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National Certification Corporation
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NOVEL INFLUENZA 2009 (H1N1)
NOTE: The following document reflects current knowledge of the 2009 H1N1 Influenza
Pandemic in the United States, based on data released by the Centers for Disease Control, the
American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists.
It is intended to aid in assessing and managing patients and is not intended to represent
standards of care or practice protocols. “Variations in practice may be warranted based on the
needs of individual patient, resources and limitations unique to the institution or type of practice”
(ACOG, Oct 15, 2009). Therefore these recommendations are considered interim guidance and
are subject to revision as newer data become available. Users are strongly advised to consult
CDC, ACOG, and AAP websites and publications as well as local and state health departments
for updates.
Background
A novel strain of Influenza A (formerly called SWINE FLU) was identified as the cause of
human illness in Mexico and the United States in April of 2009. By May 6 there were
approximately 2000 cases world-wide and 642 cases in the U.S. The 2009 outbreak of H1N1
has been declared pandemic which is defined as sustained community-level outbreaks of a new
flu virus in two or more regions of the world. Flu epidemics exclude seasonal flu; H1N1 differs
from seasonal flu because of the severity of symptoms and occurrence of complications.
By the end of July 2009, 43,677 laboratory confirmed cases of H1N1 were reported in
the U.S. On Oct 28 the CDC (2009a) announced that this was a substantial underestimate and
the true number of cases was closer to 1.8 to 5.7 million based on a study by Reed et al (2009).
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It is important to have accurate estimates of the true numbers of affected people to be able to
provide and plan for needed services. For a complete review of history and epidemiology of
H1N1 Influenza see Carlson et al, 2009, Wilkinson et al, 2006, & Labant & Greenawalt, 2009.
Table 1 compares the seasonal influenza with Pandemic Influenza H1N1.
Etiology
Vaccine
Symptoms
Complications
Seasonal Influenza A & B
Have previously caused
human illness
Available
Cough, fever, headache,
malaise, myalgia, rhinitis,
sore throat, GI symptoms
Unusual in healthy adults
Pandemic Influenza H1N1
Novel influenza virus –
population lacks previous
exposure
Available
Similar to seasonal flu; but
may be more severe
Increased risk for serious
complications in previously
healthy adults
Impact on society
Generally minimal
May lead to alterations in
patterns of daily life;
business & school closures;
possibility of quarantines,
restricted travel & public
gatherings to limit spread;
disruption of basic services
& access to supplies
Based on (CDC, 2009b; DHHS, 2009; Labant & Greenwalt, 2009)
Influenza viruses, RNA viruses, are classified into 3 groups or genera: A, B, and C.
Influenza types A and B cause human illness, particularly seasonal flu. The dominant strains of
each virus are included in yearly flu vaccines. Type C influenza virus produces mild symptoms
in humans or no illness at all (CDC, 2007).
Influenza Type A is further divided into subclasses based on the presence of 2
antigenically distinct surface proteins; hemagglutinin (H) and neuraminidase (N), which are key
virulence factors (Wilkinson, Buttery, & Andersen, 2006). Since there are 16 discrete
hemagglutinin and 9 neuraminidase subtypes many different arrangements of these surface
proteins are possible. Thus there are different types of Influenza A. H1N1 denotes the subtype
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of influenza A characterized by hemagglutinin 1 and neuraminidase 1; while avian influenza,
H5N1 (bird flu), contains hemagglutinin 5 and neuraminidase 1.
Influenza viruses evolve continuously and mutation can occur suddenly or gradually.
When a mutation is slight it is called an antigenic drift. Seasonal influenza vaccines are subject
to yearly modification because of antigenic drift. A significant mutation is called antigenic shift.
Antigenic shift is the result of mutations of nonhuman (swine, avian) viruses or the
rearrangement of human and nonhuman viruses. These mutations or rearrangements create
novel subtypes; influenza H1N1 is a genetic mixture of swine, bird, and human viruses. The
ability of the human immune system to identify and destroy this virus is limited (Carlson, Thung,
& Norwitz, 2009; Labant & Greenwalt, 2009).
