DECISION OF THE MINISTER OF HEALTH

Regarding the issuance of: "Guidelines for diagnosis, treatment, and prevention of viral pneumonia infection"

THE MINISTER OF HEALTH

Pursuant to Decision No. 1613/BYT-QD dated 15/5/2003 Pursuant to the Government's Decree on the functions, tasks, and organizational structure of the Ministry of Health;

Considering the Minutes of the meeting of the Research Council on Diagnosis and Treatment of Severe Respiratory Infections Caused by Influenza Viruses; 28/2/2004;

At the proposal of the Director of the Treatment Department;

DECIDES:

Article 1The Guidelines for Diagnosis, Treatment, and Prevention of Viral Pneumonia are hereby issued together with this Decision.

Article 2These Guidelines apply to all state, semi-state, and private healthcare facilities.

Article 3This Decision shall take effect fifteen days from the date of publication in the Official Gazette. The Decision number 158/2004/QĐ-BYT dated December 15, 2004, issuing "Guidelines for Diagnosis, Treatment, and Prevention of Severe Respiratory Infections Caused by Influenza Viruses" is hereby repealed. 19/01/2004 Directors of the Office, Heads of the Treatment Department - Ministry of Health; Directors of hospitals and institutes under the Ministry of Health; Directors of health departments of provinces and centrally governed cities; Heads of health services of relevant sectors are responsible for implementing this Decision.

Article 4(Issued together with Decision No.: 3422/2004/QĐ-BYT

GUIDELINES FOR DIAGNOSIS, TREATMENT

AND PREVENTION OF VIRAL PNEUMONIA INFECTION

dated September 30, 2004, of the Minister of Health)

Influenza viruses have caused many large outbreaks worldwide with high mortality rates. There are three types of influenza viruses: A, B, and C, among which types A and B frequently cause illness in humans. Strains can change annually.

The most recent outbreak in Hong Kong in 1997, with high mortality, was caused by the H5N1 strain of type A virus. Recently, there have been several patients hospitalized due to the H5N1 strain of type A virus in our country. The disease progresses rapidly, does not respond to conventional treatments, and has a high mortality rate.

1. Epidemiological factors related:

I. DIAGNOSIS

Based on the following factors and symptoms:

Direct contact with sick poultry within seven days prior to onset or living in areas where sick poultry or livestock are present, or having contact with individuals suffering from influenza.

The disease presents acutely with symptoms such as:

2. Clinical Symptoms

High fever persisting continuously, possibly accompanied by shivering.

Signs of bacterial infection:

Coughing, usually dry cough, rarely showing signs of respiratory tract inflammation.

- Coughing, usually dry cough, chest pain, rarely upper respiratory tract inflammation symptoms.

Chest pain.

Difficulty breathing, cyanosis, severe cases may develop acute respiratory distress syndrome progressing rapidly.

Auscultation reveals moist rales, either present or absent.

Cardiovascular symptoms:

Rapid heart rate, sometimes progressing to shock, especially in the final stages.

Headache, muscle pain.

- Multiple organ failure.

May include:

Diarrhea.

Altered consciousness.

Multiple organ failure.

a. Chest X-ray (mandatory):

Extensive infiltration on one or both sides, progressing rapidly. Chest X-rays should be taken 1-2 times daily during the acute phase.

Depending on the time of imaging, the lesions vary. Initially, the lesions appear as localized interstitial pneumonia on one side, resembling lobar pneumonia but with unclear boundaries, then rapidly progress and spread to both sides. Repeated chest X-rays should be taken daily during the acute phase. b. Blood tests:

Complete blood count:

White blood cell count and neutrophils often decrease.

Platelet count may also decrease.

Arterial blood gas analysis: Hypoxemia occurs when the disease progresses severely:

PaO

Blood pH typically decreases in severe cases.₂ + Sample collection:₂. Deep throat swab₂ . Nasopharyngeal aspirate

Ultimately leading to acute respiratory distress syndrome.

c. Microbiological diagnosis:

Virus:

Sample collection:

Deep throat swab

Nasopharyngeal aspirate

Bronchoalveolar lavage fluid

Perform PCR to identify influenza A virus

+ Isolate bacteria according to standard procedures.

Conduct ELISA and passive hemagglutination to identify subtypes (H5N1)

Bacteria:

Culture pleural fluid, endotracheal aspirate, and blood if superinfection is suspected.

Collect samples as above

Isolate bacteria according to standard procedures

4. Criteria for diagnosing viral pneumonia:

a. Suspected diagnosis:

When all of the following criteria are met:Fever of 38°C

AND one of the following respiratory symptoms: cough, sore throat, difficulty breathing^°C

AND direct contact with sick poultry or individuals with influenza within seven days.

OR:

Death due to unexplained respiratory failure

- AND direct contact with sick poultry or individuals with influenza within seven days.

b. Probable diagnosis:

Meets the criteria for suspected diagnosis

AND at least one laboratory test suggestive of viral pneumonia:

Rapid ELISA positive for influenza A

Rapidly progressive chest X-ray findings consistent with influenza

c. Confirmed diagnosis:

Positive culture of respiratory specimens for influenza A/H5

OR: positive PCR result of respiratory specimens for influenza A/H5.

