HEALTHCARE WORKERS HANDBOOK
ON INFLUENZA

Acknowledgements

Table of Contents

1. Background on influenza
   1. What is influenza?
   2. Differences between pandemic influenza A(H1N1) and seasonal A(H1N1) during the 2009 pandemic
   3. Transmission
   4. Typical symptoms of infection
   5. Public health concerns about influenza
2. Influenza in South Africa
   1. Timing of the influenza season
   2. Expected influenza serotypes and vaccine formulation for 2010
   3. Additional considerations in 2010
3. Case descriptions
   1. General considerations
   2. Categories of influenza disease:
   1. Uncomplicated influenza: ILI (Influenza-like Illness)
   2. Complicated or severe influenza:
   3. Signs and symptoms of progressive disease:
   4. Risk factors for severe or complicated influenza
4. Laboratory testing
   1. Who should be tested?
   2. Laboratories conducting testing
   3. Specimen collection, storage and transportation
   4. Post-mortem specimens
   5. Swabs and viral transport medium (VTM)
5. Clinical Management
   1. Antiviral therapy:
      1. General considerations
      2. Severe, complicated or progressive pandemic influenza in adults and adolescents
      3. Uncomplicated pandemic influenza in adults and adolescents (>12 years of age)
      4. Severe, complicated or progressive pandemic influenza in children (<12 years of age)
      5. Uncomplicated pandemic influenza in children
      6. Chemoprophylaxis of pandemic influenza
      7. Other influenza strains
   2. Other interventions for management
   3. Additional comments on management
      1. Severely ill patients
      2. Pregnant patients
      3. Children
      4. HIV-infected patients
      5. Patients with persistent severe or progressive disease despite appropriate antiviral treatment
6. Infection prevention and control (IPC)
   1. IPC precautions
   2. Duration of isolation precautions
   3. Respiratory hygiene/cough etiquette
   4. Occupational health
7. Resources for further information

• Appendix 1: Home care guidance: doctors/nurses directions to patients/parents
• Appendix 2: Summary table on management of adult patients and children >5 years with suspected or proven influenza infection

1. Background on influenza

a. What is influenza?

b. Differences between pandemic influenza A(H1N1) and seasonal A(H1N1) during the 2009 pandemic

c. Transmission

• Practice cough etiquette by covering their mouth and nose with a disposable tissue when coughing or sneezing, then discarding the tissue in a receptacle and performing hand hygiene ( washing hands with soap and water or the use of an alcohol-based hand rub)
• Stay home when they are unwell and keep some distance from healthy people, as much as possible.

d. Typical symptoms of infection

e. Public health concerns about influenza

2. Influenza in South Africa

a. Timing of the influenza season

b. Expected influenza serotypes and vaccine formulation for 2010

• Pandemic influenza (“swine flu”), an A/California/7/2009 (H1H1)-like virus;
• Influenza A(H3N2), an A/Perth/16/2009 (H3N2)-like virus; and
• Influenza B, a B/Brisbane/60/2008-like virus.

• Pregnant women
• Children <15 years with HIV/AIDS
• Adults >15 years with HIV/AIDS attending ARV clinics
• Patients with chronic heart and lung diseases
• Frontline clinicians in casualty, ICU and EMS personnel
• Frontline healthcare workers.

c. Additional considerations in 2010

3. Case descriptions

a. General considerations

b. Categories of influenza disease:

i. Uncomplicated influenza: ILI (Influenza-like Illness)

1. An individual with recent onset of an influenza-like illness (ILI), which may include fever ≥38 0C PLUS ONE OR MORE of the following acute respiratory symptoms (sore throat, rhinorrhoea/nasal congestion), ± headache, myalgia, malaise, diarrhoea/vomiting (more common in children) PLUS absence of evidence of lower respiratory tract disease (shortness of breath or dyspnoea)
2. Elderly and immunosuppressed individuals with uncomplicated illness may present with atypical symptoms and absence of fever.

ii. Complicated or severe influenza:

