Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

October 20, 2023

DEPARTMENT MEMORANDUM
No. 2023 - 0249]

___
__§
TO: ALL UNDERSECRETARIES AND ASSISTANT SECRETARIES:
DIRECTORS OF BUREAUS AND CENTERS FOR HEALTH
DEVELOPMENT (CHD); MINISTER OF HEALTH-
BANGSAMORO AUTONOMOUS _REGION MUSLIM _IN__

MINDANAO (MOH-__BARMM): CHIEFS OF MEDICAL

CENTERS, HOSPITALS, SANITARIA AND INSTITUTES; DOH
ATTACHED AGENCIES AND INSTITUTIONS AND ALL
OTHERS CONCERNED

SUBJECT: Interim Guidelines on the Prevention, Control, and Management

of Influenza and Influenza-like Illness (ILI)

Viral acute respiratory infections such as Influenza remain a major health problem
worldwide. While all age groups can get infected and are at risk of developing serious
conditions, the older age population, younger children, and those with chronic and
certain health conditions suffer the highest risk of severe complications.
Additionally, healthcare workers are at high risk of acquiring the viral infection due
to increased exposure to patients (WHO, 2023).

Influenza virus
thrives in cold and dry, or humid and rainy seasons. Consequently, in the
country, an observed rise in Flu cases coincides with the rainy season which occurs from
June until November. There are two main types of Influenza viruses: types A and B.
Although influenza can occur throughout the year, causing outbreaks in
tropical countries,
both types routinely spread among individuals, leading to seasonal flu epidemics
annually.

Based on the latest Epidemic-prone Disease Case Surveillance (EDCS) Morbidity Week
No. 39 (January 1 to September 30, 2023) there was a 44% increase in Influenza-like
Ifness (ILI) cases compared to the same period last year. Upon further perusing the
report, clustering, and an increase in cases of Influenza/ Flu in some regions potentially
signifies local outbreaks.

Subsequently, this memorandum is hereby being issued to provide guidance on the

prevention and control, detection and reporting, and treatment and management of
patients for Influenza, ILI, and Severe Acute Respiratory Infection (SARI).

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz. 1003 Manila e Trunk Line 8651-7800 local 1113, 1108
Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: dohosec@doh.gov.ph
 OBJECTIVES
. To guide the DOH offices and bureaus, Centers for Health Development (CHDs),
Local Government Units (LGUs), and health facilities on the prevention, control,
treatment and management, outbreak and risk communication strategies for Influenza,
ILI, and SARI;

. To ensure early and accurate diagnosis, administration of proper clinical management,

and appropriate outbreak response;

___
. To promptly mitigate and contain the further increase in cases of influenza, ILI and
SARI, ‘

. To underscore the importance of vaccination, especially in the highly vulnerable age

groups duringthe flu season.

IL. GENERAL GUIDELINES

. All individuals, especially those at high risk for the influenza virus are advised to
strictly adhere to standard precautions and additional transmission-based precautions
to prevent and control the transmission of these viral acute respiratory diseases.

. Healthcare facilities from the different levels of care, healthcare provider networks,
CHDs, and LGUs shall familiarize themselves with the strategies for the prevention
and control, diagnosis, and management of influenza, ILI, and SARI and directly
coordinate and promptly report identified cases and closed contacts to the DOH
through the Epidemiology Bureau (EB).

. All partner agencies and stakeholders, both public and private

organizations/institutions, schools, and business establishments, including all formal
and informal sectors, shall adhere to these guidelines and provide adequate support as
necessary in the prevention and control, and outbreak response efforts of the DOH.
. Healthcare workers shall identify cases and close contacts, immediately assess, and
collect appropriate samples/specimens for laboratory confirmation, report to the
epidemiology and surveillance network, and properly triage, coordinate, and refer
patients to proper healthcare provider networks and facilities for further management
as necessary. Care for all patients should be according to disease severity and acute
care needs.
III. SPECIFIC GUIDELINES
. Prevention and Control
Influenza/flu can spread easily, with rapid transmission in crowded areas such as
schools, healthcare facilities, and long-term care homes. Transmission occurs from
person to person through respiratory droplets (i.e. from coughing or sneezing and
talking) dispersed into the air and spread up to (1) meter. Less often, the virus can be
transmitted by indirect contact when individuals touch their faces after touching
contaminated surfaces or objects (fomites). Airborne transmission via small particle
aerosols can occur within confined air spaces.
Recommended preventive actions for influenza/ ILI and SARI include the following:

