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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Daily global mortality by any cause in Spain &#40;2010&#8211;2019&#41; and weekly incidence of in&#64258;uenza virus infection&#46; Source&#58; National Center of Epidemiology&#44; Health Institute Carlos III&#44; Ministry of Science&#44; Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Footnote&#58; red line&#58; detected mortality&#59; blue line&#58; expected mortality&#59; yellow line&#58; incidence of in&#64258;uenza&#59; x-axis&#58; week&#47;year&#59; left y-axis&#58; absolute number of deaths&#59; right y-axis&#58; number of cases of in&#64258;uenza infection per 100&#44;000 inhabitants&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction&#58; justi&#64257;cation and aims</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infection by in&#64258;uenza virus has accompanied humanity from time immemorial&#44; producing annual epidemics that can cause severe infection&#44; mainly in the elderly&#44; pregnant women&#44; or in those with previous comorbidities&#46; Moreover&#44; from time to time&#44; it produces periodic pandemics related to genomic mutations that can give rise to a devastating disease&#44; mostly in young people without previous exposure to that type of virus&#46; There is probably no other infectious disease that better correlates with population mortality as in&#64258;uenza virus infection does&#46; As shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; there is a tiny correlation between the daily oscillation of mortality for the general population and the weekly rate of in&#64258;uenza virus infection&#46;<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&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Despite these facts&#44; in&#64258;uenza virus infection is still considered a benign unimportant infection by a large proportion of citizens and&#44; even more worrisome&#44; by physicians&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the last few decades&#44; we have witnessed a huge development in the diagnostic&#44; preventive&#44; and therapeutic tools for in&#64258;uenza virus infection that have demonstrated their usefulness in reducing the incidence&#44; morbidity&#44; and mortality of this infection&#46; Meanwhile&#44; a powerful media movement has made a big fuss based on non-scienti&#64257;c statements&#44; provoking mass rejection to the application of these tools that could bene&#64257;t public health&#46; A recent study estimated that seasonal in&#64258;uenza produces between 300&#44;000 and 600&#44;000 deaths annually worldwide&#46;<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 &#40;SEIMC&#41; and was enthusiastically taken on by the following scienti&#64257;c societies&#58; the Spanish Society of Pediatric Infectious Diseases &#40;SEIP&#41;&#44; the Spanish Association of Vaccinology &#40;AEV&#41;&#44; the Spanish Society of Family and Community Medicine &#40;SEMFYC&#41;&#44; and the Spanish Society of Preventive Medicine&#44; Public Health and Health Management &#40;SEMPSPGS&#41;&#46; The result is this Consensus Document that jointly approaches in&#64258;uenza virus infection from different complementary perspectives&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the opinion of the authors of this Consensus Statement and their supporting Scienti&#64257;c Societies&#44; this document represents a great opportunity for the diffusion of systematized scienti&#64257;c knowledge to the medical community&#44; in order to improve the approach toward in&#64258;uenza virus infection in the twenty-&#64257;rst century&#46;</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&#46; The whole text is available at Appendix A&#46;</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&#46; They appointed an Infectious Diseases expert &#40;FLM&#41; and a Microbiology specialist &#40;TP&#41; as coordinators of the working group for the drafting of the manuscript in April 2018&#46; Moreover&#44; the Executive Committee of SEIMC contacted other Scienti&#64257;c Societies in order to develop a uni&#64257;ed document approaching in&#64258;uenza virus infection from a holistic point of view&#46; The following Scienti&#64257;c Societies were contacted&#58; the Spanish Society of Pediatric Infectious Diseases &#40;SEIP&#41;&#44; the Spanish Association of Vaccinology &#40;AEV&#41;&#44; the Spanish Society of Family and Community Medicine &#40;SEMFYC&#41; and the Spanish Society of Preventive Medicine&#44; Public Health and Health Management &#40;SEMPSPGS&#41;&#46; The Executive Committee of each of these societies appointed experts who were contacted and agreed to join the working group&#46; 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&#46; Each group of experts worked in their &#64257;eld of expertise and a uni&#64257;ed draft was constructed&#46; The multidisciplinary panel of experts held a teleconference &#40;May 2019&#41; and a face-to-face meeting &#40;June 2019&#41; to discuss the aspects of the document in which consensus had not been achieved&#46; Apart from the literature evidence &#40;up to June 2022&#41;&#44; 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&#46; In case of discrepancy&#44; the criteria of the coordinators were applied&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The panel experts were asked to perform a systematic review of the scienti&#64257;c literature&#44; with no time limit&#44; in order to answer the assigned queries according to the best evidence available&#46; PubMed&#44; Embase&#44; and the Cochrane Database for Systematic Reviews were consulted&#46; The literature search was updated up to June 2022&#46; The strength of the recommendations and the quality of evidence were graded based on the US Public Health Service Grading System &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Apart from the method for grading the recommendations&#44; the document was written following the Appraisal of Guidelines Research and Evaluation &#40;AGREE II&#41; tutorial&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The target of the Consensus Statement is the diagnosis&#44; treatment&#44; and prevention of seasonal in&#64258;uenza virus infection&#46; It was not designed to address the management of pandemic outbreaks by non-previously circulating in&#64258;uenza virus or the management of exceptional infections by strains of in&#64258;uenza virus of animal origin &#40;&#8220;avian &#64258;u&#8221;&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All the members of the panel participated in the building of the Consensus Statement and approved the &#64257;nal version&#46; The document was sent for audit by external peer reviewers&#46; All the members of the Scienti&#64257;c Societies involved in the preparation of the manuscript had the opportunity to review the draft and make comments before publication&#46; The &#64257;nal version was revised and approved by the Executive Committee of SEIMC and the other societies involved in the consensus &#40;SEIP&#44; AEV&#44; SEMFYC and SEMPSPGS&#41; prior to publication and adoption as an of&#64257;cial document by the respective societies&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical diagnosis and management of in&#64258;uenza virus infection in adults</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">When should in&#64258;uenza virus infection be suspected in an adult&#63;</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">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">In&#64258;uenza infection does not have speci&#64257;c clinical symptoms and its clinical picture might be undistinguishable from that produced by another respiratory virus&#46; 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in&#64258;uenza infection can be considered in people with fever and acute exacerbation of underlying chronic lung disease&#44; in elderly people with new or worsening respiratory symptoms &#40;including exacerbation of congestive heart failure or altered mental status&#44; with or without fever&#41;&#44; in severely ill people with fever or hypothermia&#44; and hospitalized adults who develop febrile respiratory illness after hospital admission &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">At any time of the year&#44; in people with acute febrile respiratory symptoms who are epidemiologically linked to an in&#64258;uenza outbreak &#40;healthcare workers&#44; household and close contacts of people with suspected in&#64258;uenza&#44; travelers returning from countries where in&#64258;uenza viruses may be circulating&#44; participants in international mass gatherings&#44; and cruise ship passengers&#41; &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Can in&#64258;uenza virus infection be clinically distinguished from another respiratory virus in an adult&#63;</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 in&#64258;uenza-like illness&#44; clinical &#64257;ndings are not particularly useful to differentiate in&#64258;uenza virus infection from another respiratory virus infection &#40;B-II&#41;&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">When should an adult patient with suspected in&#64258;uenza virus infection be sent to the Emergency Room of a hospital&#63;</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">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">An adult patient should be sent to the Emergency Department of a hospital if the patient might bene&#64257;t from hospital admission due to the development of pneumonia as a complication of in&#64258;uenza virus infection &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">From a clinical point of view&#44; this possibility should be suspected in the presence of shortness of breath&#44; pain or pressure in the chest&#44; sudden dizziness&#44; confusion&#44; and&#47;or severe or persistent vomiting&#46; It should also be considered in case of in&#64258;uenza virus infection symptoms that improve but then relapse in the form of fever and&#47;or worsening lower respiratory tract symptoms &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">A patient with a suspected or diagnosed in&#64258;uenza 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 &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">An adult patient with in&#64258;uenza virus infection should be sent to the Emergency Department of a hospital if he&#47;she presents exacerbation of underlying chronic diseases that might require hospital admission &#40;A-II&#41;&#46;</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 in&#64258;uenza virus infection&#63;</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">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Pneumonia should be considered in every patient with suspected in&#64258;uenza virus presenting with clinical features suggestive of lower respiratory tract infection in the context of the annual epidemic