In March 2009, an outbreak of “human swine flu” occurred in Mexico and spread rapidly around the world. The World Health Organization (WHO) initially called this type of influenza “human swine flu”, and later renamed it “influenza A (H1N1)”. June 11, WHO announced that the pandemic warning level of influenza A (H1N1) was raised to level 6, the global Enter the influenza pandemic phase. The influenza is a new respiratory infectious disease, the etiology of the new strain of influenza A (H1N1) virus, virus genes contain swine flu, avian influenza and human influenza three influenza virus gene fragments.
The treatment plan is based on the second version of the treatment plan on July 10, based on recent domestic and foreign research results and our experience in the treatment of influenza A (H1N1) revised. As this influenza A (H1N1) is a new disease, its disease pattern is still subject to further observation and research.
A. Pathogenesis
Influenza A (H1N1) virus belongs to the orthomyxoviridae (0rthomyxoviridae), influenza A virus genus (InfluenzavirusA). Typical virus particles are spherical, 80nm-120nm in diameter, with a capsule membrane. The virus is a single-stranded negative-stranded RNA virus with a genome of about 13,6 kb, consisting of 8 independent fragments of different sizes. The virus is sensitive to ethanol, iodophor, tincture of iodine and other common disinfectants; it is heat-sensitive and can be inactivated in 30 minutes at 56℃.
II. Epidemiology
(A) the source of infection.
Influenza A (H1N1) patients as the main source of infection, asymptomatic infected people are also infectious. There is no evidence of animal transmission of humans.
(B) the transmission route.
Mainly through droplet transmission through the respiratory tract, but also through the oral cavity, nasal cavity, eyes and other places mucous membrane direct or indirect contact transmission. Contact with the patient’s respiratory secretions, body fluids and objects contaminated with the virus may also cause infection. Transmission through the respiratory tract by aerosols needs to be further confirmed.
(iii) Susceptible population.
The population is generally susceptible.
(iv) High-risk groups that are more likely to become seriously ill.
The following groups of people with influenza-like symptoms, more likely to develop into serious cases, should be given high priority, as early as possible for influenza A (H1N1) virus nucleic acid testing and other necessary tests.
1.Women during pregnancy.
2, with the following diseases or conditions: chronic respiratory diseases, cardiovascular system diseases (except hypertension), kidney disease, liver disease, hematological system diseases, neurological and neuromuscular diseases, metabolic and endocrine system diseases, immune suppression (including the application of immunosuppressive drugs or HIV infection, etc. resulting in immune deficiency), long-term aspirin users under 19 years of age.
3, obese persons (high risk for body mass index ≥ 40, body mass index in 30-39 may be a high risk factor)
4, children aged <5 years (age <2 years are more likely to have serious complications)
5, the elderly aged ≥ 65 years.
III. Clinical manifestations and auxiliary examinations
The incubation period is usually 1-7 days, mostly 1-3 days.
(A) Clinical manifestations.
Usually present with flu-like symptoms, including fever, sore throat, runny nose, nasal congestion, cough, sputum, headache, generalized aches and pains, and malaise. Some cases present with vomiting and/or diarrhea. A small number of cases have only mild upper respiratory symptoms without fever. Signs mainly include pharyngeal congestion and enlarged tonsils.
Complications such as pneumonia may occur. In a few cases, the disease progresses rapidly, with respiratory failure, multiple organ insufficiency or failure.
Exacerbation of the existing underlying disease may be induced, presenting the corresponding clinical manifestations.
Severe cases can lead to death.
(B) Laboratory tests.
1. Peripheral blood test: total white blood cell count is generally not high or reduced.
2. Blood biochemical examination: some cases have hypokalemia, and a few cases have elevated creatine kinase, aspartate aminotransferase, alanine aminotransferase and lactate dehydrogenase.
3.Pathogenetic examination.
(1) viral nucleic acid detection: RT-PCR (preferably using real-timeRT-PCR) method to detect respiratory specimens (pharyngeal swabs, nasal swabs, nasopharyngeal or tracheal extracts, sputum) in the influenza A (H1N1) virus nucleic acid, the results can be positive.
(2) virus isolation: respiratory specimens can be isolated from the influenza A (H1N1) virus.
