Clinical_Management-Swine_Flu.doc

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Swine Flu

Clinical management Protocol

andInfection Control Guidelines

Directorate General of Health Services

Ministry of Health and Family Welfare

Government of India

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Swine Influenza

Clinical Management Protocol

1. Introduction

As on 30.04.09, 148 laboratory confirmed human cases of Swine influenza A !1"1#

has been re$orted from nine countries with 8 deaths. %e&ico '() cases, * deaths+, SA

'91 cases, one death+, -anada 13#, Austria1#, ermany 3#, Israel(#, "ew /ealand3#, S$ain4#, and nited indom 2#. er 1300 sus$ected cases hae been re$orted

with about 100 deaths. 5he outbrea6 started in %e&ico on 18 th%arch, (009 and s$read

to SA and -anada and then to other countries.

7! has heihtened the $andemic leel to hase 2 im$lyin wides$read human

infection.

(. $idemioloy

(.1 5he aent

enetic se:uencin shows a new sub ty$e of influenza A !1"1# irus withsements from four influenza iruses; "orth American Swine, "orth American

Aian, !uman Influenza and urasian Swine.

(.( !ost factors

5he marom 1 day before to * days after the onset of sym$toms. If illness $ersist for

more than * days, chances of communicability may $ersist till resolution of

illness. -hildren may s$read the irus for a loner $eriod.

5here is substantial a$ in the e$idemioloy of the noel irus which ot re=assorted

from swine influenza.

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3. -linical features

Im$ortant clinical features of swine influenza include feer, and u$$erres$iratory sym$toms such as couh and sore throat. !ead ache, body ache,

fatiue diarrhea and omitin hae also been obsered.

5here is insufficient information to date about clinical com$lications of this

ariant of swine oriin influenza A !1"1# irus infection. -linicians should

e&$ect com$lications to be similar to seasonal influenza; sinusitis, otitis media,crou$, $neumonia, bronchiolitis, status asthamaticus, myocarditis, $ericarditis,

myositis, rhabdomyolysis, ence$halitis, seizures, to&ic shoc6 syndrome and

secondary bacterial $neumonia with or without se$sis. Indiiduals at e&tremes ofae and with $ree&istin medical conditions are at hiher ris6 of com$lications

and e&acerbation of the underlyin conditions.

The reporting of cases is to be based on the case definition provided

(Annexure-I).

4. Inestiations

?outine inestiations re:uired for ealuation and manaement of a $atient withsym$toms as described aboe will be re:uired. 5hese may include

haematoloical, biochemical, radioloical and microbioloical tests as necessary.

-onfirmation of influenza A!1"1# swine oriin infection is throuh;

?eal time ?5 -? or Isolation of the irus in culture or

>our=fold rise in irus s$ecific neutralizin antibodies.

>or confirmation of dianosis, clinical s$ecimens such as naso$haryneal swab,

throat swab, nasal swab, wash or as$irate, and tracheal as$irate for intubated$atients# are to be obtained. 5he sam$le should be collected by a trained $hysician

@ microbioloist $referably before administration of the anti=iral dru. ee$

s$ecimens at 4- in iral trans$ort media until trans$orted for testin. 5hesam$les should be trans$orted to desinated laboratories with in (4 hours. If they

cannot be trans$orted then it needs to b stored at =*0-. aired blood sam$les at

an interal of 14 days for seroloical testin should also be collected.

2. 5reatment

5he uidin $rinci$les are;

arly im$lementation of infection control $recautions to minimize

nosocomical @ household s$read of disease

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rom$t treatment to $reent seere illness B death.

arly identification and follow u$ of $ersons at ris6.

2.1 Infrastructure @ man$ower @ material su$$ort

Isolation facilities; if dedicated isolation room is not aailable then$atients can be cohorted in a well entilated isolation ward with beds 6e$t

one metre a$art. %an$ower; Cedicated doctors, nurses and $aramedical wor6ers.

:ui$ment; ortable D ?ay machine, entilators, lare o&yen cylinders,

$ulse o&ymeter Su$$lies; Ade:uate :uantities of , disinfectants and medications

seltamiir, antibiotics and other medicines#

2.( Standard $eratin rocedures

?einforce standard infection control $recautions i.e. all those enterin theroom must use hih efficiency mas6s, owns, oles, loes, ca$ and

shoe coer. ?estrict number of isitors and $roide them with .

roide antiiral $ro$hyla&is to health care $ersonnel manain the case

and as6 them to monitor their own health twice a day. Cis$ose waste $ro$erly by $lacin it in sealed im$ermeable bas labeled

as Eio= !azard.

