was read the article
array:25 [ "pii" => "S2341287923000285" "issn" => "23412879" "doi" => "10.1016/j.anpede.2023.01.012" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3383" "copyright" => "Asociación Española de Pediatría" "copyrightAnyo" => "2023" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2023;98:213-27" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1695403322002971" "issn" => "16954033" "doi" => "10.1016/j.anpedi.2022.12.001" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3383" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2023;98:213-27" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ARTÍCULO ESPECIAL</span>" "titulo" => "Resumen ejecutivo – Diagnóstico, tratamiento y profilaxis de la infección por virus de la Gripe – Documento de Consenso de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), la Sociedad Española de Infectología Pediátrica (SEIP), la Asociación Española de Vacunología (AEV), la Sociedad Española de Medicina de Familia y Comunitaria (SEMFYC) y la Sociedad Española de Medicina Preventiva, Salud Pública y Gestión Sanitaria (SEMPSPGS)" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "213" "paginaFinal" => "227" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Executive summary - Diagnosis, treatment and prophylaxis of influenza virus infection – Consensus statement of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Pediatric Infectious Diseases (<span class="elsevierStyleItalic">SEIP</span>), the Spanish Association of Vaccinology (AEV), the Spanish Society of Family and Community Medicine (SEMFYC) and the Spanish Society of Preventive Medicine, Public Health and Health Management (SEMPSPGS)" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1212 "Ancho" => 2508 "Tamanyo" => 291619 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mortalidad diaria por todas las causas e incidencia semanal de gripe en España (2010-2019). Fuente: Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, España<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a>.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Línea roja: mortalidad observada. Línea azul: mortalidad esperada. Línea amarilla: tasa de gripe. Eje horizontal: semana/año. Eje vertical izquierdo: frecuencia absoluta de defunciones. Eje vertical derecho: número de casos de gripe por 100.000 habitantes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisco López-Medrano, Santiago Alfayate, Jordi Carratalà, Judith Chamorro-Camazón, Elisa Cordero, Marta Cruz-Cañete, María Fernández-Prada, Manuel García-Cenoz, María Ángeles Marcos, Santiago Melón, Nemesio Moreno-Millán, María Ángeles Onieva-García, Raúl Ortiz de Lejarazu, Jaime Jesús Pérez-Martín, Juan Rodríguez-García, Germán Schwarz-Chavarri, Alfredo Tagarro-García, Diego van Esso-Arbolave, Diego Viasus, Tomàs Pumarola" "autores" => array:20 [ 0 => array:2 [ "nombre" => "Francisco" "apellidos" => "López-Medrano" ] 1 => array:2 [ "nombre" => "Santiago" "apellidos" => "Alfayate" ] 2 => array:2 [ "nombre" => "Jordi" "apellidos" => "Carratalà" ] 3 => array:2 [ "nombre" => "Judith" "apellidos" => "Chamorro-Camazón" ] 4 => array:2 [ "nombre" => "Elisa" "apellidos" => "Cordero" ] 5 => array:2 [ "nombre" => "Marta" "apellidos" => "Cruz-Cañete" ] 6 => array:2 [ "nombre" => "María" "apellidos" => "Fernández-Prada" ] 7 => array:2 [ "nombre" => "Manuel" "apellidos" => "García-Cenoz" ] 8 => array:2 [ "nombre" => "María Ángeles" "apellidos" => "Marcos" ] 9 => array:2 [ "nombre" => "Santiago" "apellidos" => "Melón" ] 10 => array:2 [ "nombre" => "Nemesio" "apellidos" => "Moreno-Millán" ] 11 => array:2 [ "nombre" => "María Ángeles" "apellidos" => "Onieva-García" ] 12 => array:2 [ "nombre" => "Raúl" "apellidos" => "Ortiz de Lejarazu" ] 13 => array:2 [ "nombre" => "Jaime Jesús" "apellidos" => "Pérez-Martín" ] 14 => array:2 [ "nombre" => "Juan" "apellidos" => "Rodríguez-García" ] 15 => array:2 [ "nombre" => "Germán" "apellidos" => "Schwarz-Chavarri" ] 16 => array:2 [ "nombre" => "Alfredo" "apellidos" => "Tagarro-García" ] 17 => array:2 [ "nombre" => "Diego" "apellidos" => "van Esso-Arbolave" ] 18 => array:2 [ "nombre" => "Diego" "apellidos" => "Viasus" ] 19 => array:2 [ "nombre" => "Tomàs" "apellidos" => "Pumarola" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341287923000285" "doi" => "10.1016/j.anpede.2023.01.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287923000285?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403322002971?idApp=UINPBA00005H" "url" => "/16954033/0000009800000003/v2_202305161116/S1695403322002971/v2_202305161116/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2341287923000340" "issn" => "23412879" "doi" => "10.1016/j.anpede.2023.01.013" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3401" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "An Pediatr (Barc). 2023;98:228-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letters</span>" "titulo" => "Impact of the COVID-19 pandemic on pediatric invasive bacterial infections" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "228" "paginaFinal" => "229" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto de la pandemia de COVID-19 en las infecciones bacterianas invasivas en urgencias" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Garazi Martin-Irazabal, Iker Gangoiti, Borja Gomez, Libe Lizarraga, Santiago Mintegi" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Garazi" "apellidos" => "Martin-Irazabal" ] 1 => array:2 [ "nombre" => "Iker" "apellidos" => "Gangoiti" ] 2 => array:2 [ "nombre" => "Borja" "apellidos" => "Gomez" ] 3 => array:2 [ "nombre" => "Libe" "apellidos" => "Lizarraga" ] 4 => array:2 [ "nombre" => "Santiago" "apellidos" => "Mintegi" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403323000127" "doi" => "10.1016/j.anpedi.2023.01.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403323000127?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287923000340?idApp=UINPBA00005H" "url" => "/23412879/0000009800000003/v1_202303071051/S2341287923000340/v1_202303071051/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2341287923000327" "issn" => "23412879" "doi" => "10.1016/j.anpede.2022.11.005" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3381" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2023;98:204-12" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Spanish Association of Paediatrics</span>" "titulo" => "Self-injury and suicidal behavior in children and youth population: Learning from the pandemic" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:3 [ 0 => "en" 1 => "en" 2 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "204" "paginaFinal" => "212" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Autolesiones y conducta suicida en niños y adolescentes. Lo que la pandemia nos ha desvelado" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 826 "Ancho" => 1333 "Tamanyo" => 174036 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paula Vázquez López, Paula Armero Pedreira, Lidia Martínez-Sánchez, José Miguel García Cruz, Concha Bonetde Luna, Félix Notario Herrero, Ana Rosa Sánchez Vázquez, Pedro Javier Rodríguez Hernández, Azucena Díez Suárez" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Paula" "apellidos" => "Vázquez López" ] 1 => array:2 [ "nombre" => "Paula" "apellidos" => "Armero Pedreira" ] 2 => array:2 [ "nombre" => "Lidia" "apellidos" => "Martínez-Sánchez" ] 3 => array:2 [ "nombre" => "José Miguel" "apellidos" => "García Cruz" ] 4 => array:2 [ "nombre" => "Concha" "apellidos" => "Bonetde Luna" ] 5 => array:2 [ "nombre" => "Félix" "apellidos" => "Notario Herrero" ] 6 => array:2 [ "nombre" => "Ana Rosa" "apellidos" => "Sánchez Vázquez" ] 7 => array:2 [ "nombre" => "Pedro Javier" "apellidos" => "Rodríguez Hernández" ] 8 => array:2 [ "nombre" => "Azucena" "apellidos" => "Díez Suárez" ] ] ] ] "resumen" => array:1 [ 0 => array:3 [ "titulo" => "Graphical abstract" "clase" => "graphical" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><elsevierMultimedia ident="fig0010"></elsevierMultimedia></p></span>" ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403322002958" "doi" => "10.1016/j.anpedi.2022.11.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403322002958?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287923000327?idApp=UINPBA00005H" "url" => "/23412879/0000009800000003/v1_202303071051/S2341287923000327/v1_202303071051/en/main.assets" ] "en" => array:22 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special Article</span>" "titulo" => "Executive summary. Diagnosis, treatment and prophylaxis of influenza virus infection. Consensus statement of the Spanish Society of Infectious Diseases and Clinical Microbiology (<span class="elsevierStyleItalic">SEIMC</span>), the Spanish Society of Pediatric Infectious Diseases (<span class="elsevierStyleItalic">SEIP</span>), the Spanish Association of Vaccinology (<span class="elsevierStyleItalic">AEV</span>), the Spanish Society of Family and Community Medicine (<span class="elsevierStyleItalic">SEMFYC</span>) and the Spanish Society of Preventive Medicine, Public Health and Health Management (<span class="elsevierStyleItalic">SEMPSPGS</span>)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "213" "paginaFinal" => "227" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Francisco López-Medrano, Santiago Alfayate, Jordi Carratalà, Judith Chamorro-Camazón, Elisa Cordero, Marta Cruz-Cañete, María Fernández-Prada, Manuel García-Cenoz, María Ángeles Marcos, Santiago Melón, Nemesio Moreno-Millán, María Ángeles Onieva-García, Raúl Ortiz de Lejarazu, Jaime Jesús Pérez-Martín, Juan Rodríguez-García, Germán Schwarz-Chavarri, Alfredo Tagarro-García, Diego van Esso-Arbolave, Diego Viasus, Tomàs Pumarola" "autores" => array:20 [ 0 => array:4 [ "nombre" => "Francisco" "apellidos" => "López-Medrano" "email" => array:1 [ 0 => "flmedrano@yahoo.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Santiago" "apellidos" => "Alfayate" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Jordi" "apellidos" => "Carratalà" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Judith" "apellidos" => "Chamorro-Camazón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 4 => array:3 [ "nombre" => "Elisa" "apellidos" => "Cordero" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 5 => array:3 [ "nombre" => "Marta" "apellidos" => "Cruz-Cañete" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] 6 => array:3 [ "nombre" => "María" "apellidos" => "Fernández-Prada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 7 => array:3 [ "nombre" => "Manuel" "apellidos" => "García-Cenoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] ] ] 8 => array:3 [ "nombre" => "María Ángeles" "apellidos" => "Marcos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">l</span>" "identificador" => "aff0060" ] ] ] 9 => array:3 [ "nombre" => "Santiago" "apellidos" => "Melón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">m</span>" "identificador" => "aff0065" ] ] ] 10 => array:3 [ "nombre" => "Nemesio" "apellidos" => "Moreno-Millán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">n</span>" "identificador" => "aff0070" ] ] ] 11 => array:3 [ "nombre" => "María Ángeles" "apellidos" => "Onieva-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">o</span>" "identificador" => "aff0075" ] ] ] 12 => array:3 [ "nombre" => "Raúl" "apellidos" => "Ortiz de Lejarazu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">p</span>" "identificador" => "aff0080" ] ] ] 13 => array:3 [ "nombre" => "Jaime Jesús" "apellidos" => "Pérez-Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">q</span>" "identificador" => "aff0085" ] ] ] 14 => array:3 [ "nombre" => "Juan" "apellidos" => "Rodríguez-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">r</span>" "identificador" => "aff0090" ] ] ] 15 => array:3 [ "nombre" => "Germán" "apellidos" => "Schwarz-Chavarri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">s</span>" "identificador" => "aff0095" ] ] ] 16 => array:3 [ "nombre" => "Alfredo" "apellidos" => "Tagarro-García" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">t</span>" "identificador" => "aff0100" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">u</span>" "identificador" => "aff0105" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">v</span>" "identificador" => "aff0110" ] ] ] 17 => array:3 [ "nombre" => "Diego" "apellidos" => "van Esso-Arbolave" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">w</span>" "identificador" => "aff0115" ] ] ] 18 => array:3 [ "nombre" => "Diego" "apellidos" => "Viasus" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">x</span>" "identificador" => "aff0120" ] ] ] 19 => array:4 [ "nombre" => "Tomàs" "apellidos" => "Pumarola" "email" => array:1 [ 0 => "tpsvhebron@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">y</span>" "identificador" => "aff0125" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:25 [ 0 => array:3 [ "entidad" => "Unit of Infectious Diseases, University Hospital 12 de Octubre, Instituto de Investigación del Hospital 12 de Octubre (imas12), School of Medicine, Universidad Complutense, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Pediatrics, Unit of Infectious Diseases, Virgen de la Arrixaca University Hospital, Murcia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Infectious Diseases, Bellvitge University Hospital, Bellvitge Institute for Biomedical Research (IDIBELL), University of Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Department of Preventive Medicine and Hospital Hygiene, Complejo Hospitalario Navarra, IdiSNA, Pamplona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Department of Medicine, School of Medicine, University of Sevilla, Sevilla, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Institute of Biomedicine of Seville (IBiS), /CSIC/University of Sevilla, Sevilla, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Department of Pediatrics, Agencia Sanitaria del Alto Guadalquivir, Hospital de Montilla, Córdoba, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Department of Preventive Medicine and Public Health, Vital Álvarez Buylla Hospital, Mieres, Asturias, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Public Health Institute of Navarra, IdiSNA, CIBER de Epidemiología y Salud Pública (CIBERESP), Pamplona, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Department of Microbiology, Hospital Clinic-ISGlobal, University of Barcelona, Barcelona, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Department of Microbiology, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Direcció d’Atenció Primària Metropolitana Nord, Institut Català de la Salut, Sabadell, Barcelona, Member of Grupo de Enfermedades Infecciosas PAPPS-semFYC, Spain" "etiqueta" => "n" "identificador" => "aff0070" ] 14 => array:3 [ "entidad" => "Preventive Medicine Unit, Hospital Costa del Sol, Marbella, Málaga, Spain" "etiqueta" => "o" "identificador" => "aff0075" ] 15 => array:3 [ "entidad" => "National Influenza Centre (GISRS, WHO), Hospital Clínico Universitario and School of Medicine, University of Valladolid, Spain" "etiqueta" => "p" "identificador" => "aff0080" ] 16 => array:3 [ "entidad" => "Médico Especialista en Medicina Preventiva y Salud Pública, Steering Committee Spanish Vaccinology Association, Spain" "etiqueta" => "q" "identificador" => "aff0085" ] 17 => array:3 [ "entidad" => "Preventive Medicine Department, University Hospital Son Espases, School of Medicine, Universitat de les Illes Balears, Mallorca, Spain" "etiqueta" => "r" "identificador" => "aff0090" ] 18 => array:3 [ "entidad" => "San Blas Primary Care Center, Conselleria de Sanitat, Comunidad Valenciana. Member of Grupo de Enfermedades Infecciosas PAPPS-semFYC, Spain" "etiqueta" => "s" "identificador" => "aff0095" ] 19 => array:3 [ "entidad" => "Department of Pediatrics, Infanta Sofía University Hospital, Infanta Sofia University Hospital and Henares University Hospital Foundation for Biomedical Research and Innovation (FIIB HUIS HHEN), Madrid, Spain" "etiqueta" => "t" "identificador" => "aff0100" ] 20 => array:3 [ "entidad" => "Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain" "etiqueta" => "u" "identificador" => "aff0105" ] 21 => array:3 [ "entidad" => "RITIP (Translational Research Network in Pediatric Infectious Diseases), Universidad Europea de Madrid, Spain" "etiqueta" => "v" "identificador" => "aff0110" ] 22 => array:3 [ "entidad" => "Primary Care Health Service SAP Muntanya, Catalan Institute of Health, Barcelona, Spain" "etiqueta" => "w" "identificador" => "aff0115" ] 23 => array:3 [ "entidad" => "Department of Medicine, Division of Health Sciences, Universidad del Norte, and Hospital Universidad del Norte, Barranquilla, Colombia" "etiqueta" => "x" "identificador" => "aff0120" ] 24 => array:3 [ "entidad" => "Department of Microbiology, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "y" "identificador" => "aff0125" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding authors." