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6.  Seasonal influenza, or ‘the flu’ as it is often called, is an acute viral infection
caused by an influenza virus, mainly affects the respiratory system.
 Seasonal influenza viruses circulate worldwide and can affect anybody in any
age group.
 People of all ages can get the flu. However, children, the elderly, and people
with weakened immune systems are most susceptible and more likely to
develop serious complications.

11. Influenza A is subtyped by surface proteins
Heamagglutinin (HA)
● 18 different types
● help virus enter cells “key in”
● antibody to HA is protective
Neuraminidase (NA)
● 11 different types
● help virus leave cells to infect others “key out”

13. Avian Influenza A
viruses
H1 - H18
N1 – N11
H1 - H3
N1 –N2
Human Influenza
A Viruses

15.  Among many subtypes of influenza A viruses,only influenza A(H1N1)
& A(H3N2) are currently circulating among humans as seasonal
Influenza strains, In addition to influenza B.

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Seasonal Occurrence of Influenza
J F M A M J J A S O N D
Southern hemisphere Tropical Northern hemisphere
Seasonal flu occurs every year, though from year to year the strains differ, the peak of influenza attacks
occurs between October and May in the Northern Hemisphere and between April and September in
the Southern Hemisphere.

18. Influenza virus
exposure illness
Incubation: 1-4 days
(average 2 days)
Communicability:
(1 day before to 5-7 days after exposure)
While seasonal influenza outbreaks can happen as early as October, in
most seasons influenza activity peaks between December and February.

19. Clinical presentation

21. How does the Flu spread?

23. How does the Flu spread?
Droplet Infection

29.  Reducing influenza virus transmission (eg, by using appropriate hand
hygiene and respiratory hygiene and/or cough etiquette) among children
who attend out-of-home child care or school has been shown to
decrease the burden of childhood influenza and transmission of
influenza virus to household contacts and community members of all
ages.

40. Flu Shot
 Seasonal influenza epidemics can cause febrile illnesses that range in
severity from mild to debilitating and can lead in some instances to
hospitalization and even cause death.
 Persons infected by influenza virus may be asymptomatic or present with
self-limited acute febrile respiratory symptoms , with recovery in 3-7 days.
 However, those presenting with severe illness may have significant
morbidity and mortality, such a presentation has been found to be
associated with high-risk patients.

41. Flu Symptoms
• Fever or feeling feverish*
• Headache
• Fatigue or extreme tiredness
• Cough
• Sore throat
• Runny or congested nose
• Muscle and body aches
• Diarrhea and vomiting
(more common with children than
adults)
*Not everyone with flu will have a fever, and you
may not experience all of these symptoms. Be
sure to check with your health care provider if
your symptoms become severe.
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43. How to recognize patients with severe or
complicated illness (Severe ILI)?

46.  Influenza is a self limited illness ,For patients in low-risk groups who
do not develop complications, prognosis is good and a full recovery is
expected.
 Patients in high-risk groups have an increased incidence of severe
illness, hospitalization, and death.

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52. Influenza is dangerous for children

55.  Children often have the highest attack rates of influenza in the community
during seasonal influenza epidemics, play a pivotal role in the transmission
of influenza infection to household and other close contacts, and
experience relatively elevated morbidity, including severe or fatal
complications from influenza infection.

56.  Although all children aged younger than 5 years are considered at higher
risk for complications from influenza, the highest risk is for those aged
younger than 2 years, with the highest hospitalization and death rates
among infants aged younger than 6 months.
 This includes young children without pre-existing medical conditions who
are at increased risk of hospitalisation compared with older children and
adults.

57.  School-aged children bear a large influenza disease burden and have a
significantly higher chance of seeking influenza related medical care
compared with healthy adults.
 In a recent study of hospitalizations for influenza A versus influenza B,
the odds of mortality were significantly greater with influenza B than
with influenza A.

58.  Although influenza generally is an acute, self-limited, and usually uncomplicated
disease in healthy children, it can be associated with severe morbidity and
mortality.
 Certain groups of children are at increased risk of severe or complicated
influenza infection.