2.3 seltamiir %edication

seltamiir is the recommended dru both for $ro$hyla&is and treatment.

Cose for treatment is as follows;

Ey 7eiht;

- >or weiht F126 30 m EC for 2 days

- 12=(36 42 m EC for 2 days

- (4=F406 )0 m EC for 2 days

- G406 *2 m EC for 2 days

>or infants;

- F 3 months 1( m EC for 2 days

-3=2 months (0 m EC for 2 days

- )=11 months (2 m EC for 2 days

- It is also aailable as syru$ 1(m $er ml #

- If needed dose B duration can be modified as $er clinical condition.

Aderse reactions;

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seltamiir is enerally well tolerated, astrointestinal side effects

transient nausea, omitin# may increase with increasin doses,

$articularly aboe 300 m@day. ccasionally it may cause bronchitis,insomnia and ertio. Hess commonly anina, $seudo membranous colitis

and $eritonsillar abscess hae also been re$orted. 5here hae been rare

re$orts of ana$hyla&is and s6in rashes. In children, most fre:uentlyre$orted side effect is omitin. Infre:uently, abdominal $ain, e$ista&is,

bronchitis, otitis media, dermatitis and conluids.

-

arentral nutrition.- &yen thera$y@ entilatory su$$ort.

- Antibiotics for secondary infection.

- aso$ressors for shoc6.

- aracetamol or ibu$rofen is $rescribed for feer, myalia and

headache. atient is adised to drin6 $lenty of fluids. Smo6ers should

aoid smo6in. >or sore throat, short course of to$ical deconestants,saline nasal dro$s, throat lozenes and steam inhalation may be

beneficial.

- Salicylate @ as$irin is strictly contra=indicated in any influenza $atient

due to its $otential to cause ?eyeJs syndrome.-

5he sus$ected cases would be constantly monitored for clinical @radioloical eidence of lower res$iratory tract infection and for

hy$o&ia res$iratory rate, o&yen saturation, leel of consciousness#.

- atients with sins of tachy$nea, dys$nea, res$iratory distress and

o&yen saturation less than 90 $er cent should be su$$lemented witho&yen thera$y. 5y$es of o&yen deices de$end on the seerity of

hy$o&ic conditions which can be started from o&yen cannula, sim$le

mas6, $artial re=breathin mas6 mas6 with reseroir ba# and non re=breathin mas6. In children, o&yen hood or head bo&es can be used.

- atients with seere $neumonia and acute res$iratory failure S$( F

90K and a( F)0 mm! with o&yen thera$y# must be su$$orted

with mechanical entilation. Inasie mechanical entilation is$referred choice. "on inasie entilation is an o$tion whenmechanical entilation is not aailable. 5o reduce s$read of infectious

aerosols, use of !A filters on e&$iratory $orts of the entilator

circuit @ hih flow o&yen mas6s is recommended.- %aintain airway, breathin and circulation AE-#L

- %aintain hydration, electrolyte balance and nutrition.

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- If the laboratory re$orts are neatie, the $atient would be dischared

after iin full course of oseltamiir. en if the test results are

neatie, all cases with stron e$idemioloical criteria need to befollowed u$.

- Immunomodulatin drus has not been found to be beneficial in

treatment of A?CS or se$sis associated multi oran failure. !ih dosecorticosteroids in $articular hae no eidence of benefit and there is

$otential for harm. How dose corticosteroids !ydrocortisone (00=400m@ day# may be useful in $ersistin se$tic shoc6 SE F 90#.

- Sus$ected case not hain $neumonia do not re:uire antibiotic

thera$y. Antibacterial aents should be administered, if re:uired, as $erlocally acce$ted clinical $ractice uidelines. atient on mechanical

entilation should be administered antibiotics $ro$hylactically to

$reent hos$ital associated infections.

2.2 Cischare olicy

Adult $atients should be dischared * days after sym$toms hae subsided.

-hildren should be dischared 14 days after sym$toms hae subsided.

5he family of $atients dischared earlier should be educated on $ersonal

hyiene and infection control measures at homeL children should not

attend school durin this $eriod.