1. Observe the following respiratory etiquette mainly when sneezing and

coughing:
Cover mouth and nose with tissues or wipes.
ore
Properly dispose of used tissues or wipes immediately after.
If tissue is not available, use one’s upper sleeve or arm.
eae Avoid coughing into hands which can easily spread viruses.
Wash hands with soap and water after coughing or sneezing, after
contact with an infected person, and after touching potentially
contaminated surfaces. '

2. Refrain from touching one’s eyes, nose, and mouth, especially with unwashed
hands, and after touching potentially contaminated instruments and surfaces.
3. Avoid close contact with individuals who are sick. Individuals who exhibit
signs and symptoms of
influenza or SARI shall wear masks and limit contact
with others as much as
possible.
4, Vaccination is proven to be the most effective way to prevent influenza and
its complications. Individuals who are unvaccinated or those who are at
increased risk of severe illness are recommended to get their annual flu
vaccines, Additionally, children 6 months and older should also be given their
annual flu vaccine.

Individuals who are at increased risk for severe seasonal influenza and would
highly benefit from vaccination include the following:

a. Pregnant women
postpartum
at any stage of pregnancy and those at <2 weeks

Children younger than five (5) years

es
Adults older than sixty-five (65) years
d. People with chronic and certain medical’ conditions such as:
i. {[mmunocompromised due to certain medications and diseases
such as HIV/AIDS
ii. Asthma, heart, and lung diseases
iii, Endocrine disorders such as diabetes
iv. Kidney and liver disorders
v. Metabolic disorders
vi. Neurological and neurodevelopmental conditions
vii. History of stroke
e. People with increased risk of exposure to influenza, which includes
health care workers.
f. People living in nursing homes and other long-term care facilities

e® Current DOH program only provides free flu vaccines to Senior Citizens.
LGUs are strongly encouraged to procure for their constituents, while private
citizens are encouraged to
avail,
if
able.
5. In household settings: Individuals are recommended to practice standard
precautionary measures even at home. These shall include the following:

a. Frequent hand washing with soap and water, as well as hand hygiene
using alcohol-based sanitizers, on all occasions, particularly when in
contact with suspect and confirmed cases. :

Regularly clean and disinfect surfaces and objects that may be

contaminated with the virus.
Caregivers and those with children less than 6 months of age (<6
months) should get vaccinated against flu each year.
As much as possible, minimize/limit contact with individuals who
exhibit signs and symptoms of influenza. Those whoare
advised to wear masks and avoid contact with others at home,
sick are also

especially those who are vulnerable to infection such as children and

elderly households.
Monitor and observe sick individuals for signs and symptoms of
respiratory infection. Seek proper consultation with a health care
provider upon presentation of signs and symptoms, especially in caring
for children and vulnerable individuals who exhibit any emergency
warning signs of flu. These include, but are not limited to the
following:
i. Difficulty breathing/ Shortness of breath/ Fast breathing
ii. Uncontrolled/ Worsening of fever and cough
iii. Chest pain/ pressure in the chest or abdomen
iv. Bluish lips or face
v. Seizures
6. In health facilities: Health care workers should strictly adhere to infection
and prevention contro] measures by observing standard precautions
complemented with droplet and contact precautions such as the following:

a. Wear a well-fitted medical mask before entering the patient room and
remove it upon exit. Additional Personal Protective Equipment (PPEs)
may be worn upon risk assessment such as gloves.
Perform hand hygiene before and after use of PPEs, and caring for
patients.
Use dedicated patient-care equipment (e.g. stethoscopes, blood
pressure cuffs) and regularly clean and disinfect all equipment before
and after use. Properly discard used disposable materials (e.g. tissues)
immediately after use.
Avoid contaminating environmental surfaces that are not directly
related to patient care (e.g. door handles and light switches). Avoid
medically unnecessary movement and transport of patients.
Ensure availability of materials (e.g. tissues, alcohol-based sanitizers,
no-touch receptacles) for adhering to respiratory hygiene/ cough
etiquette, particularly in waiting areas for patients and personnel.

