Alya Putri Khairani | 130110110220 | E2

INFLUENZA
L ABORATORY FINDINGS
The clinical laboratory abnormalities associated with influenza are nonspecific. A relative leukopenia is frequently
seen. Chest radiographs show evidence of atelectasis or infiltrate in about 10% of children. Others can be seen by:

During acute influenza, virus may be detected in throat swabs, nasopharyngeal washes, or sputum. The virus
can be isolated by use of tissue cultureor, less commonly, chick embryoswithin 4872 h after inoculation

The laboratory diagnosis is established with rapid viral tests that detect viral nucleoprotein or neuraminidase
by means of immunologic or enzymatic techniques that are highly sensitive and 6090% as specific as tissue
culture

Viral nucleic acids can also be detected in clinical samples by reverse transcriptase polymerase chain reaction
(PCR)

The type of the infecting influenza virus (A or B) may be determined by either immunofluorescence or HI
techniques, and the Hemagglutinin subtype of influenza A virus (H1, H2, or H3) may be identified by HI with
use of subtype-specific antisera

DIAGNOSIS
ADULTS
Anamnesis
Onset of illness can occur suddenly over the course of a day, or it can progress more slowly over the course of
several days. Typical signs and symptoms include the following:

Cough and other respiratory symptoms : May be initially minimal but frequently progress as the infection
evolves. Patients may report nonproductive cough, cough-related pleuritic chest pain, and dyspnea

Fever

Sore throat : May be severe and may last 3-5 days

Myalgias

Headache
Frontal or retro-orbital headache is common and is usually severe

Nasal discharge

Weakness and severe fatigue

Tachycardia

Red, watery eyes

Physical Examinations
The general appearance varies among patients who present with influenza. Upon examination, patients may have
some or all of the following findings:

Fever of 100-104F; fever is generally lower in elderly patients than in young adults

Tachycardia, which most likely results from hypoxia, fever, or both

Pharyngitis - Even in patients who report a severely sore throat, findings may range from minimal infection
to more severe inflammation

Eyes may be red and watery

Skin may be warm to hot, depending on core temperature status; patients who have been febrile with poor
fluid intake may show signs of mild volume depletion with dry skin

Pulmonary findings may include dry cough with clear lungs or rhonchi, as well as focal wheezing

Nasal discharge is absent in most patients

Fatigued appearance
CHILDREN
Typical symptoms of influenza begin 2-3 days after exposure to the virus. Influenza produces an acute febrile
respiratory illness with cough, headache, and myalgia for 3-4 days, with symptoms that may persist for as long as
2 weeks. Symptoms that can be seen:
Patient may present with sudden onset of the following:
Anamnesis

High fever

Chills

Myalgia

Headache

Fatigue

Conjunctivitis, rhinitis, and GI tract symptoms are more common in infants and young
children than in adults.
In young infants, influenza may produce a Sepsis-like picture with shock; occasionally,
influenza viruses can cause croup or pneumonia.

Alya Putri Khairani | 130110110220 | E2

Physical Examinations
Manifestations of influenza range from mild to severe. Fever, respiratory symptoms, and myalgia are typical
Patients with avian influenza A/H5N1 virus infection predominantly present with community-acquired pneumonia,
conjunctivitis, and fever. Compared with patients who have seasonal influenza, patients avian influenza A virus
tend to have fever more than 90% of the time, vomiting, pleurisy, abdominal pain, myalgia, sore throat, rhinorrhea,
lymphadenitis, and nasal and gingival bleeding.
Patients with avian influenza can develop dyspnea within approximately 5 days from onset of illness. The sputum is
occasionally bloody.

DIFFERENTIAL DIAGNOSIS
During a community-wide outbreak, a clinical diagnosis of influenza can be made with a high degree of certainty in
patients who present to a
Physicians office with the typical febrile respiratory illness described above. In the absence of an outbreak (i.e., in
sporadic or isolated cases),
influenza may be difficult to differentiate on clinical grounds alone from an acute respiratory illness caused by any
of a variety of respiratory viruses or by Mycoplasma pneumoniae
Severe streptococcal pharyngitis or early bacterial pneumonia may mimic acute influenza, although bacterial
pneumonias generally do not run a self-limited course. Purulent sputum in which a bacterial pathogen can be
detected by Grams staining is an important diagnostic feature in bacterial pneumonia