Suspected patients must be admitted and isolated.

B. Treatment of Acute Respiratory Failure

a) Patient Positioning

Suspected patients must be admitted and isolated.

Early administration of specific antiviral drugs should be provided for all cases meeting the criteria for suspected influenza A diagnosis.

Provide intensive respiratory support.

+ Non-rebreathing face mask: sufficient flow to prevent bag collapse during inspiration, indicated when simple face mask is ineffective.

1. General principles of management

a) As in the treatment of acute lung injury and progressive acute respiratory distress syndrome

b) Management of multiple organ failure if present

2. Steps for managing acute respiratory distress

c) Continuous Positive Airway Pressure (CPAP)

Place the patient in a 30-degree head-up position^° in a well-ventilated room

- Initiate CPAP:

Indication: all patients with viral pneumonia exhibiting shortness of breath and decreased oxygen saturation (SpO2, SaO2)₂, SaO₂).

Methods of oxygen therapy:

Oxygen via nasal cannula: 1-6 liters per minute to achieve SpO2₂ > 90%.

Oxygen via simple mask: 6-12 liters per minute when oxygen via nasal cannula does not maintain SpO2₂ >90%.

Non-rebreather mask: sufficient oxygen flow to prevent alveolar collapse during inspiration, indicated when simple mask is ineffective.

> 90%. Maximum CPAP level可达10 cmH2O。

CPAP is indicated when hypoxemia is not improved by oxygen therapy, SpO2₂ <90%.

Initiating CPAP:

Select appropriate mask (adult, older child) or nasal prongs (small child).

Start CPAP at 5 cmH2O.₂O

Adjust CPAP clinically in increments of 1 cmH2O₂- Principles of mechanical ventilation:₂ until SpO2 > 90%. Maximum CPAP level可达10 cmH2O。₂O.

d) Mechanical ventilation:

Indications:

CPAP or oxygen therapy does not improve hypoxemia (SpO2₂ < 90% with CPAP = 10 cmH₂O).

The patient begins to show signs of reduced alveolar ventilation such as cyanosis and rapid shallow breathing.

Principle of artificial ventilation: Oxygenation

Goal: FiO2₂ < 0.5 with SaO2₂ >90%.

Acceptable SaO2₂ > 85%.

Non-invasive artificial ventilation (BiPAP) (see Appendix 1):

Non-invasive artificial ventilation (BiPAP) is indicated when the patient has respiratory failure but remains conscious, cooperative, and able to cough effectively.

Invasive artificial ventilation (see Appendix 2):

Indicated when the patient has severe respiratory failure progressing to acute respiratory distress syndrome, metabolic acidosis, and non-invasive ventilation fails.

Set volume-controlled ventilation mode, with tidal volume (Vt) from 6-8 ml/kg, using positive end-expiratory pressure (PEEP) and adjusting FiO2₂ to achieve SpO₂ to 88-95%. Maintain plateau pressure below 30 cm H2O, not exceeding 35 cmH2O.₂For children, pressure-limited ventilation may be used. If ineffective, switch to volume-controlled ventilation.₂O.

Transport the patient to large resuscitation centers where invasive artificial ventilation with low tidal volume and increased minute ventilation can be performed.

Avian influenza A H5N1 often leads to more progressive respiratory failure than SARS and usually ends in multiple organ dysfunction syndrome. It is necessary to limit the development of multiple organ dysfunction syndrome (high-dose corticosteroids, high-energy nutrition, anti-anemia measures, stable circulation maintenance...).

C. Adjustment of fluid and electrolyte disorders and prevention of shock:

Ensure fluid intake of 70-80% of physiological needs evenly distributed over 24 hours. Solutions include: Ringer lactate, 0.9% sodium chloride.

Route: intravenous infusion.

If shock occurs:

Principle: Shock must be treated according to protocol.

Infuse 20 ml/kg over 30 minutes, reassess shock symptoms if condition worsens, infuse another 20 ml/kg over the next 30 minutes. Subsequently, vasopressors (dopamine, dobutamine) may be administered.

If shock persists despite adequate fluid resuscitation, use vasopressors: dopamine or dobutamine: 5-10

μg/kg/min; noradrenaline: 0.01-0.5 Granite, gabbro, decorative stone...μg/kg/min. Granite, gabbro, decorative stone...g/kg/min.

Corticosteroids: Methylprednisolone: 3-5 mg/kg/day ´ for 3-5 days, intravenous injection (Prednisolone 2 mg/kg/day, intravenous injection may also be used).

D. Supportive treatment:

1-Fever

Loosen clothing, remove blankets, apply cool compresses.

Administer antipyretics when temperature exceeds 38.5°C with paracetamol orally or rectally, dose 15 mg/kg every 4 hours (Do not use aspirin).^°5 with oral or rectal paracetamol, dose 15 mg/kg every 4 times/day (Do not use aspirin).

2. Ensuring nutritional care:

Nutrition:

Mild patients: oral feeding.