7. In schools and childcare institutions: Apart from recommending that

children, parents and guardians, and school personnel get vaccinated each
year, observing healthy behaviors at school and at home can help prevent the
spread of the virus to others. These shall include the following:
 Encourage children, parents, and staff to wear medical masks and
at
maintain a safe distance of least 1 meter apart (3 feet). Moreso, to
stay at home when sick and to avoid close contact with suspected or
confirmed individuals.
Clean and disinfect frequently touched surfaces in school, such as
desks, doorknobs, handrails, and others, especially when there are sick
students.
Avoid touching the eyes, nose, and mouth, particularly with unwashed
hands or without disinfecting the hands.
Advocate for practicing proper respiratory etiquette in schools
especially if with crowds.
Maximize proper ventilation such as the use of well-ventilated and
open spaces, ensuring good airflow, and avoiding crowding especially
in indoor locations and enclosed spaces.

B. Diagnosis and Differential Testing

1. Clinical Manifestations. Acute respiratory infections may be due to
COVID-19, influenza, and other non-influenza viruses (e.g., respiratory
syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza, and human
metapneumovirus). The symptoms of COVID-19, influenza, and other
influenza-like illnesses are often difficult to differentiate from each other (See
Annex A).

2. Differential Diagnoses. The differential diagnoses of acute viral respiratory

infections are shown in Annex A.

3. Diagnostic Testing. The decision to perform diagnostic testing should be

based on local surveillance data and the availability of testing at local
healthcare facilities.

a. Strict adherence to recommended infection prevention and control

measures should be observed when collecting respiratory specimens
for testing.
Co-testing of influenza and SARS-CoV-2 may be done depending on
the clinical manifestations of the patient and the clinical suspicion of
the healthcare provider.
The following tests may be performed to differentiate influenza from
SARS-CoV-2 infection or detect co-infection:
i. COVID-19: SARS-CoV-2 nucleic acid detection (e.g.,
RT-PCR) OR antigen detection assay
ii. Influenza: Influenza nucleic acid detection assay (Note that
rapid influenza antigen detection assays are not recommended
for hospitalized patients due to low test sensitivity)
iii, Multiplex nucleic acid detection assays for SARS-CoV-2,
if
influenza A and B viruses can also be done available.
The possibility of co-infection should always be considered. A positive
influenza test without concomitant SARS-CoV-2 testing does not
exclude the latter and vice versa.
C. Isolation and Quarantine
1. All individuals who exhibit signs and symptoms of viral acute respiratory
infections shall be appropriately assessed and triaged to ensure proper referral
and timely management.

Individuals who are exposed but are asymptomatic are advised to monitor
themselves for symptoms and practice minimum public health standards.
Immediate medical consultation is recommended once symptoms are noted.

Patients suspected and confirmed with acute respiratory infections shall be

placed in single rooms. Cohorting patients with the same etiological diagnosis
in a room, maintaining at least (1)-meter distance between beds can also be
done. If an etiological diagnosis is not possible, group patients with similar
clinical diagnoses and based on epidemiological risk factors, with a spatial
separation.
Limit patient movement within the institution to medically necessary
purposes. Ensure that patients wear medical masks when being taken outside
their rooms and outside facilities.

Suspect patients and close contacts shall be catered to in a separate area/ an

isolation room with adequate ventilation if available. If it is not possible to
separate the patient, keep at least (1)-meter distance between close contacts
and suspected patients and the other patients in the waiting room.

Admission of suspected SARI patients, who otherwise may be discharged

if
based on their clinical conditions, can be considered there are no alternatives
available to ensure safe infection control. These include travelers, homeless
persons, and individuals who live in environments where infection control
measures are not feasible or practical (e.g. crowded dormitories/shelters).

D. Treatment and Patient Management

1. Post-exposure Chemoprophylaxis
US Centers for Disease Prevention and Control (CDC) does not recommend
widespread or routine use of antiviral medications for chemoprophylaxis
except as part of the interventions to control institutional influenza outbreaks.
Routine use of post-exposure chemoprophylaxis as well as seasonal or
pre-exposure chemoprophylaxis is not recommended.
Decisions on whether to administer antivirals for chemoprophylaxis should
take into account the exposed person's risk for influenza complications, the
type and duration of contact, recommendations from local or public health
authorities, and clinical judgment. Please see Annex B on the considerations in
the provision of postexposure antiviral chemoprophylaxis in a noninstitutional
setting for asymptomatic persons with influenza exposure.
 Generally, post-exposure chemoprophylaxis for persons should be only used
when antivirals can be started within 48 hours of the most recent exposure.
Please see Annex C on the recommended chemoprophylaxis according to age.

