Upper Respiratory Tract Infection - Embattling against Flu Season in Community Setting - DR. CHAN PUI KWONG SPECIALIST IN COMMUNITY MEDICINE ...
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Upper Respiratory Tract Infection – Embattling against
Flu Season in Community Setting
DR. CHAN PUI KWONG
SPECIALIST IN COMMUNITY MEDICINE
1
Upper Respiratory Tract Infection (URTI)
• Illnesses caused by an acute infection which
involves the upper respiratory tract including
the nose, sinuses, pharynx or larynx
• Commonly includes tonsillitis, pharyngitis,
laryngitis, sinusitis, otitis media, and the
common cold
• Other names
◦ Influenza like illness
◦ Common cold
◦ Flu
2
Causative agents
• Viral
◦ Over 200 different viruses have been isolated in
patients with URIs.
◦ Most common virus is called the rhinovirus.
◦ Others e.g. coronavirus, parainfluenza virus,
adenovirus, enterovirus, and respiratory syncytial
virus.[2]
• Bacteria Streptococcus pyogenes
◦ Up to 15% of acute pharyngitis cases may be caused by
bacteria
◦ most commonly Streptococcus pyogenes a Group A
streptococcus in Streptococcal pharyngitis ("Strep
Throat").[3]
◦ Others e.g. Streptococcus pneumoniae, Haemophilus
influenzae, Corynebacterium diphtheriae, Bordetella
pertussis, and Bacillus anthracis
3
Influenza
4
Influenza
• Acute illness of respiratory tract
• Fever, headache, muscle ache, running nose , cough, sore throat
• Usually self-limiting
• Recovery in 2 - 7 days
• The body produces antibody to the virus
• Young children, elderly, persons with chronic illness more likely to have
complications
5
How is a common cold
different from the flu?
Cold symptoms Flu symptoms
Low or no fever High fever
Sometimes a headache Commonly a headache
Stuffy, runny nose Sometimes a stuffy nose
Sneezing Sometimes sneezing
Mild, hacking cough Cough, may progress
Slight aches and pains Often severe aches and pains
Mild fatigue Fatigue, may persist
Sore throat Sometimes a sore throat
Normal energy level Exhaustion
6
Global Situation
2014/15 winter influenza season
beginning of Influenza activity
• United States: mid-November 2014
• Canada: December 2014
• Europe: mid-December 2014
• Japan: early December 2014
Influenza season lasted until early May
7
Global Situation
circulating virus:
• Influenza A (H3N2) was the major one
• increase in influenza B towards end of the season
• Influenza A(H1N1)pdm09 co-circulated with the above two
8
Global Situation
Antigenic characteristic of circulating viruses
• Influenza A (H3N2):
◦ significant proportion were antigenically different from the A/Texas/50/2012(H3N2)
◦ Most were similar to A/Switzerland/9715293/2013
• Influenza A(H1N1)pdm09 :
◦ majority similar to A/California/7/2009
• Influenza B:
◦ B/Yamagata/16/88 predominated over B/Victoria/2/87
◦ B/Victoria/2/87 is closely related to B/Brisbane/60/2008
◦ B/Yamagata/16/88 is closely related to B/Phuket/3073/2013
(Underline ----used in 2014/15 trivalent vaccine)
(Strike through ---used in 2014/15 quadrivalent vaccine)
9
Hong Kong Situation
2014/15 winter Influenza Season
• Arrived in the last week of December 2014
• Continued to increase rapidly in January 2015
• Reached the peak in early February
• Started to decrease gradually
• Returned to a low level in the third week of April
10ILI consultation rate at sentinel private
doctors, 2011-2015
11ILI consultation rate at sentinel GOPCs,
2011-2015
12Hong Kong Situation
2014/15 winter Influenza Season
Breakdown of the positive influenza virus isolates of Public Health Lab
of of CHP (from Dec 28, 2014 to Apr 25, 2015):
• A(H3N2): 90.1% ( >95% were A/Switzerland/9715293/2013-like)
• B : 8.4%
• A(H1N1) pdm09 : 1.1%
• C : 0.4%
13Laboratory surveillance in
2011-15 (1)
• Percentage of respiratory specimens tested positive for influenza viruses, 2011-15
(overall positive percentage)
14Laboratory surveillance in
2011-15 (2)
• Percentage of respiratory specimens tested positive for influenza viruses, 2011-15
(positive percentage by subtypes)
15General Prevention Measures –
Wearing Mask
• Persons who are in contact with those suffered from flu / respiratory
symptoms (e.g. running nose, cough and sore throat) should wear a
mask to prevent inhalation of droplets with flu virus
16Hand hygiene
• Studies have shown that proper cleaning your
hands is the most effective method of
preventing the spread of infectious diseases
• Hand hygiene is a fundamental measure to
prevent and control the spread of infectious
diseases
• Wash hands thoroughly with liquid soap or use
alcohol-based handrub are efficient measure
to maintain hand hyigene
17When should we wash hands?