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resumen ejecutivo «Diagnóstico, tratamiento y profilaxis de la infección por el virus de la gripe. Documento de consenso de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), la Sociedad Española de Infectología Pediátrica (SEIP), la Asociación Española deVacunología (AEV), la Sociedad Española de Medicina de Familia y Comunitaria (SEMFYC) y la Sociedad Española de Medicina Preventiva, Salud Pública y Gestión Sanitaria (SEMPSPGS)»" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1212 "Ancho" => 2508 "Tamanyo" => 294775 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Daily global mortality by any cause in Spain (2010–2019) and weekly incidence of influenza virus infection. Source: National Center of Epidemiology, Health Institute Carlos III, Ministry of Science, Spain.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Footnote: red line: detected mortality; blue line: expected mortality; yellow line: incidence of influenza; x-axis: week/year; left y-axis: absolute number of deaths; right y-axis: number of cases of influenza infection per 100,000 inhabitants.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction: justification and aims</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infection by influenza virus has accompanied humanity from time immemorial, producing annual epidemics that can cause severe infection, mainly in the elderly, pregnant women, or in those with previous comorbidities. Moreover, from time to time, it produces periodic pandemics related to genomic mutations that can give rise to a devastating disease, mostly in young people without previous exposure to that type of virus. There is probably no other infectious disease that better correlates with population mortality as influenza virus infection does. As shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, there is a tiny correlation between the daily oscillation of mortality for the general population and the weekly rate of influenza virus infection.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Only the recent pandemic of COVID-19 by coronavirus SARS-Cov-2 has presented a comparable effect on the mortality of the general population in modern times.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Despite these facts, influenza virus infection is still considered a benign unimportant infection by a large proportion of citizens and, even more worrisome, by physicians.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the last few decades, we have witnessed a huge development in the diagnostic, preventive, and therapeutic tools for influenza virus infection that have demonstrated their usefulness in reducing the incidence, morbidity, and mortality of this infection. Meanwhile, a powerful media movement has made a big fuss based on non-scientific statements, provoking mass rejection to the application of these tools that could benefit public health. A recent study estimated that seasonal influenza produces between 300,000 and 600,000 deaths annually worldwide.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This Consensus Statement arose as an initiative of the Spanish Society of Medical Microbiology and Infectious Diseases (SEIMC) and was enthusiastically taken on by the following scientific societies: the Spanish Society of Pediatric Infectious Diseases (SEIP), the Spanish Association of Vaccinology (AEV), the Spanish Society of Family and Community Medicine (SEMFYC), and the Spanish Society of Preventive Medicine, Public Health and Health Management (SEMPSPGS). The result is this Consensus Document that jointly approaches influenza virus infection from different complementary perspectives.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the opinion of the authors of this Consensus Statement and their supporting Scientific Societies, this document represents a great opportunity for the diffusion of systematized scientific knowledge to the medical community, in order to improve the approach toward influenza virus infection in the twenty-first century.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We invite the readers to consult the whole text of this Consensus Document that includes the rationale for all the recommendations. The whole text is available at Appendix A.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">The development of this Consensus Statement was an initiative of the Executive Committee of SEIMC. They appointed an Infectious Diseases expert (FLM) and a Microbiology specialist (TP) as coordinators of the working group for the drafting of the manuscript in April 2018. Moreover, the Executive Committee of SEIMC contacted other Scientific Societies in order to develop a unified document approaching influenza virus infection from a holistic point of view. The following Scientific Societies were contacted: the Spanish Society of Pediatric Infectious Diseases (SEIP), the Spanish Association of Vaccinology (AEV), the Spanish Society of Family and Community Medicine (SEMFYC) and the Spanish Society of Preventive Medicine, Public Health and Health Management (SEMPSPGS). The Executive Committee of each of these societies appointed experts who were contacted and agreed to join the working group. The coordinators appointed by SEIMC prepared the index of the Consensus Statement and wrote out the queries to be answered by the panel of experts. Each group of experts worked in their field of expertise and a unified draft was constructed. The multidisciplinary panel of experts held a teleconference (May 2019) and a face-to-face meeting (June 2019) to discuss the aspects of the document in which consensus had not been achieved. Apart from the literature evidence (up to June 2022), the clinical experience and personal expertise of the members of the panel were taken into consideration when high quality evidence could not be found in the literature. In case of discrepancy, the criteria of the coordinators were applied.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The panel experts were asked to perform a systematic review of the scientific literature, with no time limit, in order to answer the assigned queries according to the best evidence available. PubMed, Embase, and the Cochrane Database for Systematic Reviews were consulted. The literature search was updated up to June 2022. The strength of the recommendations and the quality of evidence were graded based on the US Public Health Service Grading System (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Apart from the method for grading the recommendations, the document was written following the Appraisal of Guidelines Research and Evaluation (AGREE II) tutorial.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The target of the Consensus Statement is the diagnosis, treatment, and prevention of seasonal influenza virus infection. It was not designed to address the management of pandemic outbreaks by non-previously circulating influenza virus or the management of exceptional infections by strains of influenza virus of animal origin (“avian flu”).</p><p id="par0050" class="elsevierStylePara elsevierViewall">All the members of the panel participated in the building of the Consensus Statement and approved the final version. The document was sent for audit by external peer reviewers. All the members of the Scientific Societies involved in the preparation of the manuscript had the opportunity to review the draft and make comments before publication. The final version was revised and approved by the Executive Committee of SEIMC and the other societies involved in the consensus (SEIP, AEV, SEMFYC and SEMPSPGS) prior to publication and adoption as an official document by the respective societies.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical diagnosis and management of influenza virus infection in adults</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">When should influenza virus infection be suspected in an adult?</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Influenza infection does not have specific clinical symptoms and its clinical picture might be undistinguishable from that produced by another respiratory virus. From an epidemiological point of view, the World Health Organization (WHO) case definition of influenza-like illness (ILI) for influenza sentinel surveillance refers to an acute respiratory infection with a temperature greater than or equal to 38°C and cough, with sudden onset within the previous 10 days (see Table 2 at full text in Appendix A) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">The symptoms that most accurately predict an influenza infection are cough and a temperature greater than or equal to 39°C.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Nevertheless, a lower temperature or even the absence of fever does not exclude the possibility of influenza virus infection (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">During influenza season, influenza infection can be considered in people with fever and acute exacerbation of underlying chronic lung disease, in elderly people with new or worsening respiratory symptoms (including exacerbation of congestive heart failure or altered mental status, with or without fever), in severely ill people with fever or hypothermia, and hospitalized adults who develop febrile respiratory illness after hospital admission (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">At any time of the year, in people with acute febrile respiratory symptoms who are epidemiologically linked to an influenza outbreak (healthcare workers, household and close contacts of people with suspected influenza, travelers returning from countries where influenza viruses may be circulating, participants in international mass gatherings, and cruise ship passengers) (A-II).</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Can influenza virus infection be clinically distinguished from another respiratory virus in an adult?</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1</span><p id="par0090" class="elsevierStylePara elsevierViewall">Among adult patients with influenza-like illness, clinical findings are not particularly useful to differentiate influenza virus infection from another respiratory virus infection (B-II).</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">When should an adult patient with suspected influenza virus infection be sent to the Emergency Room of a hospital?</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">An adult patient should be sent to the Emergency Department of a hospital if the patient might benefit from hospital admission due to the development of pneumonia as a complication of influenza virus infection (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">From a clinical point of view, this possibility should be suspected in the presence of shortness of breath, pain or pressure in the chest, sudden dizziness, confusion, and/or severe or persistent vomiting. It should also be considered in case of influenza virus infection symptoms that improve but then relapse in the form of fever and/or worsening lower respiratory tract symptoms (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">A patient with a suspected or diagnosed influenza virus infection with a chest X-ray performed outside the hospital environment showing pneumonia should be sent to the Emergency Room of a hospital to consider the need for hospital admission (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">An adult patient with influenza virus infection should be sent to the Emergency Department of a hospital if he/she presents exacerbation of underlying chronic diseases that might require hospital admission (A-II).</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">When should pneumonia be suspected in an adult with influenza virus infection?</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Pneumonia should be considered in every patient with suspected influenza virus presenting with clinical features suggestive of lower respiratory tract infection in the context of the annual epidemic period of influenza (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">Pneumonia should be considered in every patient with confirmed influenza virus infection presenting with clinical features suggestive of lower respiratory tract infection (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">The possibility of influenza virus infection should be considered in everyone with a diagnosis of pneumonia in the context of the annual epidemic period of influenza (A-II).</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Can influenza virus pneumonia be clinically distinguished from bacterial pneumonia in an adult?</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0145" class="elsevierStylePara elsevierViewall">Although certain presenting clinical features may enable recognition of influenza pneumonia, no single symptom or scoring system is sufficient to differentiate between influenza and bacterial pneumonia (B-II).</p></li></ul></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical diagnosis and management of influenza virus infection in children</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">When should influenza virus infection be suspected in a child?