Post-exposure chemoprophylaxis can be considered for pregnant women and

women who are
up to (2) weeks postpartum, including those with pregnancy
loss, who have had close contact with individuals suspected of having
influenza or viral acute respiratory infections, and those who cannot receive an
influenza vaccine due to contraindications or unavailability of vaccines, or
those who have severe immune deficiencies or suffer from other medical
conditions that make them unlikely to respond to vaccination.

An alternative to chemoprophylaxis after a suspected exposure is close

monitoring and early initiation of antiviral treatment if fever and/or respiratory
symptoms develop.

2. Clinical Management

a. In non-high-risk/otherwise healthy patients with illness <2 days,

empiric antiviral treatment for influenza may be given based on the
healthcare provider’s clinical judgment. Giving antiviral treatment in
these patients beyond 2 days of illness duration is unlikely to have
clinical benefit.

b. In patients suspected of having influenza based on clinical

manifestations and who are hospitalized, who have progressive
disease of any duration, or who are at high risk for influenza
complications, (Annex D), even without influenza testing, empiric
antiviral treatment should be initiated as soon as possible, ideally
within 48 hours of symptom onset (Annex E).

c. If there is suspicion of bacterial pneumonia or sepsis, antimicrobial

testing should be done and antimicrobial therapy should be initiated
according to existing evidence-based guidelines.
d. Patients with SARS-CoV-2 infection should be treated according to the
updated Philippine COVID-19 Living Guidelines.

e. Supportive therapies should be administered in patients with acute

viral respiratory infections, such as the following:
i. Adequate hydration
ii. Proper diet and nutrition
iii. Antipyretics for fever or pain relief
iv. Cold medications and mucolytics for symptomatic relief

IV. Surveillance
A. Influenza-like illness and SARI are mandatorily notifiable diseases under Republic
Act No. 11332 (Mandatory Reporting of Notifiable Diseases and Health Events of
Public Health Concern Act. As such, surveillance for ILI and SARI is conducted in an
integrated manner with COVID-19 under a pan-respiratory illness surveillance
system.
 B. The objectives of integrated ILI-SARI-COVID-19 surveillance are:
a. To monitor trends, disease burden, and variant distribution of priority
respiratory viruses such as influenza and SARS-CoV-2;
b. To detect and monitor co-circulation of respiratory viruses;
c. To provide targeted samples and information for genomic surveillance of
respiratory viruses to describe the genetic composition and antigenic/mutation
distribution of circulating viruses; and
d. To inform public health policies and interventions through timely provision of
data on respiratory illnesses

C. All health facilities, Rural Health Units, private clinics, and Epidemiology and
Surveillance Units (ESUs) shall register all identified suspect, probable, and
confirmed ILI, SARI, and COVID-19 cases using either the TanodKontraCOVID
(TKC) platform or through the submission of a completely-filled out case
investigation form (CIF) within the prescribed timelines.
D. Identified case clusters and unusual health events, including outbreaks and those
occurring in closed settings such as schools and workplaces, shall be reported to the
Event-based Surveillance and Response (ESR) system within 24 hours of
detection.
E. The surveillance case definitions of ILI and SARI can be found in Annex F.

F. Parallel confirmatory testing for ILI, SARI, and COVID-19 for

surveillance purposes
shall be performed by the Research Institute for Tropical Medicine and
and trained subnational laboratories (SNLs). However, suspect COVID-19 cases
its
identified

presenting with severe orcritical disease may be tested for diagnostic purposes using
validated rapid antigen kits and/or via PCRin licensed laboratories.
G. Specific guidelines for reporting and testing can be found in Department
Memorandum No. 2022-0526 (Interim Guidelines on the Pilot Implementation of
Integrated Sentinel Surveillance for SARS-CoV-2, Severe Acute Respiratory Illnesses,
and Influenza-like Ilinesses), while specific guidelines on the use of
TanodKontraCOVID can be found in Department Memorandum No. 2023-0117 (Shift
Jrom COVIDKaya (CK) and Epidemic-prone Diseases Case Surveillance Information
System (EDCS-IS) to TanodKontraCOVID (TKC) for Encoding of COVID-19, and
Severe Acute Respiratory Infections (SARI) and Influenza-like Illness (ILI) Cases).