period of in&#64258;uenza &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Pneumonia should be considered in every patient with con&#64257;rmed in&#64258;uenza virus infection presenting with clinical features suggestive of lower respiratory tract infection &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">The possibility of in&#64258;uenza virus infection should be considered in everyone with a diagnosis of pneumonia in the context of the annual epidemic period of in&#64258;uenza &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Can in&#64258;uenza virus pneumonia be clinically distinguished from bacterial pneumonia in an adult&#63;</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">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Although certain presenting clinical features may enable recognition of in&#64258;uenza pneumonia&#44; no single symptom or scoring system is suf&#64257;cient to differentiate between in&#64258;uenza and bacterial pneumonia &#40;B-II&#41;&#46;</p></li></ul></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical diagnosis and management of in&#64258;uenza virus infection in children</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">When should in&#64258;uenza virus infection be suspected in a child&#63;</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">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">In&#64258;uenza should be suspected in any child that presents acute fever with or without respiratory symptoms during the annual epidemic in&#64258;uenza period &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">The de&#64257;nition of in&#64258;uenza-like illness &#40;ILI&#41; has a very low diagnostic yield in children&#44; especially in those younger than 5 years &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">In infants younger than 6 months&#44; in&#64258;uenza may present as a sepsis-like syndrome &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Can in&#64258;uenza virus infection be clinically distinguished from other respiratory viruses in a child&#63;</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">&#8226;</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 speci&#64257;c to some viruses&#44; physicians cannot usually con&#64257;rm or rule out a particular viral infection on clinical grounds alone &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">It is essential to be able to obtain a microbiological diagnosis in patients where a speci&#64257;c diagnosis may modify patient management &#40;speci&#64257;cally&#44; the possibility to initiate antiviral in&#64258;uenza treatment&#41; &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">When should a pediatric patient with suspected in&#64258;uenza virus infection be sent to the Emergency Room of a hospital&#63;</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">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Infants&#44; children&#44; or adolescent patients should be sent to the Emergency Department of a hospital if they could bene&#64257;t from inpatient treatment due to the development of pneumonia or any other complication of in&#64258;uenza virus infection &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Infants&#44; children&#44; and adolescent patients with risk factors &#40;immunosuppressed patients&#44; chronic lung disease&#44; hemo-dynamically signi&#64257;cant heart disease&#44; severe neurological pathology&#44; nephropathies and chronic liver diseases&#41; should be microbiologically tested in the Primary Care environment or sent to the Emergency Department for a microbiological con&#64257;rmation of in&#64258;uenza virus infection if this might modify the management of these patients &#40;admission to hospital&#44; initiation of antiviral treatment&#44; performance of chest X-ray&#44; etc&#46;&#41; &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">From a clinical point of view&#44; this possibility should be suspected in the presence of poor general condition&#44; signs of sepsis&#44; altered level of consciousness or seizures&#44; dehydration&#44; shock&#44; respiratory distress &#40;tachypnea&#44; chest retractions&#44; hypoxemia&#44; and episodes of apnea&#41;&#44; or any alarming sign in clinical evolution according to medical criteria &#40;see Table 3 at full text in Appendix A&#41; It should also be considered in case of in&#64258;uenza virus infection symptoms that improve but then relapse in the form of fever and&#47;or worsening lower respiratory tract symptoms &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">A pediatric patient with suspected or X-ray con&#64257;rmed 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 &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</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&#44; based on clinical grounds&#44; in&#64258;uenza virus infection might be indistinguishable from other potentially life-threatening conditions &#40;A-II&#41;&#46;</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 in&#64258;uenza virus infection&#63; Can in&#64258;uenza virus pneumonia be clinically distinguished from bacterial pneumonia in a child&#63;</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">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Pneumonia should be considered as a possibility in every pediatric patient with suspected in&#64258;uenza virus presenting with clinical features suggestive of lower respiratory tract infection in the context of the annual epidemic period of in&#64258;uenza &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Pneumonia should be considered as a possibility in every patient with con&#64257;rmed in&#64258;uenza virus infection presenting with clinical features suggestive of lower respiratory tract infection &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">The possibility of in&#64258;uenza virus infection should be considered in every child with the diagnosis of pneumonia in the context of the annual epidemic period of in&#64258;uenza &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">In&#64258;uenza pneumonia and bacterial pneumonia may present overlapping clinical symptoms&#46; Differential diagnosis may require a chest X-ray&#44; and laboratory and microbiological tests&#44; and cannot be de&#64257;ned only on a clinical basis &#40;B-II&#41;&#46;</p></li></ul></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Microbiological diagnosis of in&#64258;uenza virus infection</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">When is the microbiological diagnosis of in&#64258;uenza indicated&#63;</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">&#8226;</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 in&#64258;uence the clinical approach to other subjects exposed to the patient tested &#40;see Table 4 at full text in Appendix A&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</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 in&#64258;uenza-related complications &#40;for instance&#44; those with underlying cardiopulmonary diseases or immunocompromised subjects&#41; &#40;see Table 4 at full text in Appendix A&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Microbiological diagnosis should be attempted in every case with clinical suspicion of in&#64258;uenza virus infection in subjects admitted to hospital &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Microbiological diagnosis should be attempted in healthcare workers &#40;HCWs&#41; with a clinical suspicion of in&#64258;uenza virus infection when they are taking care of patients with risk factors for developing severe forms of in&#64258;uenza&#44; and when taking care of patients admitted to hospital or to long-term care facilities &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</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 in&#64258;uenza virus infection when they are not going to be admitted to hospital and&#47;or they do not present a severe clinical condition &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">An accurate microbiological diagnosis of in&#64258;uenza virus infection and other respiratory viruses might help to avoid unnecessary antibiotic treatment and might help to accurately prescribe speci&#64257;c antiviral in&#64258;uenza treatment when indicated &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">For epidemiological purposes&#44; cases of in&#64258;uenza virus infection should be microbiologically diagnosed&#44; starting at week 40 and ending on week 20 of the following year &#40;for the Northern hemisphere&#41; and by designated reference laboratories&#44; in order to establish the type of virus strain circulating and the moment of initiation of the epidemic period &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">How should specimens be collected&#44; stored&#44; and transported&#63;</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">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Nasopharyngeal &#40;NPS&#41; or oropharyngeal &#40;OPS&#41; specimens collected by using sterile polyester swabs with plastic or aluminum shafts &#40;not wooden shafts&#41; are the preferred samples for noninvasive microbiological diagnosis of in&#64258;uenza virus infection in adults &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">NPS aspirate or washing is an alternative specimen that can be used for diagnosis&#46; Collection of this specimen is especially well tolerated by children &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</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 &#40;A-III&#41; &#8211; see Fig&#46; 2 at full text in Appendix A&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Alternatively&#44; saliva specimens may be used but they are associated with a lower yield for microbiological diagnosis &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Swabs must be transported to the Microbiology laboratory in sterile transport tubes with virus transport medium&#46; Dry tubes for the transport of samples for bacterial diagnosis are not adequate &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Lower respiratory tract specimens &#40;bronchoalveolar lavage or tracheobronchial aspirate&#44; depending on clinical status of patient&#41; should be collected for viral microbiological diagnosis from hospitalized patients with respiratory failure receiving mechanical ventilation&#44; 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 &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</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&#46; The earlier the sampling&#44; the higher the yield of the microbiological diagnosis &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Blood&#44; plasma&#44; serum&#44; urine&#44; stool&#44; and cerebrospinal &#64258;uid are not suitable specimens for routine in&#64258;uenza virus infection diagnosis &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Single or paired serum samples for serological