COMPILED BY: DR.SAILENDRA KUMAR.G.N.
Clinical Management Protocol
Influenza – A (H1N1) (earlier know as swine flu) is a new influenza virus causing illness in people. First detected in Mexico in April, 2009, it has spreads to many countries in the World.
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.
Influenza A (H1N1) outbreak
It is causing an epidemic among humans in Mexico and it has spread to Argentina, Australia, Austria, Belgium, Brazil, Canada, Chile, China, Colombia, Costa Rica, Cuba, Denmark, Ecuador, El Salvador, Finland, France, Germany, Guatemala, India, Ireland, Israel, Italy, Japan, Republic of Korea, Malaysia, Netherlands, New Zealand, Norway, Panama, Peru, Poland, Portugal, Spain, Sweden, Switzerland, Thailand, Turkey, UK and USA.
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.
The majority of these cases have occurred in otherwise healthy young adults.
Caused by a new virus – Influenza A H1N1
The transmission is by droplet infection
From 1 day before to 7 days after the onset of symptoms. If illness persists for more than 7 days, chances of communicability may persist till resolution of illness. Children may spread the virus for a longer period.
The symptoms of novel H1N1 flu virus in people are similar to the symptoms of seasonal flu, although vomiting and diarrhea has been reported more commonly with H1N1 flu infection than is typical for seasonal flu. CDC (Centers for Disease Control and Prevention-USA) studied the hospital records of 268 patients hospitalized with novel H1N1 flu early on during the outbreak.
Symptoms of hospitalized H1N1 patients
- Fever* 249 (93%)
- Cough 223 (83%)
- Shortness of breath 145 (54%)
- Fatigue/Weakness 108 (40%)
- Chills 99 (37%)
- Myalgias 96 (36%)
- Rhinorrhea 96 (36%)
- Sore Throat 84 (31%)
- Headache 83 (31%)
- Vomiting 78 (29%) Wheezing 64 (24%)
- Diarrhea 64 (24%)
Expect complications to be similar to seasonal influenza:
- Otitis media,
- Status asthamaticus,
- Toxic shock syndrome
- 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.
Routine investigations required for evaluation and management:
These may include: (as necessary)
- Microbiological tests.
Confirmation of influenza A (H1N1) :
- 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 obtained from:
- Nasopharyngeal swab,
- Throat swab,
- Nasal swab,
- Tracheal aspirate (for intubated patients)
Sample collection protocol:
- The sample should be collected by a trained physician / microbiologist preferably before administration of the anti-viral drug.
- Keep specimens at 4°C 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 b stored at -70°C.
- Paired blood samples at an interval of 14 days for serological testing should also be collected.
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.
In children, emergency warning signs that need urgent medical attention include:
- Fast breathing or trouble breathing
- Bluish or gray skin color
- Not drinking enough fluids
- Severe or persistent vomiting
- Not waking up or not interacting • Being so irritable that the child does not want to be held
- Flu-like symptoms improve but then return with fever and worse cough
In adults, emergency warning signs that need urgent medical attention include:
- Difficulty breathing or shortness of breath
- Pain or pressure in the chest or abdomen
- Sudden dizziness
- Severe or persistent vomiting
- Flu-like symptoms improve but then return with fever and worse cough Precautions
- Isolation facilities: if dedicated isolation room is not available then patients can be cohorted in a well ventilated isolation ward with beds kept one meter 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.
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.
- IV Fluids.
- Parentral nutrition.
- Oxygen therapy/ ventilatory support.
- 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.
The samples are to be tested in BSL-3 laboratory. At present the following laboratories are the identified laboratories for this purpose:
- National Institute of Communicable Diseases, 22, Sham Nath Marg, Delhi
- National Institute of Virology, 20-A, Dr. Ambedkar Road, Pune-411001
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 increasedaerosols),
- Plastic apron if splashing of blood, body fluids, excretions and secretions is anticipated.
The PPE should be used in situations where regular work practice requires unavoidable, relatively closed contact with the suspected human case / poultry.
Correct procedure for applying PPE in the following order:
- Follow thorough hand wash
- Wear the coverall.
- Wear the goggles/ shoe cover/and head cover in that order.
- Wear face mask
- 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.
Infection control measures at Individual level
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.
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
- 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 meter away from a person having cough or sneeze.
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.
Infection control measures at health facility
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.
Use of PPE
- The medical, nurses and paramedics attending the suspect/ probable / confirmed case should wear full complement of PPE.
- 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.
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.