59. Children at greatest risk of serious flu-related complications
include the following:
1. Children younger than 6 months old
These children are too young to be vaccinated. The best way to protect
them is to make sure people around them are vaccinated.
2. Children aged 6 months up to their 5th birthday
Even children in this age group who are otherwise healthy are at risk
because of their age.
3. Children aged 6 months old through 18 years old with chronic health
problems

60.  Children commonly need medical care because of flu, especially children
younger than 5 years old who become sick with flu.
 Complications from flu among children in this age group can include:
 Pneumonia
 Dehydration: when a child’s body loses too much water and salts, often
because fluid losses are greater than from fluid intake
 Worsening of long-term medical problems like heart disease or asthma
 Encephalopathy
 Sinus problems and ear infections
 Flu complications can lead to death.

61.  Because many children with mild febrile respiratory illness might have
other viral infections (e.g., respiratory syncytial virus, parainfluenza
virus, human metapneumovirus or rhinovirus ), knowledge of other
respiratory viruses as well as influenza virus strains circulating in the
community is important for treatment decisions.

63. Influenza Diagnosis and Management
 Influenza testing is not needed for all patients with signs & symptoms
of influenza in order to make antiviral treatment decisions.
 If testing is done, it is recommended that RT-PCR (Reverse
Transcriptase Polymerase Chain Reaction) tests be performed from
nasopharyngeal swabs or throat swabs.

64.  When influenza viruses are known to be circulating in a community,
patients presenting with features of uncomplicated influenza with
or without high risk factors of developing severe or complicated
illness can be diagnosed on clinical and epidemiological grounds,
will not require influenza laboratory confirmation.

65.  Laboratory testing of Influenza can be considered for hospitalized patients
who meet the criteria for complicated or severe influenza, where a
laboratory diagnosis will assist in patient management.
 Reverse transcriptase polymerase chain reaction or RT-PCR are diagnostic
tests of choice for accurate and timely diagnosis of influenza virus infection.
 Negative rapid influenza diagnostic test result does not rule out influenza.

66.  Although decisions on treatment and infection control can be made on
the basis of positive rapid antigen test results, negative results should
not always be used in a similar fashion because of the suboptimal
sensitivity and potential for false-negative results.
 Positive results of rapid influenza tests are helpful because they may
reduce additional testing to identify the cause of a child’s ILI and
promote appropriate antimicrobial stewardship.

68.  Clinical judgment (on the basis of underlying conditions, disease severity,
time since symptom onset, and local influenza activity) is an important
factors in treatment decisions for pediatric patients who present with ILI.
 For Decisions to start antiviral treatment,you should not wait for
laboratory confirmation of influenza because laboratory testing can delay
treatment .

69.  Patients with mild influenza like illness (ILI) who present with an uncomplicated
illness typically do not require antiviral treatment unless they are at higher risk
for serious influenza complications.
 Patients with complicated or severe influenza like illness should be hospitalized
& treated with antivirals .
 Efforts should be made to minimize treatment in patients who are not infected
with influenza.

70.  Antiviral treatment is recommended as early as possible for any
patient with confirmed or suspected influenza who :
1. is hospitalized
2. has severe, complicated, or progressive illness
3. is at higher risk for influenza complications.
Most people who are otherwise healthy and get the flu do not need to
be treated with antiviral drugs .

76. Neuraminidase inhibitors are competitive inhibitors of the active site of the influenza glycoprotein
neuraminidase, responsible for viral release from infected respiratory epithelial cells

80.  Due to high levels of resistance, Amantadine and Rimantadine are not
recommended for antiviral treatment or chemoprophylaxis of currently
circulating influenza A viruses.
 WHO recommends neuraminidase inhibitors as the first-line treatment
for people requiring influenza antiviral therapy.

81.  There are three FDA-approved influenza antiviral drugs (Neuraminidase
inhibitors), recommended by CDC this season to treat influenza:
1. Oseltamivir (trade name Tamiflu®)
2. Zanamivir (trade name Relenza®)
3. Peramivir (trade name Rapivab®).

82.  When indicated, Clinical benefit is greatest when antiviral treatment is
administered early, ideally within 48 hours of influenza illness onset.
 Clinical trials & observational data show that early antiviral treatment
can shorten the duration of fever and illness symptoms, and may reduce
the risk of complications from influenza .

83.  Patients with severe, progressive or complicated illness consistent with
a diagnosis of influenza (Severe ILI) should be treated empirically with
neuraminidase inhibitors Oseltamivir as soon as possible, irrespective
of the presence of underlying comorbidities & even if the time elapsed
between symptom onset and first opportunity to treat is >48hrs.

