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Dr K K Aggarwal

Swine Flu is back but no panic

By Dr K K Aggarwal
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• Swine flu presents with fever of more than 1000 F with cough or sore throat in the absence of any other main cause. • The diagnosis is confirmed with a lab test using rRT/PCR technique. • Mild or uncomplicated flu is characterized by fever, cough, sore throat, nasal discharge, muscle pain, headache, chills, malaise and sometimes diarrhea and vomiting. In mild cases, there is no shortness of breath. • Progressive swine flu is characterized by the above symptoms along with chest pain, increased respiratory rate, decreased oxygen in the blood, labored breathing in children, low blood pressure, confusion, altered mental status, severe dehydration and exacerbation of underlying asthma, renal failure, diabetes, heart failure, angina or COPD. • Severe or complicated swine flu is characterized by respiratory failure, requirement of oxygen or ventilator, abnormal chest x-ray, inflammation of the brain, lowering of blood pressure to less than 60 and involvement of the heart muscle. These patients will have persistent high fever and other symptoms lasting more than three days. • Most patients will remain asthmatic with illness lasting 3-7 days. • The characteristic features are presence of chills, muscle pain and joint pain. • In the pregnant women, flu can cause more serious complications including death of fetus. • Mild cases do not require admission but progressive cases need to be admitted. • Underlying, organ disease and requirement of mechanical ventilation is the indication for admission. • Oseltamivir phosphate is the treatment of choice but it should be taken under medical supervision. It has to be given in the first 48 hours. It is given in severely low patients, pregnant women, underlying organ disease or age less than 5 years. • Flu vaccine can be given to all. It should be given to all high-risk patients. • The virus spreads through droplet infection and spreads with a person coughs, sneezes, sings or speaks. The virus can cover only a distance of 3 to 6 feet. • Stay 3 feet away from the person who is coughing. • The standard prevention is respiratory hygiene, cough etiquette and hand hygiene. • Hand washing should be performed before and after every patient contact or infectious material and before putting and after removing gloves. • Hand hygiene can be performed by washing with soap and water or with alcohol based hand drops. • If hands are visibly soiled, they should be washed with soap and water. • Patients should be placed in a private room or area. The health care staff should wear a face mask while entering the patient’s room. When leaving the room, the health care workers should remove the face mask, dispose it off and then perform hand hygiene. • Patients should wear a surgical mask and should be aware of respiratory hygiene, cough etiquette and hand hygiene. • Droplet precaution should be taken for seven days after illness onset or 24 hours after resolutions of fever and respiratory syndrome. • One should not cough in the hands, handkerchief but instead cough either in the tissue paper and dispose it off or in the side of the arm. • Swine flu causes fewer deaths than normal seasonal flu. • Hong Kong Study of H1N1 (Between April and December 2009]: Overall attack rate was 10.7 percent, case-hospitalization rate was 0.47 to 0.87 % among people aged 5 to 59 years, case-ICU rate was 7.9 cases per 100,000 infections in children aged 5 to 14 years, case-ICU rate was 75 cases per 100,000 infections in adults aged 50 and 59 years, case-fatality rate was 0.4 cases per 100,000 in children aged 5 to 14 years and case-fatality rate 26.5 cases per 100,000 in adults aged 50 to 59 years. • Case fatality is 0.4 – 26.5 cases per 100,000. That means 10 deaths would occur if one lac people gets fly. For getting 95 deaths we need almost one crore people getting infected with flu. This again means 10% of the society suffering from flu or two patients per family. Either the figure 95 is wrong or the figure number of positives deaths is wrong. • Two third of deaths occur in people with underlying chronic illness. • In seasonal flu more deaths are in people above 65 years of age and in H1N1 flu more deaths are in 50-64 years old age group.

Swine flu update

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Swine flu has killed 95 people in north India since 1st January.

1.       Swine flu causes fewer deaths than the routine seasonal flu.

2.      The Hong Kong Study of H1N1 (Between April and December 2009)

  • Overall attack rate 10.7 percent.
  • Case-hospitalization rate 0.47 to 0.87 percent among people aged 5 to 59 years.
  • Case-ICU rate 7.9 cases per 100,000 infections in children aged 5 to 14 years.
  • Case-ICU rate 75 cases per 100,000 infections in adults aged 50 and 59 years.
  • Case-fatality rate 0.4 cases per 100,000 in children aged 5 to 14 years.
  • Case-fatality rate 26.5 cases per 100,000 in adults aged 50 to 59 years.

3.   Case fatality is 0.4 – 26.5 cases per 100,000. This means 10 deaths would occur if one lakh people get the flu. To have 95 deaths, almost one crore people need to be infected. This again means 10% of the society suffering from flu or two patients per family. Either the figure 95 is wrong or the number of positive cases is incorrect.

4.   From 1st Jan to 7th Feb (flu season), in 38 days, 95 deaths means 2.5 deaths per day in flu season.  According to the Economy Survey of Delhi, a total of 868 people died of pneumonia in 2006 (year average per day 2.4) and 879 in 2007 (year average per day 2.4). This statistics is pre H1N1 era and will be true for seasonal flu.

5. 2.4 deaths in a year should mean that in the flu season the deaths would be many more. This proves the medical fact that swine flu cause fewer deaths than the seasonal flu. Then why panic?

6. US data

  • 0.3 percent of cases require admissions in theUnited States.
  • The mortality rate of 2009 to 2010 pandemic H1N1 influenza A infection was 0.12 deaths per 100,000 population.
  • The mortality is high in severe cases admitted to the ICU: In California, 31 percent of patients were admitted to the intensive care unit and 11 percent died of pneumonia and dehydration.
  • Only inMexico, the mortality burden was 0.6 to 2.6 times that of a typical influenza season but lower than that of the severe epidemic in 2003-2004.
  • Two-thirds of deaths occur in people with underlying chronic illness.

7.     Severity over time: During the second wave of influenza activity of the pandemic, which peaked in late October 2009 in the United States, there were higher rates of pediatric mortality and higher rates of hospitalization in children and young adults compared with previous influenza seasons. No change in severity was observed among hospitalized children and adults with pandemic H1N1 influenza A in the United States in the fall of 2009 compared with the spring of 2010. We do not expect this year’s H1Ni flu to be more severe.

8.      Age: High rates of morbidity and mortality were noted among children and young adults across the globe. In some regions, older adults also had high rates of morbidity and mortality.

9.      The highest mortality was seen in Mexico. From this trend, the case mortality will be higher in India because of overcrowding.

10.  In seasonal flu, deaths occur more in people above 65 years of age and in H1N1 flu, deaths are more in 50-64 years age group.