1. Presenting clinical (e.g. dyspnoea, tachypnoea, hypoxia) and/or radiological signs of lower respiratory tract disease (e.g. pneumonia)
2. Presence of extrapulmonary complications, including: CNS involvement (encephalopathy, encephalitis), severe dehydration, rhabdomyolysis, myocarditis, secondary complications (renal failure, multi-organ failure, septic shock).
3. Exacerbation of underlying chronic disease, including: asthma, chronic obstructive pulmonary disease (COPD), chronic hepatic or renal insufficiency, diabetes, other cardiovascular conditions (e.g. congestive cardiac failure).
4. Other conditions/clinical presentations requiring hospital admission for clinical management (including secondary bacterial pneumonia with influenza, most commonly Streptococcus pneumoniae or Staphylococcus aureus).

c. Signs and symptoms of progressive disease:

• Symptoms and signs suggesting oxygen impairment or cardiopulmonary insufficiency:
• Shortness of breath (with activity or at rest), dyspnoea, tachypnoea, cyanosis, bloody or purulent sputum, chest pain, hypotension;
• Children: fast or laboured breathing;
• Hypoxia (as indicated by pulse oximetry or arterial blood gas).
• Symptoms and signs suggesting CNS complications: altered mental status (including confusion), unconsciousness, drowsiness, recurring/persistent seizures, severe weakness or paralysis.
• Evidence of sustained viral replication or secondary bacterial infection based on laboratory testing or clinical signs (e.g. persistent/recurrent high fever and other symptoms beyond 3 days without signs of resolution).
• Severe dehydration.

d. Risk factors for severe or complicated influenza

• Infants and young children (particularly <2 years of age)
• Pregnant women (at all stages of pregnancy, including the first two weeks of the post-partum period). It appears that women in the second- and third-trimesters of pregnancy have the highest risk.
• Persons of any age with chronic diseases, including:
• Pulmonary diseases (e.g. asthma, COPD)
• Cardiac diseases (e.g. congestive cardiac failure)
• Metabolic disorders (e.g. diabetes)
• Renal disease
• Hepatic disease
• Certain neurological conditions, including: neuromuscular, neurocognitive and seizure disorders
• Haemoglobinopathies
• Immunosuppression (e.g. HIV, persons on immunosuppressive medication, malignancy)
• Children receiving chronic aspirin therapy
• Persons aged ≥ 65 years

4. Laboratory testing

a. Who should be tested?

• Patients who meet the criteria for complicated or severe influenza, where a laboratory diagnosis will assist in patient management, or patients hospitalised due to a lower respiratory tract infection where no other explanation for illness is evident and influenza forms part of the differential diagnosis.
• Patients at risk for developing complicated or severe influenza (as per list under point 3.4) AND who are symptomatic should be considered for testing if it will guide clinical management.
• Clusters of cases where a diagnosis of the cause of the outbreak is needed (e.g. within institutions such as healthcare facilities, nursing homes). First 2-3 cases to be tested, thereafter testing not required.
• An individual who has died where influenza is suspected as the cause of death.

b. Laboratories conducting testing

• where specimens should be referred to,
• the specific test that will be conducted by that laboratory and the interpretation ± limitations thereof, and
• the cost implications to the hospital/patient/medical aid.

• Eastern Cape and Western Cape Provinces:
• NHLS Groote Schuur Hospital
• NHLS Tygerburg Hospital (Virology Department, University of Stellenbosch)
• Free State and Northern Cape Provinces:
• NHLS Universitas Hospital
• Gauteng , Limpopo, North West and Mpumalanga Provinces:
• NHLS Tshwane Academic ( Steve Biko Academic Hospital)
• NHLS Charlotte Maxeke Academic Hospital (formally Johannesburg General Hospital)
• KwaZulu-Natal Province :
• NHLS Inkosi Albert Luthuli Hospital

c. Specimen collection, storage and transportation

1. Wear appropriate personal protective equipment, including a medical mask and non-sterile gloves; wear eye-visors or goggles or a face shield if procedures include a risk of splash to the face. When performing specimen-collection procedures that may generate aerosols (e.g. aspiration or open suctioning of the respiratory tract), a particulate respirator (e.g. N95 respirator) must be worn, in addition to gloves, eye-visors/goggles or a face shield.
2. Swab each nostril with a single swab, or swab the throat, or do both. If taking specimens from both nostrils and throat on the same patient, use a single swab for both nostrils and a second swab for the throat. (Use only dacron or rayon swabs. Wooden swabs are not suitable for testing). Place the swab/s into a container of viral transport medium (VTM); if both nasal and throat swabs are taken on a patient, these can be placed into the same VTM container.
3. If using the Virocult ® specimen collection and transport device, remove the swab from its holder and swab the nostrils/throat. Place the swab into the transport tube, secure the cap, and squeeze the end of the tube around the sponge to ensure complete wetting of the swab tip.
4. Complete the specimen request form with the following details: patient name, health facility (where appropriate), healthcare worker’s name and contact numbers, lab name, contact person, telephone and fax number for receipt of results, and clinical details.
5. Transport specimens directly to the appropriate laboratory (see section 3.1). The specimens must be transported at 4 0C if transport is expected to be delayed.

