Kuwait Influenza Case Management guidelines for 3nd Flu Workshop 2017

Flu Season 2017 / 2018
Ministry of Health
State of Kuwait
WHO/EMRO Influenza Expert Team
Dr. Ashraf El-Adawy
WHO Chest Diseases Expert
Clinical Case Management of
Influenza Cases (ILI & SARI)
for the 3rd Annual Kuwait National Workshop
of Clinical Management of Influenza Cases
With the Guidance & Supervision of
Dr. Majda Alqattan the Assistant
Undersecretary of Public Health
Public Health Depar tment
Communicable Diseases Control Division

Clinical Case Management of Influenza Patients with ILI & SARI 2017
2 WHO Expert Team Dr. Ashraf El-adawy
The 3rd Annual Kuwait National Workshop
for Clinical Management of Influenza Cases (2017)
Clinical Case Management
of Influenza Cases (ILI & SARI)
With the Guidance & Supervision of Dr. Majda Alqattan
the Assistant Undersecretary of Public Health
By: Dr. Ashraf El-Adawy
Consultant Chest Physician
Chest Diseases Expert for WHO
3rdEdition, October 2017

Contents
Influenza-like-illness (ILI) case definition:.......................................................................................... 4
Guide to assessment and management of ILI :..................................................................................4
1) Mild or Uncomplicated influenza-like illness (ILI)........................................................................... 5
2) Mild or Uncomplicated influenza-like illness (ILI) in high risk groups: ........................................... 5
Complications of influenza............................................................................................................ 5
Other respiratory complications....................................................................................................6
Non-respiratory complications......................................................................................................6
Management of patients with Mild or Uncomplicated ILI at home................................................ 7
3) Severe or Complicated influenza-like illness (ILI)...........................................................................9
Diagnostic tests for severe ILI & SARI: ............................................................................................ 14
Diagnostic specimen collection for respiratory virus infection in SARI ............................................ 14
General laboratory investigations for hospitalized patients ............................................................ 16
Importance of early recognition...................................................................................................... 16
1) Early supportive therapy and monitoring: ............................................................................... 16
2) Antiviral drug therapy :.............................................................................................................17
Points to remember: ................................................................................................................... 19
3) Antibiotic treatment ................................................................................................................... 20
4) Corticosteroids............................................................................................................................ 20
Implementation of Infection prevention & Control (IPC) measures................................................. 21
Patient Placement....................................................................................................................... 21
A. Standard Precautions: Routinely, For all patients, at all times, in all healthcare settings.... 21
B. Droplet Precautions: (should be implemented empirically):............................................... 22
C. Airborne Precautions:.......................................................................................................... 22
Discharge criteria for hospitalized patients : ................................................................................... 23
Policy of Laboratory testing and hospital admission for ILI Cases ................................................... 24
Algorithm of Influenza Case Management...................................................................................... 25
Multiple choice questions................................................................................................................26
References:......................................................................................................................................31

Clinical Case Management of Outbreaks of Influenza
Like-Illness & Severe Acute Respiratory Illness (SARI)
Case Definitions
Influenza-like-illness (ILI) case definition:
An acute respiratory infection with:
 Measured fever of ≥ 38 C°
 And cough;
 With onset within the last 10 days.
 Influenza infection causes a clinical syndrome not easily distinguished from other
respiratory infections.
 Even though influenza can be caused by many different strains of influenza virus, the signs
and symptoms are similar for all types.
 The range of symptoms observed with influenza virus infections is nonspecific and
resembles the clinical picture of a variety of other pathogens. There is no single symptom or
group of symptoms that is exclusive only to influenza.
 In addition to the influenza viruses, other respiratory viruses can also cause ILI symptoms,
such as human respiratory syncytial virus , human parainfluenza viruses , rhinovirus,
adenovirus, human coronaviruses and human metapneumovirus .
Severe acute respiratory illness (SARI)
▪ A person meeting the case definition of influenza‐like illness AND requiring hospital
admission.
SARI case definition
An acute respiratory infection with:
 History of fever or measured fever of ≥ 38 C°;
 And cough;
 With onset within the last 10 days;
 And requires hospitalization
Guide to assessment and management of ILI :
▪ The clinical presentation of influenza can vary from asymptomatic infection to a serious
fatal illness that may include exacerbation of other underlying conditions and severe viral
pneumonia , ARDS, with multi‐organ failure.
▪ The clinical management of influenza‐like illnesses will follow a protocolized step in both
the primary and secondary or tertiary level health care facilities.
 The clinical assessment should ideally begin in the triage area whenever a patient is
suspected of ILI.

 The assessment will lead to screening out of patients for treatment, either in hospital or at
home ,from those without having any visible signs or symptoms of ILI requiring no
treatment.
 However, on an individual patient basis, initial treatment decisions should be based on
clinical presentation and epidemiological data and should not be delayed pending
laboratory confirmation , a decision to treat will depend upon clinical judgment.
Case description: Possible Case scenarios
1) Mild or Uncomplicated influenza-like illness (ILI)
 Influenza-like illness symptoms: fever, cough, sore throat, rhinorrhea, headache, muscle
pain, malaise, without shortness of breath or dyspnoea.
 Gastrointestinal illness such as diarrhoea and/or vomiting, especially in children, but
without evidence of dehydration.
 The general condition of these patients will be good, (stable medical condition) without
any signs of hypotension or mental confusion.
2) Mild or Uncomplicated influenza-like illness (ILI) in high risk groups:
▪ In Patients who meet ILI clinical case definition and in high risk group for serious or
life-threatening influenza complication (with stable medical condition) for example :
Complications of influenza
Influenza-associated pneumonia
Patients presenting only with mild influenza like illness and are not in a group known
to be at‐risk of developing severe or complicated illness, and without any clinical
signs of progression to severe illness can be treated at home with only symptomatic
treatment . These groups of patients need not be treated with antiviral medication.
G Pregnant women (up to two weeks post partum)
G age <2 years or ≥65 years
G Persons with the following underlying conditions at any age:
 Chronic Broncho‐pulmonary disease (Including asthma & COPD& OSA )
 Chronic cardiovascular diseases (Including CHF& MI , except hypertension)
 Metabolic disorder (specially Diabetes mellitus)
 Chronic liver or renal failure
 Chronic neurologic disorder (Cerebral palsy, stroke, multiple sclerosis,
muscular dystrophy, seizure disorders etc)
 Immune suppressed patients (HIV, immunosuppressive medications,
malignancy , long term steroids)
 Haemoglobinopathies
 Morbid obesity(i.e., body-mass index ≥40)

