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Westwood-Mansfield Pediatrics
H1N1 and TAMIFLU - OFFICE PROTOCOL
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H1N1 MANAGEMENT CONSIDERATIONS - TAMIFLU, TREATMENT, PROPHYLAXIS,
TESTING, AND TRIAGE
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In an attempt to clarify our office philosophy and treatment strategy, a group of our providers recently met to determine our office policy regarding the treatment of H1N1 ("Swine") Influenza. Topics discussed included the use of Tamiflu for treatment, the use of Tamiflu for prevention ("prophylaxis"), the use of tests to diagnose the flu, and the preparation of guidelines for determining which patients with flu-like symptoms should be seen in the office and which may be safely treated at home.
We hope this e-mail will clearly present our policy (and the reasons behind it) for the management of H1N1 Influenza.
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| A WORD ABOUT TAMIFLU
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BASICS:
Tamiflu is an antiviral medicine that is used in the treatment of influenza. It is approved for children one year of age and up - however in July the FDA made emergency-usage rules to permit its use at physician's discretion in all children (including those under one year of age).
BENEFITS:
For maximum benefit, Tamiflu should be started within 48 hours after becoming sick. When used this way, it may be useful in reducing the severity of symptoms as well as the duration of illness by 24-48 hours. Hospitalized patients and those with severe disease may occasionally benefit from Tamiflu even if starting later than 48 hours into the illness.
SIDE EFFECTS:
More than half of pediatric patients taking Tamiflu report at least one side effect. Gastrointestinal side effects are seen in around 40% of patients and include nausea, vomiting, diarrhea, or stomach pain/cramps. Neurologic side effects are seen in approximately 20% of children and include sleep disturbances (12% of patients), poor concentration, confusion, nightmares, and behavior changes. Neurologic side effects are seen more often in older children (middle school and above).
AVAILABILITY ISSUES:
In past years, Tamiflu availability has varied widely depending on disease prevalence. If you are prescribed Tamiflu and the pharmacy does not have it in stock, we recommend that you ask the pharmacist to call other pharmacies to locate some.
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| TREATMENT OF H1N1 INFLUENZA
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1) Tamiflu will be called in by our office for any child meeting all the following requirements:
A) He/she must be considered HIGH RISK for serious illness. Children considered high-risk must have one or more of the following medical issues:
- Seizure disorder
- Compromised immune system/immunodeficiency
- Moderate or Severe Asthma*
- Daily aspirin treatment
- Diabetes
- Other children in our SKIP program (excluding Autism-spectrum disorders
without seizures)
B) He/she must have symptoms for less than 48 hours.
- Symptoms must include a fever > 101 degrees and cough
C) He/she must be well enough that our staff (telephone nurses or physicians) does not feel an office visit is required.
D) We will also be willing to treat children older than 2 years of age with a infant sibling (under 6 months of age) in the house.
2) Children not meeting the above requirements may be treated in select circumstances after being seen in the office.
The decision to treat will be made at the provider's discretion and will take into consideration the following:
- Age under 2 years
- More severe symptoms
3) Healthy children (including those with mild intermittent or mild persistent asthma) with mild-moderate flu-like symptoms WILL NOT BE OFFERED TAMIFLU.
* Patients with moderate or severe asthma are those taking at least two asthma medications (for example, Singulair, Pulmicort, or Flovent) in their GREEN ZONE. Patients taking ADVAIR in their green zone are also considered to have moderate or severe asthma. Please note that allergy medicines (Allegra, Claritin, Zyrtec, Flonase, Nasonex, etc. . .) are not considered in this classification. If you are unsure of your classification, please check the bottom of your most recent asthma plan.
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PREVENTION OF H1N1 INFLUENZA WITH TAMIFLU
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Studies suggest that the majority of H1N1 influenza resistance to Tamiflu occurs when Tamiflu is used to prevent influenza following a potential exposure.
Due to our increasing concern for emerging Tamiflu resistance, WE WILL NOT BE PRESCRIBING TAMIFLU FOR PROPHYLAXIS FOR ANY PATIENT.
Following a potential H1N1 exposure, families of high-risk patients are recommended to monitor their child closely for flu-like symptoms and call at the earliest sign for potential treatment.
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TREATMENT OF HEALTHY CHILDREN WITH HIGH-RISK HOUSEHOLD CONTACTS
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Healthy children who are at low-risk for serious complications from H1N1 Influenza will not be offered treatment with Tamiflu regardless of whether or not they have high-risk household contacts.
The reason for this decision is that people will generally be contagious in the 24-48 hours prior to developing flu-like symptoms. Therefore, the treatment of healthy individuals will not prevent the spread of H1N1, as it is very likely that the exposure has already occured.
We recommend that you contact the physician of the at-risk individual for further management considerations. |
| GUIDELINES FOR TRIAGING PATIENTS - WHO SHOULD BE SEEN, WHO SHOULD STAY HOME
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Any child with flu-like symptoms (fever, cough, aches) with difficulty breathing, concerns about hydration, or age under 2 years should be evaluated in the office. As always, if you are concerned and not comfortable with your child's condition, please let us know.
All children with flu-like symptoms for whom there are no breathing or hydration concerns can be safely managed at home with fever control (Tylenol/Motrin) and fluids.
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INFLUENZA TESTING
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Data suggests that rapid flu testing is only reliable 50-70% of the time. This means that a negative flu test does not completely rule it out.
The state laboratory is only running H1N1 testing for patients admitted to the hospital. This means that a positive flu test in the office does not confirm H1N1 (nor will the test be run).
Given this information, WE WILL NOT BE ROUTINELY PERFORMING FLU TESTS IN THE OFFICE. Flu tests will be used in rare situations when a positive test may help us minimize other testing or treatment.
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| A BRIEF WORD ABOUT THE H1N1 VACCINE - NEW FLU-NURSE PHONE LINE!
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ We are all being bombarded by media reports about the H1N1 Vaccine. Often these articles are inflammatory and can contradict each other, increasing the confusion and anxiety.
"Planners at the C.D.C., the National Institutes of Health and the Food and Drug Administration are caught in a no-win situation. Having pushed private companies and themselves to make a new swine flu vaccine as soon as possible, they now stand simultaneously accused of rushing an 'untested' product to market and of not rushing enough of it.'"
To continue our goal of providing clear communication with you, we have added a "Flu-Nurse Phone Line" in which one of our nurses will be available to handle your calls between 10:30 and noon daily. Please limit your non-urgent, flu-related phone calls to this time period.
By limiting your non-urgent phone calls to this time slot, we hope to keep our phone waiting times down which enables us to provide more appropriate triage and utilization of our nurses, and better patient care.
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