• Specimens for virus isolation or for detection of viral nucleic acids or antigens should be taken preferably during the first three days after onset of clinical symptoms, but may be taken up to a week after onset or even later in severely ill or immunocompromised patients or children.
• Specimens should preferably be taken prior to commencement of antivirals.
• Nasopharyngeal swabs may be collected instead of nose and throat swabs. Swabs pose a lower risk of transmitting infection to healthcare workers than do nasopharyngeal aspirates (NPA) or nasal washes, both of which may generate aerosols. Healthcare workers performing nasopharyngeal swabs should practice appropriate infection prevention and control measures (see section 6.1 below).
• In addition to swabs from the upper respiratory tract, invasive procedures such as bronchoalveolar lavage/ bronchial aspirate or lung biopsy can be performed for the diagnosis of influenza infection of the lower respiratory tract where clinically indicated.
• Results of all diagnostic tests for influenza are dependent upon several factors (including specimen type and quality of specimen collection, timing of collection, storage and transport conditions), such that false-negative results may be obtained. When clinical suspicion is high, clinicians must consider repeat/serial testing.

d. Post-mortem specimens

• Nasal, nasopharyngeal and throat swabs
• If consent has been given for a full post-mortem, tissues that may be sampled include lung, trachea (proximal and distal), nasopharynx (best done from a supratentorial approach with removal en bloc), liver, brain and kidneys
• If consent for a full post-mortem is not forthcoming, the attending clinician should consider a para-mortem Trucut lung biopsy. Other organs which may be sampled using a Trucut biopsy needle include spleen, bone marrow and liver.

e. Swabs and viral transport medium (VTM)

• Wooden swabs are not suitable for respiratory virus PCR. Please use dacron or rayon swabs.
• All specimens must be transported in VTM as instructed above.
• The appropriate swabs and VTM may be obtained from your local laboratory.
• Laboratories should stock VTM and the appropriate swabs, which may be obtained through their usual suppliers.

5. Clinical Management

a. Antiviral therapy:

i. General considerations

ii. Severe, complicated or progressive pandemic influenza in adults and adolescents

• Oseltamivir
• Standard dose and duration: 75mg twice daily orally for 5 days
• Higher doses of oseltamivir (150 mg twice daily orally) and longer duration of treatment (7 to 10 days) may be appropriate (particularly in critically ill patients), although there is no clinical trial evidence confirming benefit. There is safety data to support treatment with higher doses, but care must be taken when treating patients with renal impairment. There is insufficient safety data for doses higher than 75 mg twice daily in pregnancy.
• For patients unable to swallow capsules, methods for preparation of an oral suspension are described in instructions from manufacturers (refer to package insert). Where suitable suspending agents or diluents containing preservatives are not available, capsules can be opened and mixed with a measured volume of water (e.g. one teaspoon) immediately before administration. Such suspensions may be administered via nasogastric/orogastric tubes in mechanically ventilated patients. (Reference: Health Protection Agency; Summary of prescribing guidance for the treatment and prophylaxis of influenza-like illness. 18 December 2009. Access at http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1243581475043).
• Adverse effects: nausea, vomiting, abdominal pain, diarrhoea, headache and conjunctivitis are the most commonly reported. Rash is uncommon. Other adverse effects that have been reported include: hepatitis, arrhythmias, neuropsychiatric disorders (in children and adolescents), visual disturbances, Stevens-Johnson syndrome and toxic epidermal necrolysis.
• Renal impairment requires a dose adjustment based on creatinine clearance as follows:

• Zanamivir
• Treatment with zanamivir is indicated in patients where oseltamivir-resistant influenza is demonstrated or highly suspected.
• Standard dose and duration: two inhalations (i.e. 2 x 5mg) twice daily for 5 days
• Zanamivir contains lactose (powder for inhalation) and must NOT be administered by a nebuliser. It may also interfere with ventilator functioning in ventilated patients.
• Adverse effects are very rare and include: bronchospasm, respiratory impairment, angioedema, urticaria, and rash. Neuropsychiatric disorders have also been reported (especially in children and adolescents).

