Respiratory Illness Advisory: Oseltamivir Prioritization and Respiratory Illness Surge Resources

Situation:

Significantly elevated respiratory viral activity, including early increases in influenza viral infections, has contributed to a shortage of commonly used medications, including oseltamivir (Tamiflu ®). Many communities in Washington state may continue to experience shortages in the coming weeks.

Assessment:

To ensure an adequate supply of antiviral medications for individuals who are at high risk for severe influenza-associated complications, the Washington State Department of Health is providing the following recommendations on the use of oseltamivir when supply is limited. Preventative strategies to reduce the burden of influenza should be maintained, including influenza vaccination and messaging about general infection prevention. Key points from the recently published CDC Interim Guidance for Clinicians to Prioritize Antiviral Treatment of Influenza in the Setting of Reduced Availability of Oseltamivir are included below. Click here to see the full CDC HAN document

Recommendations:

1. The use of oseltamivir for the purpose of chemoprophylaxis is discouraged with rare exceptions (e.g. influenza outbreak in LTCF).
2. Treatment of influenza with oseltamivir is recommended for the following populations:
   1. Hospitalized patients of any age with confirmed or suspected influenza and respiratory illness symptoms.
   2. Patients with confirmed or suspected* influenza at higher risk for decompensation/complications within 48 hours of symptom onset, or within 5 days if symptoms are progressive. These include the following groups:
      1. Children younger than 2 years old and adults 65 years of age and older
      2. Chronic conditions
         1. Asthma, COPD or other chronic respiratory conditions
         2. Severe kidney and liver disease
         3. Poorly controlled diabetes or metabolic disorders (such as inherited metabolic or mitochondrial disorders)
         4. History of heart disease and/or stroke
         5. Neurologic and neurodevelopmental conditions
         6. Morbid obesity (BMI≥40)
         7. Active malignancy/hematologic disorder
         8. Severely immunocompromised
      3. Nursing home and long-term care facility residents
      4. Pregnant people (up to 2 weeks post-partum)
3. The use of higher doses of oseltamivir (more than 75 mg per dose) for the treatment of seasonal influenza is discouraged; Recommended duration for antiviral treatment is 5 days for oseltamivir.
4. Oral suspension formulation should be reserved for pediatric patients unable to take pills
   1. If oral suspension is unavailable, consider opening capsules and mixing with a thick sweetened liquid..**
5. Alternatives for Outpatient Treatment (inhaled zanamivir, intravenous peramivir, or oral baloxavir) may be considered for outpatient treatment. Current limited evidence suggests oral baloxavir is effective for both treatment of uncomplicated influenza and post-exposure prophylaxis. Consideration of alternative antiviral medication for hospitalized patients should be made in conjunction with expert consultation. Before choosing and prescribing an alternative antiviral be sure to review approved age groups, contraindications, and any applicable renal/hepatic dosing recommendations.

*Given the increased circulation of numerous respiratory viruses in the community, we recommend testing to confirm the diagnosis of influenza as long as testing does not delay treatment for priority groups per CDC influenza antiviral medication guidance.

**Oral capsules come in 30, 45 and 75mg strengths. Attention should be paid to ensure appropriate weight-based dosing.

These recommendations are intended to provide guidance, but do not replace clinical judgement, expert consultation or other recognized guidelines (e.g. IDSA, AAP and CDC).

Additional References:

1. Influenza Antiviral Medications: Summary for Clinicians | CDC
2. Recommendations for Prevention and Control of Influenza in Children, 2022–2023 | Pediatrics | American Academy of Pediatrics (aap.org)
3. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza (idsociety.org)
4. Interim Guidance for Clinicians to Prioritize Antiviral Treatment of Influenza in the Setting of Reduced Availability of Oseltamivir

Situation

As you are aware, Washington is experiencing a significant surge in cases of respiratory syncytial virus (RSV) with a simultaneous early influenza season, causing strain on healthcare resources, most notably in pediatric acute care/ICU. Smaller or rural community hospitals are experiencing difficulties or delays in transferring pediatric patients. The Washington State Medical Association and other professional organizations have released a statement discussing this issue. We have also assembled a list of resources that may be useful, particularly those facilities and providers that do not routinely care for infants and children with respiratory illnesses who need higher acuity care.

