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Date posted: January 22, 2012

Clinical features
Fever,Upper respiratory symptoms,Cough,Sore throat.

Head ache, body ache, fatigue diarrhea and vomiting have also been observed

ABC categorization, management, and chemoprophylaxis guidelines

Categorization guidelines

Category- A- mild fever plus cough / sore throat with or without body ache, headache, diarrhoea and vomiting.
Category-B (Bi) Category-A,plus high grade fever and severe sore throat

  • (Bii) Category-A,plus one or more of the following
  • Pregnant women
  • Lung/ heart / liver/ kidney / neurological disease, blood disorders/ diabetes/ cancer /HIV-AIDS
  • On long term steroids
  • Children — mild illness but with predisposing risk factors.
  • Age 65 years+.

Category-C

  • Breathlessness, chest pain, drowsiness, fall in blood pressure, haemoptysis, cyanosis
  • Children with ILI (influenza like illness) with red flag signs
  • (Somnolence, high/persistent fever, inability to feed well, convulsions, dyspnoea/respiratory distress, etc).
  • Worsening of underlying chronic conditions.

Testing Recommendations

  • Cat- A- No testing needed
  • Cat-B-  No testing for Category-B (i) and (ii)
  • Cat-C- Test, but do not wait for test results .

If  testing is indicated in your patient-

  • Contact your hospital Nodal MO, DSO/Nodal MO of District Hospital
  • Specimen required- 1 throat swab and 1 nasal swab, using Dacron swab, and immersed in VTM (Viral Transport Medium) tube, immediately put in cold chain/ refrigerated till dispatch at 2-8deg C  in thermocol box with i-2 icepacks
  • Despatch is recorded, and should be only through the DMO/DSO of the district. Never send parcels directly/ through bystanders
  • The only authorized testing centres  for Kerala are Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, and Virology Division, KMC Hospital, Manipal, Karnataka State. Specimens directly sent by individuals/hospitals will not be accepted at either of these centres.

Management Recommendations
Category- A- No  Oseltamivir -Symptomatic treatment

  • Good supportive measures
  • Plenty of warm nourishing oral fluids,
  • Good food intake
  • Complete rest
  • Monitor progress
  • Reassess, at 24 to 48 hours
  • Self isolation at home, and telephone follow up for the next 2-3 days
  • Any  suggestion of deterioration/ failure to improve?– report in person stat.

Category-B

(i) home isolation - Oseltamivir may be needed;

(ii) Start Oseltamivir immediately- Self isolation  at home, and telephone follow up for the next 2-3 days.
Any  suggestion of deterioration/ failure to improve?– report in person stat.

Category-C - Hospitalization stat

  • Start Oseltamivir immediately, without waiting for test results
  • Intensive supportive management is usually necessary.

Pregnancy and H1N1

  • Extreme high risk category
  • 14 out of the 48 deaths in Kerala from the beginning of the pandemic, till 29 May 2010 are pregnancy related
  • Any Influenza Like Illness (ILI) in a pregnant female – suspect H1N1.
  • Early referral to appropriate  centre to start Oseltamivir /If any delay in transit expected,  start Oseltamivir, then refer.
  • Oseltamivir in pregnancy so far is considered safe
  • “Counseled prescription”  should be given. 

Oseltamivir dosage schedule

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  upwards as per clinical condition in exceptional situations.

***Dose by weight for chemoprophylaxis is similar, except that it is once daily, for 10 days 

Community spread- MOHFW guidelines
“If there is 25 or more epidemiologically linked suspect cases of Pandemic Influenza A H1N1 of which at least one or more are laboratory confirmed for Pandemic Influenza A H1N1, in two or more cities, over a period of two weeks, then the State would be considered to be having community spread”.

Kerala has community spread

Application
The curative approach

  • (i) To screen Influenza like illness in designated health facilities
  • (ii) Categorization into A, B and C categories,
  • (iii) home isolation for category A and B
  • (iv) hospitalization for Category C.
  • (v) Treatment with Oseltamivir indicated for Category B and Category C (refer to patient categorization guidelines).

Chemoprophylaxis to family, school and social contacts of a positive case-

  • No mass contact prophylaxis advised
  • For those with high risk Eg., pregnancy/ diabetes/ Asthma/immuno-suppressed/ very low or high age– Start OD dose Oseltamivir x 10 days
  • Others – assess  category, if and when  symptomatic, then treat as per ABC guidelines 

Broad guidelines for schools / educational institutions

  1. No Assembly
  2. Screening of each student in the class by class teachers for symptoms of flu.
  3. Home isolation for teachers and other employees if they develop flu like symptoms
  4. No Medical certificate  to be insisted on from preventive absentees.
  5. Promote frequent hand wash with soap and water.
  6. All to observe strict cough / sneeze etiquette
  7. Regular cleaning with  the cleaner they ordinarily use
  8. Closure of schools has not routinely recommended . Contact DSO/DMO for advice
  9. Hostels should not be closed But monitor the health of students and staff
  10. Display “DO’S AND DON’TS” for H1N1 infection at all important places.
  11. All the schools should circulate pamphlets containing “DO’S AND DONT’S” for H1N1 infection and answers to frequently asked questions (FAQ) to the students. 

If in doubt, ask the patient to report to a screening centre in your district. To get the locations and phone numbers of these centres, please contact your DMO/ Dist. Surveillance Officer.

Please do refer to the website www.mohfw.nic.in , and the link to H1N1 influenza, TODAY itself  to update your general knowledge comprehensively. It will help save many a life!

State Nodal Officer-H1N1

Comments

One Response so far.

  1. Dr.Sundaram M.K. says:

    There are hundreds of migrant workers in Kerala. They are camped in very small houses with poor sanitation and hygiene, 10-20 in a house. They do not know the language and we, doctors, do not know their language too. Extremely difficult to get the history. Severe illnesses they are transported back home by the agents.Fortunately they do not mix up freely with local population. But if any one contact H1N1 in any of these colonies they stay it will be difficult to control the spread.

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