INFLUENZA A H1N1

PREVENTIVE & CONTROL GUIDELINES

25 Jan 2015

National Scenario - 2015

Situational Update- Maharashtra

District Wise Cases & Deaths

Influenza Surveillance

INFLUENZA H1N1

• Incubation Period- 1 to 7 days.

• Infectious Period- 1 day prior to the onset of illness to 7 days after onset.

• Close Contact -Close Contact is defined within 6 feet of an ill person who is a confirmed, probable or suspected case of influenza A H1N1 virus infection during the infectious period.

Case Definition• Suspected Case of Influenza -

A person with an acute febrile respiratory illness commonly in the form of-

-High grade fever ( >38 degree C)

-Severe Pharyngitis

-Running nose & cough -Body ache

-Head ache

INFLUENZA SURVEILLANCEINLUENZA LIKE ILLNESS (ILI)

SEVERE ACUTE RESP INF (SARI)

is defined as:• Sudden onset of a

fever over 38°C, AND

• Cough or sore throat, AND

• An absence of other diagnoses.

> 5 YEARSSudden onset of fever

over 38°C, &Cough or sore throat, & Shortness of breath or

difficulty in breathing, &Requiring hospital

admission

< 5 YEARSPnumoniaRequires hospitalization

Surveillance Guidelines

• Active surveillance for ILI at all levels.

• Focus on – Schools, Hostels,Anganwadis Ashramshalas, Orphanages, madarasas.

• Report clusters of ILI to district/divisional & state authority immediately.

• ANMs should screen pregnant mothers for ILI during routine check up in ANC clinic.

• Tackle clusters effectively to avoid further spread.

CATEGORIES OF PATIENTS

Sr No

Category

Chief Symptoms Swab Collection Treatment

1 C Mild Fever(<38 C),Cough, Throat irritation, body ache,headache,diarrhoea & vomiting

Not Recommended No Oseltamivir Symptomatic t/t, Review after 24 hrs,

Home isolation

2 B In addition to above symptoms Fever >38 C, severe sore throat, running nose

Swabs of selected patients belonging to high risk group

Oseltamivir needed

3 A In addition to above symptoms breathlessness, Chest pain,hemoptysis,hypotension,bluish discoloration of nails, and in children irritation & drowsiness.

Swabs of all patients Oseltamivir and hospitalization

High Risk Patients

• Children below 5 years of age.

• Persons above 65 years of age.

• Pregnant Women.

• Persons having lung,heart,liver,kidney diseases. Persons with blood & neurological disorders.

• HIV/AIDS patients.

• Patients on long term steroid treatment.

Action Plan

Civil Surgeon District Health Officer District Nodal Officer of

H1N1Establish SDH 50 & 100

bed hospitals and DH as Lab sample collection & Treatment centers.

Isolation ward of 4 beds at each hospital - Ventilator

Ensure logistics.Training of MO,LT & Nursing

staff. Workshop for private

doctors & coordination with pvt hospitals

Coordination with FDA

Surveillance of ILI & SARI by PHC staff.

Contact tracing & treatment of symptomatic treatment.

Treatment of mild ILI cases ( Category C)

Referral of Cat B & A cases to identified hospital. ( Referral Centers for each Taluka should be identified by CS & DHO)

Training of MO & Paramedicals

IEC

ISOLATION WARD GUIDELINES

Guidelines For IIWs-1

• Separate ward for positive & suspected patients.• Distance of 6 feet between two beds.• Isolation ward should have following facilities-

1. Oxygen cylinders with accessories.

2.Pulse Oxymeter.

3.Electric & foot suction machine.

4.Emergency tray

5.Ventilators with trained staff.

Guidelines For IIWs-2

• Well ventilated ward with exhaust fan.• Disinfection measures & Biomedical waste

management according to standard guideline.• One separate on road ambulance.• Sufficient stock of Tamiflu,PPE,VTM.• Trained staff & doctors to operate all

instruments.• At least one on call physician available for 24

hours.

LAB SAMPLE COLLECTION

IDENTIFIED LABSSN NAME PLACE

1 NIV PUNE

2 HAFFKINE INSTITUTE MUMBAI

3 KASTURBA HOSPITAL MUMBAI

4 IGMC NAGPUR

ACCREDITED PRIVATE LABS

5 SRL RELIGARE COLLECTION CENTERS AT VARIOUS

CITIES 6 DR LAL PATOLOGY LAB

Guidelines About Sample Collection

Swab should be accompanied with detailed clinical history of patient.

Preferably prior to giving Oseltamivir.No swab collection on OPD basis.Swabs of admitted patients only.In clusters of ILI, send only 5% samples.Do not take samples of asymptomatic contacts. Do not collect swabs after more than 8 days of

onset of illness.If required do other tests also – eg Dengue,

Malaria, Lepto etc.