 Typical influenza disease does not occur in every infected person, In otherwise healthy
individuals, influenza infection normally results in an uncomplicated URTI that resolves
within 1–2 weeks.
 Although many people think of influenza as just a common cold, it is really a specific and
serious respiratory infection that can result in hospitalization and death
 Pneumonia is a relatively common complication (5–38% with influenza A and 10% with
influenza B), predominantly in the elderly, patients with chronic
 cardiopulmonary disease, pregnant women and immunocompromised individuals.
 The etiology may be viral, bacterial or mixed viral–bacterial. Such patients can deteriorate
rapidly and mortality can be close to 50%.
 In primary viral pneumonia, typical influenza is followed by a rapid progression (over 2–3
days) of fever, cough, dyspnoea, chest pain and cyanosis. Physical examination
& chest X-ray disclose diffuse bilateral infiltrates consistent with acute respiratory distress
syndrome. If fatal, death usually occurs within 4–5 days of first symptoms.
 Bacterial pneumonia as a complication of influenza also has a different presentation from
primary viral pneumonia, Patients initially show clinical improvement from illness and then
develop worsening respiratory symptoms. In this case, physical and chest X-ray
examinations are more likely to show localized signs of consolidation.
 Combined viral–bacterial pneumonia is more common than primary viral pneumonia , Of
patients with a severe pneumonia, 75% will have secondary bacterial infection. In these
cases, the individual will appear to be recovering from the influenza illness and then have a
recurrence of the respiratory symptoms.
 The bacteria most commonly involved are Staphylococcus aures and streptococcus
pneumoniae, with Haemophilus influenzae being less common.
 There is evidence that influenza infection actively facilitates the pathogenicity of bacteria
and the impact of illness, causing immunosuppression.
 Once the responsible pathogen has been identified, appropriate antibiotic treatment should
be initiated promptly.
 Influenza B virus can cause the same spectrum of disease as that seen afte influenza A virus
infection, and severe illness can occur, particularly in the elderly.
Other respiratory complications
 Exacerbations of asthma, chronic obstructive pulmonary disease and cystic fibrosis are
common complications of influenza illness.
Non-respiratory complications
 Myositis is reported more frequently in children with influenza B, but adults may also be
affected and may develop rhabdomyolysis with acute renal failure.
 Cardiac complications, specifically myocarditis, have been described in patients with
influenza A and B, but these complications are mostly asymptomatic. Pericarditis has been
reported rarely.
 CNS complications are rare & range from irritability and confusion to psychosis and severe
encephalopathy due to a variety of inflammatory processes, including Reye's syndrome ,
Recovery is usually complete.

Management of patients with Mild or Uncomplicated ILI at home
Prescribing oseltamivir
 Oseltamivir is active against all currently circulating human influenza viruses.
 Treatment should be started as soon as possible ,The usual dose is 75 mg taken orally twice
a day for adults and children >40 kg for 5 days , In smaller children use weight based dosing.
The principles of treatment at home for these categories of patients include the followings:
 Applying home isolation and advising rest till the patient becomes afebrile.
 Administering appropriate infection control measures at home.
 Using analgesics or antipyretics, however Acetylsalicylic acid should be avoided specially in
children (The drug of choice should be Acetaminophen).
 Aspirin‐containing products should not be administered to patients aged 18 years old and
younger due to the risk of Reye's syndrome.
For Mild or non-severe influenza-like illness (ILI) in high risk groups , treat with
antivirals (a neuraminidase inhibitor such as oseltamivir )at home, and close
home observation with instruction to return to care if they fail to improve in 72
hours or deteriorate,develop severe symptoms. If this occurs, hospitalization
should be considered.
Signs and symptoms of progressive disease or deterioration
Symptoms and signs suggesting cardiopulmonary insufficiency:
 Shortness of breath, difficulty in breathing , bloody or colored sputum, hemoptysis ,
cyanosis, chest pain and hypotension.
 In children fast or laboured breathing may indicate progressive disease.
 Hypoxia as indicated by pulse oximetry.
Symptoms and signs suggesting central nervous system (CNS) complications:
 Altered mental status, unconscious, drowsy, or difficult to awaken; recurring or
persistent convulsions (seizures), severe weakness or paralysis.
Evidence of sustained virus replication or invasive secondary bacterial infection:
 Based on laboratory testing or clinical signs (e.g. persistent high fever and other symptoms
beyond three days, sepsis, rapid deterioration).
Severe dehydration:
 Decreased activity, dizziness, decreased urine output, lethargy.
 Children can also present with poor feeding, and excessive diarrhea and vomiting.
Persons with mild influenza like illness who present with an uncomplicated
febrile illness typically do not require antiviral treatment unless they are at
higher risk for serious influenza complications.

 Hydrating patients with abundant liquids in accordance with the need and patient’s
condition.
 Following‐up clinical evolution of the patient by health care worker or by family members
checking for signs and symptoms of progression to severe illness & Recognize patients that
fail to improve within 72 hrs or deteriorate.
Home-care messages can be categorized as follows:
Regarding decision making algorithm for the patient presenting with Mild ,
uncomplicated influenza-like illness (ILI) , It takes into account the presence or
absence of risk factors for severe disease and on the progression & deterioration of
the disease over 72 hours.
All Patients who have mild uncomplicated ILI (whether with or without risk
factors) ,should be instructed to return for follow-up, when they develop any
signs or symptoms of progressive disease or fail to improve within 72 hours of
the onset of symptoms. If this occurs, hospitalization should be considered.

3) Severe or Complicated influenza-like illness (ILI)
When influenza is known or suspected to be circulating widely in the community and the patient has
ARI symptoms, suspect severe influenza virus infection when there is rapid progression to severe
critical illness, including: Severe pneumonia, ARDS (acute respiratory distress syndrome) , and
severe sepsis, or any end-organ dysfunction (shock, encephalitis, myocarditis) or exacerbation of
chronic illness, co-infection with bacterial pneumonia or severe dehydration.
influenza virus infection in any patient can result in severe or complicated illness ,even in patients
who present initially with uncomplicated influenza.
Mild or Uncomplicated influenza-like illness (ILI)
High Risk Groups
 Symptomatic care at home
 Instruction on infection
control
 Return for care if no
improvement within 72 hours
 Treat with antiviral at home
 No influenza laboratory test
 Instruction on infection
control
 Return for care if no
improvement within 72 hours
 Hospital admission
 Treat with antiviral
 Influenza laboratory
test.
When influenza viruses are known to be circulating in a community, patients
presenting with features of uncomplicated influenza( Mild ILI with or without
high risk factors of developing severe or complicated illness ) can be diagnosed
on clinical and epidemiological grounds, will not require influenza laboratory
confirmation.
Any deterioration or failure to improve within 72 hours
(Complicated OR progressive illness)
NO High Risk

In severe cases, patients generally begin to deteriorate around 3 to 5 days after symptom onset.
In some cases, especially if the cause is a primary viral pneumonia, deterioration may be rapid,
progressing to respiratory failure within 24 hours, requiring immediate admission to an intensive
care unit for respiratory support.
Note:
o Shortness of breath is not typical of uncomplicated influenza virus infection, and is suggestive of
severe disease.
o Respiratory rate is a very useful parameter in evaluating dyspnea or difficulty breathing.
Upper limits of respiratory rate by age Increased respiratory rate (tachypnea)
< 2 months > 60 breaths/minute
Criteria for hospitalization (Signs of severe influenza like illness (ILI)
Or signs of rapid progression of illness, such as :
 Presence of fever ≥ 38°C
 Dyspnoea or difficult breathing
 Cyanosis, bloody or colored sputum, chest pain
 Hypoxia as indicated by pulse oximetry ( Oxygen saturation < 92% despite full
oxygen saturation)
Alteration of vital sign :
 Arterial hypotension (Systolic blood pressure <90 mm Hg & diastolic blood pressure < 60 mm Hg)
 Respiratory rate frequency increased (over 30 breaths per minute)
 Cardiac frequency increased (Heart rate > 120bpm)
Altered level of consciousness: New confusion, striking agitation or seizures or depressed level of
consciousness
 Severe Dehydration (Loss of more than 10 % of body weight as evidenced by
absent or low peripheral pulse, poor skin turgor, undetectable blood pressure
and sunken eyes)
 Abnormal chest‐x ray (Chest x‐ray showing pulmonary infiltrates)
 Patient that return for a second consultation with recurrent or persistent fever
( fever not subsiding beyond 3 days despite under treatment with
analgesics)

