Download Influenza A (H1N1) - AIDS Education and Training Centers

Influenza A(H1N1)
Epidemic Overview
Texas Oklahoma AIDS
Education & Training Center
Clinical Directors Workgroup
Authors
P Keiser MD; UT Medical Branch, Galveston, TX
M Akbar MD; Parkland Health and Hospital System, Dallas,
TX
R Andrade MD; Baylor College of Medicine, Houston, TX
L Armas-Kolostroubis MD; Parkland Health and Hospital
System, Dallas, TX
F Garcia MD; Valley AIDS Council, Harlingen, TX
A Khalsa MD; Centro de Salud La Fe; El Paso, TX
L Machado MD; Oklahoma University, Oklahoma City, OK
D Paar MD; UT Medical Branch, Galveston, TX
D Phillips RN MPH; Parkland Health and Hospital System,
Dallas, TX
Outline
Epidemiology
Clinical Picture
Diagnosis
Treatment
Infection Control measures
H1N1 and HIV
Special populations
Epidemiology
Swine Flu
Respiratory Illness of pigs
infected by Influeza Type A
Virus
Flu outbreaks in pigs are
common
30-50% US commercial
swine have been infected
with swine flu
Vaccine available, not 100%
protective
No evidence that can be
transmitted through food
Eating properly handled and
cooked pork and pork
products is safe
Influenza A(H1N1)
2009 Influenza A(H1N1)
Based on genetic analysis “swine flu” is not
accurate
Contains genetic pieces from four different
viruses (unusual)
North American Swine Influenza
North American Avian Influenza
Human Influenza
Swine Influenza
“This virus does not contain markers for
virulence that were seen in Genome of 1918
Pandemic virus”
2009 H1N1
First reported Late March, early April 2009
– Central Mexico
– Texas
– California
Similar symptoms as in human influenza
WHO Pandemic Influenza Phases
http://www.who.int/csr/disease/avian_influenza/phase/en/index.html
Mexico Ministry of Health as of
5/01/09
Number of confirmed cases:
Discharged:
Deaths:
312
300
12
http://portal.salud.gob.mx/contenidos/noticias/influenza/estadisticas.html
Enhanced Surveillance
MMWR Dispatch; Vol. 58 / April 30, 2009
http://www.cdc.gov/h1n1flu/
Texas
County
# Confirmed Cases
Cameron
1
Comal
1
Dallas
6
Denton
1
Fort Bend
1
Guadalupe
9
Harris
1
Starr
2
Tarrant
5
Total
27
* Child from Mexico City
Deaths
1*
1
http://www.dshs.state.tx.us/swineflu/default.shtm
Clinical Picture
Clinical Symptoms of A(H1N1) Flu
Similar to regular human seasonal influenza:
–
–
–
–
–
–
–
–
–
–
Fever (temp > 102)
Body aches and muscle aches
Headaches
Chills
Fatigue
Lethargy
Lack of appetite
Coughing and sneezing
Runny nose and sore throat
Nausea, vomiting and diarrhea.
Important Facts
76% of influenza A(H1N1) exhibitors tested had
antibody evidence of influenza A(H1N1) flu infection
but no serious illnesses were detected
Severity from mild to severe.
Severe disease
–
–
–
–
Pneumonia
Respiratory failure
Death
Particularly in people with chronic medical conditions.
Bacterial infections may occur at the same time as or
after infection with influenza viruses and lead to
pneumonias, ear infections, or sinus infections
Recommendations for Possible
Influenza A(H1N1) Symptoms
Check with health care provider for:
– Accurate diagnosis
– Treatment
– Chemoprophylaxis
General care
–
–
–
–
–
Stay home for 7 days after the start of illness and fever is gone
Get plenty of rest
Drink clear fluids to keep from being dehydrated
Cover coughs and sneezes
Clean hands with soap and water or an alcohol-based hand rub
often and especially after using tissues and after coughing or
sneezing into hands.
Be watchful for emergency warning signs
Over-the-counter cold and flu medications may help lessen
some symptoms such as cough and congestion
Diagnosis
Influenza A (H1N1) Virus (S-OIV)
Case Definitions
Confirmed case
Is defined as a person with an
acute febrile respiratory illness
with laboratory confirmed infection
at CDC by one or more of the
following tests:
– real-time RT-PCR
– viral culture
Probable case
Is defined as a person with an
acute febrile respiratory illness
who is positive for influenza A, but
negative for H1 and H3 by
influenza RT-PCR
Suspected case
Person with acute febrile
respiratory illness
Onset within 7 days of close
contact with a person who is a
confirmed case of infection, or
Within 7 days of travel to
community either within the United
States or internationally where
there are one or more confirmed
cases of infection, or
Resides in a community where
there are one or more confirmed
cases of infection.
