Influenza A/B

Guidance for Out-patient Dialysis Area (ODA)  

Royal Infirmary of Edinburgh 
 
All dialysis patients are at high risk of influenza and therefore should be reminded to be vaccinated on a yearly basis. All patients should have their temperature checked at the start of each dialysis session. In patients with a temperature of >38°C a full history should be taken including asking about flu like symptoms (fever, myalgia, upper respiratory symptoms).

Influenza A/B is confirmed by throat swab- If you suspect a dialysis patient has flu please take a vital throat swab and send to virology (blue form) indicating Influenza suspected in clinical details box.

Management of Suspected Cases

Symptomatic Patients
If patients have a cough, runny nose and raised temperature they should ideally be nursed in a cubicle if available.
If a cubicle is not available patients should wear a mask throughout their dialysis treatment.
Once a mask becomes damp it will be ineffective and should then be changed, as per manufacturer’s advice.

If you have more than one patient with Influenza please cohort in the same room if possible.
Patients with Influenza A who share transport should be advised that wearing a face mask on journeys to and from haemodialysis (HD) will help to prevent further spread of the flu virus. Patients with Influenza A/B who have to travel round the hospital should also be advised that wearing a face mask will help to prevent further spread of the flu virus.

If a patient with Influenza A/B is in a cubicle with the door closed they can take the face mask off. If a nurse needs to attend to that patient they must don a face mask, apron and gloves.
Suction and sputum are aerosol generating so do carry a risk of spreading Influenza A/B.
Nebuliser therapy is not classed as a procedure that generates an aerosol so risk of spreading Influenza A/B is not enhanced. The nurse applying the nebuliser mask should however don a protection mask, apron and gloves.

At the end of the HD session of an infected patient, the cubicle or bed space should be cleaned with ActichlorTM Plus followed by a terminal clean. Once completed the cubical or bed space can then be used for other patients.

Antiviral Therapy

Symptomatic patients may be offered treatment after assessment and discussion with the clinical team and the virologist (if required). Antiviral drugs are most effective if given at the time of flu onset i.e. in the first 48 hours. Please consider the following for treatment:

  • Oseltamivir (Tamiflu®) 30mg after EACH haemodialysis session for THREE consecutive sessions. Total number of doses should be THREE doses (if immunocompromised see below)
    OR
  • Zanamivir (Relenza®) 10mg twice daily inhaled via diskhaler for 5 days

Patients with solid organ transplant [SOT], haematopoietic stem cell transplant [HSCT], HIV positive patients with a CD4+ cell count <500 cells/mm3, patients on systemic immunosuppressive therapy, and those with haematological malignancy should receive 10 days of treatment (so for Oseltamivir this will be FIVE consecutive sessions with a total of FIVE doses)

Patients who have had contact or have been in close proximity with a SYMPTOMATIC patient may be considered for prophylactic treatment. This should be assessed on a case-by-case basis. Patients who have been exposed to ASYMPTOMATIC patients DO NOT require prophylaxis. Please consider the following for prophylaxis:

  • Oseltamivir (Tamiflu®) 30mg after every ALTERNATE haemodialysis session. Total number of doses given should be THREE doses
  • Zanamivir (Relenza®) 10mg once daily inhaled via diskhaler for 10 days

The above dosing is referenced from the Public Health England document. All patients on haemodiafiltration should be switched to haemodialysis during the duration of treatment or prophylaxis.

Please see product leaflet on instructions for using the Relenza® diskhaler. Patients may require counselling on using the device. For further advice please contact Renal pharmacists at bleep 5125, 8006 or 5745.

If a patient has no cough or temperature for 24 hours they are classed as asymptomatic and all measures to prevent the spread of Influenza A/B may be stopped i.e. patient no longer needs to be nursed in a cubicle; no longer needs to wear a mask and staff attending to patient no longer needs to wear a mask.

If a patient that is not immunocompromised has been treated with antiviral medication for 5 days but are still symptomatic, please inform medical staff and/or the duty Virologist (as directed by Ingolfur Johannessen, Consultant Virologist).

Reference: PHE guidance on use of antiviral agents for the treatment and prophylaxis of influenza (2018 to 2019). Version 9.0 Public Health England. October 2018 (adopted for use in Scotland by Health protection Scotland www.hps.scot.nhs.uk)