V. Public Health Management Measures

A. School-setting

Younger children are among the vulnerable populations who have the highest risk of
developing severe complications. In coordination with the Department of Education
(DepEd), recommended school adjustments and shifts shall be undertaken to further
manage the spread of ILIs among school-aged children and minimize its
effect on
their academic performance and health, such as but not limited to the following:

a. Schools with a relatively high number of ILIs are recommended to shift

modality to distance learning upon reaching particular thresholds, to prevent
the spread of ILIs among learners, school personnel, and their families.
 i. Threshold per classroom: Classrooms with an absentee rate of 10
percent due to influenza or ILIs should institute a modality shift of two
calendar days, triggered the day after class absentee rate reaches 10
percent.
ii. Threshold per school: Schools with an absentee rate of more than four
percent due to influenza or ILIs, detected for two consecutive days,
with the second day’s absentee rate being higher or equal to the
absentee rate on the first day should institute a school-wide modality
shift for seven calendar days.

b. Schools that have shifted modalities are also recommended to inform their
Local Epidemiology and Surveillance Units (LESUs) of the shift due to
influenza or ILIs, to ensure that LESUs can conduct the appropriate
investigation and provide sound health advice to schools. A directory of
LESUs may be accessed via bit.ly/DOHDirectoryLESU2023.

The DOH-proposed School Early Warning System (SEWS), where school

heads are encouraged to report clusters and cases of unusual health events and
health-related absences, is recommended to be followed as soon as possible. A
list of unusual health events that schools shall report to the LESUs can be
found in Annex F.

VI. Risk Communication and Community Engagement

A. Implementing units shall utilize the communication products (bit.ly/RCCE-Influenza

and bit.ly/RCCE-InfluenzaVax) to increase awareness on influenza and generate
demand forthe influenza vaccines. Online and offline platforms shall be leveraged as
appropriate, especially to reach the vulnerable populations identified in Section
II.A.4.

B. CHDs shall localize the available communication products as relevant to their

communities and their information needs, while ensuring that the following
communication objectives are met:

a. Individuals should be aware of the risk of influenza, ILIs, and SARI, including
their susceptibility and severity of these diseases
b. Individuals are aware of important measures that they can take for protection,
including the following:
i. Protective measures such as individual behaviors and environmental
controls that can be applied in the household, as well as school and
childcare institutions.
ii. Home management for individuals exhibiting symptoms, and
protective behaviors that caregivers can take as self-protection.
iii. Healthcare workers must be aware of protective behaviors while in
health facilities.
Individuals must be aware of access sites for vaccination services, including
the time in whichfacilities are available to administer vaccines.
Further, individuals must also be aware and encouraged to consult their
nearest primary care provider should they feel the need to.
i. Ensure that individuals experiencing symptoms consult with the
nearest primary care provider or call DOH National Patient Navigation
 and Referral Center through 1555 and select option (2) for immediate
and proper assessment as well as corresponding management and
interventions.

C, CHDs shall identify strategic partners for community engagement to expand the
reach
of communication products and identify strategies to address possible drivers and
barriers of protective behaviors.

a. Strategic communities and stakeholders such as local chief executives,

government agencies (e.g. the Department of Education, National Commission
of Senior Citizens), medical and allied health societies (e.g. the Philippine
Pediatric Society, Inc., Integrated Midwives Association of the Philippines,
other specialty societies), faith-based organizations, patients groups, etc. that
can support in reaching vulnerable populations.
b. Community engagement activities may include evidence generation for drivers
and barriers to protective behaviors (a rapid assessment tool is available in the
community toolkit), identification of local-level interventions such as town
halls, use of public announcement systems and other mainstream broadcast
media, and monitoring of planned interventions.

D. CHD Communication Management Units shall manage crisis communications with

clearance from the DOH Communication Office (COM).

For guidance and dissemination.

