Interim Guidelines for 2009 H1N1 Influenza A in Children and Adolescents in the Primary Care Setting

Testing, Treatment, and Prevention

October 14, 2009

The H1N1 2009 Influenza pandemic is having significant impact on the delivery of health care in both the community and hospital settings. The following guidelines were prepared by Children’s Hospital of Pittsburgh of UPMC to clarify the Centers for Disease Control and Prevention (CDC) recommendations for the diagnosis, treatment, and prevention of 2009 H1N1 Influenza A in the primary pediatric care setting. They are derived from the most current guidance provided by the CDC and in consultation with the Division of Pediatric Infectious Diseases at Children’s Hospital, the Allegheny County Health Department, the CDC, and other major centers. This document does not address issues related to H1N1 influenza vaccination.

An influenza-like illness (ILI) is an acute febrile respiratory illness characterized by cough, runny nose or sore throat, and sometimes fever. Up to one in four patients with H1N1 also have nausea, vomiting, or diarrhea.

• In the majority of cases this season, patients with an ILI have exhibited mild to moderate symptoms that can be managed at home.
• Parents should be instructed to manage the symptoms of an ILI as they would any wintertime virus:
  • Fluids to prevent dehydration
  • Antipyretics if fever occurs

Referral to the Emergency Department (ED)

• In general, referral to the Emergency Department should be considered only for children who (a) are ill enough to require hospitalization or (b) will likely need additional assessment or intervention not available in the primary care office.
• These may include:
  • Assessment and treatment of dehydration
  • Assessment and treatment of respiratory distress and insufficiency
  • Assessment and treatment of serious secondary bacterial infection
• Children should not be referred to be seen in ED primarily to obtain a diagnostic test for H1N1 Influenza A. It is important to emphasize that the ED at Children’s will follow the guidelines for testing, and thus most children will not be tested if they present to the ED.

Isolation Precautions
Practices should consider screening patients and family members for presence of ILI.

• Patients and any family members with ILI should wear a standard paper mask, if possible.
• Health care workers should use droplet precautions (standard paper masks) for all patient contacts.
• N95 masks are necessary only for procedures likely to generate aerosolized secretions, like intubation, bronchoscopy, or open suctioning.

Testing of children with Influenza-like Illnesses (ILI): Note that guidance on testing may change as the outbreak evolves in our community.
Patients in whom the results will impact on care should be tested:

• Testing is recommended for patients who have household contact at risk for severe disease who may benefit from confirmation that they are exposed to H1N1 2009 by post-exposure prophylaxis or early initiation of therapy at onset of symptoms (see Treatment recommendations).
• Children with ILI who are at higher risk for severe disease*
  • Children < 2 years of age
  • Pregnant adolescents
  • Children with compromised immune systems
  • Children with chronic diseases including chronic lung disease, heart disease, kidney disease, metabolic disease, and diabetes
  • Children with neurological disorders including developmental disorders and cerebral palsy, and morbid obesity
  • Children receiving long-term aspirin therapy
  • Testing should be considered for children being admitted to hospital with ILI, or any symptoms suspicious for H1N1 2009
    
• Patients whose precise diagnosis may inform us about more unusual or severe manifestations of disease should be tested.
• The RNA PCR test for Influenza is THE recommended diagnostic test for the diagnosis of 2009 H1N1 Influenza A.
  • The rapid flu test (“influenza AB antigen”) has extremely poor sensitivity and should not be used.

Outpatient Treatment of 2009 H1N1 Influenza A with Oseltamivir (Tamiflu)

• When indicated, treatment should be initiated as early as possible and should not wait for laboratory confirmation of influenza.
• Dosing recommendations for oseltamivir and zanamavir are available at www.cdc.gov.
• Healthy children who are not at higher risk for complications or do not have severe influenza requiring hospitalization generally do not require antiviral medications for treatment or prophylaxis.
  • Children with signs or symptoms of lower respiratory tract disease (including dyspnea, tachypnea, or oxygen desaturation) should receive prompt antiviral therapy.
• Children with ILI who are at higher risk for complications of influenza and present within 48 hours of symptom onset should be treated. Base your decision to treat on the appearance of your patient and your clinical judgment. It may be appropriate to treat patients whom you would have considered treating for seasonal flu.
  • Children at higher risk of complications include:
    • Children < 2 years of age
    • Pregnant adolescents
    • Children with compromised immune systems
    • Children with chronic diseases including chronic lung disease, heart disease, kidney disease, metabolic disease, and diabetes
    • Children with neurological disorders including developmental disorders and cerebral palsy, and morbid obesity
    • Children receiving long-term aspirin therapy
• Children with immunosuppressive conditions should be treated regardless of symptom duration.

Treatment of Secondary Bacterial Infections
Secondary bacterial infections are an important cause of morbidity and mortality in children with 2009 H1N1 Influenza A. Careful consideration and evaluation for the presence of these infections is recommended as part of all evaluations of children with an influenza-like illness.

Preventing Spread in the Community

• Children with suspected/confirmed flu may return to school/day care when fever is gone for 24 hours without antipyretic. Symptom duration is no longer a factor.
• Encourage hand hygiene in affected households.
• Educate families about cough and sneeze etiquette.
• Spread to high-risk family members
  • Ask parents about high-risk family members when returning calls about positive Influenza A tests (pregnant, immunosuppressed, chronic disease).
  • High-risk contacts should follow-up with their PCP ASAP to discuss potential benefits of starting prophylaxis.
  • The CDC recommends either:
    • Considering prophylaxis in high risk flu contacts
    • Treating these contacts with antiviral therapy at the first sign of symptoms