Groups considered at high risk for severe complications and mortality
from Pandemic Influenza (H1N1)
Severe illnesses among pregnant women and infants have been reported. The
epidemiology and range of illnesses are, as yet, unknown and subject to investigation. However
children younger than 2 years of age, pregnant women, and women up to two weeks
postpartum are considered to be at high risk for severe illness, influenza-related complications,
and death. Women who experience pregnancy loss should be included in this group (CDC,
2009c). Local Public Health authorities may provide additional information about other groups at
high risk within their jurisdictions.
Susceptibility in pregnant women
The fact that the immune system is altered during pregnancy may cause increased
severity of illness. Cardiovascular and respiratory changes accompany pregnancy (increased
heart rate, stroke volume, oxygen consumption; decreased lung capacity) which may raise risk
factors.
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Pregnant women do not seem to be at increased risk of contracting influenza compared
with the general population. However they do have increased risk of complications from any
type of influenza, especially in the third trimester. Pregnant women have a higher rate of
hospitalization (four-fold) and higher mortality rates. Jamieson and colleagues revealed that by
October 1, 2009, there were 28 deaths from H1N1 among pregnant women, representing 13%
of all H1N1 deaths. The women were reported to be fairly healthy prior to contracting influenza.
Complications usually involve the respiratory system (pneumonia) or predispose to
preterm labor or premature rupture of membranes. The majority of maternal deaths occurred in
the 3rd trimester from complications of viral pneumonia and ARDS (2009). Testing for H1N1 and
beginning antiviral medications are therefore recommended for pregnant women with influenzalike illnesses (ILI) (CDC, 2009c).
Vulnerability of newborns
Influenza is not a common illness among newborn infants presumably due to the
reduced contact between neonates and ill adults and children. There are reports of spread of
influenza A in neonatal units (Bauer, Elie, Spence, & Stern, 1973; Cunney, Bialachowski,
Thornley, Smaill, & Pennie, 2000; Munoz, et al., 1999; Sagerera, et al., 2002). Risk factors for
infection were identified as mechanical ventilation, multiple gestation, prematurity, and low birth
weight (Cunney, et al., 2000).
Clinical presentation of H1N1 in adults
People with uncomplicated influenza may experience fever, chills, headache, cough, sore
throat, and rhinorrhea, shortness of breath, myalgia, arthralgia, fatigue, abdominal pain,
vomiting, or diarrhea. Some patients have respiratory symptoms without fever.
Clinical presentation of H1N1 in newborns
The spectrum of H1N1 illness in newborns is not yet fully known and is subject to
investigation. However the clinical features of influenza in neonates mimic those of sepsis
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(Wilkinson, et al., 2006): respiratory distress, hemodynamic instability, metabolic derangements,
feeding intolerance, altered CNS status, and changes in behavior.
Diagnostic tests for 2009 Pandemic H1N1
According to the CDC most patients with clinical illness consistent with uncomplicated
influenza living in an area where influenza viruses are circulating do not require diagnostic
testing for clinical management. However testing should be considered when the decision is
made to treat with antiviral medications for influenza. Treatment should be initiated without
waiting for test results (CDC, 2009d).
There are several types of diagnostic tests available:
1. Rapid influenza diagnostic test (RIDT)
2. Direct immunofluorescence assay (DFA)
3. Nucleic amplification tests such as real-time reverse transcriptase polymerase chain
reaction (rRT-PCR)
4. Viral cultures
RIDT or DFA tests have high specificity but variable sensitivity. They are useful as rapid
screening tools; results are available within 0.5 to 4 hours. A positive result indicates influenza
virus but does not reveal the type of viral infection. Negative results do not rule out Pandemic
H1N1. Nucleic amplification tests are the most sensitive and specific but results may not be
available for several days. The current CDC recommendations specify that if identification of
H1N1 is required, testing with rRT-PCR assay specific for 2009 H1N1 influenza or viral culture
should be performed.