By Authority of the Secretary of Health:

Digitally signed by

oe Vergeire Maria Rosario

II
Singh
MARIA ROSARIO SINGH-VERGEIRE, MD, MPH, CESO
Undersecretary of Health
Public Health Services Team

10
Annex A. Clinical Manifestations and Differential Diagnoses

Influenza Rhinovirus Adenovirus Respiratory Syncytial Parainfluenza Human COVID-19

Virus (RSV)
-

Inetapneumoyirus

Symptoms Fever, cough with or Symptonis of runny nose, sore throat. cough, wheeze. sometimes lethargy. body aches and fever, with or without gastrointestinal symptoms.
without sputum,
hoarseness, nasal Change in or loss of taste or smell is more frequent with COVID-19 than flu.
discharge/ congestion,
shortness of breath,
wheezing, sneezing,
sore throat, diarrhea

Incubation
Period
Median: 2 days (range
1-9 days)
12 hours to 5 days 12 hours to 5 days Up to 8 days 2 to 6 days 12 hours to 5 days Up
to 14 days

Period of Starts with the onset of Often begin 12-24 hours prior to symptom onset until 5 days afterwards 2 days prior to
infectiousness: IL] symptoms and last symptom onset
for the entire duration of until 10 days after
symptoms symptom onset

Transmission Primarily via droplet Droplet transmission, Droplet transmission, Droplet transmission, Direct contact with Droplet Droplet
transmission when in direct contact, indirect direct contact, indirect direct contact, indirect infectious droplets or by transmission, direct transmission
close contact or direct contact with contact with contact with airbome spread contact, indirect
interpersonal contact. contaminated surfaces contaminated surfaces contaminated surfaces contact with
Can also occur through contaminated
aerosols and indirect surfaces
contact with
contaminated surfaces
. .
Vaccine Available None None for the general Available in the US None None Available
public (for pregnant women
and older adults}

‘Treatment Empiric antiviral Supportive treatment Supportive treatment Supportive therapy Supportive treatment Supportive treatment Treatment
therapy ideally within Nirsevimab (for severe according to the
48 hours of symptom RSV disease) COVID-19 Living
onset (e.g. oseltamivir) Guidelines
Supportive treatment

I
Annex B. Considerations in the Provision of Post-exposure Antiviral Chemoprophylaxis

Post-exposure chemoprophylaxis Asymptomatic adults and children aged >3

months with the following conditions after
household exposure to influenza:
® With very high risk of developing
complications from influenza (e.g.,
severely immunocompromised persons)
© Contraindicated to influenza vaccine
e Instances when influenza vaccine
unavailable
is
e Expected to have low vaccine
effectiveness

Post-exposure chemoprophylaxis in Adults and children aged >3 months with the
conjunction with influenza following conditions:
vaccination e@
Unvaccinated
e@
With influenza exposure

Empiric initiation of antiviral treatment as an alternative to postexposure antiviral

chemoprophylaxis
1
©
Annex C. Recommended Dosage and Duration of Influenza Antiviral Medications for
Chemoprophylaxis

Oseltamivir Oseltamivir** Oseltamivir

75 mg once daily 75 mg orally once daily for (3-11 months)
for 7 days 7-10 days 3 mg/ kg/ dose once daily for
7 days

year

old)
Zanamivir* Zanamivir* The dose varies by child’s
10 mg (two 5-mg 10 mg (two 5-mg weight for 7 days:
inhalations) once daily for 7 inhalations) once daily for
days 7-10 days @ 15 kg or less: 30 mg once
. aday
@>15 to 23 kg: 45 mg once
a day
@ >23 to 40 kg: 60
mg once a
day
e@>40 kg: 75 mg once a day

Zanamivir*
(5 years or older)
10 mg (two 5-mg
inhalations) once daily for 7
days

*Not recommended for persons with underlying airway di isease (¢.g., asthma or chronic obstructive pulmonary diseases)
**Considered drug of choice for chemoprophylaxis in pregnant women by the American Society of Obstetrics and
Gynecology and the Infectious Diseases Society of America.

Note: For control of outbreaks in institutional settings (e.g., long-term care facilities for older adults and children) and
hospitals, the US CDC recommends antiviral chemoprophylaxis with oral oseltamivir or inhaled zanamivir for a
ininimum of 2 weeks and continuing up to 1 week after the last known case was identified.