2-11 months > 50 breaths/minute
12 months to 5 years > 40 breaths/minute
Adults > 26 breaths/minute
o Another parameter which can be used to evaluate difficulty breathing is oxygen saturation while
breathing ambient air. Measured by digital pulse oximetry, saturation should be 95% or greater.
o Saturation < 90% is an indication of severe disease, while in pregnant women, <95% can indicate
severe disease.
Differential diagnosis and diagnostic tests of severe ILI & SARI:
Patients with complicated or severe ILI should be
hospitalized & treated with antiviral.
Criteria for admission in the Intensive Care Unit :
Consider ICU admission for patients with, or at risk of severe single or multi-organ
dysfunction ,as evidenced by the followings:
G Signs of progressive infiltrates on chest x‐ray
G Persistent hypoxia ( SpO2 < 92%) or
G respiratory exhaustion despite maximum oxygen saturation
G Progressive hypercapnoea
G Presence of compromised haemodynamics
G Signs of sepsis and imminent shock
Influenza can be diagnosed based on clinical presentation in the context of
known or suspected influenza activity in your community and should be
part of a broader differential diagnosis in patients with severe acute
respiratory illness (SARI).
Hospitalize patients with SARI suspected of severe influenza infection when there is
evidence of progressive, severe or complicated disease i.e. severe pneumonia, severe
sepsis, shock or any other organ dysfunction, or exacerbation of chronic medical
conditions.

When influenza is suspected or known to be circulating in your community, for patients presenting
with signs and symptoms of severe pneumonia, include influenza virus infection on the differential
diagnosis, but also remember to include other pathogens that also present with severe pneumonia.
These include the following:
 Community acquired pneumonia pathogens (e.g. Streptococcus pneumoniae,
Staphylococcus aureus, Hemophilus influenzae, Legionella pneumophila, Mycoplasma
pneumoniae ) .
 Other respiratory viruses e.g. Respiratory Syncytial Virus (RSV), Parainfluenza, adenovirus,
human metapneumovirus, human coronavirus .
 Fungal infections, in endemic areas for certain fungal infection
 people living with HIV, consider Mycobacterium tuberculosis (TB), Pneumocystis
jirovecipneumonia (PjP or PCP) .
Examples of possible etiologic agents of unusual SARI
 Severe acute respiratory illness (SARI) has been documented as a common feature of recent
emerging, novel respiratory pathogens e.g Avian influenza A (H7N9) , A (H5N1) and Middle
East Respiratory Syndrome Coronavirus (MERS-CoV).
 All patients with signs and symptoms of
possible SARI , presenting to the
Emergency Department or admitted to
Hospital ,should be questioned about
recent travel to, residence in or contact
with sources for SARI-related novel and
emerging infections.
 Clinicians should consider the patient
clinical presentation & epidemiological
links (exposures) when investigating SARI.
Severe acute respiratory illness (SARI)
A person meeting the case definition of influenza‐like illness AND requiring hospital
admission,thise case definition is provided for use in the in-patient hospital settings.
The case definition for Severe Acute Respiratory Infection (SARI) is provided as a standard to
enumerate severe respiratory infections (including those caused by influenza) leading to
hospitalization.
The clinical manifestations Of SARI are not specific, Rather, they are shared by many different
infectious diseases.

 Exposure criteria : Clinicians should assess for epidemiological risk factors by obtaining an
exposure history including recent links to affected areas ( in countries where emerging
respiratory illnesses such as MERS-CoV1 or Avian influenza strains
 such as H7N9, H5N1 have been reported) OR close contact with an ill person (with a
confirmed or probable case within the 10-14 days prior to symptom onset) .
 In SARI patients with no epidemiological risk factors for avian influenza A (H7N9 or
H5N1) and MERS-CoV, clinicians should rule out the most common pathogens (e.g.
conventional bacteria and respiratory viruses including seasonal influenza) before
considering an unusual or more highly virulent pathogen.
 The only way of knowing with certainty the etiology of a case of SARI is by means
of laboratory diagnosis.
 Ideally, every patient meeting the SARI case definition, should be sampled.

Diagnostic tests for severe ILI & SARI:
 Respiratory tract specimens for influenza testing should be collected as soon as possible
after onset of illness in patients in whom treatment may be affected by making the
diagnosis, such as those with progressive or severe illness (severe ILI) .
 Collect respiratory specimens for laboratory testing before antiviral therapy is initiated.
 Upper respiratory tract specimens (nasopharyngeal and nasal specimens generally have
higher yields than throat swab specimens).
 Nasopharyngeal swabs are the preferred swabs for respiratory virus testing. Nasal swabs
may be used if NP swabs are not available.
 Reverse transcriptase polymerase chain reaction (RT-PCR ) are diagnostic tests of choice for
accurate and timely diagnosis of influenza virus infection.
 RT-PCR tests can detect the presence of the virus ribonucleic acid or RNA (a fragment of the
virus) and they can identify the influenza virus (A,B) and subtypes both in upper and lower
respiratory tract specimens.
 RT-PCR has both a high sensitivity (86%-100%) and high specificity and distinguishes
specific influenza virus from others.
 The test requires a special laboratory and takes about 6-8 hours to perform in the laboratory
but delays may occur during transport to laboratory and laboratory batching.
 Specimen collection should be always performed with appropriate infection prevention
precautions.
 Rapid influenza diagnostic tests (Point-of-care test) can produce quick results in 15 minutes
or less, however false negative results are common
 Rapid Influenza Diagnostic Tests (RIDTs ) should not be used to rule out influenza A , The
sensitivity of currently available RIDT for human influenza strains is variable & suboptimal.
Diagnostic specimen collection for respiratory virus infection in SARI
 Respiratory tract specimens are the most important specimens for confirming the diagnosis
of respiratory virus infection.
 Upper respiratory tract samples include nasal, naso-pharyngeal, throat swabs, nasal wash in
viral transporting medium (VTM).
➢ For seasonal influenza, nasal or nasopharyngeal samples are best specimens to collect
➢ Throat swabs should be added when novel or zoonotic influenza viruses are suspected.
Under no circumstances should influenza diagnostic testing delay initiation
of infection control practices or antiviral treatment, if influenza is suspected
clinically and epidemiologically.

