Hot Topic Meeting by:
Royal College of Physicians of Edinburgh & The
Scottish Executive Health Department
Pandemic Flu
Planning Scotland’s Health Response
5th June 2007
Queen Mother Conference Centre
June – 2007 2
Care of the Vulnerable
Population: Children
Dr. James Paton
Royal Hospital for Sick Children
Glasgow
June – 2007 3
Care of Vulnerable Population Children
• Clinical Presentations
• Triage and Severity Assessment
• Recommended treatments – Part 1
• Investigations in Hospital
• Recommended treatments – Part 2
• Ethics & Staffing during a pandemic
June – 2007 4
June – 2007 5
Fleming, D M et al. Arch Dis Child 2005;90:741-746
June – 2007 6
Clinical Characteristics of RSV and
‘Flu in Hospitalised Children
Meury et al Eur J Pediatr 2004; 163:359-363
June – 2007 7
Timing of 153 Cases of Fatal Influenza in
Children – US 2003-04
Bhat, N. et al. N Engl J Med
2005;353:2559-2567
June – 2007 8
Whose at Risk?
• Impact of Age
• Impact of pre-existing medical
conditions
June – 2007 9
'Flu Mortality Rate According to Age
Group – US 2003-04
Bhat, N. et al. N Engl J Med
2005;353:2559-2567
June – 2007 10
Relative Risk of Admission in Children without
High Risk Conditions
Izurieta H et al. N Engl J Med 2000;342:232-239
June – 2007 11
Underlying Health Status in Children with Fatal
Influenza – US 2003-04 (n- 149)
Bhat, N. et al. N Engl J
Med 2005;353:2559-2567
June – 2007 12
Triage and General Management in 1ry
Care
• Recognition of ‘At Risk Groups’
• Assessment of Illness Severity
• Current advice and guidance on
epidemiology of pandemic
June – 2007 13
Severity Assessment (CURB 65) in Adults
Item
Measure
Confusion
Urea
Respiratory
Distress
Blood
Pressure
Mental test score ≤8
>7mmol/l
Age - >65yr
Age ≥65yr
Respiratory Rate ≥30/min
SBP <90mmHg or DBP ≤60mmHg
Score
Respiratory Distress –
Severity Assessment in Children
Mild
June – 2007 14
Severe
Infants
Temp >38.5 ⁰C
Mild Respiratory
Distress
Taking Full Feed
Temp >38.5 ⁰C
Severe Respiratory
Distress
Cyanosis
Grunting / Apnoea
Not feeding
Children
Temp >38.5 ⁰C
Mild Respiratory
Distress
No vomiting
Temp >38.5 ⁰C
Severe respiratory
Distress
Cyanosis
Grunting
Signs of dehydration
Appendix 8 Thorax 2007;62: Supplement 1
June – 2007 15
Severity Assessment in Children
Item
Temperature
Confusion
Urea
Respiratory
Distress
Blood
Pressure
Age - >65yr
Measure
>38.5⁰C
Complicated or prolonged seizure;
Altered conscious level
Dehydration - Older Children
↑Rate, Recession, Nasal Flaring,
Cyanosis, Grunting, Apnoea
Not feeding
Signs of Shock – extreme pallor,
hypotension, floppy infant
Age <1yr
Score
June – 2007 16
Triage & General Management in 1ry Care
Thorax 2007;62:Supplement 1
June – 2007 17
Specific Treatment - Anti-Viral Therapy
• Amantidine / rimantidine
• Neuraminidase inhibitors
– Oseltamivir (Tabs & liquid)
• Effective if given within 2 days of start of illness
• Reduction in time to alleviation of symptoms
• Reduction in complications requiring antibiotics
• Note - faster drug clearance in younger children
• Not licensed under 1 year - but Japanese experience
suggests is safe
– Zanamavir (inhaler – so children >5yrs)
• Ribavirin
June – 2007 18
June – 2007 19
Triage of Children in Hospital
• Assessment of Illness severity
• Admit to ward if:
–
–
–
–
Severe respiratory distress; Hypoxia
Severe dehydration
Altered conscious level or prolonged seizure
Signs of septicaemia
• Consider HDU/ICU
–
–
–
–
Worsening hypoxia despite oxygen
Worsening respiratory failure
Apnoea or slow/irregular breathing
Encephalopathy
• If no ICU Beds?
June – 2007 20
Investigations for Children in Hospital
• Pulse oximetry
• CXR
– if hypoxic or severely ill, or deteriorating; Not
routinely
• FBC, U & Es, LFTs, Blood Culture
• Microbiology
June – 2007 21
Microbiological Investigations
for Children in Hospital
Early Pandemic – when you want to know
– Virology
• NPA for Respiratory panel - ‘flu A & B; RSV, Adeno,
Rhino, Paraflu 1,2,3
• Rapid influenza tests – high specificity - R/I ‘flu
• Acute & Convalescent Serum
– Bacteriology
• Blood
• Sputum
Established Pandemic – when you know
– Virology – not routine
– Bacteriology
June – 2007 22
Anti-Viral Therapy in Hospital
• Neuraminidase inhibitors
– Oseltamivir (Tabs & liquid)
– If severely ill with symptoms for <6 days
– Child <1year with severe infection with informed
consent
June – 2007 23
Antibiotics for Children in Hospital
• Secondary bacterial infections are
common
– Pneumonia
– Otitis media
June – 2007 24
Pneumococcal Pneumonia in Previously
Healthy Children
O’Brien et al. Clin Infect Dis
2000;30:784-9
June – 2007 25
Bacterial Co-infections in 24 Children
with Fatal Influenza
Bhat, N. et al. N Engl J
Med 2005;353:2559-2567
June – 2007 26
Activation-associated Cell Death of Bone Marrow GRC
during LCMV infection
Navarini, Alexander A. et al. (2006)
Proc. Natl. Acad. Sci. USA 2006; 103:
15535-15539
Early phase of infection largely controlled by innate resistance via granulocytes.
Virus-induced suppression of antibacterial resistance and immunity by IFN 1
production was caused by apoptosis of bone marrow granulocytes and
impaired granulocyte emigration. Granulocytopenia was not complete but became
functionally limiting during super-infection when large numbers of granulocytes
were rapidly required to control infection
June – 2007 27
Antibiotics for Children in Hospital
• Children at risk of complications
• Children with disease severe enough to be admitted
Treat prophylactically with antibiotic to cover
• Staph aureus
• Str pneumoniae
• H influenzae
= Co-amoxiclav;
Or clarithromycin, cefuroxime if pen. allergic
June – 2007 28
Will There be Sufficient Staff?
June – 2007 29
Professional Duty – Family or Patient
First?
Physicians
Y
It would be ethical for HCP to abandon
their workplace during a pandemic to
protect themselves and their families
D/K
N
24% 11% 64%
HCP should be allowed to decide whether 25% 8% 67%
they report to work during a pandemic
HCP without children should primarily care 16% 12% 72%
for influenza patients during a pandemic
Ehrenstein et al BMC Public Health 2006;6:311
June – 2007 30
June – 2007 31
The Next Influenza Pandemic: Will be
Ready to Care for Our Children?
“The severity of the 2003-2004 'flu season
will pale in comparison with that of the next
pandemic”
Woods and Abramson
J Pediatr 2005;147:147-155
Hot Topic Meeting by:
Royal College of Physicians of Edinburgh & The
Scottish Executive Health Department
Pandemic Flu
Planning Scotland’s Health Response
5th June 2007
Queen Mother Conference Centre