CDC WEB SITE 10/06 : What are the CDC WEB SITE 10/06 : What are the symptoms of seasonal and 2009 symptoms of seasonal and 2009

H1N1 flu?H1N1 flu?You may have the flu if you have some or all of these You may have the flu if you have some or all of these symptoms:symptoms:Fever* Fever* Cough Cough Sore throat Sore throat Runny or stuffy nose Runny or stuffy nose Body aches Body aches Headaches Headaches Chills Chills Fatigue Fatigue Sometimes, diarrhea and vomiting Sometimes, diarrhea and vomiting *It’s important to note that some people with flu will not *It’s important to note that some people with flu will not have a fever.have a fever.

CDC CASE DEFINITIONSCDC CASE DEFINITIONSInfluenza-like illness (ILI)Influenza-like illness (ILI) is defined as fever (temperature is defined as fever (temperature of of 100ºF100ºF [37.8ºC] or greater) with [37.8ºC] or greater) with cough and/or sore cough and/or sore throatthroat in the absence of a known cause other than in the absence of a known cause other than influenza influenza A A CONFIRMED CONFIRMED case of pandemic H1N1 influenza A is case of pandemic H1N1 influenza A is defined as an individual with an ILI with laboratory-defined as an individual with an ILI with laboratory-confirmed H1N1 influenza A virus detection by real-time confirmed H1N1 influenza A virus detection by real-time reverse transcriptase (RT)-PCR or culture. reverse transcriptase (RT)-PCR or culture. A A PROBABLE PROBABLE case of pandemic H1N1 influenza A is case of pandemic H1N1 influenza A is defined as an individual with an ILI who is positive for defined as an individual with an ILI who is positive for influenza A, but negative for H1 and H3 by RT-PCR influenza A, but negative for H1 and H3 by RT-PCR Pandemic H1N1 influenza A may be Pandemic H1N1 influenza A may be SUSPECTEDSUSPECTED in an in an individual who does not meet the definitions of confirmed or individual who does not meet the definitions of confirmed or probable pandemic H1N1 influenza A, but has an probable pandemic H1N1 influenza A, but has an ILI ILI and and anan EPIDEMIOLOGICAL LINK EPIDEMIOLOGICAL LINK (eg, likely exposure to a (eg, likely exposure to a confirmed or probable case within the past seven days). confirmed or probable case within the past seven days). Full case definitions can be found at the CDC's website Full case definitions can be found at the CDC's website

CDC DEFINITION OF CDC DEFINITION OF Close ContactsClose Contacts   

Having Having cared for or livedcared for or lived with a person who is a with a person who is a confirmed, probable, or suspected case of pandemic confirmed, probable, or suspected case of pandemic H1N1 influenza A H1N1 influenza A Having been in a setting where there was a high Having been in a setting where there was a high likelihood of likelihood of contact with respiratory droplets and/or contact with respiratory droplets and/or bodily fluidsbodily fluids of a confirmed, probable, or suspected of a confirmed, probable, or suspected case of pandemic H1N1 case of pandemic H1N1 Having had close contact Having had close contact (sharing eating or drinking (sharing eating or drinking utensils, physical examination, or any other contact utensils, physical examination, or any other contact likely to result in exposure to respiratory droplets)likely to result in exposure to respiratory droplets) with a confirmed, probable, or suspected case of with a confirmed, probable, or suspected case of pandemic H1N1 influenza A pandemic H1N1 influenza A Close contact does not typically include such activities Close contact does not typically include such activities as as walking bywalking by an infected individual or an infected individual or sitting acrosssitting across from a symptomatic patient in a waiting room.from a symptomatic patient in a waiting room.

CDC ADDITION TO CDC ADDITION TO “CLOSE CONTACT” 10/16“CLOSE CONTACT” 10/16

For the purposes of this document (isolation For the purposes of this document (isolation precautions) , precautions) , close contact is defined as close contact is defined as working within 6 feetworking within 6 feet of the patient or entering of the patient or entering into a small enclosed airspace shared with the into a small enclosed airspace shared with the patient (e.g., average patient room) patient (e.g., average patient room) Apply isolation precautions:Apply isolation precautions:Isolation precautions are recommended for Isolation precautions are recommended for healthcare personnel who are in close contact healthcare personnel who are in close contact with patients with suspected or confirmed 2009 with patients with suspected or confirmed 2009 H1N1 influenza.H1N1 influenza.

