MUNICIPAL CORPORATION OF GREATER MUMBAI

PUBLIC HEALTH DEPARTMENT

21.06.2010

Advisory for Screening and treatment of H1N1 cases.

This is to inform all the Physicians that the cases & deaths of H1N1 are on rise and there are pregnant women who are also tested positive and deaths are also reported amongst them in Mumbai. It is therefore necessary that all the Doctors are aware of   protocols for H1N1 treatment.

1. Give treatment to the suspected patients as per protocols.

2.. All the patients of category B i.e mild fever, cough, sore throat, running nose, body ache, headache will be treated symptomatically and with Oseltamivir (Tami flu) which can be prescribed to the patients. In selected cases of fever, cough with severe pharyngitis , breathlessness or those with signs of other systemic illness like heart diseases lung diseases kidney diseases etc. and pregnant women will be categorized as A and will be hospitalized and throat swabs can be collected.

1. The high risk patients and pregnant women with Flu like symptoms   should be focused and followed up with close monitoring & referred early for medical attention.
2. 4. Asymptomatic Contacts do not require Oseltamivir Prophylaxis. They need to be monitored for seven days following exposure and only if they develop symptoms they should be treated and the same applies to the Health Care Workers.

Influenza A (H1N1) -Maharashtra

I) Guidelines for use of screening Centre (SC), and Identified Isolation Wards (IIW)

In order to prevent the outbreak of Influenza A (H1N1) virus for Screening, Testing and Isolation following are the guidelines to be followed.

All patients will be screened. The patients attending at health centers will be categorized as follows:

Category C: Patients who do not demonstrate signs and symptoms as described in category B below, but have signs and symptoms of other ailments should be treated symptomatically and send home they will not be administered cap.Tami flu.

Category B : The patients with mild fever, sore throat, running nose, body ache, headache and in few cases, patients with diarrhea and vomiting will be categorized as B and treated symptomatically at screening center itself. They should be administered Oseltamivir treatment and sent for home quarantine. The doctor who has dispensed Oseltamivir should follow up the patient telephonically for monitoring the progress of signs and symptoms and to note side effects, if any.

Category A : In addition to the signs and symptoms demonstrated by category B if the patient has high grade fever, sore throat with severe pharyngitis, breathlessness or signs of other systemic illness like heart diseases lung diseases kidney diseases etc. will be categorized as A. They will be hospitalized in identified isolation wards and throat swabs of all admitted patients will be collected before starting Oseltamivir (Tami flu) treatment.

The task to be undertaken by screening center (SC) and identified isolation wards (IIW) will be as follows:

1) Screening center (SC): All the patients of category B will be treated symptomatically. Oseltamivir (Tami flu) treatment will be prescribed to the patients with mild fever, cough, sore throat, running nose, body ache, headache. In selected cases of fever, cough with severe pharyngitis, throat swabs can be collected. The Medical Officer/laboratory technicians should be trained for collecting throat swabs. They should adhere to strict infection control protocol.

2) Identified Isolation Ward (IIW): These are the specialized centers identified by public health authorities where the facility for screening as well as hospitalizing the patients for category A and B is available. In these wards all facilities including trained physician, ventilators and other emergency equipment etc. should be available.

Treatment for Children younger than 1 Year of Age

Guidelines for pandemic influenza case management in Pregnant women-

• Pregnant women are at increased risk of infection from H1N1 virus.
• H1N1 virus and pregnancy forms a high risk combination. Every ILI in pregnancy irrespective of trimester needs to be seen by a doctor.  Morbidity is higher in pregnancy than in non-pregnant population.
• Fever, cough, sore throat, rhinorhea, headache, shortness of breath, muscle weakness with vomiting and diarrhea in pregnancy irrespective of its trimester must be considered as indicators towards possible H1N1 infection.
• Pregnant women are likely to be admitted for Cardiopulmonary event and therefore that must be kept in mind while assessing the pregnant women.
• Obesity, hypertension, asthmatic tendency and diabetes mellitus are co morbid conditions which do exacerbate risk during pregnancy in H1N1 infection. It is recommended for pregnant patients that throat swab be taken as soon as they are seen and sent to diagnostic lab and report is asked at the earliest.
• An individualized consent explaining the risk Vs benefit ratio to mother – fetus from the expecting mother is advisable. It is recommended for pregnant patients that the anti-viral drugs be started as soon as possible after the onset of infection symptoms. The benefit is expected to be greatest if Oseltamivir (Tamiflu) is started within 36-48 hrs of onset of symptoms.
• In view of the expected effect of Pandemic H1N1 infective virus on the pregnant woman, the benefit of treatment with these drugs are likely to outweigh potential risk to the fetus.
• The pregnant woman with a positive swab or with more than one severe symptoms when the swab report is awaited, to be advised indoor admission.
• Admitted indoor patients should also undergo assessment for cardiac status in the form of ECG, Eco-cardiography, CPK-MB enzymes. These tests be reported to monitor early occurrence of mayocarditis.
• Monitoring of fetal distress is very important.
• Even after Tamiflu is started, and symptoms appear to have been relieved, patients should not be discharged for 48 hrs. They should be monitored till the last dose of Tamiflu.
• The patient must complete the course of Tamiflu for 5 days even if he/she feels symptomatically better after first or second day of anti-viral treatment.

Guidelines for management of Pediatric patients of H1N1 influenza A

• The standard A, B, C classification should be used for classifying the patients of pandemic influenza.
• Patients who have high grade fever, respiratory distress, not feeding/poorly feeding, sick, those with cyanosis, excessive vomiting or convulsions, or an other danger signs need to be admitted and monitored. There should be lower threshold for admitting patients in the pediatric age group.
• Avoid use of aspirin for treating fever. Paracetamol to be used for treating fever.
• All patients need to be treated with Oseltamivir for minimum 5 das (up to 10 days if no clinical improvement).
• Broad spectrum parenteral antimicrobials should be used for treatment.
• Any clinical deterioration should prompt PICU (Pediatric ICU) admission.
• Oxygen should be used in all patients with respiratory distress or when clinically indicated.
• Ventilation Strategy : High PEEP, low tidal volume and lowest required FiO2 should be used. Hypercapnia can be tolerated (permissive hypercapnia).
• For Pediatric ARDS patients:
  • Use Low tidal volume (6-8 ml/kg)
  • Minimal tolerable inspired O2 with high PEEP to achieve Pa)2 55- 60mm Hg and max tolerable PaCO2 50-60 mm Hg with arterial pH ≥7.25 & absence of metabolic acidosis
• Careful attention needs to be paid to the fluid and electrolyte balance.
• Shock (if any) needs to be treated with fluid therapy and ionotropes.
• Monitoring required: Clinical parameters, vital signs, chest radiography, pulse oximetry and capnography