Dr.S.K.Kabra and G.C.Khilnani

Management protocol for bird flu cases

When to suspect:

Patents presenting with Fever (body temperature of 38^o 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
2. Monitor vital signs every 1-2 hours
3. Maintain air way breathing and circulation (ABC)
4. Maintain hydration, electrolyte balance, and nutrition
5. Provide oxygen and assisted ventilation when indicated
6. Manage fever with paracetamol
7. Give antiviral Oseltamivir (For doses see annexure 2)
8. Broad spectrum antibiotics for treatment of secondary pulmonary infection
9. 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

1. 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
2. Chemoprophylaxis:

   For close contacts: Oseltamivir 75 mg daily for 7 days

   Persons at risk: Oseltamivir 75 mg daily for the entire epidemic

3. 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

1. Nsopharyngeal aspirate
2. Nasal wash
3. Throat swab

From lower respiratory tract samples >include :

1. Transtracheal aspirate
2. Bronchoalveolar lavage
3. Lung biopsy
4. 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 38^o 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

  

  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

  None of the above present

  

  Keep the patient in designated out patient area, start oseltamivir and collect lab report reportresults

  

  

  

  Send home with supportive care

  

  Transfer to general ward and manage according to

Avian influenza : Frequently Asked Questions

1. What is Avian Influenza?

   Avian influenza, or “bird flu” or “avian flu” is an infection caused by avian (bird) influenza (flu) viruses. These flu viruses occur naturally among birds. Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them. However, bird flu is very contagious among birds and can make some domesticated birds, including chickens and ducks, very sick and kill them.

2. Do avian flu viruses infect humans?

   Bird flu viruses do not usually infect humans, but several cases of human infection with bird flu viruses have occurred since 1997.

3. How does avian flu spread in birds?

   Infected birds shed flu virus in their saliva, nasal secretions, and feces (droppings). Susceptible birds become infected when they have contact with contaminated excretions or surfaces that are contaminated with excretions.

4. How does avian flu spread in humans?

   It is believed that most cases of bird flu infection in humans have resulted from contact with infected poultry or contaminated surfaces. There is no evidence of human-to-human transmission so far.

5. What is a pandemic?

   A pandemic is an epidemic that usually affects a large proportion of the population, occurring over a wide geographic area such as a section of a nation, the entire nation, a continent or the world.

6. should be done if migratory birds are sighted near one’s house?

   Migratory birds may or may not carry the avian flu virus. It depends on whether these birds have flown from a region where avian flu is prevalent. This can be determined only by an expert. Therefore in case a migratory bird is sighted, it should not be killed. However, as a precaution, one should stay away from these birds and their droppings. The municipal authorities should be informed immediately.

7. What should be done if one sight’s a dead bird?

   If the cause of death of the bird is not certain, the municipal authorities should be informed immediately. They may send the bird for testing to find out whether or not it was infected with the avian influenza virus.In case of unusual death of poultry, the civic authorities must be informed immediately.

8. Can avian flu be contracted by visiting a shop that is next to a shop that sells chicken?

   In the event of a pandemic of avian flu, it is possible

9. Is it safe to eat poultry and poultry products?

   Poultry and poultry products can be prepared and consumed as usual, with no fear of acquiring infection with the avian flu virus.One should continue to follow good hygienic and cooking practices.The virus is destroyed at a temperature of 70^o C for 30 minutes. After handling poultry and eggs, one should wash hands and other exposed parts with soap and water.

10. Are the chicken droppings on eggs infective?

    As it is likely that the eggs that reach the consumer were laid several hours ago, the likelihood of infection is low, even if the droppings were carrying the avian flu virus. The avian flu virus is destroyed by drying, and exposure to sunlight for a few hours.

    However, in the event of a pandemic, recent droppings are to be considered infective unless proven otherwise.

11. Is it safe to use chicken-droppings as manure?

    During a pandemic, do not come in contact with fresh droppings. Use some other manure until such time the pandemic has cleared

12. How can avian flu be controlled in poultry?

    At present, culling is the only way to contain avian flu in poultry.

13. Can domestic normal-appearing ducks spread avian flu?

    Yes they can. In fact, waterfowls are known to be reservoirs of infection. The avian flu virus does not harm these waterfowls. However the waterfowls can spread the avian flu virus to humans. These waterfowls are therefore “carriers” of avian flu.

14. Can a person suffering from influenza suffer from avian flu at the same time?

    Yes, it is possible. Neither suffering from influenza, nor vaccination against human influenza offers protection against avian flu. However, health care providers and others who are at high risk of infection should get themselves vaccinated against human influenza virus so that they are at least protected against one of them.

15. What are the symptoms and signs of avian flu in humans?

    Cough, fever, sore throat, muscle aches, pneumonia and other complications

16. What is the test for avian flu?

    A throat swab is taken from the patient to test for avian flu.

17. Which are the places where such testing is done?

    The testing facilities are currently available at All India Institute of Medical Sciences, New Delhi, and National Institute of Virology, Pune.

18. Is there a vaccine for humans against avian flu?

    There is no vaccine for humans against avian flu. The vaccine against human influenza virus does not protect against avian flu.

19. Are any medicines available to prevent bird flu in humans?

    There is no recommendation for the routine use of medicines for the prevention of bird flu in humans.

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