iii. Uncomplicated pandemic influenza in adults and adolescents (>12 years of age)

iv. Severe, complicated or progressive pandemic influenza in children (<12 years of age)

• Treatment with oseltamivir should be started as soon as possible and must NOT be delayed pending laboratory confirmation of pandemic influenza. Starting treatment within 48 hours of onset of symptoms is of greater benefit, but later initiation of treatment may also be effective and therefore ALL patients with severe or progressive illness should receive oseltamivir. This applies to all children, including neonates and infants.
• Routine childhood vaccination schedule must be kept up to date. Secondary bacterial pneumonia is an important cause of morbidity and death in influenza, and Streptococcus pneumoniae is one of the leading causes of secondary bacterial pneumonia. All children aged less than 2 years should be vaccinated with the pneumococcal conjugate vaccine (PCV7) if not previously done.

• Lower doses should be considered for infants who are not receiving regular oral feedings and/or those who have a concomitant medical condition which is expected to reduce renal function significantly.
• Capsule contents can be added to a sweet liquid / soft food immediately before administration to disguise bitter taste; syrup, condensed milk, yoghurt, sugar dissolved in water, or other sweet liquids/foods may be used. Open capsule/s and pour contents into a small amount of the liquid/food (one teaspoon maximum). Stir the mixture and ensure that the entire mixture is given to the patient. The mixture must be given immediately after its preparation. (Reference: Health Protection Agency; Summary of prescribing guidance for the treatment and prophylaxis of influenza-like illness. 18 December 2009. Access at http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1243581475043).
• Methods for preparation of an oral suspension using capsules are described in instructions from manufacturers (refer to package insert). Where suitable suspending agents or diluents containing preservatives are not available, capsules can be opened and mixed with a measured volume of water (e.g. one teaspoon) immediately before administration.
• Adverse effects: nausea, vomiting, abdominal pain, diarrhoea, headache and conjunctivitis are the most commonly reported. Rash is uncommon. Other adverse effects that have been reported include: hepatitis, arrhythmias, neuropsychiatric disorders (in children and adolescents), visual disturbances, Stevens-Johnson syndrome and toxic epidermal necrolysis.

• Treatment with zanamivir is indicated in patients where oseltamivir-resistant influenza is demonstrated or highly suspected. Zanamivir is only indicated for use in persons aged ≥5 years.
• Standard dose and duration: two inhalations (i.e. 2 x 5mg) twice daily for 5 days
• Zanamivir contains lactose (powder for inhalation) and must NOT be administered by a nebuliser. It may also interfere with ventilator functioning in ventilated patients.
• Adverse effects are very rare and include: bronchospasm, respiratory impairment, angioedema, urticaria, and rash. Neuropsychiatric disorders have also been reported (especially in children and adolescents).

v. Uncomplicated pandemic influenza in children

vi. Chemoprophylaxis of pandemic influenza

vii. Other influenza strains

b. Other interventions for management

• Oxygen therapy:
• Monitor O 2 saturation and maintain SaO 2 > 90% (92-95% for pregnant women) with nasal cannulae or face mask. High flow O 2 may be required in severe cases.
• Antibiotics:
• In case of pneumonia, empiric treatment for community acquired pneumonia. Increased risk of secondary infection with S. pneumoniae and S. aureus; co-amoxiclav is therefore a suitable empiric antibiotic. Submit appropriate specimens for MC&S to lab, and tailor antibiotic/s accordingly.
• Corticosteroids:
• Low doses of systemic corticosteroids may be considered for patients in septic shock who require vasopressors, or when indicated for another reason. However, systemic corticosteroids are NOT recommended as adjunctive treatment for influenza.
• Paracetamol / acetaminophen:
• Administer for fever or pain.
• Salicylates (aspirin and aspirin-containing products):
• Do NOT use in children and young adults < 18 years (increased risk of Reye’s syndrome with influenza).
• Do NOT use in pregnant women (foetal risks and maternal bleeding)
• NSAIDs:
• Do NOT use in pregnant women (foetal risks and maternal bleeding)

