Mhairi Scott Sept’ 2009

Human FLU Deaths worldwide

Seasonal flu: mainly A + B (C rare) 500,000 / yr

A,B,C of Flu

Influenza A virus pandemics:H1N1: Spanish Flu 1918 50 million H2N2: Asian Flu 1957 2 million H3N2: Hong-Kong Flu 1968 1 million

H5N1: Bird Flu

Where does Swine Flu fit in?

Swine FluNew influenza A(H1N1)

virus Unrelated to seasonal fluRespiratory disease of

pigs, birds, poultry, horses & humans

“Quadruple reassortant" virus

Bird-Flu genePig-flu gene 2 genes: Europe & AsiaHuman-gene

Never before circulated in humansWHO Phase 6 = Pandemic > 300,000 cases in over 200 countries

Pandemic H1N1 2009

SymptomsFever (> 38°C / 100.4°F)

Plus 2 or more of:

TirednessHeadacheRunny noseSore throatSOB /coughLoss of appetiteAching musclesD&V

Who Is At Risk?Chronic Disease:LungHeartKidneyLiverNeurologicalImmunosuppressedDiabetesAsthma (Rx past 3 y)

Also:Pregnant womenElderly ≥ 65 yChildren <5 y

UK 2009 TimelineMarch: first confirmed cases (US & Mexico)April: confirmed in UK June: first death in UK, GlasgowJuly: 1st death with no underlying medical probs

Sept: Rising new cases

Predictions Infected = 18.3m

Deaths 18-64,050

Hospital 366,000

Complications 2.74m

Mild 15m

Public MessagesCatch it, bin it, kill it

Cover mouth / tissues / basic hygieneHard surfaces e.g. Door handles, keyboards, phones

Stay at HomeIf symptoms (5-7d)Flu friends

Face mask unnecessary

Contact GP / NHS 24National Pandemic Flu Service

DOH: General Advice Children

Attend schools unless flu symptoms Avoid “flu-parties” See Doctor if < 1 yr

Pregnant Routine avoidance measures Safe to breastfeed if anti-virals Teachers advised to attend school

Travel: Unrestricted unless symptomatic Avoid Mecca Pilgrimages if high-risk group

Headlines“Swine flu jabs rushed through safety tests”“GPs demand more money for swine flu jabs”

TIMES ONLINE

“NHS staff don’t want swine flu jab”“Up to half of GPs and one in three nurses ... because of

concerns over safety.” Telegraph“Vaccine risk outweighs risk of virus” Irish-Times

“Swine flu over-diagnosed”“Swine-flu under-reported”

HCP AdviceTriage suspected casesAvoid in surgery if possibleDeclutter waiting rooms

Use of PPEGlovesMaskGlassesGown

AntiviralsMay lessen severity by reducing:

Length of illness (~ 1 day)Symptoms, and ? Serious complications risk

Maximum benefitAdults: Within 48 hrs of symptoms onsetChildren: Within 36 hrs of symptoms onset

Preparation: TAMIFLU (Oseltamivir) & RELENZA

(Zanamivir)neuraminidase enzyme inhibitors

ActionBlock viral enzymePrevent shedding

SafetyRelatively newreport via the

MHRA’s ‘Swine Flu ADR Portal’

Tamiflu Age 1 and over Caps: 30/45/75mg Susp: 12mg/ml solution

SEs 676 suspected ADRs since April nausea, vomiting, diarrhoea, abdo

pain, headache, mild allergic ??seizures/delirium

Caution Severe renal impairment AVOID dialysis (CrCl ≤ 10ml/min) ?methotrexate ?probenecid ?? warfarin

Dose: Age 1-12

BW ≤ 15kg: 30mg BW ≤ 23kg: 45mg BW ≤ 40kg: 60mg

Age 13+/>40kg: 75mg

Duration: Treat = bd for 5 days

Prev = od for 10 days

NB Best with food

Relenza Age 5 and over Inhaled (Diskhaler): 5mg dose Use: pregnancy, renal disorders

SEs: 22 suspected ADRs since April V rare: 1 in 10,000 allergy, bronchospasm

Caution: persistent asthma/severe COPD

AVOID severe asthma Use bronchodilator before taking

AVOID: allergy to lactose/milk protein

Dose: 2 inhalations (2 blisters) = 10mg

Duration: Treat = bd for 5 days Prev = od for 10 or 28 days*

* Longer duration if community outbreak

Vaccination

VaccinationFirst batches expected October

Once licensed by European Medicines Agency (EMEA)Safety concerns (medical / case reports Guillain-Barre

1970’s)

Prioritised by risk Grp2 doses, 3 weeks apartAnnual flu vaccination also required

“Previous Swine-flu” does not reduce riskEven if received anti-virals Exception is lab (swab) +ve cases

1st Stage Contact

SCOTLAND ENGLAND

1. High Risk: age > 6m – 65 y 640,7005 m

2. Pregnant 60,000 0.5 m3. House contacts immunosuppr 53,000 0.5 m4. High-Risk: age > 65 y 428,250 3.5

m5. Frontline Health Professionals 250,000 2 m

_________ ________

TOTAL = 1.4 million 11 million

Complications

Complications NEJM 2009

Most common severe complications Respiratory Distress Pneumonia

Youth Shift: Age 5-59 87% of total Deaths (exp ~ 17%) 71% of Severe pneumonia

(exp~32%)

• Selective Antivirals (WHO Aug 2009)• High risk groups• Serious / deteriorating cases

=SOB / Resp distress / cyanosis /

haemoptysis / chest pain / fever >3d / confusion / low BP

Second Wave?

Is it coming back?Week until 14/9/9: Sentinel GP practice data

New cases in Scotland Higher now than start of August Past week 6181 Prev week 3336

Consultation rates Tayside > Scottish average Increasing age < 65 Decreasing age > 65

Complications Hospitalised 13 cases (1 ICU) Deaths 8 cases 2nd wave likely coincide with seasonal flu

Summary High Risk “Young people” Pregnancy Chronic Disease / immuno-

suppressed esp < 5y & >65y

Course Most mild self-care Mortality ~0.3% (= seasonal flu) Second-wave

Anti-virals Best evidence severe cases / high-

risk Treat based on risk groups ? Emerging resistance

Vaccination Late-October Normal flu-risk group 6m – 65yExtra: Frontline health-care workers

The End www.direct.gov.uk www.nhs24.com www.scotland.gov.uk www.rcgp.org.uk/pandemic www.hpa.org.uk www.bma.org.uk/

health_promotion_ethics/influenza

www.documents.hps.scot.nhs.uk/respiratory/swine-influenza/situation-reports/weekly-h1n1v