 Specimens should be taken as early as possible in the course of illness as the ability to
detect virus declines with increasing delays.
 Viral testing should be done by reverse-transcriptase polymerase chain reaction (RT-PCR)
 Respiratory multiplex RT-PCR for parainfluenza, human metapneumovirus, coronavirus,
rhinovirus/enterovirus, adenovirus should be done on negative influenza specimens (48
hour TAT) when there is a clinical indication to detect non-influenza viruses.
 The most appropriate specimens for MERS-CoV testing are Lower Respiratory Tract
specimens ( LRT samples are more likely to be positive than URT specimens and virus can
be detected in LRT specimens for longer periods than in URT specimens).
 lower respiratory tract secretions are likely more sensitive for detection of both Influenza A,
including H7N9, and MERS-CoV.
In patients with lower respiratory-tract symptoms, in
addition to upper respiratory tract sampling, Collect
lower respiratory tract specimens, i.e. sputum ,
endotracheal aspirate, bronchoalveolar lavage, for
both bacterial and viral testing.
Collect pretreatment blood cultures for potential
bacterial pathogens that can also cause pneumonia and
sepsis (ideally before antimicrobial therapy is initiated)
,this must NOT significantly delay the start of
antimicrobial therapy (>45 minutes).
Collect Sputum sample for gram stain and routine culture (if there evidence of Pneumonia
If more invasive samples are collected they should be processed for a wide range
of pathogens e.g Bronchial-alveolar wash for all cultures (bacteria, viruses, fungi
mycobacteria,).

General laboratory investigations for hospitalized patients
Main Laboratory Test For hospitalized patients For patients admitted at Intensive Care Unit
 Full blood count (CBC)
 Serum electrolytes
 Hepatic function (AST, ALT)
 Renal function (BUN, Ceatinine)
 GPIC
 LDK
 Glucose
 Urinalysis
 Microbiological studies of respiratory
secretions (') and blood cultures if
suspected bacterial infection.
 Arterial blood gases
 Pulse oxirnetry
 Chest x-ray (at admission and to
followup, as per health owe facility
protocols)
 Other investigations, according to
established protocols of the health
care facility, such as erythrocyte
sedimentation rate, C-reactive protein
(CRP), and ECG
 In addition to the hospitalization
investigations
 Coagulation profile
 Procalcitonin (if available)
 Serial arterial blood gases
 Serial chest x ray
 Serial electrocardiogram
Importance of early recognition
 Routine screening & early recognition of clinical syndromes (i.e. severe sepsis, severe
pneumonia, and ARDS) and implementation of appropriate therapies, improves outcomes
and reduce morality .
 In patients with progressive or complicated illness, instigate continuous monitoring of vital
signs (e.g. temperature, blood pressure, pulse, respiratory rate, level of consciousness,
clinical signs of dehydration or shock) & oxygen saturation (pulse oximetry or blood gas
analyses).
 Initial treatment decisions should be based on clinical presentation and epidemiological
data and under no circumstances should treatment be delayed pending laboratory
confirmation.
Initial severe ILI & SARI treatment
Initial management should include appropriate infection prevention and control procedures,
evidence-based supportive critical care and empiric antibiotic and antiviral therapy while awaiting
diagnostic testing.
1) Early supportive therapy and monitoring:
A) Oxygen therapy for severe disease
 In the hospital setting, Give supplemental oxygen therapy immediately to patients (adults
and children) with SARI & Severe ILI who have signs of severe respiratory distress,
hypoxaemia (SpO2 < 90% by pulse oximetry) or shock.

 In adults initiate oxygen therapy at 5 L/min and in children at 1-2 l/min using nasal cannula
and measure SpO2 immediately because clinical signs of hypoxaemia are unreliable.
 If critically ill, consider starting with higher flow rates (10-15 l/min) using a face mask with
reservoir bag .
 Titrate oxygen flow rates to target SpO2 ≥90% in non-pregnant adults and children (or > 92-
95% in pregnant females) using the appropriate delivery device for flow rate.
 All areas where patients with SARI are cared for should be equipped with pulse oximeters,
functioning oxygen systems and disposable, single-use, oxygen-delivering interfaces (nasal
cannula, simple face mask, and mask with reservoir bag) .
 Pulse oximeters measure SpO2 quickly, easily, and reliably but have some limitations.
 Obtain an ABG (arterial blood gas analysis) for additional information about PaO2, pH and
PaCO2 in patients who may have severe hypoxaemia, hypercapnea, acidosis, unreliable
pulse oximeter readings, are deteriorating or are on invasive mechanical ventilation.
 Do NOT delay oxygen administration when caring for critically ill patients, Appropriate use
of oxygen will optimize quality care, minimizes waste and save lives.
B) Advanced respiratory support
 Recognize severe hypoxemic respiratory failure when a patient with severe respiratory
distress is failing standard oxygen therapy as: Patients may continue to have increased work
of breathing or hypoxemia even when standard oxygen therapy is delivered via a face mask
with reservoir bag (flow rates of 10 -15 L/min delivers oxygen concentration, FiO2, between
0.60 and 0.95).
 Wherever available, when staff members are trained, institute mechanical ventilation early
in patients with increased work of breathing or hypoxemia that persists despite standard
high flow oxygen therapy (Refractory H ypoxaemia) .
 Noninvasive ventilation (NIV) is the delivery of bi-level positive airway pressure through a
tight-fitting mask, however there is insufficient evidence to promote its use in patients with
severe pneumonia or ARDS, unless immunosuppression is also present or disease is mild
without impaired consciousness or cardiovascular insufficiency.
 When NIV used, it should be used as a short trial, Monitor the patient closely in an ICU ,
Because NIV has potential to generate aerosols, use with airborne precautions. If NIV is
unsuccessful, do not delay endotracheal intubation.
2) Antiviral drug therapy :
For undifferentiated SARI in which the causative agent is unknown and there is concern
about a novel influenza strain e.g animal influenza viruses like H5N1,H7N9 or influenza
is circulating in the community, empiric treatment with neuraminidase inhibitors
should not be delayed while awaiting the results of diagnostic testing.

 Adamantanes and Rimantadine are M2 ion channel blockers; they interfere with hydrogen
ion channel activity of the influenza A virus and prevent viral uncoating , thus blocking its
entry into the host cells.
 M2 proton channel blockers protect only against the A viruses, however they are ineffective
against all currently circulating influenza virus strains.
 Neuraminidase inhibitors (Oseltamivir or Zanamivir) block the viral neuraminidase enzyme,
which is critical in releasing virions from the infected host's cells. These drugs are active
against influenza A and B.
 Regarding Neuraminidase inhibitors,They are not cures and do not kill the virus but
interfere with the way the virus multiplies , they shorten flu episodes by a couple of days,
reduce the risk of complications and possibly lower the likelihood that someone will pass on
the virus. Ideally, they should be given as early as possible in an infection.
 Hospitalized patients with suspected influenza should be treated empirically with
Neuraminidase Inhibitors (Oseltamivir or Zanamivir) , which will provide protection ,
effective against both influenza A & B viruses .
 Oseltamivir is the recommended first- line antiviral agent for neuraminidase-sensitive
influenza virus infection, ideally initiated within 48 hours of symptom onset.
 Patients with severe, progressive or complicated illness consistent with a diagnosis of
influenza should be treated with neuraminidase inhibitors as soon as possible, irrespective
of the presence of underlying comorbidities and even if the time elapsed between symptom
onset and first opportunity to treat is >48hrs.
 Evidence indicates that the greatest benefit is derived from early oseltamivir treatment.
Therefore, suitable preparations of oseltamivir need to be available at the point of care.
 Do not delay initiation of oseltamivir treatment while waiting for influenza testing results.
 Clinical judgment is an important factor in antiviral treatment decisions.
 The recommended duration of treatment is 5 days, use increased (doubled) doses of
oseltamivir for severely ill patients.
 Patients who have severe or progressive clinical illness should be hospitalized and treated
with oseltamivir as soon as possible. Consideration should be given to the use of higher
doses ( up to 150 mg doses of oseltamivir twice daily in adults and double the daily dose in
children), and longer duration of treatment depending on clinical response.
 If the clinical course remains severe or progressive, despite ≥5 days of antiviral treatment,
treatment should be continued without a break until virus infection is resolved or there is a
satisfactory clinical improvement (for up to 10 days) , Clinical judgment should be the guide
to extend treatment longer than 5 days for severely ill patients.
 Patients with suspected influenza should complete antiviral treatment for a full treatment
course regardless of negative initial test results unless an alternative diagnosis can be
established and clinical judgment suggests that influenza is an unlikely diagnosis.