General situation summary and guidance for healthcare partners

See CDC HAN on increased respiratory virus activity

Resources Shared by Northwest Healthcare Response Network

• https://nwhrn.org/pediatric-toolkit/
• https://nwhrn.org/pediatric-resources/
• https://nwhrn.org/wp-content/uploads/2022/11/NWHRN-Pediatric-Respiratory-Surge- Operational-Framework-Addendum-Nov-2022.pdf

Resources Shared by REDI Coalition

• REDi HCC Situational Awarenesshcc@srhd.org

Resources Shared by REDI Coalition

• REDi HCC Situational Awarenesshcc@srhd.org

General testing guidance

CDC provides an algorithm for SARS-CoV-2 and influenza testing when both viruses are circulating. For patients who would benefit from antiviral treatment for influenza, early treatment is essential. As a result, empiric treatment may be preferable; influenza testing may not be necessary in the outpatient setting if it will not change clinical management. Given the lack of available treatment options, RSV testing may not be helpful in the outpatient setting if it will not change clinical management.

RSV clinical guidance

RSV usually causes a mild upper respiratory illness but can cause more serious lower respiratory tract disease in young children, older adults, or adults with chronic medical conditions. In young children, bronchiolitis is a common manifestation of lower respiratory tract disease, though pneumonia can also occur. While there are no directed treatments for RSV infection, eligible infants at higher risk of severe disease should receive palivizumab prophylaxis. The resources below provide further information on clinical management and prophylaxis.

• CDC provides general guidance on RSV for healthcare providers
• The Seattle Children’s bronchiolitis pathway provides a protocol for the evaluation and treatment of bronchiolitis in young children; Mary Bridge Children’s Hospital provides a similar protocol (available in PDF form)
• The American Academy of Pediatrics (AAP) provides guidelines on diagnosis, management, and prevention of bronchiolitis
• The AAP also provides guidance on the use of palivizumab prophylaxis

Influenza clinical guidance

As noted above, for patients who would benefit from antiviral treatment for influenza, early treatment is essential. As a result, empiric treatment is often preferable (rather than awaiting influenza testing). The resources below provide guidance on influenza treatment for children and adults.

• CDC provides guidance for clinicians on influenza antiviral medications
• AAP provides guidelines on influenza prevention and control in children, including information on antiviral treatment

General pediatric respiratory illness guidance

AAP does not recommend routine use of antibiotics for viral respiratory illnesses and does not recommend cough and cold medicines be used in young children.

American Academy of Pediatrics | Choosing Wisely (recommendations 1 and 2)

Healthcare surge capacity guidance

The resources below can help preparation and management of situations in which pediatric healthcare resources are strained.

• The AAP provides guidance on inpatient and outpatient care during episodes of surge
• The National Pediatric Readiness Project ED Checklist and Toolkit can help emergency departments ensure high-quality care for children
• A recent journal article provides practical advice on providing pediatric intensive care in adult medical intensive care settings
• Western Regional Alliance for Pediatric Emergency Management (WRAP-EM) has compiled a “just in time” basic clinical guidance for respiratory care of children for providers with limited pediatric experience, including High-Flow Nasal Cannula (HFNC) Protocols.
• Massachusetts General Hospital and Region 1 RDHRS is sponsoring a series of 6 free on-line webinar training sessions. NOTE: these started 11/17/2022 however recordings of each session are posted to their YouTube and available for viewing.

Infection prevention guidance

Given the shared modes of transmission for respiratory viruses, the same infection prevention measures can help prevent transmission of multiple viruses. In all settings, COVID-19 vaccination, influenza vaccination, staying home when sick, mask use in crowded indoor settings, good hand hygiene, respiratory etiquette (i.e., covering coughs and sneezes), and routine surface cleaning can help to limit transmission. CDC provides specific guidance on reducing influenza transmission in schools, which may be helpful for K-12 school partners.

Information for parents

The AAP’s HealthyChildren.org site provides a range of resources for parents, including a dedicated RSV page as well as a comparison of COVID-19, influenza, and RSV