</span><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Influenza should be suspected in any child that presents acute fever with or without respiratory symptoms during the annual epidemic influenza period (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">The definition of influenza-like illness (ILI) has a very low diagnostic yield in children, especially in those younger than 5 years (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0165" class="elsevierStylePara elsevierViewall">In infants younger than 6 months, influenza may present as a sepsis-like syndrome (A-II).</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Can influenza virus infection be clinically distinguished from other respiratory viruses in a child?</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Many of the respiratory viral illnesses in children share similar signs and symptoms and although there are clinical differences that are specific to some viruses, physicians cannot usually confirm or rule out a particular viral infection on clinical grounds alone (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0180" class="elsevierStylePara elsevierViewall">It is essential to be able to obtain a microbiological diagnosis in patients where a specific diagnosis may modify patient management (specifically, the possibility to initiate antiviral influenza treatment) (A-I).</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">When should a pediatric patient with suspected influenza virus infection be sent to the Emergency Room of a hospital?</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">•</span><p id="par0190" class="elsevierStylePara elsevierViewall">Infants, children, or adolescent patients should be sent to the Emergency Department of a hospital if they could benefit from inpatient treatment due to the development of pneumonia or any other complication of influenza virus infection (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">•</span><p id="par0195" class="elsevierStylePara elsevierViewall">Infants, children, and adolescent patients with risk factors (immunosuppressed patients, chronic lung disease, hemo-dynamically significant heart disease, severe neurological pathology, nephropathies and chronic liver diseases) should be microbiologically tested in the Primary Care environment or sent to the Emergency Department for a microbiological confirmation of influenza virus infection if this might modify the management of these patients (admission to hospital, initiation of antiviral treatment, performance of chest X-ray, etc.) (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">•</span><p id="par0200" class="elsevierStylePara elsevierViewall">From a clinical point of view, this possibility should be suspected in the presence of poor general condition, signs of sepsis, altered level of consciousness or seizures, dehydration, shock, respiratory distress (tachypnea, chest retractions, hypoxemia, and episodes of apnea), or any alarming sign in clinical evolution according to medical criteria (see Table 3 at full text in Appendix A) It should also be considered in case of influenza virus infection symptoms that improve but then relapse in the form of fever and/or worsening lower respiratory tract symptoms (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">•</span><p id="par0205" class="elsevierStylePara elsevierViewall">A pediatric patient with suspected or X-ray confirmed pneumonia should be sent to the Emergency Room of a hospital to consider the need for hospital admission if he or she is in poor clinical condition (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">•</span><p id="par0210" class="elsevierStylePara elsevierViewall">Infants younger than 3 months of age with fever of unknown origin should be sent to the Emergency Department as, based on clinical grounds, influenza virus infection might be indistinguishable from other potentially life-threatening conditions (A-II).</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">When should pneumonia be suspected in a child with influenza virus infection? Can influenza virus pneumonia be clinically distinguished from bacterial pneumonia in a child?</span><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">•</span><p id="par0220" class="elsevierStylePara elsevierViewall">Pneumonia should be considered as a possibility in every pediatric patient with suspected influenza virus presenting with clinical features suggestive of lower respiratory tract infection in the context of the annual epidemic period of influenza (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">•</span><p id="par0225" class="elsevierStylePara elsevierViewall">Pneumonia should be considered as a possibility in every patient with confirmed influenza virus infection presenting with clinical features suggestive of lower respiratory tract infection (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">The possibility of influenza virus infection should be considered in every child with the diagnosis of pneumonia in the context of the annual epidemic period of influenza (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">Influenza pneumonia and bacterial pneumonia may present overlapping clinical symptoms. Differential diagnosis may require a chest X-ray, and laboratory and microbiological tests, and cannot be defined only on a clinical basis (B-II).</p></li></ul></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Microbiological diagnosis of influenza virus infection</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">When is the microbiological diagnosis of influenza indicated?</span><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">•</span><p id="par0245" class="elsevierStylePara elsevierViewall">Microbiological diagnosis is indicated when the result of the test might change the clinical care of the patient or influence the clinical approach to other subjects exposed to the patient tested (see Table 4 at full text in Appendix A) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">Microbiological diagnosis is indicated in cases of severe clinical course and for people at high risk of developing influenza-related complications (for instance, those with underlying cardiopulmonary diseases or immunocompromised subjects) (see Table 4 at full text in Appendix A) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">Microbiological diagnosis should be attempted in every case with clinical suspicion of influenza virus infection in subjects admitted to hospital (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">•</span><p id="par0260" class="elsevierStylePara elsevierViewall">Microbiological diagnosis should be attempted in healthcare workers (HCWs) with a clinical suspicion of influenza virus infection when they are taking care of patients with risk factors for developing severe forms of influenza, and when taking care of patients admitted to hospital or to long-term care facilities (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">•</span><p id="par0265" class="elsevierStylePara elsevierViewall">Microbiological diagnosis is not indicated for nonimmunocompromised subjects and subjects not presenting risk factors for the development of severe forms of influenza virus infection when they are not going to be admitted to hospital and/or they do not present a severe clinical condition (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">•</span><p id="par0270" class="elsevierStylePara elsevierViewall">An accurate microbiological diagnosis of influenza virus infection and other respiratory viruses might help to avoid unnecessary antibiotic treatment and might help to accurately prescribe specific antiviral influenza treatment when indicated (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">•</span><p id="par0275" class="elsevierStylePara elsevierViewall">For epidemiological purposes, cases of influenza virus infection should be microbiologically diagnosed, starting at week 40 and ending on week 20 of the following year (for the Northern hemisphere) and by designated reference laboratories, in order to establish the type of virus strain circulating and the moment of initiation of the epidemic period (A-II).</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">How should specimens be collected, stored, and transported?</span><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">•</span><p id="par0285" class="elsevierStylePara elsevierViewall">Nasopharyngeal (NPS) or oropharyngeal (OPS) specimens collected by using sterile polyester swabs with plastic or aluminum shafts (not wooden shafts) are the preferred samples for noninvasive microbiological diagnosis of influenza virus infection in adults (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">•</span><p id="par0290" class="elsevierStylePara elsevierViewall">NPS aspirate or washing is an alternative specimen that can be used for diagnosis. Collection of this specimen is especially well tolerated by children (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">•</span><p id="par0295" class="elsevierStylePara elsevierViewall">A correct technique for NPS sampling must be highlighted as a factor that directly correlates with the yield of the microbiological diagnosis (A-III) – see Fig. 2 at full text in Appendix A.</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">•</span><p id="par0300" class="elsevierStylePara elsevierViewall">Alternatively, saliva specimens may be used but they are associated with a lower yield for microbiological diagnosis (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">•</span><p id="par0305" class="elsevierStylePara elsevierViewall">Swabs must be transported to the Microbiology laboratory in sterile transport tubes with virus transport medium. Dry tubes for the transport of samples for bacterial diagnosis are not adequate (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">•</span><p id="par0310" class="elsevierStylePara elsevierViewall">Lower respiratory tract specimens (bronchoalveolar lavage or tracheobronchial aspirate, depending on clinical status of patient) should be collected for viral microbiological diagnosis from hospitalized patients with respiratory failure receiving mechanical ventilation, including subjects presenting a sever clinical condition with a previous negative virus detection in an upper respiratory tract specimen sampled during the ongoing infectious episode (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">•</span><p id="par0315" class="elsevierStylePara elsevierViewall">The yield of the microbiological diagnosis is inversely related to the time elapsed since the beginning of the symptoms. The earlier the sampling, the higher the yield of the microbiological diagnosis (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">•</span><p id="par0320" class="elsevierStylePara elsevierViewall">Blood, plasma, serum, urine, stool, and cerebrospinal fluid are not suitable specimens for routine influenza virus infection diagnosis (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">•</span><p id="par0325" class="elsevierStylePara elsevierViewall">Single or paired serum samples for serological diagnosis are only indicated for epidemiological purposes (A-III).</p></li></ul></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">What test should be used for the microbiological diagnosis of influenza virus infection?</span><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">•</span><p id="par0335" class="elsevierStylePara elsevierViewall">Nucleic acid amplification test (NAAT) is the method of choice for the microbiological diagnosis of influenza virus infection. It should be able to identify type A and type B influenza virus. It is advisable to use a test that is able to identify type A influenza virus and distinguish subtypes H1 and H3 (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">•</span><p id="par0340" class="elsevierStylePara elsevierViewall">Rapid molecular assays detect influenza virus infection with high sensitivity and specificity. These tests are recommended to be used in hospitalized patients with suspected influenza virus infection and may be a better alternative to the other rapid influenza diagnostic tests in outpatient settings (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">•</span><p id="par0345" class="elsevierStylePara elsevierViewall">Antigen detection tests should be restricted to pediatric patients with samples collected within 24–48<span class="elsevierStyleHsp" style=""></span>h following the onset of symptoms, when NAAT is not available (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">•</span><p id="par0350" class="elsevierStylePara elsevierViewall">Viral culture should not be used for primary diagnosis in the clinical setting. It should be reserved for cases in which further antigenic or genetic characterization is needed (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">•</span><p id="par0355" class="elsevierStylePara elsevierViewall">Serological testing for influenza is not generally recommended except for research purposes and for Public Health surveillance (A-II).</p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">When should resistance to neuraminidase inhibitors be sought?</span><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">•</span><p id="par0365" class="elsevierStylePara elsevierViewall">Resistance to neuraminidase inhibitors should be considered when a microbiological diagnostic test continues to be positive more than 8–10 days after initiation of treatment with this type of antivirals (particularly when the antiviral dose is suboptimal) (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">•</span><p id="par0370" class="elsevierStylePara elsevierViewall">Resistance to neuraminidase inhibitors should also be considered when a microbiological diagnostic test is positive while on or immediately after prophylaxis with this type of antivirals (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">•</span><p id="par0375" class="elsevierStylePara elsevierViewall">Resistance to antivirals should be especially considered in the immunocompromised population with evidence of persistent viral replication (e.g., 7–10 days after initiation of treatment) (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">•</span><p id="par0380" class="elsevierStylePara elsevierViewall">Periodic tests to detect resistance in influenza virus from random samples from community circulating virus should be performed. This surveillance should be limited to the reference laboratories designated by regional or national government authorities or by international Public Health organizations (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">•</span><p id="par0385" class="elsevierStylePara elsevierViewall">Antiviral resistance testing can be performed by specific gene sequencing, real-time single-nucleotide polymorphism (SNP) detection, polymerase chain reaction, or by genome-wide geno-typing (C-III).