DISEASE CONTROL DIVISION MINISTRY OF HEALTH MALAYSIA INTERIM ENHANCED SURVEILLANCE GUIDELINES OF HUMAN INFECTION WITH INFLUENZA A (H1N1)

VIRUS

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INTRODUCTION There are four main influenza A virus subtypes been isolated in pigs. Those viruses are most commonly of the H1N1 subtype, but other subtypes are also circulating in pigs (e.g., H1N2, H3N1, H3N2). Pigs can also be infected with avian influenza viruses and human seasonal influenza viruses as well as swine influenza viruses. The H3N2 swine virus was thought to have been originally introduced into pigs by humans. Sometimes pigs can be infected with more than one virus type at a time, which can allow the genes from these viruses to mix resulting in an influenza virus containing genes from a number of sources, called a "reassortant" virus. The mode of spreads of this virus among pigs is by aerosols and direct and indirect contact, and asymptomatic carrier pigs exist. Outbreaks in pigs occur throughout the year, with an increased incidence in the fall and winter in temperate zones similar to outbreaks in humans. Swine Flu does not normally infect humans, although sporadic cases do occur. People usually get swine influenza through contact with infected pigs, or environments contaminated with Swine Flu viruses. However, some human cases lack contact history with pigs or environments where pigs have been located. Human-to-human transmission has been documented in some instances but was limited to close contacts and closed groups of people. The current Influenza A (H1N1) virus, which was previously referred as Swine Flu is totally a new virus subtype. It has a mixture of genes from avian, human and swine Influenza viruses as a result of reassortment process in the pig. This new virus subtype is efficiently able to be transmitted from human to human which may cause Pandemic Influenza.

This is an Interim Enhanced Surveillance Guidelines of Human Infection with Influenza A (H1N1) virus. This guidelines is adapted from the interim WHO guidance for the surveillance of human infection with Swine Influenza A (H1N1) virus. The main aims of this Enhanced Surveillance Guidelines is to strengthen the early warning of virus spread and laboratory confirmation of the virus circulating in new geographical areas and countries. This guidelines is meant to enhance our surveillance and diagnostic capacities for influenza and other acute respiratory infections, building on existing structures and resources.

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OBJECTIVE General: To enhance the surveillance system for detection of Influenza A (H1N1) in human 1. To establish a mechanism for the urgent reporting of potential Influenza A (H1N1) cases from health care workers and members of public. To facilitate early detection and response towards Influenza A (H1N1) cases/ outbreak. To maintain a heightened awareness of potential Swine Influenza cases among clinical staff in private and public clinics, and hospitals. To establish a local network of professionals working in communicable diseases to response to Influenza A (H1N1).

Specific:

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TRIAGING OF OUTPATIENT CASES All clinics should set up triaging counter for outpatient cases. Any individual who fulfils the criteria for suspected case definition as mentioned below should be directed to the triaging counter. The patient should then be further investigated and managed appropriately according to flow chart as Annex 1.

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CASE DEFINITION OF INFLUENZA A (H1N1) VIRUS The purpose of using a more sensitive case definition is for notification and early implementation of planned local response. Clinical case description: Acute febrile respiratory illness (fever 38 C) with the spectrum of disease from influenza-like illness to pneumonia. i. A suspected case of Influenza A (H1N1) virus infection is defined as an individual after 17th of April 2009, presenting with: high fever 38C, AND One or more of the following respiratory symptoms: cough, shortness of breath, body ache, difficulty in breathing, AND One or more of the following: close contact* with a person diagnosed as Influenza A (H1N1) or recent travel to an area with reported foci of transmission of Influenza A (H1N1)**.

*Close contact means having cared for, lived with, or having had direct contact with respiratory secretions or body fluids of a person with Influenza A (H1N1). **Areas in which there are reported foci of transmission of Influenza A (H1N1)are updated on the WHO website http://www.who.int/csr/don/en/

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A probable case of Influenza A (H1N1) virus 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.

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A confirmed case of Influenza A (H1N1) virus 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 four-fold rise in Influenza A(H1N1) virus specific neutralizing antibodies

*Note: The test(s) should be performed according to the most currently available guidelines on testing.
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NOTIFICATION OF INFLUENZA A (H1N1) CASES All medical practitioners need to notify the nearest District Health Office (DHO) using the notification format (KKM/BKP/SF/2009/1) as in Annex 2, if there is any case fulfilling the criteria as Suspected/Probable/Confirmed Influenza A (H1N1). The patient is to be admitted into an isolated ward/room in a designated hospital/district hospital, as the situation warrants. The flow of notification is as shown in Annex 3. The patients daily progress (using format KKM/BKP/SF/2009/2 as in Annex 4) should be sent to the Disease Control Division, Ministry of Health (MOH) at/before 10.00 am until the patient is discharged. All hospitals that have any case fulfilling the criteria as Suspected Influenza A (H1N1) are required to send the clinical specimens to IMR using the format KKM/BKP/SF/2009/3 as shown in Annex 5.

