SLCH ID and EU Recommendations (UPDATED 9.24.09)
Testing
There is no special test to diagnose H1N1 that is routinely available at this time. For mildly ill patients with influenza-like illness in high risk groups consider empiric treatment with antivirals without testing.
Hospitalized patients should be tested for influenza so that appropriate cohorting may occur.
Because influenza testing and antiviral therapy are not currently recommended for patients at low risk for complications of influenza infection, PLEASE DO NOT send patients who are at low risk for complications of H1N1 and who are only mildly ill to the Emergency Department purely for purposes of testing for H1N1.
Influenza-like illness is defined by the CDC as:
1) Temperature >37.8C
AND
2) A symptom of upper respiratory infection: cough, sore throat, rhinorrea
Referral to the Emergency Department
Patients should be referred to the Emergency Department only if they have one of the following conditions:
1) Dehydration
2) Respiratory distress
3) Altered mental status
4) Severe illness possibly requiring hospitalization
High risk groups for serious illness from novel H1N1 are:
1) Patients who are hospitalized
2) Patients with coexisting bacterial pneumonia
3) Patients at high risk for complications of H1N1:
- Age < 5 years and illness onset within past 48 hours
- Age < 2 years are at increased risk for severe disease
- Immunosuppressed patients
- Pregnant patients
- Patients with chronic medical conditions including an established diagnosis of asthma
- Patients <age 19 years on chronic aspirin therapy
Treatment
Most patients who develop influenza can be managed at home, with symptomatic treatment. Most patients will not require medical attention. PLEASE DO NOT send patients who are at low risk for complications of H1N1 and who are mildly ill to the Emergency Department purely for purposes of testing or treating for H1N1.
CDC has identified the following groups as priority groups for treatment with Tamiflu (oseltamivir) or Relenza (zanamivir) if they have suspected or confirmed Influenza :
1) Patients who are hospitalized
2) Patients with coexisting bacterial pneumonia
3) Patients at high risk for complications of H1N1:
- Age < 2 years and illness onset within past 48 hours; (consider treating age 2-4 years, particularly if illness onset within the past 48 hours)
- Immunosuppressed patients
- Pregnant patients
- Patients with chronic medical conditions including an established diagnosis of asthma
- Patients <age 19 years on chronic aspirin therapy
Antiviral treatment is most effective if initiated within 48 hours of illness onset; however, individual characteristics (including severity and duration of illness) should be considered in deciding whether to treat with antivirals.
Patients who are treated in accordance with this guideline do not require Infectious Diseases approval for Tamiflu or Relenza.
Patients with influenza-like illness who fall into high risk groups should be treated with antivirals. If they are mildly ill, consider prescribing antivirals via a telephone triaging system. Given that the sensitivity of the current rapid influenza test for detection of novel H1N1 is 40-70%, CDC recommends treatment in these patients regardless of the result of the negative rapid influenza test. Performance of influenza testing is not necessary for mildly ill, non-hospitalized patients.
Prophylaxis
Use of antiviral drugs to prevent illness (chemoprophylaxis) is usually reserved for certain specific situations. Widespread use of antiviral medications for chemoprophylaxis is not encouraged. Inappropriate use of antiviral drugs might be a factor in causing more viruses to become resistant.
It is not recommended that antiviral chemoprophylaxis be provided to anyone exposed to a person with H1N1 influenza virus infection unless they are:
1. Close contacts of cases (confirmed, probable, or suspected) that are at high-risk for complications of influenza (see risk groups above).
2. Health care personnel, public health workers, or first responders who have had a recognized unprotected close contact exposure to a person with H1N1 influenza virus infection (confirmed, probable or suspected) during that person’s infectious period.
An alternative to prophylaxis in high risk patients exposed to novel H1N1 is counseling regarding signs and symptoms of influenza with early treatment when symptoms appear.
There are currently adequate supplies of Tamiflu and Relenza for patients and employees. PLEASE DO NOT write scripts for pre-exposure prophylaxis, treatment of asymptomatic individuals, or personal antiviral stockpiling. These practices will deplete availability of antiviral medications for treatment of actually infected patients and prophylaxis of high-risk individuals.
The SLCH Emergency Department will refer high-risk household contacts of Emergency Department patients to their primary care physicians for prophylaxis.
Return to school
Children may return to school when they have been afebrile for 24 hours without administration of antipyretics.
Vaccination
Vaccines against novel H1N1 are under development. These will be purchased by the federal government and distributed to local health departments to community providers. Please contact your local health department if you are interested in being a vaccine provider.
The first doses of H1N1 vaccine are anticipated to arrive in mid-October. Priority groups for vaccination are:
1) Pregnant women
2) Caregivers of children < age 6 months
3) Children ages 6 months-4 years
4) Children ages 5-18 years with immunosuppression and/or chronic medical conditions including asthma
5) Healthcare providers with direct patient contact
We anticipate there will be a need for 2 doses of novel H1N1 vaccine separated by 21-28 days. Inactivated novel H1N1 vaccine may be co-administered with inactivated seasonal influenza vaccine. Live attenuated novel H1N1 and seasonal vaccines should not be co-administered.
Vaccination against seasonal influenza should begin as soon as vaccine is available.