CCF International Church

Pandemic influenza A (H1N1) 2009 or SWINE FLU

 1.1   What is pandemic influenza A (H1N1) 2009 virus?

A new strain of influenza A (H1N1) virus that has never before circulated among humans has been found. This virus is unrelated to previous or current human seasonal influenza viruses. This is commonly known as “swine flu” and “novel flu”.

 1.2   Transmission

The virus spreads from person-to-person. It is transmitted as easily as the normal seasonal flu and can be passed to other people by exposure to infected droplets expelled by coughing or sneezing that can be inhaled, or that can contaminate hands or surfaces. To prevent spread, people who are ill should cover their mouth and nose when coughing or sneezing, stay home when they are unwell, clean their hands regularly, and keep some distance from healthy people, as much as possible.

 

1.3   Typical signs and symptoms of infection

Signs of pandemic influenza A (H1N1) 2009 are flu-like, including:  fever, cough, headache, muscle and joint pain, sore throat and runny nose, and sometimes vomiting and diarrhea.

 

2. Case definitions for identification of pandemic influenza A(H1N1) 2009

The symptoms of pandemic influenza are non-specific and may be similar to seasonal influenza infections. The case

definitions below will enable you to recognise a case that may be infected with pandemic influenza, and classify them into one of two categories:

 

2.1 ILI (Influenza Like Illness) – Mild Disease:

• • An individual with recent onset of an influenza-like illness (ILI), which may include fever ≥380C PLUS ONE OR MORE of the following acute respiratory symptoms (sore throat, rhinorrhoea / nasal congestion, cough or other signs part of the respiratory complex, myalgia, diarrhoea ).

 

2.2 SARI (Severe Acute Respiratory Infection) – Moderate to Severe Disease:

• • Persons 2 days to < 3 months old:

o Any child with diagnosis of suspected sepsis or physician diagnosed lower respiratory tract infection (LRTI)

irrespective of signs and symptoms. Patient presenting within 7 days of the onset of illness.

• • ≥ 3 months old to < 5 years old:

o Any child ≥ 3 months to < 5 years with physician-diagnosed acute lower respiratory infection (LRTI) including

bronchiolitis, pneumonia, bronchitis and pleural effusion. Patient presenting within 7 days of the onset of illness

• • ≥ 5 years old:

o Any person presenting with: sudden onset of fever (>38oC) AND cough or sore throat AND shortness of breath, or difficulty breathing with or without clinical or radiographic findings of pneumonia. Patient presenting within 7 days of the onset of illness.

 

 

 

 

2.3 Features of severe illness

The criteria for severe pneumonia according to the WHO integrated management of childhood illness (IMCI) guidelines are below:

a.       Any child age 2 months up to 5 years with:

a.       Cough or difficult breathing, AND with

b.      Any general danger signs (unable to drink or breast-feed, vomits everything, convulsions, lethargy or

b.      Unconsciousness), OR

a.       Chest in drawing or stridor in a calm child.

c.       Severity criteria in adults of any age group include: respiratory distress, dyspnoea, hypotension and / or evidence of hypoxia.

 

3. Who should be tested?

 

As of 16 July 2009, the laboratory testing strategy has been modified to only conduct testing if a clinical decision warrants these investigations.

Therefore, testing is only recommended for the following patients:

• • Patients who meet the SARI case definition (i.e. severe infections) where a laboratory diagnosis will assist in patient management or patients hospitalised due to a lower-respiratory infection, and where no other explanation for illness is indicated and influenza forms part of the differential diagnosis.
• • Patients with co-morbid disease and at risk for serious complications and who are symptomatic with SARI or ILI should be considered for testing if it will guide clinical management.
• • Clusters of cases where a diagnosis of the cause of the outbreak is needed.
• • An individual who has died where pandemic influenza A (H1N1) is suspected as the cause of death.

 

4. Case Management & Infection Control

 

4.1 Mild cases

• • Mild cases do NOT require confirmatory laboratory testing and should NOT be admitted to hospital. They should be advised to isolate themselves at home for 7 days after the onset of symptoms and managed symptomatically.
• • Supportive care at home is adequate for recovery. Provide the patient with advice which should include: resting, drinking plenty of fluids and keeping warm and dry. Use a pain reliever for head and muscle aches. Non-aspirin pain relievers should be used by children and young adults due to the risk of Reye’s syndrome.
• • Antiviral medication is NOT recommended for mild cases or contacts not at risk for development of severe disease unless these patients are at high risk for serious complications of influenza.
• • Patients at high risk for serious complications of influenza should be offered antiviral therapy at the discretion of the attending physician.
• • The patient and their contacts should be given infection control guidance as follows:

o Regular hand washing with soap and water

o Cover nose and mouth with a tissue when coughing and sneezing (or use the upper part of your sleeve).Dispose of used tissues in a dustbin, and then wash hands with soap and water.

• • Contacts of cases should stay at home at the first sign of illness and follow guidelines as above. They should seek medical care only if required.

 

 

 

4.2 Moderate to severe cases

• • Cases with moderate to severe illness (based on a clinical assessment) that require hospital admission should be managed as follows:

o Where possible these cases should be isolated in their own room with the door closed for the duration of hospital stay. If discharged prior to day 7 of onset of illness, they can complete home isolation as outlined above.

o Droplet and contact precautions should be instituted.

o Health workers should wear a properly fitting N95 mask on entry into the patient’s room (if available).

o The patient should wear a standard surgical mask whenever he/she is required to leave the isolation room.

o Where separate isolation rooms are not available, suspected cases should be cohorted in a designated ward and the above precautions instituted.

o Oseltamivir should be used for treatment of moderate to severe cases (see section 4.3)

 

4.3 Treatment

Use of antiviral agents should be limited to persons with the following indications:

• • Individuals with moderate or severe influenza-related illness, OR
• • Any individual at high risk for serious complications of influenza and in whom treatment can be commenced within 2 days of onset of illness.

Oseltamivir (TamifluR) and zanamivir (RelenzaR) are active against influenza A and B viruses. Oseltamivir (TamifluR) is orally administered and is registered for use in individuals aged ≥1 year of age. Zanamivir (RelenzaR) is administered through an inhaler and is registered for use in individuals aged ≥ 12 year of age. Antiviral treatment with zanamivir or oseltamivir , should be initiated as soon as possible after the onset of symptoms.

 

4.4 Pregnant Women :

No clinical studies have been conducted to assess the safety of these antiviral for pregnant women. Because of the unknown effects of these drugs on pregnant women and their fetuses, oseltamivir or zanamivir should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus; the manufacturers’ package inserts should be consulted.

 

4.5 Adverse events and contraindications

Consult manufacturers’ package inserts for further information on adverse events and contraindications for these anti viral drugs.

 

5.  Further information:

 

Answers to most questions are available on the following websites:

• • NICD Website: http://www.nicd.ac.za
• • Department of Health Website: http://www.doh.gov.za/swineflu/swineflu-f.html
• • World Health Organisation Website: http://www.who.int/csr/disease/swineflu/en/
• • Centers for Disease Control and Prevention (CDC, Atlanta): http://www.cdc.gov/h1n1flu

(Information taken from Revised Health Workers Guide- Department of Health South Africa)

Dr Rosanna Moonsamy

Medical Doctor

CCF International Church South Africa