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Background: During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the profile of Acute Respiratory Infection (ARI) during H1N1 outbreak in a tertiary care centre in Pune.âMethods: This was retrospective observational study. Information was collected from records on 100 consecutive cases of ARI admitted in the hospital. It was compiled from day of admission till final outcome which was either survival or mortality. Clinical history & physical examination were carried out, including serial SOFA (Sequential Organ Failure Assessment) score. Laboratory data included examination of throat sample & Endotracheal tube secretion by a real-time reverse-transcriptaseâ polymerase-chain-reaction (rRT-PCR)Results: Out of total 100 cases, 68% were viral & 12% were bacterial,& for the rest 20% cases etiological agent could not be determined (undetermined). All viral cases were positive for H1N1 Influenza virus. In Bacterial group 10 cases were positive for Klebsiella pneumonia & 2 cases positive for S.pneumoniae. Mean age in this study was 39.82 yrs ( SD12.611). Fever & cough were most common symptoms. Duration of symptom prior to admission was in range of 1day -12 days. Tachypnea,. Tachycardia, low mean arterial pressure (MAP) & High SOFA scores were associated with poor survival.Conclusion: Mortality was higher in ARI cases where, microbial etiology could not be found. Delay in presentation & Hypoxia were associated with high mortality in ARI cases during H1N1 outbreak.
Acute Respiratory Infection, H1N1 outbreak, tertiary care center, SOFA (Sequential Organ Failure Assessment), ARDS (Acute respiratory Distress Syndrome), CXR (Chest X-Ray)
The epidemiology of ARI might be conceived as a constantly changing scene in which viral and bacterial causal agents play various roles according to age, immunological status of the population, and the degree of exposure of individuals. The pandemic of H1N1 influenza had itâs beginning in Mexicoin March 2009 and soon spread to other parts of the globe in a rampant fashion. On June 11, 2009, the World Health Organisation (WHO) signaled that a global pandemic of novel Influenza A (H1N1) was underway. The pandemic started in Indiain the month of August 2009 and the index cases were reported from Pune. Soon the epidemic spread itself to other parts of the country[1]. This epidemic was notoriously seen to affect the younger population in the age group of 15-40 years.[2] Severe pandemic (H1N1) 2009 manifesting predominantly as cases of pneumonia requiring admission to intensive care occurred more frequently in young [3,4] , obese [5,6], and pregnant persons [7], The pandemic strain of H1N1 virus caused severe illness, including pneumonia and ARDS, and resulted in ICU admissions and mortality.[3] Present study was conducted to analyse DATA of ARI during pandemic of Influenza A H1N1
Information was compiled retrospectively from day of admission till final outcome which was either survival or mortality. The study had ethical clearance from the institutional ethical committee. Inclusion criteria were, A person presenting with history of  high fever (>38°C) and cough or breathing difficulty, A person with an unexplained acute respiratory illness, A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-ray (CXR). Exclusion criteria were an alternative diagnosis which can fully explain their illness, A case is known case of chronic respiratory illness with no acute respiratory infection, A case of aspiration pneumonia or health care associated pneumonia A case with age
In Our study we followed 100 patients & we were able to diagnose microbial etiology of 80 % of acute respiratory infection, out of total  100 cases , 68 % were viral & 12 % were bacterial for the rest 20 %  we could not determine etiology of primary infection. We found that all viral cases were positive for H1N1Influenza virus& in Bacterial infection we found 10 cases positive for Klebsiella pneumonia & 2 cases positive for S.pneumoniae. We found 4 patients died In bacterial group , 8 in viral & 12 in undetermimined group . Overall mortality was 22%. It was 33.34 % in bacterial ,14. 71 % viral & 40 % in undetermined group (Illustration 1.) Mean age in this study was 39.82 (SD 12.611) yrs , in survived group it was 38.8 (SD 12.6) yrs & in non survived group it was 43.2(SD 12.1 )  yrs. Out of total 100 patients 63 were males & 37 were female. Out of 63 male 14 died & out of 37 females 8 died. Fever & cough was present in all patients , followed by breathlessness in 84 patients. In H1N1 group 64 out of 68 had breathlessness , & 44  out of 68 patients had constitutional symptoms of bodyache diarrhea etc. Duration of symptom prior to admission ranged from min.1 day to max 12 days. Median duration of symptoms prior to hospital admission was 4 days. In non-survived group as per etiology wise it was observed that duration of symptom was more in bacterial & undetermined group,i.e. 6 days & 6.38 days respectively, which was statistically significant as compared to survived patients. (p
The Present study of âProfile of ARI cases among adults during H1N1 outbreak in a tertiary care centre in Pune.â was carried out to study profile of ARI cases admitted in hospital during H1N1 outbreak. Data from total 100 patients were compiled & analyzed. Viral infection was predominant in this study(68%), & all were H1N1 influenza infection (as during our study it was pandemic of Swine Flu H1N1 virus infection), Microbial etiology detection rate was 80%. . Out of total diagnosed cases (n=80) 85 % were viral  & 15 % bacterial. We could not determine etiology in 20 % cases, this can be explained by the fact that serology for both atypical & viral,(other than influenza), was not done at the time of study. possibility of partial treatment from outside or delay presentation could be one of the factor. As study by Ling et al 1showed that when oseltamivir was prescribed during first 3 days of illness ,it shortened duration of viral shedding.  Mean age group in our study was 39.82 (SD12.611)  yrs, while as per etiology wise 46.75 ( SD 8.529) in bacterial, 37.85 (SD 13.005) in viral, & 42.35(SD 11.798) in undetermined group. Median age of study was 40 years. As from the data we conclude that older patient were associated with more bacterial infection, which was statistically significant (p o.o46). Kristoffer et al [8] in their study stated that median age of community acquired pneumonia is 71 years. In our study viral infection incidence was more, and younger population was more commonly affected possibly because of some degree of pre existing immunity in older individuals against antigenically similar influenza virus. Study by ANZIC [6]influenza investigators on H1N1 showed median age was 40 yrs. Comparing with outcome it was found that mean age in survived patients was 38.8(SD12.6) while those in non survived group was 43.2(SD 12.1) yrs , which was statistically not significant. Overall as per etiology wise infection was more common in male  which was statistically not significant (p 0.610).As compared to information from American Lung association [9]  & Kung HC et al [10] incidence of pneumonia in greater in Males than Females. Kadam et al  [11] in their study found female sex preponderance which was carried out strictly in H1N1 patients. Overall mortality was 22 %. It was 21.62 % in male & 22.22 % in female, which was statistically not significant (p 0.857) Viral infection was associated with other symptom like diarrhea, bodyachae, Sore throat etc more commonly as compared to other pneumonia, which was statistically significant (p 0.008) , Breathlessness was found significantly present in viral pneumonia.(p
It can be concluded that in hospitalized cases of ARI during H1N1 outbreak, Mortality was high in undetermined group. Statistically significant correlation were found between Mortality & Tachypnea , Tachycardia , Low mean arterial pressure on admission, & High SOFA score on admission. Mean duration of symptom prior to admission was significantly associated with mortality in bacterial & undetermined group.
ARI: Acute Respiratory Infection SOFA: Sequential Organ Failure Assessment CDC: Centre for Disease Control WHO: World Health Organisation
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