INCUBATION PERIODINCUBATION PERIODCDC 10/16CDC 10/16

In general, the incubation period for influenza is In general, the incubation period for influenza is estimated to range from estimated to range from 1 to 4 days1 to 4 days with an with an average of 2 days.  average of 2 days.  Influenza virus shedding begins the day before Influenza virus shedding begins the day before illness onset and can illness onset and can persist for 5 to 7 persist for 5 to 7 daysdays,, although some persons may shed virus although some persons may shed virus for longer periods, particularly young children for longer periods, particularly young children and severely immunocompromised persons.and severely immunocompromised persons.The amount of virus shed is greatest in the first The amount of virus shed is greatest in the first 2-3 days of illness and appears to correlate with 2-3 days of illness and appears to correlate with fever, with fever, with higher amounts of virus shed higher amounts of virus shed when temperatures are highest.when temperatures are highest.

Co-Morbidities that predispose patients to Co-Morbidities that predispose patients to Complications from InfluenzaComplications from Influenza

Chronic pulmonary diseaseChronic pulmonary disease, including , including ASTHMAASTHMA (particularly if (particularly if systemic systemic glucocorticoidsglucocorticoids have been required during the past year) have been required during the past year)

CHRONIC MEDICAL CONDITIONSCHRONIC MEDICAL CONDITIONS -  Cardiovascular disease (except isolated hypertension) -  Cardiovascular disease (except isolated hypertension)

      -  Active malignancy       -  Active malignancy       -  Chronic renal insufficiency       -  Chronic renal insufficiency       -  Chronic liver disease       -  Chronic liver disease       -  Diabetes mellitus       -  Diabetes mellitus       -  Hemoglobinopathies such as       -  Hemoglobinopathies such as sickle cell diseasesickle cell disease       -       - ImmunosuppressionImmunosuppression, including HIV infection (particularly if , including HIV infection (particularly if CD4 <200 cells/microL), organ or hematopoietic stem cell CD4 <200 cells/microL), organ or hematopoietic stem cell transplantationtransplantation

IInflammatory disorders treated with immunosuppressantsnflammatory disorders treated with immunosuppressants

Individuals who have any condition that canIndividuals who have any condition that can compromise compromise handling of respiratory secretionshandling of respiratory secretions (eg, cognitive dysfunction, (eg, cognitive dysfunction, spinal cord injuries, seizure disorders, neuromuscular disorders, spinal cord injuries, seizure disorders, neuromuscular disorders, cerebral palsy, metabolic conditions)cerebral palsy, metabolic conditions)

Complications from 2009 H1N1 Complications from 2009 H1N1 causing Severe Maternal Diseasecausing Severe Maternal Disease

VIRAL PNEUMONIA VIRAL PNEUMONIA

SECONDARY BACTERIAL PNEUMONIASECONDARY BACTERIAL PNEUMONIA

PROGRESSION TO ARDS IF SEVERE PROGRESSION TO ARDS IF SEVERE DISEASE PERSISTDISEASE PERSIST

Primary Viral Pneumonia Primary Viral Pneumonia Clinical Presentation Clinical Presentation     Flu symptoms Flu symptoms PPersist and Increaseersist and Increase over 24- over 24-48 hrs 48 hrs instead of resolving in a patient with instead of resolving in a patient with acute influenza. Shortness of breath and acute influenza. Shortness of breath and persistent cough will be the predominant persistent cough will be the predominant Sx/Sx for those most at risk of severe Sx/Sx for those most at risk of severe disease.disease.The vast majority of pregnant women will not The vast majority of pregnant women will not develop pneumonia or ARDS. Rarely maternal develop pneumonia or ARDS. Rarely maternal deaths secondary to Viral Pneumonia deaths secondary to Viral Pneumonia progressing to ARDS as a complication of 2009 progressing to ARDS as a complication of 2009 H1N1 Influenza have been reported. H1N1 Influenza have been reported.

Lancet 2009; 374: 451–58 N Engl J Med 2009;361

INFLUENZA FACILTATESINFLUENZA FACILTATES BACTERIAL PNEUMONIA INFECTIONBACTERIAL PNEUMONIA INFECTION

Influenza virus alters and damages the lungs in a way Influenza virus alters and damages the lungs in a way that predisposes them to: adherence, invasion, and that predisposes them to: adherence, invasion, and induction of disease by Streptococcus pneumoniae induction of disease by Streptococcus pneumoniae which is the most common cause( ~50%) of secondary which is the most common cause( ~50%) of secondary bacterial pneumonia. bacterial pneumonia.

