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 few cases & Deaths of H1N1 are recently being reported in the month of June and there are some pregnant women who are also tested positive for H1N1 in Mumbai. It is therefore necessary that all the Doctors are aware of   protocols for H1N1 & do the following.

1.Strengthen the screening of flu patients.

2.Give treatment to the suspected patients as per protocols.(Attached)

3.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.

4.All the close contacts to be screened for symptoms & followed up for 7 days. Symptomatic contacts should be treated. Asymptomatic contacts can be given prophylaxis.

5.All the heads of institutions where isolation wards were established earlier are requested to keep isolation ward prepared and start screening the patients &give treatment. The report should be sent daily to Epid cell regarding screening and treatment in the format provided earlier

-Sd/-

Executive Health Officer

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 at Screening Centers.  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.

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 melitus are comorbid 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.
• In the case of pregnant woman, the symptoms may worsen very rapidly and viral pneumonia or secondary bacterial pneumonia may set in.
• 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.

Table 1.Antiviral medication dosing recommendations for treatment or chemoprophylaxis of 2009 H1N1 infection. (Table extracted from IDSA guidelines for seasonal influenza.)
Agent, group		Treatment (5 days)	Chemoprophylaxis (10 days)
Oseltamivir
Adults		75-mg capsule twice per day	75-mg capsule once per day
Children ≥ 12 months	15 kg or less	60 mg per day divided into 2 doses	30 mg once per day
	16-23 kg	90 mg per day divided into 2 doses	45 mg once per day
	24-40 kg	120 mg per day divided into 2 doses	60 mg once per day
	>40 kg	150 mg per day divided into 2 doses	75 mg once per day

Treatment and Chemoprophylaxis for Children younger than 1 Year of Age

Table 2. Dosing recommendations for antiviral treatment or chemoprophylaxis of children younger than 1 year using oseltamivir.
Age	Recommended treatment dose for 5 days	Recommended prophylaxis dose for 10 days
Younger than 3 months	12 mg twice daily	Not recommended unless situation judged critical due to limited data on use in this age group
3-5 months	20 mg twice daily	20 mg once daily
6-11 months	25 mg twice daily	25 mg once daily