2009: Influenza A (H1N1) vaccine approved
· Case (confirmed) definition for notification under IHRs (2005) : [Mnemonic:FRALL]
o Fever (≥38.3º C/101º F) acute onset at any age, malaise, prostration, headache, backache occurring 2-4 days prior to onset of rash AND
o Rash maculo-papular starting from face & forearms, evolving to vesicles (48 hours) and pustules (umblicated/confluent) later AND
o Lesions at same stage of development at any part of body AND
o Absence of Alternative diagnosis to explain illness AND
o Laboratory confirmation.
Coverage of 1st dose of Measles vaccine in world: 82% 
· Proportional mortality rate in children <5 years: 1% 
INFLUENZA: PANDEMIC (H1N1) 2009 INFLUENZA
· WHO declaration of Influenza pandemic: 11 June 2009
· World is now post-pandemic EXCEPT: INDIA & NEW ZEALAND (locally intense transmission)
· Problem statement India: 37000 cases, 1833 deaths [May 2009- August 2010]
· Incubation period : 2-3 days
· Clinical features:
o Uncomplicated influenza: Influenza like illness (Fever, cough, sorethroat, rhinorrhoea, headache, muscle pain), GIT illness (diarrhoea WITHOUT dehydration)
o Complicated/severe influenza: Pneumonia, CNS involvement, Severe diarrhoea, Secondary complications, Exacerbation of chronic diseases.
o Progressive disease: Oxygen impairment/cardiopulmonary insufficiency, CNS complications, Invasive secondary bacterial infection, Severe dehydration.
· Risk factors of severe disease:
o Infants & children < 2 years
o Pregnant females
o Chronic cardiac disease
o Metabolic disorders
o Chronic renal/hepatic/neurological/hemoglobinopathies/immunosuppression (INCLUDING HIV) disorders
o Children on aspirin therapy
o Persons aged ≥ 65 years
o Morbid obesity.
· Laboratory diagnosis:
o Most timely & sensitive detection: RT-PCR test
o Samples: Nasopharyngeal + throat swabs [Tracheal/bronchial aspirates in lower respiratory tract infection cases]
o Point-of-care/Rapid diagnostic tests: Not recommended.
· Duration of isolation: for 7 days after onset of illness OR 24 hours after resolution of fever/respiratory symptoms whichever is longer.
· H1N1 Inactivated vaccine: Single i/m injection
o Strain : A/California/7/2009 (H1N1) V like strain
o Storage temperature: +2º to +8 º C
o Contraindications: History of anaphylaxis/severe reaction/Guillian Barre Syndrome, Infants <6 months, Moderate-to-severe illness with fever.
o Protective immunity: Develops after 14 days (NOT 100%).
· H1N1 Live attenuated vaccine: Nasal spray
o Side effects: Rhinorrhoea, nasal congestion, cough, sore throat, fever, wheezing, vomiting
· Priority groups (in order) for Influenza vaccines:
o Pregnant women
o Age > 6 months with chronic medical conditions
o 15-49 years healthy young adults
o Healthy young children
o Healthy adults 49-65 years
o Healthy adults >65 years.
· Antiviral therapy:
o Severe/progressive clinical illness: Oseltamivir (if not available or resistance, use Zanamivir)
o High risk of severe/complicated illness: Oseltamivir OR Zanamivir
o Not high risk OR Uncomplicated confirmed/suspected illness: No need of treatment.
o Oseltamivir 75 mg BD X 5 days
o Zanamivir 2 inhalations (2 X 5 mg) BD X 5 days
ARI/PNEUMONIA: KEY INDICATORS (INDIA)-
· % under-five deaths due to Pneumonia: 20%
· % under-weight children : 46% (moderate to severe); 18% (severe)
· % exclusive breast-fed infants <6 months:46%
· % 1-year old immunised against Measles: 67%
· % under-five taken to appropriate health care provider for Pneumonia: 69%
Daily self-administered Non-DOTS regime: ONLY if there are adverse reactions to drugs or patients compliance is not possible.
Non-DOTS regime 1 (ND1)
o Pulmonary (SS+ve) seriously ill
2 (SHE) + 10 (HE)
o Extra-pulmonary seriously ill
Non-DOTS regime 2 (ND2)
o Pulmonary (SS-ve) not seriously ill
o Extra-pulmonary not seriously ill
· DOTS-PLUS (Category IV DOTS MDR-TB treatment):
Cat IV* MDR- TB
(* IP extended by 3 months if culture +ve at end of 4 months treatment
Follow-up sputum smears: 4, 6, 12, 18, 24 months of treatment)
· Six primary Malaria vectors in India:
o Anopheles culicifacies: Rural and peri-urban areas [Species A-P, vivax & P, falciparum; Species B-P.falciparum]
o Anopheles stephensi : Urban and industrial areas
o Anopheles fluviatilis: Hilly, forest and forest fringe areas
o Anopheles minimus: Foot-hills of NE states
o Anopheles dirus : Forests of NE states
o Anopheles epiroticus: Andaman & Nicobar islands
· Diagnosis of Malaria in India:
o Microscopy: Thick smear (High sensitivity in searching for parasite, parasite load estimation) + Thin file (for species identification, stages)
o Serological testing: Malaria Fluorescent Antibody Test (MFAT) necomes +ve after 2 weeks of infection (not indicative of current infection)
o Rapid diagnostic test (RDT): Detect circulating parasite antigens.
· Active intervention measures for Malaria control:
o Micro-stratification of problem
o Vector control strategies
1) Anti-adult measures: Indoor residual spray (DDT/Malathion,Fenitrothion), Space
2) Anti-larval measures: Larvicides (temephos), Source reduction, Integrated control.
· Changes in WHO recommendations for Malaria control  :
o New ACT recommended: Dihydroartemisin-piperaquine
o Artemisin derivatives should not be used as montherapies for uncomplicated malaria
o Single dose of Primaquine (anti-gametocyte) added to ACT treatment of P, falciparum.
HIV/AIDS: WHO RECOMMENDATIONS ON ART (2010):
· Start ART: CD4≤350 cells/mm3
· First line therapy: 1 NNRTI + 2 NRTIs (including Zidovudine/Tenofovir)
· Second line therapy: PI + 2NRTIs (including Zidovudine/Tenofovir)
· Treatment 2.0:
o Is a new approach ‘to simplify the way HIV treatment is currently provided, and to scale-up access to life-saving medicines.
o Could reduce newly HIV+ upto 1 million annually and avert additional 10 million deaths by 2025
o Requires progress across five areas: [Mnemonic: C2D3]
1) Reduce Costs
2) Mobilize Communities
3) Optimize Drug regimes: “Smarter,better pill”
4) Adopt Delivery systems
5) Provide access to point of care Diagnostics.