Medinews e-Newsletter - August 2009 - A service from the IJCP Group of Publications
Editorial Swine flu update : Mortality
In This Issue...
Dr K K Aggarwal
Dear Colleagues,
Mortality from flu
Seasonal influenza results in higher mortality rates among patients with certain chronic medical conditions, as well as in pregnant women and those at the extremes of age. A similar pattern is observed with pandemic H1N1 influenza A, although few elderly individuals have been affected.
As of July 27, 2009, there have been 134,503 laboratory-confirmed cases of pandemic H1N1 influenza A worldwide, including 816 deaths (0.6%)
In Mexico, 119 of 10,262 laboratory-confirmed cases (1.2 percent) have been fatal. Most of these deaths were related to respiratory failure resulting from severe pneumonia with multifocal infiltrates and acute respiratory distress syndrome.
In addition to respiratory failure, renal or multi-organ failure occurred in 24 percent of cases in Mexico.
As of July 24, 2009, among 43,771 cases reported in the United States, there have been 302 deaths (0.7 percent). In Argentina, 60 of 2485 cases (2.4 percent) have been fatal.
Of 45 fatal cases in Mexico, 24 (54 percent) occurred in previously healthy individuals, most of whom were between the ages of 20 and 59. Most of the deaths outside Mexico have occurred in individuals with underlying health problems.
Patient do not need N95 mask
Only health care workers need N 95 mask, as it is inspiratory mask and filter air before it is inhaled. For patients we need simple three layered surgical masks, which can prevent infectious material expectorated out from contaminating the environment. N95 mask means a tightly fitted mask with a capacity to filter out 95% of the organisms of 1-micron size at a flow rate of 50 L/minute and with less than 10% leakage.
Stop reporting routine flu case
CDC stopped reporting of individual confirmed and probable cases of novel H1N1 infection on July 24, 2009. Now CDC reports only total number of hospitalizations and deaths on a weekly basis.
As per the US figures only 2-5% of the flu patients required admissions. As on 7th August out of 6506 patients admitted 436 died with a mortality of 6.7%.
Imagining the worst situation in Delhi, 100% people getting affected by swine flu, with a population of 1.38 crores, 2.76 lac people affected with flu may require admissions. Delhi has a total bed capacity of 41629 only as on 31st March 2008 with eighty percent beds in the private sector. In terms of mortality it may translate to a total of 19320 deaths over time (once hundred percent of Delhi population is affected). But as per "WHO" only 33% are expected to get swine flu in the next two years which translates to 17% this year. The first year swine flu deaths in Delhi will translate to 3284 deaths.
As per "economic survey" 100974 people died in Delhi in 2008. Out of them heart diseases (including diabetes) caused 19362 deaths, TB 2516, cancer 2597, pneumonia 879, accidents 1088, anemia deaths, measles 52, burns 824, meningitis 476, cholera 54 and others 72474 deaths.
Every year over 5 lac people die of human flu all over the world. In the US alone flu and pneumonia is responsible for 6% of all deaths. In Delhi with annual deaths of 100974 it (human flu) will translate to 6058 deaths every year.
Deaths can be reduced
Adapting to a correct heart friendly lifestyle can reduce heart disease deaths. Postponing getting flu infection till an effective vaccine is available can reduce swine flu deaths. One can postpone getting swine flu infection by adapting to respiratory flu hygiene measures incorporating 3 feet distance precautions, frequent hand hygiene, and learning cough etiquettes. One must also remember that not all are at risk of flu deaths. The ones at risk are people with co-morbid conditions like heart patients not including high blood pressure; uncontrolled diabetes; chronic patients with liver, kidney or lung diseases; cancer and the elderly.
From AMA
Cabinet secretaries detail new guidelines for flu-related school closings: need not be closed
NBC Nightly News (8/7, story 8, 2:30, Williams) reported that on Friday, the federal government "had some guidance for parents and communities worried about the expected resurgence of swine flu just as schools open for the fall term. They're urging precautions, but of course no panic." NBC's Bazell added, "Most schools should try to stay open this fall and winter, even if they have cases of swine flu. That message [Friday] from top federal officials, who also say they expect some outbreaks could get so bad that some schools will have to close. But the decision should always be made by local authorities."
        ABC World News (8/7, story 6, 2:05, Gibson) reported that "the government guidelines were issued as US trials begin on a vaccine." ABC's Stark added, "In Seattle late [Friday], the first US trial of an H1N1 swine flu vaccine got underway. Seven other vaccine centers start their trials next week. A vaccine isn't expected until at least mid-October."
        The AP (8/7, Quaid) noted, "The government is urging school officials to stay calm when swine flu strikes this fall, closing buildings only in drastic cases and allowing sick students to return as soon as 24 hours after their fever is gone. ... Closing schools is rarely warranted, even if students or teachers have swine flu," Frieden said.
        The Washington Post (8/8, Hsu) added, "Top Obama health, education and homeland security officials said that new evidence about the global pandemic shows that the disruption caused by mass closures outweighs any potential benefits of closures, at least for now." The New York Times (8/8, A11, Grady) reported that the "secretaries of education, homeland security and health and human services described the guidelines for schools with grades kindergarten through 12 on Friday at a news briefing in Washington, along with the director of the Centers for Disease Control and Prevention. Guidelines for colleges and employers are set to be issued on Aug. 23."
        According to the Wall Street Journal (8/8, A5, Prada, McKay), "Now that the virus is better understood, and perceived as less of a threat, the guidelines remain cautious but seek to avoid widespread closures. Instead of shutting down, schools should isolate students and staff who appear to have the flu, keeping them in a separate room until they can be sent home, the CDC said. Those who are ill and those caring for them should wear surgical masks to prevent transmission, the agency said."
 
