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Treatment

 

 

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.

 

1                  Infrastructure / manpower / material support

 

·         Isolation facilities: if dedicated isolation room is not available then patients can be cohorted in a well ventilated isolation ward with beds kept one metre 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 (Oseltamivir, antibiotics and other medicines)

 

 

2                  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.

 

3                  Oseltamivir Medication

 

—  Oseltamivir is the recommended drug both for prophylaxis and treatment.

 

—  Dose for treatment is as follows:

—  By Weight:

—  For weight <15kg       30 mg BD for 5 days

—  15-23kg                       45 mg BD for 5 days

—  24-<40kg                    60 mg BD for 5 days

—  >40kg                         75 mg BD for 5 days

·         For infants:

·         < 3 months      12 mg BD for 5 days

·         3-5 months      20 mg BD for 5 days

·         6-11 months    25 mg BD for 5 days

·         It is also available as syrup (12mg per ml )

·         If needed dose & duration can be modified as per clinical condition.

Adverse reactions:

Oseltamivir is generally well tolerated, gastrointestinal side effects (transient nausea, vomiting) may increase with increasing doses, particularly above 300 mg/day. Occasionally it may cause bronchitis, insomnia and vertigo. Less commonly angina, pseudo membranous colitis and peritonsillar abscess have also been reported. There have been rare reports of anaphylaxis and skin rashes.  In children, most frequently reported side effect is vomiting.  Infrequently, abdominal pain, epistaxis, bronchitis, otitis media, dermatitis and conjunctivitis have also been observed. There is no recommendation for dose reduction in patients with hepatic disease. Though rare reporting of fatal neuro-psychiatiric illness in children and adolescents have been linked to oseltamivir, there is no scientific evidence for a causal relationship.

 

4                  Supportive therapy

 

·         IV Fluids.

·         Parentral nutrition.

·         Oxygen therapy/ ventilatory support.

·         Antibiotics for secondary infection.

·         Vasopressors for shock.

·         Paracetamol or ibuprofen is prescribed for fever, myalgia and headache. Patient is advised to drink plenty of fluids. Smokers should avoid smoking. For sore throat, short course of topical decongestants, saline nasal drops, throat lozenges and steam inhalation may be beneficial.

·         Salicylate / aspirin is strictly contra-indicated in any influenza patient due to its potential to cause Reye’s syndrome.

·         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.

·         If the laboratory reports are negative, the patient would be discharged after giving full course of oseltamivir. Even if the test results are negative, all cases with strong epidemiological criteria need to be followed up.

·         Immunomodulating drugs has not been found to be beneficial in treatment of ARDS or sepsis associated multi organ failure. High dose corticosteroids in particular have no evidence of benefit and there is potential for harm. Low dose corticosteroids (Hydrocortisone 200-400 mg/ day) may be useful in persisting septic shock (SBP < 90).

·         Suspected case not having pneumonia do not require antibiotic therapy. Antibacterial agents should be administered, if required, as per locally accepted clinical practice guidelines.  Patient on mechanical  ventilation should be administered antibiotics prophylactically to prevent hospital associated infections.

 

5                  Discharge Policy       

 

—  Adult patients should be discharged 7 days after symptoms have subsided.

—  Children should be discharged 14 days after symptoms have subsided.

—  The family of patients discharged earlier should be educated on personal hygiene and infection control measures at home; children should not attend school during this period.

 

6                  Chemo Prophylaxis

 

—  All close contacts of suspected, probable and confirmed cases. Close contacts include household /social contacts, family members, workplace or school contacts, fellow travelers etc.

—  All health care personnel coming in contact with suspected, probable or confirmed cases

—  Oseltamivir is the drug of choice.

—  Prophylaxis should be provided till 10 days after last exposure (maximum period of 6 weeks)

—  By Weight:

—  For weight <15kg       30 mg OD

—  15-23kg                       45 mg OD

—  24-<40kg                    60 mg OD

—  >40kg                         75 mg OD

·         For infants:

·         < 3 months      not recommended unless situation judged critical due to limited data on use in this age group

·         3-5 months      20 mg OD

·         6-11 months    25 mg OD

 

 

 

 

 

7                  Non-Pharmaceutical Interventions

 

·         Close Contacts of suspected, probable and confirmed cases should be advised to remain at home (voluntary home quarantine) for at least 7 days after the last contact with the case. Monitoring of fever should be done for at least 7 days.  Prompt testing and hospitalization must be done when symptoms are reported.

·         All suspected cases, clusters of ILI/SARI cases need to be notified to the State Health Authorities and the Ministry of Health & Family Welfare, Govt. of India (Director, EMR and NICD)

 

 

 

Government of India

Ministry of Health & Family Welfare

Directorate General of Health Services

(Emergency Medical Relief)

 

 

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