/ State Protocol for Swine Flu (HINt), West Bengal, December-2017

The following is a protocol for laboratory diagnosis & anti-viral therapy of H1Nl based on case
categorization. This is in partial modification of the protocol issued in 2016. The same is to be
adhered to by all concerned coming within the jurisdiction of the Department of H&FW, GoWB until
further order:-

Categorization of ARI/ILI Cases:-

ARI = acute respiratory infection; III = influenza-like illness.

1. Category A : Patients with mild fever and cough / sore throat with or without other
symptoms like diarrhoea, headache, body ache etc.
2. Category B (i) : Patients with clinical features of category A but having high fever and
severe sore throat.
3. Category B (ii) : In addition to all the signs and symptoms mentioned under Category A,
individuals having one or more ofthe following high risk condition.
a) Children with mild illness but with predisposing risk factors.
b) Age >= 65 yea rs.
c) Pregnancy.
d) Patient having co-morbidity like lung disease, heart'disease, liver disease, kidney
disease, neurological disorder, metabolic disorder including diabetes, blood disorder,
cancer, HIV/AIDS ..... (for details see the Guidelines on care & prevention of H1Nl).
e) Patients with immuno-suppressed or immune-compromised status including severe
malnutrition.
f) Patient on long term steroid therapy.
g) Persons who are extremely obese (BMI ~40).
4. Category C : In addition to the above signs and symptoms of Category A or B, if the
patient has one or more of the following :-
• Breathlessness, chest pain, drowsiness, fall in blood pressure, sputum mixed with
blood or bluish discoloration of nails.
• Children with influenza like illness who had a severe disease as manifested by the red
flag signs(Somnolence, high and persistent fever, inability to feed well, convulsions,
shortness of breath, difficulty in breathing etc.

• Worsening of underlying chronic conditions.

Category-wise steps:-

Category A:

No anti-viral drug will be given.

General treatment, as given for any mild ARI, will be advised.
The Case will preferably get itself re-assessed by a doctor at 24-48 hours.
He should be advised to confine himself at home and avoid mixing up with public and high risk
members in the family. The patient/party should be so advised that in case the sore throat
becomes severe or there is appearance of severe symptoms (as suggestive of Category C),
medical attention should be sought for without any delay.

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Category B (i)

• A clinician, on finding a case of III of category B (i), will advise admission of the case.
Cases belonging to this category should be, after admission to IPD, dealt as Category C so far as
testing for H1N1 & anti-viral therapy are concerned. Clinical sample(s) will be taken and sent in
VTM to the designated laboratory for confirmation of H1N1.' Proper methods of sample
collection, packaging & transportation have to be followed. Oseltamivir should be started in
such cases without waiting for the test report for HINI.

Category B (ii)

• Cases belonging to Category B (ii) should be put on oseltamivir therapy as early as possible.
1. However, if admission is not required at the point of time, and the patient is put under
domiciliary treatment, he should confine himself at home and avoid mixing up with
public and high risk members in the family till 8 to 10 days from the day of disease onset.
If during domiciliary care he becomes ill and hospitalization is necessary, he is to be
admitted and managed as B(ii) (2)
2. If the clinical condition demands so, the case should be admitted to a health institution
having the necessary arrangements. Clinical samples will have to be sent to the
designated laboratory for test of H1N1 even if oseltamivir has been started earlier. If
Oseltamivir has not yet been started, it should be started in such cases immediately
without waiting for the test report for H1N1.

Category C:

Cases belonging to this category would require admission per se for management of their
critical/severe condition. Sample(s) will be properly collected, packaged & transported in V.T.M.
to the designated laboratory for confirmation of H1N1.
Patient has to be kept in isolation. Oseltamivir should be started immediately (if not started
earlier) after sending sample(s) for lab confirmation of H1N1. Oseltamivir should be started in
such cases without waiting for the test report for H1N1.

Contacts of confirmed HINI cases:

A. Asymptomatic contacts have to be kept under regular watch. If they develop symptoms of III
within 7 days of known exposure to a lab-confirmed case of H1N1, they have to be dealt with
like Category B (ii) (1) so far as H1N1 testing & oseltamivir therapy are concerned.

B. Close contacts (e.g. family contacts) of a lab-confirmed H1N1 case, who are pregnant or have
risk factors as mentioned in (a), (d) or (e) under Category B (ii), should be given
chemoprophylaxis with oseltamivir in the dosage as shown below.