        The Chicago Tribune (8/8, Glanton) reports, "Saying the hardships related to school closures outweighed the benefits, the federal government today issued new guidelines encouraging schools to remain open this fall when there are only small numbers of students diagnosed with swine flu." TheWashington Times (8/8, Geracimos) reports, "Affected people are advised to stay home at least 24 hours after they no longer have a fever of 100 degrees or greater, under the new guidelines that officials said are meant to help decrease the spread of flu among students and school staff during the 2009-10 school year. A previous recommendation said people should stay home for one week and schools should stay closed for about two weeks if swine flu, or the H1N1 virus, was suspected."
        The San Francisco Chronicle (8/8, Allday) reports, "The revised guidelines suggest that schools close only if illness is so widespread that it becomes difficult to hold classes, or if a single case is found at a school where a large number of students have underlying health risks, such as schools for disabled children or pregnant teenagers."
        CQ HealthBeat (8/8, Norman) reported, "School districts might want
to start setting up school-based clinics at which mass vaccinations for the H1N1 influenza virus would be administered to students once the vaccine is available this fall, federal government officials said Friday." Education Secretary Arne Duncan said that officials have found "a tremendous outpouring of support" for the idea, adding that the setting was "a natural location" for the vaccination effort.
 
Regards
Dr KK Aggarwal
 

Swine Flu: Clinical management Protocol and Infection Control Guidelines
Directorate General of Health Services Ministry of Health and Family Welfare Government of India
Swine Influenza Clinical Management Protocol

1.
Introduction
As on August 4, 2009. World Health Organization (WHO) regions have reported 162,380 laboratory-confirmed cases of novel influenza A (H1N1) and 1,154 deaths. The laboratory-confirmed cases represent an underestimation of total cases in the world as many countries have shifted to strategies of clinical confirmation and prioritization of laboratory testing for only persons with severe illness and/or high risk conditions. More than 300 of the new deaths were in the Americas, bringing the death toll in that region to 1,008 since the virus first emerged in Mexico and the United States, and developed into the global epidemic.
The outbreak started in Mexico on 18th March, 2009 and spread to USA and Canada and then to other countries.
WHO raised the influenza pandemic alert to the highest level, Phase 6 on June 11, 2009.
 
2. Epidemiology
2.1 The agent
Genetic sequencing shows a new sub type of influenza A (H1N1) virus with segments from four influenza viruses: North American Swine, North American Avian, Human Influenza and Eurasian Swine.
2.2 Host factors
The majority of these cases have occurred in otherwise healthy young adults.
2.3 Transmission
The transmission is by droplet infection and fomites.
2.4 Incubation period
1-7 days.
2.5 Communicability
From 1 day before to 7 days after the onset of symptoms. If illness persist for more than 7 days, chances of communicability may persist till resolution of illness. Children may spread the virus for a longer period.
There is substantial gap in the epidemiology of the novel virus which got re-assorted from swine influenza. 
 
3. Clinical features
Important clinical features of swine influenza include fever, and upper respiratory symptoms such as cough and sore throat. Head ache, body ache, fatigue diarrhea and vomiting have also been observed.
There is insufficient information to date about clinical complications of this variant of swine origin influenza A (H1N1) virus infection. Clinicians should expect complications to be similar to seasonal influenza: sinusitis, otitis media, croup, pneumonia, bronchiolitis, status asthamaticus, myocarditis, pericarditis, myositis, rhabdomyolysis, encephalitis, seizures, toxic shock syndrome and secondary bacterial pneumonia with or without sepsis. Individuals at extremes of age and with preexisting medical conditions are at higher risk of complications and exacerbation of the underlying conditions.  
The reporting of cases is to be based on the case definition provided (Annexure-I). 