Testing for Influenza A (H1N1) Virus
Recommended Tests:
Real-time RT-PCR for influenza A, B, H1, H3 at a State
Health Department Laboratory
Currently, influenza A (H1N1) virus will test positive for
influenza A and negative for H1 and H3 by real-time RTPCR
Confirmation as influenza A (H1N1) virus is performed at
CDC
Testing for Influenza A (H1N1) Virus
Other influenza tests
Rapid influenza antigen test*
(*these tests have unknown sensitivity and specificity to detect
human infection with swine-origin influenza A (H1N1) virus in clinical
specimens)
Immunofluorescence (DFA or IFA)*
(*It can distinguish between influenza A and B viruses; It is not
possible to differentiate from seasonal influenza A viruses)
Viral culture*
(*Isolation of swine-origin influenza A (H1N1) virus is diagnostic of
infection, but may not yield timely results for clinical management)
Testing for Influenza A (H1N1) Virus
Preferred respiratory specimens:
nasopharyngeal swab/aspirate or
nasal wash/aspirate
If these specimens cannot be collected:
a combined nasal swab with an oropharyngeal swab is
acceptable
For patients who are intubated, an endotracheal
aspirate should also be collected
Specimens should be placed into sterile viral transport media (VTM) and immediately
placed on ice or cold packs or at 4°C (refrigerator) or transport to the laboratory
Treatment
Treatment for Influenza A (H1N1) Virus
Antiviral treatment should be considered for confirmed,
probable or suspected cases of influenza A(H1N1) flu.
Hospitalized patients and those at higher risk for
influenza complications should be prioritized.
Antiviral treatment should be initiated within 48 hours of
symptom onset, but even those treated after 48 hours
may have reduced morbidity and mortality.
Recommended duration of treatment is 5 days.
www.cdc.gov.swineflu/recommendations
Chemoprophylaxis Influenza A (H1N1)
Recommended
Close household contacts who are at high-risk
for complications of influenza of a confirmed or
probable case.
Health care workers or public health workers
who were not using appropriate personal
protective equipment during close contact with
an ill confirmed, probable, or suspect case
during the case’s infectious period.
www.cdc.gov.swineflu/recommendations
Chemoprophylaxis for Influenza A (H1N1)
Consider
Close household contacts who are at high-risk for
complications of influenza of a suspected case.
Children attending school or daycare who are at highrisk for complications of influenza and who had close
contact with a confirmed, probable, or suspected case.
Health care workers who are at high-risk for
complications of influenza who are working in an area
housing confirmed cases or who are caring for patients
with any acute febrile respiratory illness.
www.cdc.gov.swineflu/recommendations
Groups at High Risk for
Complications from Influenza
Children less than 5 years old.
Persons aged 50 years or older.
Children and adolescents (6 months – 18 years) who are
receiving long-term aspirin therapy (risk of Reye’s
Syndrome).
Pregnant women.
Adults and children who have chronic pulmonary,
cardiovascular, hepatic, hematological, neurologic,
neuromuscular, or metabolic disorders.
Adults and children who have immunosuppression
(including HIV).
Residents of nursing homes and other chronic-care
facilities
Treatment Options for Influenza A (H1N1)
Susceptible to
– Oseltamivir (Tamiflu)
– Zanamivir (Relenza)
Resistant to
– Amantadine
– Rimantadine
Additional antibacterial agents at the discretion of the
clinician given the patient’s clinical presentation
Hospitalized patients with severe community-acquired
pneumonia requiring intensive care unit admission,
suspect MRSA infection and treat empirically if
– Necrotizing or cavitary infiltrates
– Empyema
www.cdc.gov/swineflu/identifyingpatients
Oseltamivir and Zanamivir Treatment
and Chemoprophylaxis Dosages
Table 1. Influenza A(H1N1) antiviral medication dosing recommendations.
(Table extracted from IDSA guidelines for seasonal influenza.)
Agent, group
Treatment
Chemoprophylaxis
Oseltamivir
75 mg capsule twice per
day for 5 days
75 mg capsule once per
day
15 kg or less
60 mg per day divided into
2 doses
30 mg once per day
15–23 kg
90 mg per day divided into
2 doses
45 mg once per day
24–40 kg
120 mg per day divided into
2 doses
60 mg once per day
>40 kg
150 mg per day divided into
2 doses
75 mg once per day
Adults
Two 5 mg inhalations (10
mg total) twice per day
Two 5 mg inhalations (10
mg total) once per day
Children
Two 5 mg inhalations (10
mg total) twice per day
(age, 7 years or older)
Two 5 mg inhalations (10
mg total) once per day
(age, 5 years or older)
Adults
Children (age, 12 months
or older), weight:
Zanamivir
www.cdc.gov.swineflu/recommendations
Treatment with Oseltamivir* for
Children < 1 year of age
Table 2. Dosing recommendations for antiviral treatment of children younger
than 1 year using oseltamivir.
