h1n1

MANAGEMENT IN OUTPATIENT SETTING

SUSPECTED CASE CONFIRMED CASE

Px stable, no pulmonary complications, Px stable, no pulmonary complications,
Definition no chronic comorbidities, does not fit no chronic comorbidities, does not fit
criteria for admission criteria for admission
Outpatient Symptomatic and supportive treatment Symptomatic and supportive treatment
Management
Antiviral NO NO
Integrated Surgical mask by patient Surgical mask by patient
Comprehensive
Care Measure
Until at least 24hrs afebrile without any Until at least 24hrs afebrile without any
fever medications fever medications
Home Isolation
-OR-
Has a negative swab test
Refer to hospital of condition Refer to hospital if condition
Advice
deteriorates deteriorates
 For patients working in a health care setting: Should remain at home for 7 days from symptom
onset, or until resolution.

MANAGEMENT OF HOSPITALIZED PATIENTS  Intubated patients; 1-2mL endotracheal

aspirate sample for H1N1 RT-PCR in
WHEN TO SUSPECT INFECTION AMONG
addition to swabs.
PATIENTS:
 Chest Xray
 Consider infected with H1N1 among  Pulse oximetry
hospitalized patients with:  CBC
1. History of acute influenza-like  Other lab tests
illness,
GENERAL TREATMENT CONSIDERATIONS
2. Having moderate to severe or
unusual manifestations of  Supportive care using antipyretics for
pneumonia or sepsis fever and pain, and fluids for
3. Had close contact exposure to a rehydration.
confirmed case in the past 10  Salicylates should not be given.
days,  Watch for signs for possible clinical
4. Have history of travel on local deterioration.
or foreign affected areas.  Oxygen therapy should be given to
DIAGNOSTIC WORKUP correct hypoxemia- maintain >90%
 Antimicrobial therapy for cases when
 Nasopharyngeal or oropharyngeal swab pneumonia also considered
RT-PCR test.  Management for signs of sepsis.
 Pregnant women require special care.
  Proper management of underlying  Antiviral therapy (Oseltamivir) should
conditions and comorbidities. be done immediately
 5 days of treatment are likely to be
required and that treatment should be
ANTIVIRAL THERAPY continued for at least 10 days
o Caution to patients with renal
1. All hospitalized suspected/confirmed
impairment – adjust to
patients without history of influenza-
appropriate dosage
like illness but with moderate to severe
pneumonia, non-resolving or with Adjunctive pharmacologic therapy
unusual manifestations.
 Low doses of corticosteroids may be
2. All hospitalized patients with influenza-
considered for patients in septic shock
like illness and clinical and radiologic
who require vasopressors
signs of pneumonia
o Prolonged or high doses of
3. All hospitalized patients belonging to
corticosteroid is not
high-risk groups with mild illness.
recommended unless indicated
 DOES NOT NEED antiviral treatment:
for another reason.
suspected or confirmed patients that
o Recent studies show that
presents with uncomplicated febrile
corticosteroid use fail to show
illness.
any beneficial effects for
 Chemoprophylaxis/Post-Exposure
Influenza infection
Prophylaxis Considered for:
o Close contacts of confirmed Supportive care
cases which belongs to the
high-risk group.  Should be given with patients
o HCW with unprotected close presenting with Acute Respiratory
distress syndrome associate with H1N1
contact exposer to confirmed
case, within 10 days after last  Standard lung-protective ventilation
known exposure. strategies (pressure/volume-limited
ventilation) are appropriate initially
 *Pre-Exposure Prophylaxis is NOT
recommended.  Individual patients with refractory
hypoxemia have benefited from
negative fluid balance, prone
positioning, and advance respiratory
CARE OF THE SEVERELY ILL PATIENT
support such as nitric oxide, high
Initial evaluation: frequency oscillation (HFO), and/or
extracorporeal membrane oxygenation
 Shortness of breath w/ tachypnea are
(ECMO)
cardinal symptoms for severe cases
 Pulse oximetry and Chest X-ray CRITERIA FOR DISCHARGE
 For intubated patients, check for
 Once afebrile and stable for at least 24
positive RT-PCR test. Repeat test every
hours.
2-3 days if result is negative.
 Chronic or underlying conditions
Antiviral therapy controlled.
 NO NEED TO REPEAT swab collection.
DISCHARGE INSTRUCTIONS: Diarrhea and/or Other complications
vomiting but without include
 Continue home isolation for 24hrs after evidence of rhabdomyolysis and
being afebrile without taking dehydration myocarditis.
antipyretics *Patients may present Exacerbation of
 Infection control measures should some or all of these underlying chronic
continue until all are resolved. symptoms but some disease like asthma,
 Emphasize importance of hand hygiene patients with COPD, renal
as a routine. uncomplicated illness insufficiency,
 Advise consultation if other members of may experience diabetes and other
the household developed similar atypical symptoms cardiovascular
symptoms, especially those that belong and may not have conditions (CHF).
fever e.g. elderly or
to the high-risk.
immunocompromised
patients)