</p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">What is the role of rapid diagnostic tests at point-of-care in primary care medicine and emergency rooms of hospitals?</span><p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">•</span><p id="par0395" class="elsevierStylePara elsevierViewall">Genomic assays are preferred over antigen detection assays as rapid diagnostic tests when used for microbiological diagnosis of influenza virus infection at point-of-care (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">•</span><p id="par0400" class="elsevierStylePara elsevierViewall">Rapid diagnostic tests performed by clinicians at point-of-care must be implemented and used under the quality control of a reference laboratory of virology, in both the primary care setting and emergency facilities (B-III).</p></li></ul></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Capacity of microbiology laboratories for influenza virus diagnosis and characterization. How far should they go?</span><p id="par0405" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">•</span><p id="par0410" class="elsevierStylePara elsevierViewall">Detection of influenza virus by genomic tests (at the type and sub-type level) for seasonal strains should be available for laboratories performing microbiological diagnosis (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">•</span><p id="par0415" class="elsevierStylePara elsevierViewall">SNP assays for well-established single mutations associated with viral resistance should be implemented in large regional hospitals.</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">•</span><p id="par0420" class="elsevierStylePara elsevierViewall">Deep genetic and antigenic characterization (clades and subclades or minor antigenic variants) as well as specific serological assays should be limited to the reference laboratories designated by regional or national government authorities or by international Public Health organizations (A-II).</p></li></ul></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Virological surveillance of influenza</span><p id="par0425" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">•</span><p id="par0430" class="elsevierStylePara elsevierViewall">Active viral surveillance of influenza virus is the cornerstone for detecting emerging influenza virus strains with pandemic potential (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">•</span><p id="par0435" class="elsevierStylePara elsevierViewall">Viral surveillance is the backbone for the selection of candidate viruses for the next-season vaccine (A-III), and also provides relevant and crucial information for interpreting vaccine effectiveness.</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">•</span><p id="par0440" class="elsevierStylePara elsevierViewall">Seasonal influenza virus surveillance is necessary in order to establish when the epidemic annual period starts. It can also determine the proportions of type, subtype, and lineage of circulating viruses and assess antigen or genetic mismatch of circulating viruses with those included in the seasonal vaccine (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">•</span><p id="par0445" class="elsevierStylePara elsevierViewall">Virologic surveillance should be limited to the reference laboratories designated by regional or national government authorities or by international Public Health organizations (A-II).</p></li></ul></p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Treatment of influenza virus infection in the community</span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Which adult patients with influenza virus infection should be treated with antivirals in the community?</span><p id="par0450" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">•</span><p id="par0455" class="elsevierStylePara elsevierViewall">Adults diagnosed with non-complicated influenza virus infection within the community should start specific antiviral treatment as outpatients if they present risk factors for the development of a complicated infection (see Table 5 at full text in Appendix A) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">•</span><p id="par0460" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the first line drugs to be prescribed for those in whom treatment is indicated as outpatients (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">•</span><p id="par0465" class="elsevierStylePara elsevierViewall">Oral oseltamivir doses in Table 6 at full text in Appendix A) is preferred over inhaled zanamivir for adults who can take oral drugs (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">•</span><p id="par0470" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors, the greater the beneficial effect (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">•</span><p id="par0475" class="elsevierStylePara elsevierViewall">Treatment with neuraminidase inhibitors should ideally be started within the first 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but a clinical benefit might be obtained even if started later than 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">•</span><p id="par0480" class="elsevierStylePara elsevierViewall">Competent health authorities should adopt the measures to ensure access to these drugs for those in whom treatment is indicated, in the context of the National Health System (A-III).</p></li></ul></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Is there an indication for antiviral treatment without microbiological diagnosis in adults?</span><p id="par0485" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">•</span><p id="par0490" class="elsevierStylePara elsevierViewall">Adults fulfilling the criteria for outpatient treatment of the influenza virus infection (see 6.1) should start antiviral treatment as soon as possible when they are evaluated throughout the period of annual influenza epidemic, providing a microbiological diagnosis to confirm or exclude the infection is not available in less than 6<span class="elsevierStyleHsp" style=""></span>h (A-III).</p></li></ul></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Apart from antivirals, what other therapeutic measures should be offered to an adult patient with influenza virus infection in the community or in long-term facilities?</span><p id="par0495" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">•</span><p id="par0500" class="elsevierStylePara elsevierViewall">Symptomatic treatment is recommended to alleviate the symptoms of influenza (C-II).</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">•</span><p id="par0505" class="elsevierStylePara elsevierViewall">Symptomatic treatment of influenza for fever, headache, and myalgia is appropriate with paracetamol, ibuprofen, or dipyrone (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">•</span><p id="par0510" class="elsevierStylePara elsevierViewall">Cough can be relieved with honey and dextromethorphan, but the use of over-the-counter medications should be carefully weighed against the risk of adverse effects (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">•</span><p id="par0515" class="elsevierStylePara elsevierViewall">Treatment with antibiotics is not indicated unless bacterial super-infection is suspected (A-III).</p></li></ul></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Which pediatric patients with influenza virus infection should be treated with antivirals in the community?</span><p id="par0520" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">•</span><p id="par0525" class="elsevierStylePara elsevierViewall">Selected previously healthy patients with a confirmed early diagnosis of seasonal influenza during the epidemic period may start specific antiviral treatment as outpatients in the first 24<span class="elsevierStyleHsp" style=""></span>h after the start of the clinical picture. It must be considered that expected benefit is limited to the reduction of time of illness or the development of acute otitis media and not to a reduced rate of hospitalization or other complications. Parents must be informed of the benefit-risk balance obtained with the treatment. The Panel of this Consensus Statement considers this benefit does not justify the recommendation for the indiscriminate use of antiviral treatment in the general pediatric population (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">•</span><p id="par0530" class="elsevierStylePara elsevierViewall">Selected children diagnosed with non-complicated influenza virus infection within the community may start specific antiviral treatment as outpatients if they present significant risk factors for the development of a complicated infection (immunosuppressed patients, chronic lung disease, hemodynamically significant heart disease, severe neurological pathology, nephropathies, and chronic liver diseases) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">•</span><p id="par0535" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the first line drugs to be prescribed for those in whom treatment is indicated as outpatients (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">•</span><p id="par0540" class="elsevierStylePara elsevierViewall">Oral oseltamivir (capsules or oral suspension – see posology in Table 7 at full text in Appendix A) is preferred over inhaled zanamivir (not indicated in any case for those under 5 years of age) for children who can take oral drugs (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">•</span><p id="par0545" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors, the greater the beneficial effect (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">•</span><p id="par0550" class="elsevierStylePara elsevierViewall">Treatment with neuraminidase inhibitors should ideally be started in the first 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but a clinical benefit might be obtained even if started later than 48<span class="elsevierStyleHsp" style=""></span>h after symptom onset (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">•</span><p id="par0555" class="elsevierStylePara elsevierViewall">Competent health authorities should adopt the measures to ensure access to these drugs for children in whom treatment is indicated, in the context of the National Health System (C-III).</p></li></ul></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Is there an indication for antiviral treatment without microbiological diagnosis in children?</span><p id="par0560" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">•</span><p id="par0565" class="elsevierStylePara elsevierViewall">It is not indicated for the general pediatric population (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">•</span><p id="par0570" class="elsevierStylePara elsevierViewall">It is indicated in exceptional cases where pediatric patients present risk factors for an adverse outcome in the context of a strong clinical suspicion of influenza virus infection while simultaneously presenting an impossibility of performing diagnostic tests (C-III).</p></li></ul></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Apart from antivirals, what other therapeutic measures should be offered to a pediatric patient with influenza virus infection in the community?</span><p id="par0575" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">•</span><p id="par0580" class="elsevierStylePara elsevierViewall">Symptomatic treatment of influenza for fever, headache, and myalgia is appropriate with paracetamol, ibuprofen, or dipyrone (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">•</span><p id="par0585" class="elsevierStylePara elsevierViewall">Cough can be relieved with honey and dextromethorphan, but the use of over-the-counter medications should be carefully weighed against the risk of overdose (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">•</span><p id="par0590" class="elsevierStylePara elsevierViewall">The use of salicylates and codeine should be avoided in patients younger than 18 years of age because of risk of fatal outcomes (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">•</span><p id="par0595" class="elsevierStylePara elsevierViewall">Treatment with antibiotics is not indicated unless bacterial super-infection is suspected (A-III).</p></li></ul></p></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Treatment of influenza virus infection in hospital</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Which adult patients admitted to hospital due to influenza virus infection should be treated with antivirals?</span><p id="par0600" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">•</span><p id="par0605" class="elsevierStylePara elsevierViewall">Prompt use of antivirals is recommended for adult patients admitted to hospital with suspected or confirmed influenza virus infection (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">•</span><p id="par0610" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the first-line drugs to be prescribed for those in whom treatment is indicated when admitted to hospital (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">•</span><p id="par0615" class="elsevierStylePara elsevierViewall">Oral oseltamivir is preferred over inhaled zanamivir for adults who can take oral drugs (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">•</span><p id="par0620" class="elsevierStylePara elsevierViewall">Oseltamivir can be administered as an oral solution through a nasogastric tube for those unable to swallow the capsules or to inhale zanamivir (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">•</span><p id="par0625" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors, the greater the beneficial effect. Neuraminidase inhibitors should be started as soon as possible, preferably within the first 6<span class="elsevierStyleHsp" style=""></span>h after arrival at the Emergency Room (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">•</span><p id="par0630" class="elsevierStylePara elsevierViewall">Treatment with neuraminidase inhibitors should ideally be started in the first 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but, for those admitted to hospital, treatment must be started regardless of duration of symptoms (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">•</span><p id="par0635" class="elsevierStylePara elsevierViewall">Adults fulfilling the criteria for treatment of influenza virus infection when admitted to hospital should start antiviral treatment as soon as possible when they are evaluated during the period of annual influenza epidemic (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">•</span><p id="par0640" class="elsevierStylePara elsevierViewall">Competent health authorities should adopt the measures to ensure access to these drugs for those in whom treatment is indicated, in the context of the National Health System (A-III).</p></li></ul></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Apart from antivirals, what other therapeutic measures should be offered to an adult patient with influenza virus infection admitted to hospital?