13
Annex D. Patients at High-Risk for Influenza Complications
HIGH-RISK GROUPS
(RECOMMENDED TO RECEIVE EMPIRIC ANTIVIRAL
INFLUENZA)
TREATMENT FOR
_
e Adults 65 years and older
¢ Children younger than 2 years old!
e@
Asthma
e@
Neurologic and neurodevelopment conditions
e Blood disorders (such as sickle cell disease)
@ Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic
fibrosis)
e Endocrine disorders (such as diabetes mellitus)
e Heart disease (such as congenital heart disease, congestive heart failure and coronary artery
disease)
@
Kidney diseases
e Liver disorders .

® Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)

e@
People whoare obese with a body mass index [BMI] of 40 or higher
e@
People younger than 19 years old on long-term aspirin- or salicylate-containing
medications.
e People with a weakened immune system due to disease (such as people with HIV or AIDS,
or some cancers suchas leukemia) or medications (such as those receiving chemotherapy
or radiation treatment for cancer, or persons with chronic conditions requiring chronic
corticosteroids or other drugs that suppress the immune system)
People who have had stroke
Pregnant people and people up to 2 weeks after the end of pregnancy
People who live in nursing homes and other long-term care facilities
all
‘Although children younger than 5 years old are considered at higher risk for
complications from influenza, the highest risk is for those younger than 2 years old, with
the highest hospitalization and death rates among infants younger than 6 months old.
Because many children with mild febrile respiratory illness might have other viral
infections (e.g., respiratory syncytial virus, rhinovirus, parainfluenza virus, or human
metapneumovirus), knowledge of other respiratory viruses as well as influenza virus strains
circulating in the community is important for treatment decisions.
e@
People from certain racial and ethnic minority groups are at increased risk for
hospitalization with influenza, including non-Hispanic Black persons, Hispanic or Latino
persons, and American Indian or Alaska Native persons
«

Adapted from: US Centers for Disease Control and Prevention. September 27, 2023. Influenza Antiviral
Medications: Summary for Clinicians.
https: flu/prof Is/antiviral celine:

14
Annex E. Antiviral Therapies for Influenza

Oseltamivir Adults: 75 mg orally twice daily Children:

for 5 days (extended duration up <8 months: 3 mg/kg/ dose orally
PNF Status: to 10 days may be considered in twice daily
Listed patients with severe disease, >9 months: 3-3.5 mg/kg/dose orally
FDA: with CPR particularly if twice daily
immunosuppressed) <15 kg: Oral: 30 mg orally twice
daily.
>15 to 23 kg: Oral: 45 mg orally
twice daily.
>23 to 40 kg: Oral: 60 mg orally
twice daily.
>40 kg: Oral: 75 mg orally twice
daily.

Zanamivir Adults: 10 mg (two 5 mg Children >7 years and Adolescents: Oral

PNF Status: Not inhalations) twice daily for 5 inhalation: Two 5-mg inhalations (10 mg)
Listed days twice daily for 5 days; doses the first
on

FDA: with CPR day should be separated by at least 2 hours;

on subsequent days, doses should be spaced
by ~12 hours.

Paremivir Adults: 600 mg intravenously as Children 6 months to 12 yrs of age: One 12

a single dose mg/kg dose, up to 600 mg maximum, via
PNF Status: Not intravenous infusion for a minimum of 15
listed minutes
FDA: No CPR
(US FDA approved and recommended
for use in children 6 months or older)
Baloxavir Adults: Children 5 yrs and older weighing <20 kg:
40 kg to <80 kg: 40 mg orally as single dose of 2 mg/kg by suspension;
PNF

Listed
Status: Not a single dose
280 kg: 80 mg orally as a single
Children5 years and older weighing 20 kg
to <80 kg: single dose of 40 mg tablet or
by

FDA: Expired dose suspension

CPR Children 5 years and older weighing >80
kg: single dose of 80 mg by tablet or
suspension}

(US FDA approved and recommended

for use in otherwise healthy children 5
yrs and older.)