2.) -hemo ro$hyla&is

All close contacts of sus$ected, $robable and confirmed cases. -lose

contacts include household @social contacts, family members, wor6$lace or

school contacts, fellow traelers etc. All health care $ersonnel comin in contact with sus$ected, $robable or

confirmed cases

seltamiir is the dru of choice.

ro$hyla&is should be $roided till 10 days after last e&$osure ma&imum

$eriod of ) wee6s#

Ey 7eiht;

- >or weiht F126 30 m C

- 12=(36 42 m C

- (4=F406 )0 m C

-G406 *2 m C >or infants;

- F 3 months not recommended unless situation


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2.* "on=harmaceutical Interentions

o

-lose -ontacts of sus$ected, $robable and confirmed cases should be adisedto remain at home oluntary home :uarantine# for at least * days after thelast contact with the case. %onitorin of feer should be done for at least *

days. rom$t testin and hos$italization must be done when sym$toms are

re$orted.

o All sus$ected cases, clusters of IHI@SA?I cases need to be notified to the

State !ealth Authorities and the %inistry of !ealth B >amily 7elfare, ot.

of India Cirector, %? and "I-C#

). Haboratory 5ests

o 5he sam$les are to be tested in ESH=3 laboratory. At $resent the followin

laboratories are the identified laboratories for this $ur$ose;

(i) "ational Institute of -ommunicable Ciseases, ((, Sham "ath %ar, Celhi'5el. "os. Influenza %onitorin -ell; 011=(39(1401L Cirector; 011=

(3913148+(ii) "ational Institute of iroloy, (0=A, Cr. Ambed6ar ?oad, une=411001

'5el."o. 0(0=()1(438)+

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Guidelines on Infection control Measures

Infection control measures would be tareted accordin to the ris6 $rofile asfollows;

! Health facility managing the human cases of avian influenza

1.1 Curin re !os$ital -are

o Standard $recautions are to be followed while trans$ortin $atient to a

health=care facility. 5he $atient should also wear a three layer surical mas6.

o Aerosol eneratin $rocedures should be aoided durin trans$ortation

as far as $ossible.o 5he $ersonnel in the $atientJs cabin of the ambulance should wear full

com$lement of includin "92 mas6s, the drier should wear three

layered surical mas6.

o nce the $atient is admitted to the hos$ital, the interior and e&terior ofthe ambulance and reusable $atient care e:ui$ment needs to be sanitized usinsodium hy$ochlorite @ :uaternary ammonium com$ounds.

o ?ecommended $rocedures for dis$osal of waste includin used

by $ersonnel# enerated in the ambulance while trans$ortin the $atient

should be followed.

1.( Curin !os$ital -are

o 5he $atient should be admitted directly to the isolation facility and

continue to wear a three layer surical mas6.o 5he identified medical, nursin and $aramedical $ersonnel attendin

the sus$ect@ $robable @ confirmed case should wear full com$lement of

includin "92 mas6#. If s$lashin with blood or other bodyfluids is antici$ated, a water $roof a$ron should be worn oer the .

o Aerosol=eneratin $rocedures such as endotracheal intubation,

nebulized medication administration, induction and as$iration of

s$utum or other res$iratory secretions, airway suction, chest$hysiothera$y and $ositie $ressure entilation should be $erformed

by the treatin $hysician@ nurse wearin full com$lement of with

"92 res$irator on.

o Sam$le collection and $ac6in should be done under full coer of.

o erform hand hyiene before and after $atient contact and followin

contact with contaminated items, whether or not loes are worn.

o ntil further eidence is aailable, infection control $recautions

should continue in an adult $atient for * days after resolution of

sym$toms and 14 days after resolution of sym$toms for children

youner than 1( years because of loner $eriod of iral sheddin

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e&$ected in children. If the $atient insists on returnin home, after

resolution of feer, it may be considered, $roided the $atient and

household members follow recommended infection control measuresand the cases could be monitored by the health wor6ers in the

community.

o

5he irus can surie in the enironment for ariable $eriods of timehours to days#. -leanin followed by disinfection should be done forcontaminated surfaces and e:ui$ments.

