When to suspect:
Patents presenting with Fever (body temperature of 38o Celsius or high) with one of the following symptoms:
Muscle ache, cough, abnormal breathing (unusual breathing difficulty) or suspected pneumonia by the physician, or influenza
in addition to
History of direct contact with infected / dead birds in past 7 days or
Occurrence of unusual death of birds in the community within the past 14 days; or
Contact with a pneumonia patient or another patient suspected of avian influenza
Case definition of probable case: symptoms of suspected case and
Preliminary test shows infection of influenza group A, but cannot yet be confirmed whether it is from human or birds or
Respiratory failure or
Death
Case definition of Confirmed cases: A suspected or probable case with at least one of the following:
• Positive viral culture for influenza A/H5
• Positive RT PCR for influenza A/H5
• Positive IFA for influenza A/H5
• A 4 fold rise in influenza A/H5 specific antibody titers.
Management guideline for all suspected cases of avian flu:
Obtain NP swabs from all the patients (see annexure 1)
Assess severity of illness: Look for presence of following:
Respiratory distress as indicated by: increased respiratory rates, chest indrawing, dehydration, hypotension, altered sensorium or oxygen saturation of less than 93% in room air. If any of these are present patient should be admitted to ward in designated area and manage on following principles
1. Isolate cases
Monitor vital signs every 1-2 hours
Maintain air way breathing and circulation (ABC)
Maintain hydration, electrolyte balance, and nutrition
Provide oxygen and assisted ventilation when indicated
Manage fever with paracetamol
Give antiviral Oseltamivir (For doses see annexure 2)
Broad spectrum antibiotics for treatment of secondary pulmonary infection
Avoid giving nebulized medications: chances of spread
Management of non severe cases
If patient is stable: (absence of above clinical features): take NP aspirate from all the patients and isolate them in the designated area identified for them and Start on Oseltamivir
Obtain lab results and see clinical course. If lab tests negative: discontinue Oseltamivir and provide supportive care, shift them to regular wards if hospitalization indicated otherwise send them home
If lab test is positive: Transfer to designated in patient area and continue supportive care and oseltamivir
Discharge policy
Adult patients: Infection control precautions for 7 days after resolution of fever
Children: Infection control measures for 21 days after onset of illness.
If discharged earlier: child should not attend school and parents should be educated to observe infection control measures at home.
Precautions for health care workers handling cases of avian flu
Wear personal protective equipments
A. Protective clothings:
1. Overall plus an impermeable apron or surgical gown with long cuffed sleeves plus impermeable apron
2. Heavy duty rubber work gloves that may be disinfected
3. Standard well fitted surgical masks should be used if N 95 respiratory masks are not available.
4. Goggles
5. Rubber or polyurethane boots or protective foot cover
B .Chemoprophylaxis:
For close contacts: Oseltamivir 75 mg daily for 7 days
Persons at risk: Oseltamivir 75 mg daily for the entire epidemic
C. Monitoring of close contacts and health care workers exposed: observe for fever of >38 Celsius, watery diarrhoea, pain abdomen, headache, cough, rhinorrhoea, sore throat, shortness of breath and CNS manifestations. Check for them daily till 14 days of last exposure
Annexure 1
Collection and transport of samples
Samples from upper respiratory tract include
Nsopharyngeal aspirate
Nasal wash
Throat swab
From lower respiratory tract samples include :
Transtracheal aspirate
Bronchoalveolar lavage
Lung biopsy
Post-mortem lung or tracheal tissue
Specimens for the laboratory diagnosis of avian influenza A should be collected in the following order of priority:
· nasopharyngeal aspirate/swab
· acute serum
· convalescent serum.
The sample collection should be done with all the necessary biosafety precautions including use of gowns, gloves and masks
The samples should be kept on ice and transported to virology laboratory as soon as possible
Annexure II
Antiviral drugs and their doses
Oseltamivir: is the only drug effective against H5N1 virus Doses are:
• Adults: 75 mg twice a day for adults,
• Children weighing < 15 Kg: 30 mg twice a day
15-23 Kgs: 45 mg twice a day
23-40 kgs: 60 mg twice a day
> 40 kg: 75 mg twice a day
Adverse effects of oseltamivir
Nausea and vomiting: transient and occur in the beginning and are self limiting
Abdominal pain, epistaxis, conjuctivitis
Should be used in pregnancy with caution
Contraindications: Hypersensitivity to drug
Algorithm for management of Avian flu patients
Suspect case of Avian flu
(Patents presenting with Fever (body temperature of 38o Celsius or high) with one of the following symptoms: Muscle ache, cough, abnormal breathing (unusual breathing difficulty) or suspected pneumonia by the physician, or influenza in addition to History of direct contact with infected / dead birds in past 7 days or Occurrence of unusual death of birds in the community within the past 14 days; or Contact with a pneumonia patient or another patient suspected of avian influenza)
Obtain NP aspirates and send to lab
Asses severity of illness
(Look for presence of following Respiratory distress as indicated by: increased respiratory rates, chest indrawing, dehydration, hypotension, altered sensorium or oxygen saturation of less than 93% in room air)
Any one of the above present None of the above present
Admit in designated area and treat as follows
Isolate cases
Monitor vital signs every 1-2 hours
Maintain air way breathing and circulation (ABC)
Maintain hydration, electrolyte balance, and nutrition
Provide oxygen and assisted ventilation when indicated
Manage fever with paracetamol
Give antiviral Oseltamivir (For doses see annexure 2)
Broad spectrum antibiotics for treatment of secondary pulmonary infection
Avoid giving nebulized medications: chances of spread
Keep the patient in designated out patient area, start oseltamivir and collect lab report reportresults
Transfer to general ward and manage according to
Send home with supportive care
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