SWINE FLU EPIDEMIC

HIV Treat Bull - 2009 Jul/Aug;10(7/8): 02

HIV swine flu telephone triage tool

The following resource was developed by Birmingham Heartlands Hospital and is to be used with flow diagram ‘HIV and Influenza H1N1v‘. This is an empirical protocol drawn up by individuals with some experience in the recent UK swine flu outbreak. Modifications have been made following a meeting at the HIV/ IAS conference 2009 in July. This is just one suggested clinical approach.

Please use and adapt this to your own clinic, if you would like to suggest improvements or share experiences please contact: steve.taylor@heartofengland.nhs.uk.

As they are produced, updated drafts will be posted online: http://www.sexualhealthbirmingham.co.uk.

At the IAS meeting we heard that no country, so far, appears to have seen significant numbers of complicated cases of swine flu in their HIV-positive populations. This was communicated by clinicians from New York, Canada, the UK and Mexico.

Inquiry re HIV and swine flu: a suggested approach

• Does the patient have symptoms consistent with “typical” flu?

FLU DIAGNOSTIC CRITERIA

• An acute-onset illness with history of feeling feverish and confirmed temperature >38°C
• AND flu-like illness (two or more of the following symptoms: cough, sore throat, runny nose, limb/joint pain, headache)
• Significant diarrhea has also been described by several clinicians
• If they fulfil the above criteria but have none of the conditions * or symptoms ** listed below, then advise the patient that they may be suffering from flu. Treatment can be obtained by calling the pandemic flu service line on 0800 1513 100 / 0800 1513 200 or visiting the website:
• They should be advised NOT to attend hospital unless they deteriorate, or if symptoms fail to improve within 48 hours of commencing flu antivirals, when they should be clinically assessed.
• Reassure them that it‘s appears safe to take antiretrovirals (ART) with flu antivirals e.g. oseltamivir (Tamiflu).
• Although there is the potential for drug interactions between ART and osteltamivir we have taken the approach that potential benefits exceed the potential for side effects. Obviously this can be modified as new data emerges.
• The theoretical interactions with renally excreted drugs and osteltamivir have led us to recommend that if patients have significant renal impairment (ie eGFR <40 mL/min) inhaled Zanamivir can be considered as an alternative (see below).
• In pregnancy we have recommended inhaled Zanamivir (Relenza). However systemic treatment should not be withheld if the clinical condition warrants treatment. (Deaths have occurred in pregnant women who maybe at greater risk of severe infection).
• Reassure the patient that most people with uncomplicated flu will be significantly better within 48 hours.
• Alternatively persons with severe symptoms that are not classically flu-like should be assessed and have flu swabs performed since a negative test can be very informative.

If the patient meets the flu diagnostic criteria above AND has any of the following conditions* then they need to be assessed by the ID/HIV/GU registrar on call for the day: [INSERT APPROPRIATE NUMBER].

*Conditions requiring assessment by a registrar:

• Pregnancy (any trimester)
• Asthma and other chronic lung disease
• Morbid obesity
• Significant immune suppression

Note: We suggest assessing patients with CD4 counts <200 or CD4% <15% with symptoms as they may have an alternative non-flu diagnosis. These cases should be discussed with a senior member of the HIV team or the ID /HIV/GUM registrar on call.

If the patient meets the flu diagnostic criteria above, but also has any of the following symptoms** they should be assessed by the ID/HIV/GUM registrar on call for the day immediately.

** Additional symptoms requiring immediate assessment