H1N1 Management Guidelines
H1N1 Testing Guidelines
Criteria for Specimen Submission to the Texas Department of State Health Services Lab
- Hospitalized Patients
- Patients hospitalized for at least 48 hours with ILI (influenza-like illness) symptoms (fever greater than 100° F AND cough and/or sore throat) plus one or both of the following conditions:
- Severe illness such as lower respiratory tract infections or pneumonia
- Unusual presentation in children, adults older than 64 years of age, and individuals with suppressed immune systems
- Deaths
- Patients who have died with ILI
- Patients who have no other known cause of death
- Specimens must be collected before death
- Pregnant Women
- Pregnant patients with ILI
- Public Health Investigations
- Specimens that are part of a critical public health investigation as identified by DSHS or the local health department
- Enrolled Providers
- Providers who are participants in the DSHS Influenza laboratory Surveillance Program as designated the DSHS Infectious Disease Control Unit
Specimens not meeting one of the criteria above should be submitted to a commercial or reference laboratory for diagnostic testing. Consult the DSHS Flu website for a current list of reference laboratories, http://www.dshs.state.tx.us/txflu/Lab-Test-Protocol.shtm
Algorithm to assist in the interpretation of Rapid Influenza Diagnostic Test (RIDT) results during periods when influenza viruses are circulating in the community
Rapid Influenza Diagnostic Testing (RIDT) Limitations
- Knowledge of the presence of influenza A or B virus infection can help to inform influenza treatment decisions.
- A negative rapid test result does not rule out influenza virus infection.
- Since false negative results can occur, if clinical suspicion of influenza is high in a patient who tests negative by RIDT (or if RIDT is not offered), empiric antiviral therapy should be administered, if appropriate, and infection control measures implemented.
- This test can not distinguish influenza A virus subtypes. For example, this test cannot distinguish influenza infections caused by novel influenza A viruses versus seasonal influenza A viruses.
http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm
Antiviral Indications for Novel (H1N1) Influenza A
Treatment is recommended for:
- All hospitalized patients with confirmed, probable or suspected novel influenza A (H1N1)
- Persons who are at high risk for complications of novel influenza A (H1N1):
- Children younger than 2 years old
- Adults 65 years of age and older
- Persons with the following conditions:
- Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus);
- Immunosuppression, including that caused by medications or by HIV;
- Pregnant women;
- Persons younger than 19 years of age who are receiving long-term aspirin therapy;
- Residents of nursing homes and other chronic-care facilities
- Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus);
- Children younger than 2 years old
Post-exposure antiviral chemoprophylaxis can be considered for the following:
- Close contacts* of cases (confirmed, probable, or suspected) who are at high-risk for complications of influenza
- Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact* exposure to a person with novel (H1N1) influenza virus infection (confirmed, probable, or suspected) during that person’s infectious period
(*Close contact defined as having cared for or lived with a person who is a confirmed, probable, or suspected case of influenza, or having been in a setting where there was a high likelihood of contact with respiratory droplets and/or body fluids of such a person. Examples include sharing eating or drinking utensils, physical examination, or any other contact between persons likely to result in exposure to respiratory droplets. Typically does not include activities such as walking by an infected person or sitting across from a symptomatic patient in a waiting room or office)
Pregnancy
Pregnancy is not a contraindication to oseltamivir or zanamivir use. Because of its systemic activity, oseltamivir is preferred for treatment of pregnant women. The drug of choice for chemoprophylaxis is less clear. Zanamivir may be preferable because of its limited systemic absorption; however, respiratory complications that may be associated with zanamivir because of its inhaled route of administration need to be considered, especially in women at risk for respiratory problems.
