Hot Topic Meeting by:

Royal College of Physicians of Edinburgh & The Scottish Executive Health Department

Pandemic Flu

Planning Scotland’s Health Response

5th June 2007

Queen Mother Conference Centre

June – 2007 2

Care of the Vulnerable Care of the Vulnerable Population: ChildrenPopulation: Children

Dr. James Paton Royal Hospital for Sick Children

Glasgow

June – 2007 3

Care of Vulnerable Population - Care of Vulnerable Population - ChildrenChildren

• Clinical Presentations

• Triage and Severity Assessment

• Recommended treatments – Part 1

• Investigations in Hospital

• Recommended treatments – Part 2

• Ethics & Staffing during a pandemic

June – 2007 4

June – 2007 5

Fleming, D M et al. Arch Dis Child 2005;90:741-746

June – 2007 6

Clinical Characteristics of RSV and Clinical Characteristics of RSV and ‘Flu in Hospitalised Children‘Flu in Hospitalised Children

Meury et al Eur J Pediatr 2004; 163:359-363

June – 2007 7

Bhat, N. et al. N Engl J Med 2005;353:2559-2567

Timing of 153 Cases of Fatal Influenza in Timing of 153 Cases of Fatal Influenza in Children – US 2003-04Children – US 2003-04

June – 2007 8

Whose at Risk?Whose at Risk?• Impact of Age

• Impact of pre-existing medical conditions

June – 2007 9

'Flu Mortality Rate According to Age 'Flu Mortality Rate According to Age Group – US 2003-04Group – US 2003-04

Bhat, N. et al. N Engl J Med 2005;353:2559-2567

June – 2007 10

Izurieta H et al. N Engl J Med 2000;342:232-239

Relative Risk of Admission in Children without Relative Risk of Admission in Children without High Risk ConditionsHigh Risk Conditions

June – 2007 11

Bhat, N. et al. N Engl J

Med 2005;353:2559-2567

Underlying Health Status in Children with Fatal Underlying Health Status in Children with Fatal Influenza – US 2003-04 (n- 149)Influenza – US 2003-04 (n- 149)

June – 2007 12

Triage and General Management in 1ry Triage and General Management in 1ry CareCare

• Recognition of ‘At Risk Groups’• Assessment of Illness Severity• Current advice and guidance on

epidemiology of pandemic

June – 2007 13

Severity Assessment (CURB 65) in Adults

Item Measure ScoreConfusion Mental test score ≤8 Urea >7mmol/l

Respiratory Distress

Respiratory Rate ≥30/min

Blood Pressure

SBP <90mmHg or DBP ≤60mmHg

Age - >65yr Age ≥65yr

June – 2007 14

Respiratory Distress – Severity Assessment in Children

Mild Severe

Infants Temp >38.5 ⁰CMild Respiratory Distress Taking Full Feed

Temp >38.5 ⁰CSevere Respiratory DistressCyanosisGrunting / ApnoeaNot feeding

Children Temp >38.5 ⁰CMild Respiratory DistressNo vomiting

Temp >38.5 ⁰CSevere respiratory DistressCyanosisGruntingSigns of dehydration

Appendix 8 Thorax 2007;62: Supplement 1

June – 2007 15

Severity Assessment in Children

Item Measure ScoreTemperature >38.5⁰CConfusion Complicated or prolonged seizure;

Altered conscious levelUrea Dehydration - Older Children

Respiratory Distress

↑Rate, Recession, Nasal Flaring, Cyanosis, Grunting, ApnoeaNot feeding

Blood Pressure

Signs of Shock – extreme pallor, hypotension, floppy infant

Age - >65yr Age <1yr

June – 2007 16

See CHP(Nurse or Doctor if Child <7yrs)

Cough, fever and/or 'flu-like symptoms

Temp >38.5 deg C

Age <1yr or Child atRisk of Complications

Refer to GP

Yes

Yes

Treat at home withantipyretics and fluids

No

Antipyreticsand fluids

Symptoms <2 daysNo No

Triage & General Management in 1ry CareTriage & General Management in 1ry Care

Thorax 2007;62:Supplement 1

June – 2007 17

Specific Treatment - Anti-Viral TherapySpecific Treatment - Anti-Viral Therapy• Amantidine / rimantidine

• Neuraminidase inhibitors– Oseltamivir (Tabs & liquid)

• Effective if given within 2 days of start of illness• Reduction in time to alleviation of symptoms• Reduction in complications requiring antibiotics• Note - faster drug clearance in younger children• Not licensed under 1 year - but Japanese experience

suggests is safe– Zanamavir (inhaler – so children >5yrs)

• Ribavirin

June – 2007 18

See CHP(Nurse or Doctor if Child <7yrs)

Cough, fever and/or 'flu-like symptoms

Temp >38.5 deg C

Age <1yr or Child atRisk of Complications

Refer to GP

Yes

Yes

Treat at home withantipyretics and fluids

No

Antipyreticsand fluids

Symptoms <2 daysNo No

Chronic Disease?

or Breathing Difficulties Severe earache Vomiting > 24hrs Drowsiness

Is the Child Severely Ill?

