1. Hot Topic Meeting by: Royal College of Physicians of Edinburgh & The Scottish Executive Health Department Pandemic Flu Planning Scotland’s Health Response 5 th June 2007 Queen Mother Conference Centre

2. June – 2007 2 Care of the Vulnerable Population: Children Dr. James Paton Royal Hospital for Sick Children Glasgow

3. June – 2007 3 Care of Vulnerable Population - Children Clinical Presentations Triage and Severity Assessment Recommended treatments – Part 1 Investigations in Hospital Recommended treatments – Part 2 Ethics & Staffing during a pandemic

4. June – 2007 4

5. June – 2007 5 Fleming, D M et al. Arch Dis Child 2005;90:741-746

6. June – 2007 6 Clinical Characteristics of RSV and ‘Flu in Hospitalised Children Meury et al Eur J Pediatr 2004; 163:359-363

7. June – 2007 7 Timing of 153 Cases of Fatal Influenza in Children - United States, 2003-2004 Season Bhat, N. et al. N Engl J Med 2005;353:2559-2567 Timing of 153 Cases of Fatal Influenza in Children – US 2003-04

8. June – 2007 8 Timing of 153 Cases of Fatal Influenza in Children - United States, 2003-2004 Season Whose at Risk? Impact of Age Impact of pre-existing medical conditions

9. June – 2007 9 'Flu Mortality Rate According to Age Group – US 2003-04 Bhat, N. et al. N Engl J Med 2005;353:2559-2567

10. June – 2007 10 Izurieta H et al. N Engl J Med 2000;342:232-239 Relative Risk of Admission in Children without High Risk Conditions

11. June – 2007 11 Bhat, N. et al. N Engl J Med 2005;353:2559-2567 Underlying Health Status in Children with Fatal Influenza – US 2003-04 (n- 149)

12. June – 2007 12 Triage and General Management in 1ry Care Recognition of ‘At Risk Groups’ Assessment of Illness Severity Current advice and guidance on epidemiology of pandemic

13. June – 2007 13 Severity Assessment (CURB 65) in Adults ItemMeasureScore ConfusionMental test score ≤8 Urea >7mmol/l Respiratory Distress Respiratory Rate ≥30/min Blood Pressure SBP <90mmHg or DBP ≤60mmHg Age - >65yrAge ≥65yr

14. June – 2007 14 Respiratory Distress – Severity Assessment in Children MildSevere Infants Temp >38.5 ⁰C Mild Respiratory Distress Taking Full Feed Temp >38.5 ⁰C Severe Respiratory Distress Cyanosis Grunting / Apnoea Not feeding Children Temp >38.5 ⁰C Mild Respiratory Distress No vomiting Temp >38.5 ⁰C Severe respiratory Distress Cyanosis Grunting Signs of dehydration Appendix 8 Thorax 2007;62: Supplement 1

15. June – 2007 15 Severity Assessment in Children ItemMeasureScore Temperature>38.5⁰C ConfusionComplicated or prolonged seizure; Altered conscious level Urea Dehydration - Older Children Respiratory Distress ↑Rate, Recession, Nasal Flaring, Cyanosis, Grunting, Apnoea Not feeding Blood Pressure Signs of Shock – extreme pallor, hypotension, floppy infant Age - >65yrAge <1yr

16. June – 2007 16 Triage & General Management in 1ry Care Thorax 2007;62:Supplement 1

17. June – 2007 17 Specific Treatment - Anti-Viral Therapy Amantidine / rimantidine Neuraminidase inhibitors –Oseltamivir (Tabs & liquid) Effective if given within 2 days of start of illness Reduction in time to alleviation of symptoms Reduction in complications requiring antibiotics Note - faster drug clearance in younger children Not licensed under 1 year - but Japanese experience suggests is safe –Zanamavir (inhaler – so children >5yrs) Ribavirin

18. June – 2007 18

19. June – 2007 19 Triage of Children in Hospital Assessment of Illness severity Admit to ward if: –Severe respiratory distress; Hypoxia –Severe dehydration –Altered conscious level or prolonged seizure –Signs of septicaemia Consider HDU/ICU –Worsening hypoxia despite oxygen –Worsening respiratory failure –Apnoea or slow/irregular breathing –Encephalopathy If no ICU Beds?

20. June – 2007 20 Investigations for Children in Hospital Pulse oximetry CXR –if hypoxic or severely ill, or deteriorating; Not routinely FBC, U & Es, LFTs, Blood Culture Microbiology

21. June – 2007 21 Microbiological Investigations for Children in Hospital Early Pandemic – when you want to know –Virology NPA for Respiratory panel - ‘flu A & B; RSV, Adeno, Rhino, Paraflu 1,2,3 Rapid influenza tests – high specificity - R/I ‘flu Acute & Convalescent Serum –Bacteriology Blood Sputum Established Pandemic – when you know –Virology – not routine –Bacteriology

22. June – 2007 22 Anti-Viral Therapy in Hospital Neuraminidase inhibitors –Oseltamivir (Tabs & liquid) –If severely ill with symptoms for <6 days –Child <1year with severe infection with informed consent

23. June – 2007 23 Antibiotics for Children in Hospital Secondary bacterial infections are common –Pneumonia –Otitis media

24. June – 2007 24 O’Brien et al. Clin Infect Dis 2000;30:784-9 Pneumococcal Pneumonia in Previously Healthy Children

25. June – 2007 25 Bhat, N. et al. N Engl J Med 2005;353:2559-2567 Bacterial Co-infections in 24 Children with Fatal Influenza

26. June – 2007 26 Navarini, Alexander A. et al. (2006) Proc. Natl. Acad. Sci. USA 2006; 103: 15535-15539 Activation-associated Cell Death of Bone Marrow GRC during LCMV infection Early phase of infection largely controlled by innate resistance via granulocytes. Virus-induced suppression of antibacterial resistance and immunity by IFN 1 production was caused by apoptosis of bone marrow granulocytes and impaired granulocyte emigration. Granulocytopenia was not complete but became functionally limiting during super-infection when large numbers of granulocytes were rapidly required to control infection Early phase of infection largely controlled by innate resistance via granulocytes. Virus-induced suppression of antibacterial resistance and immunity by IFN 1 production was caused by apoptosis of bone marrow granulocytes and impaired granulocyte emigration. Granulocytopenia was not complete but became functionally limiting during super-infection when large numbers of granulocytes were rapidly required to control infection

27. June – 2007 27 Antibiotics for Children in Hospital Children at risk of complications Children with disease severe enough to be admitted Treat prophylactically with antibiotic to cover Staph aureus Str pneumoniae H influenzae = Co-amoxiclav; Or clarithromycin, cefuroxime if pen. allergic

28. June – 2007 28 Will There be Sufficient Staff?

29. June – 2007 29 Physicians YD/KN It would be ethical for HCP to abandon their workplace during a pandemic to protect themselves and their families 24%11%64% HCP should be allowed to decide whether they report to work during a pandemic 25%8%67% HCP without children should primarily care for influenza patients during a pandemic 16%12%72% Professional Duty – Family or Patient First? Ehrenstein et al BMC Public Health 2006;6:311

30. June – 2007 30

31. June – 2007 31 The Next Influenza Pandemic: Will be Ready to Care for Our Children? “The severity of the 2003-2004 'flu season will pale in comparison with that of the next pandemic” Woods and Abramson J Pediatr 2005;147:147-155

32. Hot Topic Meeting by: Royal College of Physicians of Edinburgh & The Scottish Executive Health Department Pandemic Flu Planning Scotland’s Health Response 5 th June 2007 Queen Mother Conference Centre