Age
Recommended treatment dose for 5 days
<3 months
12 mg twice daily
3-5 months
20 mg twice daily
6-11 months
25 mg twice daily
*not licensed for use in children < 1 year of age, but limited retrospective data have
not demonstrated age-specific toxicities to date.
www.cdc.gov.swineflu/recommendations
Chemoprophylaxis with Oseltamivir*
for Children < 1 year of age
Table 3. Dosing recommendations for antiviral chemoprophylaxis
of children younger than 1 year using oseltamivir.
Age
Recommended prophylaxis dose for 10 days
<3 months
Not recommended unless situation judged
critical due to limited data on use in this age group
3-5 months
20 mg once daily
6-11 months
25 mg once daily
*not licensed for use in children < 1 year of age, but limited retrospective data have
not demonstrated age-specific toxicities to date.
www.cdc.gov.swineflu/recommendations
Special Considerations for Children
Aspirin or aspirin-containing products (e.g. Pepto Bismol)
should not be administered to any confirmed or
suspected case of influenza A(H1N1) influenza virus
infection aged 18 years old and younger due to risk of
Reye’s Syndrome.
For relief of fever, other anti-pyretic medications such as
acetaminophen or NSAIDS are recommended
The safest care for flu symptoms in children younger than 2
years of age is using a cool-mist humidifier and a suction bulb to
help clear away mucus.
www.cdc.gov.swineflu/recommendations
Adverse Reactions and Drug Interactions
associated with Oseltamivir and Zanamivir
Nausea and vomiting are the primary side-effects of
oseltamivir (can be reduced by administration with food).
Decline in FEV1 in patients with underlying asthma who
are treated with zanamivir (zanamivir is not licensed for
patients with underlying asthma or cardiac disease).
No known drug interactions with zanamivir.
Oseltamivir and metabolite are excreted in the urine by
glomerular filtration and tubular secretion therefore coadministration with other agents (e.g. probenicid) may
result in increased plasma levels of oseltamivir.
www.cdc.gov/flu/professionals/antivirals/side-effects
Recommendations to Go to the
Hospital
Difficulty breathing or chest pain
Vomiting and unable to keep liquids down
Signs of dehydration
– Dizziness when standing
– Absence of urination
– In infants, a lack of tears when they cry
Less responsive than normal or confused
Infection Control
Infection Control:
For All Persons with Signs/Symptoms
of Respiratory Infection
Cover the nose/mouth when coughing or sneezing
Use tissues to contain respiratory secretions and
dispose of them in the nearest waste receptacle after
use
Perform hand hygiene (e.g., hand washing with nonantimicrobial soap and water, alcohol-based hand rub, or
antiseptic handwash) after having contact with
respiratory secretions and contaminated
objects/materials.
http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
Infection Control:
Healthcare personnel
Healthcare personnel should not report to work if they have a febrile
respiratory illness.
In communities where influenza A (H1N1) virus transmission is occurring,
healthcare personnel should be monitored daily for signs and symptoms of
febrile respiratory illness
In communities where influenza A(H1N1) influenza virus transmission is
occurring, healthcare personnel who develop a febrile respiratory illness
should be excluded from work for 7 days or until symptoms have resolved,
whichever is longer.
In communities where influenza A(H1N1) influenza virus transmission is not
occurring, healthcare personnel who develop febrile respiratory illness and
have not been in areas of the facility where influenza A(H1N1) influenza
patients are present should follow facility guidelines on returning to work.
http://www.cdc.gov/swineflu/guidelines_infection_control.htm
Infection Control:
Items for Healthcare Facilities
Provide tissues and no-touch receptacles for used tissue
disposal.