Testing is performed on specimens from the upper respiratory tract and should be collected
using swabs with synthetic tips (polyester or Dacron) on plastic or aluminum shafts (CDC,
2009d; Labant & Greenwalt, 2009).
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Current CDC recommendations for management of Pandemic 2009
H1N1 Influenza in intrapartum and postpartum hospital settings (CDC,
2009h)
The CDC provides guidance for prevention and management of novel H1N1 flu infection
in inpatient and outpatients at higher risk for complications. Both passive (signage) and active
screening (interview and assessment) and limited points of entry (one established triage area)
are recommended. Facilities are advised to implement mechanisms to identify and isolate ill
patients, visitors, and staff. The risk of contact with H1N1 influenza virus should be minimized
for pregnant women and newborns.
Healthy pregnant women and infants who have NOT been in close contact with persons
with suspected, probable, or confirmed cases of H1N1 flu should be managed in the usual
manner according to established infection control guidelines. This should include: hand hygiene,
respiratory hygiene and cough etiquette, avoidance of close contact (3 – 6 feet distance), use of
PPE (face masks for patients, fit-tested N95 respirators for staff (CDC, 2009i)), isolation
precautions (standard, contact, droplet).
Care of Suspected or Confirmed H1N1 Influenza Infected Mother and
Newborn in Stable Condition in Labor & Delivery, Recovery, and
Postpartum Settings.
Labor/Antepartum (CDC, 2009h, 2009i)
Single patient room, when possible or cohort
Facemask for patient when outside room
Staff use of fit-tested respirator within 6 feet of patient
Standard precautions for all patient care
Diagnostic testing and immediate empiric antiviral therapy with neuraminidase inhibitor;
do not delay antiviral therapy pending diagnostic testing results
Allow presence of healthy adults who are necessary for woman’s emotional well-being
and care
Educate patient and family of procedures for infection control for mother & newborn
Encourage breastfeeding as an important method of protection for the infant (Lawrence
& Bradley, 2009)
Delivery/Intrapartum Setting
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There are no reports of H1N1 influenza infection in the fetus transmitted via the
placenta. However, the neonate may be exposed to infected respiratory secretions from a
symptomatic mother through droplet transmission. The newborn is immunologically immature
and, although maternal antibodies may have been acquired during the 3rd trimester, may still
lack sufficient immunologic competence against H1N1. To protect the infant from exposure to
respiratory secretions the following guidelines are recommended:
Delivery/Intrapartum (CDC, 2009h)
Mother wears a facemask throughout labor, as tolerated, and when outside room
Single patient room, when possible or cohort
Staff use of fit-tested respirator within 6 feet of patient, wear surgical mask with face
shield, gloves, and gown during delivery
Immediately place newborn on open warmer at least 6 feet away from the mother
Stable neonates may remain in delivery area prior to transfer to newborn nursery
Bathe the neonate as soon as temperature is stable
Recovery/Postpartum Setting
The CDC recommends a two-step process for management of postpartum women and
their newborns. Step 1 is reviewed in this section; Step 2 is addressed below.
Recovery/Postpartum (CDC, 2009h)
Step 1: Consider temporary separation of mother and newborn until ALL of the following criteria
have been met:
The mother has received antiviral medication for at least 48 hours AND;
She is fever-free for 24 hours without the use of antipyretics AND;
She is able to control coughing and respiratory secretions
When these criteria are met, close contact between mother & infant may begin.
The most appropriate placement of mother and infant should be based on hospital
configuration and current infection control practices. It is acceptable to place the infant in an
incubator in the mother’s room. If incubators are not available, the neonate can be placed in an
open bassinet at a distance of greater than 6 feet from the mother, “ideally separated by a
Plexiglas barrier or curtain. Depending on staff/resources, the newborn may also be placed in
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separate room, including the newborn nursery using standard precautions. Infant care should be
provided by a healthy family or staff member” (CDC, 2009i, p. 5).