diagnosis are only indicated for epidemiological purposes &#40;A-III&#41;&#46;</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 in&#64258;uenza virus infection&#63;</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">&#8226;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Nucleic acid ampli&#64257;cation test &#40;NAAT&#41; is the method of choice for the microbiological diagnosis of in&#64258;uenza virus infection&#46; It should be able to identify type A and type B in&#64258;uenza virus&#46; It is advisable to use a test that is able to identify type A in&#64258;uenza virus and distinguish subtypes H1 and H3 &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Rapid molecular assays detect in&#64258;uenza virus infection with high sensitivity and speci&#64257;city&#46; These tests are recommended to be used in hospitalized patients with suspected in&#64258;uenza virus infection and may be a better alternative to the other rapid in&#64258;uenza diagnostic tests in outpatient settings &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Antigen detection tests should be restricted to pediatric patients with samples collected within 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h following the onset of symptoms&#44; when NAAT is not available &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Viral culture should not be used for primary diagnosis in the clinical setting&#46; It should be reserved for cases in which further antigenic or genetic characterization is needed &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">Serological testing for in&#64258;uenza is not generally recommended except for research purposes and for Public Health surveillance &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">When should resistance to neuraminidase inhibitors be sought&#63;</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">&#8226;</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&#8211;10 days after initiation of treatment with this type of antivirals &#40;particularly when the antiviral dose is suboptimal&#41; &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8226;</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 &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8226;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Resistance to antivirals should be especially considered in the immunocompromised population with evidence of persistent viral replication &#40;e&#46;g&#46;&#44; 7&#8211;10 days after initiation of treatment&#41; &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Periodic tests to detect resistance in in&#64258;uenza virus from random samples from community circulating virus should be performed&#46; This surveillance should be limited to the reference laboratories designated by regional or national government authorities or by international Public Health organizations &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">&#8226;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Antiviral resistance testing can be performed by speci&#64257;c gene sequencing&#44; real-time single-nucleotide polymorphism &#40;SNP&#41; detection&#44; polymerase chain reaction&#44; or by genome-wide geno-typing &#40;C-III&#41;&#46;</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&#63;</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">&#8226;</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 in&#64258;uenza virus infection at point-of-care &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8226;</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&#44; in both the primary care setting and emergency facilities &#40;B-III&#41;&#46;</p></li></ul></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Capacity of microbiology laboratories for in&#64258;uenza virus diagnosis and characterization&#46; How far should they go&#63;</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">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">Detection of in&#64258;uenza virus by genomic tests &#40;at the type and sub-type level&#41; for seasonal strains should be available for laboratories performing microbiological diagnosis &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8226;</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&#46;</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">Deep genetic and antigenic characterization &#40;clades and subclades or minor antigenic variants&#41; as well as speci&#64257;c serological assays should be limited to the reference laboratories designated by regional or national government authorities or by international Public Health organizations &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Virological surveillance of in&#64258;uenza</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">&#8226;</span><p id="par0430" class="elsevierStylePara elsevierViewall">Active viral surveillance of in&#64258;uenza virus is the cornerstone for detecting emerging in&#64258;uenza virus strains with pandemic potential &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">&#8226;</span><p id="par0435" class="elsevierStylePara elsevierViewall">Viral surveillance is the backbone for the selection of candidate viruses for the next-season vaccine &#40;A-III&#41;&#44; and also provides relevant and crucial information for interpreting vaccine effectiveness&#46;</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">&#8226;</span><p id="par0440" class="elsevierStylePara elsevierViewall">Seasonal in&#64258;uenza virus surveillance is necessary in order to establish when the epidemic annual period starts&#46; It can also determine the proportions of type&#44; subtype&#44; and lineage of circulating viruses and assess antigen or genetic mismatch of circulating viruses with those included in the seasonal vaccine &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#8226;</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 &#40;A-II&#41;&#46;</p></li></ul></p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Treatment of in&#64258;uenza virus infection in the community</span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Which adult patients with in&#64258;uenza virus infection should be treated with antivirals in the community&#63;</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">&#8226;</span><p id="par0455" class="elsevierStylePara elsevierViewall">Adults diagnosed with non-complicated in&#64258;uenza virus infection within the community should start speci&#64257;c antiviral treatment as outpatients if they present risk factors for the development of a complicated infection &#40;see Table 5 at full text in Appendix A&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8226;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the &#64257;rst line drugs to be prescribed for those in whom treatment is indicated as outpatients &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#8226;</span><p id="par0465" class="elsevierStylePara elsevierViewall">Oral oseltamivir doses in Table 6 at full text in Appendix A&#41; is preferred over inhaled zanamivir for adults who can take oral drugs &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">&#8226;</span><p id="par0470" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors&#44; the greater the bene&#64257;cial effect &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">&#8226;</span><p id="par0475" class="elsevierStylePara elsevierViewall">Treatment with neuraminidase inhibitors should ideally be started within the &#64257;rst 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but a clinical bene&#64257;t might be obtained even if started later than 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">&#8226;</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&#44; in the context of the National Health System &#40;A-III&#41;&#46;</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&#63;</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">&#8226;</span><p id="par0490" class="elsevierStylePara elsevierViewall">Adults ful&#64257;lling the criteria for outpatient treatment of the in&#64258;uenza virus infection &#40;see 6&#46;1&#41; should start antiviral treatment as soon as possible when they are evaluated throughout the period of annual in&#64258;uenza epidemic&#44; providing a microbiological diagnosis to con&#64257;rm or exclude the infection is not available in less than 6<span class="elsevierStyleHsp" style=""></span>h &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Apart from antivirals&#44; what other therapeutic measures should be offered to an adult patient with in&#64258;uenza virus infection in the community or in long-term facilities&#63;</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">&#8226;</span><p id="par0500" class="elsevierStylePara elsevierViewall">Symptomatic treatment is recommended to alleviate the symptoms of in&#64258;uenza &#40;C-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">&#8226;</span><p id="par0505" class="elsevierStylePara elsevierViewall">Symptomatic treatment of in&#64258;uenza for fever&#44; headache&#44; and myalgia is appropriate with paracetamol&#44; ibuprofen&#44; or dipyrone &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">&#8226;</span><p id="par0510" class="elsevierStylePara elsevierViewall">Cough can be relieved with honey and dextromethorphan&#44; but the use of over-the-counter medications should be carefully weighed against the risk of adverse effects &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">&#8226;</span><p id="par0515" class="elsevierStylePara elsevierViewall">Treatment with antibiotics is not indicated unless bacterial super-infection is suspected &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Which pediatric patients with in&#64258;uenza virus infection should be treated with antivirals in the community&#63;</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">&#8226;</span><p id="par0525" class="elsevierStylePara elsevierViewall">Selected previously healthy patients with a con&#64257;rmed early diagnosis of seasonal in&#64258;uenza during the epidemic period may start speci&#64257;c antiviral treatment as outpatients in the &#64257;rst 24<span class="elsevierStyleHsp" style=""></span>h after the start of the clinical picture&#46; It must be considered that expected bene&#64257;t 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&#46; Parents must be informed of the bene&#64257;t-risk balance obtained with the treatment&#46; The Panel of this Consensus Statement considers this bene&#64257;t does not justify the recommendation for the indiscriminate use of antiviral treatment in the general pediatric population &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">&#8226;</span><p id="par0530" class="elsevierStylePara elsevierViewall">Selected children diagnosed with non-complicated in&#64258;uenza virus infection within the community may start speci&#64257;c antiviral treatment as outpatients if they present signi&#64257;cant risk