4. Investigations
Routine investigations required for evaluation and management of a patient with symptoms as described above will be required. These may include haematological, biochemical, radiological and microbiological tests as necessary.
Confirmation of influenza A(H1N1) swine origin infection is through:
  • Real time RT PCR  or
  •  Isolation of the virus in culture or
  • Four-fold rise in virus specific neutralizing antibodies.

For confirmation of diagnosis, clinical specimens such as nasopharyngeal swab, throat swab, nasal swab, wash or aspirate, and tracheal aspirate (for intubated patients) are to be obtained. The sample should be collected by a trained physician / microbiologist preferably before administration of the anti-viral drug. Keep specimens at 4C in viral transport media until transported for testing. The samples should be transported to designated laboratories with in 24 hours. If they cannot be transported then it needs to b stored at -70C.  Paired blood samples at an interval of 14 days for serological testing should also be collected.

5. Treatment

The guiding principles are:

  • Early implementation of infection control precautions to minimize nosocomical / household spread of disease
  • Prompt treatment to prevent severe illness & death.
  • Early identification and follow up of persons at risk.
5.1 Infrastructure / manpower / material support
  • Isolation facilities: if dedicated isolation room is not available then patients can be cohorted in a well ventilated isolation ward with beds kept one metre apart.
  • Manpower: Dedicated doctors, nurses and  paramedical workers. 
  • Equipment: Portable X Ray machine, ventilators, large oxygen  cylinders, pulse oxymeter
  • Supplies: Adequate quantities of PPE, disinfectants and medications (Oseltamivir, antibiotics and other medicines)
5.2 Standard Operating Procedures
  • Reinforce standard infection control precautions i.e. all those entering the room must use high efficiency masks, gowns, goggles, gloves, cap and shoe cover.
  • Restrict number of visitors and provide them with PPE.
  • Provide antiviral prophylaxis to health care personnel managing the case and ask them to monitor their own health twice a day.
  • Dispose waste properly by placing it in sealed impermeable bags labeled as Bio- Hazard.
5.3 Oseltamivir Medication
  • Oseltamivir is the recommended drug both for prophylaxis and treatment.
  • Dose for treatment is as follows:
  • By Weight:
    - For weight <15kg       30 mg BD for 5 days
    - 15-23kg                       45 mg BD for 5 days
    - 24-<40kg                    60 mg BD for 5 days
    - >40kg                         75 mg BD for 5 days
  • For infants:
    - < 3 months 12 mg BD for 5 days
    - 3-5 months 20 mg BD for 5 days
    - 6-11 months 25 mg BD for 5 days
    - It is also available as syrup (12mg per ml )
    - If needed dose & duration can be modified as per clinical condition.

Adverse reactions:
Oseltamivir is generally well tolerated, gastrointestinal side effects (transient nausea, vomiting) may increase with increasing doses, particularly above 300 mg/day. Occasionally it may cause bronchitis, insomnia and vertigo. Less commonly angina, pseudo membranous colitis and peritonsillar abscess have also been reported. There have been rare reports of anaphylaxis and skin rashes.  In children, most frequently reported side effect is vomiting.  Infrequently, abdominal pain, epistaxis, bronchitis, otitis media, dermatitis and conjunctivitis have also been observed. There is no recommendation for dose reduction in patients with hepatic disease. Though rare reporting of fatal neuro-psychiatiric illness in children and adolescents have been linked to oseltamivir, there is no scientific evidence for a causal relationship.

