact with poultry.
He was the fourth to die of bird flu in Indonesia this year.
Bird flu has killed at least 347 people worldwide since it began ravaging
poultry stocks in 2003. Indonesia is the worst-affected country
with 185 confirmed infections.
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Type A - mild, moderate to severe illness- all age groups- humans & animals (multiple species)
Type B - milder epidemics- primarily affects children - humans only
Type C - rarely reported in humans- no epidemics- humans
Type of Influenza Virus
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Influenza A Viruses
Subtyped based on surface glycoproteins:
• 16 hemagglutinins (HA) and
9 neuraminidases (NA)
• current human subtypes:
H1N1, H2N2, H3N2
NA
HA
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Current human subtypes
H1N1
H2N2
H3N2 SPEED-1
SEMARANG, 26-27 MEI 2012
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Human Influenza (flu musiman)
Penyakit demam pernafasan akut yang mengenai hidung, tenggorokan, bronkus dan paru
Sebagian besar disebabkan oleh virus influenza endemikyang telah beradaptasi dengan manusia yaitu virus Influenza A (H3N2, some H1N1) & Influenza B
Antigenic drift: perubahan materi genetik sedikit demi sedikit strain untuk vaksin berubah-ubah
Antigenic shift / Reassortment, contoh: 2009 H1N1 (New H1N1 or “swine”/ H1N1 pdm 09 )
Setiap tahun , suatu vaksin baru diproduksi untuk menghadapi strain virus baru Pencegahan dengan vaksin dan praktek higiene perorangan yang baik
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The silent reservoirs
STRAINS OF AVIAN FLU IN HUMANS DURING THE LAST 20 YEARS
SPEED-1
SEMARANG, 26-27 MEI 2012
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Migratory
water birdsDomestic birds
• United Kingdom,
1996, H7N7
•Hong Kong 1997,
H5N1
• Hong Kong 1999,
H9N2
• Netherlands 2003,
H7N7
• Hong Kong 2003,
H5N1
•Vietnam/ Thailand,
2004, H5N1
• Indonesia 2005,
H5N1
• United Kingdom,
2006, H7N3
Avian influenza
from birds to humans
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AVIAN INFLUENZA (AI) IN HUMANS
Why AI became a dangerous threat for global community ?
Has infected large populations of birds & poultry
Has infected humans exposed to diseased birds
Causing high mortality rates (~100% poultry; ~ 80% human)
AI virus may mutate to cause human infection & human-to-human transmission
No natural human immunity
No current approved vaccine under production
Potential for a next pandemic influenza?
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H5 (H7, H9) ?
Two Mechanisms for Pandemic Influenza
H5N1
Belshe, NEJM 353 ;21: 2005
2009 Pandemic Influenza
New 2009 H1N1
(swine flu)
"quadruple reassortant" virus
A/ H1N1 pdm 09
H5N1
SPEED-1
SEMARANG, 26-27 MEI 2012
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DEFINISI KASUS AVIAN FLU PADA MANUSIA
Suspect AI
Seseorang yang menderita demam / suhu >38o C disertai satu ataulebih gejala di bawah ini :
• batuk
• sakit tenggorokan
• pilek
• sesak napas
dan diikuti satu atau lebih keadaan di bawah ini :
1. Pernah kontak dengan unggas (ayam, itik, burung) sakit atau mati
mendadak yang belum diketahui penyebabnya dan produk mentahnya
(daging, telur, kotoran unggas, dll) dalam 7 hari terakhir sebelum
timbul gejala di atas.
2. Tinggal atau pernah berkunjung di daerah yang terdapat kematian
unggas yang tidak biasa (dalam jumlah banyak dan dalam waktu
singkat), dalam 7 hari terakhir sebelum timbul gejala di atas.
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3. Pernah kontak dengan pasien kasus AI konfirmasi dalam 7 hari
terakhir sebelum timbul gejala di atas.