Age Dose for ,10 days

(years)
Body weight (kg)

::;; 15 1-2 30 mg once daily

>15-23 3-5 45 mg once daily

,
>23-40 6-9 60 mg once daily

>40 10-12 75 mg once daily

2
 ..
Body weight (kg) Dose by age Recommended treatment dose for 10 days (@12 mg/ml
of commercially manufactured Oseltamivir Oral
Suspension)

Dosing for infants < 3 months Not recommended unless situation judged critical
younger than 1 year (not ;

based on weight) 3-5 months 20 mg (1.6 ml) once daily

6-11 months 25 mg (2ml) once daily

laboratory Request:-

Samples being sent for lab diagnosis of H1Nl must be accompanied by a lab request
mentioning the following points:-

(a) Particulars of the patient (name, age, sex, name of guardian/husband, detailed address,
contact phone no. etc.
(b) Name of the hospital where admitted along with date of admission, registration no.,
ward name (if any), bed no. & name of the doctor under whom admitted.
(c) Relevant signs & symptoms of the patient and co-morbidity (if any)
(d) Mention as 'pregnant' if known to be so.
(e) History of specific exposure to H1Nl case (if any) with date
(f) Mention of the category of HINI management - Category C / B(i) / B(ii)
(g) Name of the doctor sending the sample (in legible writing) & his signature.

It may please be noted that unless the above conditions are fulfilled, samples may not be
received at the laboratory of STM/ NICED, Kolkata.

Drug Requisition :-

Each District, Health District & Medical College Hospital are supposed to procure their own
requirement of oseltamivir round the year with provision for a reserve stock to meet any emergency
situation. For non-CMS drugs (Oseltamivir 30mg Cap & Suspension) the district will send requisition
to the PH & CD Branch of the Directorate in Swasthya Bhawan.

Dosage of Oseltamivir :-

The recommended dosage as per the national guideline is laid down hereunder. **
Does (based on body weight):

./ ~ 40 Kg - 75 mg BD for 5 days
./ 24- <40 Kg - 60 mg BD for 5 days
./ 15- <24 Kg - 45 mg BD for 5 days
./ < 15 Kg - 30 mg BD for 5 days
For infants:
./ < 3 months -12 mg BD for 5 days
./ 3 - < 6 months - 20 mg BD for 5 days
./ 6 - < 12 months - 25 mg BD for 5 days
** According to WHO, consideration should be given to the use of higher doses, such as 150 mg
twice daily (for adults), and longer duration of treatment depending on clinical response,

especially in cases having immunosuppression. • ~~~\\ilf

~ ",\l~')' _ '\
ft \ ) (f)" 6asis (]3fiattacfiaryya 'rector of Health Se ices & Ex-officio Secretary
crrof~(j)r. Jv . \ Education
Directorof Me?t~a&.
FamilYWelfare
.
wasthya Bhavan,
Salt Lak Kol91
e,-
oepartment of H~aof west Bengal 3 Government of West Bengal
Govetnmen
/
Guidelines on care & prevention of HINI & other Seasonal Influenzas

A. Guideline for clinical management

Incubation period
Incubation period is 1- 4 days (typically 2-3 days).

Period of Communicability

From 1 day before and up to 7 days after the onset of symptoms. Viral shedding peaks on day
1 of the symptoms. If illness persists for more than 7 days, chances of communicability may
persist till resolution of illness. Viral shedding is proportional to severity of illness, influenced
by age, level of immunocompetence and treatment. Mild cases can also shed influenza virus.
Children and immuno-suppressed/ immune-compromised patients affected with influenza
may spread the virus for a longer period.

Symptoms
The hallmark of influenza is the sudden, rapid onset of symptoms. Influenza symptoms may
include fever, chills, body aches, sore throat, non-productive cough, runny nose and headache.
Gastrointestinal symptoms and muscle inflammation occur more often in young children, and
infants can present with a sepsis-like syndrome.

Physical findings
The following signs may be present.

Fever: rapid onset, peaking at 38.4°C (up to 41°C, especially in children), typically lasting 3
days (up to 4-8 days), gradually diminishing

Face: flushed
Skin: hot and moist
Eyes: watery, reddened
Nose: nasal discharge
Ear: otitis Mucous membranes: hyperaemic
Cervical lymph nodes enlargement: (especially in children)

Course of Illness
Severity varies from afebrile symptoms mimicking common cold to severe prostration
without major respiratory signs and symptoms, especially in the elderly. Fever and systemic
symptoms typically last 3 days, occasionally 5-8 days, and gradually diminish. Cough and
malaise may persist more than 2 weeks. Full recovery may take 1-2 weeks or longer,
especially in the elderly.