</span><p id="par0645" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">•</span><p id="par0650" class="elsevierStylePara elsevierViewall">Corticosteroids should not be added to influenza treatment in hospitalized patients, unless indicated for other reasons (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">•</span><p id="par0655" class="elsevierStylePara elsevierViewall">Adding macrolides and naproxen to oseltamivir might be of benefit in patients with simultaneous pneumonia and influenza virus infection (C-I).</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">•</span><p id="par0660" class="elsevierStylePara elsevierViewall">Passive immunotherapy and sirolimus need further studies to be recommended in cases of severe influenza virus infection (B.II).</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">•</span><p id="par0665" class="elsevierStylePara elsevierViewall">Other therapeutic measures studied in humans, such as statins, nitazoxanide and herbal medicines, have not been consistently proven to improve prognosis in hospitalized adults with influenza infection, and therefore are not routinely recommended (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">•</span><p id="par0670" class="elsevierStylePara elsevierViewall">Cough can be relieved with dextromethorphan, but the use of over-the-counter medications should be carefully weighed against the risk of adverse effects (B-II).</p></li></ul></p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Which adult patients admitted to hospital due to influenza virus infection should be treated with other antimicrobials?</span><p id="par0675" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0505"><span class="elsevierStyleLabel">•</span><p id="par0680" class="elsevierStylePara elsevierViewall">Adults presenting a clinical picture of a severe respiratory infection (extensive pneumonia, respiratory failure, hypotension) while infected by influenza virus should receive early antibiotic treatment in addition to antiviral therapy.</p></li><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">•</span><p id="par0685" class="elsevierStylePara elsevierViewall">In adults with influenza virus infection whose respiratory symptoms deteriorate after an initial improvement, antibiotic therapy should be considered (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">•</span><p id="par0690" class="elsevierStylePara elsevierViewall">Microbiological diagnostic tests to confirm bacterial coinfection or superinfection must be performed in these situations in patients admitted to hospital (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">•</span><p id="par0695" class="elsevierStylePara elsevierViewall">If started when indicated, antibiotic treatment of adults with influenza virus infection should be active against commonly influenza-associated bacteria, such as <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>, <span class="elsevierStyleItalic">Staphylococcus aureus</span>, <span class="elsevierStyleItalic">Streptococcus pyogenes</span>, and <span class="elsevierStyleItalic">Haemophilus influenzae</span> (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">•</span><p id="par0700" class="elsevierStylePara elsevierViewall">In case of nosocomial superinfection, the possibility of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> should be considered (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">•</span><p id="par0705" class="elsevierStylePara elsevierViewall">Aspergillus spp. coinfection should also be considered, especially in immunosuppressed patients and those admitted to an intensive care unit (A-II).</p></li></ul></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Which pediatric patients admitted to hospital due to influenza virus infection should be treated with antivirals?</span><p id="par0710" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">•</span><p id="par0715" class="elsevierStylePara elsevierViewall">Antiviral treatment is recommended for children presenting risk factors for a complicated course (immunosuppressed, chronic lung disease other than asthma, hemodynamically significant heart disease, severe neurological pathology, nephropathies, and chronic liver diseases) when admitted to hospital due to influenza virus infection (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">•</span><p id="par0720" class="elsevierStylePara elsevierViewall">Antiviral treatment may also be considered for children admitted to hospital due to influenza virus infection but not fulfilling the risk factors for a complicated course when presenting pneumonia or respiratory failure or at the time of admission into the critical care unit (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">•</span><p id="par0725" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the first line drugs to be prescribed for those in whom treatment is indicated when admitted to hospital (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">•</span><p id="par0730" class="elsevierStylePara elsevierViewall">Oral oseltamivir is preferred over inhaled zanamivir for children who can take oral drugs (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">•</span><p id="par0735" class="elsevierStylePara elsevierViewall">Oseltamivir as an oral solution might be a better option than capsules for the pediatric population (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">•</span><p id="par0740" class="elsevierStylePara elsevierViewall">Zanamivir is not indicated, under any circumstances, for children younger than five years of age (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">•</span><p id="par0745" class="elsevierStylePara elsevierViewall">Oseltamivir can be administered as an oral solution through a nasogastric tube for those unable to swallow the capsules or to inhale zanamivir (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">•</span><p id="par0750" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors, the greater the beneficial effect. When indicated, neuraminidase inhibitors should be started as soon as possible, preferably within the first six hours after arrival at the Emergency Room (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">•</span><p id="par0755" class="elsevierStylePara elsevierViewall">When indicated, treatment with neuraminidase inhibitors should ideally be started within the first 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but, for severely ill children, treatment might be started regardless of duration of symptoms (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">•</span><p id="par0760" class="elsevierStylePara elsevierViewall">Microbiologically confirmed influenza diagnoses should ideally be made before antiviral indication, due to the lack of specificity of symptoms. Etiological diagnosis also enables patient isolation in seasonal influenza period, which overlaps with other viruses, such as Respiratory Syncytial Virus (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">•</span><p id="par0765" class="elsevierStylePara elsevierViewall">Exceptionally in patients who are critically ill and/or have risk factors, a strong clinical suspicion of influenza, and impossibility of performing a diagnostic test, antivirals could be prescribed without microbiological confirmation (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">•</span><p id="par0770" class="elsevierStylePara elsevierViewall">Competent health authorities should adopt the measures to ensure access to these drugs for those in whom treatment is indicated, in the context of the National Health System (C-III).</p></li></ul></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Apart from antivirals, what other therapeutic measures should (and should not) be offered to a pediatric patient with influenza virus infection admitted to hospital?</span><p id="par0775" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">•</span><p id="par0780" class="elsevierStylePara elsevierViewall">Symptomatic treatment of influenza for fever, headache, and myalgia is appropriate with paracetamol, ibuprofen or dipyrone (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">•</span><p id="par0785" class="elsevierStylePara elsevierViewall">The use of salicylates should be avoided in children younger than 18 years of age because of the risk of developing Reye’s syndrome (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">•</span><p id="par0790" class="elsevierStylePara elsevierViewall">Supported sitting position and gentle suction of the nares when secretions block them can be useful (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">•</span><p id="par0795" class="elsevierStylePara elsevierViewall">Intravenous fluid therapy is indicated if adequate oral intake is not possible, and oxygen therapy or mechanical ventilation as indicated (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">•</span><p id="par0800" class="elsevierStylePara elsevierViewall">Other drugs such as antihistamines, nasal decongestants, antitussives, expectorants, or mucolytics are not generally recommended (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">•</span><p id="par0805" class="elsevierStylePara elsevierViewall">Corticosteroids should not be added to influenza treatment in hospitalized patients, unless indicated for other reasons (A-III).</p></li></ul></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Which pediatric patients admitted to hospital due to influenza virus infection should be treated with antibiotics?</span><p id="par0810" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0625"><span class="elsevierStyleLabel">•</span><p id="par0815" class="elsevierStylePara elsevierViewall">Antibiotic treatment is indicated in proven or strongly suspected secondary bacterial infections cases (including bacterial otitis media, sinusitis, and pneumonia). Empiric antibiotics should generally be directed at the most common bacterial pathogens following influenza: <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>, <span class="elsevierStyleItalic">Staphylococcus aureus</span>, and <span class="elsevierStyleItalic">Streptococcus pyogenes</span> (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">•</span><p id="par0820" class="elsevierStylePara elsevierViewall">There is no indication for prescribing antibiotics in order to prevent secondary bacterial complication (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0635"><span class="elsevierStyleLabel">•</span><p id="par0825" class="elsevierStylePara elsevierViewall">In hospitalized children with influenza infection when bacterial pneumonia is suspected, complementary tests are recommended, as symptoms and signs of virus and bacteria often overlap. No complementary test on its own is enough to define bacterial coinfection (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0640"><span class="elsevierStyleLabel">•</span><p id="par0830" class="elsevierStylePara elsevierViewall">The best performing clinical decision rule for the diagnosis of bacterial coinfection or superinfection combines C-reactive protein (CRP) higher than 13<span class="elsevierStyleHsp" style=""></span>mg/dl, procalcitonin higher than 0.52<span class="elsevierStyleHsp" style=""></span>ng/mL, and/or alveolar consolidation in chest X-ray (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0645"><span class="elsevierStyleLabel">•</span><p id="par0835" class="elsevierStylePara elsevierViewall">In children with influenza virus infection whose respiratory symptoms deteriorate after an initial improvement, antibiotic therapy should be considered (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0650"><span class="elsevierStyleLabel">•</span><p id="par0840" class="elsevierStylePara elsevierViewall">Microbiological diagnostic tests to confirm bacterial coinfection or superinfection must be performed in these situations, in patients admitted to hospital (A-III).</p></li></ul></p></span></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Prophylaxis of influenza transmission in the community</span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">What measures should be taken to avoid the transmission of influenza virus in the community?</span><p id="par0845" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0655"><span class="elsevierStyleLabel">1</span><p id="par0850" class="elsevierStylePara elsevierViewall">Annual influenza vaccination of people in high-risk groups is recommended (A-I) – see Section 10.</p></li><li class="elsevierStyleListItem" id="lsti0660"><span class="elsevierStyleLabel">2</span><p id="par0855" class="elsevierStylePara elsevierViewall">It is recommended to perform hand hygiene after contact with respiratory secretions by means of hand washing with soap and water (or alcohol-based hand sanitizers containing at least 60% ethanol or isopropanol when soap and water are not available) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0665"><span class="elsevierStyleLabel">•</span><p id="par0860" class="elsevierStylePara elsevierViewall">People should cover their nose and mouth when coughing or sneezing using tissues or flexed elbow (if a tissue is not available) in order to contain respiratory secretions, followed by hand hygiene. Touching eyes, nose, or mouth should be avoided where possible (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0670"><span class="elsevierStyleLabel">•</span><p id="par0865" class="elsevierStylePara elsevierViewall">Routine cleaning of frequently touched surfaces and objects that might be contaminated with respiratory secretions (at home, schools, childcare facilities, and workplaces) is recommended (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0675"><span class="elsevierStyleLabel">•</span><p id="par0870" class="elsevierStylePara elsevierViewall">Post-exposure chemoprophylaxis could be considered in asymptomatic people at high risk of developing complications from influenza and for those in whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness (e.g., people who are significantly immunocom-promised) (C-II).</p></li><li class="elsevierStyleListItem" id="lsti0680"><span class="elsevierStyleLabel">•</span><p id="par0875" class="elsevierStylePara elsevierViewall">Clinicians can also consider post-exposure chemoprophylaxis for people who are unvaccinated and are household contacts of a patient at very high risk of complications from influenza (e.g., severely immunocompromised patients) (C-II).</p></li><li class="elsevierStyleListItem" id="lsti0685"><span class="elsevierStyleLabel">•</span><p id="par0880" class="elsevierStylePara elsevierViewall">A 10-day regimen with a neuraminidase inhibitor is recommended as post-exposure chemoprophylaxis. It should be initiated as soon as possible (within 48<span class="elsevierStyleHsp" style=""></span>h of exposure for oral oseltamivir [see recommended dosage for adults at Table 8 and for children at Table 9, both in full text in Appendix A] or within 36<span class="elsevierStyleHsp" style=""></span>h for inhaled zanamivir) (A-III).