(3) serum antibody test: dynamic detection of double serum influenza A (H1N1) virus-specific antibody level is 4 times or more than 4 times elevated.
(C) chest imaging.
In combination with pneumonia, lamellar shadows are seen in the lungs.
IV. Diagnosis
Diagnosis is mainly combined with epidemiological history, clinical manifestations and pathogenic examination, early detection, early diagnosis is the key to prevention and control and effective treatment.
(A) Suspected cases.
A suspected case can be diagnosed if one of the following conditions is met.
1, within 7 days before the onset of the infectious period with confirmed cases of influenza A (H1N1) have close contact, and the emergence of influenza-like clinical manifestations.
Close contact is not taken in the case of effective protection, consultation, care of the infectious period influenza A H1N1 patients; living with patients; contact with the patient’s respiratory secretions, body fluids, etc.
2, within 7 days before the onset of influenza A (H1N1) epidemic (the emergence of sustained human transmission of the virus and community-based level of epidemics and outbreaks) in areas with influenza-like clinical manifestations.
3, the emergence of influenza-like clinical manifestations, positive test for influenza A virus, not yet further detection of virus subtypes.
For the above three cases, where conditions permit, arrangements can be made for pathogenic examination of influenza A (H1N1).
(B) clinical diagnosis of cases.
Only the following cases to make a clinical diagnosis: the same influenza A (H1N1) outbreak, without laboratory confirmation of influenza-like symptoms of the case, in excluding other influenza-like symptoms of disease, can be diagnosed as a clinical diagnosis of the case.
Influenza A (H1N1) outbreak is a short period of time in an area or unit with an abnormal increase in influenza-like cases, confirmed by laboratory tests for influenza A (H1N1) outbreak.
Where conditions permit, clinically diagnosed cases can be arranged for pathogenic testing.
(C) confirmed cases.
The presence of influenza-like clinical manifestations, along with one or more of the following laboratory test results.
1, positive nucleic acid test for influenza A (H1N1) virus (real-time RT-PCR and RT-PCR methods can be used).
2, the isolation of influenza A (H1N1) virus.
3, double serum influenza A (H1N1) virus-specific antibody levels are 4-fold or more than 4-fold elevated.
V. Serious and critical cases
(A) one of the following conditions for serious cases.
1, persistent high fever > 3 days.
2, violent cough, coughing up pus or blood sputum, or chest pain.
3. rapid respiratory rate, dyspnea, and cyanosis of the lips and mouth.
4. altered mental status: unresponsiveness, drowsiness, agitation, convulsions, etc.
5. severe vomiting and diarrhea with signs of dehydration.
6, signs of pneumonia on imaging.
7, rapid increase in the level of cardiac enzymes such as creatine kinase (CK) and creatine kinase isoenzyme (CK-MB).
8, the original underlying disease significantly aggravated.
(ii) Critical cases are those with one of the following conditions.
1, respiratory failure.
2, infectious toxic shock.
3.Multi-organ insufficiency.
4.Other serious clinical conditions that require monitoring and treatment.
VII. Principles of clinical classification and treatment
(A) suspected cases: isolated in a room with good ventilation. Hospitalized cases must do pathogenic examination of influenza A (H1N1).
(B) clinical diagnosis of the case: in a well-ventilated room isolated. Inpatient cases must do the pathogenic examination of influenza A (H1N1).
(C) confirmed cases: isolation in a well-ventilated room. Inpatient cases can be more than one person in the same room.
Eight, the principle of hospitalization
According to the patient’s condition and the status of local medical resources, in accordance with the principle of priority of serious illness to arrange hospitalization.
(a) Prioritize the admission of serious and critical cases. For critical cases, according to the conditions of local medical facilities, timely transfer to the intensive care unit (ICU) with conditions for prevention and control.
(B) does not have the conditions for the treatment of serious and critical cases of medical institutions, under the premise of ensuring medical safety, the case should be transferred to a hospital with the conditions; the condition is not suitable for referral, the local health administrative department or higher health administrative departments to organize experts in situ for active treatment.
(C) high-risk groups of people infected with influenza A (H1N1) are more likely to become serious cases, it is appropriate to arrange inpatient consultation and treatment. Such as the implementation of home isolation treatment, should be closely monitored, once the deterioration of the disease must be promptly arranged for inpatient consultation and treatment.
