Directorate of Health Services, Kerala
Influenza A H1N1
A B C Guidelines
(adapted from the GoI- MoHFW guidelines, and updated 2017 July )
Case definition of ILI ( Influenza Like Illness )
An acute respiratory infection with:-
· Measured fever of ≥ 38 C° (≥100oF)
· And any of the respiratory symptoms including coryza, sore throat, cough with onset within the last 10 days.
1. Categorization
Category A- An ILI case not requiring hospitalization.
Category-B
(Bi) An ILI case which might require hospitalization, due to comparatively severe onset
(Bii) Cat A ILI cases with any of the following physiological or co-morbid condition irrespective of hospitalisation --
· Pregnancy or post natal period
· Pre-existing Diabetes / lung/ heart / liver/ kidney / neurological disease, blood disorders/ / cancer / HIV-AIDS etc
· On long term steroids, or those with immuno-supression due to drugs, radiation, etc .
· Age ≥ 65 years.
Category-C
· ILI cases with ANY ONE of the following conditions--
Ø breathlessness,
Ø chest pain
Ø drowsiness
Ø fall in blood pressure,
Ø haemoptysis
Ø cyanosis
· ILI cases in children with with ANY ONE of the red flag signs
Ø somnolence,
Ø high / persistent fever,
Ø inability to feed,
Ø convulsions,
Ø dyspnoea /respiratory distress, etc.
2. Influenza A H1N1 Testing:
Only Sentinel type testing now needs to be done regularly for epidemiological purposes (,ie, for a constant monitoring of the prevalence in a District / region, keeping watch on swab positivity rates etc) supervised by respective District Surveillance Officers (DSO) Other than this, testing may sometimes be indicated in unusual clinical presentations, for retrospective confirmation in such a death, failure to respond even after 5 days extension of conventional Oseltamivir therapy, localised outbreak-like situation in an institution like a school, hostel, campus, etc
Testing SHOULD NOT be used for clinical management decision to initiate Oseltamivir treatment. Do NOT wait for test results on any occasion, to initiate Oseltamivir treatment.
If testing is felt indicated, contact your DSO for guidance.
Specimens required -
· 1 throat swab and 1 nasal swab, using a Dacron swab, and immersed together in single VTM (Viral Transport Medium) tube, immediately put in cold chain/ refrigerated till dispatch at 2-8 degrees C .
· Endo tracheal aspirate in VTM tube , if the patient is ventilated.
Specimen should be Triple layer packed and despatched through the DSO of the district under reverse cold chain. Never send parcels directly/ through bystanders.
Testing centres – Two authorized testing centres for Kerala**---
1. Manipal Centre for Virus Research (MCVR), KMC, Manipal University Manipal, Udupi , Karnataka State.
2. NIV Unit, Medical College, Alappuzha
** At any point in time either lab may not be active due to materials /supplies issues. Details from time to time will be available with DSO/DMO of your district
3. Management:
ILI- Category- A-
Ø No Oseltamivir required
Ø Symptomatic treatment
Ø Good supportive measures
· Plenty of warm nourishing oral fluids,
· Good food intake including locally available Vit A rich fruits and green leafy vegetables
· Complete rest
Ø Monitor progress , and reassess , at 24 to 48 hours
Any suggestion of deterioration / failure to improve?-- Advise patient to report in person immediately to treating doctor for reassessment and appropriate treatment.
ILI Category-B
(Bi and Bii)
(B-i) Home isolation / rest
Ø Oseltamivir may very often need to be started as per clinical assessment and the availability of patient for direct follow up ;
(B-ii) Start Oseltamivir immediately
If any suggestion of deterioration/ failure to improve, patient is to report in person immediately to treating doctor.
ILI Category-C
· Start Oseltamivir immediately, WITHOUT WAITING FOR TEST RESULTS if testing already done. This has to be given as co prescription along with all other intensive measures and drugs being used.
· Hospitalization immediately
· Intensive supportive management as necessary.
4. IMPORTANT NOTES:
· Pregnancy and antenatal period, as well as immediate post natal period are extremely high risk periods
· So in any Influenza Like Illness (ILI) related with pregnancy (both antenatal and post natal period) – suspect H1N1, START OSELTAMIVIR IMMEDIATELY at standard dose.
· If referring to a higher centre then IT IS MANDATORY TO START OSELTAMIVIR before referral and the drug should be continued at higher centre also.
· Oseltamivir in pregnancy is considered safe
· “Counseled prescription” should be given.
· NEGATIVE Real Time PCR for Influenza A H1N1 DOES NOT RULE OUT Influenza A H1N1 infection.
· Irrespective of any Influenza A H1N1 Real Time PCR test result, Oseltamivir therapy full course should be completed once started .
· Influenza A H1N1 is a seasonal virus and it is prevalent in the community.
· Best infection control practices include regular and frequent hand-washing / hand hygiene also.
5. Oseltamivir dosage schedule
· Dose for treatment is as follows:
Ø 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
Ø 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
Ø It may also be available as syrup (12mg per ml )
Ø In case suspension is not in stock, the contents of the capsule can be divided and administered in powdered sugar, sugar syrup, or honey.
Ø SPECIAL DOSE---If needed dose & duration can be modified as per clinical condition Eg, in Cat C cases only, where the response is assessed as 'not enough' by the treating team, dose may be increased to 150 mg BD one a one to one basis.
***Dose for chemoprophylaxis (only in special circumstances-see section 6 ) is similar, except that it is Once daily, for 10 days ( see section 6)
6. Implications of the endemic status of Influenza A -H1N1
Widespread Chemoprophylaxis to family/school/social contacts of a positive case NOT NEEDED- But --
· For those contacts of a documented case of H1N1 with high risk Eg. pregnancy/ diabetes / liver / kidney disease, Asthma / immuno-suppressed / very low or high age etc etc as in Cat B-ii, Oseltamivir 1 OD x 10 daysmay be given
· Other contacts – reassure, recommend watchfulness, assess category. If and when they show any symptoms, , then treat as per ABC guidelines
7. General Guidelines for schools / educational institutions if outbreak escalates
- No Medical certificate to be insisted on from preventive absentees.
- Promote frequent hand wash with soap and water.
- All to observe strict cough / sneeze etiquette, teachers to continuously educate and mentor students in this regard
- Regular cleaning with the regular cleaning agent they ordinarily use
- Hostels need not be closed down, but monitor the health of resident students and staff regularly
For any clarifications or any related advice, please contact your DMO / DSO (Dist. Surveillance Officer), or call DISHA Helpline on 0471-2552056, or 1056 toll free
Please visit www.dhs.kerala.gov.in or www.arogyakeralam.gov.in
to update your health information comprehensively. It will help save many a life!
**** 2017/ STATE H1N1 CONTROL ROOM ****