Severe patients: enteral feeding with milk and nutritional supplements (Ensure, Isocal) through a nasogastric tube.

Pressure ulcer prevention:Use water mattresses, massage, and change positions regularly.

Respiratory care: Assist the patient in coughing and expectoration; perform chest percussion.

3. Platelet transfusion: 10 ml/kg when bleeding occurs and platelets < 80,000/mm3.³.

E. Antibiotic treatment

1. Antiviral drugs: Oseltamivir (Tamiflu):

Children aged 1-13 years: oral solution based on body weight: < 15 kg: 30mg twice daily; 16-23 kg: 45 mg twice daily; 24-40 kg: 60 mg twice daily for 5 days. ´ Adults and children over 13 years: 75 mg

twice daily ´ for 5 days. ´ 5 days

Monitor liver and kidney function to adjust dosage accordingly.

2. Broad-spectrum antibiotics against hospital-acquired infections:

May use a broad-spectrum antibiotic (Tienam, Tazocin, Timentin) or combine Ceftazidime + Amikacin.

F. Discharge Criteria

Discontinue antibiotics after 7 days without fever.

Good overall condition.

Stable blood tests, chest X-rays.

III. INFECTION CONTROL

1. Principles

Implement strict isolation and infection control measures. Healthcare workers must direct suspected patients to designated healthcare facilities for examination, classification, and isolation if necessary upon discovery.

2. Isolation area organization in hospitals

Organize isolation areas as for other dangerous infectious diseases.

Limit access to isolation areas.

Place a basin of 5% chloramine B or 0.5% chlorhexidine solution at the entrance of the ward for hand washing before entering and after leaving, and place a cloth soaked in chloramine B or formaldehyde at the floor entrance so that everyone must walk through it.

3. Prevention for patients and visitors

Isolate suspected patients in single rooms immediately upon detection.

Confirmed patients should be placed in single rooms and not share rooms with suspected patients.

All patients must wear standard masks. Suspected patients must wear standardized masks both inside and outside the ward.

Patients requiring X-rays, laboratory tests, and specialty consultations should be conducted at the bedside. If conditions do not permit, prior notification to relevant departments is required for medical staff to prepare protective equipment. Patients must wear masks and gowns during transport within the hospital.

Limit family visits to hospitalized patients. Prohibit family members and visitors from entering isolation areas.

Family members visiting patients outside isolation areas must wear masks.

Place a basin of 5% chloramine B or 0.5% chlorhexidine solution at the entrance of the ward for hand washing before entering.

4. Prevention for healthcare workers

Protective equipment includes: N95 masks, protective goggles, full-face shields, single-use paper gowns, gloves, caps, shoe covers or boots.

Each staff member in the strict isolation area must be provided with and wear all personal protective equipment before contacting patients and respiratory secretions at the start of their shift. After the shift ends, they must dispose of the personal protective equipment in the waste bin and handle it as infectious medical waste, then shower and change clothes before leaving the hospital.

Specimens for testing: Must be placed in a plastic bag or transport container as prescribed before being sent to the laboratory.

Surveillance: Compile a list of healthcare workers directly caring for and treating patients and those working in departments with patients. These employees will self-monitor daily. Those showing signs of suspected infection will be examined, tested, and monitored like suspected severe influenza patients.

Immediately report suspected and confirmed cases to the local Preventive Health Center and the Ministry of Health.

5. Handling medical equipment, textiles, and patient-use items:

Medical equipment: Equipment that is reusable must be disinfected immediately, then transferred to the cleaning room for washing and sterilization according to regulations.

Patient equipment: must be washed and sanitized with soap and disinfectants daily and each time they become soiled. Each patient has separate equipment for hygiene and nutrition services.

Textiles: Steam under pressure before washing. Apply handling and processing methods as for contaminated textiles. Collect textiles in yellow plastic bags before transporting them to the laundry. Soak textiles in detergent solutions. Add more detergent concentration during washing if necessary.

6. Environmental and hospital waste management

Follow the procedures for environmental and waste management as prescribed for contaminated cases.

7. Patient transport

Principles:

Limit patient transportation.

Transport patients only when their condition exceeds the treatment capacity of the facility.

Ensure safety for patients and those transporting them (drivers, healthcare workers, family members, etc.) following the guidelines in the disease prevention section.

Staff transporting patients must wear complete personal protective equipment: N95 masks, single-use gowns, full-face shields, gloves, caps.

Disinfect ambulances with standard disinfectants after each patient transport.

8. Handling deceased patients

Deceased patients must be embalmed on-site according to epidemic prevention regulations, using disinfectants such as chloramine B and formaldehyde.

Transport deceased patients to burial or cremation sites in dedicated vehicles and ensure compliance with infection control regulations.

Within 24 hours after death, cremation or burial must occur, preferably cremation.

9. General preventive measures:

Personal hygiene, nasal irrigation, mouth and throat rinsing with antiseptic medications.

Take vitamin C.

10. Specific disease-preventing vaccines:

Currently, there is no specific vaccine for the H5N1 strain of avian influenza virus.