factors for the development of a complicated infection &#40;immunosuppressed patients&#44; chronic lung disease&#44; hemodynamically signi&#64257;cant heart disease&#44; severe neurological pathology&#44; nephropathies&#44; and chronic liver diseases&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">&#8226;</span><p id="par0535" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the &#64257;rst line drugs to be prescribed for those in whom treatment is indicated as outpatients &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">&#8226;</span><p id="par0540" class="elsevierStylePara elsevierViewall">Oral oseltamivir &#40;capsules or oral suspension &#8211; see posology in Table 7 at full text in Appendix A&#41; is preferred over inhaled zanamivir &#40;not indicated in any case for those under 5 years of age&#41; for children who can take oral drugs &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">&#8226;</span><p id="par0545" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors&#44; the greater the bene&#64257;cial effect &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">&#8226;</span><p id="par0550" class="elsevierStylePara elsevierViewall">Treatment with neuraminidase inhibitors should ideally be started in the &#64257;rst 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but a clinical bene&#64257;t might be obtained even if started later than 48<span class="elsevierStyleHsp" style=""></span>h after symptom onset &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">&#8226;</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&#44; in the context of the National Health System &#40;C-III&#41;&#46;</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&#63;</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">&#8226;</span><p id="par0565" class="elsevierStylePara elsevierViewall">It is not indicated for the general pediatric population &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">&#8226;</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 in&#64258;uenza virus infection while simultaneously presenting an impossibility of performing diagnostic tests &#40;C-III&#41;&#46;</p></li></ul></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Apart from antivirals&#44; what other therapeutic measures should be offered to a pediatric patient with in&#64258;uenza virus infection in the community&#63;</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">&#8226;</span><p id="par0580" class="elsevierStylePara elsevierViewall">Symptomatic treatment of in&#64258;uenza for fever&#44; headache&#44; and myalgia is appropriate with paracetamol&#44; ibuprofen&#44; or dipyrone &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">&#8226;</span><p id="par0585" class="elsevierStylePara elsevierViewall">Cough can be relieved with honey and dextromethorphan&#44; but the use of over-the-counter medications should be carefully weighed against the risk of overdose &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">&#8226;</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 &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">&#8226;</span><p id="par0595" class="elsevierStylePara elsevierViewall">Treatment with antibiotics is not indicated unless bacterial super-infection is suspected &#40;A-III&#41;&#46;</p></li></ul></p></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Treatment of in&#64258;uenza virus infection in hospital</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Which adult patients admitted to hospital due to in&#64258;uenza virus infection should be treated with antivirals&#63;</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">&#8226;</span><p id="par0605" class="elsevierStylePara elsevierViewall">Prompt use of antivirals is recommended for adult patients admitted to hospital with suspected or con&#64257;rmed in&#64258;uenza virus infection &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">&#8226;</span><p id="par0610" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the &#64257;rst-line drugs to be prescribed for those in whom treatment is indicated when admitted to hospital &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">&#8226;</span><p id="par0615" class="elsevierStylePara elsevierViewall">Oral oseltamivir is preferred over inhaled zanamivir for adults who can take oral drugs &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">&#8226;</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 &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">&#8226;</span><p id="par0625" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors&#44; the greater the bene&#64257;cial effect&#46; Neuraminidase inhibitors should be started as soon as possible&#44; preferably within the &#64257;rst 6<span class="elsevierStyleHsp" style=""></span>h after arrival at the Emergency Room &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">&#8226;</span><p id="par0630" class="elsevierStylePara elsevierViewall">Treatment with neuraminidase inhibitors should ideally be started in the &#64257;rst 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but&#44; for those admitted to hospital&#44; treatment must be started regardless of duration of symptoms &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">&#8226;</span><p id="par0635" class="elsevierStylePara elsevierViewall">Adults ful&#64257;lling the criteria for treatment of in&#64258;uenza virus infection when admitted to hospital should start antiviral treatment as soon as possible when they are evaluated during the period of annual in&#64258;uenza epidemic &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">&#8226;</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&#44; in the context of the National Health System &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Apart from antivirals&#44; what other therapeutic measures should be offered to an adult patient with in&#64258;uenza virus infection admitted to hospital&#63;</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">&#8226;</span><p id="par0650" class="elsevierStylePara elsevierViewall">Corticosteroids should not be added to in&#64258;uenza treatment in hospitalized patients&#44; unless indicated for other reasons &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">&#8226;</span><p id="par0655" class="elsevierStylePara elsevierViewall">Adding macrolides and naproxen to oseltamivir might be of bene&#64257;t in patients with simultaneous pneumonia and in&#64258;uenza virus infection &#40;C-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">&#8226;</span><p id="par0660" class="elsevierStylePara elsevierViewall">Passive immunotherapy and sirolimus need further studies to be recommended in cases of severe in&#64258;uenza virus infection &#40;B&#46;II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">&#8226;</span><p id="par0665" class="elsevierStylePara elsevierViewall">Other therapeutic measures studied in humans&#44; such as statins&#44; nitazoxanide and herbal medicines&#44; have not been consistently proven to improve prognosis in hospitalized adults with in&#64258;uenza infection&#44; and therefore are not routinely recommended &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">&#8226;</span><p id="par0670" class="elsevierStylePara elsevierViewall">Cough can be relieved with dextromethorphan&#44; but the use of over-the-counter medications should be carefully weighed against the risk of adverse effects &#40;B-II&#41;&#46;</p></li></ul></p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Which adult patients admitted to hospital due to in&#64258;uenza virus infection should be treated with other antimicrobials&#63;</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">&#8226;</span><p id="par0680" class="elsevierStylePara elsevierViewall">Adults presenting a clinical picture of a severe respiratory infection &#40;extensive pneumonia&#44; respiratory failure&#44; hypotension&#41; while infected by in&#64258;uenza virus should receive early antibiotic treatment in addition to antiviral therapy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">&#8226;</span><p id="par0685" class="elsevierStylePara elsevierViewall">In adults with in&#64258;uenza virus infection whose respiratory symptoms deteriorate after an initial improvement&#44; antibiotic therapy should be considered &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">&#8226;</span><p id="par0690" class="elsevierStylePara elsevierViewall">Microbiological diagnostic tests to con&#64257;rm bacterial coinfection or superinfection must be performed in these situations in patients admitted to hospital &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">&#8226;</span><p id="par0695" class="elsevierStylePara elsevierViewall">If started when indicated&#44; antibiotic treatment of adults with in&#64258;uenza virus infection should be active against commonly in&#64258;uenza-associated bacteria&#44; such as <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; <span class="elsevierStyleItalic">Streptococcus pyogenes</span>&#44; and <span class="elsevierStyleItalic">Haemophilus in&#64258;uenzae</span> &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">&#8226;</span><p id="par0700" class="elsevierStylePara elsevierViewall">In case of nosocomial superinfection&#44; the possibility of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> should be considered &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">&#8226;</span><p id="par0705" class="elsevierStylePara elsevierViewall">Aspergillus spp&#46; coinfection should also be considered&#44; especially in immunosuppressed patients and those admitted to an intensive care unit &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Which pediatric patients admitted to hospital due to in&#64258;uenza virus infection should be treated with antivirals&#63;</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">&#8226;</span><p id="par0715" class="elsevierStylePara elsevierViewall">Antiviral treatment is recommended for children presenting risk factors for a complicated course &#40;immunosuppressed&#44; chronic lung disease other than asthma&#44; hemodynamically signi&#64257;cant heart disease&#44; severe neurological pathology&#44; nephropathies&#44; and chronic liver diseases&#41; when admitted to hospital due to in&#64258;uenza virus infection &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">&#8226;</span><p id="par0720" class="elsevierStylePara elsevierViewall">Antiviral treatment may also be considered for children admitted to hospital due to in&#64258;uenza virus infection but not ful&#64257;lling the risk factors for a complicated course when presenting pneumonia or respiratory failure or at the time of admission into the critical care unit &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">&#8226;</span><p id="par0725" class="elsevierStylePara elsevierViewall">Neuraminidase inhibitors are the &#64257;rst line drugs to be prescribed for those in whom treatment is indicated when