TREATMENT
Two classes of antiviral drugs are effective in the treatment of influenza. Guidelines for the use of the
neuraminidase inhibitors Zanamivir and Oseltamivir for both influenza A and influenza B and the Adamantane
agents Amantadine and Rimantadine for influenza A
Oseltamivir or Zanamivir reduces
the duration of signs and symptoms
of influenza
by 11.5 days if treatment is started
within 2 days of the onset of illness.
Zanamivir may exacerbate
bronchospasm in asthmatic
patients, and Oseltamivir has been
associated with nausea and
vomiting, whose frequency can be
reduced by administration of the
drug with food. Oseltamivir has also
been associated with
neuropsychiatric side effects in
children.
If begun within 48 h of the onset of
illness due to sensitive influenza A
virus strains, treatment with
Amantadine or Rimantadine reduces
the duration of systemic and
respiratory symptoms of influenza
by ~50%. Of individuals who
receive amantadine, 510%
experience mild CNS side effects,
primarily jitteriness, anxiety,
insomnia, or difficulty
Antibacterial drugs should be reserved for the treatment of bacterial complications of acute influenza, such as
concentrating. These side effects
secondary bacterial pneumonia. The choice of antibiotics should be guided by Grams staining and culture of
appropriate specimens of respiratory secretions, such as sputum or transtracheal aspirates. If the etiology of a
case of bacterial pneumonia is unclear from an examination of respiratory secretions, empirical antibiotics effective
against the most common bacterial pathogens in this setting (S. pneumoniae, S. aureus, and H. influenzae) should
be selected

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SUPPORTIVE CARE
Adequate fluid intake and rest are important components in the management of influenza. Acetaminophen or
Ibuprofen, but not salicylates because of the risk for Reye syndrome should be used as antipyretics to control fever.
Bacterial superinfections are relatively common, and in that case antibiotic therapy should be administered.
Bacterial superinfections should be suspected with recrudescence of fever, prolonged fever, or deterioration in
clinical status. With uncomplicated influenza, children should feel better after the 1st 48-72 hr

COMPLICATIONS
Otitis media and pneumonia are common complications of influenza in young children. Acute otitis media may be
seen in up to 25% of cases of documented influenza. Pneumonia accompanying influenza may be a primary viral
process. An acute hemorrhagic pneumonia may be seen in the most severe cases. The more common cause of
pneumonia is probably secondary bacterial infection through the damaged epithelial layer. Unusual clinical
manifestations of influenza include acute myositis seen with influenza type B, which follows the acute respiratory
illness by 5-7 days and is marked by muscle weakness and pain, particularly in the calf muscles, and
myoglobinuria. Myocarditis also follows influenza, and toxic shock syndrome can be associated with toxinproducing staphylococcal colonization

PREVENTION
CDC SAYS TAKE 3 ACTIONS TO STOP THE FLU
1. Take time to get a Flu vaccine

CDC recommends a yearly flu vaccine as the first and most important step in protecting against flu
viruses

While there are many different flu viruses, a flu vaccine protects against the three viruses that research
suggests will be most common

Everyone 6 months of age and older should get a flu vaccine as soon as the current season's vaccines
are available

People at high risk of serious flu complications include young children, pregnant women, people with
chronic health conditions like asthma, diabetes or heart and lung disease and people 65 years and
older

Vaccination also is important for health care workers, and other people who live with or care for high
risk people to keep from spreading flu to high risk people

Children younger than 6 months are at high risk of serious flu illness, but are too young to be
vaccinated. People who care for them should be vaccinated instead
2. Take everyday preventive action to stop the spread of the germs

Try to avoid close contact with sick people.

If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your
fever is gone except to get medical care or for other necessities. (Your fever should be gone without
the use of a fever-reducing medicine.)

While sick, limit contact with others as much as possible to keep from infecting them.

Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after
you use it.

Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based
hand rub.

Avoid touching your eyes, nose and mouth. Germs spread this way.