Secondary bacterial pneumonia causes ~ 25 percent of Secondary bacterial pneumonia causes ~ 25 percent of Influenza A associated deathsInfluenza A associated deaths

Clin Microbiol Rev. Clin Microbiol Rev. 2006 July; 19(3): 2006 July; 19(3): 571571

N Engl J Med 2009;361.Morb Mortal Wkly Rep. 2007 Apr 13;56(14):325-9Morb Mortal Wkly Rep. 2007 Apr 13;56(14):325-9

2009 H1N1 CASES ASSOCIATED 2009 H1N1 CASES ASSOCIATED WITH BACTERIAL PNEUMONIA WITH BACTERIAL PNEUMONIA

Bacterial CoinfectionBacterial Coinfection was found in was found in (29%) of lung tissue specimens from 77 (29%) of lung tissue specimens from 77 deaths associated with 2009 deaths associated with 2009 H1N1.H1N1.Streptococcus pneumoniaeStreptococcus pneumoniae was the was the most common isolated pathogen most common isolated pathogen Community Acquired Methicillin-Resistant Community Acquired Methicillin-Resistant Staphylococcus aureus pneumonia IF Staphylococcus aureus pneumonia IF PRESENT can be associated with high mortalityPRESENT can be associated with high mortality

MMWR 2009;58:749--52. September 29, 2009 BACETRIAL CO-INFECTION WITH H1N1N Engl J Med 2009;361.Morb Mortal Wkly Rep. 2007 Apr 13;56(14):325-9Morb Mortal Wkly Rep. 2007 Apr 13;56(14):325-9

Secondary Bacterial PneumoniaSecondary Bacterial Pneumonia CLINICAL PRESENTATIONCLINICAL PRESENTATION

Fever may resolve for one to three days Fever may resolve for one to three days after the onset of acute influenza BUTafter the onset of acute influenza BUT

Instead of continuing to improve, the Instead of continuing to improve, the patient with secondary bacterial patient with secondary bacterial pneumonia usually pneumonia usually relapsesrelapses with with higher higher fevers ( > 101.5 ) fevers ( > 101.5 ) , , coughcough, production of , production of purulent sputumpurulent sputum, and , and CXRCXR evidence of evidence of pulmonary infiltrates. pulmonary infiltrates.

Clinical features of severe cases of Clinical features of severe cases of 2009 H1N1 2009 H1N1

As these bacterial co-infections are more frequent than initially As these bacterial co-infections are more frequent than initially recognized, recognized, clinicians stressed the need to consider clinicians stressed the need to consider empiric empiric antimicrobial therapy for community antimicrobial therapy for community acquired pneumonia as an early treatment. acquired pneumonia as an early treatment.

Pneumonia caused by co-infection with bacteria can also contribute Pneumonia caused by co-infection with bacteria can also contribute to a severe, rapidly progressive illness. Bacteria frequently reported to a severe, rapidly progressive illness. Bacteria frequently reported include Streptococcus pneumoniae and Staphylococcus aureus, include Streptococcus pneumoniae and Staphylococcus aureus, including methicillin-resistant strains in some cases. including methicillin-resistant strains in some cases.

In severe cases, patients generally In severe cases, patients generally begin to deteriorate around 3 begin to deteriorate around 3 to 5 days after symptom onsetto 5 days after symptom onset. . Deterioration is rapid, with Deterioration is rapid, with many patients progressing to respiratory failure within 24 many patients progressing to respiratory failure within 24 hourshours, requiring immediate admission to an intensive care unit. , requiring immediate admission to an intensive care unit.

WHO 10/16/2009WHO 10/16/2009

RIVERSIDE OB INTERIM RIVERSIDE OB INTERIM RECOMMENDATIONSRECOMMENDATIONS

10/2610/26TriageTriage

EvaluationEvaluationClinical Management Clinical Management Outpatient Follow upOutpatient Follow up

Co-Morbidities that predispose patients to Co-Morbidities that predispose patients to Complications from InfluenzaComplications from Influenza

Chronic pulmonary diseaseChronic pulmonary disease, including , including ASTHMAASTHMA (particularly if (particularly if systemic systemic glucocorticoidsglucocorticoids have been required during the past year) have been required during the past year)

CHRONIC MEDICAL CONDITIONSCHRONIC MEDICAL CONDITIONS -  Cardiovascular disease (except isolated hypertension) -  Cardiovascular disease (except isolated hypertension)

      -  Active malignancy       -  Active malignancy       -  Chronic renal insufficiency       -  Chronic renal insufficiency       -  Chronic liver disease       -  Chronic liver disease       -  Diabetes mellitus       -  Diabetes mellitus       -  Hemoglobinopathies such as       -  Hemoglobinopathies such as sickle cell diseasesickle cell disease       -       - ImmunosuppressionImmunosuppression, including HIV infection (particularly if , including HIV infection (particularly if CD4 <200 cells/microL), organ or hematopoietic stem cell CD4 <200 cells/microL), organ or hematopoietic stem cell transplantationtransplantation