84.  Oral oseltamivir remains the antiviral drug of choice for the management of
influenza infections. Although more difficult to administre, inhaled zanamivir
is an equally acceptable alternative for patients who do not have chronic
respiratory disease.
 Current treatment guidelines for antiviral medications applicable to both
infants and children with suspected influenza when strains are known to
be circulating in the community or when infants or children are tested and
confirmed to have influenza.

86.  The optimal duration and dosing are uncertain for severe or complicated
influenza.
 Treatment regimens might need to be altered to fit the clinical situation,
For example, clinical judgment should be the guide regarding the need
to extend daily treatment regimens longer than 5 days for patients
whose illness is prolonged.

87. Management of ILI

88. Oseltamivir should be offered as early as possible ,without waiting for laboratory
confirmatory of influenza to the following individuals :
1. For children with severe, complicated or progressive diseases presumptively
or definitively caused by influenza, irrespective of influenza vaccination status
or whether illness began greater than 48 hours before admission, continues
to be recommended by the AAP, CDC, Infectious Diseases Society of America,
and Pediatric Infectious Diseases Society.

89. Oseltamivir should be offered as early as possible ,without waiting for laboratory
confirmatory of influenza to the following individuals :
2. For children with suspected influenza of (any severity) and at high risk of
influenza related complications.
 Efforts should be made to minimize treatment in patients who are not infected
with influenza.

90.  Oseltamivir is available in capsule and oral suspension formulations ,The
available capsule doses are 75 mg.
 The commercially manufactured liquid formulation has a concentration of
12 mg/mL in a 60 mL bottle in Egypt.
 If the commercially manufactured oral suspension is not available, the
capsule may be opened and the contents mixed with simple syrup or oral
sweet SF (sugar free) for a final concentration of 12 mg/mL.

97.  Oseltamivir administered orally or by oro/naso gastric tube is well
absorbed in critically ill influenza patients, including those in the intensive
care unit, on continuous renal replacement therapy, and/or on
extracorporeal membrane oxygenation.
 Intubated patients with influenza illness should receive oseltamivir
through a nasogastric tube.

98.  In adverse event data collected systematically in prospective trials,
vomiting was the only adverse effect seen more often with oseltamivir
compared with a placebo when studied in children 1 through 12 years
of age.
Side effects :

99.  Transient neuropsychiatric events (self-injury or delirium) have been
reported postmarketing among persons taking oseltamivir; the
majority of reports were among Japanese adolescents and adults .
 Several recent analyses and reviews have found that oseltamivir is
not associated with an increased risk for neuropsychiatric events.

100.  Oseltamivir is recommended by the World Health Organization for
use in the clinical management of pandemic and seasonal influenza
of varying severity, and as the primary antiviral agent for treatment
of avian H5N1 influenza infection in humans.

104.  Zanamivir is only available in the form of a dry powder inhaler because of
the drug’s poor oral bioavailability.
 Some patients have had bronchospasm (wheezing) or serious breathing
problems when they used zanamivir.
 Zanamivir is not recommended for people with chronic respiratory
diseases such as asthma or chronic obstructive pulmonary disease.

105.  Zanamivir powder for inhalation should NEVER be made into nebuliser
solution or administered to a mechanically ventilated patient.
 Zanamivir powder for inhalation should NOT be nebulised by dissolving
the capsules in water. This practice has been linked to deaths in ICU
believed to be due to blockage of ventilator tubes.

106. Post exposure Chemoprophylaxis
 According to the CDC, antiviral chemoprophylaxis generally should be
reserved for persons at higher risk for influenza-related complications
who have had contact with someone likely to have been infected with
influenza.
 Antiviral chemoprophylaxis is not appropriate for healthy children or
adults based on potential exposure in the community.

107.  Pediatricians should inform recipients of antiviral chemoprophylaxis
that risk of influenza is lowered but still remains while taking the
medication, and susceptibility to influenza returns when the
medication is discontinued.

108.  Patients receiving post exposure chemoprophylaxis should be
encouraged to seek medical evaluation ,as soon as they develop a
febrile respiratory illness suggestive of influenza because influenza virus
infection still can occur while a patient is on antiviral chemoprophylaxis .