o 5he irus is inactiated by a number of disinfectants such as *0K

ethanol, 2K benzal6onium chloride Hysol# and 10K sodiumhy$ochlorite. atient rooms@areas should be cleaned at least daily and

finally after dischare of $atient. In addition to daily cleanin of floors

and other horizontal surfaces, s$ecial attention should be ien to

cleanin and disinfectin fre:uently touched surfaces. 5o aoid$ossible aerosolization of the irus, dam$ swee$in should be

$erformed. !orizontal surfaces should be dusted by moistenin a cloth

with a small amount of disinfectant.o -lean heaily soiled e:ui$ment and then a$$ly a disinfectant effectie

aainst influenza irus mentioned aboe# before remoin it from the

isolation room@area. If $ossible, $lace contaminated $atient=caree:ui$ment in suitable bas before remoin it from the isolation

room@area.

o 7hen trans$ortin contaminated $atient=care e:ui$ment outside the

isolation room@area, use loes followed by hand hyiene. se standard$recautions and follow current recommendations for cleanin and

disinfection or sterilization of reusable $atient=care e:ui$ment.o All waste enerated from influenza $atients in isolation room@area

should be considered as clinical infectious waste and should be treated

and dis$osed in accordance with national reulations $ertainin to

such waste. 7hen trans$ortin waste outside the isolation room@area,loes should be used followed by hand hyiene.

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Annexure I

Case Definition

Asuspected caseof swine influenza A !1"1# irus infection is defined as a $erson

with acute febrile res$iratory illness feer M 38 0 -# with onset.;

within 7 days of close contact with a person who is a confirmed case of swine

influenza A (H1N1) virus infection, or within 7 days of travel to community where there are one or more confirmed swine

influenza A(H1N1) cases, or

resides in a community where there are one or more confirmed swine influenza cases.

Aprobable caseof swine influenza A !1"1# irus infection is defined as a $erson withan acute febrile res$iratory illness who;

is positive for influenza A, but unsubtypable for H1 and H by influenza !"#$%! or

rea&ents used to detect seasonal influenza virus infection, or

is positive for influenza A by an influenza rapid test or an influenza

immunofluorescence assay ('A) plus meets criteria for a suspected case

individual with a clinically compatible illness who died of an uneplained acute

respiratory *illness who is considered to be epidemiolo&ically lin+ed to a probable or

confirmed case.

A confirmed caseof swine influenza A !1"1# irus infection is defined as a $erson withan acute febrile res$iratory illness with laboratory confirmed swine influenza A !1"1#

irus infection at 7! a$$roed laboratories by one or more of the followin tests;

!eal "ime $%!

viral culture

our#fold rise in swine influenza A (H1N1) virus specific neutralizin& antibodies.

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Annexure II

Standard "#erating Procedures on $se of PP%

Personal Protection %&ui#ments

reduces the ris6 of infection if used correctly. It includes;

N loes nonsterile#,

N %as6 hih=efficiency mas6# @ 5hree layered surical mas6,N Hon=sleeed cuffed own,

N rotectie eyewear oles@isors@face shields#,

N -a$ may be used in hih ris6 situations where there may be increased

aerosols#,

N lastic a$ron if s$lashin of blood, body fluids, e&cretions and secretions isantici$ated.

oles "=92 %as6

?

ownmust for lab wor6# 5ri$le layer %as6

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loes Shoe coers

5he should be used in situations were reular wor6 $ractice re:uires

unaoidable, relatiely closed contact with the sus$ected human case @$oultry.

-orrect $rocedure for a$$lyin in the followin order;

1. >ollow thorouh hand wash

(. 7ear the coerall.3. 7ear the oles@ shoe coer@and head coer in that order.

4. 7ear face mas6

2. 7ear loes

5he mas6s should be chaned after eery si& to eiht hours.

?emoe in the followin order;

N ?emoe own $lace in rubbish bin#.

N ?emoe loes $eel from hand and discard into rubbish bin#.N se alcohol=based hand=rub or wash hands with soa$ and water.

N ?emoe ca$ and face shield $lace ca$ in bin and if reusable $lace face shield in

container for decontamination#.N ?emoe mas6 = 'y gras#ing elastic 'ehind ears ( do not touch front of mas)N se alcohol=based hand=rub or wash hands with soa$ and water.

N Heae the room.

N nce outside room use alcohol hand=rub aain or wash hands with soa$ andwater.

