CME INDIA Presentation by Admin.

CME INDIA Red Alert

Dr. Ravi Premchand Kachhela, Cardiologist, Ranchi asks in CME INDIA Group (30/09/2022):

• We have seen 8-10 cases of B/L Pneumonia (Likely Viral) in last 07 days requiring ICU admission, affecting all age groups at Ranchi.
• 02 Fatal.
• Does anybody else is seeing similar cases?
• Right now, we have a 14-year-old Girl.
• Hypersplenism. EHPVO. Fever x 2 days.
• Dry cough. No nasal discharge. Dyspnoea x 1 day.
• Rapidly progressed to NIV requirement over 06 hours of admission.
• TLC – 2700 (P-62/L-30), Platelet 85000/cmm., RFT normal, FT Normal, Echo – Normal
• HRCT Chest B/L multiple GGOs in all lobes of both lungs.
• COVID 19 RT PCR-Negative.

Dr. Rajesh Naik, Goa:

• Do RTPCR for H1N1.

Dr. Ashwin, Cardiologist, Bengaluru:

• H1N1.
• Many cases encountered.
• Our Pulmonologist says to take vaccination as he is expecting the cases to go high after mid-October.

Dr. Ananda Bagchi Kolkata:

• Consider Legionella also.

Dr. Sunetha S., DGO, Coimbatore:

• We are also getting cases at Coimbatore.

Dr. G. B. Sattur, Hubli:

• Likely H1N1.

Dr. Murali Mohan, Pulmonologist, Bengaluru:

• Look for Influenza A and H1N1 – we are seeing a lot more and a lot more severe “flu” than Covid now. With the CT showing more central, denser consolidations, unlike the peripheral GGOs that are more typical of Covid 19.
• Symptoms are almost identical. I find non-respiratory symptoms are commoner in Covid 19.

Dr. Vijay Arora, Consultant Physician, Max Hosp. Delhi:

• Yes, I also encountered 6 Pt in last 45 days 4 in the age group of 25-35 & other two in late fifties.
• Three came out to be Influenzas -A, one influenza A/B, two were confirmed as H1N1.
• All were RAT+RTPCR negative.
• Three required ventilatory support from day 2 of admission.
• Two of the younger lot had to be put on ECMO. Fortunately, all were discharged… went walking, although after difficult hospital stay. Have followed them thereafter 2-3 time. Only one required Domiciliary oxygen @2-3 litres during night or intermittently.
• Three were also found to have K. Pneumonia, candida, Aeromonas, Acinetobacter.

Dr. Ravi Premchand Kachhela, Cardiologist, Ranchi

• Should we use steroids here.
• Day 3 of illness today.
• Hypersplenism.

Dr. R. L. Khare, Prof Med. Raipur:

• And Unlike Covid the Ferritin and D-Dimer is normal in these patients, we treated 2 such patients with similar HRCT but the GGO distribution is random with Relative sparing of Lower zone in CXR, very high CRP of 400, responded very well to Dexamethasone and Oxygen only.

Dr. Gaurang Buch, MD, Rajkot:

• We have a flare of H1N1 in my city Rajkot for last 6 weeks.
• More H1N1 than COVID.
• We are seeing GGO IDENTICAL TO COVID-peripheral located.
• Steroids when used in first week in H1N1 have worse prognosis-large no of studies.
• They do improve even when oseltamivir started late.
• Steroids may help in absence of sec infection between 7-10/12 days of illness.
• Currently, I have a case on ventilator-day 11 at presentation CRP dropped fromm167–> to 32 in 6 days but no significant improvement in lung function.
• So too early and little late steroids not helpful.
• Keen to know inputs from colleagues with greater experience of h1n1 treatment.
• These are 3 recent cases who were admitted and required O2 or ventilatory support.
• Cost of test is around 4500/-.
• Hence only admitted and critical category C Cases are willing to for test.
• So, this is just tip of iceberg.
• Thankfully cases have slowed down.
• about CT is if these patients had come in 2021, we would have treated them as COVID even with a neg RT PCR.
• PERIPHERAL GGO ARE PROBABLY NOT SPECIFIC FOR COVID.
• ACTUALLY, WE HAVE NOT STUDIRD CT APPEARANCES OF DIFFERENT VIRAL PNEUMONIA AS RT PCR TEST WERE NOT EASILY ABAILABLE.