 Clinicians should consider influenza virus infection as a possible cause of any febrile
respiratory illness requiring hospitalization during influenza season and consider testing for
influenza and starting empiric antiviral therapy & Do not wait for laboratory confirmation of
diagnosis.
Oseltamivir Treatment Dosage (Tamiflu®)
Agent, group Treatment usually for 5 days
Oseltamivir
Adults 75-mg capsule twice per day
Children ≥
12 months
15 kg or less 60 mg per day divided into 2 doses
16-23 kg 90 mg per day divided into 2 doses
24-40 kg 120 mg per day divided into 2 doses
>40 kg 150 mg per day divided into 2 doses
Oseltamivir Dosage for Children under one Year
Age Recommended treatment of Oseltamivir for 5 days
<3 months 12 mg twice daily usually for 5 days
3-5 months 20 mg twice daily usually for 5 days
6-11 months 25 g twice daily usually for 5 days
Points to remember:
 Pregnant and postpartum women (including those who have had pregnancy loss) are at risk
of severe influenza-related complications
 Neuraminidase inhibitors be prescribed for pregnant women and for those up to two weeks
postpartum who have suspected or confirmed influenza.
 When considering antiviral treatment, pregnancy should not be considered as
contraindication to Oseltamivir use.
 Pregnant women should receive the same standard dose regimen as adults for antiviral
treatment e.g Oseltamivir (Tamiflu) : 75 mg capsule twice/ day for 5 days in mild
uncomplicated ILI.
 Also ,women can continue to breastfeed while being treated with antivirals.
 Dose modification should be considered in patients with impaired renal function as serum
concentrations of oseltamivir carboxylate, the active metabolite of oseltamivir, increase
with declining renal function .
 For patients with creatinine clearance of 10--30 mL per minute, a reduction of the treatment
dosage of Oseltamivir to 75 mg once daily is recommended.
 Intubated patients with influenza illness should receive oseltamivir through a nasogastric
tube .

 Antiviral agents should not be used for post‐exposure chemoprophylaxis in healthy children
or adults, Antiviral agents are not a substitute for vaccination.
3) Antibiotic treatment
 Patients may have co-infection with bacterial pathogens or other respiratory viruses;
therefore, investigations and/or empiric therapy for other pathogens should also be
considered.
 During an influenza outbreak, cases of pneumonia both from influenza and from secondary
bacterial pneumonia may be expected to increase, adding to the high burden of pneumonia
already seen in community settings.
 Secondary bacterial infections have been found in approximately 30% of fatal cases.
 When pneumonia is present, co-infecting bacteria frequently reported include
Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae and
Staphylococcus aureus (which may include Methicillin sensitive Staphylococcus aureus and
Methicillin-resistant Staphylococcus aureus).
 When secondary bacterial pneumonia is suspected, treatment with antibiotics should follow
recommendations from national guidelines for community‐acquired pneumonia.
 Give empiric, effective antimicrobials to treat all likely pathogens, including community-
acquired pneumonia or health care-associated pneumonia (if infection was acquired in
health care setting) and sepsis. Give within one hour.
 Antibiotic treatment should be selected empirically based on local patterns of bacterial
resistance , the individual patient contraindications or allergies, and the national protocol
for CAP ,until the diagnosis is confirmed.
 Empiric therapy can then be adjusted on the basis of laboratory results (If microbiologic
results identify pathogen, therapy should be tailored towards this pathogen).
 Don not delay commencement of empiric antiviral treatment plus empiric antibiotics for
community-acquired pathogens, while awaiting confirmatory diagnostic test results In Patients
who have severe or progressive clinical illness.
4) Corticosteroids
 Corticosteroids should not be used routinely for treatment of influenza virus infection but
should not be withheld from patients with exacerbations of asthma if this forms a normal
part of treating their exacerbation.
 Low doses of corticosteroids may be considered for patients in septic shock who require
vasopressors and have suspected adrenal insufficiency.
 Prolonged use of or high dose corticosteroids can result in serious adverse events in
influenza virus-infected patients, including opportunistic infection and possibly prolonged
viral replication.
Chemoprophylaxis for Healthy close contacts is not generally recommended

NOTES:
 Patients with SARI should be treated cautiously with intravenous fluids, because aggressive
fluid resuscitation may worsen oxygenation especially in settings where there is limited
availability of mechanical ventilation
 Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly
progressive respiratory failure and sepsis syndrome and apply supportive care interventions
immediately.
 Understand the patient’s co-morbid condition(s) as this will impact the management of
their critical illness and their prognosis.
 Clinicians will require guidance on the management of patients presenting with SARI in the
ICU setting, since most severe cases require ICU admission, mechanical ventilation and
frequently multisystem organ support
Implementation of Infection prevention & Control (IPC) measures
 Prior to any patient interaction, all healthcare workers (HCWs) have a responsibility to
assess the infectious risk posed to themselves and to other patients, visitors.
Patient Placement
 At triage, recognize patients with severe ILI & SARI, give the patient a surgical mask and
place the patient in separate area , If possible, in an adequately ventilated single room away
from other patient care areas.
 If single rooms are insufficient for the number of individuals, then apply cohorting
(placement of patients with the same etiological diagnosis in the same designated unit or
ward) to reduce transmission to other patients or health care workers.
 Organize the space and process to permit spatial separation , Keep at least 1-2 meter
between each patient with SARI and other individuals not wearing PPE.
A. Standard Precautions: Routinely, For all patients, at all times, in all healthcare settings.
1) Hand hygiene : should be performed before and after any contact with patients and
after contact with contaminated items. Use an alcohol-
based hand product if hands are NOT visibly soiled. Wash hands with soap and running
water when visibly dirty or contaminated with proteinaceous material.
2) Respiratory Etiquette (i.e. covering the mouth and nose during coughing or sneezing
with a tissue, sleeve or flexed elbow), followed by hand hygiene and disposing tissue
immediately.
3) Waste management and environmental cleaning : Cleaning can be done with water and
neutral detergents. Only surfaces that enter contact with patient skin/mucosa and
surfaces frequently touched by health care worker require disinfection after cleaning.
4) Safe injection procedures and sharps disposal
When caring for patients with SARI, use standard and droplet precautions at
all times and airborne precautions during certain high-risk procedures.