Complications

In infants and children complications include sinus or ear infections, viral and bacterial
pneumonia, bronchiolitis, croup, dehydration (with or without diarrhoea), febrile seizures, and
worsening of underlying chronic conditions. Immediate hospitalization, assessment and
management may be required for exacerbation of chronic disease, severe dehydration, sepsis-
like syndrome, respiratory complications (bronchiolitis, croup, reactive airway disease, and
pneumonia), rhabdomyolysis, encephalopathy/encephalitis and cardiac complications such as

1
myocarditis and pericarditis. Reye syndrome (with aspirin use), toxic shock syndrome and
sudden death (may be due to cytokine dysregulation) have also been reported.

In adults and elderly, exacerbation of chronic illness like cardiac diseases (congestive cardiac
failure, coronary artery disease), chronic pulmonary disease (COPD), metabolic disease (e.g.
diabetes) etc. is the most common reason for hospitalization due to complications from
influenza. Respiratory complications include bronchitis, sinusitis, reactive airway disease and
pneumonia. There may be invasive bacterial co-infection (sepsis, pneumonia), mainly from
Staphylococcus aureus (MRSA, MSSA), Streptococcus pneumoniae, Group A Streptococcus
and Haemophilus influenza. In geriatric age group, viral pneumonia is common.

High Risk Groups

Pregnant women and elderly above 65 years are at higher risk of acquiring influenza! severe
disease. Apart from co-morbidities like chronic pulmonary or cardiovascular disease, renal
dysfunction & chronic metabolic diseases, haemoglobinopathies, chronic neurological
conditions (that impair breathing or clearance of respiratory secretions) and immune-
suppression! immune-compromisation are risk factors too.

Investigations
Routine investigations may include haematological, biochemical, radiological and
microbiological tests as necessary for evaluation and management of a patient. Confirmation
of seasonal influenza (including HINI) infection is through:

• Real time RTPCR or

• Isolation of the virus in culture or
• Four-fold rise in virus specific neutralizing antibodies.

The first of the above only is available at present in govt. health system or approved private
laboratories in the State. For confirmation of diagnosis, clinical specimens such as
nasopharyngeal swab, throat swab, nasal swab, wash or aspirate, and tracheal aspirate (for
intubated patients) are to be obtained. The sample should ,be collected by a trained
physician/microbiologist/technical or nursing staff, preferably before administration of the
anti-viral drug. Keep specimens at 4 C in viral transport media until they reach the designated
0

laboratory. The samples should be transported to the laboratory within 24 hours. If they
cannot be transported, they need to be stored at (-) 70°C.

Treatment
The guiding principles are:
~ Early implementation of infection control precautions to muunuze nosocomial/
household spread of disease
~ Prompt treatment to prevent severe illness & death.
~ Early identification and follow up of persons at risk.

Isolation facility: If dedicated isolation room is not available for individual patients of ILl
(awaiting confirmation of BINI), then patients can be cohorted in a well-ventilated isolation
ward with beds kept one metre apart. Confirmed cases of BINI of the same gender may be
kept together in a single (isolation) ward.

2
Standard Operating Procedures
~ Reinforce standard infection control precautions i.e. all those entering the room must
use hand washing practices, high efficiency masks, gowns, goggles, gloves, cap and
shoe cover.
~ Restrict number of visitors and provide them with PPE.
~ Provide antiviral prophylaxis to unprotected / unvaccinated / accidently exposed
health care personnel managing a case and ask them to monitor their own health twice
a day. Dispose waste properly by placing it in sealed impermeable bags labelled as
Bio-Hazard.

Oseltamivir therapy
Already discussed in State Protocol along with categorization.