Dr. Urman Dhruv, Consultant physician, Ahmedabad:

• We noticed the same 3 weeks back but now H1N1 on decline at Ahmedabad.
• No steroids.
• Only Oseltamivir used early in course of disease in Stage II B and in hospitalised cases.
• GGO and high D dimer seems to be a part of respiratory viral LRTI rather than specific to Covid.

Dr. Noni G. Singha, MD, Dibrugarh, Assam:

• This is a northern hemisphere vaccine which is commonly used in India. Northern H vaccination used for OCT to MARCH and Southern hemisphere for April to September.
• But WHO recommends Southern hemisphere flu vaccine for India?
• This is the Paradox.

Dr. Ananad Malani, MD, Sangil, Maharashtra:

1. H1N1 is on resurgence as Covid got benign. One strain or virus dominates. Covid dominated last 2 years, hardly any cases of H1N1 were noticed then. Lot of cases seen this year. Seen more than 40 in last 2 months. Tip of iceberg.
2. High fevers, headaches, bodyache, throat pain and cough are common symptoms. Symptoms are relatively severe than Covid-Omicron. Conjunctival injection is seen in H1N1 and Influenza A. Less likely in Covid.
3. If RAT is negative, treat as Influenza. Oseltamivir is a wonder drug. Symptoms melt away in 48 hours. Dont wait for swab reports.
4. COVI-INFLUENZA panel from Metropolis is a comprehensive RT PCR combo test for Covid, H1N1, Influ A, B, H3N2 and RSV. TAT 36 hours.
5. If diagnosed early or suspected clinically and treated as above, all improve without any need of hospitalization. No complications.
6. If late then high mortality and morbidity than Covid.
7. We had almost 20 admissions at our tertiary care hospital of H1N1/ Influenza A. 80% H1N1. Most were referred from outside after average of 8 days without any specific treatment and with severe hypoxia with very low pf ratios. All needed some form of ventilatory therapy. Many were with sepsis- secondary lung infections as source.
8. Out of 20, 10 got away with HFNC, NIV. Those were free of secondary infection. Elderly did better than young. Oseltamivir worked well even if started late. All were discharged. Nobody developed fibrosis or became oxygen dependent.
9. 10 needed invasive ventilation- Many were young, very very sick, many were with sepsis, many developed sepsis. Needed prolonged invasive ventilation, prolonged proning, one was ECMOed. Results were poor. Only 1 survived and is still in ICU. Acinetobacter was commonest infection. Klebsiella was second commonest. Developed despite standard practices. LATE PRESENTATION CARRIES A VERY POOR PROGNOSIS. Ventilator days were from 5-17.
10. Very rapidly worsening disease is also seen. One senior medico was with frank viral pneumonia and on HFNC on day 4 of illness.
11. D dimer is elevated modestly in many. No thrombotic complications observed like in Covid.
12. Leucopenia and mild thrombocytopenia were common.
13. HRCT- More perihilar and more dense consolidations. But this is not the rule. One patient had all peripheral and soft fluffy lesions. One patient had almost unilateral lesions.
14. Steroids are contraindicated and should be avoided.
15. OSELTAMIVIR – relatively safe even in elderly. No much toxicity or intolerance observed.

These are keen personal observations. The numbers are approximate. Statistical analysis was not done.

There is a very strong need to educate family physicians. Most of the late presenters were treated by them. If covid is negative they are treated as non-specific viral infection or LRTI. Even many physicians are not aware. Covid negative is taken as a big relief and the thinking process just stops there-the virus does not. Just needs 1000 Rs for cure if picked up clinically or early.

Dr. Ravi Premchand Kachhela, Cardiologist, Ranchi:

Updated the case on 01/10/2022

• H1N1 positive.
• Now stable.
• On Hi-flow Oxygen.
• Hemodynamically stable.
• Steroids not given so far.
• Tamiflu going on.
• Antibiotics going on.