• For example:
Before touching the eyes, nose and mouth
When hands are contaminated with respiratory secretions, such as
coughing and sneezing
After handling contaminated objects
Eating and before handling food after using the toilet and so on…
18Frequently clean hands &
Pay attention to hand hygiene
• When hands is visibly soiled or stained with body fluids & secretions,
wash hands with liquid soap and water
• If hands are not visibly soiled, 70-80% alcohol-based handrub should be
used for washing hand
19Proper hand washing
20Personal Hygiene (1)
• To be effective in preventing influenza,
students and staff in school should be
reminded to develop good hygiene
habits to prevent the spread of germs
in schools:
• Cough etiquette
• Attention to hand hygiene
• Do not wipe the eyes, nose and mouth
• See doctor when sick. Rest at home
and avoid going out
21Personal Hygiene (2)
• Handle common eating food with
care to avoid contamination
• Avoid sharing personal items with
others (e.g. towels, utensils,
toothbrushes…)
• Adequate sleep, exercise regularly,
do not have excessive amount of
pressure, drink plenty of waters, and
also eat healthy foods
• Develop good health habits
22Environmental Hygiene (1)
• Since virus could survive in the
environment for some time, paying
attention to sanitation is very important
• Maintain good indoor ventilation
• Daily cleaning and disinfecting in schools &
centers, including: classrooms, kitchen,
dining halls, toilets, bathrooms, etc
• For items which is regularly contacted,
frequency of washing should be increased
• Instant wash contaminated environment
23Environmental Hygiene (2)
• Different disinfectant can be used to clean the environment.
• Household bleach containing 5.25% sodium hypochlorite is a
convenient and effective disinfectant
• For general cleaning, 1:99 diluted household bleach (5.25%) could be
used
• For cleaning area polluted by respiratory secretions, vomit, apply 1 to
49 diluted household bleach (5.25%)
• Wait for 15-30 mins, wash with water
• As to disinfect metal surface, use 70% alcohol
24Culture & Gargling
“The custom of gargling as a preventive approach is not widespread in
many Western countries. In Japan, however, health authorities have
officially recommended gargling to prevent respiratory infections for
more than 90 years, and almost all Japanese believe in the preventive
effect of gargling”
Noda et al 2012. Gargling for Oral Hygiene and the Development of Fever in Childhood: A Population Study in
Japan. J Epidemiol 2012;22(1):45-49
25Japan Ministry of Health
Ministry of Health LaW: Guideline for new type of influenza management(phase 4 or later). 2007.
26Wearing face masks in public during the influenza season may reflect
other positive hygiene practices in Japan
• Wearing a face mask in public was associated with various self-reported
hygiene practices including:
◦ Frequent hand washing (adjusted Odds Ratio [OR]: 1.67; 95% Confidence Interval
[95%CI]: 1.34-1.96),
◦ Occasional hand washing (OR: 1.43; 95%CI: 1.10-1.75),
◦ Frequently avoiding crowds (OR: 1.85; 95%CI: 1.70-1.98),
◦ Occasionally avoiding crowds (OR: 1.65; 95%CI: 1.53-1.76),
◦ Frequent gargling (OR: 1.68; 95%CI:1.51-1.84),
◦ Occasional gargling (OR: 1.46; 95%CI: 1.29-1.62),
◦ Regularly avoiding close contact with an infected person(OR: 1.50; 95%CI: 1.33-
1.67)
◦ Occasionally avoiding close contact with an infected person (OR: 1.31; 95%CI:
1.16-1.46)
◦ Being vaccinated of influenza in the last season (OR: 1.31; 95%CI: 1.17-1.45).