Sample Collection & Laboratory Diagnosis-1

What sample to be collected?

• Nasopharyngeal/oropharyngeal swabs.

• Brochoalveolar lavage.

• Tracheal aspirates.

• Nasopharyngeal/oropharyngeal aspirates as washes.

• Samples should be collected in VTM.

Sample Collection & Laboratory Diagnosis-2

When to collect Specimens

-As soon as possible after symptoms begin

-Before administration of antiviral medications.

• Full complement of PPE should be worn before initiating sample collection.

Transportation of Samples• All samples should be kept at 2-8 degree

Celsius until they can be placed at -70 C.

• Samples transported on dry ice in triple packaging.

• Clear labels with patient’s complete information.

• Samples should be sent to NIV,Pune, IGMC Nagpur, Kasturba Hospital Mumbai or Haffkine Mumbai within 24 hrs.

TREATMENT PROTOCOL

PEDIATRIC DOSES- TAMIFLUAGE DOSE

< 3 months

3-5 months

6-11 months

12 mg bid for 5 days

20 mg bid for 5 days

25 mg bid for 5 days

Guidelines for Close Contacts

• Search meticulously for all close contacts of every positive case of Influenza A H1N1 case.

• Start Oseltamivir in therapeutic dose to all close contacts with Influenza like symptoms.

• Keep asymptomatic contacts under surveillance for 10 days, if any one of them develop Influenza like symptoms within that period start Oseltamivir in therapeutic dose.

• Don’t give Oseltamivir to close contacts who are asymptomatic during the entire period of observation.

No Need of chemoprophylaxis.

.

Treatment of Serious Patients

Sr. No

Particulars Treatment Duration

1 Normal H1N1 PatientCap. Oseltamivir

75 mg BD5 days

2Signs & symptoms of

Pneumonia

Cap. Oseltamivir 150 mg BD 10 days

3After 10 days

treatment, X ray shows signs of Pneumonia

Continue Oseltamivir

OR

Replace Oseltamivir with

Zanamivir

7 days

Antiviral drugs in Pregnancy

• Category C medication.

• No clinical studies to assess safety.

• It should be used when potential benefit justifies the potential risk to the embryo/fetus.

• So far no adverse effects have been reported.

• Some prefer Zanamivir over Oseltamivir as systemic absorption is minimal.

Warning Signs- Children

• Fast breathing/trouble breathing.• Bluish skin colour.• Not drinking enough fluids/eating food.• Increased irritability.• Flu like symptoms improve but later return

with fever and worse cough.• Fever with rash.

EMERGENCY WARNING SIGNS NEED URGENT MEDICAL ATTENTION.

Warning Signs- Adults

• Difficulty breathing/shortness of breath.

• Pain /pressure in the chest or abdomen.

• Sudden dizziness.

• Confusion.

• Severe or persistent vomiting.

EMERGENCY WARNING SIGNS NEED URGENT MEDICAL ATTENTION.

Pregnant Women

• Active Screening of pregnant women during routine ANC check up by MOs & paramedical staff for ILI.

• Timely initiation of Oseltamivir in symptomatic pregnant women.

Influenza- Educating the Public

• Covering nose & mouth with a tissue/handkerchief when coughing / sneezing Dispose the tissue in the trash after use.

• Hand washing with soap & water-especially after coughing/sneezing.

• Cleaning hands with alcohol based hand cleaners.• Avoiding close contact with sick people.• Avoiding touching eyes ,nose or mouth with unwashed hands.• Avoid hand shaking & spitting.• If sick with Influenza staying home away from work/school & limit

contact with others to keep from infecting them.• No need to use mask by common public.• If you found more people suffering from Flu like symptoms from your

area, inform concerned health authority.

Use of Masks

• No need of mask for common people.• Tissue or handkerchief is sufficient to cover

nose/mouth while sneezing or coughing.• Improper use of disposable mask spreads

infection.

Guidelines for Educational Institutions

• Avoid large gatherings.• Active screening of flu like symptoms by teacher.• Students, teaching/non teaching staff with ILI- ask for medical

consultation & home isolation.• No need of medical certificate for such preventive absentees.• Identify students with high risk condition.• Regular cleaning of area with ordinary cleaner.• Hostel- regular check up of students & staff. Closure of

school not advised.• Local district administration can take decision after reviewing

the situation.• Display Do’s and Don’ts prominently.

Ensure ….Surveillance of ILI & SARISpecial focus on pregnant women & childrenContact tracing & treatment of symptomatic contacts.Functional screening centers & IIWsStock positionCoordination with FDA for availability of Oseltamivir in

private medical stores.Coordination with private hospitals & labs.Death investigation Coordination with educational institutionsSharing of H1N1 prevention & control guidelines with

all stake holdersHealth Education