This year again, H1N1 influenza has arrived in several States of India,
and public is likely to get panicky if the number of cases or mortality
due to the virus rises. For appropriate disease management, H1N1 wards
have been activated in various hospitals in Delhi and a document titled
‘National Treatment Guidelines for Treatment of Seasonal Influenza" has
been circulated among the hospitals by Directorate of Health Services,
Delhi . The new guidelines are not yet available on the website of
Delhi Government which still displays the 2012 recommendations .
Salient features of the new guidelines are as follows:
H1N1 mostly presents like other seasonal influenza
cases but may have severe manifestations in certain situations. Children
mostly have influenza like illness (ILI), and are to be managed with
home isolation and cough hygiene, along with immediate reporting to
health facility if they present with of warning signs (persistent high
fever beyond 3-4 days, hemoptysis, breathing difficulty, chest pain,
altered sensorium, worsening of associated comorbidity, inability to
feed, vomiting, tachypnea, seizure in a young child). Mild or moderate
complications include otitis media, bronchiolitis, croup, or reactive
airway disease. Severe complications include diarrhea, dehydration,
sepsis, exacerbation of chronic illness, or febrile seizure.
Complications are more in ‘high-risk group’ that includes all
children <5 y age, and those with chronic underlying pulmonary (e.g.
asthma), cardiovascular (e.g. congenital heart disease), neurological
(e.g. cerebral palsy), metabolic (e.g. diabetes), renal, hematologic
(e.g. thalassemia), or immunological (e.g. primary or secondary
immunodeficiency) conditions. Severe cases include those with clinical
and radiological signs of lower respiratory tract disease, shock and
multi-organ failure, exacerbation of underlying illness, progressive
disease with respiratory compromise, central nervous system
complications, or invasive bacterial infection. Nasopharyngeal swabs for
real-time polymerase-chain-reaction for influenza should be sent if the
patient has severe, complicated, or progressive disease; cluster of
cases; and in high risk cases with ILIs. Antivirals are indicated only
in confirmed cases of H1N1. Need of hospitalization is determined on
individual basis. There is no role of chemoprophylaxis for the contacts.
These guidelines appear evasive on certain issues.
Previous guidelines  included categories A, B and C, but in present
guidelines the categorization has been done away with. According to the
present guidelines, nasopharyngeal sampling is advised for all
under-five children with ILIs. In a typical Governmental set-up,
under-five children comprise almost two-thirds of the total daily
pediatric outpatient attendance in this season. Approximately half of
these children have symptoms of ILIs which amounts to approximate case
load of 150 per day in our hospital. As per the new guidelines, these
children constitute the high-risk group, and need to be sampled, which
is neither practical nor feasible. Lack of clear-cut categories may
amount to delayed treatment of cases and continuation of the virus in
circulation by ignoring the contacts for treatment. Children with
suspected H1N1 infection need to be classified in four distinct
categories viz. A: where no intervention is required; B: where we
test, but do not treat; C: where we test and treat, but hospitalization
is not required; and D: where testing is followed by in-hospital
treatment. The new guidelines have also done away with chemoprophylaxis
of contacts, in keeping with the current international recommen-dations;
however it does not specify whether contacts are to be sampled or not.
WHO guidelines recommend giving presumptive treatment to high risk cases
 but the Delhi Government guidelines forbid antiviral treatment,
except in proven cases. In a suspected case, by the time results of PCR
are available, the patient is either cured or it may be too late for the
antivirals to have a meaningful effect on the course of the disease;
though the guidelines recommend treatment whenever the positive H1N1
report is available, irrespective of the duration of illness. Finally,
the role of vaccination is not clearly spelt out.
Government guidelines on management and control of a
public health issue need to be a benchmark backed by bull-eye accuracy
and evidence-base, since these are followed by a large group of
care-providers, including those from private sector. With the expertise
available, the guidelines could have been focused and practical. It is
time for the Indian Academy of Pediatrics to lead and advise its members
on the correct approach to management and diagnosis of H1N1 cases.
1. National Treatment Guidelines for Seasonal
Influenza (Sentinel Hospitals for H1N1). Edited at DHS (HQ)-2015. New
Delhi: Directorate of Health Services; 2015.
2. Ministry of Health and Family Welfare General
Advisory for H1N1 (FLU) 2012. Available from:
Health+ Wing. Accessed February 1, 2015.
3. Pandemic influenza A H1N1. Clinical Management
Protocol and Infection Control Guidelines. Available from:
%20Management%20Protocol-Pandemic %20influenza% 20A%20H1N1.pdf.
Accessed February 1, 2015.
4. WHO Guidelines for Pharmacological Management of
Pandemic Influenza A (H1N1) 2009 and Other Influenza Viruses. Available
pharmaceutical_mngt.pdf. Accessed February 1, 2015.