admitted to hospital &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">&#8226;</span><p id="par0730" class="elsevierStylePara elsevierViewall">Oral oseltamivir is preferred over inhaled zanamivir for children who can take oral drugs &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">&#8226;</span><p id="par0735" class="elsevierStylePara elsevierViewall">Oseltamivir as an oral solution might be a better option than capsules for the pediatric population &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">&#8226;</span><p id="par0740" class="elsevierStylePara elsevierViewall">Zanamivir is not indicated&#44; under any circumstances&#44; for children younger than &#64257;ve years of age &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">&#8226;</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 &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">&#8226;</span><p id="par0750" class="elsevierStylePara elsevierViewall">The earlier the initiation of treatment with neuraminidase inhibitors&#44; the greater the bene&#64257;cial effect&#46; When indicated&#44; neuraminidase inhibitors should be started as soon as possible&#44; preferably within the &#64257;rst six hours after arrival at the Emergency Room &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">&#8226;</span><p id="par0755" class="elsevierStylePara elsevierViewall">When indicated&#44; treatment with neuraminidase inhibitors should ideally be started within the &#64257;rst 48<span class="elsevierStyleHsp" style=""></span>h after the onset of symptoms but&#44; for severely ill children&#44; treatment might be started regardless of duration of symptoms &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">&#8226;</span><p id="par0760" class="elsevierStylePara elsevierViewall">Microbiologically con&#64257;rmed in&#64258;uenza diagnoses should ideally be made before antiviral indication&#44; due to the lack of speci&#64257;city of symptoms&#46; Etiological diagnosis also enables patient isolation in seasonal in&#64258;uenza period&#44; which overlaps with other viruses&#44; such as Respiratory Syncytial Virus &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">&#8226;</span><p id="par0765" class="elsevierStylePara elsevierViewall">Exceptionally in patients who are critically ill and&#47;or have risk factors&#44; a strong clinical suspicion of in&#64258;uenza&#44; and impossibility of performing a diagnostic test&#44; antivirals could be prescribed without microbiological con&#64257;rmation &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">&#8226;</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&#44; in the context of the National Health System &#40;C-III&#41;&#46;</p></li></ul></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Apart from antivirals&#44; what other therapeutic measures should &#40;and should not&#41; be offered to a pediatric patient with in&#64258;uenza virus infection admitted to hospital&#63;</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">&#8226;</span><p id="par0780" class="elsevierStylePara elsevierViewall">Symptomatic treatment of in&#64258;uenza for fever&#44; headache&#44; and myalgia is appropriate with paracetamol&#44; ibuprofen or dipyrone &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">&#8226;</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&#8217;s syndrome &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">&#8226;</span><p id="par0790" class="elsevierStylePara elsevierViewall">Supported sitting position and gentle suction of the nares when secretions block them can be useful &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">&#8226;</span><p id="par0795" class="elsevierStylePara elsevierViewall">Intravenous &#64258;uid therapy is indicated if adequate oral intake is not possible&#44; and oxygen therapy or mechanical ventilation as indicated &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">&#8226;</span><p id="par0800" class="elsevierStylePara elsevierViewall">Other drugs such as antihistamines&#44; nasal decongestants&#44; antitussives&#44; expectorants&#44; or mucolytics are not generally recommended &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">&#8226;</span><p id="par0805" class="elsevierStylePara elsevierViewall">Corticosteroids should not be added to in&#64258;uenza treatment in hospitalized patients&#44; unless indicated for other reasons &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Which pediatric patients admitted to hospital due to in&#64258;uenza virus infection should be treated with antibiotics&#63;</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">&#8226;</span><p id="par0815" class="elsevierStylePara elsevierViewall">Antibiotic treatment is indicated in proven or strongly suspected secondary bacterial infections cases &#40;including bacterial otitis media&#44; sinusitis&#44; and pneumonia&#41;&#46; Empiric antibiotics should generally be directed at the most common bacterial pathogens following in&#64258;uenza&#58; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; and <span class="elsevierStyleItalic">Streptococcus pyogenes</span> &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">&#8226;</span><p id="par0820" class="elsevierStylePara elsevierViewall">There is no indication for prescribing antibiotics in order to prevent secondary bacterial complication &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0635"><span class="elsevierStyleLabel">&#8226;</span><p id="par0825" class="elsevierStylePara elsevierViewall">In hospitalized children with in&#64258;uenza infection when bacterial pneumonia is suspected&#44; complementary tests are recommended&#44; as symptoms and signs of virus and bacteria often overlap&#46; No complementary test on its own is enough to de&#64257;ne bacterial coinfection &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0640"><span class="elsevierStyleLabel">&#8226;</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 &#40;CRP&#41; higher than 13<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; procalcitonin higher than 0&#46;52<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; and&#47;or alveolar consolidation in chest X-ray &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0645"><span class="elsevierStyleLabel">&#8226;</span><p id="par0835" class="elsevierStylePara elsevierViewall">In children with in&#64258;uenza virus infection whose respiratory symptoms deteriorate after an initial improvement&#44; antibiotic therapy should be considered &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0650"><span class="elsevierStyleLabel">&#8226;</span><p id="par0840" class="elsevierStylePara elsevierViewall">Microbiological diagnostic tests to con&#64257;rm bacterial coinfection or superinfection must be performed in these situations&#44; in patients admitted to hospital &#40;A-III&#41;&#46;</p></li></ul></p></span></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Prophylaxis of in&#64258;uenza 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 in&#64258;uenza virus in the community&#63;</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 in&#64258;uenza vaccination of people in high-risk groups is recommended &#40;A-I&#41; &#8211; see Section 10&#46;</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 &#40;or alcohol-based hand sanitizers containing at least 60&#37; ethanol or isopropanol when soap and water are not available&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0665"><span class="elsevierStyleLabel">&#8226;</span><p id="par0860" class="elsevierStylePara elsevierViewall">People should cover their nose and mouth when coughing or sneezing using tissues or &#64258;exed elbow &#40;if a tissue is not available&#41; in order to contain respiratory secretions&#44; followed by hand hygiene&#46; Touching eyes&#44; nose&#44; or mouth should be avoided where possible &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0670"><span class="elsevierStyleLabel">&#8226;</span><p id="par0865" class="elsevierStylePara elsevierViewall">Routine cleaning of frequently touched surfaces and objects that might be contaminated with respiratory secretions &#40;at home&#44; schools&#44; childcare facilities&#44; and workplaces&#41; is recommended &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0675"><span class="elsevierStyleLabel">&#8226;</span><p id="par0870" class="elsevierStylePara elsevierViewall">Post-exposure chemoprophylaxis could be considered in asymptomatic people at high risk of developing complications from in&#64258;uenza and for those in whom in&#64258;uenza vaccination is contraindicated&#44; unavailable&#44; or expected to have low effectiveness &#40;e&#46;g&#46;&#44; people who are signi&#64257;cantly immunocom-promised&#41; &#40;C-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0680"><span class="elsevierStyleLabel">&#8226;</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 in&#64258;uenza &#40;e&#46;g&#46;&#44; severely immunocompromised patients&#41; &#40;C-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0685"><span class="elsevierStyleLabel">&#8226;</span><p id="par0880" class="elsevierStylePara elsevierViewall">A 10-day regimen with a neuraminidase inhibitor is recommended as post-exposure chemoprophylaxis&#46; It should be initiated as soon as possible &#40;within 48<span class="elsevierStyleHsp" style=""></span>h of exposure for oral oseltamivir &#91;see recommended dosage for adults at Table 8 and for children at Table 9&#44; both in full text in Appendix A&#93; or within 36<span class="elsevierStyleHsp" style=""></span>h for inhaled zanamivir&#41; &#40;A-III&#41;&#46;</p></li></ul></p></span></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Prophylaxis of nosocomial transmission of in&#64258;uenza</span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">What measures should be taken to avoid the transmission of in&#64258;uenza virus in healthcare settings&#63;</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">&#8226;</span><p id="par0895" class="elsevierStylePara elsevierViewall">Annual in&#64258;uenza vaccination of healthcare workers and people in high-risk groups is recommended &#40;A-I&#41; &#8211; see Section 10&#46;</p></li><li class="elsevierStyleListItem" id="lsti0695"><span class="elsevierStyleLabel">&#8226;</span><p id="par0900" class="elsevierStylePara elsevierViewall">Annual in&#64258;uenza vaccination and pneumococcal vaccine of residents in long term care facilities is recommended &#40;A-II&#41; &#8211; see Section 10&#46;</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">&#8226;</span><p id="par0910" class="elsevierStylePara elsevierViewall">Post-exposure antiviral chemoprophylaxis should not be used routinely &#40;B-III&#41;&#46; Antiviral prophylaxis can be considered after exposure &#40;see criteria in Table 10 at full text in Appendix A&#41; to a person with in&#64258;uenza in some circumstances&#44; such as asymptomatic patients&#44; healthcare workers at high risk of developing