Recommendations for the management of children with H1N1 novel influenza infection

Preparing for pandemics: a systematic review of pandemic influenza clinical management guidelines

BACKGROUND

The COVID-19 pandemic has highlighted the importance of evidence-based clinical decision-making. Clinical management guidelines (CMGs) may help reduce morbidity and mortality by improving the quality of clinical decisions. This systematic review aims to evaluate the availability, inclusivity, and quality of pandemic influenza CMGs, to identify gaps that can be addressed to strengthen pandemic preparedness in this area.

METHODS

Ovid Medline, Ovid Embase, TRIP (Turning Research Into Practice), and Guideline Central were searched systematically from January 2008 to 23rd June 2022, complemented by a grey literature search till 16th June 2022. Pandemic influenza CMGs including supportive care or empirical treatment recommendations were included. Two reviewers independently extracted data from the included studies and assessed their quality using AGREE II (Appraisal of Guidelines for Research & Evaluation). The findings are presented narratively.

RESULTS

Forty-eight CMGs were included. They were produced in high- (42%, 20/48), upper-middle- (40%, 19/48), and lower-middle (8%, 4/48) income countries, or by international organisations (10%, 5/48). Most CMGs (81%, 39/48) were over 5 years old. Guidelines included treatment recommendations for children (75%, 36/48), pregnant women (54%, 26/48), people with immunosuppression (33%, 16/48), and older adults (29%, 14/48). Many CMGs were of low quality (median overall score: 3 out of 7 (range 1-7). All recommended oseltamivir; recommendations for other neuraminidase inhibitors and supportive care were limited and at times contradictory. Only 56% (27/48) and 27% (13/48) addressed oxygen and fluid therapy, respectively.

CONCLUSIONS

Our data highlights the limited availability of up-to-date pandemic influenza CMGs globally. Of those identified, many were limited in scope and quality and several lacked recommendations for specific at-risk populations. Recommendations on supportive care, the mainstay of treatment, were limited and heterogeneous. The most recent guideline highlighted that the evidence-base to support antiviral treatment recommendations is still limited. There is an urgent need for trials into treatment and supportive care strategies including for different risk populations. New evidence should be incorporated into globally accessible guidelines, to benefit patient outcomes. A 'living guideline' framework is recommended and further research into guideline implementation in different resourced settings, particularly low- and middle-income countries.

Influenza-related postinfectious encephalomyelitis complicated by a perforated peptic ulcer

Influenza virus infection is extremely common and raises global concern due to the increasing prevalence of pandemic H1N1 infection. Influenza may occasionally be associated with neurologic complications and, also, rarely with gastrointestinal complications. Here, we report a rare case complicated with appendicitis, duodenum perforation, and transient delirious behavior after influenza A viral infection in a pediatric patient aged 14 years. The transient delirious behavior could be attributed to postinfectious encephalopathy. The perforated peptic ulcer could have resulted from influenza infection, could have been an adverse event related to oseltamivir administration, or could have been a complication of preceding gastroenteritis. Our case highlights the importance of pediatric healthcare workers to be aware of possible complications arising from both influenza infection and oseltamivir therapy, even though some of these complications may be relatively rare.

Historical review of pandemic influenza A in Taiwan, 2009

Influenza is an important disease in children. In April 2009, human infections caused by a novel swine H1N1 virus were reported in Mexico, followed by a pandemic. As of 14 March 2010, more than 213 countries and overseas territories or communities have reported laboratory-confirmed cases of pandemic influenza H1N1 2009, including at least 16,813 deaths. This influenza pandemic is unique in many respects. Large outbreaks occurred outside the usual season for influenza infection. The virus also caused severe illnesses and deaths in younger people, with many deaths caused by severe pneumonia. A comprehensive approach to pandemic control has been launched, including infection control interventions, antiviral drugs and vaccines. Vaccination is the most efficient way to control morbidity and mortality resulting from influenza infections in humans. For the first time, an influenza vaccine against a pandemic strain became available before the winter. However, the initially smooth influenza vaccination program was disturbed by the fear of possible adverse events following immunization. In Taiwan, mistrust of the influenza vaccination has also caused significant social impacts towards the end of 2009. Lessons learned from this pandemic influenza H1N1 2009 might help health authorities and physicians shape their preparedness for the next pandemic.