Wada et al. BMC Public Health 2012, 12:1065
27Role of gargling in preventing viral
upper respiratory tract infection
• Comparison of outcomes in gargling and non-gargling children1
Gargling Non-gargling
Total: 391,900 317,180 person- 74,720 person- P value
person-days days days
Fever onsetEfficacy of povidone-iodine against enveloped
and non-enveloped viruses
Virucidal activities of povidone-iodine (PVP-I) and other antiseptics
Adeno Herpes Rubella Measles Mumps Flu Rota Polio Rhino HIV
Enveloppe no yes yes yes yes yes no no no yes
PVP-I solution ✓ ✓✓ ✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓ ✓ ✓✓
PVP-I gargle ✓ ✓✓ ✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓ ✓ ✓✓
PVP-I cream - - - - - - - - -
CHG X ? ✓✓ ✓✓ ✓✓ ✓ X X X ✓✓
AEG X ? ✓✓ ✓✓ ? X X X X ✓✓
BAC X ? ✓✓ ✓✓ ✓ ✓ ✓✓ X X ✓✓
BEC X ? ✓✓ ✓✓ ✓ ✓ ✓✓ X X ✓✓
✓✓=clearly effective ✓=effective X= ineffective ?=uncertain -=not tested
AEG: alkyldiaminoethylglycine hydrochloride
PVP-I: povidone-iodine BAC: benzalkonium chloride
CHG: chlorhexidine gluconate BEC: benzethonium chloride
• PVP-I is effective against all the virus species tested
• PVP-I had a wider virucidal spectrum, covering both enveloped and non-enveloped viruses, than
the other commercially available antiseptics
Kawana R, Kitamura T, Nakagomi O, Matsumoto I, Arita M, Yoshihara N, Yanagi K, Yamada A, Morita O, Yoshida Y, Furuya Y, Chiba S.
Inactivation of human viruses by povidone-iodine in comparison with other antiseptics. Dermatology 1997;195(suppl 2):29-35Efficacy of povidone-iodine for the
prevention of common cold and influenza
Comparison of absence rates due to common cold and influenza between:
School A: 1 middle school where the PVP-I gargle was
used
School B: 7 middle schools where it was not
Results: The absence rate due to common cold and
influenza was significantly lower at the middle school
where the use of the PVP-I gargle was encouraged as
compared to those at middle schools where it was not
(PVaccination
31Type of Vaccine Available (1)
Trade name Manufacturer Presentation Mercury Ovalbumin Age Latex Route
content from content indications
thimerosal (µg/0.5mL)
(µg Hg/0.5 mL)
Inactivated influenza vaccine, quadrivalent (IIV4), standard dose
Fluarix GlaxoSmithKline 0.5 mL single- — ≤0.05 ≥3 yrs No IM†
Quadrivalent dose prefilled
syringe
†
FluLaval ID Biomedical 5.0 mL multi-Type of Vaccine Available (2)
Inactivated influenza vaccine, trivalent (IIV3), standard dose.
†† †
Afluria bioCSL 0.5 mL —Type of Vaccine Available (3)
Inactivated influenza vaccine, cell-culture-based (ccIIV3), standard dose
¶¶ §§ †
Flucelvax Novartis 0.5 mL single- — ≥18 yrs Yes IM
Vaccines and dose prefilled
Diagnostics syringe
Inactivated influenza vaccine, trivalent (IIV3), high dose
.
§ †
Fluzone High- Sanofi Pasteur 0.5 mL single- — ≥65 yrs No IM
Dose*** dose prefilled
syringe
Recombinant influenza vaccine, trivalent (RIV3), standard dose
†
FluBlok Protein Sciences 0.5 mL single- — 0 ≥18 yrs No IM
dose vial
Live attenuated influenza vaccine, quadrivalent (LAIV4)
FluMist MedImmune 0.2 mL single- —Vaccine Effectiveness
• Varies with:
1. Varies with characteristics of the person being vaccinated (such as
their age and health)
2. Varies with the similarity or "match" between the flu viruses the flu
vaccine is designed to protect against and the flu viruses spreading
in the community
3. IF matches, 70 to 90% in those < 65; at best modest in those >65
35Benefits of Flu vaccination
• Flu vaccination can keep you from getting sick from flu. Protecting
yourself from flu also protects the people around you who are more
vulnerable to serious flu illness.