Oseltamivir,antipyretics and fluids

Antipyreticsand fluids

Symptoms <2 daysNo

Oseltamivir,antipyretics and

fluids

Age<1yr?

If deterioratesAntipyretics,

fluids & (antibiotics)

NoNo

Yes

Yes

Yes

Yes Yes

Refer for Hospital AdmissionYes

June – 2007 19

Triage of Children in HospitalTriage of Children in Hospital• Assessment of Illness severity• Admit to ward if:

– Severe respiratory distress; Hypoxia– Severe dehydration– Altered conscious level or prolonged seizure– Signs of septicaemia

• Consider HDU/ICU– Worsening hypoxia despite oxygen– Worsening respiratory failure– Apnoea or slow/irregular breathing– Encephalopathy

• If no ICU Beds?

June – 2007 20

Investigations for Children in HospitalInvestigations for Children in Hospital

• Pulse oximetry• CXR

– if hypoxic or severely ill, or deteriorating; Not routinely

• FBC, U & Es, LFTs, Blood Culture • Microbiology

June – 2007 21

Microbiological Investigations Microbiological Investigations for Children in Hospitalfor Children in Hospital

Early Pandemic – when you want to know– Virology

• NPA for Respiratory panel - ‘flu A & B; RSV, Adeno, Rhino, Paraflu 1,2,3

• Rapid influenza tests – high specificity - R/I ‘flu• Acute & Convalescent Serum

– Bacteriology• Blood • Sputum

Established Pandemic – when you know– Virology – not routine– Bacteriology

June – 2007 22

Anti-Viral Therapy in HospitalAnti-Viral Therapy in Hospital• Neuraminidase inhibitors

– Oseltamivir (Tabs & liquid)

– If severely ill with symptoms for <6 days– Child <1year with severe infection with informed

consent

June – 2007 23

AntibioticsAntibiotics for Children in Hospitalfor Children in Hospital

• Secondary bacterial infections are common– Pneumonia– Otitis media

June – 2007 24

O’Brien et al. Clin Infect

Dis 2000;30:784-9

Pneumococcal Pneumonia in Previously Pneumococcal Pneumonia in Previously Healthy ChildrenHealthy Children

June – 2007 25

Bhat, N. et al. N Engl J

Med 2005;353:2559-2567

Bacterial Co-infections in 24 Children Bacterial Co-infections in 24 Children with Fatal Influenzawith Fatal Influenza

June – 2007 26

Navarini, Alexander A. et al. (2006) Proc. Natl. Acad. Sci. USA 2006; 103: 15535-15539

Activation-associated Cell Death of Bone Marrow GRC Activation-associated Cell Death of Bone Marrow GRC during LCMV infectionduring LCMV infection

Early phase of infection largely controlled by innate resistance via granulocytes.Virus-induced suppression of antibacterial resistance and immunity by IFN 1 production was caused by apoptosis of bone marrow granulocytes and impaired granulocyte emigration. Granulocytopenia was not complete but became functionally limiting during super-infection when large numbers of granulocytes were rapidly required to control infection

Early phase of infection largely controlled by innate resistance via granulocytes.Virus-induced suppression of antibacterial resistance and immunity by IFN 1 production was caused by apoptosis of bone marrow granulocytes and impaired granulocyte emigration. Granulocytopenia was not complete but became functionally limiting during super-infection when large numbers of granulocytes were rapidly required to control infection

June – 2007 27

Antibiotics for Children in HospitalAntibiotics for Children in Hospital• Children at risk of complications• Children with disease severe enough to be admitted

Treat prophylactically with antibiotic to cover • Staph aureus • Str pneumoniae• H influenzae

= Co-amoxiclav; Or clarithromycin, cefuroxime if pen. allergic

June – 2007 28

Will There be Sufficient Staff?

June – 2007 29

PhysiciansY D/K N

It would be ethical for HCP to abandon their workplace during a pandemic to protect themselves and their families

24% 11% 64%

HCP should be allowed to decide whether they report to work during a pandemic

25% 8% 67%

HCP without children should primarily care for influenza patients during a pandemic

16% 12% 72%

Professional Duty – Family or Patient First?

Ehrenstein et al BMC Public Health 2006;6:311

June – 2007 30

June – 2007 31

The Next Influenza Pandemic: Will be Ready to Care for Our Children?

“The severity of the 2003-2004 'flu season will pale in comparison with that of the next pandemic”

Woods and AbramsonJ Pediatr 2005;147:147-155

Hot Topic Meeting by:

Royal College of Physicians of Edinburgh & The Scottish Executive Health Department

Pandemic Flu

Planning Scotland’s Health Response

5th June 2007

Queen Mother Conference Centre