(D) mild cases can be arranged for home isolation observation and treatment.
IX. Treatment
(A) general treatment.
Rest, drink more water, closely observe changes in the condition; antipyretic treatment can be given to cases of high fever.
(B) antiviral treatment.
Studies have shown that such influenza A (H1N1) virus currently on the neuraminidase inhibitor oseltamivir (oseltamivir), zanamivir (zanamivir) sensitive to amantadine and amantadine resistance.
For mild clinical symptoms and no comorbidities, the disease tends to self-limited cases of influenza A (H1N1), no active application of neuraminidase inhibitors.
For the onset of the disease that is serious, the onset of the disease is a dynamic deterioration of the case, influenza A (H1N1) infection of high-risk groups should be promptly given neuraminidase inhibitors for antiviral therapy. The start of drug administration should be within 48 hours of onset (36 hours is optimal) if possible. For high-risk groups that are more likely to become severe cases, it is not necessary to wait for the results of viral nucleic acid testing to start antiviral therapy once influenza-like symptoms appear. It is advisable to give neuraminidase inhibitor therapy to pregnant women as soon as possible after the onset of influenza-like symptoms.
Oseltamivir: The dosage for adults is 75 mg b,i,d, for a 5-day course. In critical or severe cases, the dosage of oseltamivir can be increased to 150mgb,i,d, as appropriate. For children aged 1 year and above, the dose should be given according to body weight: 30mgb,i,d for those weighing less than 15kg; 45mgb,i,d for those weighing 15-23kg; 60mgb,i,d for those weighing 23-40kg; 75mgb,i,d for those weighing more than 40kg. For children who have difficulty swallowing capsules, oseltamivir suspension may be used.
Zanamivir: for adults and children over 7 years of age. The dosage for adults is 10 mg inhaled b, i, d, for 5 days. for children 7 years and above, the dosage is the same as for adults.
(iii) Other treatment.
1.If hypoxemia or respiratory failure occurs, appropriate therapeutic measures should be given promptly, including oxygen therapy or mechanical ventilation, etc.
2.Give the corresponding anti-shock treatment when combined with shock.
3.Give corresponding supportive treatment when other organ function damage occurs.
4. In case of combined bacterial and/or fungal infection, give appropriate antibacterial and/or antifungal drug treatment.
5.For severe and critical cases, the use of influenza A (H1N1) recovery plasma from recently recovered persons or immune plasma from vaccinated persons can also be considered for treatment.
For severe and critical cases within 1 week of onset, early use is advisable under the premise of ensuring medical safety. Recommended Use: Generally 100-200 ml for adults and 50 ml for children (or adjust dosage according to plasma-specific antibody titers), administered intravenously. May be repeated if necessary. During use, pay attention to allergic reactions.
(iv) Chinese medicine evidence-based treatment.
Treatment plan for mild cases
1. Wind-heat offending the guard
Main symptoms: early onset, fever or no fever, red throat and discomfort, light cough with little sputum, no sweating.
Tongue and pulse: red tongue, thin or thin and greasy coating, floating pulse.
Treatment: Drain wind and clear heat
Basic prescription: Yinhua 15g, Lianxiao 15g, Mulberry Leaf 10g, Hanging Chrysanthemum 10g
Radix Platycodon grandiflorus 10g Arctium lappa 15g Bamboo leaf 6g Radix rehmanniae 30g
Peppermint (later on) 3g Licorice 3g
Decoction method: Decoction in water, 400 ml of water per dose, 200 ml per time orally, 2 times a day; if necessary, 2 doses per day, 200 ml per time orally every 6 hours.
Addition and subtraction: add patchouli and pelargonium for thick and greasy moss.
Heavy cough plus almond and loquat leaf.
diarrhea plus Chuan Huang Lian and Guang Mu Xiang.
For sore throat, add Jin Lantern.
Commonly used Chinese medicines: Chinese medicines for clearing wind and heat, such as capsule for clearing wind and heat, Xiang Ju capsule, Yin Qiao detoxification, Sang Ju cold and flu, Shuang Huang Lian oral preparations; Huo Xiang Zheng Qi, Ge Gen Scutellaria preparations, etc.