5) Appropriate personal protective equipments (PPE): If direct contact with blood or
body fluids, secretions, excretions, mucous membranes, or non-intact skin is
anticipated, then use hand hygiene and gloves. If there is a risk of splashes onto
the health care workers body use a gown also. If there is a risk of splashes onto
the body and face, then use medical mask and eyewear also.
B. Droplet Precautions: (should be implemented empirically):
When caring for patients with SARI, droplet precautions are recommended in addition to
standard precautions. Critical additional measures under droplet precautions include:
1) The use of a medical-surgical mask when within one metre of a patient.
2) Physically maintaining distance between the infected patient and other persons by
patient placement in single room, cohorted area, or separated from others by at least 1
metre.
3) Limiting patient movement out of the hospital room and having the patient use a
medical-surgical mask, if tolerated, when they are outside of their room.
C. Airborne Precautions:
 Airborne precautions should be used during certain procedures with an increased risk of
infection transmission, When performing an aerosol generating procedures (AGMPs) such
as aspiration or open suctioning of respiratory tract secretions, intubation, cardiopulmonary
resuscitation, and bronchoscopy.
 Whenever possible, AGMPs should be performed in an airborne infection isolation room
(Negative pressure room).
 Use PPE including gloves , long-sleeved gowns ,a particulate respirator with seal check (N95
or equivalent) and face/eye protection should be used by all HCWs present in a room where
an AGMP is being performed on a patient suspected or confirmed to have SARI infection.
 There are two main types of masks :
1) Medical-surgical masks are masks that are sufficient for use when within one metre
of patient with ARI as part of droplet precaution interventions. However, these
masks do not completely seal around the mouth and nose.
2) Facial particulate respiratory masks completely seal around the mouth and nose.
These masks are used when there is a concern for aerosolized particles capable of
spreading infection
 Limit the number of people entering the assigned area to the minimum number required for
patient care ,Instruct them on personal protection equipment (PPE) use and hand hygiene.
 Limit visitors to those essential for support. Advise that anyone who is at increased risk of
severe disease does not care for the ill person.
 Isolation precautions for hospitalized patients with influenza symptoms should be
continued for 7 days after onset of illness or 24 hours after the resolution of fever and
respiratory symptoms, whichever is longer, while a patient is in a health care facility.

Infection Control Precautions in Specific Situations When Caring
For Patients with Infectious Acute Respiratory Diseases (ARDS)
SCENARIO Hand
hygiene
Gloves
Medical
Mask
Medical
goggles
Gown N95
FOR ROUTINE CARE: when working in direct contact with patients Standard and Droplet Precautions should
always be applied
G Before and after patient contact 4 4
G If direct contact with blood and body fluids,
secretions. , excretions, mucous membranes 4 4
G If there is risk of splashes into the body 4 4 4 4
G If there is risk of splashes into the body and
face 4 4 4 4 4
FOR AEROSOL GENERATING PROCEDURES: wear a particulate respirator and eye protection. Perform the
procedure in a adequately ventilated room. Avoid unnecessary individuals in the room
G Resuscitation, intubation, aspiration of
respiratory tract and bronchoscopy 4 4 4 4 4
FOR LABORATORY SPECIMENS COLLECTION
G Blood sample, (if performed during the acute
infection phase) 4 4 4
G Nasal swabs and nasal wash 4 4 4 4 4
G Nasopharyngeal aspirate, nasopharyngeal
swab, throat swab or bronchial aspirate 4 4 4 4 4
Discharge criteria for hospitalized patients :
Patient showing clinical signs of improvement and proof of responding to antiviral treatment as
evidenced by the followings:
▪ Patient becomes afebrile
▪ Absence of dyspnoea
▪ Satisfactory oral fluid tolerance
▪ No signs of dehydration
▪ Respiratory rate ≤30 bpm
▪ Oxygen saturation ≥ 92%
▪ Underlying chronic health conditions not exacerbated in patients in high‐risk group for
complication.
Vaccination of all health care workers is strongly recommended to protect
from infection and to reduce risk of nosocomial infection of patients

Policy of Laboratory testing and hospital admission for ILI Cases
Guide to assessment and management of ILI
(Policy of Laboratory testing and hospital admission for ILI Cases) :
* STEP 1 Confirm Patient Presents With Influenza-like Illness
* STEP 2 Conduct Illness-Severity Assessment
* STEP 3 Assess for Co-morbid Conditions
Accordingly cases can be classified into:
1. Mild ILI (Group 1) :
Patients with ILI clinical case definition in low risk people in the absence of other
diagnoses. They will not require laboratory confirmation, or admission to hospital,
only symptomatic treatment at home.
2. Mild ILI in high risk group (Group 2) :
Patients with ILI clinical case definition in high risk people (for serious influenza
complications), with stable medical condition and no serious or life-threatening
influenza complication, and in the absence of other diagnoses. Patients of this group
Do not require laboratory confirmation, or admission to hospital only antiviral
treatment at home.
3. Severe ILI (Group 3) :
Patients with ILI clinical case definition (whether in high risk people or not) ,with
Unstable medical condition and vulnerable to serious or life-threatening influenza
complication, and in the absence of other diagnoses.. Those Patients are considered
vulnerable to severe outcomes should be the focus of early identification. They will
require laboratory confirmation, and hospital admission & antiviral treatment in the
hospital .

Algorithm of Influenza Case Management
CASE MANAGEMENT OF IFUENZA LIKE ILLNESS (ILI)
ILI: Fever ≥ º C AND Cough or sore throat, with onset within the last seven days, in the absence
of other known causes other than influenza
Does the patient has any symptoms
& signs of severe illness ?
No
Does the patient has underlying
medical conditions or at a high risk
group for influenza complication?
SEVERE SYMPTOMS:
•
•
•
•
•
•
•
•
•
mmHg.
• Sever persistent vomiting.
• Sever dehydration & signs of imminent
shock.
• Altered Level of consciousness (New
•
days in spite
of treatment.
Additional Symptoms in children:
• Not eating or drinking enough fluids.
• Not waking up or interacting
• Irritability, not wanting to play or be-
held.
• Fast or laboured breathing
Hospitalization
Testing:
• Upper respiratory tract specimens :
Nasopharyngeal (NP) -preferred OR nasal
swabs.
• lower respiratory tract specimens:
Bronchoalveolar lavage , endotracheal
aspirate (intubated patients).
 Collect specimens before antivial
therapy initiated
 Consider testing Respiratory speci-
mens for influenza by RT-PCR
 Store in refrigerator while waiting
transport (DO NOT FREEZE).
• Sputum (if evidence of Pneumonia).
• Pretreatment blood culture before anti-
microbial therapy is initiated.
Treatment:

hours.
 Do not delay treatment pending laboratory
confirmation of influenza.
 Use clinical Judgment to decide additional
antibiotic therapy for community-acquired
pathogens is needed.
Prescribing oseltamivir:




days, however longer treatment regimen

days of treatment: con-
days)
Indications for ICU admission:

 )
or respiratory exhaustion despite
maximum oxygen saturation
 Progressive hypercapnia
 Presence of compromised hea-
modynamics
 Signs of sepsis and imminent
shock
 Multi-organ failure
Mild ILL + No
Risk factors
Mild ILL + Risk
factors
Home isolation Home isolation
Testing:
No influenza lab
testing
Severe ILI
Testing:
No influenza laboratory
testing
Treatment:
Symptomatic
treatment
No Antiviral
Treatment:
• Treat empirically with
antiviral (oseltamivir)
as soon as possible
The usual dose is:

