Swine Flu - Current Epidemic

Karishma Kulkarni*, Nikhil Thatte*, Rucha Shelgikar*, Ira Shah**
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Swine Flu - Current Epidemic - Treatment
Treatmentis largely supportive and consists of bed rest, increased fluid consumption, cough suppressants, and antipyretics and analgesics (eg. Acetaminophen, non steroidal anti-inflammatory drugs) for fever and myalgias. Aspirin should be avoided in pediatric patients to avoid Reye’s sundrome. Severe cases may require intravenous hydration and other supportive measures. Antiviral agents may also be considered for treatment or prophylaxis. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with swine flu virus. Antiviral drugs may reduce the symptoms and duration of illness, just as they do for seasonal influenza. They also may contribute to preventing severe disease and death.

Figure: Algorithm to manage H1N1 influenza
Algorithm to manage H1N1 influenza


Table 1. Antiviral medication dosing recommendations for treatment or chemoprophylaxis of novel influenza A (H1N1) infection. (Table extracted from IDSA guidelines for seasonal influenza.)
Agent, groupTreatmentChemoprophylaxis
Oseltamivir
Adults75-mg capsule twice per day for 5 days75-mg capsule once per day
Children >_ 12 months15 kg or less60 mg per day divided into 2 doses30 mg once per day
16-23 kg
90 mg per day divided into 2 doses
45 mg once per day
24-40 kg120 mg per day divided into 2 doses60 mg once per day
>40 kg
150 mg per day divided into 2 doses
75 mg once per day
Zanamivir
AdultsTwo 5-mg inhalations (10 mg total) twice per dayTwo 5-mg inhalations (10 mg total) once per day
Children
Two 5-mg inhalations (10 mg total) twice per day (age, 7 years or older)
Two 5-mg inhalations (10 mg total) once per day (age, 5 years or older)


Table 2. Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir.
Age Recommended treatment dose for 5 days
<3 months12 mg twice daily
3-5 months20 mg twice daily
6-11 months25 mg twice daily


In the hospital:
• Place patients in a single-patient room with the door kept closed. Isolation facility need to have negative pressure, air control (10-12 air changes per hour), double door entry and dedicated staff. Air can be exhausted directly outside or can be recirculated after filtration by a high efficiency particulate air (HEPA) filter.
• If dedicated isolation room is not available, then patients can be kept in a well ventilated isolation ward with beds kept (at least) one metre apart.
• Aerosol-generating procedures such as endotracheal intubation, nebulized medication administration, induction and aspiration of sputum or other respiratory secretions, airway suction, chest physiotherapy and positive pressure ventilation should be performed by the treating physician/ nurse wearing full complement of PPE with N95 respirator on.
• Hospitals with centralized air conditioning are not allowed by the Government to treat swine flu cases as the centralized AC may help in spread of infection within the hospital.
• Until further evidence is available, infection control precautions should continue in an adult patient for 7 days after resolution of symptoms and 14 days after resolution of symptoms for children younger than 12 years because of longer period of viral shedding expected in children. If the patient insists on returning home, after resolution of fever, it may be considered, provided the patient and household members follow recommended infection control measures and the cases could be monitored by the health workers in the community.

At home
• Infected person should stay home for seven days; preferably isolate himself / herself in a well ventilated room. Avoid common areas frequented by other family members of the family.
• If the living space is small and more than one person need to sleep in a room, ensure that the head end of patient and others sleeping in that room are in opposite direction
• Infected person should a wear mask all the time.

Health care personnel who may come in contact with patients suffering from H1N1 influenza should take precautions when dealing with suspected cases. They should wear proper masks for prevention of transmission of infection. After a thorough hand wash, wear the gown, followed by goggles, shoe cover, head cover, face mask and finally gloves. Similarly, remove gown followed by gloves. Wash hands thoroughly and then remove head cover, face mask (by grasping elastic behind ears – do not touch front of mask) and goggles and again wash hands thoroughly. After leaving the room, again wash hands thoroughly.