5.4 Supportive therapy
- IV Fluids.
- Parentral nutrition.
- Oxygen therapy/ ventilatory support.
- Antibiotics for secondary infection.
- Vasopressors for shock.
- Paracetamol or ibuprofen is prescribed for fever, myalgia and headache. Patient is advised to drink plenty of fluids. Smokers should avoid smoking. For sore throat, short course of topical decongestants, saline nasal drops, throat lozenges and steam inhalation may be beneficial.
- Salicylate / aspirin is strictly contra-indicated in any influenza patient due to its potential to cause Reye's syndrome.
- The suspected cases would be constantly monitored for clinical / radiological evidence of lower respiratory tract infection and for hypoxia (respiratory rate, oxygen saturation, level of consciousness).
- Patients with signs of tachypnea, dyspnea, respiratory distress and oxygen saturation less than 90 per cent should be supplemented with oxygen therapy.  Types of oxygen devices depend on the severity of hypoxic conditions which can be started from oxygen cannula, simple mask, partial re-breathing mask (mask with reservoir bag) and non re-breathing mask.  In children, oxygen hood or head boxes can be used. 
- Patients with severe pneumonia and acute respiratory failure (SpO2 < 90% and PaO2 <60 mmHg with oxygen therapy) must be supported with mechanical ventilation.  Invasive mechanical ventilation is preferred choice. Non invasive ventilation is an option when mechanical ventilation is not available. To reduce spread of infectious aerosols, use of HEPA filters on expiratory ports of the ventilator circuit / high flow oxygen masks is recommended.
- Maintain airway, breathing and circulation (ABC);
- Maintain hydration, electrolyte balance and nutrition.
- If the laboratory reports are negative, the patient would be discharged after giving full course of oseltamivir. Even if the test results are negative, all cases with strong epidemiological criteria need to be followed up.
- Immunomodulating drugs has not been found to be beneficial in treatment of ARDS or sepsis associated multi organ failure. High dose corticosteroids in particular have no evidence of benefit and there is potential for harm. Low dose corticosteroids (Hydrocortisone 200-400 mg/ day) may be useful in persisting septic shock (SBP < 90).
- Suspected case not having pneumonia do not require antibiotic therapy. Antibacterial agents should be administered, if required, as per locally accepted clinical practice guidelines.  Patient on mechanical  ventilation should be administered antibiotics prophylactically to prevent hospital associated infections.
 
5.5 Discharge Policy 
  • Adult patients should be discharged 7 days after symptoms have subsided.
  • Children should be discharged 14 days after symptoms have subsided.
  • The family of patients discharged earlier should be educated on personal hygiene and infection control measures at home; children should not attend school during this period.
5.6 Chemoprophylaxis
  • All close contacts of suspected, probable and confirmed cases. Close contacts include household /social contacts, family members, workplace or school contacts, fellow travelers etc.
  • All health care personnel coming in contact with suspected, probable or confirmed cases
  • Oseltamivir is the drug of choice.
  • Prophylaxis should be provided till 10 days after last exposure (maximum period of 6 weeks) 
  • By Weight:
    - For weight <15kg       30 mg OD
    - 15-23kg                       45 mg OD
    - 24-<40kg                    60 mg OD
    - >40kg                         75 mg OD
  • For infants:
    - < 3 months not recommended unless situation judged critical due to limited data on use in this age group
    - 3-5 months 20 mg OD
    - 6-11 months 25 mg OD
5.7 Non-Pharmaceutical Interventions
  • Close Contacts of suspected, probable and confirmed cases should be advised to remain at home (voluntary home quarantine) for at least 7 days after the last contact with the case. Monitoring of fever should be done for at least 7 days.  Prompt testing and hospitalization must be done when symptoms are reported.
  • All suspected cases, clusters of ILI/SARI cases need to be notified to the State Health Authorities and the Ministry of Health & Family Welfare, Govt. of India (Director, EMR and NICD)
6.  Laboratory Tests
  • The samples are to be tested in BSL-3 laboratory. At present the following laboratories are the identified laboratories for this purpose:
(i) National Institute of Communicable Diseases, 22, Sham Nath Marg, Delhi [Tel. Nos. Influenza Monitoring Cell: 011-23921401; Director: 011-23913148]
(ii) National Institute of Virology, 20-A, Dr. Ambedkar Road, Pune-411001 [Tel.No. 020-26124386]
 
Guidelines on Infection control Measures
Infection control measures would be targeted according to the risk profile as follows:
  1. Health facility managing the human cases of avian influenza
1.1 During Pre Hospital Care 
  • Standard precautions are to be followed while transporting patient to a health-care facility. The patient should also wear a three layer surgical mask.
  • Aerosol generating procedures should be avoided during transportation as far as possible.
  • The personnel in the patient's cabin of the ambulance should wear full complement of PPE including N95 masks, the driver should wear three layered surgical mask.
  • Once the patient is admitted to the hospital, the interior and exterior of the ambulance and reusable patient care equipment needs to be sanitized using sodium hypochlorite / quaternary ammonium compounds.
  • Recommended procedures for disposal of waste (including PPE used by personnel) generated in the ambulance while transporting the patient should be followed.

