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Influenza: Diagnosis and Treatment

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Influenza: Diagnosis and Treatment Influenza: Diagnosis and Treatment David Y. Gaitonde, MD; Cpt. Faith C. Moore, USA, MC; and Maj. Mackenzie K. Morgan, USA, MC Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia Influenza is an acute viral respiratory infection that causes significant morbidity and mortality worldwide. Three types of influ- enza cause disease in humans. Influenza A is the type most responsible for causing pandemics because of its high susceptibility to antigenic variation. Influenza is highly contagious, and the hallmark of infection is abrupt onset of fever, cough, chills or sweats, myalgias, and malaise. For most patients in the outpatient setting, the diagnosis is made clinically, and laboratory con- firmation is not necessary. Laboratory testing may be useful in hospitalized patients with suspected influenza and in patients for whom a confirmed diagnosis will change treatment decisions. Rapid molecular assays are the preferred diagnostic tests because they can be done at the point of care, are highly accurate, and have fast results. Treatment with one of four approved anti-influenza drugs may be considered if the patient presents within 48 hours of symptom onset. The benefit of treatment is greatest when antiviral therapy is started within 24 hours of symptom onset. These drugs decrease the duration of illness by about 24 hours in otherwise healthy patients and may decrease the risk of serious complications. No anti-influenza drug has been proven superior. Annual influenza vaccination is recommended for all people six months and older who do not have contraindications. (Am Fam Physician. 2019; 100:online. Copyright © 2019 American Academy of Family Physicians.) Published online November 11, 2019 BEST PRACTICES IN INFECTIOUS DISEASE Influenza is an acute respiratory infection caused by a negative-strand RNA virus of the Orthomyxoviridae fam- Recommendations from the Choosing ily. Tere are three distinct types of infuenza viruses that Wisely Campaign infect humans: infuenza A, B, and C. Infuenza A infects Recommendation Sponsoring organization multiple species, including humans, swine, equines, and birds. It is more susceptible to antigenic variation and, Do not routinely avoid American Academy of Allergy, influenza vaccination in Asthma, and Immunology 1,2 hence, is the cause of major pandemics. Te surface of egg-allergic patients. the virion envelope is covered with proteins hemaggluti- nin (HA), neuraminidase (NA), and matrix 2.1 Antigenic Source: For more information on the Choosing Wisely Campaign, see https:// www.choosingwisely.org. For supporting citations and variation is associated with changes in the HA or NA sur- to search Choosing Wisely recommendations relevant to primary face proteins and is generally classifed as antigenic drif or care, see https:// www.aafp.org/afp/recommendations/search.htm. shif.1 Antigenic drif involves small, gradual amino acid substitutions of the HA or NA proteins that can result in smaller outbreaks. Antigenic shif occurs when there are novel infuenza subtypes with the potential to cause wide- signifcant changes in the HA or NA proteins that create spread pandemics.1,3 Each infuenza A subtype is charac- terized by numbering both the HA and NA proteins (e.g., H3N2, H5N1). See related Practice Guideline at https://www.aafp.org/ Epidemiology afp/2019/1015/p505.html. From 2010 to 2018, estimated seasonal infuenza activity Author disclosure: No relevant financial afliations. in the United States ranged from 9.3 million to 49 million cases and 12,000 to 79,000 deaths per year.4 Te 2017-2018 Patient information: Handouts on this topic are available infuenza season was the third most severe since 2003-2004 at https:// family doctor.org/preventing-the-flu and https:// family doctor.org/flu-myths. and was characterized by high severity of disease in all age groups.5 Most cases were secondary to the A/H3N2 subtype, and low vaccine efectiveness was a signifcant contributing Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the private, noncom- Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the private, noncom- ◆ 1 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Novembermercial use 11, of2019 one individual ePub user of the website. All other rightswww.aafp.org/afp reserved. Contact [email protected] for copyright questionsAmerican and/or permission Family Physician requests. TABLE 1 People at Increased Risk of Complications from Influenza factor.5 Based on public health laboratory specimens, the People with coexisting medical conditions predominant infuenza A subtype for the 2018-2019 season Any