| This section apprises health care workers on the latest guidelines issued by the Government of India (GoI) and other international technical agencies on screening and isolation and use of antivirals. It also advises health care workers on recognising danger signs in patients at the earliest through diagnosis/ treatment/management of seriously ill patients. |
 First case of novel influenza A(H1N1) was reported in India on 16th May 2009 but the epidemiology and distribution of the novel virus has since changed.
With change in epidemiology, public health measures and strategy of the GoI also changed from that of ‘containment’ to ‘mitigation’ of the epidemic, shifting the focus from an initial rigorous entry screening, isolation (quarantine in some cases), contact tracing and chemoprophylaxis to that of selective laboratory testing and prudent use of antiviral treatment and mortality prevention.
For latest guidelines on surveillance, see WHO’s guidelines: “Human infection with pandemic (H1N1) 2009 virus: updated interim WHO guidance on global surveillance” (http://www.who.int/csr/disease/swineflu/guidance/surveillance/
WHO_case_definition_swine_flu_2009_04_29.pdf).
Clinical care
 Ministry of Health & Family Welfare (MoHFW) has issued guidelines for screening and categorisation of patients. All patients with influenza like illness will be screened at designated screening centres (including identified private institutions) and categorised into category A, B (I&II) and C. They will then be advised on laboratory testing, antiviral treatment, domiciliary care and hospitalisation.
Central and state governments initially identified and designated screening and isolation facilities but with increase in patient load, there was pressure to create more centres. MoHFW responded by issuing guidelines for isolation and screening facilities.
For information see: Guidelines on categorisation of A(H1N1) cases during screening for home isolation, testing, treatment and hospitalisation (http://mohfw-h1n1.nic.in/) and refer to standard guidelines on clinical management on http://www.who.int/csr/resources/publications/swineflu/
clinical_managementH1N1_21_May_2009.pdf
As a critical element of clinical case management, both patient and care giver should recognise early danger signs in a patient suffering from influenza like illness, including novel influenza A(H1N1). Emergency warning signs include:
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Adults: Difficulty breathing or shortness of breath; pain or pressure in the chest or abdomen; sudden dizziness; confusion and/or severe or persistent vomiting.
Children: Fast breathing or trouble breathing; bluish skin colour, not drinking enough fluids/eating food; 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; fever with a rash. |
Emergency signs and systematic evaluation of clinical case presentation will allow the physician at the screening centre to decide on hospitalisation and level of critical care required for individual patients. This will help initiate specific treatment (including antiviral drugs) and aid in mortality reduction.
Refer to GoI guidelines for further information (Swine Flu: Clinical Management Protocol and Infection Control Guidelines (http://mohfw-h1n1.nic.in/). For detailed protocols see guidelines on "Pandemic flu: clinical management of patients with an influenza-like illness during an influenza pandemic"
(http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Influenza/
Guidelines/pandemicflupdf07.pdf)
Also read: People with Medical Conditions and High Risk Groups
Antiviral treatment and chemoprophylaxis
Clinical disease from infection with current strains of novel influenza A(H1N1) has been mild in most cases as observed globally and also in India. In few cases however, the disease has taken a serious course especially where the persons have had an underlying medical condition.
Management of the latter category involves use of antivirals (oseltamivir and zanamivir) for treatment and chemoprophylaxis. However, use of these drugs, the only specific and effective treatment available so far, has to be safeguarded against over-prescription and the potential danger of side effects and development and emergence of drug resistance, of which there have been sporadic reports.
GoI has issued guidelines on use of antivirals for treatment and chemoprophylaxis to prevent the above dangers and to make them accessible enough so that early treatment is possible and mortality can be avoided in most cases.
Evidence has been accumulating on benefits and use of oseltamivir and zanamivir in specific clinical and epidemiological situations such as treatment and chemoprophylaxis of novel influenza A(H1N1). This understanding is guided by experience with seasonal influenza viruses and their use in treatment and prophylaxis of avian influenza A(H5N1). WHO recently issued guidelines on Pharmaceutical Management of Pandemic (H1N1) and other Influenza Viruses
http://www.who.int/csr/resources/publications/swineflu/
h1n1_guidelines_pharmaceutical_mngt.pdf
Laboratory diagnosis and testing
 Novel influenza A(H1N1) is clinically indistinguishable from seasonal influenza. Early evidence points that epidemiologically the strain is more transmissible but virulence is comparable to seasonal influenza. This leaves laboratory diagnosis as the only tool to distinguish between the two clinical entities.
