This pilot study is designed to demonstrate the feasibility of utilizing Emergency Departments (EDs) as a primary site for subject enrollment in clinical trials evaluating influenza therapeutics, and to provide pilot data for future clinical trial design and planning.

Primary Objective: To prospectively enroll high-risk subjects with laboratory-confirmed influenza into a randomized, open label study of oral versus IV influenza therapeutic to include symptom evaluation and outcome assessments.

Secondary Objective 1: To identify influenza positive patients utilizing a previously established triage-based assessment and rapid testing algorithm for suspected influenza infection.

Secondary Objective 2: To retrospectively evaluate all potentially eligible patients for potential enrollment biases.

Secondary Objective 3: To create a repository of residual nasopharyngeal samples collected from ED patients with suspected influenza illness.

Title: A Pilot Randomized Controlled Trial for Feasibility of Enrolling Subjects for Influenza Therapeutic Trials and Administering Influenza Antivirals in the Emergency Department to High Risk Subjects

Population: Adults presenting to the emergency department (ED) with laboratory confirmed influenza who meet Centers for Disease Control and Prevention (CDC) criteria for antiviral treatment

Informed consent: Written informed consent

Number of Sites: 2 - large, urban, academically-affiliated, US EDs

Study Duration: November 2015 - June 2018

Subject Participation Duration: 4 weeks

Description of Agent or Intervention: Subjects will be randomized to either oral (oseltamivir) or intravenous (IV) (peramivir) antiviral treatment.

Description of Study Design: This is an open-label randomized controlled clinical trial in which subjects with influenza are randomized to either oral (oseltamivir) or IV (peramivir) antiviral treatment.

Estimated Time to Complete Enrollment: Subject enrollment will occur over two influenza seasons (November 2015 - April 2016 and November 2016 - April 2017) or longer, at the Principal Investigator's discretion, based on influenza prevalence.

Inclusion Criteria:

• Eligible patients include all patients who present to the emergency department (ED) between November and April of each influenza season, or later, at the Co-PIs' discretion, based on influenza prevalence, with the following criteria:

  1. 18 years of age or older
  2. Laboratory confirmed positive influenza test associated with their current ED visit
  3. Symptoms of acute respiratory illness for ≤4 days (96 hours)
  4. Meets CDC criteria for antiviral treatment

• For the purpose of this study, acute respiratory illness is defined as presence of any of the following symptoms: new or increased cough, new or increased shortness of breath, change in sputum production (for adults 65 years or older), sinus pain, nasal congestion, rhinorrhea, sore throat, subjective fever reported at time of triage or documented fever (defined here as ≥ 38 degrees Celsius).

• CDC criteria for influenza antiviral treatment is defined as: being age 65 years old or older, pregnant or less than two weeks postpartum, American Indian or Alaska native, morbid obesity (BMI ≥40), a current resident of nursing home or other chronic-care facility, having chronic pulmonary disease, cardiovascular disease (except hypertension alone), renal disease, hepatic disease, hematologic disease, metabolic disorders, neurologic and neurodevelopment conditions, immunosuppression (including that caused by medications or by HIV infection), being admitted to inpatient or an observation unit, or having a clinical diagnosis of pneumonia (by the ED physician).

Exclusion Criteria:

1. Does not speak and understand English (or English or Spanish)
2. Unable or unwilling to provide informed consent
3. Previously enrolled in the study during the current influenza season
4. Unable to take oral medication
5. Unable to comply with all planned study procedures including availability for follow-up and willingness to complete study diary and self-assessment
6. Use of neuraminidase inhibitors within the past seven days
7. Known allergic reaction to neuraminidase inhibitors
8. Pregnant or breastfeeding
9. End-stage renal disease, defined as 9a. Currently undergoing dialysis (either hemo or peritoneal); or 9b. Creatinine clearance (CrCl) of <10 mL/min.
10. End-stage liver disease, as determined by the treating ED provider
11. Glucose-6-phosphate dehydrogenase (G6PD) deficiency by patient report
12. Immunodeficiency, defined as:

12a. Solid organ transplant patients receiving immunosuppression; 12b. Hematopoietic stem cell transplant patients within 12 months of transplant or with ongoing immunosuppression; 12c. Oncology patients who have had chemotherapy within the past 30 days; 12d. Current treatment with steroids equivalent to 10 mg of prednisone or more per day for greater than two weeks; 12e. Rheumatologic patients receiving immunosuppressive therapy; or 12f. HIV patients who meet one of the following criteria: 12fi. Have a cluster of differentiation 4 (CD4) cell count of <200 cells/mm3 within the past 3 months ; 12fii. Not actively receiving highly active antiretroviral therapy (HAART); or 12fiii. Have an absolute lymphocyte count <1.0 x 103 cells/μL conducted at the current ED visit

For baseline analyses, overall characteristics (seasons 2015-2016 & 2016-2017) & characteristics stratified by influenza season (2015-2016 vs. 2016-2017) are presented. Total number of subjects contributing data to 2015-2016 baseline analyses was 58, compared to 121 subjects for 2016-2017 season. Information unavailable: 1 oseltamivir participant

Accrual for the 2015-2016 influenza season opened on 11/1/2015 and closed on 4/30/2016. Accrual for the 2016-2017 influenza season opened on 11/1/2016 and closed on 4/30/2017. All enrolled participants were assessed for adverse events from enrollment visit until the end of study follow up on Day 28.

1. Not designed or powered to assess differences in clinical outcomes.
2. Planned to recruit >= 50 subjects/site, but MMC enrolled 44 due to lower-than-expected flu incidence and Hopkins Uni. increased enrollment to make up for the shortfall.