4. Pernah kontak dengan spesimen AI dalam 7 hari terakhir sebelum
timbul gejala di atas (bekerja di laboratorium untuk AI).
5. Ditemukan leukopeni (< 5000/mm3)
6. Foto toraks menggambarkan pneumonia yang cepat memburuk
pada serial foto.
Suspect AI
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Suspect AI
Atau ditemukannya Acute Respiratory Distress Syndrome
(ARDS) yang tidak ditemukan penyebab lain dengan satu
atau lebih keadaan di bawah ini:
Leukopeni atau limfositopeni relatif yang didapat dari
hitung jenis, dengan atau tanpa trombositopeni (< normal)
Foto toraks: gambaran pneumonia atipikal atau infiltrat di
kedua sisi paru yang makin cepat meluas pada serial foto.
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Probable AI
Kriteria kasus suspek ditambah dengan satu atau lebih
keadaan di bawah ini:
Ditemukan kenaikan titer antibodi terhadap H5,
minimum 4 kali, dengan pemeriksaan uji HI
menggunakan eritrosit kuda atau uji ELISA.
Hasil laboratorium terbatas untuk Influenza H5
(terdeteksinya antibodi spesifik H5 dalam
spesimen serum tunggal) menggunakan uji
netralisasi (dikirim ke Laboratorium Rujukan).
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Confirmed AI
Suspect atau probable AI dengan satu atau
lebih keadaan di bawah ini :
Biakan virus Influenza A/H5N1 positif.
Positif PCR Influenza (H5)
Pada uji Immunofluorescence Assay (IFA)
ditemukan antigen (positif) dengan menggunakan
antibodi monoklonal Influenza A/H5N1.
Kenaikan titer antibodi spesifik Influenza A/H5N1
fase konvalesen (paired sera) dengan uji
netralisasi sebanyak 4 kali nilai awal (fase akut).
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TATALAKSANA PASIEN AI (1)
Pasien suspect AI harus dirawat di RS dg observasi ketat
Isolasi pasien di dalam ruang tersendiri. Di RSDK, dirawat
di Ruang Isolasi PINERE yg memiliki 2 ruang (kapasitas
dapat 2 orang per-kamar)
Lakukan kewaspadaan universal & tatacara isolasi pasien
Segera koleksi spesimen aspirasi nasofaring (NPA) dan
darah. Kirim segera ke Lab. rujukan regional AI:
Lab. Bagian Mikrobiologi FK Undip.
Terapi sedini mungkin dg oseltamivir (Tamiflu) sesuai
indikasi
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PINERE
SPEED-1
SEMARANG, 26-27 MEI 2012
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TATALAKSANA PASIEN AI (2)
Pasien AI dengan indikasi tertentu seperti pnemonia berat ,
dengan ancaman gagal nafas dsb harus dirawat di ICU
(ventilator, life support monitoring dsb).
Jangan lupa monitor saturasi oksigen dan keseimbangan
cairan-elektrolit.
Petugas harus selalu diingatkan akan pentingnya
kewaspadaan kontak dan droplets
Gunakan APP bagi seluruh petugas kesehatan
yang menangani pasien AI)
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SPEED-1
SEMARANG, 26-27 MEI 2012
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Penutup kepala/rambut
Masker (N-95, N80 or masker bedah)
Pelindung mata (goggle)
Gaun (apron)
Sarung tangan
Penutup sepatu
Alat Perlindungan Perorangan (APP)Personal Protective Equipment (PPE)
“APP lengkap”
SPEED-1
SEMARANG, 26-27 MEI 2012
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Pneumonia pada pasien Avian Influenza
25-03-06 26-03-06 27-03-06
Pneumonia AI umumnya bersifat progresif.