• Flu vaccination can help protect people who are at greater risk of
getting seriously ill from flu, like older adults, people with chronic
health conditions and young children (especially infants younger than
6 months old who are too young to get vaccinated).
• Flu vaccination also may make your illness milder if you do get sick.
• Flu vaccination can reduce the risk of more serious flu outcomes, like
hospitalizations
• Recent studies show vaccine can reduce the risk of flu illness by about
50-60% among the overall population
36Vaccine composition in the
2015/16 season
Trivalent Vaccine
• A/California/7/2009(H1N1)pdm09
• A/Switzerland/9715293/2013 (H3N2)
• B/Phuket/3073/2013
Quadrivalent Vaccine
• B/Brisbane/60/2008
Both types are recommended for people six months of age or older.
37Priority Groups
• Pregnant women
• elderly persons living in residential care homes
• Long stay residents of institutions for persons with disabilities
• Persons aged 50 years or above
• Persons with chronic medical problems
• Healtth care workers
• Children aged 6 months to 5 years
• Poultry workers
• Pig farmers and pig-slaughtering industry personnel
38Dose and Schedule
• 9 years or above ----- A single intramuscular injection
• Below 9 years (vaccine naïve) ----- two doses with an interval of at
least 4 weeks
• Below 9 years (had previous vaccination) ----- one dose
• Below 3 years ----- use half adult dose
39Vaccine Precautions
• Local reaction (pain, swelling): 15 -20%
• Systemic side effect (fever, malaise, myalgia): 1 – 10%
• Gullian-Barre syndrome : 1 to 2 cases per million
• Meningitis, encephalopathy : 1 in 3 million
• Anaphylaxis: 9 in 10 million
• Contraindicated in persons with severe egg allergy
40Drug Treatment
Antiviral Agent Activity Against Use Recommended For Not Recommended for
Use in
1
Oseltamivir (Tamiflu®) Influenza A and B Treatment Any age N/A
1
Chemo- prophylaxis 3 months and older N/A
Zanamivir (Relenza®) Influenza A and B Treatment 7 yrs and older people with underlying
respiratory disease
2
(e.g., asthma, COPD)
Chemo- prophylaxis 5 yrs and older people with underlying
respiratory disease
2
(e.g., asthma, COPD)
3
Peramivir (Rapivab®) Influenza A and B Treatment 18 yrs and older N/A
Chemo- prophylaxis N/A N/A
Abbreviations: N/A = not applicable, COPD = chronic obstructive pulmonary disease.
41Dosage
• Duration:
◦ The recommended duration of treatment is 5 days
• Dosage:
◦ Zanamivir.
treatment : 2 inhalations (1 5-mg blister per inhalation for a total dose of
10 mg) twice daily (approximately 12 hours apart).
chemoprophylaxis : 10 mg (2 inhalations) once a day.
◦ Oseltamivir.
treatment: 75 mg B.D.
chemoprophylaxis : 75 mg O.D.
42Summary of Influenza Antiviral Treatment
Recommendations
• early antiviral treatment can shorten the duration of fever and illness
symptoms, and may reduce the risk of complications from influenza .
• Early treatment of hospitalized patients can reduce death.
• In hospitalized children, early antiviral treatment has been shown to
shorten the duration of hospitalization.
• Clinical benefit is greatest when antiviral treatment is administered early,
especially within 48 hours of influenza illness onset.
• Antiviral treatment is recommended as early as possible for any patient
with confirmed or suspected influenza who:
◦ is hospitalized;
◦ has severe, complicated, or progressive illness; or
◦ is at higher risk for influenza complications
43Persons at higher risk for influenza
complications recommended for antiviral
treatment include:
• children aged younger than 2 years;1
• adults aged 65 years and older;
• persons with chronic medical conditions;
• persons with immunosuppression, including that caused by medications or
by HIV infection;
• women who are pregnant or postpartum (within 2 weeks after delivery);
• persons aged younger than 19 years who are receiving long-term aspirin
therapy;
• persons who are morbidly obese (i.e., body mass index is equal to or
greater than 40); and
• residents of nursing homes and other chronic care facilities.
44Thank You!
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