Note: Oseltamivir and peramivir should be dose-adjusted in patients with renal impairment
Adapted from: US Centers for Disease Control and Prevention. September 27, 2023. Influenza Antiviral
Medications: Summary for Clinicians.
https: cde.gov/flu/professi ntiviral mmary-clinicians.h

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Annex F, Surveillance Case Definitions

Influenza-like Illness (LI)

Suspect Case: Any person with an acute respiratory infection with ALL
of the following:
a. Measured fever of >38°C;
b. Cough or
sore throat; AND
c. With symptom onset within the last 10 days.

Severe Acute Respiratory Infection (SARI)

Suspect Case: of the following:

Any

a. Any
person older than five years old with ALL of the following:
i. Acute respiratory infection with history of fever or measured fever of >38°C
and cough;
ii. With onset within the last 10 days; AND
iii. Requires hospitalization.
b. Any child 2 months to 5 years of age with cough or difficulty of breathing AND:
i. Breathing faster than 60 breaths/min (for infants aged < 2 months)
ii. Breathing faster than 50 breaths/min (for infants aged 2-12 months)
iii. Breathing faster than 40 breaths/min (for children aged 1-5 years old)
iv. Requires hospitalization
c. Any child 2 months to 5 years of age with cough or difficulty of breathing and
ANY
ofthe following danger signs:
i. Unable to drink or breastfeed;
ii. Vomits everything;
iii. Convulsions;
iv. Lethargic or unconscious;
y. Chest in-drawing or stridor in a calm child;
vi. Requires hospitalization.

Probable Case: A person fitting the definition above of a “Suspect Case” fulfilling ALL
of the criteria:
a. With clinical, radiological, or histopathological evidence of pulmonary parenchyma
disease (e.g., pneumonia or ARDS) but no possibility of laboratory confirmation
either because the patient or samples are not available or there is no testing
available for other respiratory infections;
b. Close contact with a laboratory-confirmed case; AND,
c. Condition not already explained by any other infection or etiology, including
alternative clinically-indicated tests for community-acquired pneumonia according
to local management guidelines.

Confirmed Case: A suspected case that is laboratory-confirmed.

Cluster: Three (3) or more cases with onset of signs or symptoms within the same 14-day
period and who are associated with a specific setting, such as a community, classroom,
workplace, household, extended family, hospital, other residential institution, military
barracks or recreational camp.
Source: Philippine Integrated Disease Surveillance and Response (PIDSR) Manual of Procedures (MOP), 3rd
Edition, 2014

16
Note: Case definitions may change without prior notice as the latest scientific consensus on
these diseases evolves. Please consult with the Regional Epidemiology and Surveillance
Units or the Epidemiology Bureau for any questions regarding these case definitions.

17
Annex G. List of Signals in a School for Reporting to ESUs
Signals are raw data or unverified information that tells people that something is happening or
suggesting a possible problem which may represent a potential acute public health risk. These
signals will trigger the LESU to either monitor or investigate once they are detected, by filtering
and verifying the report.

The list of signals in a school setting may include, but are not limited to, the following:

1. Two (2) or more students in a class/section or school employees within seven (7) days with
any of the following:

Influenza-like illness (Fever and cough/cold/sore throat);

of
Respiratory illness (cough, colds, sore throat, difficulty of breathing);
Fever and rash;
eno Blisters on hand, foot, and/or mouth;
Fever or headache with changes in mental status/sensorium, seizures, neck
stiffness, and/or other neurological signs or symptoms.

2. Three (3) or more students in a class/section or school employees who have sudden onset
of gastrointestinal signs and symptoms, which may include watery or bloody diarrhea*,
abdominal pain, and vomiting;

3. Two (2) or more students who developed any signs and symptoms following immunization
and/or deworming in school (Example: Fever, rash, vomiting, abdominal pain, dizziness);

4, One (1) or more student reported to have sudden onset of weakness in the arms and/or legs;
5. Two (2) or more students or school employees who became ill due to heat stroke;
6. Two (2) or more students or school employees who were absent from school due to the
illness within seven (7) days
same

*Criteria for diarrhea: must be three (3) or more episodes in a day

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 References

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https://www.ecdc.europa.eu/en/seasonal-influenza/facts/factsheet
Public Health England. 2020. PHE guidelines on the management of outbreaks of
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https://bit.ly/WHOToolkitforSARI

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 '

15. World Health Organization. 2023. Influenza (Seasonal).

https://www.who.int/news-room/fact-sheets/detail/influenza-(seasonal)#
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