CME INDIA Learning Points

• Most recently, in 2009, a strain of influenza A (H1N1) virus pdm2009 emerged in Mexico and spread all over the world. 
• WHO declared it a pandemic.  Since then, A (H1N1) pdm2009 has replaced the previous A (H1N1) seasonal strain of influenza and has been seen regularly as a seasonal virus.
• Influenza A (H1N1) continues to pose a major challenge to public health, causing many deaths each year and will continue to do so well into the foreseeable future.
• Adults of working age appear to be most seriously affected
• Swine influenza is transmitted from person to person by inhalation or ingestion of droplets containing the virus from people sneezing or coughing; it is not transmitted by eating cooked pork products.
• The newest swine flu virus that has caused swine flu is influenza A H3N2v (commonly termed H3N2v) which began as an outbreak in 2011. The “v” in the name means the virus is a variant that normally infects only pigs but has begun to infect humans.
  • There have been small outbreaks of H1N1 influenza since the pandemic.
  • Recent outbreaks in India relates to H1N1.
• For How Long Is Swine Flu Contagious? Persons with swine flu are considered infectious for 1 day before onset of the illness to 7 days after the onset. However, people with weakened immune systems and children may be contagious for a longer period of time (for example, about 10 to 14 days).

• Presentation:

• Mild or uncomplicated illness is characterized by
  • Typical symptoms like fever
  • Cough,
  • Sore throat,
  • Rhinorrhoea,
  • Muscle pain,
  • Headache,
  • Chills,
  • Malaise,
  • Sometimes diarrhoea and vomiting,
  • No shortness of breath and little change in chronic health conditions.
  • Not everyone with influenza will have a fever.
• Progressive illness
  • Typical symptoms plus signs or symptoms suggesting more than mild illness:  chest pain, poor oxygenation
  • (e.g. tachypnoea, hypoxia, labored breathing in children),
  • cardiopulmonary insufficiency (e.g., low blood pressure),
  • CNS impairment (e.g. confusion, altered mental status),
  • severe dehydration
  • exacerbations of chronic conditions (e.g. asthma, chronic obstructive pulmonary disease
  • chronic renal failure, diabetes or other cardiovascular conditions).
• Severe or complicated
  • Signs of lower respiratory tract disease (e.g., hypoxia requiring supplemental oxygen
  • Abnormal chest radiograph, mechanical ventilation),
  •  CNS findings (encephalitis, encephalopathy),
  •  Complications of low blood pressure (shock, organ failure),
  •  Myocarditis or rhabdomyolisis, or invasive secondary bacterial infection based on laboratory testing or clinical signs (e.g., Persistent high fever and other symptoms beyond three days).
• Diagnose: H1N1 Acute phase: RT PCR Naso/Oropharyngeal swab.
• Treatment:
  • When indicated, should begin as soon as possible after the onset of typical influenza-like symptoms.
  • Four antiviral agents, zanamivir (Relenza), oseltamivir (Tamiflu), peramivir (Rapivab), and baloxavir marboxil (Xofluza), have been reported to help prevent or reduce the effects of swine flu if taken within 48 hours of the onset of symptoms.
  • Dose of Tamiflu-75mg BD for 5 days.

1. Oseltamivir is administered orally without regard to meals, although administration with meals may improve gastrointestinal tolerability.
2. Oseltamivir is available as Tamiflu(r) in 30 mg, 45 mg, and 75 mg capsules; and a as a powder for oral suspension that is reconstituted to provide a final concentration of 12 mg/mL.
3. If the commercially manufactured oral suspension is not available, the capsules may be opened and the contents mixed with a sweetened liquid to mask the bitter taste or a suspension can be compounded by retail pharmacies (final concentration 15 mg/mL).
4. In patients with renal insufficiency the dose should be adjusted based on creatinine clearance.
5. For treatment of patients with creatinine clearance 10-30 mL/min: 75 mg once daily for 5 days. For chemoprophylaxis of patients with creatinine clearance 10-30 mL/min: 30 mg once daily or 75 mg once every other day continuing for 10 days after the exposure.
6. Oseltamivir and zanamivir are generally well-tolerated among FDA-approved age groups. Nausea and vomiting were reported more frequently among adults receiving oseltamivir for treatment (nausea without vomiting, approximately 10%; vomiting, approximately 9%) than among persons receiving placebo (nausea without vomiting, approximately 6%; vomiting, approximately 3%). Among children treated with oseltamivir, 14% had vomiting, compared with 8.5% of placebo recipients. Oseltamivir suspension is formulated with sorbitol, which may be associated with diarrhea and abdominal pain in patients who are fructose-intolerant.
7. Allergic reactions (rash, swelling of the face or tongue, anaphylaxis) have been reported in clinical practice from both oseltamivir and zanamivir.

