CME INDIA Presentation by Dr. S. K. Gupta, MBBS MD (Med), FICP, FIMSA, FRCP (Edinburgh) CFM (France), Author of Book – ‘Journey of Covid in India,’ Honorary Consultant Physician and Internist, MAX Super Speciality Hospital, Secretary, Community Health Care Foundation, Director, Shivam Nursing Home, Clinical Assistant Professor, GS Medical College, CCSU, Uttar Pradesh.

 Flu in Delhi & Some Indian states.

• Dec 2022 and Jan 2023.
• Delhi and NCR are witnessing a massive increase in Respiratory Tract Infections this winter. Same is the scenario in few Indian states.

What is it? Common Cold, Seasonal Flu, or Streptococcal infection?

• Answer: After investigation, in most cases, it has been found influenza A, H3N2. However, some cases of H1N1 and other respiratory viruses are also being reported.
• Though the virus is affecting people of all age groups, it is affecting children the most.  Symptoms like fever, cough, runny nose / blocked nose, body ache, and headache are seen in most of the patients.
• It is making people more miserable than the common cold. Recovery is taking more than a week to 10 days. In some cases, even more.

Is Flu Contagious?

• Yes. It is transmitted by droplet infection when the patient coughs or sneezes. People can spread the virus to others up to six feet away when they cough or sneeze.
• People with flu are most contagious in the first 3-4 days after the illness begins.

Credit: https://ourworldindata.org/influenza-deaths

People at Higher Risk of Flu

• Anyone can get the flu (even healthy people), and complications of the flu can happen at any age.
• People are at higher risk of developing serious flu-related complications:

Preventing Flu

• The influenza vaccine is the most effective option to prevent Influenza.
• Available as InfluvacTetra® and FluQuadri® single dose pre-filled syringe
• Safe: Influenza vaccines are safe for everyone, including children and adults.
• Annual vaccination against influenza is important, especially for patients with serious illnesses. 

Certain myths about influenza vaccine

Myth: Influenza is not a severe illness

• There is no need to take the vaccine.
• Truth: Many people get serious complications from seasonal flu.
• Do not believe it and call it just the common cold.
• The reality is that influenza could be a serious condition that can lead to hospitalization, especially for patients who have diabetes and high blood pressure, CKD, and CAD, and for children, the elderly, and pregnant women.

Myth: The flu vaccine is only for children.

• Reality: Annual influenza vaccination is recommended for all age groups.  This is especially beneficial for patients suffering from a serious illness. Flu vaccination reduces hospitalizations for complications related to influenza or pneumonia by 80 percent for diabetics.

Myth: I’ve already had the COVID-19 vaccine. That’s why I’m safe.

• Truth: The COVID-19 vaccination does not protect against the flu.  Therefore, it is important to take both vaccines as per schedule. Flu vaccination can prevent 70-90% of influenza-specific illnesses in healthy adults.

Myth: My Child got the Hib vaccine, so the influenza vaccine is not needed

• Reality: Haemophilus influenzae disease is a name for any illness caused by bacteria called H. influenza. Some of these illnesses, like ear infections, are mild, while others, like bloodstream infections, are very serious.
• Despite the name, H. influenza does not cause influenza (the flu).  Vaccines (type b Hib) protect against severe meningitis caused by H. influenzae but not against Flu

When should you take the flu vaccine?

• People can take the flu vaccine two weeks before flu season. In India, September or October every year is the right time for an annual flu vaccine.

Myth: You don’t need the flu vaccine if you’ve had the flu in the past.

• Reality: It is important to get the flu vaccine every year against the rapidly evolving influenza virus and its variants. Influenza strains change every year, so annual flu vaccines are updated every year according to WHO recommendations and guidelines, which are based on constant global monitoring and mice experiments. Updated vaccines provide the best protection. 
• Also, the immune protection from the flu vaccine wears off over time, and it must be taken every year.

Credit: https://www.cdc.gov/flu/about/qa/coldflu.htm 

Who should take the flu Vaccine?

How much time is required to develop protection?

• It takes about 2 weeks for protection to develop after vaccination.

Treatment of Flu:

Routine measured

• Steam inhalation
• Paracetamol/NSAIDs
• Anti-histamines like Levocetirizine (Tulsi kadha is common home remedy, used in India) Note-Tulsi is not a modern system of medicine entry but now studies do show that tulsi has a unique combination of actions that include: Antimicrobial (including antibacterial, antiviral, antifungal, antiprotozoal, antimalarial, anthelmintic), anti-diarrheal, anti-oxidant, anti-cataract, anti-inflammatory, chemopreventive, radioprotective, and hepatoprotective etc.
• Hydration
• Avoid Crowded places. Cold air
• Use Mask

Anti-Virials are reserved for some priority

• Antiviral treatment is recommended as soon as possible for any patient with suspected or confirmed influenza who:
• If hospitalized;
• If severe, complicated, or progressive illness; or
• If at higher risk for influenza complications.