Clean and disinfect surfaces and objects that may be contaminated with germs like the flu
3. Take flu antiviral drugs if the doctors prescribe them
ABOUT THE VACCINE
Why?
During Seasonal Flu season, flu viruses are circulating in the population. An annual seasonal flu vaccine (either the
flu shot or the nasal-spray flu vaccine) is the best way to reduce the chances that you will get seasonal flu and
spread it to others. When more people get vaccinated against the flu, less flu can spread through that community
How?
Flu vaccines cause antibodies to develop in the body about two weeks after vaccination. These antibodies provide
protection against infection with the viruses that are in the vaccine.
The seasonal flu vaccine protects against the influenza viruses that research indicates will be most common during
the upcoming season. Traditional flu vaccines (called Trivalent vaccines) are made to protect against three flu
viruses; an Influenza A (H1N1) virus, an Influenza A (H3N2) virus, and an Influenza B virus. In addition, this
season, there are flu vaccines made to protect against four flu viruses (called Quadrivalent vaccines). These
vaccines protect against the same viruses as the trivalent vaccine as well as an additional B virus

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What kinds of vaccine that are available?
The following trivalent flu vaccines are available:

Standard dose trivalent shots that are manufactured using virus grown in eggs. These are approved for
people ages 6 months and older. There are different brands of this type of vaccine, and each is approved
for different ages. However, there is a brand that is approved for children as young as 6 months old and up.

A standard dose trivalent shot containing virus grown in cell culture, which is approved for people
18 and older.

A standard dose trivalent shot that is egg-free, approved for people 18 through 49 years of age.

A high-dose trivalent shot, approved for people 65 and older.

A standard dose intradermal trivalent shot, which is injected into the skin instead of the muscle and
uses a much smaller needle than the regular flu shot, approved for people 18 through 64 years of age
The following quadrivalent flu vaccines are available:

A standard dose quadrivalent shot

A standard dose quadrivalent flu vaccine, given as a nasal spray, approved for healthy people 2
through 49 years of age
Who should get vaccineated?
Everyone older than 6 months is recommended for flu vaccination with rare exception
Vaccination efforts should focus on delivering vaccination to the following persons (no hierarchy is implied by order
of listing):

are aged 6 months through 4 years (59 months);

are aged 50 years and older;

have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic,
neurologic, hematologic, or metabolic disorders (including diabetes mellitus);

are immunosuppressed (including immunosuppression caused by medications or by human

immunodeficiency virus);

are or will be pregnant during the influenza season;

are aged 6 months through 18 years and receiving long-term aspirin therapy and who therefore might be
at risk for experiencing Reye syndrome after influenza virus infection;

are residents of nursing homes and other chronic-care facilities;

are American Indians/Alaska Natives;

are morbidly obese (body-mass index is 40 or greater);

are health-care personnel;

are household contacts and caregivers of children aged younger than 5 years and adults aged 50 years
and older, with particular emphasis on vaccinating contacts of children aged younger than 6 months; and

are household contacts and caregivers of persons with medical conditions that put them at higher risk for
severe complications from influenza
Following groups should not get the Flu Shot (TIV):

People who have ever had a severe allergic reaction to influenza vaccine.

People with a history of Guillain-Barr Syndrome that occurred after receiving influenza vaccine and who
are not at risk for severe illness from influenza should generally not receive vaccine. Tell your doctor if you
ever had Guillain-Barr Syndrome

People who are moderately or severely ill with or without fever should usually wait until they recover before
getting flu vaccine. If you are ill, talk to your doctor about whether to reschedule the vaccination. People
with a mild illness can usually get the vaccine.
Following groups should not receive certain types of flu shots:

People under 65 years of age should not receive the high-dose flu shot

People who are under 18 years old or over 64 years old should not receive the intradermal flu shot
Following groups should not receive the nasal spray vaccine (LAIV):

Children younger than 2 years

Adults 50 years and older

People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of
any influenza vaccine

People with asthma

Children or adolescents on long-term aspirin treatment.

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Children and adults who have chronic pulmonary, cardiovascular (except isolated hypertension), renal,
hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders
Children and adults who have immunosuppression (including immunosuppression caused by medications
or by HIV)
Pregnant women

Special Vacinnation Instructions for Children aged 6 months through 8 years of age
Children aged 6 months through 8 years who are receiving influenza vaccine for the first time, and some in this
age group who have previously been vaccinated, require two doses of vaccine administered 4 weeks apart. Two
approaches for determining the number of doses are recommended, both of which are acceptable:
1. The first approach

2.