c. Additional comments on management

i. Severely ill patients

• Antiviral therapy
• Oseltamivir therapy should be started immediately upon admission. Treatment decisions should be based on clinical presentation and should NOT be delayed pending laboratory confirmation of influenza. Higher doses (150 mg twice daily) for prolonged duration (10 days) may be of benefit.
• Dose adjustment according to creatinine clearance is necessary for patients with renal impairment.
• Other issues regarding critical care management of patients with influenza are beyond the scope of this document. A recent review appears in the journal Critical Care Medicine 2010 Vol. 38, No. 4(Suppl.) pp e1-e142: H1N1 Novel Influenza: Pandemic Issues for Critical Care Practitioners. Free access is available online at: http://journals.lww.com/ccmjournal/toc/2010/04001

ii. Pregnant patients

• Pregnant women (at all stages including 2 weeks postpartum, and especially those with co-morbidities) are at increased risk for severe or complicated influenza which may be rapidly progressive. HIV-infected pregnant patients seem to be at even higher risk. Influenza in pregnancy carries an increased risk of adverse pregnancy outcomes, including spontaneous abortion, preterm birth and foetal distress. Consequently, pregnant women with suspected/confirmed influenza warrant closer observation and early antiviral therapy. Treatment decisions should be based on clinical presentation and should NOT be delayed pending laboratory confirmation of influenza.
• Paracetamol is recommended for pain and fever. Salicylates and NSAIDs are contraindicated in pregnancy.
• There is currently no safety data on the use of higher doses of oseltamivir in pregnancy.

iii. Children

• Symptoms may be non-specific, therefore clinicians need to maintain a high index of suspicion.
• Antiviral therapy should be started early. Treatment decisions should be based on clinical presentation and should NOT be delayed pending laboratory confirmation of influenza.
• Paracetamol is recommended for pain and fever. No salicylates should be given to children, since there is an increased risk of Reye’s syndrome with influenza and salicylates in younger children.
• Consider early antibiotic treatment for secondary bacterial infection.
• Lower doses of oseltamivir should be considered for infants who are not receiving regular oral feedings and/or those who have a concomitant medical condition which is expected to reduce renal function significantly.
• Routine childhood vaccination schedule must be kept up to date. Secondary bacterial pneumonia is an important cause of morbidity and death in influenza, and Streptococcus pneumoniae is one of the leading causes of secondary bacterial pneumonia. All children aged less than 2 years should be vaccinated with the pneumococcal conjugate vaccine (PCV7) if not previously done.
• Infant feeding and maternal separation: infants can stay with their mothers and should breastfeed if both are well enough and there are no other contraindications to breastfeeding. If a non-infectious carer is available to administer expressed breastmilk to the infant for 7 days then that may be preferable, but is not always feasible. If the mother or infant is too ill to breastfeed, separate the infant from mother but continue to give expressed breast milk if it is available.
• Treatment of preterm infants should be done in consultation with a specialist in the field.
• Infants born to mothers with influenza: currently, most experts are not recommending use of antivirals to protect normal babies, and their use for treatment is only for those infants requiring hospitalisation.

iv. HIV-infected patients

v. Patients with persistent severe or progressive disease despite appropriate antiviral treatment

• Bacterial secondary infections and nosocomial infections
• Presence of influenza-related complications (e.g. CNS involvement, myocarditis, rhabdomyolysis)
• Pandemic influenza A(H1N1) with ongoing viral replication (as evidenced by laboratory tests): liaise with infectious diseases specialists/virologists regarding appropriate specialised testing. This may indicate infection with oseltamivir-resistant virus. Zanamivir is the treatment of choice for all patients where oseltamivir-resistance is demonstrated or highly suspected.
• Infection with seasonal influenza A(H1N1): most strains are resistant to oseltamivir. Liaise with laboratory to interpret initial influenza test result ± submit further specimens for specialised testing. If seasonal influenza A(H1N1) is proven or highly suspected, treatment with zanamivir, amantadine or rimantadine is advised.