</p></li></ul></p></span></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Prophylaxis of nosocomial transmission of influenza</span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">What measures should be taken to avoid the transmission of influenza virus in healthcare settings?</span><p id="par0885" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span></p><p id="par0890" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vaccination</span><ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0690"><span class="elsevierStyleLabel">•</span><p id="par0895" class="elsevierStylePara elsevierViewall">Annual influenza vaccination of healthcare workers and people in high-risk groups is recommended (A-I) – see Section 10.</p></li><li class="elsevierStyleListItem" id="lsti0695"><span class="elsevierStyleLabel">•</span><p id="par0900" class="elsevierStylePara elsevierViewall">Annual influenza vaccination and pneumococcal vaccine of residents in long term care facilities is recommended (A-II) – see Section 10.</p></li></ul></p><p id="par0905" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Chemoprophylaxis</span><ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0700"><span class="elsevierStyleLabel">•</span><p id="par0910" class="elsevierStylePara elsevierViewall">Post-exposure antiviral chemoprophylaxis should not be used routinely (B-III). Antiviral prophylaxis can be considered after exposure (see criteria in Table 10 at full text in Appendix A) to a person with influenza in some circumstances, such as asymptomatic patients, healthcare workers at high risk of developing complications from influenza, or for those in whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness (e.g., people who are significantly immunocompromised) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0705"><span class="elsevierStyleLabel">•</span><p id="par0915" class="elsevierStylePara elsevierViewall">A 10-day regimen with a neuraminidase inhibitor is recommended as post-exposure chemoprophylaxis. It should be initiated as soon as possible (within 48<span class="elsevierStyleHsp" style=""></span>h of exposure for oral oseltamivir or within 36<span class="elsevierStyleHsp" style=""></span>h for inhaled zanamivir) (A-I) – see recommended dosage for adults at Table 8 and for children at Table 9, both in full text in Appendix A).</p></li></ul></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Standard precautions, hand hygiene, and respiratory hygiene/cough etiquette</span><p id="par1300" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0710"><span class="elsevierStyleLabel">•</span><p id="par0920" class="elsevierStylePara elsevierViewall">Reinforce effective hand hygiene and cough etiquette when in contact with patients, visitors, and staff (Catch it, Bin it, Kill it) (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0715"><span class="elsevierStyleLabel">•</span><p id="par0925" class="elsevierStylePara elsevierViewall">Provide disposable tissues, no-touch receptacles for disposal of tissues, and alcohol-based hand rubs (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0720"><span class="elsevierStyleLabel">•</span><p id="par0930" class="elsevierStylePara elsevierViewall">Provide instructions to cover mouths/noses when coughing or sneezing, use disposable tissues, and perform hand hygiene (i.e., by posting signs at entrances and in strategic places) (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0725"><span class="elsevierStyleLabel">•</span><p id="par0935" class="elsevierStylePara elsevierViewall">Standard cleaning and disinfection procedures as well as food handling, laundry, and waste management are adequate when attending patients with suspected or confirmed influenza (B-II).</p></li></ul></p></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Triage for rapid identification of patients with influenza-like illness (ILI)</span><p id="par1305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0730"><span class="elsevierStyleLabel">•</span><p id="par0940" class="elsevierStylePara elsevierViewall">Instruct people to inform healthcare professionals upon arrival if they present symptoms of respiratory infection so that preventive actions can be taken (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0735"><span class="elsevierStyleLabel">•</span><p id="par0945" class="elsevierStylePara elsevierViewall">Offer masks to coughing persons upon entry to hospital (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0740"><span class="elsevierStyleLabel">•</span><p id="par0950" class="elsevierStylePara elsevierViewall">Enable differentiated spaces in waiting rooms for patients with symptoms of respiratory infection (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0745"><span class="elsevierStyleLabel">•</span><p id="par0955" class="elsevierStylePara elsevierViewall">It is recommended that patients be separated one or more meters from each other and by physical barriers (B-III).</p></li></ul></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Infection prevention and control precautions when caring for patients with ILI or confirmed influenza infection</span><p id="par1310" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0750"><span class="elsevierStyleLabel">•</span><p id="par0960" class="elsevierStylePara elsevierViewall">Droplet precautions are required for all cases of ILI that are known or suspected to be influenza virus infection until influenza has been excluded or the patient is no longer deemed contagious (AII).</p></li><li class="elsevierStyleListItem" id="lsti0755"><span class="elsevierStyleLabel">•</span><p id="par0965" class="elsevierStylePara elsevierViewall">Place patients with suspected or confirmed influenza in individual rooms or specific areas. If an individual room is not available, consult the Infection Prevention and Control Team for assessing isolation by cohort (B-III). In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis after considering infection risks of other patients in the room and available alternatives (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0760"><span class="elsevierStyleLabel">•</span><p id="par0970" class="elsevierStylePara elsevierViewall">Patients with suspected or proven influenza who require noninvasive ventilation should have priority for negative-pressure rooms (if available) and/or rooms with 100% exhaust capability (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0765"><span class="elsevierStyleLabel">•</span><p id="par0975" class="elsevierStylePara elsevierViewall">For aerosol generating procedures, use of FFP2 face mask or a respirator, fluid repellent gown, disposable gloves, and eye protection (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0770"><span class="elsevierStyleLabel">•</span><p id="par0980" class="elsevierStylePara elsevierViewall">Closed-ventilation suction circuits should be used where available, with bacterial and viral filters placed over the expiratory port (B-III).</p></li></ul></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Peri- and postpartum care</span><p id="par1315" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0775"><span class="elsevierStyleLabel">•</span><p id="par0985" class="elsevierStylePara elsevierViewall">A pregnant woman with suspected or confirmed influenza virus infection admitted to hospital should be attended according to the recommendations for the general population before, during, and after delivery. These measures include standard and droplet precautions (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0780"><span class="elsevierStyleLabel">•</span><p id="par0990" class="elsevierStylePara elsevierViewall">After delivery, due to the risk of serious complications were the newborn to become infected by influenza, temporary separation from the baby should be considered, in accordance with the mother’s wishes. The baby should be cared for by a healthy caregiver whenever possible (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0785"><span class="elsevierStyleLabel">•</span><p id="par0995" class="elsevierStylePara elsevierViewall">Mothers with the intention to breastfeed should express their milk in order to establish and maintain the milk supply. This breastmilk can be fed to the newborn by the healthy caregiver (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0790"><span class="elsevierStyleLabel">•</span><p id="par1000" class="elsevierStylePara elsevierViewall">In case the baby remains in the same room (due to the mother’s wishes or for logistic reasons), standard and droplet precautions should be established in order to minimize transmission (B-III). The hospital must implement measures to reduce viral exposure of the newborn including physical barriers (i.e., a curtain between the mother and the newborn), maintaining at least 2 meters between the mother and the newborn, and ensuring another adult is present to care for the newborn.</p></li><li class="elsevierStyleListItem" id="lsti0795"><span class="elsevierStyleLabel">•</span><p id="par1005" class="elsevierStylePara elsevierViewall">If breastfeeding is maintained while the mother presents influenza virus infection, she should wear a surgical face mask and practice hand hygiene before each feeding or contact with her newborn (B-III).</p></li></ul></p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Containment measures</span><p id="par1320" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0800"><span class="elsevierStyleLabel">•</span><p id="par1010" class="elsevierStylePara elsevierViewall">During periods of increased influenza activity, minimize visits by patients seeking care for mild influenza-like illness who are not at increased risk of complications (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0805"><span class="elsevierStyleLabel">•</span><p id="par1015" class="elsevierStylePara elsevierViewall">Limit visitors with acute respiratory symptoms and/or with high risk of influenza complications (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0810"><span class="elsevierStyleLabel">•</span><p id="par1020" class="elsevierStylePara elsevierViewall">Healthcare workers presenting symptoms that suggest influenza virus infection should stop patient care activities, don a face-mask, and immediately notify their supervisor (and infection control personnel) to determine appropriateness of contact with patients, temporary reassignment, or exclusion from work until criteria for a non-infectious status are met (B-III).</p></li></ul></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Training and education of healthcare workers (HCWs)</span><p id="par1325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0815"><span class="elsevierStyleLabel">•</span><p id="par1025" class="elsevierStylePara elsevierViewall">Educate healthcare workers on the importance of source control measures to contain respiratory secretions so as to prevent droplet and fomite transmission of respiratory pathogens (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0820"><span class="elsevierStyleLabel">•</span><p id="par1030" class="elsevierStylePara elsevierViewall">Staff education and training on infection control methods, policies, and procedures should be delivered to all staff members (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0825"><span class="elsevierStyleLabel">•</span><p id="par1035" class="elsevierStylePara elsevierViewall">Healthcare settings must establish mechanisms to find out about influenza virus activity in the community as well as for the prompt detection of outbreaks in healthcare settings (B-III).</p></li></ul></p></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">What is the definition of a nosocomial outbreak of influenza virus infection?</span><p id="par1040" class="elsevierStylePara elsevierViewall">A nosocomial outbreak is defined by the diagnosis of healthcare-associated influenza infection (at least one of the cases with microbiological confirmation) in two or more patients admitted to the same ward in a period of less than 48<span class="elsevierStyleHsp" style=""></span>h (A-II).</p></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">What measures should be adopted to control an influenza outbreak?</span><p id="par1045" class="elsevierStylePara elsevierViewall">A bundle of measures, rather than one measure alone, must be implemented when a nosocomial influenza outbreak is detected in an institution (A-II). This includes administrative, pharmacological, and non-pharmacological measures (see Table 11 at full text in Appendix A) (A-II).</p></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Acute care hospitals</span><p id="par1050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0830"><span class="elsevierStyleLabel">•</span><p id="par1055" class="elsevierStylePara elsevierViewall">Non-pharmacological measures must be used to prevent virus dissemination (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0835"><span class="elsevierStyleLabel">•</span><p id="par1060" class="elsevierStylePara elsevierViewall">Administer post-exposure prophylaxis as soon as possible to patients in close contact with a confirmed or suspected case of influenza and risk factors for developing serious complications in case of infection (see Table 11 at full text in Appendix A) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0840"><span class="elsevierStyleLabel">•</span><p id="par1065" class="elsevierStylePara elsevierViewall">Post-exposure prophylaxis should be used in healthcare workers with comorbidities who are prone to complications in case of influenza infection (see Table 11 at full text in Appendix A) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0845"><span class="elsevierStyleLabel">•</span><p id="par1070" class="elsevierStylePara elsevierViewall">Routine pre-exposure prophylaxis for all patients or staff is not recommended, not even in an outbreak situation, but could be considered in wards admitting immunocompromised patients or when staff members are suspected of being involved in maintaining an outbreak (B-II).