109.  An emphasis on close monitoring and early initiation of antiviral
treatment is an alternative to chemoprophylaxis for some patients who
have had contact with someone likely to have been infectious with
influenza.
 Clinical judgment is an important factor in treatment decisions.

110.  Optimally, postexposure chemoprophylaxis should only be used
when antiviral agents can be started within 48 hours of exposure.
 Early, full treatment doses (rather than prophylaxis doses) provided
to patients who are at high-risk and symptomatic without waiting for
laboratory confirmation is an alternate strategy.

111.  CDC does not recommend widespread or routine use of influenza
antiviral medications for chemoprophylaxis so as to limit the
possibilities that antiviral resistant viruses could emerge.
 Influenza Antiviral chemoprophylaxis is currently NOT
recommended by the WHO.

112. Duration of Chemoprophylaxis
 Postexposure chemoprophylaxis is typically administered for a total
of no more than 10 days after the most recent known exposure to
a close contact known to have influenza.

113. 2013

114.  Among some people at high risk of influenza complications , both
vaccination and antiviral chemoprophylaxis may be considered for example,
Prevention of influenza in persons at high risk of influenza complications
during the first two weeks following vaccination after exposure to an
infectious person.
 For persons taking antiviral chemoprophylaxis after inactivated flu
vaccine,the recommended duration is until immunity after vaccination
develops (antibody development after vaccination takes about two weeks in
adults and can take longer in children depending on age and vaccination

115.  Chemoprophylaxis with antiviral medications is not a substitute for
influenza vaccination (Oseltamivir is not a substitute for the flu shot) .
 Annual influenza vaccination is the best way to prevent influenza and
its related complications.

122. Every flu season is different, A flu vaccine is needed every season for
two reasons:
1. The body’s immune response from vaccination declines over time, so an
annual vaccine is needed for optimal protection , Even if the strains have
not changed, getting influenza vaccine every year is necessary to maximize
protection.
2. Antigenic drift (Flu viruses are constantly changing),which may occur in
one or more influenza virus strains.

133. Flu Mist - nasal spray flu vaccine

136. HOW MANY DOSES OF FLU
VACCINE DOES MY CHILD NEED?
Flu Shot

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Vaccine Storage
Store vaccine between 2º and 8º C at all times.
Vaccine should be placed on the middle shelves of the refrigerator
Influenza vaccine should never be exposed to freezing temperature!.
The vaccine effectiveness can be decreased by exposure to light

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Note: Influenza Vaccine must not be frozen.
It should never come into direct contact with ice.
Transporting Vaccine
Use insulated containers with a temperature monitoring
device and appropriate cooling agents
Keep vaccine in insulated bags – do not carry it in your pocket!

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90° Angle
Dermis
Fatty tissue
(subQ)
Muscle tissue
Trivalent Inactivated Influenza Vaccine is Administered by the
Intramuscular Route
Needle length & Site depend on:
Muscle size, Fatty tissue thickness,
Vaccine volume, Injection technique
Aspiration is NOT required

148. x
x
Anterolateral thigh
Inactivated Influenza Vaccine IM Injections
Deltoid

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Anterolateral thigh
Needle gauge
- 22 - 25 gauge
Needle length
- 1 inch
Inactivated seasonal Influenza Vaccine
IM Injections – Infant (6-12 months)

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Inactivated seasonal Influenza Vaccine
IM Injections – Toddlers (1-2 years)
Needle size
- 22 - 25 gauge
Needle length
- anterolateral thigh – 1 inch
- deltoid – 1 inch

151. Comforting Restraints
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.
 For adults and older children, the recommended
site of vaccination is the deltoid muscle.
 The preferred site for infants (< 12 months old )
and young children (older than 12 months of
age with inadequate deltoid muscle mass) is
the anterolateral aspect of the thigh.

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Standard Technique for Injection

154.  TIV does not interfere with the effectiveness of other vaccines, it can be
given at the same time or at any time before or after administration of
other inactivated vaccines (e.g. Hepatitis B vaccine) or live attenuated
vaccines (e.g. Measles, mumps and rubella vaccine).
 For concomitant parenteral injections, different injection sites and
separate needles and syringes should be used.
Can TIV be administered simultaneously with other vaccines?

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Is Flu Vaccine Safe?
YES!
Vaccination is the BEST protection
you have against the flu!

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THANK YOU