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H1N1+Management+-+case+under+Ix - Influenza A H1N1...

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Unformatted text preview: Influenza A H1N1 infection Clinical Management Clinical of Patient under of Investigation Investigation Hospital Sungai Buloh DISTRIBUTED BY WWW.MEDICALPPT.BLOGSPOT.COM For More Lectures www.medicalppt.blogspot.com For More Lectures www.medicalppt.blogspot.com Case Definitions for Influenza A H1N1 Cases A Case under Investigation of Influenza A / H1N1 virus infection is defined as an individual after 17th of April 2009**, presenting with a. high fever >38°C, AND b. One or more of the following respiratory symptoms: cough, shortness of breath, body ache, difficulty in breathing, AND c. One or more of the following: close contact with a person diagnosed as Influenza A/H1N1 OR recent travel to an area reporting cases of confirmed Influenza A/H1N1 (Acute febrile respiratory illness (fever > 38 °C) with the spectrum of disease from influenza-like illness to pneumonia) ** Depends on when the country had its first confirmed case For More Lectures www.medicalppt.blogspot.com Case Definitions for Influenza A H1N1 Cases A Probable Case of Influenza A/H1N1 infection is defined as an individual that fulfill the criteria for a suspected case, with an influenza test that is positive for influenza A, but is unsubtypable by reagents used to detect seasonal influenza virus infection OR An individual with a clinically compatible illness or who died of an unexplained acute respiratory illness who is considered to be epidemiologically linked to a probable or confirmed case. A Confirmed Case of Influenza A/H1N1 infection is defined as an individual with laboratory confirmed Influenza A/H1N1 virus infection by one or more of the following tests*: real-time RT-PCR viral culture 4-fold rise in swine influenza A(H1N1) virus specific neutralizing antibodies * Note: The test(s) should be performed according to the most currently available guidance on testing. For More Lectures www.medicalppt.blogspot.com Antiviral Recommendations for Patients Antiviral with Confirmed or Suspected Influenza A H1N1 Infection H1N1 Infectious period for a confirmed case of swine influenza A (H1N1) virus infection is defined as 1 day prior to the case’s illness onset to 7 days after onset. Close contact is defined as: within about 3 feet of an ill person who is a confirmed or suspected case of influenza A H1N1 virus infection during the case’s infectious period. Acute respiratory illness is defined as recent onset of at least two of the following: rhinorrhea, sore throat, cough (with or without fever / feverishness) High-risk groups: A person who is at high-risk for complications of influenza A H1N1 virus infection is defined as the same for seasonal influenza For More Lectures www.medicalppt.blogspot.com Clinical Features of Clinical Influenza A/H1N1 Influenza Clinical Findings Uncomplicated disease manifest with fever, headache, upper respiratory tract symptoms (cough, sore throat, rhinorrhea), myalgia, fatigue, vomiting, or diarrhea. Complications Insufficient information to date about clinical complications of influenza A (H1N1) virus infection. Clinical syndromes have ranged from mild respiratory illness, to lower respiratory tract illness, dehydration, or pneumonia. Can expect complications similar to seasonal flu: exacerbation of underlying chronic medical conditions, URTIs (sinusitis, otitis media, croup) LRT disease (pneumonia, bronchiolitis, status asthmaticus), cardiac (myocarditis, pericarditis), musculoskeletal (myositis, rhabdomyolysis), neurologic (acute & post-infectious encephalopathy, encephalitis, febrile seizures, status epilepticus), and 2° bacterial pneumonia. For More Lectures www.medicalppt.blogspot.com Disease Characteristics With exception of Mexico, the H1N1 virus tends to cause mild illness in otherwise healthy people. Outside Mexico, nearly all cases of illness, and all deaths, have been in people with co-morbidities. In the 2 largest & best documented outbreaks ie. in Mexico & the US, a younger age group has been affected than seen during seasonal epidemics of influenza. Though cases have been confirmed in all age groups, from infants to the elderly, the youth of patients with severe or lethal infections is a striking feature of these early outbreaks. In terms of population vulnerability, the tendency of the H1N1 virus to cause more severe and lethal infections in people with underlying conditions is of particular concern. For More Lectures www.medicalppt.blogspot.com High risk groups / High Co-morbidities Older age group > 65 yr pregnancy chronic lung disease (eg., COPD, cystic fibrosis,asthma) congestive heart failure renal failure immunosuppression (due to underlying disease or therapy) haematological abnormalities (anemia, haemaglobinopathies) Diabetes mellitus Chronic hepatic disease socially unable to cope (i.e., without personal support at home ). For More Lectures www.medicalppt.blogspot.com Transmission of Influenza A / H1N1 Limited data indicate that transmission is similarly as in other influenza viruses. Spread is 1° from person to person through large-particle respiratory droplets. This requires close contact between source & recipient, as droplets do not remain suspended in air & travel only short distances (<1m ). Contact with respiratory-droplet contaminated surfaces is another possible source of transmission. As data from influenza viruses H1A1 are limited, potential for ocular, conjunctival, or GI infection is unknown. Being a novel influenza A virus, transmission from infected persons to close contacts maybe common. All respiratory secretions & bodily fluids (diarrheal stool) of H1N1 cases should be considered infectious. For More Lectures www.medicalppt.blogspot.com Infectiousness & Incubation period The estimated incubation period is unknown The and could range from 1-7 days, and more likely 1-4 days. H1N1 appears to be more contagious than H1N1 seasonal influenza. The 2° attack rate of seasonal influenza ranges from 5% to 15%. Current estimates of the 2° attack rate of H1N1 range from 22% to 33%. range For More Lectures www.medicalppt.blogspot.com Triage and infection control in health Triage facilities (in all ED & OPDs) (in Triage and strict infection control guidelines similar to those during the SARS outbreak are to be implemented in all health facilities and are esp. important in hospitals where patients are treated. Isolation of patients and their subsequent management should adhere strictly to level of infection control needed to handle such cases. The use of recommended PPEs by HCWs & the importance of hand hygiene should be strictly enforced to prevent staff from being infected. HCWs should be educated regarding such appropriate infection control practices, to prevent spread of influenza and guidelines should be strictly enforced. For More Lectures www.medicalppt.blogspot.com Triage & Screening Special counter set up in A & E of all PI designated hospitals. Should be Special manned by designated staff. manned All patients who come to A & E should be triaged for suspected H1N1 All Patients with suspected H1N1 should be diverted to designated exam rooms Patients with to to ↓ transmission to others. Suspected patients given a surgical mask to wear Staff in 1° triage should wear surgical mask with face shield, gloves & to wash Staff hands before & after contact with any patient. hands Staff in close contact with suspected PI patients (e.g. examination of patient) Staff must also wear N95 masks, disposable gowns, visors and gloves must If admitted, patient must be taken to the dedicated isolation ward via preidentified route (exclusive) Trolley/wheelchair used to transport patient to be disinfected with Sodium Trolley/wheelchair hypochlorite 1000 ppm & left to dry hypochlorite Recommendations to be modified in event of widespread community Recommendations involvement. involvement. For More Lectures www.medicalppt.blogspot.com Triage in ED / OPD: What needs to be done? Facilities needed to provide this service: Triage / Information counter* Holding area Screening / examination room** Changing and un-gowning area/s For More Lectures www.medicalppt.blogspot.com What is needed at Triaging counter*? Clearly written out instructions; well Clearly displayed displayed Assigned staff member with appropriate Assigned PPEs PPEs Attention bell / buzzer Surgical masks for patients For More Lectures www.medicalppt.blogspot.com What is needed in screening / What examination room**? examination Room with good ventilation (negative pressure if possible) ~ with air exchanges of at least 6 cycles/min Some distance from other patient service areas Minimal furniture Essential equipment eg. BP, thermometer, stethoscope, spatula, yellow bins, etc. Decontamination after every patient For More Lectures www.medicalppt.blogspot.com Hospital Admission policies Depending on phase of pandemic, admission policies vary Depending from admitting all probable / suspected cases to only admitting those who are ill or with complications. As of 27th. April 09 27 In early phases; to prevent importation or to reduce viral In transmission in