complications from in&#64258;uenza&#44; or for those in whom in&#64258;uenza vaccination is contraindicated&#44; unavailable&#44; or expected to have low effectiveness &#40;e&#46;g&#46;&#44; people who are signi&#64257;cantly immunocompromised&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0705"><span class="elsevierStyleLabel">&#8226;</span><p id="par0915" class="elsevierStylePara elsevierViewall">A 10-day regimen with a neuraminidase inhibitor is recommended as post-exposure chemoprophylaxis&#46; It should be initiated as soon as possible &#40;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&#41; &#40;A-I&#41; &#8211; see recommended dosage for adults at Table 8 and for children at Table 9&#44; both in full text in Appendix A&#41;&#46;</p></li></ul></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Standard precautions&#44; hand hygiene&#44; and respiratory hygiene&#47;cough etiquette</span><p id="par1300" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0710"><span class="elsevierStyleLabel">&#8226;</span><p id="par0920" class="elsevierStylePara elsevierViewall">Reinforce effective hand hygiene and cough etiquette when in contact with patients&#44; visitors&#44; and staff &#40;Catch it&#44; Bin it&#44; Kill it&#41; &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0715"><span class="elsevierStyleLabel">&#8226;</span><p id="par0925" class="elsevierStylePara elsevierViewall">Provide disposable tissues&#44; no-touch receptacles for disposal of tissues&#44; and alcohol-based hand rubs &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0720"><span class="elsevierStyleLabel">&#8226;</span><p id="par0930" class="elsevierStylePara elsevierViewall">Provide instructions to cover mouths&#47;noses when coughing or sneezing&#44; use disposable tissues&#44; and perform hand hygiene &#40;i&#46;e&#46;&#44; by posting signs at entrances and in strategic places&#41; &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0725"><span class="elsevierStyleLabel">&#8226;</span><p id="par0935" class="elsevierStylePara elsevierViewall">Standard cleaning and disinfection procedures as well as food handling&#44; laundry&#44; and waste management are adequate when attending patients with suspected or con&#64257;rmed in&#64258;uenza &#40;B-II&#41;&#46;</p></li></ul></p></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Triage for rapid identi&#64257;cation of patients with in&#64258;uenza-like illness &#40;ILI&#41;</span><p id="par1305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0730"><span class="elsevierStyleLabel">&#8226;</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 &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0735"><span class="elsevierStyleLabel">&#8226;</span><p id="par0945" class="elsevierStylePara elsevierViewall">Offer masks to coughing persons upon entry to hospital &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0740"><span class="elsevierStyleLabel">&#8226;</span><p id="par0950" class="elsevierStylePara elsevierViewall">Enable differentiated spaces in waiting rooms for patients with symptoms of respiratory infection &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0745"><span class="elsevierStyleLabel">&#8226;</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 &#40;B-III&#41;&#46;</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 con&#64257;rmed in&#64258;uenza infection</span><p id="par1310" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0750"><span class="elsevierStyleLabel">&#8226;</span><p id="par0960" class="elsevierStylePara elsevierViewall">Droplet precautions are required for all cases of ILI that are known or suspected to be in&#64258;uenza virus infection until in&#64258;uenza has been excluded or the patient is no longer deemed contagious &#40;AII&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0755"><span class="elsevierStyleLabel">&#8226;</span><p id="par0965" class="elsevierStylePara elsevierViewall">Place patients with suspected or con&#64257;rmed in&#64258;uenza in individual rooms or speci&#64257;c areas&#46; If an individual room is not available&#44; consult the Infection Prevention and Control Team for assessing isolation by cohort &#40;B-III&#41;&#46; In long-term care and other residential settings&#44; make decisions regarding patient placement on a case-by-case basis after considering infection risks of other patients in the room and available alternatives &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0760"><span class="elsevierStyleLabel">&#8226;</span><p id="par0970" class="elsevierStylePara elsevierViewall">Patients with suspected or proven in&#64258;uenza who require noninvasive ventilation should have priority for negative-pressure rooms &#40;if available&#41; and&#47;or rooms with 100&#37; exhaust capability &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0765"><span class="elsevierStyleLabel">&#8226;</span><p id="par0975" class="elsevierStylePara elsevierViewall">For aerosol generating procedures&#44; use of FFP2 face mask or a respirator&#44; &#64258;uid repellent gown&#44; disposable gloves&#44; and eye protection &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0770"><span class="elsevierStyleLabel">&#8226;</span><p id="par0980" class="elsevierStylePara elsevierViewall">Closed-ventilation suction circuits should be used where available&#44; with bacterial and viral &#64257;lters placed over the expiratory port &#40;B-III&#41;&#46;</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">&#8226;</span><p id="par0985" class="elsevierStylePara elsevierViewall">A pregnant woman with suspected or con&#64257;rmed in&#64258;uenza virus infection admitted to hospital should be attended according to the recommendations for the general population before&#44; during&#44; and after delivery&#46; These measures include standard and droplet precautions &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0780"><span class="elsevierStyleLabel">&#8226;</span><p id="par0990" class="elsevierStylePara elsevierViewall">After delivery&#44; due to the risk of serious complications were the newborn to become infected by in&#64258;uenza&#44; temporary separation from the baby should be considered&#44; in accordance with the mother&#8217;s wishes&#46; The baby should be cared for by a healthy caregiver whenever possible &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0785"><span class="elsevierStyleLabel">&#8226;</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&#46; This breastmilk can be fed to the newborn by the healthy caregiver &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0790"><span class="elsevierStyleLabel">&#8226;</span><p id="par1000" class="elsevierStylePara elsevierViewall">In case the baby remains in the same room &#40;due to the mother&#8217;s wishes or for logistic reasons&#41;&#44; standard and droplet precautions should be established in order to minimize transmission &#40;B-III&#41;&#46; The hospital must implement measures to reduce viral exposure of the newborn including physical barriers &#40;i&#46;e&#46;&#44; a curtain between the mother and the newborn&#41;&#44; maintaining at least 2 meters between the mother and the newborn&#44; and ensuring another adult is present to care for the newborn&#46;</p></li><li class="elsevierStyleListItem" id="lsti0795"><span class="elsevierStyleLabel">&#8226;</span><p id="par1005" class="elsevierStylePara elsevierViewall">If breastfeeding is maintained while the mother presents in&#64258;uenza virus infection&#44; she should wear a surgical face mask and practice hand hygiene before each feeding or contact with her newborn &#40;B-III&#41;&#46;</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">&#8226;</span><p id="par1010" class="elsevierStylePara elsevierViewall">During periods of increased in&#64258;uenza activity&#44; minimize visits by patients seeking care for mild in&#64258;uenza-like illness who are not at increased risk of complications &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0805"><span class="elsevierStyleLabel">&#8226;</span><p id="par1015" class="elsevierStylePara elsevierViewall">Limit visitors with acute respiratory symptoms and&#47;or with high risk of in&#64258;uenza complications &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0810"><span class="elsevierStyleLabel">&#8226;</span><p id="par1020" class="elsevierStylePara elsevierViewall">Healthcare workers presenting symptoms that suggest in&#64258;uenza virus infection should stop patient care activities&#44; don a face-mask&#44; and immediately notify their supervisor &#40;and infection control personnel&#41; to determine appropriateness of contact with patients&#44; temporary reassignment&#44; or exclusion from work until criteria for a non-infectious status are met &#40;B-III&#41;&#46;</p></li></ul></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Training and education of healthcare workers &#40;HCWs&#41;</span><p id="par1325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0815"><span class="elsevierStyleLabel">&#8226;</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 &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0820"><span class="elsevierStyleLabel">&#8226;</span><p id="par1030" class="elsevierStylePara elsevierViewall">Staff education and training on infection control methods&#44; policies&#44; and procedures should be delivered to all staff members &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0825"><span class="elsevierStyleLabel">&#8226;</span><p id="par1035" class="elsevierStylePara elsevierViewall">Healthcare settings must establish mechanisms to &#64257;nd out about in&#64258;uenza virus activity in the community as well as for the prompt detection of outbreaks in healthcare settings &#40;B-III&#41;&#46;</p></li></ul></p></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">What is the de&#64257;nition of a nosocomial outbreak of in&#64258;uenza virus infection&#63;</span><p id="par1040" class="elsevierStylePara elsevierViewall">A nosocomial outbreak is de&#64257;ned by the diagnosis of healthcare-associated in&#64258;uenza infection &#40;at least one of the cases with microbiological con&#64257;rmation&#41; in two or more patients admitted to the same ward in a period of less than 48<span class="elsevierStyleHsp" style=""></span>h &#40;A-II&#41;&#46;</p></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">What measures should be adopted to control an in&#64258;uenza outbreak&#63;</span><p id="par1045" class="elsevierStylePara elsevierViewall">A bundle of measures&#44; rather than one measure alone&#44; must be implemented when a nosocomial in&#64258;uenza outbreak is detected in an institution &#40;A-II&#41;&#46; This includes administrative&#44; pharmacological&#44; and non-pharmacological measures &#40;see Table 11 at full text in Appendix A&#41; &#40;A-II&#41;&#46;</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">&#8226;</span><p id="par1055" class="elsevierStylePara elsevierViewall">Non-pharmacological