DISEASE CONTROL DIVISION

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

1.

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.

2.

3.

OBJECTIVE
General:

To enhance the surveillance system for detection of

Influenza A (H1N1) in human

Specific:

1.

To establish a mechanism for the urgent reporting of

potential Influenza A (H1N1) cases from health care
workers and members of public.

2.

To facilitate early detection and response towards

Influenza A (H1N1) cases/ outbreak.

3.

To maintain a heightened awareness of potential

Swine Influenza cases among clinical staff in private
and public clinics, and hospitals.

4.

To establish a local network of professionals working

in communicable diseases to response to Influenza A
(H1N1).

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.

4.

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/

ii.

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.

iii.

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.
3

5.

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.

6.

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.

7.

ENHANCED SURVEILLANCE FOR INFLUENZA A (H1N1)

7.1

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.

7.2.

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
5

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.

7.3

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.

8.

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.

9.

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)

10.

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.

11.

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