PHARMACOLOGIC MANAGEMENT

 Addresses the most widely available

and licensed antiviral medicines:
o 2 neuraminidase inhibitors:
oseltamivir and zanamivir
o 2 M2 inhibitors: amantadine
and rimantadine

UNCOMPLICATED COMPLICATED OR
INFLUENZA SEVERE INFLUENZA
Fever Dyspnea
Cough Tachypnea
Sore throat Hypoxia and/or
radiological signs of
lower respiratory
tract disease
(pneumonia)
Nasal congestion or CNS involvement
rhinorrhea (encephalopalopath
y, encephalitis)
Headache Severe dehydration
Muscle pain and Secondary
malaise complications such
as: renal failure,
multi-organ failure
and septic shock.
USE OF ANTIVIRALS FOR TREATMENT OF PANDEMIC INFLUENZA A (H1N1) 2009 VIRUS INFECTION IN
ADULTS AND ADOLESCENTS

CONSIDERATION INDICATIONS MEDICATION

Adults and adolescents All patient groups, including:  Oseltamivir 150mg BID PO as
with confirmed or strongly  Pregnant soon as possible x 5 days
suspected infection with  Postpartum to 2 weeks  In situations where
pandemic influenza following delivery oseltamivir is not available,
A(H1N1) 2009 virus, where  Breastfeeding women or not possible to use, treat
clinical presentation is with inhaled zanamivir 10mg
severe or progressive Q12H x 5 days, where
feasible.
Treatment of patients with  Hematopoietic stem  Oseltamivir 150mg BID PO as
confirmed or strongly cell recipients soon as possible x 5 days and
suspected infection with  Transplant patients on longer duration of treatment
pandemic influenza immunosuppressive depending on clinical
A(H1N1) 2009 virus, and Chemotherapy response.
who have severe  Severe  In situations where there is
immunosuppression immunosuppression antiviral resistance, treat
expected to delay viral  Graft versus host with inhaled zanamivir 10mg
clearance disease Q12H x 5 days where
 Haematological feasible.
malignancies.

USE OF ANTIVIRALS FOR TREATMENT OF UNCOMPLICATED PANDEMIC INFLUENZA A (H1N1) 2009 VIRUS
INFECTION IN ADULTS AND ADOLESCENTS

CONSIDERATION INDICATIONS MEDICATION

Treatment of adult and All patient groups, including:  Oseltamivir 150mg BID
adolescent patients with  Pregnant PO as soon as possible x
confirmed or strongly  Postpartum to 2 weeks 5 days
suspected, but uncomplicated following delivery   In situations where
illness, due to pandemic  Breastfeeding women there is antiviral
(H1N1) 2009 virus infection, resistance, treat with
and where antiviral inhaled zanamivir 10mg
medications for influenza are Q12H x 5 days where
available feasible.