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LABORATORY INVESTIGATION All clinical specimens should be sent to IMR for identification of Influenza A(H1N1) virus as per the format KKM/BKP/SF/2009/3 as shown in Annex 5. The method of collection, transportation and storage of specimens should follow the procedures mentioned in the National Influenza Pandemic Preparedness Plan (NIPPP) document. History of visit to swine flu affected areas or contact with suspected/probable cases MUST be mentioned in all request forms for Influenza A (H1N1) testing.

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ENHANCED SURVEILLANCE FOR INFLUENZA A (H1N1)

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INFLUENZA-LIKE ILLNESS (ILI) AND SEVERE ACUTE RESPIRATORY INFECTION (sARI) Case definition of influenza-like illness (ILI): A person presenting with a sudden onset of fever 38oC and cough or sore throat, in the absence of other diagnosis

Case definition of Severe Acute Respiratory Infections (sARI): Meets ILI case definition (sudden onset of fever 38oC and cough or sore throat, in the absence of other diagnosis), AND Shortness of breath or difficulty breathing, AND Requiring hospital admission.

ILI surveillance during this period will involve ALL government health clinics and not limited to the sentinel sites as previously designated. Whereas, sARI surveillance will involve data collection from all government hospitals. In view of the current global situation, these Surveillance of ILI and sARI will be done DAILY. Data are collected using the formats contain in the following Annexes: Annex 6: daily return format from Health Clinics (KKM/BKP/SF/2009/4) Annex 7: daily return format from Government Hospitals (KKM/BKP/SF/2009/5) Annex 8: daily return format from District Health Office (KKM/BKP/SF/2009/6) Annex 9: daily return format from State Health Department (KKM/BKP/SF/2009/7)

The flow of data collection is as shown in Annex 10.

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CLUSTER OF ATYPICAL PNEUMONIA. A cluster is defined as two or more persons presenting with manifestations of unexplained, acute respiratory illness with fever 38C or who died of an unexplained respiratory illness that are detected with onset of illness within a period of 14 days and in the same geographical area and/or are epidemiologically linked Case definition of atypical pneumonia: Moderate or severe respiratory illness with: Temperature of 38C, AND One or more clinical findings of lower respiratory illness (e.g. cough, shortness of breath, difficulty in breathing, or hypoxia), AND
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Radiographic evidence consistent with pneumonia, OR Severe acute respiratory respiratory distress syndrome (RDS), OR Autopsy finding consistent with the pathology of pneumonia or RDS without an identifiable cause.

Any clustering of suspected atypical pneumonia cases at any level of health care or community should be reported to CPRC, Disease Control Division using format KKM/BKP/SF/2009/8 as Annex 11 and according to flow chart as in Annex 10.

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ACUTE RESPIRATORY SYNDROME In view of this current situation, all acute respiratory syndrome cases should be notified to Disease Control Division as mentioned in the Syndromic Notification Guidelines. Please refer to Syndromic Notification Guidelines. Acute Respiratory Syndrome is defined as following: Acute onset of cough or respiratory distress tachypnoea, chest recession, dyspnoea, cyanosis) AND severe illness WITH an absence of known predisposing factors. (e.g.

When a doctor encounters a patient who satisfies the definition of Acute Respiratory Syndrome is to complete the Syndromic Notification Form (KKM-syndssurv/2003.2 Annex 12). The completed forms should be sent by fax or e-mail attachment within 24 hours to: i. ii. the nearest District Health Office with a copy to the Crisis Preparedness and Response Centre (CPRC), Disease Control Division, Ministry of Health Malaysia (fax: 03-8881 0400 or 03-8881 0500 / e-mail: cprc@moh.gov.my).

The flow of notification is as shown in Annex 3.

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ROLE OF PRIVATE HEALTH CARE PRACTITIONERS All Medical Officers of Health (MOHs) are required to inform the private health care practitioners in their respective districts to be more vigilant for Influenza like illness (ILI) and acute respiratory syndrome cases. The private health care practitioners should refer any suspected case of Influenza A (H1N1), as per the case definition, to the nearest government hospital and if required for further management at the designated hospitals. The private health care practitioners should ask for history of travel to and/or contact with pigs in Influenza A (H1N1) affected areas, if the patient(s) has symptoms suggestive of Influenza A (H1N1). This is to increase the index of suspicion for picking up Influenza A (H1N1) cases amongst the patients fulfilling the case definition.

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PERSONAL PROTECTIVE EQUIPMENT In the management and triaging of Influenza A (H1N1) cases, use of PPE to prevent transmission should adhere to the National Influenza Pandemic Preparedness Plan (NIPPP)

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PERSONNEL MONITORING The monitoring of the health status of the following personnel should be carried out: laboratory personnel involved in the processing of clinical specimens derived from suspected Influenza A (H1N1) cases both among humans and pigs; health personnel involved in Active Case Detection activities and triaging; medical personnel involved in managing suspected Influenza A (H1N1)cases in the ward; personnel involved in surveillance activities in pig farms.

The daily monitoring of healthcare workers should follow the format as in Annex 13.

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CONTACT Crisis Preparedness and Response Centre (CPRC) Disease Control Division Ministry of Health Malaysia Level 3, Block E10, Parcel E 62590 PUTRAJAYA Tel: 03-8881 0200 / 0300 / 0600 / 0700 Fax: 03-8881 0400 / 0500 Email: cprc@moh.gov.my