Newborn Care/Infant Feeding Considerations (CDC, 2009h)
Healthy term newborns of infected mothers with suspected or confirmed H1N1 influenza
are considered EXPOSED, rather than infected, providing they are delivered in the inpatient
setting when infection control guidelines have been followed. Although these infants should be
monitored for signs of infection, they may be housed in the term nursery and cared for using
standard precautions. If the infant is temporarily separated from his mother, feeding should be
provided by a healthy caregiver until criteria are met for close contact.
Step 2: The following guidelines are recommended when close contact is permissible to protect
the newborn from droplet exposure. The baby should be brought to the mother’s room and she
should avoid visiting the newborn nursery.
Immediately before feeding and/or caring for her newborn, the mother should:
Wash hands with soap and water
Put on a face mask
Observe respiratory hygiene/cough etiquette
These precautions should be continue for 7 days after symptom onset or 24 hours after
resolution of symptoms whichever is longest
If the infant develops symptoms of influenza, he/she should be tested for influenza virus
infection (CDC, 2009e).
Antiviral Treatment & Chemoprophylaxis for Infants Younger than 1
Year of Age
Current CDC Recommendations Include (CDC, 2009g)
Oseltamivir (TamiFlu) has been authorized by the FDA for emergency use in infants
younger than 1 year of age.
Age
Recommended Treatment Dose
Recommended Prophylaxis Dose
(5 days) twice daily
(10 days) once daily
Under 3
12 mg
Not recommended; limited data on
months
use in this age group
3–5
20 mg
20 mg
months
6 – 11
25 mg
25 mg
months
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Antiviral Treatment for Pregnant Women and New Mothers
Current CDC Recommendations Include (CDC, 2009g)
Empiric antiviral treatment initiated as soon as possible after the onset of influenza
symptoms, ideally within 48 hours, regardless of gestational age.
Treat for 5 days with oseltamivir (TamiFlu) 75 mg capsule twice per day or zanamivir
(Relenza) 10 mg (two 5-mg inhalations) twice per day. Both drugs are in Category C.
Oseltamivir may be preferred due to higher systemic absorption, may suppress viral
loads more effectively
Lower serum concentrations achieved with zanamivir; may be preferred when concern
exists over potential in-utero fetal exposure (e.g. 1st trimester)
Do not delay antiviral treatment pending results of laboratory testing
A negative rRT for influenza does not rule out H1N1
Post-Exposure Antiviral Chemoprophylaxis for Pregnant Women and
New Mothers
Current CDC Recommendations Include (CDC, 2009g)
Do not wait for test results to begin prophylaxis
Consider 10 day course of oseltamivir (TamiFlu) 75 mg capsule once per day or
zanamivir (Relenza) 10 mg (two 5-mg inhalations) once per day.
Zanamivir may be preferred because of lower systemic concentrations, NOT
recommended for women with asthma or underlying respiratory disorder
Risk of H1N1 influenza is lowered with chemoprophylaxis but not eliminated. Immunity
from infection is not conferred, protection ceases when medication is discontinued
Visitation, Hospital Discharge, and Home Considerations
Maternity and neonatal services are strongly urged to restrict visiting for all areas during
influenza season (ambulatory, inpatient, birthing units, nurseries and NICUs). Limit hospital
visitors to healthy persons who are necessary for patient’s care and emotional well-being.
Educate mother, family and other caretakers on techniques to prevent transmission of H1N1
influenza virus and how to recognize signs of illness in the newborn after discharge. Assure
timely postpartum and newborn follow-up visits. Encourage breastfeeding and refer mother for
lactation consultation as needed.
All persons in the home with suspected or confirmed H1N1influenza infection should
avoid close contact with the newborn until they have been free of fever for 24 hours without
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medication or until 7 days after symptom onset, whichever is longer. If avoidance is not
possible, contacts should perform careful hand hygiene, environmental hygiene, respiratory
hygiene, and cough etiquette. All persons who live with or provide care for infants younger than
6 months of age should be vaccinated against H1N1 influenza as well as seasonal influenza.
H1N1 Exposed Preterm Neonates
All exposed preterm neonates should be closely monitored, placed in incubators,
isolated or cohorted. Caretakers are advised to wear eye shields and fit-tested N95 respirators.