≥ Kgm
In smaller children use
weight based dosing.
Home Care Precautions
i)
hours
after fever has resolved)
ii) Instruction on infection prevention; Rein-
force hand hygiene and respiratory eti-
quette measures.
iii) When return for care: close home obser-
hours.
If the patient develops severe symptoms
at home
High risk groups for serious influenza copmplications:
• Pregnant women (up to two weeks post partum)
• ≥ years
• Persons with the following underlying conditions at any age:
. Chronic Broncho‐pulmonary diseases ( Including asthma & COPD & OSA )
. Chronic cardiovascular diseases ( Including CHF& MI except hypertension )
. Chronic neurologic disorder (Cerebral palsy, stroke, multiple sclerosis,muscular dystrophy, seizure disorders etc)
. Immune suppressed patients (HIV, immunosuppressive medications, malignancy, long term steroids )
. Haemoglobinopathies
. Chronic liver or renal failure
. Metabolic disorder (specially Diabetes mellitus)
. Morbid obesity - ≥ )
Yes
No Yes
Yes
No influenza testing recommended
Additional work up &follow up as
clinically indicated
No
Designed by :Dr .Ashraf eladawy , TB TEAM EXPERT–WHO

Multiple choice questions
Question 1
Influenza is transmitted by droplets and is probably airborne.
A. True
B. False
Question 2
For how long is an otherwise healthy adult with symptomatic influenza infectious to others?
A. Only while symptoms are present
B. For about one day before the onset of the symptoms until about five to seven days
thereafter
C. For about three days before the onset of the symptoms until about seven days
thereafter
D. Non of the above
Question 3
Which of the following is NOT an appropriate infection prevention and control practices for
influenza in healthcare settings?
A. Perform hand hygiene before and after contact with patient and contaminated
surfaces
B. Always use a particulate respirator (for example, N95), gloves and gown when in
close contact with the patient.
C. Have the patient use a medical-surgical mask when outside the hospital room.
D. Place patient in single room, cohorted or at least 1 metre from other patients.
E. Non of the above
Question 4
A patient with severe influenza like illness is admitted to the ICU. Which of the following
precautions are indicated?
A. Airborne precautions when you are carrying out intubation.
B. Standard precautions at all times
C. Droplet precautions at all times
D. B and C
E. A, B and C
Question 5
During performing aerosol generating procedures as bronchoscope , nasopharyngeal sampling
,intubation:
A- N95 respirator and all PPE is required
B- Negative pressure room is required
C- Minimize health care personal during the procedure
D- None of the above
E- All of the above
Question 6
Coughing etiquette includes which of the following:
A. Washing your hands after coughing
B. Turn your head away from food/people when coughing
C. Covering your mouth when coughing

D. Cough/sneeze into your elbow area
E. All of the above
Question 7
A basic precaution to prevent the contraction of the flu is _______________.
A. washing hands often with soap and water
B. Avoid touching the eyes and nose
C. Avoid contact with those known to be sick
D. All of the above
Question 8
Which of the following common symptoms is not usually a feature of flu in adults?
A. Chills and a high fever.
B. Muscle aches and pains.
C. A runny nose, sore throat and a cough.
D. Vomiting and diarrhoea.
Question 9
During a case of the flu, which of the following is a sign you need to see a doctor urgently?
A. Dry cough.
B. Sore throat.
C. Runny nose.
D. Shortness of breath.
Question 10
Patients at high risk for developing complications from seasonal influenza include all of the
following except:
A. > 65 years old
B. A 35 year old busy mother who does not want the flu
C. Diabetics
D. Asthmatics
Question 11
The most common respiratory complications of influenza are:
A. Primary viral pneumonia
B. Secondary bacterial pneumonia
C. Common cold
D. Combined viral-bacterial pneumonia
E. Gastroenteritis (commonly called the stomach flu)
Question 12
Complications of influenza infection include:
A. S. aureus pneumonia
B. Reye’s syndrome
C. Persistent hyponatremia
D. Myositis and rhabdomyolysis
E. Chorioretinitis
Question 13
The best way to avoid the flu include...
A. Getting a yearly flu shot
B. Washing your hands often

C. Avoiding unnecessary contact with a lot of people during peak flu months
D. Take antiviral medications
E.All of the above
Question 14
If during flu season a patient starts to get better after 3 or 4 days of flu-like symptoms and then
on day 5 or 6 starts to feel worse, the most likely diagnosis is:
A. Viral (influenza) pneumonia.
B. Bacterial pneumonia.
C. Relapsing influenza.
D. Reinfection with influenza virus.
E. Infection with different virus
Question 15
A patient with influenza-like illness symptoms and signs of dehydration does not have a
complicated infection and should NOT be treated with antivirals or considered for
hospitalization.
A. True
B. False
Question 16
In patients with severe hypoxaemia from shunt physiology, the delivery of oxygen therapy by
nasal cannula at 4 l/min provides sufficient FiO2 to maintain aSpO2>90 %.
A. True
B. False
Question 17
You included influenza in differential diagnosis of a patient with severe acute respiratory
infection. It is appropriate to wait for laboratory confirmation of influenza virus infection
before starting antiviral treatment?
A. True
B. False
Question 18
A patient is admitted to the medical wards with community-acquired pneumonia and treated
with appropriate antimicrobials. After 48 hours the condition worsens and the patient is
transferred to the ICU. Specimens for influenza were not yet collected. Which statement is
correct about collecting specimens now?
A. Specimens for influenza virus detection should not be taken as it is too late
B. Tracheal aspirate specimens are not appropriate sample to submit
C. Specimens should be stored at room temperature while awaiting transport to the
laboratory
D. Specimens should be placed in viral transport medium once collected
Question 19
A patient is admitted with respiratory failure due to rapidly progressing pneumonia and ARDS.
As part of the differential diagnosis you consider
influenza virus infection. Which of the following statements regarding therapy is correct?

A. Oseltamivir therapy should be delayed pending confirmation of the diagnosis in order
to avoid selecting for resistant virus
B. Oseltamivir may be administered at a dosage of 150mg twice a day
C. Oseltamivir cannot be used in ventilated patients as they cannot take medications
orally
D. Do not give antibiotics for community acquired pneumonia until diagnostic tests
confirm bacterial infection
Question 20
For that same patient, results of the rapid influenza test are reported as negative. Which of the
following should you NOT do?
A. Stop antiviral therapy as influenza infection is unlikely
B. Send a repeat specimen for RT-PCR testing if confirmation will affect clinical
management
C. Continue treatment for bacterial pneumonia
D. Continue antiviral treatment and infection control measures as rapid tests cannot
exclude the diagnosis of influenza virus infection
Question 21
The antiviral drugs Zanamivir (Relenza) and Oseltamivir (Tamiflu) combat the flu virus by which
of the following mechanisms?
A. Degrading viral DNA
B. Blocking entry of the virus into the host cell
C. Blocking the release of virions from the host cell
D. All of the above
Question 22
With regard to anti-influenza drugs which of the following statements are true:
A. Amanantidine is effective as a prophylactic agent against influenza B virus
B. The mode of action of Amanantidine involves blockage of an ion channel and prevention
of viral uncoating
C. Neuroaminidase inhibitors have no activity against influenza B virus
D. Zanamivir should not be used in patients with history of egg allergy
E. Aciclovir has a proven efficacy against influenza A viruses
Question 23
Which of these statements about neuraminidase inhibitors is true? Choose 1 answer:
A. They work best when given early in infection
B. They cure influenza
C. They are no longer effective because the virus has developed resistance to them
D. They are only active on seasonal flu strains
Question 24
Prescribe antiviral treatment for :
A. Hospitalized patients with severe, complicated influenza-like illness
B. Outpatients with Mild influenza-like illness
C. Outpatients with Mild influenza-like illness who are at risk of complications
D. All of the above