the country, all suspect influenza H1N1 cases will be admitted in designated hospitals and kept in isolation. In full pandemic situation, where cases go beyond capacity In of health facilities to cope, a policy of surveillance & Tx. at home or the use of non-traditional health facilities may be instituted. Hospital admissions will only be for those with respiratory distress or with assoc complications of influenza or those in high risk groups (ie.with coinfluenza groups morbidities). Such admission policies will be updated as morbidities). pandemic evolves. For More Lectures www.medicalppt.blogspot.com Isolation & Infection Control * Cases should be isolated as follows in ↓ order of preference: Negative pressure rooms with door closed Single rooms with bath. (extractor fans if available). Cohort placement (if large number of cases) in an area with an independent air supply, exhaust system and bath facilities * Turning off A/C & opening windows if independent air supply unfeasible. Windows & extractors should not open directly into public places. * Nursed according to Isolation Procedures for droplet infections. For More Lectures www.medicalppt.blogspot.com Cohorting (when isolation facilities are Cohorting stretched) stretched) Guidelines for Cohorting: Guidelines Suspect and probable cases should not be nursed Suspect together. together. Beds should be placed > 3 feet apart Patients use mask when using common areas in Patients cohort area Common areas regularly cleaned using std Common hypochlorite solution hypochlorite Good ventilation: with air exchanges of at least 6 Good cycles/min; an exhaust extractor fan maybe useful. Good hand & personal hygiene encouraged among Good patients including regular hand washing or use of alcohol hand gels. alcohol For More Lectures www.medicalppt.blogspot.com Infection Control Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Maintain adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure. For More Lectures www.medicalppt.blogspot.com Masks and respirators Recommendations: Personnel engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) for suspected or confirmed influenza A H1N1 cases should wear a fit-tested disposable N95 fit-tested respirator.* Personnel providing direct patient care for suspected or confirmed influenza A H1N1 cases should wear a fittested disposable N95 respirator when entering patient’s room. *Staff should be fit-tested, and trained for respirator use, including: proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use. For More Lectures www.medicalppt.blogspot.com Work processes in Wards Scheduled encounters: Doctors rounds Observations: if stable – at least once a shift Meals & snacks Serving of medicines Merge functions of encounters to reduce number of entries into isolation room. For More Lectures www.medicalppt.blogspot.com Goal: A Cooperative Patient Information & instructions (briefing / patient pamphlets) Scheduled encounters informed to patient Improving communication without necessarily increasing physical encounters (eg. Phone, intercom, etc) Room Comforts: drinks, snacks, newspapers (?) Friendly and responsive staff: address patient’s concerns For More Lectures www.medicalppt.blogspot.com PATIENTS’ INFORMATION Isolation Ward, Hospital Sungai Buloh WE understand that this can be a distressing WE time for you and we shall try our utmost to make your stay here in our isolation ward as comfortable and as brief as possible. While we await your laboratory results, our ward staff who are available at all times, will provide you with the necessary treatment, care and support. Your cooperation is much appreciated esp. with regards to the following areas; As there are other patients in the ward, we As appreciate that you stay within your room at all times until otherwise instructed by the ward staff. the Each isolation room has an attached Each bathroom and toilet Should you need any assistance : kindly Should use the call pad The call pad is found at the end of the cord The attached to the wall near your bed Just press on the red button on the call pad and the ward staff would respond to your call through the intercom system as soon as possible. The intercom system: You can communicate with the ward staff via the intercom. It is attached to the wall above your head board. Just press on the green button & speak through the speaker. Meals and snacks will be served to you Meals in your room at the following times : ………. etc ………. As this is an isolation ward, visitors are As generally not allowed generally If you need assistance in contacting your If family on urgent matters, please