Supportive therapy

• IV Fluids.
• Parenteral nutrition.
• Oxygen therapy/ ventilator support.
• Antibiotics for secondary infection.
• Vasopressors for shock.
• Paracetamol or ibuprofen is prescribed for fever, myalgia and headache.
• Patient is advised to drink plenty of fluids.
• Smokers should avoid smoking. For sore throat, short course of topical decongestants,
saline nasal drops, throat lozenges and steam inhalation may be beneficial. Salicylate /
aspirin is strictly contraindicated in any influenza patient due to its potential to cause
Reye's syndrome.
• The suspected cases would be constantly monitored for clinical/radiological evidence
of lower respiratory tract infection and for hypoxia (respiratory rate, oxygen
saturation, level of consciousness).
• Patients with signs of tachypnea, dyspnoea, respiratory distress and oxygen saturation
less than 90 per cent should be supplemented with oxygen therapy. Types of oxygen
devices depending on the severity of hypoxic conditions, can be started from oxygen
cannula, simple mask, partial re-breathing mask (mask with reservoir bag) and non re-
breathing mask. In children, oxygen hood or head boxes can be used.
• Patients with severe pneumonia and acute respiratory failure (Sp02 < 90% and Pa02
< 60 mm Hg with oxygen therapy) must be supported with mechanical ventilation.
Invasive mechanical ventilation is preferred. on-invasive ventilation is an option
when mechanical ventilation is not available. To reduce spread of infectious aerosols,
use of HEP A filters on expiratory ports of the ventilator circuit! high flow oxygen
masks is recommended.
• Maintain airway, breathing and circulation (ABC).
• Maintain hydration, electrolyte balance and nutrition.
• If the laboratory reports are negative, the patient would be discharged after giving full
course of oseltamivir. Even if the test results are negative, all cases with strong
epidemiological criteria need to be followed up.
• Immunomodulating drugs have not been found to be beneficial in treatment of ARDS
or sepsis associated multi organ failure. High dose corticosteroids in particular have no
evidence of benefit and there is potential for harm. Low dose corticosteroids

3
 --------~~----------------.-

(Hydrocortisone 200-400 mg/day) may be useful in persisting septic shock (SBP <
90).
• Suspected case not having pneumonia do not require antibiotic therapy. Antibacterial
agents should be administered, if required, as per locally accepted clinical practice
guidelines. Patient on mechanical ventilation should be administered antibiotics
prophylactically to prevent hospital associated infections. '
Protocol for the ventilator management of patient with ALIIARDS following Seasonal
Influenza

• Indications for Mechanical Ventilation:

• Severe Respiratory Failure
•
• Failure to achieve oxygen saturation of> or equal to 90% (or p02 of> or equal to 60
mm Hg) on an FI02 < 0.6.
• Ventilator Settings:
• Pressure pre-set (controlled)
.• Low tidal volume ventilator support
• Tidal volume - 6 ml/kg ideal body weight (Respiratory rate to a maximum of 30- 35
per minute).
• Open lung strategy of ventilation with PEEP titration to keep the lung recruited to
achieve an FI02 of < 0.5 and a saturation of> 90% or a Pa02 of> 60 mmHg
• Plateau (Pause) pressure not to exceed of> 30-35 mmHg.
• Alternative modes of ventilation APRV (Airway Pressure Release Ventilation), IRV
I

(Inverse Ratio Ventilation) in patients with persistent Hypoxemia (Sp02 of < 88-90%
with high PEEP & PI02 > 0.8).
• Rescue therapy - recruitment manoeuvres, Sedation, Neuromuscular Blockage &
Prone Ventilations can be considered if above oxygen goals are not met.

B. Guidelines for Providing Home Care

In outbreak situations large number of patients attends hospital and the services may be
overwhelmed. To avoid such situation, categorization of patients by risk needs to be done for
which guidelines have been laid down.
Domiciliary care would be sufficient for patients of Category A and also some of B(ii). The
following guidelines would be relevant in such cases. '
Patient should be counselled for to:

~ stay home for seven days, preferably isolate himself / herself in a well-ventilated
room. Avoid common areas frequented by other family members of the family. If the
living space is small and more than one person need to sleep in a room, ensure that the
head end of patient and others sleeping in that room are in opposite direction (head to
toe).
~ wear mask all the time. Three layered surgical mask should be provided by the
hospital/community health worker at the time of screening. If mask is not readily
available, mouth and nose should be covered with a piece of cloth or handkerchief.
The mask or handkerchief should be changed every six hours or earlier if it gets wet.
~ avoid smoking.
~ avoid close contact with others. If inevitable, they should always maintain an arm's
length (at least one metre).

4
 ~ avoid having visitors and avoid hand shaking.
~ wash hands frequently with soap and water.
~ be monitored to assess worsening of symptoms.
~ take plenty of fluids.
~ follow cough etiquettes whenever mask is not worn/not available -
- Cover mouth and nose with a tissue/ handkerchief when coughing or sneezing;
Not to spit/blow nose here and there, use a water filled receptacle for collecting
sputum, thereby minimizing aerosol generation.