1.2 During Hospital Care
  • The patient should be admitted directly to the isolation facility and continue to wear a three layer surgical mask.
  • The identified medical, nursing and paramedical personnel attending the suspect/ probable / confirmed case should wear full complement of PPE (including N95 mask). If splashing with blood or other body fluids is anticipated, a water proof apron should be worn over the PPE.
  • Aerosol-generating procedures such as endotracheal intubation, nebulized medication administration, induction and aspiration of sputum or other respiratory secretions, airway suction, chest physiotherapy and positive pressure ventilation should be performed by the treating physician/ nurse wearing full complement of PPE with N95 respirator on.  
  • Sample collection and packing should be done under full cover of PPE.
  • Perform hand hygiene before and after patient contact and following contact with contaminated items, whether or not gloves are worn.
  • Until further evidence is available, infection control precautions should continue in an adult patient for 7 days after resolution of symptoms and 14 days after resolution of symptoms for children younger than 12 years because of longer period of viral shedding expected in children. If the patient insists on returning home, after resolution of fever, it may be considered, provided the patient and household members follow recommended infection control measures and the cases could be monitored by the health workers in the community.
  • The virus can survive in the environment for variable periods of time (hours to days). Cleaning followed by disinfection should be done for contaminated surfaces and equipments.
  • The virus is inactivated by a number of disinfectants such as 70% ethanol, 5% benzalkonium chloride (Lysol) and 10% sodium hypochlorite. Patient rooms/areas should be cleaned at least daily and finally after discharge of patient. In addition to daily cleaning of floors and other horizontal surfaces, special attention should be given to cleaning and disinfecting frequently touched surfaces. To avoid possible aerosolization of the virus, damp sweeping should be performed. Horizontal surfaces should be dusted by moistening a cloth with a small amount of disinfectant.
  • Clean heavily soiled equipment and then apply a disinfectant effective against influenza virus (mentioned above) before removing it from the isolation room/area. If possible, place contaminated patient-care equipment in suitable bags before removing it from the isolation room/area.
  • When transporting contaminated patient-care equipment outside the isolation room/area, use gloves followed by hand hygiene. Use standard precautions and follow current recommendations for cleaning and disinfection or sterilization of reusable patient-care equipment.
  • All waste generated from influenza patients in isolation room/area should be considered as clinical infectious waste and should be treated and disposed in accordance with national regulations pertaining to such waste. When transporting waste outside the isolation room/area, gloves should be used followed by hand hygiene.
 
Annexure I
 
Case Definition

A suspected case of swine influenza A (H1N1) virus infection is defined as a person with acute febrile respiratory illness (fever => 38C) 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.

A probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness who: 

  • is positive for influenza A, but unsubtypable for H1 and H3 by influenza RT-PCR or reagents used to detect seasonal influenza virus infection, or
  • is positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case 
  • individual with a clinically compatible illness who died of an unexplained acute respiratory -illness who is considered to be epidemiologically linked to a probable or confirmed case.
    A confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at  WHO approved laboratories by one or more of the following tests:
  • Real Time PCR
  • Viral culture
  • Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies.

Annexure II

Standard Operating Procedures on Use of PPE


Personal Protection Equipments
PPE reduces the risk of infection if used correctly. It includes:
  • Gloves (nonsterile),
  • Mask (high-efficiency mask) / Three layered surgical mask,
  • Long-sleeved cuffed gown,
  • Protective eyewear (goggles/visors/face shields),
  • Cap (may be used in high risk situations where there may be increased
    aerosols),
  • Plastic apron if splashing of blood, body fluids, excretions and secretions is
    anticipated.
       

    Goggles 

    N-95 Mask 

    Gown(must for lab work) 

       

    Triple layer Mask   

    Gloves 

    Shoe covers

           The PPE should be used in situations were regular work practice requires unavoidable, relatively closed contact with the suspected human case  / poultry.

Correct procedure for applying PPE in the following order:

  1. Follow thorough hand wash
  2. Wear the coverall.
  3. Wear the goggles/ shoe cover/and head cover in that order.
  4. Wear face mask
  5. Wear gloves
The masks should be changed after every six to eight hours.
Remove PPE in the following order:
  • Remove gown (place in rubbish bin).
  • Remove gloves (peel from hand and discard into rubbish bin).
  • Use alcohol-based hand-rub or wash hands with soap and water.
  • Remove cap and face shield (place cap in bin and if reusable place face shield in container for decontamination).
  • Remove mask - by grasping elastic behind ears ? do not touch front of mask
  • Use alcohol-based hand-rub or wash hands with soap and water.
  • Leave the room.
  • Once outside room use alcohol hand-rub again or wash hands with soap and water.
 Annexure III
 
Guidelines/ operating procedures for infection control practices
1. Infection control measures at Individual level
1.1 Hand Hygiene
Hand hygiene is the single most important measure to reduce the risk of transmitting infectious organism from one person to other.
Hands should be washed frequently with soap and water / alcohol based hand rubs/ antiseptic hand wash and thoroughly dried preferably using disposable tissue/ paper/ towel.
  • After contact with respiratory secretions or such contaminated surfaces.
  • Any activity that involves hand to face contact such as eating/ normal grooming / smoking etc.

