Child with Flu — Avian Influenza, H5N1 — Clinical Pathway: Emergency

Influenza/Flu Clinical Pathway — Emergency Department

Highly Pathogenic Avian Influenza, H5N1

Background

  • Avian flu is widespread in wild birds worldwide
  • There have been outbreaks in U.S. poultry and dairy cows
  • Since spring 2024, there have been 67 human cases and 1 death in the U.S.
  • There has been no human-to-human transmission documented to date
  • Current risk to the general population remains low; however, providers should have a low threshold to test those with symptoms and exposures of risk
  • PA Department of Public Health and the CDC have requested continued influenza A testing to monitor for novel influenza viruses, including H5N1, for awareness

Recommendations for Influenza A Testing

  • All children admitted for respiratory symptoms and/or conjunctivitis
  • Any children with respiratory symptoms and/or conjunctivitis and high-risk-exposure
    • Quad or influenza A RNA PCR (NP or anterior nares swab)
    • Consider conjunctival swab if clinical conjunctivitis, as save our specimen
    • Avoid rapid flu antigen testing if H5N1 is of concern due to low sensitivity in the setting of a high-risk pathogen
    • Note
      Avian influenza is one of many subtypes of influenza A
      PCR positive for influenza A is not likely to be avian flu
    • Call 5-SAFE if
      High clinical concern/exposure, patients should isolate at home until testing results
      PCR positive for influenza A with presence of any high-risk exposure
    • Patients with avian influenza or high-suspicion of avian influenza should be placed on expanded precautions
      • AIIR room, N95, gown, gloves, and eye protection

Exposure Definition

For children who are Influenza A positive, review if any of the following Risk Factors are present in the preceding 10 days:

  • Had contact with birds, poultry (including chickens), or dairy cows?
  • Had contact with any wild or domestic non-pet animals including any birds (which includes home chickens) or cows in their enclosures?
  • Participated in hunting birds (e.g., duck or geese hunting)?
  • Had contact with outdoor cats that have recently been ill or died?
  • Consumed raw or unpasteurized milk?
  • Consumed or handled raw meat-based pet food?

Recommendations for Subtyping

If yes to any of the above questions, contact IP&C at 5-SAFE to help coordinate subtyping with the PA State Bureau of Labs (BOL).

  • Order miscellaneous send out lab which will be run on existing respiratory specimen.
    • Enter “HPAI – Influenza Surveillance” for Name of Desired Test.
  • Send nasopharyngeal (NP) or anterior nares and oropharyngeal (OP) swabs for Influenza A PCR (QUAD or single pathogen).
  • Each specimen should be sent in a separate viral transport media (VTM).
  • If conjunctivitis is present, a conjunctival swab should be collected from both eyes  , even in children with single-eye involvement, and must be sent as a miscellaneous send-out to the Pennsylvania State Bureau of Labs for testing along with the above specimens. Both of the swabs should be placed in a single VTM.
  • Requisition form required for each source (NP/anterior nares, OP and conjunctival if conjunctivitis present).
    • IP&C will provide Medical Director name and contact information.

All Patients Under Investigation (PUIs) should be started on oseltamivir awaiting results of
the subtyping.

Epic Order for Miscellaneous Send Out Test

Order for Miscellaneous Send Out Test, Epic screenshot

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Order Requisition Form

Requisition form required for each source (NP/anterior nares, OP and conjunctival if conjunctivitis present).

Requisition form screenshot

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Additional Resources