Pandemic flu
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Pandemic Flu. Clinical Assessment, Triage and Treatment. Dr Graham Douglas Consultant Physician Aberdeen Royal Infirmary. Influenza. Clinical Case Definition.

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Pandemic Flu

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Pandemic flu

Pandemic Flu

Clinical Assessment, Triage and Treatment

Dr Graham Douglas

Consultant Physician

Aberdeen Royal Infirmary


Pandemic flu

Influenza

Clinical Case Definition

“The presence of fever and new (or in those with chronic lung disease worsening) cough of acute onset in the context of influenza circulating in the community”

NB:This definition may need to be modified once the pandemic appears

Clinical diagnosis of ‘typical’ influenza is easy during epidemics/pandemics


Pandemic flu

Influenza

  • Incubation period: commonly 2-4 days (range 1-7 days)

  • Fever is the most important symptom

    - may reach 41oC

    - peaks within 24 hrs of onset

    - typically lasts for 3 days (range 1-5 days)


Pandemic flu

Influenza

RANGE OF SYMPTOMS ASSOCIATED WITH UNCOMPLICATED INFLUENZA INFECTION

Cough ~ 85%Anorexia ~ 60%

Malaise ~ 80%Coryzal (cold) symptoms ~ 60%

Chills ~ 70%Myalgia ~ 53%

Headache ~ 65%Sore throat ~ 50%

Cough & malaise - persist for 1-2 weeks and up to 6 weeks


Pandemic flu

Influenza

ASSESSMENT IN PRIMARY CARE

Majority with uncomplicated influenza will make a full recovery

Symptomatic management – Rest

Fluids

Paracetamol

Antibiotics rarely useful


Pandemic flu

Avian Influenza A/H5N1


Pandemic flu

Influenza

ASSESSMENT IN PRIMARY CARE

EXAMPLES OF WHAT SHOULD PROMPT PATIENTS TO RECONSULT

  • Shortness of breath at rest

  • Painful or difficult breathing

  • Coughing up bloody sputum

  • Fever for 4-5 days and not getting better

  • Starting to feel better then developing high fever

  • Drowsiness, disorientation or confusion


Pandemic flu

Influenza

There is no validated severity assessment tool developed specifically for Influenza or Influenza-related Pneumonia


Pandemic flu

Influenza

SEVERITY ASSESSMENT

CURB – 65 Score

Well known and validated for Community Acquired Pneumonia

  • Confusion

  • Urea > 7 mmol/l

  • Respiratory rate >30/mm

  • Blood pressure (diastolic < 60mmHg)

  • >65 years of age

    Score 1 point for each feature


Pandemic influenza age and mortality

Pandemic InfluenzaAge and mortality


Pandemic flu

Influenza

SEVERITY ASSESSMENT

CRB – 65

Also well validated

  • 0Likely to be suitable for home treatment

  • 1 & 2Consider hospital referral

  • 3 & 4Urgent hospital referral

Consider hospital referral if there are bilateral lung crackles


Pandemic flu

Influenza

SEVERITY ASSESSMENT IN HOSPITAL

CURB -65 score 3 or more = ‘Severe Pneumonia’

CURB -65 score 4 or more

Should be considered for HDU/ITU care

Other general indications for HDU/ITU:

Hypoxia – pO2<8 despite oxygen

Progressive CO2 retention

Severe acidosis – pH<7.26

Septic shock

Bilateral shadowing on CXR


Pandemic flu

Influenza

COMMON COMPLICATIONS

RESPIRATORY

  • Acute Bronchitis

  • Secondary Bacterial Pneumonia (~20%)

    Appears 4-5 days after start of ‘flu

Microbiology:

  • 1918 H.influenza, S.pneumoniae, βhaem.strept

  • 1957 Staph.aureus (>2/3rds)

  • 1968 S.pneumoniae, Staph.aureus, H.influenzae

    (48%) (26%) (11%)

  • Community MRSA uncommon in Europe/concern in US


Pandemic flu

Influenza

COMMON COMPLICATIONS

CVS:

  • ECG changes 80%

    (Twave inversion; ‘minor’ rhythm disturbances)

CHILDREN:

  • Otis media

EXACERBATION OF PRE-EXISTING DISEASE:

  • COPD

  • Bronchiectasis

  • Heart failure

  • Diabetes mellitus


Pandemic flu

Influenza

UNCOMMON COMPLICATIONS

RESPIRATORY:

  • Primary viral pneumonia

    - appears common in human cases of H5N1

    - rapid respiratory failure; within 48 hours

    - mortality >40%; within 7 days

CVS:

  • Myocarditis/pericarditis

CNS:

  • Transverse myelitis/Guillain-Barre

  • Myositis & Myoglobinuria

(Influenza is a multi-system disorder)


Pandemic flu

Influenza

ANTIBIOTICS – WHEN?

  • Previously well adults

    - Uncomplicated acute bronchitis – NO

    - Pneumonia (lung crackles/abnormal CXR) - YES

  • High risk patients/pre-existing disease

    - Lower respiratory tract features - YES

    - Pneumonia - YES


Pandemic flu

Influenza

ANTIBIOTICS – WHICH?

  • Empirical cover

    - S.pneumoniae, H.influenzae, S.aureus - YES

    - Legionella ssp, ‘atypical pathogens’ - NO

  • Co-amoxiclav or Doxycycline

ANTIBIOTICS – HOW?

  • Oral route for non-severe

  • IV route for severe infection (CURB 65 > 3)


Pandemic flu

Antiviral Therapyin ‘Ordinary Flu’

  • <30h after onset of symptoms

    - significant effect on reduction of duration of

    symptoms esp fever (shorten by 1 day)

  • >30h after onset of symptoms

    - no significant effect

  • No known effect on mortality


Pandemic flu

Neuraminidase inhibitors

  • Oseltamivir

  • Oral

  • Zanamivir

  • Dry powder inhaler


Pandemic flu

Pandemic Influenza

EFFICACY OF ANTIVIRALS

  • Oseltamivir active in vitro and in vivo against

    previous pandemic strains:

    H2N2 (1957), H3N2 (1968), N1N1 (1977) etc

  • But only 1 mutation required for full resistance

  • Rates of development of resistance to oseltamivir in clinical isolates:

    - Trials in adults: 0.33%

    - Trials in children: 4-18%

  • ? Combining neuraminidase inhibitors with M2 ion channel inhibitors (Amantadine & Rimantadine)


Pandemic flu

Pandemic Influenza

POSSIBLE BENEFITS OF ANTIVIRAL USE IN THE PANDEMIC

  • Reduction of illness duration by an average of 24hr and therefore more rapid mobilisation of essential workers

  • Reduction in viral secretion & clinical attack rates

  • Reduction in hospitalisation

  • Reduction of complications and therefore need for other drugs especially antibiotics


Pandemic flu

Pandemic Influenza

RECOMMENDATIONS FOR ANTIVIRAL THERAPY

  • Patients to receive antivirals if they have all of

    - Acute influenza-like illness

    - Fever >38oC

    - Within 30hrs of onset

  • Oseltamivir (Tamiflu) 75ug bd for 5 days

    - reduce dose in renal failure

    - adjust dose by body weight in children (liquid)

    - avoid in children under 1 year

  • Currently stockpile for 25% population in Scotland

  • Logistics!


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