We read with interest the recently published correspondence about
the treatment guidelines for seasonal flu [1]. The re-emergence and
deaths due to H1N1
influenza in 2014-2015 in India is a cause for greater concern. The
number of H1N1
influenza deaths in 2015 has been reported to be 624 in comparison to
218 in 2014, probably due to a more virulent strain [2]. The lack of
easy availability of testing and scarce availability of ostelmavir are
still major issues in dealing with the situation. This often creates
panic among the public, especially when H1N1
tests are not done in all cases. The National guidelines given by
Ministry of Health and Family Welfare (MOHFW) have not changed much
between 2009 and 2015, and are reactive rather than proactive [3,4]. It
raises a very important question whether enough is being done?
The primary objective of management of any epidemic
is early detection and timely intervention, and unfortunately the
present guidelines fail to address it adequately. As per the guidelines,
influenza like illness (ILI) has been categorized as category A, B and C
[4]. Category A includes milder symptoms and do not require oseltamavir
and are not tested for H1N1.
Category B is subdivided into B1 with moderate symptoms, and B2 with
high risk category cases, where testing is not done but oseltamavir is
given. Category C comprises of children with severe acute respiratory
infection (SARI), shock, multi-organ failure, sepsis, and detoriation/exacerbation
of underlying illness. Such patients are recommended to be immediately
hospitalized, tested for H1N1
and treated.
The guidelines appear evasive on certain issues. The
new guidelines have done away with chemoprophylaxis for contacts but do
not specify any guidelines for contacts. Children with category-A
symptoms are advised home quarantine which is difficult to implement,
especially when the H1N1
status is not known and that is where the maximum spread of virus occurs
in the community. The health ministry has recommended vaccination and
use of Personal Protective Equipment (N95 masks and triple layer
surgical masks) for health care personnel, but there is lack of adequate
vaccines and face masks. Another problem with these guidelines is that
by the time H1N1
tests are available, it is too late for the antivirals to have a
meaningful effect on the course of the disease. The cases which are
monitored, tested and treated are only the tip of the iceberg.
The approach towards tackling swine flu should be
long term and pragmatic. It is true that all suspected cases do not need
treatment. But it is vital to strengthen the screening methods for H1N1
as symptoms of swine flu are non-specific. The empirical use and
availability of oseltamivir needs to be expanded, especially in states
where the case fatality rate is high. The preventive measures should be
aggressively implemented which include home quarantine, hand hygiene,
active vigilance in schools and work place, proper travel precautions,
screening at airports, respiratory etiquette, liberal and proper use of
facial masks and early referral to the hospitals, especially for those
with severe symptoms. It is time pediatricians take an active role in
creating awareness regarding screening, management and preventive
measures to tackle H1N1
influenza.
References
1. Sachdeva S, Gupta P. Treatment guidelines for
‘seasonal influenza: Need for a Rethink. Indian Pediatr. 2015;52:259-60.
2. Swine Flu Kills 600 plus, Refuses to Die. Times of
India 2015; New Delhi: Page15 (Col 1).
3. Ministry of Health and Family Welfare. Government
of India. Influenza A [H1N1]. Status as on 17th August, 2009. Available
from: http://mohfw.nic.in. Accessed May 13, 2015.
4. Pandemic influenza A H1N1. Clinical Management
Protocol and Infection Control Guidelines. Available from:http://mohfw-h1n1.nic.in/documents/pdf/5.%20
Clinical %20 Management % 20 Protocol-Pandemic % 20 Influenza % 20A% 20H 1N1.pdf.
Accessed May 13, 2015.
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