Interactive Session

on SWINE FLU ( H1N1)

.

Hindu Rao Hospital, Delhi 4th February 2015

Our Set Up at HRH

Sample Collection Facility

Swine Flu ward

Guidelines for Sample Collection

• Sample Type: Throat Swab or Nasal Swab

• Collection: You will need PPE kit, N95 mask, Viral media, Swab stick

• Transportation of Specimens

Sample for Real time-PCR (polymerase chain reaction) for H1N1 should taken:

1. If the patient has a severe or progressive disease in both high risk and other groups with warning signs

2. There is cluster of cases

3. High risk individuals with ILI

Government Guidelines on Categorization of

Influenza A H1N1 Cases for Testing, Home isolation,

Treatment at Home and Hospitalization

• Category A:Mild fever plus cough/ sore throat. A mild illness.Do not require Oseltamivir (Fluvir or Tamiflu). No need of Testing for H1N1. Noneed of hospital admission. Should confine themselves at home and observeprecautions.• Category B:(i) Cat. B1: Moderate S/Ss. Treatment strategy same like Cat. A.(ii) Cat. B2: Moderate S/Ss with high risk. Should be treated with Oseltamivir.Testing for H1N1 is optional.• Category C:S/Ss of a severe disease. Breathlessness, chest pain, altered consciousness, fall inBP, blood tinged sputum, peripheral cyanosis. In children with ILI havingsomnolence, high and persistent febrile state, not accepting feeds, shortness ofbreath, convulsions.The Cat. C patients require immediate hospitalization and treatment.

High Risk Groups for Complications of H1N1

•Pregnant women

• Infant and Children below 5 yrs

• Elderly >65 yrs

•Patients with COPD/chronic resp disease, CAD, Chronic neurological disease which impairs breathing or clearance of secretions, CRF, DM, haemoglobin-pathies, or immunocompromised (on steroids and such drugs, cancers, HIV).

Care of a

Suspected or Confirmed Case of H1N1

• As per the National Guidelines, a confirmed H1N1 case has to be treated:

At Home, or

In the Hospital Setting

Depending on:

Clinical presentation and presence of complications

For this, the Respiratory Disease Activity is to be monitored.

A special emphasis is on whether he/she belongs to the high risk group

Guidelines for the Patient Care at Home

•Dos:

1. Wear mask

2. Wash hands frequently

3. Observe cough etiquettes

4. Stay at home and avoid going into the community

5. Take the prescribed treatment

6. Self monitor health and report to hospital in case S/S worsen.

Guidelines for the Patient Care at Home

..2

• Don’ts:1. Smoke2. Close contact with others3. Touching of eyes, nose or mouth• Alerts:1. Persistent fever2. Difficulty in breathing3. Blood tinged sputum4. Alteration of sensorium5. Exacerbation of S/S of associated comorbidities6. In case of children: irritability, not accepting orally, vomiting, fast

breathing, seizures, etc

Management of H1N1 Patients admitted in Hospital

Treatment decisions involve:

1. Complications of influenza

2. Worsening of pre-existing illness

3. High risk groups

4. Tools to assess Resp. status:

X Ray Chest

CURB65 used as a means of deciding the action that is needed to be taken

for that patient.0-1: Treat as an outpatient2-3: Consider a short stay in hospital or watch very closely as an outpatient4-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit

CRB65 The CRB-65 score can be simplified by omitting DBP as a criterion of hypotension. Thus, risk class 1 for thosewith no points, risk class 2 for those with 1 or 2 points and risk class 3 for those with 3 or 4 points. Patients meeting riskclass 1 would be ideal candidates for ambulatory treatment in the absence of any severe comorbidity.

CURB-65

Symptom Points

Confusion 1

BUN>7 mmol/l 1

Respiratory rate>=30 1

SBP<90mmHg, DBP=<60mmHg

1

Age>=65 1

Warning Signs for Severe Disease

• Dyspnoea

• ALI (Acute lung injury) – Pneumonia

• Hypoxia (pO2 <60mmHg, SaO2 <90%)

• Hypercapnia

• Persistent fever

• Hypotension

• Acidosis

• Altered mental status

• Septic shock

Predictors of Severe Disease

•Clinical and radiological signs of LRTI

• Exacerbation of underlying disease

• Shock and multi-organ involvement

•CNS complications

•Higher CURB65 / CRB65 score

• Signs of secondary bacterial infection

• Signs of respiratory compromise / poor oxygenation

Treatment of Indoor H1N1 Patient

•ABC

• Supplemental Oxygen and Respiratory support including mechanical ventilation

•Antipyretics (avoid aspirin), Bronchodilators, Treatment of Complications like shock, bacterial infection

•Nutritional supplementation and rehydration

• Stress ulcer prophylaxis

•Other supportive treatment.

Anti-Viral Treatment

• Anti-viral treatment should be started in ILI in high risk group and in case of Severe and progressive illness

• Oseltamivir (a neuraminidase) is the primary drug. Adv.: oral administration and a higher lung availability.

• Dose schedule:

Adult: 75 mg twice daily for 5 days

Children: <15 Kg – 30 mg twice daily

15-23 Kg – 45 mg twice daily

23 to less than 40 Kg – 60 mg twice daily

40 Kg or more – 75 mg twice daily

Infants: <3m – 12mg BD; 3-5m – 20mg BD; 6-11 m – 25 mg BD

Oseltamivir: Side Effects and Toxicity

• Nausea and vomiting

• Allergic reaction, skin rash, facial swelling

• Hepatitis

• Various neuropsychiatric adverse effects

ZANAMIVIR: Given by inhalation. For the treatment in those of 7 years or older. Not recommended for individuals with underlying respiratory disease. SIDE EFFECTS: headaches, diarrhea, nausea,cough, vomiting, disturbance in temperature regulation, and dizziness. NOT AVAILABLE.

DRUGS TO BE AVOIDED: Steroids and Aspirin.

Respiratory Support

• Non-invasive Ventilation: In milder cases where Pt. is conscious

• Pt. with PaO2/FiO2 > 200 and those with APACHE II <6 may benefit (APACHE II was designed to measure the severity of disease for adult patients admitted to intensive care units. It has not been validated for use in children or young people aged under 16).

• Invasive Ventilation: It will ensure adequate oxygen therapy, tidal volume 5-7 ml/kg PBWPEEP to achieve adequate oxygenation.

• Lung protective ventilation strategy (LPVS).

• Treatment of each patient need to be individualised.

Swine Flu OPD / Ward: Waste Disposal

• All the waste has to be treated as infectious waste anddecontaminated as per standard procedures.

• Articles like swabs/gauges etc. are to be discarded in the Yellowcoloured autoclavable biosafety bags after use, the bags are to beautoclaved followed by incineration of the contents of the bag.

• All the Waste like used gloves, face masks and disposable syringesetc are to be discarded in Blue/White autoclavable biosafety bagswhich should be autoclaved/microwaved before disposal

• All hospitals and laboratory personnel should follow the standardguidelines (Biomedical waste management and handling rules,1998) for waste management.