Question 25
You admit a 24 year old HIV-infected pregnant woman with severe respiratory distress and
hypoxia. She gives a 4 day history of shortness of breath and fever. On chest X-ray you observe
diffuse infiltrates. You suspect severe influenza virus infection. Which of the following
statements is NOT correct?
A. The differential diagnosis should include pneumocystis pneumonia and tuberculosis
B. Oseltamivir should be avoided as it is known to be teratogenic
C. Oseltamivir is the recommended therapy in severely ill pregnant women
D. Give empiric antiiotics for community acquired pneumonia
Question 26
A number of complications are associated with influenza ,which of the following is NOT one of
these complications?
A. Nephritis.
B. Pneumonitis. b
C. Myocarditis.
D. Encephalitis.
E. Death.
Question 27
Severe acute respiratory illness (SARI) has been documented as a common feature of which of
the following recent emerging respiratory pathogens:
A. Avian influenza A (H7N9)
B. Avian influenza A (H5N1)
C. Middle East Respiratory Syndrome Coronavirus (MERS-CoV).
D. All of the above
E. Non of the above
Question 28
A patient with severe pneumonia, has been receiving high flow oxygen (15 l/min by face mask
with reservoir bag) for 1 hour but continues to have signs of severe respiratory distress with a
RR of 40 and SpO2 of 85%. Which is the most appropriate next step?
A. Fluid bolus of 1 litre of NS
B. Continue the same management
C. Initiate noninvasive ventilation with BIPAP
D. Intubation and mechanical ventilation
Question 29
A 50 year old woman presents to your hospital with a suspected infection and shock. For initial
diagnostic and therapeutic considerations, which of the following is correct?
A. Diagnosis cannot be influenza because flu does not present with hypotension
B. Consider non-influenza etiologies of septic shock only
C. Empiric therapy should be initiated as soon as possible and should consider multiple
etiologies of septic shock, such as influenza and bacterial pathogens.
D. Wait until a definitive diagnosis is made before initiating antimicrobial therapy
E. All of the above
Question 30
Using aspirin as an antipyretic in children who are down with flu may lead to a fatal side-effect called:
A. Meningitis
B. Kawasaki Disease
C. Encephalitis
D. Reye's Syndrome

References:
1. Critical care training (severe forms of influenza infection) - WHO 2012
2. Community case management during an influenza outbreak- WHO 2011.
3. National guidelines of influenza A/H1N1 pandemic for health care providers (Pakistan ) 2009.
4. Clinical management of human infection with pandemic (H1N1) -WHO 2009
5. Antiviral agents for the treatment and chemoprophylaxis of influenza ACIP, 2011.
6. Guidance on the use of antiviral agents for the treatment and prophylaxis of influenza, 2014-2015 ,
Influenza Subgroup of the Scientific Advisory Committee of the Health Protection Surveillance Centre
(HPSC)
7. Algorithm to assist in decisions on testing and treatment for novel influenza A (H1N1) virus in
Arizona,2009
8. Operational guideline for ARI, ILI & SARI surveillance- Public Health Laboratory Department of Public
Health -Ministry of Health Thimphu: Bhutan 2012
9. Severe Acute Respiratory Infection(SARI) Jan 2015 NHS
10.Malaysia Influenza Surveillance Protocol -2015
11. Guidance for the Management of Severe Acute Respiratory Infection in the Intensive Care ( Prepared
on behalf of the Canadian Critical Care Society -2013)
12.Protocol for Microbiological Investigations of Severe Acute Respiratory Infections (SARI) 2013
13.Severe acute respiratory illness (SARI)* Screening tool- Public Health Agency of Canada
14.Operational Guidelines for Sentinel Severe Acute Respiratory Infection (SARI) Surveillance -
September 2014
15.Health Establishments Preparation for Unusual or Unexpected Cases or Clusters of Severe Acute
Respiratory Infection SARI-Version APRIL 2009 Pan American health orginization
16.Severe Acute Respiratory Infection (SARI) Guidelines-Canada 2013
17. ILI & SARI Surveillance Second Edition 2014
18.IMAI District Clinician Manual: Hospital Care for Adolescents and Adults. Geneva: WHO 2012.
19.Clinical management of severe acute respiratory infection when Middle East respiratory syndrome
coronavirus (MERS-CoV) infection is suspected- Interim guidance - July 2015
20.Global epidemiological surveillance standards for influenza-who 2013
21.WHO Regional Office for Europe guidance for sentinel influenza surveillance in humans- May 2011
22.WHO Interim Global Epidemiological Surveillance Standards for Influenza (July 2012)
23.Questions and answers on seasonal influenza - Regional Office for the Americas of the World Health
Organization 2015
24.Respiratory MCQ’s
25.Multiple choice questions against infectious disease- UIK updated version October 2015
26.Infection prevention and control of epidemic - and pandemic - prone acute respiratory diseases in
health care 2007
27.The WHO pulse oximetry training manual - WHO, 2011
28.Oxygen is an essential medicine: a call for international action - WHO-ITUTLD, 2009
29.Use of influenza rapid diagnostic test - WHO, 2011
30.Course "Special Considerations when Caring for the Pregnant Patient" –WHO.

Acknowledgement
This workshop would not have been possible without the supervision and support of Dr. Majda Alqattan
the Assistant Undersecretary of Public Health at Kuwait Ministry of Health. We especially indebted to Dr.
Ashraf El-Adawy how was the main writer of this Handout, and who worked actively to provide us with most
of the information provided in this work.
The Public Health sector is grateful to all of those who worked with us to make this workshop reach its
final scientific goals. Our utmost appreciation also extends to those who helped in this workshop which
included speakers from international Arena and Local expert to whom we accentuate our gratitude and
acknowledgement:
From WHO & Other International Groups
Dr. Amgad Elkholy Dr. Almal Salah Aldin Dr. Malak Elshabky
And From Kuwait Ministry of Health
Dr. Nasser Bahbahni
Dr. Mariam Alfadli
Dr. Sarah Alqabandi
Dr. Suad Alsheridah
Dr. Mona Foda
Dr. Wafaa Hamza
And Also
Dr. Sondos Alqabandi
Dr. Najla Alayhaady
Dr. Radiah Almathkori
Dr. Abdulrahaman Lotfy
Dr. Muhammad Barakat
H.I. Wadha N. Al-Hajri
Dr. Mona Alhajj Hussian
Dr. Lamia M. Basioni
‫ورعايته‬ ‫اهلل‬ ‫حبمد‬ ‫مت‬

Kuwait Influenza Case Management guidelines for 3nd Flu Workshop 2017

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