1(

Used PPE should be handled as waste as per waste management protocol


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Annexure III

Guidelines* o#erating #rocedures for infection control #ractices

1. Infection control measures at Individual level

! Hand Hygiene

!and hyiene is the sinle most im$ortant measure to reduce the ris6 of

transmittin infectious oranism from one $erson to other.

!ands should be washed fre:uently with soa$ and water @ alcohol based hand

rubs@ antise$tic hand wash and thorouhly dried $referably usin dis$osable

tissue@ $a$er@ towel.

After contact with res$iratory secretions or such contaminated

surfaces.

Any actiity that inoles hand to face contact such as eatin@ normal

roomin @ smo6in etc.

Ste#s of hand washing

Ste$ 1. Ste$ (.

7ash $alms and finers. 7ash bac6 of hands.

Ste$ 3. Ste$ 4.

7ash finers and 6nuc6les. 7ash thumbs.

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Ste$ 2. Ste$ ).7ash finerti$s. 7ash wrists.

!+ ,es#iratory Hygiene*Cough %ti&uette

5he followin measures to contain res$iratory secretions are recommended for allindiiduals with sins and sym$toms of a res$iratory infection.

-oer the nose@mouth with a hand6erchief@ tissue $a$er when couhin or sneezinL

se tissues to contain res$iratory secretions and dis$ose of them in the nearest waste

rece$tacle after useL

erform hand hyiene e.., hand washin with non=antimicrobial soa$ and water,

alcohol=based hand rub, or antise$tic hand wash# after hain contact with res$iratory

secretions and contaminated ob


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Adise healthcare $ersonnel to obsere Cro$let recautions i.e., wearin a surical or

$rocedure mas6s for close contact#, in addition to Standard recautions, when e&aminin

a $atient with sym$toms of a res$iratory infection, $articularly if feer is $resent. 5hese$recautions should be maintained until it is determined that the cause of sym$toms is not

an infectious aent that re:uires Cro$let recautions.

+!+ 0isual 1lerts

ost isual alerts in a$$ro$riate lanuaes# at the entrance to out$atient facilities e..,emerency de$artments, $hysician offices, out$atient, clinics# instructin $atients and

$ersons who accom$any them e.., family, friends# to inform healthcare $ersonnel of

sym$toms of a res$iratory infection when they first reister or care and to #ractice

,es#iratory Hygiene*Cough %ti&uette!

(.3 $se of PP%

o 5he medical, nurses and $aramedics attendin the sus$ect@ $robable @ confirmed case

should wear full com$lement of Anne&ure=ID#.o se "=92 mas6s durin aerosol=eneratin $rocedures.

o erform hand hyiene before and after $atient contact and followin contact with

contaminated items, whether or not loes are worn.

o Sam$le collection and $ac6in should be done under full coer of .

(.4 Decontaminating contaminated surfaces2 fomites and e&ui#ments

-leanin followed by disinfection should be done for contaminated surfaces and

e:ui$ments.o use $henolic disinfectants, :uaternary ammonia com$ounds , alcohol or sodium

hy$ochlorite. atient rooms@areas should be cleaned at least daily and terminally after

dischare. In addition to daily cleanin of floors and other horizontal surfaces, s$ecial

attention should be ien to cleanin and disinfectin fre:uently touched surfaces.o 5o aoid $ossible aerosolization of AI irus, dam$ swee$in should be $erformed.

o -lean heaily soiled e:ui$ment and then a$$ly a disinfectant effectie

aainst influenza irus before remoin it from the isolation room@area.

o 7hen trans$ortin contaminated $atient=care e:ui$ment outside the isolation room@area,

use loes followed by hand hyiene. se standard $recautions and follow current

recommendations for cleanin and disinfection or sterilization of reusable $atient=care

e:ui$ment.

(.2 Guidelines for waste dis#osal

All the waste has to be treated as infectious waste and decontaminated as $er

standard $rocedures

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Articles li6e swabs@aues etc are to be discarded in the Oellow coloured

autoclaable biosafety bas after use, the bas are to be autoclaed followed by

incineration of the contents of the ba.

7aste li6e used loes, face mas6s and dis$osable syrines etc are to be discarded

in Elue@7hite autoclaable biosafety bas which should be

autocalaed@microwaed before dis$osal All hos$itals and laboratory $ersonnel should follow the standard uidelines

Eiomedical waste manaement and handlin rules, 1998# for waste

manaement.

1)

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