IInflammatory disorders treated with immunosuppressantsnflammatory disorders treated with immunosuppressants

Individuals who have any condition that canIndividuals who have any condition that can compromise compromise handling of respiratory secretionshandling of respiratory secretions (eg, cognitive dysfunction, (eg, cognitive dysfunction, spinal cord injuries, seizure disorders, neuromuscular disorders, spinal cord injuries, seizure disorders, neuromuscular disorders, cerebral palsy, metabolic conditions)cerebral palsy, metabolic conditions)

Asthma and Pregnancy confer a Asthma and Pregnancy confer a high risk for Severe Disease with high risk for Severe Disease with

Seasonal Influenza or H1N1 Seasonal Influenza or H1N1

Asthmatic pregnant patients may present with what Asthmatic pregnant patients may present with what appears to be an asthma exacerbationappears to be an asthma exacerbationMAY ACTUALLY HAVE ILI MAY ACTUALLY HAVE ILI (Seasonal or H1N1)(Seasonal or H1N1)

Viral Studies, CXR, “further work up”, with a Viral Studies, CXR, “further work up”, with a very low very low thresholdthreshold to treat for “ ILI” with Tamiflu & Antibiotics. to treat for “ ILI” with Tamiflu & Antibiotics.Have a very low threshold to “admit” or at least observe Have a very low threshold to “admit” or at least observe these patients these patients in the hospitalin the hospital until they improve until they improve

MMWR Morb Mortal Wkly Rep. 2009 May 15;58(18):497-500. N Engl J Med 2009;361

Mild ILI SymptomsMild ILI SymptomsSEVERE DISEASE NOT LIKELYSEVERE DISEASE NOT LIKELY

1) NO Co-morbidity (Consider BMI > or = to 40 also)1) NO Co-morbidity (Consider BMI > or = to 40 also)2) NO difficulty breathing while: performing routine 2) NO difficulty breathing while: performing routine

physical activity, child care, talking, etc. NO SOB physical activity, child care, talking, etc. NO SOB while laying down flat. Basically NO complaints of while laying down flat. Basically NO complaints of SOB and the patient feels well. SOB and the patient feels well.

3) NO c/o "green/yellow sputum" or "severe coughing" 3) NO c/o "green/yellow sputum" or "severe coughing" 4) Patient has no dehydration. They are tolerating 4) Patient has no dehydration. They are tolerating

liquids/food with no problem and they do not have liquids/food with no problem and they do not have severe diarrhea &/or vomiting.severe diarrhea &/or vomiting.

5) No CNS symptoms eg disorientation, confusion, 5) No CNS symptoms eg disorientation, confusion, Seizure Seizure

6) No chest pain/pressure.6) No chest pain/pressure.7) No difficulty getting 10 fetal movements in 2 hours7) No difficulty getting 10 fetal movements in 2 hours

MILD ILI SYMPTON ONSET MILD ILI SYMPTON ONSET > 72 HOURS> 72 HOURS No Treatment with TamifluNo Treatment with Tamiflu, NO culture, No Observation, NO culture, No Observation

MMore than 72 hoursore than 72 hours has elapsed since the has elapsed since the patient developed Sx Sx of ILI and she has started to patient developed Sx Sx of ILI and she has started to

improve with a improve with a decrease in her decrease in her symptomssymptoms and currently feels better. and currently feels better.

NoNo significant lower respiratory tract significant lower respiratory tract symptoms symptoms (No persistent cough and not short of breath)(No persistent cough and not short of breath)

No Co-morbiditiesNo Co-morbidities No culture, No further evaluation ,No Tamiflu treatment.No culture, No further evaluation ,No Tamiflu treatment.General recommendations & RN follow up onlyGeneral recommendations & RN follow up onlyRN case manager will call for 3 daysRN case manager will call for 3 days

MILD ILI SYMPTON ONSET MILD ILI SYMPTON ONSET < 72 HOURS< 72 HOURSTreat with Tamiflu Treat with Tamiflu & Release & Release NO culture No Observation NO culture No Observation