USE OF ANTIVIRALS FOR TREATMENT OF PANDEMIC INFLUENZA A (H1N1) 2009 VIRUS INFECTION IN
CHILDREN
 CONSIDERATION INDICATIONS MEDICATION
Treatment of children All children, including:  (14 days up to 1 year)
with confirmed or strongly  neonates Oseltamivir 3 mg/kg/dose BID
suspected infection with  young children (in PO x 5 days
pandemic (H1N1) 2009 particular those less  (<14 days of age) Oseltamivir
virus where clinical than 2 years of age). 3 mg/kg/dose OD PO x 5 days
presentation is severe or  Lower doses should be
progressive considered for infants who are
not receiving regular oral
feedings and/or those who
have a concomitant medical
condition.
Treatment of children All children, including:  (14 days up to 1 year)
with confirmed or strongly  neonates Oseltamivir 3 mg/kg/dose BID
suspected, but  young children (in PO x 5 days
uncomplicated, illness due particular those less  (<14 days of age) Oseltamivir
to pandemic (H1N1) 2009 than 2 years of age). 3 mg/kg/dose OD PO x 5 days
virus infection  In situations where there is
antiviral resistance, treat with
inhaled zanamivir 10mg Q12H
x 5 days where feasible.

USE OF ANTIVIRALS WHERE ANTIVIRAL RESISTANCE IS KNOWN OR SUSPECTED

CONSIDERATION INDICATIONS MEDICATION

Patients who have severe or All patient groups who have  Zanamivir 10mg iv
progressive clinical illness with uncomplicated illness, including: Q12H x 5 days
virus resistant to oseltamivir  Pregnant depending on clinical
but known or likely to be  postpartum to 2 weeks response.
susceptible to zanamivir following delivery
 breastfeeding women

ANTIVIRAL TREATMENT RECOMMENDATIONS: OTHER INFLUENZA VIRUS STRAINS

CONSIDERATION INDICATIONS MEDICATION
Pregnant women and children  pregnant women  Not be treated with
aged less than 1 year with  young children aged <1 amantadine or
uncomplicated illness due to yr old rimantadine due to
seasonal influenza A (H1N1) increased risk of adverse
virus infection effect
USE OF ANTIVIRALS FOR CHEMOPROPHYLAXIS OF PANDEMIC INFLUENZA A (H1N1) 2009 VIRUS
INFECTION
Higher risk individuals have  caregivers  Oseltamivir 150mg BID
been exposed to a patient  immunosuppressed PO as soon as possible x
with influenza persons with no 5 days or inhaled
 fever/influenza zanamivir 10mg Q12H x
infection 5 days as post-exposure
prophylaxis
OTHER CONSIDERATIONS
Renal Impairment  Pregnant  Caution over the use of
 Pediatric patient higher doses of
oseltamivir
Obesity  Obese patients  Higher dosing needed
Pregnancy and breastfeeding  Pregnant  No exclusions
 breastfeeding women  Oseltamivir 150mg BID
PO as soon as possible x
5 days
 In situations where
oseltamivir is not
available, or not possible
to use, treat with
inhaled zanamivir 10mg
Q12H x 5 days, where
feasible.

AH1N1 TIMELINE IN THE PHILIPPINES

1st px - arrived on May 18 and was hospitalized the day after at the Research Institute for Tropical
Medicine in Muntinlupa City.

May 2009

 First case of H1N1 was reported.

 a 10-year-old child, returning from a trip from US , which also included a visit to Canada

June 11, 2009

 With nearly 30,000 cases reported worldwide, a full pandemic alert was declared by the World
Health Organization (WHO).

June 22, 2009

 First H1N1 fatality was reported in the Philippines.

 Also the 1st death associated with the disease in Asia.
 Patient was a 49-year-old female from Metro manila. Employee of the House of Congress, with a
pre-existing chronic heart disease.

June 25, 2009

 At least 128 cases in 40 schools

 32 schools in Metro Manila - Caloocan, Makati, Mandaluying, Manila, Marikina, Muntinlupa,
Paranaque, Pasig, Quezon City, San Juan, Taguig
  8 schools in the provinces - Rizal, Bulacan, Cebu, Laguna, Leyte, Nueva Ecija

October 9, 2009

 The Philippine government sought to ensure availability of vaccine supplies by requesting

donated vaccines from WHO.