Contact and droplet precautions should be enforced and antiviral treatment considered.
Recommendations for Breastfeeding (Lawrence & Bradley, 2009)
Breastfeeding should be encouraged as human milk conveys immune protection to
neonates. H1N1 influenza virus does not pass through human milk however the close contact
between mother and newborn can facilitate transmission of the virus.
Breastfeeding and H1N1
Careful hand washing prior to any contact
Wash breast with soap and water; rinse well
Mother should wear a surgical mask to prevent inoculation of newborn
Use clean blankets and burp cloths for each contact
Monitor compliance while on inpatient units
Antiviral medication is not a contraindication
If the mother is too ill to directly nurse the infant she can express milk; wear mask and
gloves while collecting milk
Containers with expressed human milk should be wiped down and stored separately
Healthy persons should feed EHM to the infant until the mother improves
H1N1 Influenza Vaccine and Seasonal Influenza Vaccine (CDC, 2009j)
There are separate vaccines available for H1N1 Influenza and seasonal flu; both are
recommended for pregnant and breastfeeding women and women up to 2 weeks postpartum.
Since infants younger than 6 months of age are ineligible for the vaccine, everyone who lives
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with or cares for an infant less than 6 months of age should also receive the vaccine. H1N1
monovalent flu vaccine has not shown to cause harm to pregnant women or their babies.
Adjuvants are substances added to vaccines to increase their effectiveness. There are
no adjuvants in either the H1N1 influenza vaccine or the seasonal influenza vaccine. Multi dose
vials of flu vaccine contain the preservative thimerosal to prevent bacterial growth. Since there
are concerns regarding exposure to thimerosal during pregnancy, preservative free vaccine has
been manufactured. The 2009 H1N1 influenza vaccine in a single dose syringe is preservative
free. There is no evidence that thimerosal is harmful to pregnant women or fetuses; the CDC
recommends pregnant women receive the vaccine either with or without preservative.
There is a nasal spray vaccine available for both H1N1 influenza and seasonal flu. Nasal
sprays contain live attenuated viruses and are NOT licensed for use in pregnant women. After
delivery women can receive the nasal spray even if they are breastfeeding. Inactivated seasonal
flu vaccine and H1N1 monovalent vaccine may be administered on the same day, but given at
different sites. Co-administration of two live vaccines on the same day is not recommended;
they should be separated by at least 4 weeks.
Pregnant women are not known to have an increased risk of side effects from vaccines.
Clinically significant adverse effects following vaccination should be reported to the Vaccine
Adverse Event Reporting System (http://vaers.hhs.gov/)
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References
Bauer, C. R., Elie, K., Spence, L., & Stern, I. (1973). Hong Kong influenza in a neonatal unit.
JAMA, 223(11), 1233 - 1235.
Carlson, A., Thung, S. F., & Norwitz, E. R. (2009). H1N1 influenza in pregnancy: What all
obstetric care providers ought to know. Reviews in Obstetrics and Gynecology, 2(3), 139
- 145.