No Co-Morbidities No Co-Morbidities No Shortness of Breath No CXRNo Shortness of Breath No CXRRR < or = 20 No CXRRR < or = 20 No CXRNormal Chest Exam by Auscultation No CXRNormal Chest Exam by Auscultation No CXRNo or minimal clear productive cough No CXRNo or minimal clear productive cough No CXRSaO2 96 % or higher on RA while awake No CXRSaO2 96 % or higher on RA while awake No CXRTemperature < 101.5Temperature < 101.5No: Dehydration, persistent vomiting, confusion or No: Dehydration, persistent vomiting, confusion or disorientation, chest pain, dizziness, or difficulty disorientation, chest pain, dizziness, or difficulty tolerating PO. Patient feels well & desires to go home.tolerating PO. Patient feels well & desires to go home.NST Reactive for EGANST Reactive for EGATamiflu 75 mg BID X 5 days & General GuidelinesTamiflu 75 mg BID X 5 days & General GuidelinesCase manager Case manager RN follow up for 3 daysRN follow up for 3 days

Concerning ILI Signs & Symptoms Concerning ILI Signs & Symptoms Warrant further Evaluation, Tamiflu Tx, Warrant further Evaluation, Tamiflu Tx,

Culture & ObservationCulture & Observation

Co-Morbidities present Co-Morbidities present Shortness of Breath CXRShortness of Breath CXRRR > or = to 22 CXRRR > or = to 22 CXRPositive Chest Exam by Auscultation CXRPositive Chest Exam by Auscultation CXRSaO2 < or = to 95 % on RA CXRSaO2 < or = to 95 % on RA CXRPositive CXR - Add Ceftriaxone / AzithromycinPositive CXR - Add Ceftriaxone / AzithromycinTemperature > or equal to 101.5Temperature > or equal to 101.5Complains of any one: Dehydration, persistent Complains of any one: Dehydration, persistent vomiting, confusion or disorientation, chest pain, vomiting, confusion or disorientation, chest pain, dizziness, or difficulty tolerating PO. dizziness, or difficulty tolerating PO.

Evaluation for Concerning ILI Evaluation for Concerning ILI

Viral Studies Viral Studies (see current protocols for specific Viral studies & infection Control)(see current protocols for specific Viral studies & infection Control)

CXR / Continuous Pulse Oximetry CXR / Continuous Pulse Oximetry Document MRSA status Document MRSA status ( pos, neg, unknown / risk ie pos family member)( pos, neg, unknown / risk ie pos family member)

ALT / ASTALT / AST ( > 2X upper limit of normal in 16% & 18% respectively ) ( > 2X upper limit of normal in 16% & 18% respectively )

CBC in patients with H1N1CBC in patients with H1N1 20 % WBC < 5K 20 % WBC < 5K 18 % WBC > 11K 18 % WBC > 11K

CONSIDER FURTHER EVALUATION FOR CONSIDER FURTHER EVALUATION FOR BUN, Creatinine, Lytes, (if suspect dehydration)BUN, Creatinine, Lytes, (if suspect dehydration)Blood Culture Blood Culture ( If Temp ( If Temp >> or equal 101.5 ) or equal 101.5 )Sputum Culture & Gram Stain Sputum Culture & Gram Stain (if productive cough) (if productive cough)

Consider ABG based on SaO2 / CXRConsider ABG based on SaO2 / CXRConsider Streptococcus pneumoniae urine antigen for positive CXRConsider Streptococcus pneumoniae urine antigen for positive CXR

N Engl J Med 2009;361(10.1056/NEJMoa0906695)

Obstet & Gynecol VOL. 114, NO. 4, 2009

Consider Viral Studies, Tamiflu, Observation Consider Viral Studies, Tamiflu, Observation WITH No FEVERWITH No FEVER

HOWEVER CLINICALLY CONCERNING ILI HOWEVER CLINICALLY CONCERNING ILI Sx/Sx Sx/Sx ANDAND

1) HIGH RISK Co-Morbidities 1) HIGH RISK Co-Morbidities (Asthma, Pre-(Asthma, Pre-Gestational Diabetes , Immunosuppression , etc)Gestational Diabetes , Immunosuppression , etc)

2) HAVE A SIGNIFICANT EXPOSURE 2) HAVE A SIGNIFICANT EXPOSURE eg. eg. family member or close contact treated or with classic ILIfamily member or close contact treated or with classic ILI

3) You are concerned about their Sx/Sx and/or 3) You are concerned about their Sx/Sx and/or suspect pneumoniasuspect pneumonia

ILI of Concern ILI of Concern Further Workup & Treatment IndicatedFurther Workup & Treatment Indicated

Patient symptoms have progressed over the preceding Patient symptoms have progressed over the preceding 24-72 hours. ( suspect viral pneumonia)24-72 hours. ( suspect viral pneumonia)Patient symptoms initially improved in the first 24-96 Patient symptoms initially improved in the first 24-96 hours ; However they have developed a progression of hours ; However they have developed a progression of respiratory symptoms and/or return of high fever respiratory symptoms and/or return of high fever