Steps of hand washing
   

Step 1.  Wash palms and fingers. 

Step 2. Wash back of hands.

Step 3. Wash fingers and knuckles.               

Step 4. Wash thumbs.  

Step 5. Wash fingertips. 

Step 6. Wash wrists.   

                          
  
1.2 Respiratory Hygiene/Cough Etiquette
The following measures to contain respiratory secretions are recommended for all individuals with signs and symptoms of a respiratory infection.                                       
  • Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing;
  • Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use;
  • Perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/materials
1.3 Staying away
  • Stay away from poultry. Keep them secure in cages. Keep children out of reach.
  • Wash hands if in contact with poultry or poultry products.
  • Stay at least one metre away from a person having cough or sneeze.
1.4 Use of mask
As there is no efficient human to human transmission in phase III, masks are not recommended for individuals or community. As a matter of abundant precaution, PUI/ suspected cases managed at home and there family contacts are trained on using  three layered surgical masks.

2. Infection control measures at health facility
 
2.1  Droplet Precautions:
Advise healthcare personnel to observe Droplet Precautions (i.e., wearing a surgical or procedure masks for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory infection, particularly if fever is present.  These precautions should be maintained until it is determined that the cause of symptoms is not an infectious agent that requires Droplet Precautions.
 
2.2 Visual Alerts
Post visual alerts (in appropriate languages) at the entrance to outpatient facilities (e.g., emergency departments, physician offices, outpatient, clinics) instructing patients and persons who accompany them (e.g., family, friends) to inform healthcare personnel of symptoms of a respiratory infection when they first register or care and to practice Respiratory Hygiene/Cough Etiquette.
 
2.3 Use of PPE 
 
  • The medical, nurses and paramedics attending the suspect/ probable / confirmed case should wear full complement of PPE(Annexure-IX).
  • Use N-95 masks during aerosol-generating procedures.
  • Perform hand hygiene before and after patient contact and following contact with contaminated items, whether or not gloves are worn.
  • Sample collection and packing should be done under full cover of PPE.
2.4  Decontaminating contaminated surfaces, fomites and equipments
Cleaning followed by disinfection should be done for contaminated surfaces and equipments.
  • use phenolic disinfectants, quaternary ammonia compounds , alcohol or sodium hypochlorite. Patient rooms/areas should be cleaned at least daily and terminally after discharge. In addition to daily cleaning of floors and other horizontal surfaces, special attention should be given to cleaning and disinfecting frequently touched surfaces.
  • To avoid possible aerosolization of AI virus, damp sweeping should be performed.
  • Clean heavily soiled equipment and then apply a disinfectant effective against influenza virus before removing it from the isolation room/area.
  • When transporting contaminated patient-care equipment outside the isolation room/area, use gloves followed by hand hygiene. Use standard precautions and follow current recommendations for cleaning and disinfection or sterilization of reusable patient-care equipment.
2.5 Guidelines for waste disposal
  • All the waste has to be treated as infectious waste and decontaminated as per standard procedures
  • Articles like swabs/gauges etc are to be discarded in the Yellow coloured autoclavable biosafety bags after use, the bags are to be autoclaved followed by incineration of the contents of the bag.
  • Waste like used gloves, face masks and disposable syringes etc are to be discarded in Blue/White autoclavable biosafety bags which should be autocalaved/microwaved before disposal
  • All hospitals and laboratory personnel  should follow the standard guidelines (Biomedical waste management and handling rules, 1998)  for waste management. 
 
DIRECTORATE GENERAL OF HEALTH SERVICES MINISTRY OF HEALTH AND FAMILY WELFARE GOVT OF INDIA
Guidelines for Sample Collection and Handling of Human Clinical samples for Laboratory Diagnosis of H1N1 Influenza

CASE DEFINITION OF H1N1 INFLUENZA

A suspected case of swine influenza A (H1N1) virus infection is defined as a person with acute febrile respiratory illness  (fever =   38C) 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 areas 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.

A probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness who:

  • is positive for influenza A, but unsubtypable for H1 and H3 by influenza RTPCR or reagents used to detect seasonal influenza virus infection, or
  • is positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case, or
  • individual with a clinically compatible illness who died of an unexplained acute respiratory illness who is considered to be epidemiologically linked to a probable or confirmed case.

A confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at WHO approved laboratories by one or more of the following tests:

  • Real Time PCR
  • Viral culture
  • Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies.

If any case fits in the case definition then samples should be collected according to the sample collection guidelines.

 

What sample to be collected?

Respiratory specimens including: bronchoalveolar lavage, tracheal aspirates, nasopharyngeal or oropharyngeal aspirates as washes, and nasopharyngeal or oropharyngeal swabs. Swab specimens should be collected only on swabs with a synthetic tip (such as polyester or Dacron) and aluminium or plastic shaft. Swabs with cotton and wooden shafts are not recommended. Specimens collected with swabs made of calcium alginate are acceptable.

 

When to Collect Respiratory Specimens?

  • As soon as possible after symptoms begin
  • Before antiviral medications are administered
  • Even if symptoms began more than one week ago
  • Multiple specimens on multiple days could be collected if you have access to patient

Specimen: before initiating collection of sample a full complement of PPE should be worn.

Personal Protective Equipment

  • Masks (N-95)
  • Gloves
  • Protective eye wear (goggles)
  • Hair covers
  • Boot or shoe covers
  • Protective clothing (gown or apron)

Methods of Collection

  • Throat swab
  • Nasal / Nasopharyngeal swab

Throat Swab

  • Easy to do
  • Highest yield in detecting H1N1 influenza in suspected cases
  • Have the patient open his/her mouth wide open.
  • The patient should try to resist gagging and closing the mouth while the swab touches the back of the throat near the tonsils.

 

  • Nasal / Nasopharyngeal Swab: Insert dry swab into nostril and back to nasopharynx. Leave in place for a few seconds. Slowly remove swab while
  • slightly rotating it. Use a different swab for the other nostril. Put tip of swab into vial containing VTM, breaking applicator's stick.
  • Nasal Swab is collected from the anterior turbinate.

   Throat swabs can be collected into the same VTM to increase the viral yield

How to Label Samples Use pre-printed barcode* labels:

  • On the specimen container
  • On the field data collection form
  • On the log book
  • Subject's name
  • Subject's unique identification number

Label

Specimen No. :
Patient's Name :
Hospital Name :
Unique ID No. :

How to Store Specimens

  •  Store specimens at 4 C before and during transportation within 48 hours
  •  Store specimens at -70 C beyond 48 hours
  •  Do not store in standard freezer - keep on ice or in refrigerator
  •  Avoid freeze-thaw cycles
  •  Better to keep on ice for a week than to have repeat freeze and thaw

Transportation of specimens
Refer to WHO guidelines for the safe transport of infectious substances and diagnostic specimens

  •  Follow local regulations on the transportation of infectious material
  •  Coordinate with the laboratory

should be transported after proper packaging using the standard triple packaging system (WHO) and it should accompany with the clinical details as per proforma enclosed in Annexure I

While transportation cold chain should be maintained


Waste Disposal: should be done as per guidelines of your hospital Maintain adequately stocked specimen collection kits and store them properly.

Throat swabs are the easiest and best specimens to collect for suspected cases of avian influenza. Nasal swabs are easy to collect as well and should be done to increase yield.
Collect multiple specimens (respiratory and blood) on multiple days.

General Biosafety Measures

  • Clinical samples should be collected by hospital staff and not by the laboratory staff.
  • All clinical samples have to be collected wearing complete complement of PPE.
  • While taking samples always use N95 mask.
  • Use Latex disposable gloves.
  • Wear laboratory coat/disposable apron.
  • Always cover your hairs with head cover.
  • Use protective eye wear (goggles)/face shields
  • The clinical samples should be processed only in designated laboratory having the appropriate containment facilities.
  • All technical procedures should be performed in a way that minimizes the formation of aerosols and droplets.
  • Adequate and conveniently located biohazard containers should be available for disposal of contaminated materials.
  • Work surfaces must be decontaminated after any sp ill of potentially dangerous material and at the end of the working day. Generally, 5% bleach solutions are appropriate for dealing with biohazard us spillage. More information on disinfections and sterilization is provided in the WHO laboratory biosafety manual.
  • Personnel must wash their hands often ? especially after handling infectious materials and , before leaving the laboratory working areas, and before eating.
  • Personal protective equipment must be removed before leaving the laboratory.