Medication during Home Care

Medicines should be taken as advised by the doctor.
Aspirin should not be given for fever or body ache, as it may cause Reye syndrome (hepatic
encephalopathy) in presence of influenza, particularly in children,

Precautions to be taken by Care Giver

The care provider should
. ~ wear triple layer surgical mask;
~ wash hands frequently.

Early warning signs/ symptoms for hospitalization

The early warning signs in adults are:
• High grade fever not responding to antipyretics
• Difficulty in breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness, Confusion and
• Severe or persistent vomiting.
The early warning signs in children are:
• Fast breathing or trouble breathing
• Bluish skin colour
• Not drinking enough fluids
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• High fever with rash.
These signs/ symptoms needs to be identified early for immediate start of treatment and
hospitalization. Most of the adverse outcomes occur because oflate reporting to hospital.

* If fever is not responding, there is worsening of symptoms and in particular altered

sensorium (confusion, incoherent speech etc) / loss of consciousness or difficulty in
breathing, patient should be referred to nearest identified health facility.
* In particular, patients with co-morbid condition (hypertension, diabetes, bronchial
asthma, chronic bronchitis or Obstructive airway diseases, jmmune-compromised
status etc) need to be observed for worsening of symptoms.

Infection Control
The infection control practices listed in the guiding principles would be followed including
frequent hand wash, cough etiquettes, maintaining arm's length distance from others.
The contact surfaces would be disinfected by wiping, with sodium hypochlorite solution or
with household bleach (5%) solution.

5
Masks, tissue papers should be disposed of in dustbins. Hands should be washed after
handling these wastes.
Utensils used by the case should not be used by others without washing.
Wash hands with soap and water before and after handling linens and towels used by the
patient.
Preventive care for the contacts
All the contacts need to self monitor their health.

Indications of testing for H1N1 and preventive anti-viral medicine are mentioned in "Contacts
of Confirmed H1N1 Cases" in State Protocol for Swine Flu, WB, December-2017.

c. Guidelines on use of masks

Masks are personal protective devices which if used correctly would protect the user from
contracting Seasonal Influenza or for that matter, any other aerosol/droplet borne/air-borne
infe.ction.There are two types of masks which are recommended for various categories of
personnel depending upon the work environment:

1. Triple layer surgical mask 2. N 95 Respirator.

The specifications of these masks are in the table below.

The use of these masks in context of the work setting is enumerated below:

1. Hospital Setting
(a) Screening Area: All medical personnel including nursing and paramedical staff would
use Disposable Triple layer surgical mask while interacting with patients.
(b) Isolation Ward: All patients kept in the isolation wards must wear disposable Triple layer
surgical mask. Medical and nursing staff involved in Clinical Care in isolation facilities
would require Triple layer surgical mask, along with other Personal Protective
Equipments (PPE). However, if the staff is involved in any aerosol generating procedure
like suction, intubation, nebulization, etc. or collection of clinical samples from patients,
they must use N95 Respirator.

(c) Critical Care Facility: Medical and nursing staff involved in critical care in Intensive Care
Unit should use N 95 Respirators.
(d) Laboratory: All personnel working in laboratories and handling clinical samples related
to Influenza should use N 95 Respirators.
(e) Mortuary: Personnel involved in handling dead bodies of. suspect/confirmed cases of
Seasonal Influenza should use Triple layer surgical mask, along with other infection
control practices.

(f) Ambulance Staff: Staff of the ambulance earmarked for transporting patients of Influenza
should use Triple layer surgical mask. The paramedic in the patient cabin should also use
Triple layer surgical mask and if performance of any aerosol generating procedures is
contemplated (suction, oxygen administration by nasal catheter, intubation, nebulization
etc) N 95 respirator should be used.

6
2. Health Workers in Community Setting
(a) Doctors in screening centreslPrivate practitioners attending Influenza Like Illness (ILl) in
general practice and other health workers working with them should use Triple layer
surgical mask.
(b) Health workers involved in community surveillance, contact tracing and health monitoring
of cases at home or home quarantine should use Triple layer surgical mask.

3. Security personnel
Security personnel working in an infected/ potentially infected area for example Influenza
ward in a hospital, screening centre etc should use Triple layer surgical mask.