6. Infection prevention and control (IPC)

a. IPC precautions

• When working in direct contact with patients, Standard and Droplet Precautions should be applied
• Standard Precautions:
• Hand hygiene: washing hands with soap and water or the use of an alcohol-based hand rub
• Use of personal protective equipment (PPE): this includes facial protection (by means of a medical mask and eye-visor /goggles or a face shield) as well as use of a gown and clean gloves.
• Droplet Precautions:
• Wear a medical mask if working within ±1 metre of the patient or upon entering the room/cubicle of a patient on Droplet Precautions
• Perform hand hygiene before and after patient contact and immediately on removal of a medical mask
• IPC precautions when performing aerosol-generating procedures associated with an increased risk of infection transmission (e.g. aspiration/open suctioning of the respiratory tract, including for the collection of respiratory tract specimens, intubation, resuscitation, bronchoscopy, autopsy)
• Wear a particulate respirator (e.g. N95 respirator), a clean non-sterile, long-sleeved gown, and gloves.
• Perform hand hygiene before and after patient contact and after PPE removal
• IPC precautions for patients who are mechanically ventilated or undergoing respiratory therapy
• Mechanically ventilated patients: Standard and Droplet Precautions (but when aerosol-generating procedures are performed, particulate respirators need to be worn).
• Chest physiotherapy: Standard and Droplet Precautions. A medical mask should be worn by the patient if possible.
• Nebulisation: Standard and Droplet Precautions.

b. Duration of isolation precautions

• All patients should remain on Droplet Precautions for a minimum of 7 days following symptom onset.
• Droplet Precautions should be maintained until 24 hours following resolution of acute influenza symptoms, particularly fever. However, Standard Precautions remain in effect for all patient care. Certain groups of patients may have prolonged viral shedding which extends beyond resolution of acute symptoms, such that there may still be a risk of influenza transmission in the absence of symptoms. These include:
• Infants and children
• Elderly patients
• Severely immunosuppressed or immunocompromised patients: these individuals may shed more virus for a longer time period and are at increased risk for development of antiviral-resistant virus. For such patients, Droplet Precautions should be maintained for the duration of the ILI/illness.

c. Respiratory hygiene/cough etiquette

d. Occupational health

7. Resources for further information

• WHO guidelines for pharmacological management of pandemic influenza A(H1N1) 2009 and other influenza viruses (revised February 2010): http://www.who.int/csr/resources/publications/swineflu/h1n1_guidelines_pharmaceutical_mngt.pdf
• Clinical management of human infection with pandemic (H1N1) 2009: revised guidelines (November 2009): http://www.who.int/csr/resources/publications/swineflu/clinical_management_h1n1.pdf
• Infection prevention and control during health care for confirmed, probable or suspected cases of pandemic (H1N1) virus infection and influenza-like illness (Updated guidance, 16 December 2009): http://www.who.int/csr/resources/publications/cp150_2009_1612_ipc_interim_guidance_h1n1.pdf

• NICD Website: www.nicd.ac.za ,
• Department of Health Website: www.doh.gov.za
• World Health Organisation Website: http://www.who.int/topics/influenza/en/
• Centers for Disease Control and Prevention (CDC, Atlanta): http://www.cdc.gov/flu/index.htm

• The NICD Hotline - 082 883 9920 *strictly for use by health professionals only*

• The Department of Health Communicable Disease Control hotline: 0861-DOH-CDC (0861-364-232)

Appendix 1: Home care guidance: doctors/nurses directions to patients/parents

• Take all of the antiviral medication as directed (where applicable).
• Continue to cover your cough and wash your hands often (even when taking antiviral medications), to prevent spreading influenza to others.
• Call the clinic/GP if you (or your child) experience any side effects; i.e. nausea, vomiting, rash, or unusual behaviour.
• Take medications for symptom relief as needed for fever and pain such as paracetamol or ibuprofen. These medicines do not need to be taken regularly if your symptoms improve. 
• Do not give aspirin (acetylsalicylic acid) or products that contain aspirin to children or teenagers 18 years old or younger.
• Do not give aspirin or NSAIDs to pregnant women.
• Children younger than 4 years of age should not be given over-the-counter cold medications without first speaking with a health care provider. 

• Fast breathing or trouble breathing
• Bluish or grey skin colour
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough

• Stay home for 7 days after your symptoms begin
• Drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to keep from being dehydrated.
• Dishes etc. can be washed with hot soapy water.
• Throw away tissues and other disposable items used by the sick person in the rubbish bin. Wash your hands after touching used tissues and similar waste.
• Have everyone in the household wash hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleaners are also effective.
• Avoid touching your eyes, nose and mouth.
• Continue with medication for chronic diseases as prescribed (e.g. ART, TB treatment).

Appendix 2: Summary table on management of adult patients and children >5 years with suspected or proven influenza infection