Gambaran radiologiknya sangat bervariasi seperti infiltrat difus, multifokal
atau “patchy”, bisa suatu konsolidasi segmental atau lobuler, efusi pleura
(jarang) dsb SPEED-1
SEMARANG, 26-27 MEI 2012
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Kriteria perawatan di ICU
ARDS
Gagal nafas
Foto dada: kelainan paru bilateral difus
PaO2/FiO2 < 200 mmHg
Tekanan darah Sistolik < 90 mmHg
Indikasi pemakaian ventilator
Perlu pemberian inotropik/vasopresor
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ARDS
Acute onset Bilateral infiltrates on chest radiographs
PAOP <18 mmHg if measured or absence of clinical signs
of left atrial hypertension
ARDS = PaO2 / FiO2 <200 mmHg
SPEED-1
SEMARANG, 26-27 MEI 2012
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Tatalaksana ARDS pada Pneumonia AI
Ventilasi mekanik (ventilator)
Perhatian: proteksi terhadap jejas paru (“lung injury”)
Kontroversi kostikosteroid dlm tatalaksana ARDS pneumonia AI
-Menurut American-European Consensus Committee,
kortikosteroid tidak diindikasikan untuk ARDS tahap awal
-Penggunaan kortikosteroid pada tahap akhir
(fase fibroproliferatif) bisa bermanfaat
-Hydrocortison 200 mg, or Metil prednisolon 4 mg/KgBB /hari
WHO SEARO 2007: National Consultation on Avian Influenza
“Clinical management for ARDS should include treatment of associated
bacteial sepsis and specialized lung protective ventilation strategies”
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LUNG-PROTECTIVE STRATEGIES
to prevent lung injury caused by ventilator
This is achieved by adjusting tidal volumes and respiratory rate to smaller minute volumes as a lung-protective strategy
A PaCO2 of 50 to 77 mm Hg and a pH of 7.20 to 7.30 seem well tolerated
The ARDS Network study 21 reported a 22 percent reduction in mortality in patients who were managed with a low tidal volume (< 6 mL per kg BW) and low plateau pressure ventilator strategy
*) Am Fam Physician 2003;67(2):318 www.aafp.org/afp
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Apakah perlu diberikan antibiotika
untuk pneumonia AI?
Dasar : Kemungkinan terjadi super infeksi bakterial sepsis
Terapi antibotika perlu diberikan secara empirik dan sedapat mungkin
mencakup semua mikroorganisme yang merupakan penyebab
Pneumonia Komunitas (CAP=Community Acquired Pneumonia) baik
kuman tipikal atau atipikal.
Pada pasien yang menggunakan ventilator, perlu dipikirkan
kemungkinan suatu pneumonia karena ventilator (VAP=Ventilator
Associated Pneumonia). Penambahan antibiotika yang mencakup
kuman yang sering ditemukan pada pneumonia ini seperti P.
aeruginosa, Acinetobacter, S. aureus (termasuk MRSA) dll harus
dipertimbangkan.
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Obat Anti Virus Influenza
Ada 2 gologan utama:
1. Neuraminidase inhibitor (Oseltamivir dll)
2. M2 inhibitor (Amantadine dll)
Oseltamivir direkomendasikan untuk pengobatan kasus AI dan kontak dekat, dan untuk terapi pre-emptive pada saat terjadi pandemi AI
Oseltamivir efektif terhadap semua sub-tipe virus influenza A dalam periode 48 jam sejak munculnya gejala. Efikasi setelah 48 jam belum diketahui secara pasti
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OseltamivirOlsetamivir
Neuraminidase Inhibitors (NI)
Oseltamivir & Zanamivir Harus diberikan dalam 48 jam sejak awitan penyakit
Memperpendek periode simtomatik (1-2 hari), mengurangi komplikasi,
lama dan besarnya replikasi virus
Resistensi virus thd obat ini rendah
Efektif sebagai profilaksis
Oseltamivir diberikan secara oral (kapsul atau suspensi)
Efek samping: < 20 % pasien mengeluh mual setelah minum
dosis yang pertama.
