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Hot Topic Meeting by: Royal College of Physicians of Edinburgh & The Scottish Executive Health Department Pandemic Flu Planning Scotland’s Health Response 5th June 2007 Queen Mother Conference Centre Clinical characteristics of ‘Flu’ Dr Dermot H Kennedy Consultant Physician in Infectious Diseases (Retd.) Glasgow “Influenza A is an unvarying disease due to a varying virus” E. Kilbourne New York 1975 Variation Complicated: - by pandemic virus - by co-infecting bacteria - by risk factors Uncomplicated: - by age - by virus type THE MENU Clinical features of: • Typical influenza A - milder complications • Serious complications - respiratory - non respiratory • Variation by pandemic outbreak Clinical Spectrum of Influenza A Incidence / range of systemic features Collated from 10 studies of 520 virologically confirmed adult cases 1937-1992 ( after Nicholson Ch. 19 in ‘Human Influenza’ ) MILDER COMPLICATIONS OF INFLUENZA A - TRACHEOBRONCHITIS - OTITIS MEDIA - SINUSITIS - POST INFLUENZAL ASTHENIA AND DEPRESSION Who is at risk of influenza? ‘Typical’ Influenza A: Pandemic Influenza • As across • + young adults • +pregnant women Peak mortality 1918 • • • • Age <2 >65yrs Chronic disease : respiratory, cardiac, renal, diabetes, immunosuppression ‘at risk’ settings Risk factor influences presentation / complications SERIOUS COMPLICATIONS OF INFLUENZA A RESPIRATORY: . 2y bacterial pneumonia . 1y viral pneumonitis . Mixed viral and bacterial pneumonia . Exacerbation of COAD, asthma NON RESPIRATORY: . CNS eg encephalopathy, myositis . CARDIAC eg decompensated CCF Complications of Influenza A Infection 2y pneumonia due to bacterial suprainfection The problem : 2y BACTERIAL PNEUMONIA • Influenza A accounts for 5→10% of all C.A.P. • Biphasic disease – usually • Pattern different from “CAP norm”, and between pandemics • Pneumococcal pneumonia commonest 2y bacterial pneumonia pneumococcus H.influenza Staphylococcal pneumonia complicating Influenza A A sinister synergy Complications of Influenza A Virus Iy Pneumonitis due to virus What is role of cytokine storm? Often fulminant and fatal Dyspnoea, wheeze, cyanosis, blood Diffuse CXR infiltrates (like ARDS) Pregnant, cardiac, young Pandemic Influenza 1918/19 Morbidity Mortality • Global mortality 23-50M • Occurred in 3 waves • Globally estimated 750m-Ib. ill • UK mortality 240K • Peak mortality - young adults 1918/19 Spanish ‘flu - Heliotrope cyanosis “We have always been thankful when (facial) colour remains red …there is ample room for hope of recovery When the colour of the patient’s face is heloitrope or mauvy-blue the prospect is grave indeed…” Features Avian Influenza H5/N1 - Z genotype traced to geese in Guangdong, China 1996 1997: Hong Kong - 6/18 fatal (33%) 2003/7: Asia - 175/290 fatal (60%) Majority < 25yr old Severe disease in: older, late presentation + pneumonia, leuko/lymphopenia (16%) Vietnamese cases – encephalopathy + diarrhoea Multi system involvement and Multi organ damage at Post Mortem COMPARING PANDEMICS UK MORTALITY ’18/’19 240k ’57/’58 33k ’68 30k AGE Young Elderly Elderly adult (young) (young) S. pyogenes S. aureus S. aureus E+W ‘notable’ BACTERIA + others Hot Topic Meeting by: Royal College of Physicians of Edinburgh & The Scottish Executive Health Department Pandemic Flu Planning Scotland’s Health Response 5th June 2007 Queen Mother Conference Centre