measures must be used to prevent virus dissemination &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0835"><span class="elsevierStyleLabel">&#8226;</span><p id="par1060" class="elsevierStylePara elsevierViewall">Administer post-exposure prophylaxis as soon as possible to patients in close contact with a con&#64257;rmed or suspected case of in&#64258;uenza and risk factors for developing serious complications in case of infection &#40;see Table 11 at full text in Appendix A&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0840"><span class="elsevierStyleLabel">&#8226;</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 in&#64258;uenza infection &#40;see Table 11 at full text in Appendix A&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0845"><span class="elsevierStyleLabel">&#8226;</span><p id="par1070" class="elsevierStylePara elsevierViewall">Routine pre-exposure prophylaxis for all patients or staff is not recommended&#44; not even in an outbreak situation&#44; but could be considered in wards admitting immunocompromised patients or when staff members are suspected of being involved in maintaining an outbreak &#40;B-II&#41;&#46;</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">&#8226;</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 in&#64258;uenza virus infection &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0855"><span class="elsevierStyleLabel">&#8226;</span><p id="par1085" class="elsevierStylePara elsevierViewall">Mask&#44; gown&#44; and gloves should be worn when taking care of patients with in&#64258;uenza virus infection admitted to neonatal or pediatric intensive care units &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0860"><span class="elsevierStyleLabel">&#8226;</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 &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0865"><span class="elsevierStyleLabel">&#8226;</span><p id="par1095" class="elsevierStylePara elsevierViewall">Post-exposure prophylaxis should be used in healthcare workers whose comorbidities for high-risk in&#64258;uenza complications are present in themselves or in their household members &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0870"><span class="elsevierStyleLabel">&#8226;</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 &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0875"><span class="elsevierStyleLabel">&#8226;</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 &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0880"><span class="elsevierStyleLabel">&#8226;</span><p id="par1110" class="elsevierStylePara elsevierViewall">Entry to the ward must be restricted to people presenting respiratory symptoms &#40;A-III&#41;&#46;</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">&#8226;</span><p id="par1120" class="elsevierStylePara elsevierViewall">Whenever a case of in&#64258;uenza virus infection is detected in a resident of a long-term care facility or nursing home&#44; the rest of the residents should receive antiviral prophylaxis&#44; regardless of their vaccination status &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0890"><span class="elsevierStyleLabel">&#8226;</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 in&#64258;uenza infection &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0895"><span class="elsevierStyleLabel">&#8226;</span><p id="par1130" class="elsevierStylePara elsevierViewall">Routine pre-exposure prophylaxis for all staff is not recommended&#44; not even in an outbreak situation&#44; but could be considered when staff members are suspected to be involved in maintaining an outbreak &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0900"><span class="elsevierStyleLabel">&#8226;</span><p id="par1135" class="elsevierStylePara elsevierViewall">Reinforce hand hygiene and the use of face masks among staff &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0905"><span class="elsevierStyleLabel">&#8226;</span><p id="par1140" class="elsevierStylePara elsevierViewall">Vaccination of staff and residents when the &#64257;rst cases of in&#64258;uenza virus infection are detected should not be considered an adequate control measure &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0910"><span class="elsevierStyleLabel">&#8226;</span><p id="par1145" class="elsevierStylePara elsevierViewall">Implementation of other non-pharmacological measures such as social distancing and cohorting could be considered &#40;B-III&#41;&#46;</p></li></ul></p></span></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Vaccination against in&#64258;uenza virus</span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Among children&#44; who should receive the in&#64258;uenza vaccine&#63;</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">&#8226;</span><p id="par1155" class="elsevierStylePara elsevierViewall">Vaccination is recommended for children between 6 months and 18 years of age in certain circumstances &#40;see criteria in Table 12 at full text in Appendix A&#41; &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0920"><span class="elsevierStyleLabel">&#8226;</span><p id="par1160" class="elsevierStylePara elsevierViewall">Vaccination of healthy children between six months and &#64257;ve years of age is universally recommended &#40;AIII&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0925"><span class="elsevierStyleLabel">&#8226;</span><p id="par1165" class="elsevierStylePara elsevierViewall">Both political authorities and healthcare workers should redouble their efforts in order to boost vaccination against in&#64258;uenza virus among children belonging to target groups &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Among adults&#44; who should receive the in&#64258;uenza vaccine&#63;</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">&#8226;</span><p id="par1175" class="elsevierStylePara elsevierViewall">Vaccination is recommended for all adults aged 65 years old or older &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0935"><span class="elsevierStyleLabel">&#8226;</span><p id="par1180" class="elsevierStylePara elsevierViewall">Vaccination is recommended for adults between 19 and 64 years of age in certain circumstances &#40;see criteria in Table 13 at full text in Appendix A&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0940"><span class="elsevierStyleLabel">&#8226;</span><p id="par1185" class="elsevierStylePara elsevierViewall">Both political authorities and healthcare workers should redouble their efforts in order to boost vaccination against in&#64258;uenza virus among adults belonging to target groups &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">What type of vaccine is indicated for children&#63;</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">&#8226;</span><p id="par1195" class="elsevierStylePara elsevierViewall">Vaccination of children and adolescents with quadrivalent vaccine &#40;against in&#64258;uenza virus A H3N2&#44; in&#64258;uenza A H1N1pdm09&#44; in&#64258;uenza B&#47;Victoria lineage&#44; and in&#64258;uenza B&#47;Yamagata lineage&#41; is recommended &#40;B-III&#41;&#46;</p></li></ul></p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">What type of vaccine is indicated for adults&#63;</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">&#8226;</span><p id="par1205" class="elsevierStylePara elsevierViewall">For those older than or equal to 19 years of age in whom vacci-nation is indicated&#44; a quadrivalent vaccine &#40;against in&#64258;uenza A H3N2&#44; in&#64258;uenza A H1N1pdm09&#44; in&#64258;uenza B&#47;Victoria lineage&#44; and in&#64258;uenza B&#47;Yamagata lineage&#41; is recommended &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0955"><span class="elsevierStyleLabel">&#8226;</span><p id="par1210" class="elsevierStylePara elsevierViewall">For adults for whose age group the vaccine is licensed&#44; a quadrivalent &#40;against in&#64258;uenza A H3N2&#44; type A H1N1pdm09&#44; in&#64258;uenza B&#47;Victoria lineage&#44; and in&#64258;uenza B&#47;Yamagata lineage&#41; enhanced seasonal in&#64258;uenza vaccine is recommend &#40;either adjuvant &#40;B-III&#41;&#44; high-dose &#40;B-II&#41;&#44; or recombinant &#40;B-II&#41;&#41;&#46;</p></li></ul></p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">What is the correct schedule for vaccination&#63;</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">&#8226;</span><p id="par1220" class="elsevierStylePara elsevierViewall">One dose of the vaccine and another dose separated from the &#64257;rst one by an interval of four weeks is recommended for children between six months and eight years of age&#44; if they have never before received a dose of in&#64258;uenza vaccine &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0965"><span class="elsevierStyleLabel">&#8226;</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 in&#64258;uenza seasons &#40;AI&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0970"><span class="elsevierStyleLabel">&#8226;</span><p id="par1230" class="elsevierStylePara elsevierViewall">For everyone older than nine years of age&#44; a single annual dose of the in&#64258;uenza vaccine is recommended regardless of vaccination in previous seasons &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0975"><span class="elsevierStyleLabel">&#8226;</span><p id="par1235" class="elsevierStylePara elsevierViewall">A full dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>ml of the in&#64258;uenza vaccine is recommended for everyone&#44; independently of their age &#40;A&#46;I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0980"><span class="elsevierStyleLabel">&#8226;</span><p id="par1240" class="elsevierStylePara elsevierViewall">The vaccine should be administered in October&#8211;November for those living in the Northern Hemisphere &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0985"><span class="elsevierStyleLabel">&#8226;</span><p id="par1245" class="elsevierStylePara elsevierViewall">Vaccination is indicated until the end of the annual in&#64258;uenza season for those who did not receive the vaccine in October&#8211;November &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">What are the contraindications for in&#64258;uenza virus vaccination&#63;</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">&#8226;</span><p id="par1255" class="elsevierStylePara elsevierViewall">In&#64258;uenza virus vaccination should be avoided in those who previously developed a severe allergic reaction &#40;e&#46;g&#46;&#44; anaphylaxis&#41; to a previous in&#64258;uenza vaccine or any of its components &#40;A-III&#41;&#46;</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 in&#64258;uenza infection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> From an epidemiological point of view&#44; it will be necessary to develop tools for a better prediction of epidemics&#44; pandemics&#44; and interactions with other respiratory viruses&#46; We also