Zanamivir diberikan secara “diskhaler”
Ditoleransi dengan baik, jarang terjadi bonchospasme
Function of neuramidase:
Remove neuraminic acid from
mucin and release from cell
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SPEED-1
SEMARANG, 26-27 MEI 2012
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WHO Rapid Advice Guidelines on pharmacological management
of humans infected with Avian Influenza A (H5N1) virus *)
*) WHO, March 29th, 2006
Untuk pengobatan pasien dengan diagnosis pasti atau sangat dicurigai
menderita infeksi virus H5N1
Jika obat neuraminidase inhibitors tersedia:
-Klinisi/dokter harus memberikan oseltamivir (rekomendasi kuat) atau sebagai
alternatif digunakan zanamivir (rekomendasi lemah)
- Klinisi/dokter jangan memberikan amantadine or rimantadine saja sebagai
terapi lini pertama (rekomendasi kuat)
Jika obat neuraminidase inhibitors tidak tersedia:
-Klinisi bisa memberikan amantadine or rimantadine sebagai terapi lini pertama
jika virus H5N1 virus diketahui peka/sensitif terhadap obat-obat tersebut
(rekomendasi lemah)
Jika difikirkan pemberian kemoprofilaksis terhadap infeksi virus H5N1, prioritas
harus diberikan bagi upaya tindakan pengendalian infeksi termasuk petugas
kesehatan, individu yang terlibat dalam usaha pemberantasan binatang / unggas
dan kontak dalam rumah tangga pasien H5N1.
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PENGOBATAN UNTUK PASIEN AVIAN INFLUENZA
(HUMAN CASE OF AVIAN INFLUENZA)
OSELTAMIVIR (Tamiflu)
Dewasa : 2 x 1 kapsul 75 mg/hari
diberikan selama 5 hari
Anak : ( usia ≥ 1 thn )
< 15 kg = 2 x 30 mg/hari
> 15-23 kg = 2 x 45 mg/hari
> 23-40 kg = 2 x 60 mg/hari
> 40 kg = 2 x 75 mg/hari ;
diberikan selama 5 hari
Catatan: 1. Diberikan segera pada saat masuk RS
2. Kasus berat dapat s/d 10 hari
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A higher dose of oseltamivir (e.g., 150 mg twice daily in adults)
and an increased duration of therapy, for a total of 10 days,
may be reasonable, given the high levels of replication of the influenza
A (H5N1) virus, observations of progressive disease despite
early administration of standard-dose oseltamivir
(75 mg twice daily for 5 days in adults) within 1 to 3 days
after the onset of the illness, and the proven safety of
higher doses in adults with seasonal influenza, especially if there
is pneumonic disease at presentation or evidence of clinical progression.
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Efek samping oseltamivir
Ahli farmakologi & studi literatur tidak menemukan efek
samping Oseltamivir (Tamiflu) yang serius pada
penggunaan obat ini untuk manusia.
Komplikasi yang sering dilaporkan adalah:
-Mual dan muntah 9.9%,
-Diare 6%.
-Rash di kulit
-Delirium
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On April 17, 2007, the FDA approved an inactivated, monovalent
avian influenza virus vaccine (produced by Sanofi Pasteur)
for the active immunization of adults aged 18 through 64 yrs
who are at increased risk for exposure to the H5N1 viral subtype
contained in the product.
The immunization regimen consists of two 90-µg/mL doses
administered intramuscularly 28 days apart
VAKSIN UNTUK AVIAN INFLUENZA
SPEED-1
SEMARANG, 26-27 MEI 2012
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DEPOPULASI ATAU “STAMPING-OUT “ AYAM ATAU UNGGAS LAIN,
DAN DIIKUTI OLEH TINDAKAN BIOSEKURITI YANG BAIK
ADALAH SATU-SATUNYA CARA TERBAIK UNTUK MENCEGAH
TERJADINYA KASUS AVIAN FLU PADA MANUSIA
SPEED-1
SEMARANG, 26-27 MEI 2012
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TERIMAKASIH
SPEED-1
SEMARANG, 26-27 MEI 2012