Nov 2009

 WHO pledged to provide free supplies of at least 9 million doses of the vaccine to the Philippines

Mid-March of 2010

 A national orientation on vaccine deployment and vaccination strategies was conducted in mid-
March of 2010.

April 6, 2010

 Pandemic vaccination campaign commenced

August 2010

 Declaration of the post-pandemic period

The Philippines had recorded more than 85,000 ILI with nearly 6,000 laboratory confirmed AH1N1

MAJORITY OF THE CASES WERE:

 Young children
 Teenagers
 Pregnant women

RESPONSE

 Travel bans were implemented especially on countries like the US, Mexico, Canada, etc.
  Airports were put on heightened alert, conducted screening of passengers, and released
frequent travel advisories.
 At the local level, school reopening days were postponed
 Social distancing were recommended and mass precautions were implemented.

NATIONAL INFLUENZA SURVEILLANCE IN THE PHILIPPINES

 A routine influenza surveillance is conducted in 13 regions in the Philippines from 2006 to 2012.
 To describe the annual seasonal epidemics of confirmed influenza virus infection, seasonal and
alert thresholds, epidemic curve, and circulating influenza strains.

Plot of confirmed weekly influenza positivity rates from 2006 to 2011, National Influenza Surveillance,
Philippines
  CONCLUSION:
Influenza seasonality in the Philippines is from June to November.
 The ideal time to administer Southern Hemisphere influenza vaccine should be from April to
May.
 With two lineages of influenza B circulating annually, quadrivalent vaccine might have more
impact on influenza control than trivalent vaccine.

REFERENCES:

 https://www.mayoclinic.org/diseases-conditions/swine-flu/symptoms-causes/syc-
20378103#:~:text=The%20H1N1%20flu%2C%20commonly%20known,can%20cause%20the
%20seasonal%20flu.
 https://emedicine.medscape.com/article/1807048-overview
 https://www.cdc.gov/h1n1flu/background.htm
 https://www.medicinenet.com/swine_flu/article.htm
 https://www.who.int/csr/disease/swineflu/frequently_asked_questions/about_disease/en/
 https://www.cdc.gov/h1n1flu/qa.htm
 https://www.scientificanimations.com/swine-flu-h1n1-mechanism-of-action-moa-animation/
 https://www.who.int/influenza/gisrs_laboratory/WHO_information_for_the_molecular_detecti
on_of_influenza_viruses_20171023_Final.pdf
 RITM Laboratory Response During the 2009 Influenza H1N1 Pandemic Report
 https://www.cdc.gov/h1n1flu/specimencollection.htm
 http://www.pidsphil.org/download/InterimGuidelines22-December2009.pdf
 Microsoft Word - CP149A_2009-0911_Clinical_Management_revised_Guidance_H1N1-
FINAL.doc (who.int)
 Nedel, W. L., Nora, D. G., Salluh, J. I., Lisboa, T., & Póvoa, P. (2016). Corticosteroids for severe
influenza pneumonia: A critical appraisal. World journal of critical care medicine, 5(1), 89–95.
https://doi.org/10.5492/wjccm.v5.i1.89
 https://www.who.int/csr/resources/publications/swineflu/h1n1_guidelines_pharmaceutical_m
ngt.pdf?fbclid=IwAR2iZCtGNtNrCSCX3l5W66OSmI65UjDwUm5ZQzp605j9PB2JnK18g9zEaLY
 https://www.who.int/medicines/publications/WHO_PSM_PAR_2006.6.pdf?ua=1
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5168815/
 https://www.gmanetwork.com/news/news/nation/198594/doh-stays-alert-as-a-h1n1-shifts-to-
post-pandemic-stage/story/
 WPRO | Response to pandemic A H1N1 (who.int)
 Influenza A(H1N1) in the Philippines (gmanetwork.com)