</p></li></ul></p></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Neonatal or pediatric intensive care units and pediatric wards</span><p id="par1075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0195"><li class="elsevierStyleListItem" id="lsti0850"><span class="elsevierStyleLabel">•</span><p id="par1080" class="elsevierStylePara elsevierViewall">Patients admitted to neonatal or pediatric intensive care units should be placed in individual rooms whenever they develop influenza virus infection (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0855"><span class="elsevierStyleLabel">•</span><p id="par1085" class="elsevierStylePara elsevierViewall">Mask, gown, and gloves should be worn when taking care of patients with influenza virus infection admitted to neonatal or pediatric intensive care units (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0860"><span class="elsevierStyleLabel">•</span><p id="par1090" class="elsevierStylePara elsevierViewall">Post-exposure prophylaxis should be administered as soon as possible to unvaccinated exposed neonates or infants admitted to pediatric intensive care units (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0865"><span class="elsevierStyleLabel">•</span><p id="par1095" class="elsevierStylePara elsevierViewall">Post-exposure prophylaxis should be used in healthcare workers whose comorbidities for high-risk influenza complications are present in themselves or in their household members (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0870"><span class="elsevierStyleLabel">•</span><p id="par1100" class="elsevierStylePara elsevierViewall">Administer antiviral prophylaxis to unvaccinated healthcare workers and family members including those vaccinated in the previous two weeks or if vaccine failure is suspected (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0875"><span class="elsevierStyleLabel">•</span><p id="par1105" class="elsevierStylePara elsevierViewall">Massive prophylaxis for all neonates or infants admitted to pediatric intensive care units and their staff should be considered in case of a persistent outbreak despite other more restrictive measures or in case the staff are suspected to be involved in maintaining the outbreak (C-III).</p></li><li class="elsevierStyleListItem" id="lsti0880"><span class="elsevierStyleLabel">•</span><p id="par1110" class="elsevierStylePara elsevierViewall">Entry to the ward must be restricted to people presenting respiratory symptoms (A-III).</p></li></ul></p></span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Long-term care facilities and nursing homes</span><p id="par1115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0885"><span class="elsevierStyleLabel">•</span><p id="par1120" class="elsevierStylePara elsevierViewall">Whenever a case of influenza virus infection is detected in a resident of a long-term care facility or nursing home, the rest of the residents should receive antiviral prophylaxis, regardless of their vaccination status (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0890"><span class="elsevierStyleLabel">•</span><p id="par1125" class="elsevierStylePara elsevierViewall">Post-exposure prophylaxis should be administered to healthcare workers with comorbidities who are prone to complications in case of influenza infection (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0895"><span class="elsevierStyleLabel">•</span><p id="par1130" class="elsevierStylePara elsevierViewall">Routine pre-exposure prophylaxis for all staff is not recommended, not even in an outbreak situation, but could be considered when staff members are suspected to be involved in maintaining an outbreak (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0900"><span class="elsevierStyleLabel">•</span><p id="par1135" class="elsevierStylePara elsevierViewall">Reinforce hand hygiene and the use of face masks among staff (B-II).</p></li><li class="elsevierStyleListItem" id="lsti0905"><span class="elsevierStyleLabel">•</span><p id="par1140" class="elsevierStylePara elsevierViewall">Vaccination of staff and residents when the first cases of influenza virus infection are detected should not be considered an adequate control measure (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0910"><span class="elsevierStyleLabel">•</span><p id="par1145" class="elsevierStylePara elsevierViewall">Implementation of other non-pharmacological measures such as social distancing and cohorting could be considered (B-III).</p></li></ul></p></span></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Vaccination against influenza virus</span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Among children, who should receive the influenza vaccine?</span><p id="par1150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0915"><span class="elsevierStyleLabel">•</span><p id="par1155" class="elsevierStylePara elsevierViewall">Vaccination is recommended for children between 6 months and 18 years of age in certain circumstances (see criteria in Table 12 at full text in Appendix A) (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0920"><span class="elsevierStyleLabel">•</span><p id="par1160" class="elsevierStylePara elsevierViewall">Vaccination of healthy children between six months and five years of age is universally recommended (AIII).</p></li><li class="elsevierStyleListItem" id="lsti0925"><span class="elsevierStyleLabel">•</span><p id="par1165" class="elsevierStylePara elsevierViewall">Both political authorities and healthcare workers should redouble their efforts in order to boost vaccination against influenza virus among children belonging to target groups (A-III).</p></li></ul></p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Among adults, who should receive the influenza vaccine?</span><p id="par1170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0930"><span class="elsevierStyleLabel">•</span><p id="par1175" class="elsevierStylePara elsevierViewall">Vaccination is recommended for all adults aged 65 years old or older (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0935"><span class="elsevierStyleLabel">•</span><p id="par1180" class="elsevierStylePara elsevierViewall">Vaccination is recommended for adults between 19 and 64 years of age in certain circumstances (see criteria in Table 13 at full text in Appendix A) (A-II).</p></li><li class="elsevierStyleListItem" id="lsti0940"><span class="elsevierStyleLabel">•</span><p id="par1185" class="elsevierStylePara elsevierViewall">Both political authorities and healthcare workers should redouble their efforts in order to boost vaccination against influenza virus among adults belonging to target groups (A-III).</p></li></ul></p></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">What type of vaccine is indicated for children?</span><p id="par1190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0945"><span class="elsevierStyleLabel">•</span><p id="par1195" class="elsevierStylePara elsevierViewall">Vaccination of children and adolescents with quadrivalent vaccine (against influenza virus A H3N2, influenza A H1N1pdm09, influenza B/Victoria lineage, and influenza B/Yamagata lineage) is recommended (B-III).</p></li></ul></p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">What type of vaccine is indicated for adults?</span><p id="par1200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0950"><span class="elsevierStyleLabel">•</span><p id="par1205" class="elsevierStylePara elsevierViewall">For those older than or equal to 19 years of age in whom vacci-nation is indicated, a quadrivalent vaccine (against influenza A H3N2, influenza A H1N1pdm09, influenza B/Victoria lineage, and influenza B/Yamagata lineage) is recommended (B-III).</p></li><li class="elsevierStyleListItem" id="lsti0955"><span class="elsevierStyleLabel">•</span><p id="par1210" class="elsevierStylePara elsevierViewall">For adults for whose age group the vaccine is licensed, a quadrivalent (against influenza A H3N2, type A H1N1pdm09, influenza B/Victoria lineage, and influenza B/Yamagata lineage) enhanced seasonal influenza vaccine is recommend (either adjuvant (B-III), high-dose (B-II), or recombinant (B-II)).</p></li></ul></p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">What is the correct schedule for vaccination?</span><p id="par1215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0225"><li class="elsevierStyleListItem" id="lsti0960"><span class="elsevierStyleLabel">•</span><p id="par1220" class="elsevierStylePara elsevierViewall">One dose of the vaccine and another dose separated from the first one by an interval of four weeks is recommended for children between six months and eight years of age, if they have never before received a dose of influenza vaccine (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0965"><span class="elsevierStyleLabel">•</span><p id="par1225" class="elsevierStylePara elsevierViewall">A single annual dose is recommended for younger than nine-year-olds who have been vaccinated in previous influenza seasons (AI).</p></li><li class="elsevierStyleListItem" id="lsti0970"><span class="elsevierStyleLabel">•</span><p id="par1230" class="elsevierStylePara elsevierViewall">For everyone older than nine years of age, a single annual dose of the influenza vaccine is recommended regardless of vaccination in previous seasons (A-I).</p></li><li class="elsevierStyleListItem" id="lsti0975"><span class="elsevierStyleLabel">•</span><p id="par1235" class="elsevierStylePara elsevierViewall">A full dose of 0.5<span class="elsevierStyleHsp" style=""></span>ml of the influenza vaccine is recommended for everyone, independently of their age (A.I).</p></li><li class="elsevierStyleListItem" id="lsti0980"><span class="elsevierStyleLabel">•</span><p id="par1240" class="elsevierStylePara elsevierViewall">The vaccine should be administered in October–November for those living in the Northern Hemisphere (A-III).</p></li><li class="elsevierStyleListItem" id="lsti0985"><span class="elsevierStyleLabel">•</span><p id="par1245" class="elsevierStylePara elsevierViewall">Vaccination is indicated until the end of the annual influenza season for those who did not receive the vaccine in October–November (A-III).</p></li></ul></p></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">What are the contraindications for influenza virus vaccination?</span><p id="par1250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0230"><li class="elsevierStyleListItem" id="lsti0990"><span class="elsevierStyleLabel">•</span><p id="par1255" class="elsevierStylePara elsevierViewall">Influenza virus vaccination should be avoided in those who previously developed a severe allergic reaction (e.g., anaphylaxis) to a previous influenza vaccine or any of its components (A-III).</p></li></ul></p></span></span><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0310">Research priorities</span><p id="par1260" class="elsevierStylePara elsevierViewall">Future studies should address several points concerning influenza infection.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> From an epidemiological point of view, it will be necessary to develop tools for a better prediction of epidemics, pandemics, and interactions with other respiratory viruses. We also need the development of new tools, for example machine learning, in order to diagnose influenza virus infection more accurately in the clinical context. In order to improve the diagnosis of infection, the development of easy-to-use “point-of-care” techniques that can give reliable information to the clinician to adopt immediate therapeutic decisions are necessary. The therapeutic armamentarium against influenza virus needs to be expanded with new oral antivirals to be administered in the early phases of the infection. New evidence is needed regarding the transmission of the virus (via droplets or aerosols) in order to set more accurate recommendations for isolation and personal protective equipment. Finally, vaccines that produce an enhanced immunological response are required, along with universal vaccines presenting activity against different types of influenza virus in order to avoid annual revaccination. Some lessons learned from the SARS-Cov-2 pandemic should be applied to dealing with the influenza virus in the future.</p></span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0315">Funding</span><p id="par1265" class="elsevierStylePara elsevierViewall">This Consensus Statement was funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC)</span>.</p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">Conflict of interests</span><p id="par1270" class="elsevierStylePara elsevierViewall">Francisco López-Medrano, Diego van Esso-Arbolave, Santiago Alfayate, Manuel García Cenoz, Santiago Melón, Judith Chamorro-Camazón, Alfredo Tagarro, Marta Cruz, Diego Viasus, Jordi Carratalà, Elisa Cordero, Germán Schwarz-Chávarri, M Ángeles Marcos and Nemesio Moreno-Millán declare no conflict of interests. María Fernández-Prada has been a member of advisory boards and has given talks for continuing medical education for Pfizer, GSK, Seqirus, MSD, Sanofi, and Sanofi-Genzyme. Jaime Pérez-Martín has given talks for continuing medical education for Seqirus and Sanofi. Tomàs Pumarola has been a member of advisory boards for Seqirus and Sanofi. Juan Rodríguez García has been a member of advisory boards or has given talks for continuing medical education for Pfizer, GSK and Sanofi.<ul class="elsevierStyleList" id="lis0235"><li class="elsevierStyleListItem" id="lsti0995"><span class="elsevierStyleLabel">•</span><p id="par1275" class="elsevierStylePara elsevierViewall">Currently, egg allergy is not considered a contraindication for the administration of egg-cultured influenza vaccine (A-III).</p></li><li class="elsevierStyleListItem" id="lsti1000"><span class="elsevierStyleLabel">•</span><p id="par1280" class="elsevierStylePara elsevierViewall">Any acute disease of moderate or severe intensity (e.g., asthmatic crisis, decompensated heart failure, acute diarrhea), with or without fever, constitutes a temporary contraindication for the administration of the vaccine. In these circumstances, vaccination should be postponed until the acute illness is resolved (A-III).</p></li></ul></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:19 [ 0 => array:3 [ "identificador" => "xres1858661" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1615910" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1858660" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1615911" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction: justification and aims" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Clinical diagnosis and management of influenza virus infection in adults" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "When should influenza virus infection be suspected in an adult?" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Can influenza virus infection be clinically distinguished from another respiratory virus in an adult?" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "When should an adult patient with suspected influenza virus infection be sent to the Emergency Room of a hospital?" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "When should pneumonia be suspected in an adult with influenza virus infection?" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Can influenza virus pneumonia be clinically distinguished from bacterial pneumonia in an adult?" ] ] ] 7 => array:3 [ "identificador" => "sec0045" "titulo" => "Clinical diagnosis and management of influenza virus infection in children" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "When should influenza virus infection be suspected in a child?" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Can influenza virus infection be clinically distinguished from other respiratory viruses in a child?" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "When should a pediatric patient with suspected influenza virus infection be sent to the Emergency Room of a hospital?" