Association of Obstetricians and Gynaecologists of Delhi (AOGD)

 Information

Seasonal Influenza A, H1N1 (Swine Flu)

Dr Sruthi Bhaskaran, Assistant Professor, Department of Obstetrics and Gynecology, UCMS/ GTB Hospital

Epidemiology

Agent : Seasonal Influenza is caused by a number of circulating Influenza viruses ( Single stranded RNA virus) such as Influenza A H1 N 1, H3N2, H2N2, Influenza B etc. The Pandemic Influenza A (H1N1) pdm 2009 virus that caused Pandemic [2009-2010] continues to circulate causing outbreaks of Seasonal Influenza in various parts of the country

Host factor:  May affect all age groups- globally incidence is higher in young children and those > 65 years.

High risk-

  • Infants, young children,
  • pregnant women
  • elderly above the age of 65
  • Health workers
  • Chronic illness-Chronic pulmonary or cardiovascular conditions, Chronic neurological conditions that impair breathing or clearance of respiratory secretions, Chronic metabolic diseases, Renal dysfunction, Hemoglobinopathies
  • Immuno-compromised persons

Season:

  • Monsoon is the usual season for large parts of India.
  • In north, north-west and Central India, the surge in cases usually occurs in winter months (January to March)

Mode of Transmission

  • Air borne from person-to-person, through large droplets generated by the act coughing and sneezing
  • Other modes of transmission-

Indirect contact by touching a contaminated object or surface (fomite transmission), close contact (including hand shaking)

Incubation period

  • 1- 4 days
  • Viral shedding can begin before symptom onset and peaks on day 1 of the symptoms.

Period of Communicability - From 1 day before to 7 days after the onset of symptoms

 

 

  • Clinical features-

 

Symptoms (sudden, rapid onset of symptoms-hallmark of influenza)

  • fever, chills,
  • body aches,
  • sore throat,
  • non-productive cough,
  • runny nose
  • headache
  • Diarrhea and vomiting (some cases)

Signs


  • Fever: rapid onset, peaking at 38.4 0C (up to 41 0C, especially in children), typically lasting 3 days (up to 4-8 days), gradually diminishing
  • Face: flushed
  • Skin: hot and moist
  • Eyes: watery, reddened
  • Nose: nasal discharge
  • Ear: otitis
  • Mucous membranes: hyperemic
  • Cervical lymph nodes enlargement: (especially in children)

 

Severity varies from afebrile symptoms mimicking common cold to severe prostration without major respiratory signs and symptoms.  Fever and systemic symptoms typically last 3 days, occasionally 5-8 days, and gradually diminish over 1-2 weeks.

 

  • Complications- In adults and elderly,
  • exacerbation of chronic illness Chronic pulmonary disease (COPD), Metabolic disease (diabetes) etc] is the most common reason for hospitalization.
  • Respiratory complications- Bronchitis, Sinusitis, Reactive airway disease and Pneumonia.
  • Invasive bacterial co-infection (sepsis, pneumonia), mainly from Staphylococcus aureus [MRSA, MSSA], Streptococcus pneumoniae, Group A Streptoccocus and Hemophilous influenza.
  • In geriatric age group, viral pneumonia is common.

 

 

 

  • Investigation- (haematological, biochemical, radiological and microbiological tests as necessary)

 

Confirmation of seasonal influenza (including HI N 1) infection is through:

  • Real time RTPCR or
  • Isolation of the virus in culture or
  • Four-fold rise in virus specific neutralizing antibodies.

Clinical Specimen (to be collected before administration of antiviral):

  • nasopharyngeal swab, throat swab, nasal swab, wash or aspirate, and tracheal aspirate (for intubated patients) are to be obtained
  • Keep specimens at 4 0C in viral transport media until transported for testing.
  • The samples should be transported to designated laboratories within 24 hours. If they cannot be transported then it needs to be stored at -70 0C.

 

  • Treatment

 

SOP-

  • Reinforce standard infection control precautions - all contacts must use hand washing practices, high efficiency masks (N95, triple layer surgical masks), gowns, goggles, gloves, cap and shoe cover.
  • Restrict number of visitors and provide them with PPE( personal protection equipment).
  • Provide antiviral prophylaxis to unprotected / unvaccinated / accidently exposed health care personnel managing a case and ask them to monitor their own health twice a day.
  • Dispose waste properly in sealed impermeable bags labelled as Bio-Hazard.

        Medication

  • Oseltamivir – Drug of choice
  • Dose-  By weight-

              For weight <15kg- 30 mg BD for 5 days

                          15-23kg - 45 mg BD for 5 days

                                                                 

                                                                           24-<40 kg-  60 mg BD for 5 days

                                                                           

                                                                                >40kg -   75 mg BD for 5 days

      Supportive therapy

  • IV Fluids.
  • Parentral nutrition.
  • Oxygen therapy/ ventilatory support.
  • Antibiotics for secondary infection.
  • Vasopressors for shock
  • Paracetamol or ibuprofen for fever, myalgia and headache
  • Plenty of oral fluids, avoid smoking,
  • sore throat- short course of topical decongestants, saline nasal drops, throat lozenges and steam inhalation
  • Salicylate / aspirin is strictly contra-indicated - potential to cause Reye's syndrome.
  • Constant monitoring for clinical / radiological evidence of lower respiratory tract infection and for hypoxia (respiratory rate, oxygen saturation, level of consciousness).
  • Signs of respiratory distress (tachypnea, dyspnea ) and oxygen saturation < 90%- oxygen therapy
  • Severe pneumonia and acute respiratory failure (SpO2 < 90% and PaO2 <60 mmHg with oxygen therapy-  Mechanical ventilation (use of HEPA filters on expiratory ports of the ventilator circuit / high flow oxygen masks is recommended).
  • Antibiotics for patients on mechanical ventilator and suspected pneumonia.
  • If the laboratory reports are negative       the patient to be discharged after full course of oseltamivir.