The Genus Epidemicus
Homoeopathic genus epidemicus (identified on the basis of common symptoms presented by a significant number of patients during an epidemic) is administered orally to people at risk of contracting infection.
On the ground of non-availability of recorded symptoms of H1N1 in our region, I collected the recorded symptoms of 268 hospitalized patients from CDC (Centers for Disease Control and Prevention-USA) and then repertorized with complete repertory with the help of homoeopathic software ‘Hompath’. The details as follows:
Symptoms of hospitalized novel H1N1 patients and its converted rubrics
|Fever*||Heat, in general||Fever, heat|
|Cough||Cough, catarrah with||Cough|
|Shortness of breath||Respiration, difficult||Respiration|
|Chills||Fever, chill with||Fever, heat|
|Myalgias||Pain, sore bruised||Generalities|
|Rhinorrhea||Combined with cough as “cough, catarrah with”|
|Sore Throat||Pain. Sore bruised||Throat|
|Headache||Head pain, heat during||Head, pain|
|Vomiting||Vomiting, heat during||Stomach|
From the above repertorization result the most indicated medicine is ARSENICUM ALBUM. The other medicines are Bell, Nux.v, Sil, Sulp, Acon, Puls etc.
On Preventive aspect:
My above said study also point out ARSENICUM ALBUM is the most suitable remedy the symptom picture of H1N1 patients reported from CDC (Centers for Disease Control and Prevention-USA).
Ars alb – 30 /2 doses daily for 5 days is ideal.
On curative aspect:
The same Arsenicum album is the most indicated on according to the symptomatology of H1N1. Of course any medicine may indicate on the basis of individual symptomatology.
Liga Mediocorum Homoeopathica Internationalis recommends the following Homeopathic Medicines for HINI FLU 2009
Homeopathic medical treatment is individual, but in the face of an epidemic, we can obtain groups of drugs characterized by the peculiarities of the symptoms of the sick. For this specific epidemic, we have obtained the following remedies for the symptoms found in different patients. The symptoms listed above are the common symptoms of the disease that, for the homeopathic doctor, serve to show whether or not it is Influenza. However, they are not useful for the prescription of homeopathic medicines. The pattern and the individuality of the symptoms of each patient are what determine the prescription of a homeopathic remedy.
We have listed the symptoms for which these remedies have been indicated, without determining an epidemic genius. The drugs mostly indicated for this epidemic given by homeopathic Mexican doctors are the following:
- Fear will die because of the disease
- Red Throat
- Onset of the symptoms after exposure to cold
- Harsh beginning
- The symptoms appeared suddenly
- Red Congested face
- Muscle aches and pains
- Red teary eyes
- Red flushed face
- High fever – greater than 39oC (102.2°F).
- Acute inflammation of the throat
- Throbbing Pain while coughing
- Severe headache
- Violent pulsations caused by the headache
- Red face. Brilliant and Injected Eyes
- Cannot stand the least light or noise
- Begins with sudden head pains
- Worsened by body movement
- Painful cough
- Fever with chills.
- Intense back and leg pain
- Aggravated by the least movement, improved by rest
- Extreme thirst for large amounts of liquid
- Cold, red throat
- Limb pain while walking.
- Dryness of mucous
- Begins with arduous throat pain
- Improvement by consuming hot drinks
- Widespread cold, feels cold
- He covers himself too much
- Feels prostrated, tired, exhausted
- Violent vomiting, and has frequent, but scanty diarrhea
- Thinks will die
- Burning evacuation
- Cough after drinking
- Agitated and anxious
- Does not want to be alone
- Fever that starts with chills, shivering and shaking
- Back pain
- Continued fever, with intense and insatiable thirst
- Bone pain, as if they had been beaten
- Back pain, as if it were broken
- Painful cough, aggravates the chest when coughing
- Great pain of muscles and bones
- Feels as if the back were dislocated
- Congested face during fever
- The sweating improves all the symptoms, except the headache
- Begins with hoarseness and aphony
- Catarrh, running nose, burning.
- Sore throat as if it were raw meat
- Dry cough, spasmodic
- Fever with night sweats that do not improve
- Constant thirst
- Indented tongue
- Very wary
- 10 Bone Pain
- Has a fever chill
- Hand trembles
- Abundant perspiration
- Intense muscle aches, with leg pain
- Remains immobile in bed
- Face congestion
- Injected Eyes, sore throat
- Dry cough, rapid pulse
- Despite the fever, has no thirst
- Depression and pain