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "When should pneumonia be suspected in a child with influenza virus infection? Can influenza virus pneumonia be clinically distinguished from bacterial pneumonia in a child?" ] ] ] 8 => array:3 [ "identificador" => "sec0070" "titulo" => "Microbiological diagnosis of influenza virus infection" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "When is the microbiological diagnosis of influenza indicated?" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "How should specimens be collected, stored, and transported?" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "What test should be used for the microbiological diagnosis of influenza virus infection?" ] 3 => array:2 [ "identificador" => "sec0090" "titulo" => "When should resistance to neuraminidase inhibitors be sought?" ] 4 => array:2 [ "identificador" => "sec0095" "titulo" => "What is the role of rapid diagnostic tests at point-of-care in primary care medicine and emergency rooms of hospitals?" ] 5 => array:2 [ "identificador" => "sec0100" "titulo" => "Capacity of microbiology laboratories for influenza virus diagnosis and characterization. How far should they go?" ] 6 => array:2 [ "identificador" => "sec0105" "titulo" => "Virological surveillance of influenza" ] ] ] 9 => array:3 [ "identificador" => "sec0110" "titulo" => "Treatment of influenza virus infection in the community" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0115" "titulo" => "Which adult patients with influenza virus infection should be treated with antivirals in the community?" ] 1 => array:2 [ "identificador" => "sec0120" "titulo" => "Is there an indication for antiviral treatment without microbiological diagnosis in adults?" ] 2 => array:2 [ "identificador" => "sec0125" "titulo" => "Apart from antivirals, what other therapeutic measures should be offered to an adult patient with influenza virus infection in the community or in long-term facilities?" ] 3 => array:2 [ "identificador" => "sec0130" "titulo" => "Which pediatric patients with influenza virus infection should be treated with antivirals in the community?" ] 4 => array:2 [ "identificador" => "sec0135" "titulo" => "Is there an indication for antiviral treatment without microbiological diagnosis in children?" ] 5 => array:2 [ "identificador" => "sec0140" "titulo" => "Apart from antivirals, what other therapeutic measures should be offered to a pediatric patient with influenza virus infection in the community?" ] ] ] 10 => array:3 [ "identificador" => "sec0145" "titulo" => "Treatment of influenza virus infection in hospital" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0150" "titulo" => "Which adult patients admitted to hospital due to influenza virus infection should be treated with antivirals?" ] 1 => array:2 [ "identificador" => "sec0155" "titulo" => "Apart from antivirals, what other therapeutic measures should be offered to an adult patient with influenza virus infection admitted to hospital?" ] 2 => array:2 [ "identificador" => "sec0160" "titulo" => "Which adult patients admitted to hospital due to influenza virus infection should be treated with other antimicrobials?" ] 3 => array:2 [ "identificador" => "sec0165" "titulo" => "Which pediatric patients admitted to hospital due to influenza virus infection should be treated with antivirals?" ] 4 => array:2 [ "identificador" => "sec0170" "titulo" => "Apart from antivirals, what other therapeutic measures should (and should not) be offered to a pediatric patient with influenza virus infection admitted to hospital?" ] 5 => array:2 [ "identificador" => "sec0175" "titulo" => "Which pediatric patients admitted to hospital due to influenza virus infection should be treated with antibiotics?" ] ] ] 11 => array:3 [ "identificador" => "sec0180" "titulo" => "Prophylaxis of influenza transmission in the community" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0185" "titulo" => "What measures should be taken to avoid the transmission of influenza virus in the community?" ] ] ] 12 => array:3 [ "identificador" => "sec0190" "titulo" => "Prophylaxis of nosocomial transmission of influenza" "secciones" => array:12 [ 0 => array:2 [ "identificador" => "sec0195" "titulo" => "What measures should be taken to avoid the transmission of influenza virus in healthcare settings?" ] 1 => array:2 [ "identificador" => "sec0200" "titulo" => "Standard precautions, hand hygiene, and respiratory hygiene/cough etiquette" ] 2 => array:2 [ "identificador" => "sec0205" "titulo" => "Triage for rapid identification of patients with influenza-like illness (ILI)" ] 3 => array:2 [ "identificador" => "sec0210" "titulo" => "Infection prevention and control precautions when caring for patients with ILI or confirmed influenza infection" ] 4 => array:2 [ "identificador" => "sec0215" "titulo" => "Peri- and postpartum care" ] 5 => array:2 [ "identificador" => "sec0220" "titulo" => "Containment measures" ] 6 => array:2 [ "identificador" => "sec0225" "titulo" => "Training and education of healthcare workers (HCWs)" ] 7 => array:2 [ "identificador" => "sec0230" "titulo" => "What is the definition of a nosocomial outbreak of influenza virus infection?" ] 8 => array:2 [ "identificador" => "sec0235" "titulo" => "What measures should be adopted to control an influenza outbreak?" ] 9 => array:2 [ "identificador" => "sec0240" "titulo" => "Acute care hospitals" ] 10 => array:2 [ "identificador" => "sec0245" "titulo" => "Neonatal or pediatric intensive care units and pediatric wards" ] 11 => array:2 [ "identificador" => "sec0250" "titulo" => "Long-term care facilities and nursing homes" ] ] ] 13 => array:3 [ "identificador" => "sec0255" "titulo" => "Vaccination against influenza virus" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0260" "titulo" => "Among children, who should receive the influenza vaccine?" ] 1 => array:2 [ "identificador" => "sec0265" "titulo" => "Among adults, who should receive the influenza vaccine?" ] 2 => array:2 [ "identificador" => "sec0270" "titulo" => "What type of vaccine is indicated for children?" ] 3 => array:2 [ "identificador" => "sec0275" "titulo" => "What type of vaccine is indicated for adults?" ] 4 => array:2 [ "identificador" => "sec0280" "titulo" => "What is the correct schedule for vaccination?" ] 5 => array:2 [ "identificador" => "sec0285" "titulo" => "What are the contraindications for influenza virus vaccination?" ] ] ] 14 => array:2 [ "identificador" => "sec0290" "titulo" => "Research priorities" ] 15 => array:2 [ "identificador" => "sec0295" "titulo" => "Funding" ] 16 => array:2 [ "identificador" => "sec0300" "titulo" => "Conflict of interests" ] 17 => array:2 [ "identificador" => "xack655096" "titulo" => "Acknowledgements" ] 18 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-12-04" "fechaAceptado" => "2022-12-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1615910" "palabras" => array:6 [ 0 => "Influenza" 1 => "Clinical picture" 2 => "Diagnosis" 3 => "Treatment" 4 => "Prevention" 5 => "Vaccine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1615911" "palabras" => array:6 [ 0 => "Gripe" 1 => "Manifestaciones clínicas" 2 => "Diagnóstico" 3 => "Tratamiento" 4 => "Prevención" 5 => "Vacuna" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The influenza virus has accompanied humans since time immemorial, in the form of annual epidemics and occasional pandemics. It is a respiratory infection with multiple repercussions on people’s lives at an individual and social level, as well as representing a significant burden on the health system. This Consensus Document arises from the collaboration of various Spanish scientific societies involved in influenza virus infection. The conclusions drawn are based on the highest quality evidence available in the scientific literature and, failing that, on the opinion of the experts convened. The Consensus Document addresses the clinical, microbiological, therapeutic, and preventive aspects (with respect to the prevention of transmission and in relation to vaccination) of influenza, for both adult and pediatric populations. This Consensus Document aims to help facilitate the clinical, microbiological, and preventive approach to influenza virus infection and, consequently, to reduce its important consequences on the morbidity and mortality of the population.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El virus de la gripe ha acompañado al ser humano desde tiempo inmemorial, en forma de epidemias anuales y pandemias ocasionales. Se trata de una infección respiratoria con múltiples repercusiones sobre la vida de las personas a nivel individual y social, así como una importante sobrecarga para el sistema sanitario. El presente documento de consenso surge de la colaboración de diversas sociedades científicas españolas implicadas en la atención de la infección por virus de la gripe. Las conclusiones extraídas se han fundamentado en las evidencias de mayor calidad disponibles en la literatura científica y, en su defecto, en la opinión de los expertos convocados. En el documento de consenso se abordan los aspectos clínicos, microbiológicos, terapéuticos y preventivos (respecto de la prevención de la transmisión y en relación con la vacunación) de la gripe, tanto para población pediátrica como para adultos. Este documento de consenso pretende ayudar a facilitar el abordaje clínico, microbiológico y preventivo de la infección por virus de la gripe y, consecuentemente, a disminuir sus importantes consecuencias sobre la morbimortalidad de la población.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Article previously published in Enfermedades Infecciosas y Microbiología Clínica (<span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.eimc.2022.10.010">https://doi.org/10.1016/j.eimc.2022.10.010</span>), with the consent of the authors and publishers.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par1295" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0310" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1212 "Ancho" => 2508 "Tamanyo" => 294775 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Daily global mortality by any cause in Spain (2010–2019) and weekly incidence of influenza virus infection. Source: National Center of Epidemiology, Health Institute Carlos III, Ministry of Science, Spain.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Footnote: red line: detected mortality; blue line: expected mortality; yellow line: incidence of influenza; x-axis: week/year; left y-axis: absolute number of deaths; right y-axis: number of cases of influenza infection per 100,000 inhabitants.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Category/grade \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definition \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strength of recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Good evidence to support a recommendation for or against use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate evidence to support a recommendation for or against use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Poor evidence to support a recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quality of evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence from one or more properly randomized controlled trial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence from one or more well-designed clinical trial without randomization; from cohort or case-controlled analytical studies (preferably from more than one center); from multiple time-series; or from dramatic results from uncontrolled experiments \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports from expert committees \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Strength of the recommendations and quality of the evidence.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 1534602 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Centro Nacional de Epidemiología. Instituto de Salud Carlos III. Ministerio de Ciencia e Innovación, España. Informe de Vigilancia de la Gripe en España. Temporada 2018–2019." ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estimates of global seasonal influenza-associated respiratory mortality: a modelling study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.D. Iuliano" 1 => "K.M. Roguski" 2 => "H.H. Chang" 3 => "D.J. Muscatello" 4 => "R. Palekar" 5 => "S. Tempia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(17)33293-2" "Revista" => array:6 [ "tituloSerie" => "Lancet." "fecha" => "2018" "volumen" => "391" "paginaInicial" => "1285" "paginaFinal" => "1300" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29248255" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lessons from influenza pandemics of the last 100 years" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.S. Monto" 1 => "K. Fukuda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Infect Dis." "fecha" => "2020" "volumen" => "70" "paginaInicial" => "951" "paginaFinal" => "957" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack655096" "titulo" => "Acknowledgements" "texto" => "<p id="par1285" class="elsevierStylePara elsevierViewall">We would like to thank the Executive Committee of the Spanish Society for Clinical Microbiology and Infectious Diseases (SEIMC) for trusting us to develop this Consensus Statement (especially José Ramón Blanco and Antonio Aguilera). We are particularly grateful to Carlota Gudiol, Ma Nieves Larrosa, Manuel Crespo, and Juan Carlos Rodríguez Díaz (former members of the Executive Committee of SEIMC). We also acknowledge the enthusiastic welcome to SEIMC’s proposal of the other Scientific Societies involved in drawing up the document. Many thanks to Nuria Jiménez, secretary of SEIMC, for her assistance with logistic affairs. Moreover, we acknowledge José María Martínez-Ávila for his original illustrations specifically designed for this Consensus statement and Meryl Jones for the review of the English version of the manuscript.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000009800000003/v1_202303071051/S2341287923000285/v1_202303071051/en/main.assets" "Apartado" => array:4 [ "identificador" => "44360" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special Article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000009800000003/v1_202303071051/S2341287923000285/v1_202303071051/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287923000285?idApp=UINPBA00005H" ]
Year/Month | Html | Total | |
---|---|---|---|
2024 October | 58 | 42 | 100 |
2024 September | 65 | 32 | 97 |
2024 August | 80 | 53 | 133 |
2024 July | 64 | 36 | 100 |
2024 June | 81 | 33 | 114 |
2024 May | 70 | 44 | 114 |
2024 April | 70 | 39 | 109 |
2024 March | 48 | 16 | 64 |
2024 February | 80 | 30 | 110 |
2024 January | 64 | 19 | 83 |
2023 December | 134 | 19 | 153 |
2023 November | 68 | 25 | 93 |
2023 October | 95 | 36 | 131 |
2023 September | 67 | 37 | 104 |
2023 August | 50 | 17 | 67 |
2023 July | 56 | 41 | 97 |
2023 June | 59 | 33 | 92 |
2023 May | 112 | 41 | 153 |
2023 April | 77 | 36 | 113 |
2023 March | 176 | 73 | 249 |
2023 February | 49 | 19 | 68 |