  • Even if the test results are negative         all cases with strong epidemiological criteria need to be followed up.

Discharge policy

  • Adult patients should be discharged 7 days after symptoms have subsided.

Children should be discharged 14 days after symptoms have subsided




Guidelines on categorization of Seasonal Influenza cases during screening for home isolation, testing, treatment and hospitalization

 

  • Individuals seeking consultations for flu like symptoms should be screened at healthcare facilities both Government and private or examined by a doctor and these will be categorized:

 

Category A-

  • Mild fever plus cough / sore throat with or without bodyache, headache, diarrhoea and vomiting       do not require Oseltamivir and should be treated for the symptoms
  • Monitor their progress and reassess at 24 to 48 hours
  • No testing of the patient for Influenza is required
  • Should confine themselves at home* and avoid mixing up with public and high risk members in the family.



Category-B

1)i) In addition to all S/S under Category-A if the patient has high grade fever and severe sore throat           may require home isolation and Oseltamivir

ii) In addition to all S/S under Category-A, individuals having one or more of the following high risk conditions shall be treated with Oseltamivir-

-Children with mild illness but with predisposing risk factors.

- Pregnant women;

-Persons aged ≥ 65 years

-Patients with lung diseases, heart disease, liver disease, kidney disease, blood disorders, diabetes, neurological disorders, cancer and HIV/AIDS.

-Patients on long term cortisone therapy


2)No tests for Influenza is required for Category-B (i) and (ii).

3)Confine themselves at home* and avoid mixing with public and high risk members in the family.

4)Broad Spectrum antibiotics as per the Guideline for Community-acquired pneumonia (CAP) may be prescribed

Category-C

1)In addition to S/S of Category-A and B, if the patient has one or more of the following-


-Breathlessness, chest pain, drowsiness, fall in blood pressure, sputum mixed with blood, bluish discolouration of nails

- Children with influenza like illness who had a severe disease as manifested by the red flag signs (Somnolence, high and persistent fever, inability to feed well, convulsions, shortness of breath, difficulty in breathing, etc).

-Worsening of underlying chronic conditions


2)All patients require testing, immediate hospitalization and treatment.

 

*Guiding principle for home care

  • stay home for seven days, preferably isolate himself / herself in a wellventilated room
  • wear mask all the time ( three layered surgical mask)

           The mask or handkerchief( if mask not available)s should be changed every six hours   

          or earlier if it gets wet

  • avoid smoking.  
  • avoid close contact with others ( atleast an arm’s length or one meter distance)
  • avoid having visitors. avoid hand shaking and wash hands frequently with soap and water
  • Monitor to assess worsening of symptoms.
  • Plenty of fluids.
  • Follow cough etiquettes whenever mask is not worn/not available -

    Cover mouth and nose with a tissue/ handkerchief when coughing or sneezing;

Do not spit/blow nose here and there, use a water filled receptacle for collecting sputum, thereby minimizing aerosol generation.

  • Medicines should be taken as advised by the doctor
  • The care provider - wear triple layer surgical mask and wash hands frequently
  • Care giver should know the early warning signs (High grade fever not responding to antipyretics, difficulty in breathing or shortness of breath, Pain or pressure in the chest or abdomen, Sudden dizziness, Confusion and Severe or persistent vomiting).
  • House hold contacts with co morbid conditions - put on chemoprophylaxis (Oseltamivir).
  • Prophylaxis provided till 10 days after last exposure (maximum period of 6 weeks) – Usual dosage for adults is 75 mg OD.



Vaccination

Government of India recommends vaccination of High Risk Groups with Seasonal Influenza Vaccine which includes- :

  1. Health Care workers, working in hospital / institutional settings (doctors, nurses, paramedics) with likelihood of exposure to Influenza virus should be vaccinated*
  2. Pregnant women, irrespective of the duration of pregnancy.
  3. Persons with chronic illnesses such as COPD, Bronchial Asthma, Heart disease etc. and immunocompromised.
  4. Children with chronic illness like Asthma, Neuro developmental conditions- CP, epilepsy etc., Immunocompromised, metabolic disorders etc.

Vaccine is desirable for

  1. elderly individuals (≥ 65 years of age)
  2. children between 6 months to 8 years of age

Type of Vaccine

Trivalent inactivated influenza vaccine


Frequency of vaccination -Yearly



*for the health care workers working in an environment with likelihood of exposure

to Influenza virus, vaccine should be administered at least one month prior to the

commencement of the season, till such time use of chemoprophylaxis may be

considered







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