Health care personnel at medium -high risk: These persons should wear complete protection equipment including masks (N-95), gloves, protective eye wear (goggles), hair covers, boot or shoe covers and gown or apron. The personnel include
• Medical and nursing staff involved in clinical examination at airport and quarantine centre
• Medical personnel involved in sample collection
• Rapid response Team while transporting or attending suspect case in the ambulance
• Health staff involved in managing a suspect case at the health facility
• Staff handling dead body of a suspect/ probable/ confirmed case

Health care personnel at low-medium risk: These persons will only need a three layered surgical mask. They include
• Paramedical staff involved in public health screening at the airports.
• Immigration and other ground staff at the airport
• Passengers in the same row, three rows in front and three layers behind a suspect case
• Health workers involved in surveillance
• Rapid response Team during supervisory field operations
• Security personnel involved in quarantine, social distancing measures, law and order maintenance
• Personnel providing essential services
• Close household contacts of a suspect/ probable/confirmed cases

Precautions in OPD
While dealing with patients with flu-like symptoms, it is essential that the doctor carries out the following safety precautions:

1. Clean hands before and after every patient interaction, preferably with alcohol-based disinfectants.
2. Wear a disposable facemask or respirator.
3. Segregate patients with flu-like symptoms in a separate waiting area; those patients who can tolerate facemasks should be asked to wear them.
4. While collecting throat/nasal swabs – wear a facemask or respirator, gloves and protective eye equipment.
5. Keep all surfaces in your OPD clean

PROPHYLAXIS
Ideally all health care personnel coming in contact with suspected, probable or confirmed cases of H1N1 influenza should receive post exposure prophylaxis. Osetamivir is a drug recommended for treatment of swine flu. It can be given as post exposure prophlaxis to contacts of H1N1 influenza patients. However doctors may get repeated exposures to H1N1 influenza virus and repeated courses of prophlaxis may not be useful and may infact have side effects. Prophylaxis should be provided till 10 days after last exposure (maximum period of 6 weeks).

A facemask or a respirator needs to be used in one of the following conditions only:

1) For a person who is at increased risk of severe illness from influenza, and if there is a new outbreak of swine flu in the community in a crowded environment, a facemask or a respirator may be considered only if the crowded setting is unavoidable.
2) For a person who is at increased risk of severe illness from influenza, and if he/she is a caregiver to a person with influenza like illness, facemask or respirator is recommended only if being the caregiver is unavoidable. If you are caring for a sick person, you can wear a mask when you are in close contact with the ill person and dispose of it immediately after contact, and clean your hands thoroughly afterwards.
3) For a person who is at increased risk of severe illness from influenza, and if there is exposure in an occupational setting (but not health care) when there is an outbreak of swine flu in the community, use of facemask or respirator may be recommended under certain conditions.
4) For persons who may or may not be at increased risk of severe illness from influenza, but who are exposed in an occupational setting, providing care to persons known or suspected to have swine flu, respirators are recommended.

Using a mask correctly in all situations is essential. Incorrect use actually increases the chance of spreading infection. A face mask or a respirator is not necessary for persons who are not included in the above categories.

N95 RESPIRATOR
There are important differences between facemasks and respirators. Facemasks do not seal tightly to the face and are used to block large droplets from coming into contact with the wearer’s mouth or nose. Most respirators (e.g. N95) are designed to seal tightly to the wearer’s face and filter out very small particles that can be breathed in by the user. For both facemasks and respirators, however, limited data is available on their effectiveness in preventing transmission of H1N1 (or seasonal influenza) in various settings. However, the use of a facemask or respirator is likely to be of most benefit if used as early as possible when exposed to an ill person and when the facemask or respirator is used consistently. Use of N95 respirators or facemasks generally is not recommended for workers in non-healthcare occupational settings for general work activities.

An N95 respirator in addition to blocking splashes, sprays and large droplets is also designed to prevent the wearer from breathing in very small particles that may be in the air. To work as expected, an N95 respirator requires a proper fit to your face. Generally, to check for proper fit, you should put on your respirator and adjust the straps so that the respirator fits tight but comfortably to your face. For information on proper fit, refer to the manufacturer’s instructions.

The 'N95' designation means that when subjected to careful testing, the respirator blocks at least 95% of very small test particles. If properly fitted, the filtration capabilities of N95 respirators exceed those of face masks. However, even a properly fitted N95 respirator does not completely eliminate the risk of illness. N95 respirators are not designed for children or people with facial hair. Because a proper fit cannot be achieved on children and people with facial hair, the N95 respirator may not provide full protection. People with chronic respiratory, cardiac, or other medical conditions that make it harder to breathe should check with their healthcare provider before using an N95 respirator because the N95 respirator can require more effort to breathe. Some models have exhalation valves that can make breathing out easier and help reduce heat build-up.

N95 respirators are labeled as "single use", disposable devices. If your respirator is damaged or soiled, or if breathing becomes difficult, you should remove the respirator, discard it properly, and replace it with a new one. To safely discard your N95 respirator, place it in a plastic bag and put it in the trash. Wash your hands after handling the used respirator.


References
Swine Flu - Current Epidemic Swine Flu - Current Epidemic 01/08/2009
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