The preferred standardised diagnostic method for novel influenza A(H1N1) is real time RT-PCR. For more information on laboratory diagnosis and other available diagnostic tools see WHO Information for Laboratory Diagnosis of New Influenza A (H1N1) Virus in Humans (http://www.who.int/csr/resources/publications/swineflu/
WHO_Diagnostic_RecommendationsH1N1_20090521.pdf).
The recommended real time RT-PCR is based on US CDC and WHO protocols (http://www.who.int/csr/resources/publications/swineflu/
CDCRealtimeRTPCR_SwineH1Assay-2009_20090430.pdf).
The test currently is conducted in designated government laboratories with a minimum of biosafety level 2 plus containment design. For details of biosafety requirement and standards refer to WHO’s laboratory bio-risk management guideline for laboratories handling human specimens suspected or confirmed to contain influenza A (H1N1) causing the current international epidemics (http://www.who.int/csr/resources/publications/swineflu/
Laboratorybioriskmanagement.pdf)
Recently, as a preparedness measure, GoI issued guidelines for diagnostic laboratories specifying minimal/essential working conditions associated with specific manipulations in laboratory settings safety and other requirements [Guidelines for diagnostic laboratories (http://mohfw-h1n1.nic.in/)]. Resultantly, state governments are inviting private sector labs with requisite facilities to step forward and offer testing facilities with due diligence and adherence to standard guidelines.
Specimen packaging and transportation
 Clinical, diagnostic specimen, viral genetic material and cultures are amongst the variety of specimen that may be collected and transported for diagnosis and surveillance of H1N1. Proper collection, labelling, storage, packaging and transportation of specimens is critical for maintaining quality of specimen, ensuring worker's safety and envrionmental safety too. For more information see Guidelines for Sample Collection and Handling of Human Clinical samples for Laboratory Diagnosis of H1N1 Influenza (http://mohfw-h1n1.nic.in/) and Instructions for storage and transport of suspected or confirmed human and animal specimens and virus isolates of pandemic (H1N1)2009 (http://www.who.int/csr/resources/publications/
swineflu/storage_transport/en/index.html).
For guidance on international shipment requirements of specimen, see Instructions for shipments of pandemic (H1N1) 2009 specimens and virus isolates to WHO Collaborating Centres for influenza:
(http://www.who.int/csr/resources/publications/swineflu/
Shipmentoutbreakinstructions.pdf).
Who to test and what is the purpose of testing?
Since the illness due to the current novel influenza A(H1N1) is mild and self-limiting in vast majority of cases, most cases neither need testing not treatment as part of their clinical management. According to MoHFW guidelines only patients in category C need to be tested for H1N1.
Not all people with suspected novel influenza (H1N1) infection need to have the diagnosis confirmed, especially if the person resides in an affected area or if the illness is mild. Recommendations on who to test may differ by state or community. Clinicians should be aware of local guidance on testing and should use their clinical judgment in addition to this guidance for deciding when to test for H1N1.
This guideline of Government of India is a reflection of the change in strategy from that of containment in the initial phase to that of mitigation. Current strategy of lab testing has 2-fold objectives: first diagnosis and specific treatment/management of seriously ill patients to prevent mortality and second, virological surveillance to track changes in the genetic makeup of the circulating virus that may result in enhanced virulence and/or drug resistance. Lab testing is therefore not required in all patients affected by H1N1.
Infection control in case management
Novel influenza A(H1N1) is a new virus that spreads though droplet infections and accordingly, infection control in health care settings (screening centre, isolation ward) and other settings of patient care (home isolation) is central to case management and for ensuring safety of health care workers, fellow patients and community.
An important component of infection control is proper use of personal protective equipment. See 'Should I wear a Face Mask?' and for more information on infection control in health care settings, see “Infection prevention and control in health care for confirmed/ suspected cases of H1N1 and influenza-like illnesses.
(http://www.who.int/csr/resources/publications/SwineInfluenza_infectioncontrol.pdf)
Guidelines for screening centres and isolation facilities in hospitals
(http://mohfw-h1n1.nic.in/)
Guidelines for testing, Home isolation and treatment
(http://mohfw-h1n1.nic.in/)
Additional resources
http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1240812234677/
http://mohfw-h1n1.nic.in/ |