When to start Anti-Viral?

• Decisions about starting antiviral treatment should not wait for laboratory confirmation of influenza virus infection. Empiric antiviral treatment should be started as soon as possible in the above priority groups. Anti-Virials work best if started within the first 5 days of the onset of illness. The earlier, the better.

Antiviral Drug:

• For outpatients with complications or progressive disease and suspected or confirmed influenza (e.g., pneumonia or exacerbation of underlying chronic medical conditions), initiation of antiviral treatment with oral oseltamivir (Tamiflu) is recommended as soon as possible
• For hospitalized patients with suspected or confirmed influenza, initiation of antiviral treatment with oral or enterically-administered oseltamivir is recommended as soon as possible. (CDC)
• For outpatients with complications or progressive disease and suspected or confirmed influenza (e.g., pneumonia or exacerbation of underlying chronic medical conditions), initiation of antiviral treatment with oral oseltamivir is recommended as soon as possible. (CDC)

CME INDIA Learning Edge

(CDC)

• There two types of influenza viruses (A and B) that cause most human illness and that are responsible for flu seasons each year. Influenza A viruses are further classified into subtypes, while influenza B viruses are further classified into two lineages: B/Yamagata and B/Victoria.
• Both influenza A and B viruses can be further classified into clades and sub-clades (which are sometimes called groups and sub-groups.) (CDC)

Credit: CDC

• Current seasonal flu vaccines are formulated to protect against influenza viruses known to cause epidemics, including: one influenza A(H1N1) virus, one influenza A(H3N2) virus, one influenza B/Victoria lineage virus, and one influenza B/Yamagata lineage virus.
• Getting a flu vaccine can protect against these viruses as well as additional flu viruses that are antigenically similar to the viruses used to make the vaccine
• CDC clearly says about Influenza Testing and Treatment
  • a) Test for influenza if results will change clinical management or for infection control decisions (e.g., long-term care facility resident returning to a facility, or a person of any age returning to a congregate setting): order rapid influenza nucleic acid detection assay if rapid influenza nucleic acid detection assay is not available on-site, order rapid influenza antigen assay; prescribe antiviral treatment if positive. OR
  • b) Prescribe empiric antiviral treatment as soon as possible without influenza testing based on a clinical diagnosis of influenza for patients of any age with progressive disease of any duration, and for children and adults at high risk for influenza complications.

Co-circulation of Influenza Viruses and SARS-CoV-2

Influenza and COVID-19 have overlapping signs and symptoms.

Testing can help distinguish between influenza virus infection and SARS-CoV-2 infection. However, clinicians should not wait for the results of influenza testing, SARS-CoV-2 testing, or multiplex molecular assays that detect influenza A and B viruses and SARS-CoV-2 to initiate empiric antiviral treatment for influenza in the above priority groups.

• Co-infection with influenza A or B viruses and SARS-CoV-2 can occur and should be considered, particularly in hospitalized patients with severe respiratory disease.
• Clinicians should be aware that a positive SARS-CoV-2 test result does not preclude influenza virus infection. For hospitalized patients with suspected influenza who are started on empiric antiviral treatment with oseltamivir, use of influenza molecular assays or multiplex assays that detect both influenza viruses and SARS-CoV-2 can inform clinical management.
• Clinicians should be aware that a positive influenza test result does not preclude SARS-CoV-2 infection. For hospitalized patients with a positive influenza test result, antiviral treatment of influenza with oseltamivir should be started as soon as possible.
•  Oseltamivir does not have in-vitro activity against SARS-CoV-2.
• Clinicians can consider starting early (≤48 hours after illness onset) empiric antiviral treatment of non-high-risk outpatients with suspected influenza [e.g., influenza-like illness (fever with either cough or sore throat)], based upon clinical judgement, including without an office visit. SARS-CoV-2 and other etiologies of influenza-like illness should also be considered.
• Chemoprophylaxis
• In general, CDC does not recommend seasonal or pre-exposure antiviral chemoprophylaxis, but antiviral medications can be considered for chemoprophylaxis to prevent influenza in certain situations
• Antiviral chemoprophylaxis generally is not recommended if more than 48 hours have elapsed since the first exposure to a person with influenza.
• Patients receiving antiviral chemoprophylaxis should be encouraged to seek medical evaluation as soon as they develop a febrile respiratory illness that might indicate influenza.

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References:

1. https://www.cdc.gov/flu/about/viruses/types.htm
2. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022-2023 Influenza Season
3. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm
4. https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-covid-19-similarities-and-differences-with-influenza
5. https://ourworldindata.org/influenza-deaths
6. https://abionline.com/history-of-influenza/

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