contact the ward staff. We shall try our best to assist whenever possible. assist We apologize for any inconvenience and We discomfort caused but we trust you will understand that these measures are necessary to ensure the continued good health of the society at large. health THANK YOU FOR YOUR COOPERATION AND UNDERSTANDING For More Lectures www.medicalppt.blogspot.com Antiviral therapy Oseltamivir & zanamivir can be released for use for suspected, probable & confirmed H1N1 cases (through KPK’s approval) Current approach at HSB: Use for probable & confirmed cases In suspected cases: - empirical treatment if patients present with complications of influenza eg. Pneumonia, mental confusion, metabolic derangement, etc - if patient is clinically comfortable (no complications), treatment deferred till IMR results Duration of treatment: 5 days For More Lectures www.medicalppt.blogspot.com MANAGEMENT OF SUSPECTED AND MANAGEMENT CONFIRMED CASES CONFIRMED Detailed history obtained: clinical, travel and contact history including occurrence of respiratory disease in contact patients during the last 10 days Clinical workup should follow measures stated in Syndromic Approach Protocol for acute respiratory syndromes Virology samples sent to Virology Unit, IMR Bacteriology samples are processed in respective hospitals All specimens should be transported in accordance to KKM Guidelines of Transport of Infectious Material. In event of death, post-mortem should be performed in accordance with KKM Guidelines For Post-Mortems Involving Unknown/Uncertain Infectious Agents Dead bodies handled as per KKM Guidelines on Handling of Bodies with HIV/AIDS For More Lectures www.medicalppt.blogspot.com Supportive Care Care Supportive care should be provided when necessary i.e. oxygen & ventilation support, hydration, blood gas monitoring, nutrition, etc. To ↓ possible spread to HCWs, nebuliser use should be avoided (if possible). If mechanical ventilation is required, the critical care team (ICU) will support patient within the isolation ward (if facilities allow). Otherwise, an alternative site for ventilation support must be identified For More Lectures www.medicalppt.blogspot.com DISCHARGE OF PATIENTS The patients can be discharged with the following criteria: Suspected cases: When PCR results are negative (IMR) If patient is still unwell, he can be transferred out of isolation ward Probable & Confirmed cases: At least 7 days from onset of illness and Completed at least 5 days of antiviral therapy and Well / asymptomatic If the patient has fulfilled the first 2 criteria but is still recovering, he can be transferred out of isolation ward For More Lectures www.medicalppt.blogspot.com Staff welfare Adequate provision for staff welfare and Clear System, Well publicized & monitored wellbeing during the pandemic is important to ensure there is enough staff looking after patients. Guidelines on prophylactic treatment of staff having symptoms or the like and the prioritization of staff for vaccination when vaccines are made available need to be planned for and made available for implementation when indicated. A surveillance system to detect early staff coming down with influenza should be followed. For More Lectures www.medicalppt.blogspot.com Resource Management for Health care Facilities Facilities During an pandemic, demand on health care services During expected to ↑ , peak & ↓ during weeks in which any one location is affected. Need for resource management in terms of ↑ bed capacity, Need patient prioritization of usage of facilities, provision of care outside hospitals, critical equipment & supplies, drugs & use of volunteers and voluntary organizations, to help meet demands. There is also issue of human resource management in There terms of optimal use of HCWs, designated staff for influenza case management, deployment of HCWs, provision of training, immunization, care and support for HCWs. For More Lectures www.medicalppt.blogspot.com Human resource: Clinical Medical / Paediatric Emergency Pathology Radiology Others: Intensive care, mortuary, etc. For More Lectures www.medicalppt.blogspot.com Targeted Training Train enough to have multiple teams that can be rostered to serve 3 – 4 week stints (the outbreak is expected to last at least 2-3 months) Designated teams so as to ensure high level of adherence to ward procedures / infection control as well as to facilitate staff health surveillance Team leaders / “champions”: crucial For More Lectures www.medicalppt.blogspot.com DISTRIBUTED BY WWW.MEDICALPPT.BLOGSPOT.COM ...
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