1. Zanamivir is administered by inhalation using a proprietary “Diskhaler” device distributed together with the medication. 
2. Zanamivir is a dry powder, not an aerosol, and should not be administered using nebulizers, ventilators, or other devices typically used for administering medications in aerosolized solutions.
3. Zanamivir is not recommended for persons with chronic respiratory diseases such as asthma or chronic obstructive pulmonary disease that increase the risk of bronchospasm.

• The CDC recommends that the following populations receive chemoprophylaxis:

What Infection-Control Precautions Should Be Taken in Healthcare Settings? (CDC) 

• Patients who have a suspected or confirmed case of swine flu and who need to be hospitalized should be placed in a single-patient room with the door kept closed.
• The patient should wear a mask when outside the room.
• Standard, droplet, and contact precautions should be implemented and maintained by healthcare professionals for 7 days after the illness onset or until symptoms have resolved.

How long does the swine flu last?

• In uncomplicated infections, swine flu typically begins to resolve after three to seven days, but the malaise and cough can persist for two weeks or more in some patients.
•  Severe swine flu may require hospitalization which increases the length of time of infection to about nine to 10 days.

How to avoid H1N1 infection on an airplane?

CME INDIA Tail-Piece

CDC Input

• The first two human cases of novel swine-origin influenza A (H1N1) virus (S-OIV), known as swine flu, in the United States were detected through these programs.
• In the first case, an untypeable influenza A strain was identified at a surveillance site of the Naval Health Research Center by a new diagnostic device.
• The test results were forwarded per protocol to the study reference laboratory for polymerase-chain-reaction (PCR) confirmation and were subsequently forwarded to the CDC for identification by sequencing.
• In the second case, a sample that was obtained at a border surveillance site was found to contain an untypeable influenza A strain on PCR testing at the center. Further characterization by PCR assay and electrospray ionization mass spectrometry indicated a swine-origin virus, and sequence data that were sent to the CDC revealed that the viruses in the two samples were identical (CDC).

What happened at KANPUR: 27th September 2022?

• The third-year medical student of GSVM medical college here, who slipped into coma due to acute necrotizing encephalitis (ANE), has been found infected with H1N1 (swine flu).
• Her blood sample sent to King George’s Medical University (KGMU) and the micro-biology department of the GSVM medical college tested positive for H1N1.
• Acute necrotizing encephalopathy (ANE) is a rare complication of influenza and other viral infections.
• ANE has been related to intracranial cytokine storm, which results in blood–brain barrier breakdown, but without direct viral invasion or parainfectious demyelination
• There is no current evidence from any randomized control trails (RCTs) to recommend any specific treatment for suspected or confirmed patients with COVID-19 with acute necrotizing encephalitis.
• High-dose corticosteroids, immunoglobulins, and plasmapheresis can be tried as treatment options could potentially be useful for patients with ANE if diagnosed early.
• Mortality-40%.

Awareness Alert

References:

1. Kulkarni SV, Narain JP, Gupta S, Dhariwal AC, Singh SK, Macintyre CR. Influenza A (H1N1) in India: Changing epidemiology and its implications. Natl Med J India. 2019 Mar-Apr;32(2):107-108. doi: 10.4103/0970-258X.253355. PMID: 31939410.
2. Jain, S et al. Hospitalized Patients with 2009 H1N1 Influenza in the United States, April-June 2009 N Engl J Med 2009;361.
3. Swine Flu | National Health Portal Of India (nhp.gov.in)
4. CDC H1N1 Flu | Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season
5. ANE outbreak on GSVM medical college campus, one student in coma – Hindustan Times
6. https://www.cdc.gov/swineflu/recommendations.htm)
7. https://www.cdc.gov/swineflu/guidelines_infection_control.htm
8. Kumar N, Kumar S, Kumar A, Pati BK, Kumar A, Singh C, Sarfraz A. Acute Necrotizing Encephalitis as a Probable Association of COVID-19. Indian J Crit Care Med. 2020 Oct;24(10):991-994. doi: 10.5005/jp-journals-10071-23636. PMID: 33281329; PMCID: PMC7689130.
9. Rossi A. Imaging of acute disseminated encephalomyelitis. Neuroimaging Clinics. 2008;18(1):149–161. doi: 10.1016/j.nic.2007.12.007.



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