2.Heat poison attacking the lungs
Symptoms: high fever, cough, sticky phlegm, unpleasant phlegm, thirsty for drinks, sore throat, red eyes.
Tongue and pulse: red tongue, yellow or greasy coating, slippery pulse.
Treatment: Clearing the lung and detoxifying the toxin
Basic prescription: Roasted Ephedra 3g, Almond 10g, Licorice 10g
Raw gypsum (first decoction) 30g Zhi Mu 10g Zhe Bei Mu 10g Radix Platycodon 15g Scutellaria 15g Radix Bupleurum 15g
Decoction method: Decoction in water, 400 ml of water per dose, 200 ml orally each time, 2 times a day; if necessary, 2 doses can be taken daily, 200 ml orally every 6 hours.
Addition and subtraction: add raw rhubarb for constipation.
For persistent high fever, add Artemisia annua and Danpi.
Commonly used Chinese medicines: lung-clearing and detoxifying Chinese medicines such as Lianhua Qingfeng capsule, Yinhuang class preparation, Lotus Qingfeng class preparation, etc.
Treatment plan for severe and critical illnesses
1.Heat toxin congestion in lung
Symptoms: High fever, cough with sputum, yellow sputum, shortness of breath; or palpitation, restlessness, purple lips.
Tongue and pulse: red tongue, yellow or grayish coating, slippery pulse.
Treatment: Clearing heat and dipping the lung, detoxifying and dispersing blood stasis
Basic prescription: Roasted Ephedra 5g Raw gypsum (first decoction) 30g Almond 10g Zhi Mu 10g
Fishoil 15g, Daphne scabra 10g, Buckwheat 10g, Scutellaria baicalensis 10g
Zhe Bei Mu 10g Sheng Da Huang 10g Dan Pi 10g Artemisia annua 15g
Decoction method: Decoction in water, 400 ml of water per dose, 200 ml orally each time, 2 times a day; if necessary, 2 doses can be taken daily, 200 ml orally every 6 hours.
Add and subtract: persistent high fever and delirium plus Angong Niuhuang Pill.
Convulsions add Antelope horn, Stibrium, Guang Di Long, etc.
For abdominal distension and bowel movement, add Hovenia, Yuanming powder.
Commonly used Chinese medicines: Xiyanping, Phlegm Fever Qing, Qingkailing Injection.
2.Burnt Qi and Ying
Symptoms: high fever, thirst, restlessness, or even delirium, coughing or hemoptysis, chest tightness and shortness of breath.
Tongue and pulse: red and vivid tongue, yellow coating, fine pulse.
Treatment: Clearing Qi and cooling Ying
Basic prescription: Buffalo’s horn 30g, Radix Rehmanniae 15g, Red peony 10g, Silver flower 15g
Radix Salviae Miltiorrhiza 12g, Forsythiae 15g, Mai Dong 10g, Bamboo Leaf 6g
Psidium guajava 30g Sheng Shi Jiao (first decoction) 30g Gardenia jasminoides 12g
Decoction method: Decoction in water, 400 ml of water per dose, 200 ml per time orally, 2 times a day; if necessary, 2 doses per day, 200 ml per time orally every 6 hours.
Addition and subtraction: add raw rhubarb for constipation.
Add antelope horn powder for high fever and limb convulsions.
Commonly used Chinese medicines: Angong Niuhuang Pill, Blood Bebop, Awakening Brain Jing Injection, etc.
Note: The above drugs should be used under the guidance of physicians; the dosage is for reference, and the dosage for children should be reduced as appropriate; patients with complications and a history of chronic underlying diseases should be treated with evidence. If shock, multi-organ dysfunction syndrome or other serious diseases are seen, the patients should be treated according to the actual situation while applying western medical treatment.
X. Discharge criteria
1.The body temperature is normal for 3 days, other flu-like symptoms basically disappeared, and the clinical condition is stable, so the patient can be discharged from the hospital.
2, due to underlying diseases or serious comorbidities, requiring a longer hospitalization of influenza A (H1N1) cases, after the pharyngeal swab influenza A (H1N1) virus nucleic acid test turns negative, can be transferred from the isolation ward to the corresponding ward for further treatment.