condition that may compromise the handling of respira- tory secretions (e.g., neuromuscular diseases, cerebral palsy, was (H1N1)pdm09 (56.6% of positive specimens), followed stroke, seizure disorder, dementia) by the A/H3N2 subtype (43.6%) and infuenza B (4%).6 Asthma or other chronic pulmonary disease Seasonal infuenza occurs primarily in the colder months Chronic kidney disease in temperate regions. Te primary mode of transmission is via inhalation of infectious respiratory particles (large drop- Chronic liver disease let transmission) when an infected person coughs or sneezes. Heart disease (acquired or congenital) Tere is also evidence of airborne (small particles transmit- Immunosuppression (e.g., HIV infection, cancer, transplant recipients, use of immunosuppressive medications) ted by talking or exhalation) and fomite transmission.6,7 Te typical incubation period is 24 to 48 hours. Patients are Long-term aspirin therapy in patients younger than 19 years infectious one to two days before symptom onset and for fve Metabolic disorders (acquired [e.g., diabetes mellitus] or inherited [e.g., mitochondrial disorders]) to seven days aferward. Children and immunosuppressed people may exhibit prolonged viral shedding.8,9 Morbid obesity In 2009, a novel H1N1 subtype (pH1N1) emerged from Sickle cell anemia and other hemoglobinopathies a quadruple reassortment of two swine viruses, one avian Special groups 10 virus, and one human virus. First identifed in Mexico Adults 65 years and older in 2009, it caused millions of cases worldwide and an esti- American Indians and Alaska Natives 11 mated 18,500 laboratory-confrmed deaths. Children younger than 5 years (particularly those younger Since 2011, outbreaks of a swine-origin H3N2 virus have than 2 years) been reported in the United States. Cases predominantly Institutionalized adults (e.g., residents of nursing homes or involved young children exposed to swine, ofen at state chronic care facilities) 12,13 fairs. Additionally, the H5N1 avian infuenza virus has Pregnant and postpartum women (up to 2 weeks postpartum, become a global concern. First identifed solely in wild geese including pregnancy loss) populations in China in 1997, the virus quickly spread to Adapted with permission from Erlikh IV, Abraham S, Kondamudi VK. domestic poultry and ultimately to human populations. Management of influenza. Am Fam Physician. 2010; 82(9): 1088, with Tere are now avian infuenza cases reported worldwide, additional information from references 18 and 19. although poultry-to-human and human-to-human trans- mission remains relatively low. Despite low transmissibility, the reported fatality rate is high (approximately 60%).14 immunosuppressed people, children younger than two years, children two to four years of age who have had asthma Prevention or wheezing in the past 12 months, and adults 50 years and Te Centers for Disease Control and Prevention’s (CDC’s) older.15 For children six months to eight years of age, two Advisory Committee on Immunization Practices (ACIP) doses of IIV administered at least four weeks apart are rec- and the American Academy of Family Physicians (AAFP) ommended if the child has not received at least two doses recommend annual infuenza vaccination for all people six of the infuenza vaccine previously. RIV is not licensed for months and older who do not have contraindications.15,16 children younger than 18 years.15 Vaccination eforts should target people at increased risk of In August 2019, ACIP recommended that LAIV may be complicated or severe infuenza (Table 117-19) and those who used in age-appropriate patients without contraindications care for or live with high-risk individuals, including health for the 2019-2020 infuenza season because it was deemed care professionals.15 Two previous FPM articles provided as efective as the IIV for prevention of the H3N2 and communication strategies and tools for increasing infuenza infuenza B viruses.15,22 Notably, infuenza-specifc antiviral vaccination rates in practice.20,21 medications may reduce the efectiveness of LAIV if given Multiple formulations of the infuenza vaccine are avail- within two days before to 14 days afer vaccine administra- able, including inactivated infuenza vaccines (IIV); a recom- tion.15 Te AAFP has made a preferential recommendation binant inactivated vaccine (RIV); and a live, attenuated for vaccination with IIV over LAIV.16 infuenza vaccine (LAIV). For physicians and patients con- A high-dose, inactivated trivalent vaccine (Fluzone High- cerned about egg allergy, quadrivalent RIV and cell culture– Dose) is licensed for adults 65 years and older, and multiple based quadrivalent IIV are completely egg-free.15 studies show
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