(suspect secondary bacterial pneumonia)(suspect secondary bacterial pneumonia)Treat with Tamiflu 75 mg bid for ten doses Treat with Tamiflu 75 mg bid for ten doses Add IV antibiotics to Tamiflu Add IV antibiotics to Tamiflu

If posititve CXR or bacterial pneumonia Treat with If posititve CXR or bacterial pneumonia Treat with IV Ceftriaxone 2 G Q 24 hoursIV Ceftriaxone 2 G Q 24 hours IV Azithromycin 500mg Q 24 hours IV Azithromycin 500mg Q 24 hours

N Engl J Med 2009;361.Obstet & Genecol VOL. 114, NO. 4, 2009

SEVERE ILI SEVERE ILI Stabilization & Consider Delivery Stabilization & Consider Delivery

SaO2 < or = to 90 % on RASaO2 < or = to 90 % on RA

RR > 30 RR > 30

ABG Ph < 7.35 ABG Ph < 7.35

Sepsis Syndrome Sepsis Syndrome

Temp > or = 103Temp > or = 103

BUN > 30 BUN > 30

Disoriented, confused, or seizuresDisoriented, confused, or seizures

Complications & 2009 H1N1Complications & 2009 H1N1

Viral pneumonia may be rapidly progressive in 24 – 48 Viral pneumonia may be rapidly progressive in 24 – 48 hourshoursEvaluate for complications : Secondary Bacterial Evaluate for complications : Secondary Bacterial Pneumonia ,DVT and/or PE, ARDS, Renal failure, Pneumonia ,DVT and/or PE, ARDS, Renal failure, MODS, CNS involvement ( Seizures, Disorientation).MODS, CNS involvement ( Seizures, Disorientation).Consider Evaluation for exacerbation of underlying Consider Evaluation for exacerbation of underlying medical Co-Morbiditiesmedical Co-MorbiditiesEGA dependent for NST / Continuous EFMEGA dependent for NST / Continuous EFMContinuous SaO2 Continuous SaO2 Serial CBC , Chest Exam , Temperature, Vital SignsSerial CBC , Chest Exam , Temperature, Vital SignsAccurate I & OAccurate I & OF/U CXR , ABG , dependent on above.F/U CXR , ABG , dependent on above.

TREATMENT WITH TAMIFLUTREATMENT WITH TAMIFLURequires Approval By (…..) in Comments SectionRequires Approval By (…..) in Comments Section

The CDC has recommended that The CDC has recommended that symptomatic symptomatic pregnant women be treated with oseltamivir pregnant women be treated with oseltamivir (TAMIFLU) Pregnant women who meet current (TAMIFLU) Pregnant women who meet current case definitions for case definitions for confirmed, probable, or confirmed, probable, or suspectedsuspected pandemic H1N1 influenza A infection pandemic H1N1 influenza A infection should receive antiviral therapy with should receive antiviral therapy with

Treat-Tamiflu 75 mg Q 12 HOURS FOR FIVE Treat-Tamiflu 75 mg Q 12 HOURS FOR FIVE DAYSDAYS

CXR positive or secondary bacterial pneumonia -CXR positive or secondary bacterial pneumonia -Treatment with Ceftriaxone 2 G IV Q 24 & Treatment with Ceftriaxone 2 G IV Q 24 & Azithromycin 500 mg IV Q 24Azithromycin 500 mg IV Q 24

PREGNANCY HI RISKPREGNANCY HI RISK

Pregnant women:Pregnant women:  Pregnancy increases the risk of complications,   Pregnancy increases the risk of complications, hospitalization, and severe disease. (Lancet. 2009;374:451-458). hospitalization, and severe disease. (Lancet. 2009;374:451-458). While oseltamivir and zanamivir are "Pregnancy Category C" available While oseltamivir and zanamivir are "Pregnancy Category C" available data suggest pregnant women with suspected or confirmed influenza data suggest pregnant women with suspected or confirmed influenza should receive prompt antiviral therapy, and pregnancy should not be should receive prompt antiviral therapy, and pregnancy should not be considered a contraindication to treatment with oseltamivir or considered a contraindication to treatment with oseltamivir or zanamivir. zanamivir. Oseltamivir is preferred for treatment of pregnant women because of Oseltamivir is preferred for treatment of pregnant women because of its systemic activity. Anecdotal reports suggest postpartum women, its systemic activity. Anecdotal reports suggest postpartum women, similar to pregnant women, might be at increased risk for severe similar to pregnant women, might be at increased risk for severe complications and death from 2009 H1N1 influenza.  complications and death from 2009 H1N1 influenza.  The transition to normal immune, cardiac, and respiratory function The transition to normal immune, cardiac, and respiratory function occurs quickly, but not immediately after delivery.  Therefore, the occurs quickly, but not immediately after delivery.  Therefore, the increased risk associated with pregnancy should be considered to increased risk associated with pregnancy should be considered to extend for 2 weeks postpartum regardless of the outcome of the extend for 2 weeks postpartum regardless of the outcome of the pregnancy (including live birth, premature birth, termination of pregnancy (including live birth, premature birth, termination of pregnancy, miscarriage, fetal death).  pregnancy, miscarriage, fetal death).  Prompt empiric antiviral treatment is indicated for suspected or Prompt empiric antiviral treatment is indicated for suspected or confirmed 2009 H1N1 influenza in women who are up to 2 weeks confirmed 2009 H1N1 influenza in women who are up to 2 weeks postpartum regardless of how the pregnancy ended.postpartum regardless of how the pregnancy ended.