http://cdc.gov/h1n1flu/recommendations.htm
Use of Antivirals for Treatment of Influenza
| Population | Pandemic (H1N1) Influenza virus 2009 | Multiple co-circulating influenza A sub-types or viruses with different antiviral susceptibilities |
| Mild to moderate uncomplicated clinical presentation | ||
| At-risk population | oseltamivir or zanamivir | zanamivir or oseltamivir plus M2 inhibitor* |
| Otherwise healthy | Need not treat | Need not treat |
| Severe or progressive clinical presentation | ||
| At-risk population | oseltamivir (zanamivir should be used where virus is known to be resistant to oseltamivir or if oseltamivir is unavailable) | oseltamivir plus M2 inhibitor*, or zanamivir |
| Otherwise healthy | ||
*M2 Inhibitors: Amantadine (should not be used in pregnant women) and Rimantadine
http://www.who.int/csr/resources/publications/swineflu/h1n1_guidelines_pharmaceutical_mngt.pdf
Antiviral Dosing Guidelines
| Table 1. Antiviral medication dosing recommendations for treatment or chemoprophylaxis of novel influenza A (H1N1) infection. (Table extracted from IDSA guidelines for seasonal influenza.) |
|||
| Agent, group | Treatment | Chemoprophylaxis | |
|---|---|---|---|
| Oseltamivir | |||
| Adults | 75-mg capsule twice per day for 5 days | 75-mg capsule once per day for 10 days | |
| Children ≥ 12 months | 15 kg or less | 30 mg twice per day | 30 mg once per day |
| 16-23 kg | 45 mg twice per day | 45 mg once per day | |
| 24-40 kg | 60 mg twice per day | 60 mg once per day | |
| >40 kg | 75 mg twice per day | 75 mg once per day | |
| Zanamivir | |||
| Adults | Two 5-mg inhalations (10 mg total) twice per day | Two 5-mg inhalations (10 mg total) once per day | |
| Children | Two 5-mg inhalations (10 mg total) twice per day (age 7 years or older) | Two 5-mg inhalations (10 mg total) once per day (age 5 years or older) | |
Antiviral Dosing Guidelines
| Table 2. Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir. | |
| Age | Recommended treatment dose for 5 days |
|---|---|
| <3 months | 12 mg twice daily |
| 3-5 months | 20 mg twice daily |
| 6-11 months | 25 mg twice daily |
| Table 3. Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir. | |
| Age | Recommended prophylaxis dose for 10 days |
|---|---|
| <3 months | Not recommended unless situation judged critical due to limited data on use in this age group |
| 3-5 months | 20 mg once daily |
| 6-11 months | 25 mg once daily |
http://cdc.gov/h1n1flu/recommendations.htm
Emergency Compounding of an Oral Suspension from TAMIFLU Capsules
In the event that the commercially manufactured TAMIFLU Oral Suspension is not available, the pharmacist may compound a suspension from TAMIFLU (oseltamivir phosphate) Capsules. See DSHS website for details:
http://www.dshs.state.tx.us/txflu/emer-compound-tamiflu.shtm
Instruction Sheets for Families Preparing Tamiflu Solutions from a Capsule
Easy to follow instruction guides, by dose, for preparing solutions from capsules for Tamiflu treatment and prophylaxis. See website below to print instruction sheets:
http://www.dshs.state.tx.us/txflu/flu-healthcare.shtm
Influenza A H1N1 Vaccination Guidelines
The groups recommended to receive the novel H1N1 influenza vaccine include:
- Pregnant women
- Household contacts and caregivers for children younger than 6 months of age
- Healthcare and emergency medical services personnel
- All persons from 6 months through 24 years of age
- Children from 6 months through 18 years of age
- Young adults 19 through 24 years of age
- Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza
There is some possibility that initially the vaccine will be available in limited quantities. Recommendation for vaccine prioritization:
- Pregnant women
- Persons who live with or care for children younger than 6 months of age
- Healthcare and emergency medical services personnel with direct patient contact
- Children 6 months through 4 years of age
- Children 5 through 18 years of age who have chronic medical conditions.
Once the demand for vaccine for these prioritized groups has been met at the local level, programs and providers should begin vaccinating everyone from ages 25 through 64 years.
Current studies indicate the risk for infection among persons age 65 or older is less than the risk for younger age groups. Therefore, as vaccine supply and demand for vaccine among younger age groups is being met, programs and providers should offer vaccination to people over the age of 65.
The novel H1N1 vaccine is not intended to replace the seasonal flu vaccine.
Persons over the age of 65 should receive the seasonal vaccine as soon as it is available.
Seasonal flu and novel H1N1 vaccines may be administered on the same day.
It is anticipated that 2 doses of H1N1 vaccine will be needed, given 28 days apart, in order to produce immunity.
http://www.cdc.gov/h1n1flu/vaccination/acip.htm
http://www.cdc.gov/media/pressrel/2009/r090729b.htm
Infection Prevention & Control Precautions for Patients With Respiratory Illness To Include Influenza and Influenza A H1N1
| Hand hygiene | Gloves | Gowns | Surgical mask | Eye protection | N95 respirator | |
|---|---|---|---|---|---|---|
| Patient presents with respiratory symptoms which may include fever, cough and/or sore throat | Educate patient | For the patient | ||||
| Healthcare worker in direct contact with a coughing patient, and/or probable, suspected, confirmed influenza case | As per Standard Precautions (before and following patient contact and contact with the patient’s environment) | As per Standard Precautions (for anticipated contact with body fluids, mucous membranes, non-intact skin, contaminated environmental surfaces) | As per Standard Precautions (if clothing or exposed skin will have direct contact with the patient or patient’s environment) | For direct patient care and upon entering the patient’s room | As per Standard Precautions (for activities that are likely to generate splashes or sprays of body fluids to the eyes) | For aerosol generating procedures (bronchoscopy, open suctioning of airway secretions, resuscitation involving emergency intubation or cardiac pulmonary resuscitation, endotracheal intubation) |
Guidelines prepared 9/9/2009 (Revised 10/2/09) by JDixon, MN, RN, CIC, Director of Infection Prevention & Control
(Reviewed by Doctors Bissett, Hauger, LeBlanc, Ziebell)