need the development of new tools&#44; for example machine learning&#44; in order to diagnose in&#64258;uenza virus infection more accurately in the clinical context&#46; In order to improve the diagnosis of infection&#44; the development of easy-to-use &#8220;point-of-care&#8221; techniques that can give reliable information to the clinician to adopt immediate therapeutic decisions are necessary&#46; The therapeutic armamentarium against in&#64258;uenza virus needs to be expanded with new oral antivirals to be administered in the early phases of the infection&#46; New evidence is needed regarding the transmission of the virus &#40;via droplets or aerosols&#41; in order to set more accurate recommendations for isolation and personal protective equipment&#46; Finally&#44; vaccines that produce an enhanced immunological response are required&#44; along with universal vaccines presenting activity against different types of in&#64258;uenza virus in order to avoid annual revaccination&#46; Some lessons learned from the SARS-Cov-2 pandemic should be applied to dealing with the in&#64258;uenza virus in the future&#46;</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 &#40;SEIMC&#41;</span>&#46;</p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">Con&#64258;ict of interests</span><p id="par1270" class="elsevierStylePara elsevierViewall">Francisco L&#243;pez-Medrano&#44; Diego van Esso-Arbolave&#44; Santiago Alfayate&#44; Manuel Garc&#237;a Cenoz&#44; Santiago Mel&#243;n&#44; Judith Chamorro-Camaz&#243;n&#44; Alfredo Tagarro&#44; Marta Cruz&#44; Diego Viasus&#44; Jordi Carratal&#224;&#44; Elisa Cordero&#44; Germ&#225;n Schwarz-Ch&#225;varri&#44; M &#193;ngeles Marcos and Nemesio Moreno-Mill&#225;n declare no con&#64258;ict of interests&#46; Mar&#237;a Fern&#225;ndez-Prada has been a member of advisory boards and has given talks for continuing medical education for P&#64257;zer&#44; GSK&#44; Seqirus&#44; MSD&#44; Sano&#64257;&#44; and Sano&#64257;-Genzyme&#46; Jaime P&#233;rez-Mart&#237;n has given talks for continuing medical education for Seqirus and Sano&#64257;&#46; Tom&#224;s Pumarola has been a member of advisory boards for Seqirus and Sano&#64257;&#46; Juan Rodr&#237;guez Garc&#237;a has been a member of advisory boards or has given talks for continuing medical education for P&#64257;zer&#44; GSK and Sano&#64257;&#46;<ul class="elsevierStyleList" id="lis0235"><li class="elsevierStyleListItem" id="lsti0995"><span class="elsevierStyleLabel">&#8226;</span><p id="par1275" class="elsevierStylePara elsevierViewall">Currently&#44; egg allergy is not considered a contraindication for the administration of egg-cultured in&#64258;uenza vaccine &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti1000"><span class="elsevierStyleLabel">&#8226;</span><p id="par1280" class="elsevierStylePara elsevierViewall">Any acute disease of moderate or severe intensity &#40;e&#46;g&#46;&#44; asthmatic crisis&#44; decompensated heart failure&#44; acute diarrhea&#41;&#44; with or without fever&#44; constitutes a temporary contraindication for the administration of the vaccine&#46; In these circumstances&#44; vaccination should be postponed until the acute illness is resolved &#40;A-III&#41;&#46;</p></li></ul></p></span></span>"
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              "titulo" => "Among adults&#44; who should receive the in&#64258;uenza vaccine&#63;"
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              "titulo" => "What are the contraindications for in&#64258;uenza virus vaccination&#63;"
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          "titulo" => "Research priorities"
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          "identificador" => "sec0300"
          "titulo" => "Con&#64258;ict of interests"
        ]
        17 => array:2 [
          "identificador" => "xack655096"
          "titulo" => "Acknowledgements"
        ]
        18 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2022-12-04"
    "fechaAceptado" => "2022-12-05"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1615910"
          "palabras" => array:6 [
            0 => "In&#64258;uenza"
            1 => "Clinical picture"
            2 => "Diagnosis"
            3 => "Treatment"
            4 => "Prevention"
            5 => "Vaccine"
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        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1615911"
          "palabras" => array:6 [
            0 => "Gripe"
            1 => "Manifestaciones cl&#237;nicas"
            2 => "Diagn&#243;stico"
            3 => "Tratamiento"
            4 => "Prevenci&#243;n"
            5 => "Vacuna"
          ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The in&#64258;uenza virus has accompanied humans since time immemorial&#44; in the form of annual epidemics and occasional pandemics&#46; It is a respiratory infection with multiple repercussions on people&#8217;s lives at an individual and social level&#44; as well as representing a signi&#64257;cant burden on the health system&#46; This Consensus Document arises from the collaboration of various Spanish scienti&#64257;c societies involved in in&#64258;uenza virus infection&#46; The conclusions drawn are based on the highest quality evidence available in the scienti&#64257;c literature and&#44; failing that&#44; on the opinion of the experts convened&#46; The Consensus Document addresses the clinical&#44; microbiological&#44; therapeutic&#44; and preventive aspects &#40;with respect to the prevention of transmission and in relation to vaccination&#41; of in&#64258;uenza&#44; for both adult and pediatric populations&#46; This Consensus Document aims to help facilitate the clinical&#44; microbiological&#44; and preventive approach to in&#64258;uenza virus infection and&#44; consequently&#44; to reduce its important consequences on the morbidity and mortality of the population&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El virus de la gripe ha acompa&#241;ado al ser humano desde tiempo inmemorial&#44; en forma de epidemias anuales y pandemias ocasionales&#46; Se trata de una infecci&#243;n respiratoria con m&#250;ltiples repercusiones sobre la vida de las personas a nivel individual y social&#44; as&#237; como una importante sobrecarga para el sistema sanitario&#46; El presente documento de consenso surge de la colaboraci&#243;n de diversas sociedades cient&#237;&#64257;cas espa&#241;olas implicadas en la atenci&#243;n de la infecci&#243;n por virus de la gripe&#46; Las conclusiones extra&#237;das se han fundamentado en las evidencias de mayor calidad disponibles en la literatura cient&#237;&#64257;ca y&#44; en su defecto&#44; en la opini&#243;n de los expertos convocados&#46; En el documento de consenso se abordan los aspectos cl&#237;nicos&#44; microbiol&#243;gicos&#44; terap&#233;uticos y preventivos &#40;respecto de la prevenci&#243;n de la transmisi&#243;n y en relaci&#243;n con la vacunaci&#243;n&#41; de la gripe&#44; tanto para poblaci&#243;n pedi&#225;trica como para adultos&#46; Este documento de consenso pretende ayudar a facilitar el abordaje cl&#237;nico&#44; microbiol&#243;gico y preventivo de la infecci&#243;n por virus de la gripe y&#44; consecuentemente&#44; a disminuir sus importantes consecuencias sobre la morbimortalidad de la poblaci&#243;n&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Article previously published in Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica &#40;<span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.eimc.2022.10.010">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;eimc&#46;2022&#46;10&#46;010</span>&#41;&#44; with the consent of the authors and publishers&#46;</p>"
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            "apendice" => "<p id="par1295" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0310"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Daily global mortality by any cause in Spain &#40;2010&#8211;2019&#41; and weekly incidence of in&#64258;uenza virus infection&#46; Source&#58; National Center of Epidemiology&#44; Health Institute Carlos III&#44; Ministry of Science&#44; Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Footnote&#58; red line&#58; detected mortality&#59; blue line&#58; expected mortality&#59; yellow line&#58; incidence of in&#64258;uenza&#59; x-axis&#58; week&#47;year&#59; left y-axis&#58; absolute number of deaths&#59; right y-axis&#58; number of cases of in&#64258;uenza infection per 100&#44;000 inhabitants&#46;</p>"
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                  \t\t\t\t">Strength of recommendations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Good evidence to support a recommendation for or against use&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>B&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Moderate evidence to support a recommendation for or against use&nbsp;\t\t\t\t\t\t\n
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                  \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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Quality of evidence&nbsp;\t\t\t\t\t\t\n
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                  \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">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Evidence from one or more well-designed clinical trial without randomization&#59; from cohort or case-controlled analytical studies &#40;preferably from more than one center&#41;&#59; from multiple time-series&#59; or from dramatic results from uncontrolled experiments&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Evidence from opinions of respected authorities&#44; based on clinical experience&#44; descriptive studies&#44; or reports from expert committees&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Estimates of global seasonal in&#64258;uenza-associated respiratory mortality&#58; a modelling study"
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        "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 &#40;SEIMC&#41; for trusting us to develop this Consensus Statement &#40;especially Jos&#233; Ram&#243;n Blanco and Antonio Aguilera&#41;&#46; We are particularly grateful to Carlota Gudiol&#44; Ma Nieves Larrosa&#44; Manuel Crespo&#44; and Juan Carlos Rodr&#237;guez D&#237;az &#40;former members of the Executive Committee of SEIMC&#41;&#46; We also acknowledge the enthusiastic welcome to SEIMC&#8217;s proposal of the other Scienti&#64257;c Societies involved in drawing up the document&#46; Many thanks to Nuria Jim&#233;nez&#44; secretary of SEIMC&#44; for her assistance with logistic affairs&#46; Moreover&#44; we acknowledge Jos&#233; Mar&#237;a Mart&#237;nez-&#193;vila for his original illustrations speci&#64257;cally designed for this Consensus statement and Meryl Jones for the review of the English version of the manuscript&#46;</p>"
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