CDC (2007, December 20, 2007). Types of influenza viruses Retrieved Nov 10, 2009, from
http://www.cdc.gov.flu/about/viruses/types.htm
CDC (2009a, October 28, 2009). Questions and answers: EID article "Estimates of the
prevalence of pandemic (H1N1) 2009, United States, April-July 2009" Retrieved
November 5, 2009, from http://www.cdc.gov/h1n1flu/eid_qa.htm
CDC (2009b). Clinical signs & symptoms of influenza Retrieved November 5, 2009, from
http//:www.cdc.gov/flu/professionals/acip/clinical/htm
CDC (2009c, October 16, 2009). Updated interim recommendations for the use of antiviral
medications in the treatment and prevention of influenza for the 2009-2010 season
Retrieved November 8, 2009, from http://www.cdc.gov/h1n1flu/recommendations.htm
CDC (2009d, September 29, 2009). Interim recommendations for clinical use of influenza
diagnostic tests during the 2009-10 influenza season Retrieved November 8, 2009, from
http://www.cdc.gov/h1n1flu/guidance/diagnostic_tests.htm
CDC (2009e). Interim guidelines on specimen collection, processing, and testing for patients
with suspected novel influenza A (H1N1) virus infection Retrieved November 8, 2009,
2009, from http://www.cdc.gov/h1n1flu/specimencollection.htm
CDC (2009g, October 16, 2009). Recommendations for use of antiviral medications for the
management of influenza in children and adolescent for the 2009-2010 season-Pediatric supplement for health care providers Retrieved November 8, 2009, from
http://www.cdc.gov/h1n1flu/recommendations_pediatric_supplement.htm
CDC (2009h, November 11, 2009). Interim guidance: Considerations regarding 2009 H1N1
influenza in intrapartum and postpartum hospital settings Retrieved november 20, 2009,
from http://www.cdc.gov.h1n1flu/guidance/obstetric.htm
CDC (2009i, September 24, 2009). Interim recommendations for facemask and respirator use to
reduce 2009 influenza A (h1n1) virus transmission Retrieved November 21, 2009, from
http://www.cdc.gov/h1n1flu/masks.htm
CDC (2009j, November 2, 2009). 2009 influenza vaccine and pregnant women: Information for
health care providers Retrieved November 21, 2009, from
http://www.cdc.gov/h1n1flu/vaciicination/providers_qua.htm
Cunney, R. J., Bialachowski, A., Thornley, D., Smaill, F. M., & Pennie, R. A. (2000). An outbreak
of influenza A in a neonatal internsive care unit. Infect Control Hosp Epidemiol, 21(7),
449 - 454.
DHHS, U. S. (2009). Retrieved November 5, 2009, from http://www.hhs.gov/news/press
Jamieson, D. J., Honein, M. A., Rasmussen, S. A., & al, e. (2009). Novel influenza A (H1N1)
pregnancy working group. H1N1 2009 influenza virus infection during pregnancy in the
USA. Lancet, 374, 451 - 458.
Labant, A., & Greenwalt, J. A. (2009). Pandemic flu. A major concern for pregnant women.
Nursing for Women's Health, 13(5), 374 - 382. Retrieved from http://nwh.awhonn.org
Lawrence, R. A., & Bradley, J. S. (2009). Breastfeeding advice for mothers with possible H1N1
infaction. AAP News, 30(11), 11.
Munoz, F. M., Campbell, J. R., Atmar, R. I., Garcia-Prats, J., Baxter, B. D., Johnson, L. E., et al.
(1999). Influenza A outbreak in a neonatal intensive care unit. Pediatr Infect Dis J, 18(9),
811 - 815.
NCC Update of H1N1 Influenza -12/2009
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© National Certification Corporation (NCC) 2009
Reed, C., Angulo, F.J., Swerdlow, D.L., Lipsitch, M., Meltzer, M.I., Jernigan, D., Finelli, L.
(2009). Estimates of the prevalence of pandemic (H1N1) 2009, United States, April-July
2009. Emerg Infect Dis. doi:10.3201/eid1512.091413
Sagerera, X., Ginovart, G., Raspall, F., Rabella, N., Sala, P., Sierra, M., et al. (2002). Outbreaks
of influenza A virus in neonatal intensive care units. Pediatr Infect Dis J, 21(3), 196 200.
Wilkinson, D. J., Buttery, J. P., & Andersen, C. C. (2006). Influenza in the neonatal intensive
care unit. Journal of Perinatology, 26, 772 - 776
Author
Terri A. Cavaliere, DNP (c), NNP-BC
NNP, Neonatal Intensive Care Unit
North Shore University Hospital
Clinical Assistant Professor
North Shore University Hospital, Manhasset, NY
School of Nursing
State University of New York, Stony Brook, NY
Clinical Preceptor
Neonatal Nurse Practitioner Program
Columbia University, New York, NY
Copies of this document can made for personal use without
charge. For commercial purposes, contact Betty Burns, NCC
Executive Director, [email protected]
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