Takes into consideration only doses of seasonal influenza

vaccine received since July 1, 2010. This approach has
the advantage of simplicity, particularly in settings in
which it is difficult to ascertain vaccination history prior to
the 2010-11 season. Using this approach, children 6
months through 8 years of age need only 1 dose of
vaccine in 2013-14 if they received a total of 2 or more
doses of seasonal vaccine since July 1, 2010. Children
who did not receive a total of 2 or more doses of seasonal
vaccine since July 1, 2010 require 2 doses in 2013-14
In settings where adequate vaccination history from prior to the 2010-11 season is available, the second
approach may be used
By this approach, if a child 6 months through 8 years of age is known to have received at least 2 doses of
seasonal influenza vaccine during any prior season, and at least 1 dose of a 2009(H1N1)-containing vaccine-i.e., 2010-11, 2011-12, or 2012-13 seasonal vaccine or the monovalent 2009(H1N1) vaccine--then the child
needs only 1 dose for 2013-14. Using this approach, children 6 months through 8 years of age need only 1
dose of vaccine in 2013-14 if they have received any of the following:

2 or more doses of seasonal influenza vaccine since July 1, 2010 or;

2 or more doses of seasonal influenza vaccine before July 1, 1010 and 1 or more doses of monovalent
2009(H1N1) vaccine or;

1 or more doses of seasonal influenza vaccine before July 1, 2010 and 1 or more doses of seasonal
influenza vaccine since July 1, 2010

ATTENTION!
1. The first dose should be given as soon as vaccine becomes available
2. The second dose should be given at least 28 days after the first dose. The first dose primes the
immune system; the second dose provides immune protection. Children who only get one dose but need two
doses can have reduced or no protection from a single dose of flu vaccine
3. If your child needs the two doses, begin the process early. This will ensure that your child is protected
before influenza starts circulating in your community
4. Be sure to get your child a second dose if he or she needs one. It usually takes about two weeks after
the second dose for protection to begin.
5. Children should be vaccinated every flu season. For children who will need two doses of flu vaccine, the
first dose should be given as early in the season as possible
When?
Flu vaccination should begin soon after vaccine becomes available, ideally by October. However, as long as flu
viruses are circulating, vaccination should continue to be offered throughout the flu season, even in
January or later. While seasonal influenza outbreaks can happen as early as October, most of the time influenza
activity peaks in January or later. Since it takes about two weeks after vaccination for antibodies to develop in the
body that protect against influenza virus infection, it is best that people get vaccinated so they are protected
before influenza begins spreading in their community
Why do I need Flu vaccine every year?
A flu vaccine is needed every year because flu viruses are constantly changing. Its not unusual for new flu viruses
to appear each year. The flu vaccine is updated annually to keep up with the flu viruses as they change. Also,
multiple studies conducted over different seasons and across vaccine types and influenza virus subtypes have
shown that the bodys immunity to influenza viruses (acquired either through natural infection or vaccination)
declines over time
Can I get Seasonal Flu even though I got a Flu vaccine this year?
Yes. There is still a possibility you could get the flu even if you got vaccinated. The ability of flu vaccine to protect a
person depends on various factors, including the age and health status of the person being vaccinated, and also
the similarity or match between the viruses used to make the vaccine and those circulating in the community. If

Alya Putri Khairani | 130110110220 | E2

the viruses in the vaccine and the influenza viruses circulating in the community are closely matched, vaccine
effectiveness is higher. If they are not closely matched, vaccine effectiveness can be reduced
Any side effects?
These side effects are mild and short-lasting, especially when compared to symptoms of influenza infection:
The flu shot: The viruses in the flu shot are killed (inactivated), so you cannot get the flu from a flu shot. Some
minor side effects that could occur are:

Soreness, redness, or swelling where the shot was given

Fever (low grade)

Aches
The nasal spray: The viruses in the nasal spray vaccine are weakened and do not cause severe symptoms often
associated with influenza illness. In children, side effects from the nasal spray can include:

Runny nose

Wheezing

Headache

Vomiting

Muscle aches

Fever
In adults, side effects from the nasal spray vaccine can include

Runny nose

Headache

Sore throat

Cough

CHEMOPROPHYLAXIS
Amantadine and Zanamivir are licensed for prophylaxis of influenza A infections

They are recommended for prophylaxis for:

Vaccinated and unvaccinated high-risk patients and their unvaccinated health care providers during
influenza A outbreaks in closed settings

Unvaccinated persons and health care providers during community influenza A outbreaks and during the
period of peak influenza A activity

Immunodeficient persons

Those for whom the influenza vaccine is contraindicate

PROGNOSIS
The prognosis for recovery is excellent, although full return to normal levels of activity and freedom from cough
usually require weeks rather than days

References:
Nelsons Textbook of Pediatrics 18th edition
Harrisons Principles of Internal Medicine 17th edition
http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm
recommendations.htm#vaccine-dose-children