NOTE: Whenever sample is send to laboratory(NICD, Delhi; NIV, Pune) a certificate should be attached with it stating that the sample is for research purpose and is packed properly and not hazardous to the community .

 

Revised Guidelines for testing of persons with flu-like symptoms reporting at hospitals notified for influenza H1N1

So far, the present guidelines stipulate that a person suspected of influenza A H1N1 should be referred to an identified Government health facility. He/she needs should be kept in an isolation facility in that hospital and if found positive, treated accordingly. 

Due to the onset of the Influenza season in the country, the existing guidelines have been revised with the intention of making the testing facilities for H1N1 more accessible at large and

Under the new guidelines, any person with flu like symptoms such as fever, cough, sore throat, cold, running nose etc. should go to a designated Government facility to give his/her sample for testing for the H1N1 virus. After clinical assessment, the designated medical officer would then decide on the need for testing. Except for cases that are severe, the patient would be allowed to go home (This was not allowed under the existing guidelines).   

The sample of the suspect case would be collected and sent to the notified laboratory for testing.

If tested as positive for H1N1 and in case the symptoms are mild, the patient would be informed and given the option of either admission into the hospital or isolation and treatment at his own home.

In case the patient opts for home isolation and treatment, he/she would be provided with detailed guidelines/safety measures to be strictly adhered to by the entire household of the patient.  He/she would have to provide full contact details of his entire household. The household and social contacts also would be provided with the preventive treatment.

Notwithstanding the above guidelines, the decision of the doctor of the notified hospital about admitting the patient would be final.

In case the test is negative, the patient will accordingly be informed.

These guidelines have been issued by the Government in public interest and shall be reviewed from time to time depending on the spread of the pandemic and its severity in the country. 

These guidelines would however not apply to passengers who are identified through screening at the points of entry.  The existing policy of isolating passengers with flu like symptoms would continue.

 

GUIDELINES FOR SCHOOLS/COLLEGES/INSTITUTIONS ON INFLUENZA A/H1N1

D.32020/5/2009-EMR
Government of India
Ministry of Health & Family Welfare
Directorate General of Health Services
(Emergency Medical Relief)

There have been some cases of Influenza A H1N1 virus among students and staff in certain schools, primarily in Delhi and Maharashtra.  There has been considerable speculation over the need for closure of schools to control the outbreak.  This matter has been considered by the Joint Monitoring Group in the Ministry of Health and Family Welfare.  All schools and colleges are advised to observe the following guidelines for managing cases of infection of Influenza AH1N1.

(i) Any student or staff member showing flu like symptoms such as fever, cough, running nose and difficulty in breathing should be allowed to stay at home for a period of 7 to 10 days.

(ii) Educational institutions should not insist on production of medical certificate by the student/staff.

(iii) Educational institutions should monitor the health status of such students/staff who might have come in contact with a suspected case of Influenza AH1N1 to see whether they develop flu like symptoms.  In case they do so, they should be allowed to stay home, as outlined at (i) above

(iv) In case of students staying in Hostels, the educational institutions would not only monitor the health status of the students, but also that of care providers.  It has to be ensured that the care providers wear face mask and wash hands regularly.  It might not be advisable to send the boarders back to home, as it would spread infection further.

(v) Educational institutions are further encouraged to report such cases to local health officers for further monitoring.

(vi) Given the current magnitude of the spread of AH1N1 infection and the fact that the current virus is fairly mild, closure of educational institutions on account of any student/staff member falling ill with flu like symptoms is not recommended.

(vii)  In the first place, the schools should discourage the excursions of the students to the affected countries.

(viii) In  case  if the students had proceeded to affected countries on unavoidable tours, then on their  return,  if  some  students  show flu like symptoms of fever, sore- throat , cough , body ache, running nose, difficulty breathing etc.  they should be advised to abstain from attending school and be allowed to stay at home for a period of 7 to 10 days.

 

 

Branch

Swine Flu: Clinical management Protocol and Infection Control Guidelines


DIRECTORATE GENERAL OF HEALTH SERVICES MINISTRY OF HEALTH AND FAMILY WELFARE GOVT OF INDIA
Guidelines for Sample Collection and Handling of Human Clinical samples for Laboratory Diagnosis of H1N1 Influenza


Revised Guidelines for testing of persons with flu-like symptoms reporting at hospitals notified for influenza H1N1 


GUIDELINES FOR SCHOOLS/ COLLEGES/ INSTITUTIONS ON INFLUENZA A/H1N1 

 

 
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