4. Members of Public
There is no scientific evidence to show health benefit of using triple layer masks for members
of public. In fact erroneous use of masks or continuous use of a disposablemask for longer
.than 6 hours or repeated use of same mask may actually increase risk of infection further.

Suspect! probable/confirmed cases of influenza should use Triple layer surgical mask. The
I

care provider in home care settings should use triple layer mask. Close family contacts of
such cases undergoing home care should also use Triple layer surgical mask.

Do-s and Don't-s

1. The correct procedure of wearing triple layer surgical mask:

• Unfold the pleats; make sure that they are facing down.
• Place over nose, mouth and chin.
• Fit flexible nose piece over nose bridge.
• Secure with tie strings (upper string to be tied on top of head above the ears -lower
string at the back of the neck.)
• Ensure there are no gaps on either side of the mask, adjust to fit.
• Do not let the mask hanging from the neck.
• Change the mask after six hours or as soon as they become wet.
• Disposable masks are never to be reused and should be disposed off.
• While removing the mask great care must be taken not to touch the potentially infected
outer surface of the mask
• To remove mask first untie the string below and then the string above and handle the
mask using the upper strings.
2. Disposal of used masks
Used mask should be considered as potentially infected medical waste. In the hospital setting
it should be disposed off in the identified infectious waste disposal bag/container. In
community settings where medical waste management protocol cannot be practiced, it may
be disposed off either by burning or deep burial.

3. Triple layer mask should not be re-used. Masks used by patients / care givers/ close
contacts during home care and should be disinfected using ordinary bleach solution (5%)
or sodium hypochlorite solution (1%) or appropriate concentration of Quaternary
Ammonium household disinfectant (e.g. Savlon) and then disposed off either by burning or
deep burial.

7
4. Health facilities should adopt appropriate Bio-medical Waste Management practices for
disposal of used masks.

Specification for Masks

Item Specification
Triple Layer Surgical Mask Tie on Mask of Non-woven, Hypoallergenic 3 ply
construction with filter in between offering >99
percent standard with 4 tie strings
N-95 Face Respirator Mask. Filter efficiency of 95 % or more against particulate
aerosols. The mask should be provided with expiration
valve. It should be disposable & to be able to fit for
wide range of face sizes. It should accompany with
certification from NIOSH or any other internationally
accepted certification.

D. Guideline on Influenza Vaccine

Over the years, evidence has been established globally on the protection provided by Seasonal
Influenza Vaccine, in particular for those at higher risk. It helps protect women during
pregnancy and their babies up to six months and among vaccinated, reduction in influenza
related hospitalizations across all age groups is expected.

Selection of Vaccine
The Indian Council of Medical Research (1CMR) has recommended on the following
Seasonal Influenza vaccine composition, for the period 2017-2018. So, persons intending to
take an Influenza Vaccine should go for a Trivalent vaccine that contains:
~ an AlMichiganl4512015 (HIN1)pdm09-like virus
~ an AlHong Kong/4801l2014 (H3N2) -like virus
~ a B/Brisbane/60/2008-like virus.
It may be noted that the ICMR recommendations are in line with those recommended by
WHO for Seasonal Influenza Vaccine composition 2017-18. This vaccine is expected to offer
good effectiveness against currently circulating subtypes of Influenza. Further, this vaccine
has the approval of Drug Controller General (1).
Frequency of vaccination - Yearly.
Limitations of the Influenza Vaccination
Influenza vaccination is most effective when circulating viruses are well-matched with
vaccine viruses. Even with appropriate matching, efficacy of vaccine may be about 70% to
80%. In case the locally circulating virus is different from vaccine virus recommended by
WHO, it may be partially effective or not be effective at all. Hence, vaccine should not give a
false sense of security. Considering the risk perspective, the modalities of infection prevention
and control practices like personal hygiene, frequent washing of hands, respiratory etiquettes
and airborne precautions (in hospital or domiciliary care settings) should be strictly adhered
to.
The available vaccine takes about 2-3 weeks for development of immunity.

~ ~,", >'

(prof ((]Jr.)(]Je6asis CBfiattacfiaryya

W '~\l~ yY
Director of Health Services & Ex-officio Secretary
Swasthya Bhavan, Salt Lake, Kol-91
[)irpctor of Medical Education 8 Government of West Bengal
rf ""''1IHl & Family Welfare
• ""I •.... ""'=tt