SEVERE ILI SEVERE ILI Stabilization in the ICU Stabilization in the ICU

SaO2 < or = to 90 % on RASaO2 < or = to 90 % on RA

RR > 30 RR > 30

ABG Ph < 7.35 ABG Ph < 7.35

Sepsis Syndrome Sepsis Syndrome

Temp > or = 103Temp > or = 103

BUN > 30 BUN > 30

Disoriented, confused, or seizuresDisoriented, confused, or seizures

Who to treat CDPHWho to treat CDPHTreatment of Confirmed or Suspected InfluenzaTreatment of Confirmed or Suspected InfluenzaWho to treat Who to treat Prompt empiric treatment is recommended for persons with suspected or confirmed Prompt empiric treatment is recommended for persons with suspected or confirmed influenza and: influenza and: Illness requiring hospitalization Illness requiring hospitalization Progressive, severe, or complicated illness, regardless of previous health status, Progressive, severe, or complicated illness, regardless of previous health status, and/or  and/or  Patients at risk for severe disease pregnqncy and up to 2 weeks psopstpartum(see Patients at risk for severe disease pregnqncy and up to 2 weeks psopstpartum(see below for groups at high risk) below for groups at high risk) How to treat How to treat Antiviral drugs: oseltamivir (oral), zanamivir (inhaled) Antiviral drugs: oseltamivir (oral), zanamivir (inhaled) Initiate treatment as early as possible after onset of symptoms Initiate treatment as early as possible after onset of symptoms Treat empirically before diagnostic test results are reported Treat empirically before diagnostic test results are reported When definitive diagnosis is indicated, request definitive diagnostic tests (rRT-PCR*, When definitive diagnosis is indicated, request definitive diagnostic tests (rRT-PCR*, viral culture) rather than rapid tests (RIDT*, DFA*) viral culture) rather than rapid tests (RIDT*, DFA*) * rRT-PCR: real-time reverse transcriptase polymerase chain reaction; RIDT:  rapid * rRT-PCR: real-time reverse transcriptase polymerase chain reaction; RIDT:  rapid influenza diagnostic test, DFA: direct immunofluorescence assayinfluenza diagnostic test, DFA: direct immunofluorescence assay

TREATMENT VS PROPHYLAXISTREATMENT VS PROPHYLAXIS

75 mg twice daily FOR 5 DAYS IS 75 mg twice daily FOR 5 DAYS IS TRAETMENT75 mg once dailyTRAETMENT75 mg once daily

75 MG ONCE DAILY FOR 10 DAYS IS 75 MG ONCE DAILY FOR 10 DAYS IS PROPHYLAXISPROPHYLAXIS

TAMIFLU INFORMATIONTAMIFLU INFORMATION

OseltamivirOseltamivir - The neuraminidase inhibitor - The neuraminidase inhibitor oseltamivir formulated as capsules or oral oseltamivir formulated as capsules or oral suspension (Tamiflu®) is FDA-approved for the suspension (Tamiflu®) is FDA-approved for the treatment of uncomplicated acute influenza in treatment of uncomplicated acute influenza in patients 1 year and older who have been patients 1 year and older who have been symptomatic for no more than 2 days.symptomatic for no more than 2 days.

  In addition, the CDC authorizes treatment of In addition, the CDC authorizes treatment of patients symptomatic with 2009 H1N1 influenza patients symptomatic with 2009 H1N1 influenza for more than 2 daysfor more than 2 days and patients sick enough and patients sick enough to require hospitalization (see to require hospitalization (see www.cdc.gov/h1n1flu/eua/tamiflu.htm).  www.cdc.gov/h1n1flu/eua/tamiflu.htm). 

IV THERAPY RECOMMENDEDIV THERAPY RECOMMENDED

PeramivirPeramivir - A third neuraminidase inhibitor peramivir formulated for - A third neuraminidase inhibitor peramivir formulated for intravenous (IV) administration is an investigational product intravenous (IV) administration is an investigational product currently being evaluated in clinical trials.  As of October, 2009, currently being evaluated in clinical trials.  As of October, 2009, safety and/or efficacy data from 1,891 patients with acute safety and/or efficacy data from 1,891 patients with acute uncomplicated seasonal influenza A has been submitted to the FDAuncomplicated seasonal influenza A has been submitted to the FDAEven though the data are insufficient to allow FDA approval, the Even though the data are insufficient to allow FDA approval, the FDA issued an EUA for treatment with peramivir of hospitalized FDA issued an EUA for treatment with peramivir of hospitalized patients with 2009 H1N1 influenza who have potentially life-patients with 2009 H1N1 influenza who have potentially life-threatening suspected or laboratory confirmed infection. threatening suspected or laboratory confirmed infection. Peramivir IV is available through the CDC upon request of a Peramivir IV is available through the CDC upon request of a licensed physician. Under the EUA, treatment of adult patients with licensed physician. Under the EUA, treatment of adult patients with IV peramivir is approved only if:  (1) the patient has not responded IV peramivir is approved only if:  (1) the patient has not responded to either oral or inhaled antiviral therapy; (2) drug delivery by a route to either oral or inhaled antiviral therapy; (2) drug delivery by a route other than IV is not expected to be dependable or is not feasible; or other than IV is not expected to be dependable or is not feasible; or (3) the clinician judges IV therapy is appropriate due to other (3) the clinician judges IV therapy is appropriate due to other circumstances.  Treatment of pediatric patients is approved if either circumstances.  Treatment of pediatric patients is approved if either of the first two criteria apply.of the first two criteria apply.

INHALATION THERAPYINHALATION THERAPY

1.1. Zanamivir is administered by inhalation using a Zanamivir is administered by inhalation using a proprietary “Diskhaler” device distributed together with proprietary “Diskhaler” device distributed together with the medication. the medication. 

2.2. Zanamivir is a dry powder, not an aerosol, and should Zanamivir is a dry powder, not an aerosol, and should not be administered using nebulizers, ventilators, or not be administered using nebulizers, ventilators, or other devices typically used for administering other devices typically used for administering medications in aerosolized solutions. medications in aerosolized solutions.

3.3. Zanamivir is Zanamivir is not recommended for persons with not recommended for persons with chronic respiratory diseases such as asthma or chronic respiratory diseases such as asthma or chronic obstructive pulmonary diseasechronic obstructive pulmonary disease that that increase the risk of bronchospasm. increase the risk of bronchospasm.

MEDICAL COMPLICATIONSMEDICAL COMPLICATIONS

Pregnant women:Pregnant women: 2 weeks postpartum 2 weeks postpartum regardless of the outcome of the regardless of the outcome of the pregnancy (including live birth, premature pregnancy (including live birth, premature birth, termination of pregnancy, birth, termination of pregnancy, miscarriage, fetal death).  miscarriage, fetal death). 

Adults aged 65 years and older:Adults aged 65 years and older:

AsthmaAsthma

MEDICAL COMPLICATIONSMEDICAL COMPLICATIONSHIGH RISK FOR ADVERSE OUTCOMEHIGH RISK FOR ADVERSE OUTCOME

Chronic  lung disease   (such as chronic obstructive pulmonary Chronic  lung disease   (such as chronic obstructive pulmonary disease  [COPD] and cystic fibrosis) disease  [COPD] and cystic fibrosis) Heart diseaseHeart disease (such as congenital heart disease, congestive heart (such as congenital heart disease, congestive heart failure and coronary artery disease)   failure and coronary artery disease)   Blood disorders (such as sickle cell disease) Blood disorders (such as sickle cell disease) Endocrine disorders (such as Endocrine disorders (such as diabetesdiabetes mellitus) mellitus) Kidney disorders Kidney disorders Liver disorders Liver disorders Metabolic disorders (such as inherited metabolic disorders and Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders) mitochondrial disorders) Weakened immune systemWeakened immune system due to disease or medication (such as due to disease or medication (such as people with HIV or AIDS, or cancer, or those on chronic steroids) people with HIV or AIDS, or cancer, or those on chronic steroids) People younger than 19 years of age who are receiving long-term People younger than 19 years of age who are receiving long-term aspirin therapy aspirin therapy