Provide conveniently located dispensers of alcoholbased hand rub
Where sinks are available, ensure that supplies for hand
washing (i.e., soap, disposable towels) are consistently
available
http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
Infection Control
Common sense
Panic and massive hysteria control
Contact your institution’s officials
Report any suspected case
Contact your County’s Health Department
Contact your State Health Department
Follow CDC, WHO recommendations
Example of
Institutional
Procedures
Healthcare worker (wearing
protective equipment)
screens patient entering
facility for symptoms of
influenza
+ screen
- screen
Patient enters clinic
as usual
-Place surgical mask on patient
-Escort patient into private exam
room and close door
-Clinical evaluation
-Influenza point-of-care test
(POCT) administered
- POCT
+ POCT
-Send viral culture if the patient:
•had contact with someone with influenza
•has traveled to Mexico within the past 7 days
•requires hospitalization
-Collect sample from
nose/oropharynx for
viral culture
-Place in viral
transport media
-Send to UTMB
Clinical Micro Lab
No
Hospitalization
required
-Instruct patient to return
home and provide handout on infection control
-Give Oseltamivir Rx to
patient
-Consider Oseltamivir Rx
for family contacts vs.
referral to their PCP
-Instruct patient to call
clinic if symptoms worsen
No hospitalization required
Hospitalization
required
Hospitalization required
(consider patient
potentially infectious)
-Follow routine admission procedures
-Call EMS (if off-campus) or transportation
(if on-campus)
-Inform them that they will be transporting
an infectious patient
-Patient continues to wear a surgical mask
during transport
-Notify the UTMB Department of
Healthcare Epidemiology at (409) 7723192 (phone) or (409) 643-3133 (pager)
-Dispense medication at
the discretion of the
physician
-Patient to return home for
the duration of illness
-Instruct patient to call
clinic if symptoms worsen
At UT medical Branch in Galveston this is their recommended
procedure as of 4/30/09.Courtesy of Dr Philip Keiser
Special Populations
HIV and Influenza A(H1N1)
Initial presentation is typical acute
respiratory illness
HIV with low CD4 counts
– May progress rapidly
– May complicate with secondary bacterial
infections, including pneumonia
If suspected, should get tested
Treatment and general recommendations
are no different than non-HIV
http://www.cdc.gov/h1n1flu/guidance_HIV.htm
Pregnant Women
Initial presentation is typical acute respiratory
illness
If suspected, should get tested
Treatment or chemoprophylaxis with Oseltamivir
or Zanamivir (Pregnancy Category C) likely
outweigh the theoretical risks of antiviral use
Because Zanamivir is inhaled  less systemic
absorption but careful in those at risk for
respiratory problems
http://www.cdc.gov/h1n1flu/clinician_pregnant.htm
Pregnant Women
Maternal hyperthermia in first trimester
– Doubles the risk of neural tube defects
– Associated with other birth defects and adverse outcomes
Maternal fever during labor:
– Risk factor for adverse neonatal and developmental oucomes
Neonatal Seizures
Encephalopathy
Cerebral Palsy
Neonatal death
Fever in pregnant women should be treated
– Acetaminophen
http://www.cdc.gov/h1n1flu/clinician_pregnant.htm
Breastfeeding
Infants who are not breastfeeding are
more susceptible
– HIV infection contra-indicates
breastfeeding
If non-HIV infected encourage early
and frequent breastfeeding so infant
can receive maternal antibodies
– Even if woman is ill
http://www.cdc.gov/h1n1flu/clinician_pregnant.htm
Breastfeeding
Reports of viremia with seasonal
influenza are rare
Donor Human Milk from a HMBANAcertified milk bank
Antiviral treatment or
chemoprophylaxis not a
contrainidication for breastfeeding
Influenza A(H1N1) in Correctional
Facilities as of 4/30/09
There are still no reported cases of H1N1
flu in correctional facilities.
The Indiana Department of Corrections
has now suspended visitation as a
precautionary measure.
ACA Flu Bulletin 4/30/09
Impact in US/Border Area
Death of a 23 m/o baby from Mexico City who
crossed US/MX Border at Brownsville early April
Additional 3 Suspect cases identified in the Lower
Rio Grande Valley
Pharmacists across the region have struggled to
keep face masks, hand sanitizer and flu medications
on the shelves.
In the South of the border, U.S. citizens has bought
medications in pharmacies in Reynosa and Nuevo
Progreso to stock up on the drug even if they didn't
have a prescription
Recent SUSPECTED Cases:
Mexico Border Area
City
# Suspected Cases
The only confirmed case to date is in Antiguo Morelos where one person died as a result of Influenza
Reynosa
17
A(H1N1)
Matamoros
3
Nuevo Laredo
1
Rio Bravo
3
Hidalgo
1
Soto La Marina
2
Victoria
1
Tampico
3
Madero
7
Mante
2
Nuevo Morelos
5
Antiguo Morelos
4
Mante
2
Influenza A(H1N1) Flu
Helpful Links
Interim Guidance—HIV-Infected Adults and Adolescents:
Considerations for Clinicians Regarding Swine-Origin Influenza
A (H1N1) Virus (CDC)
http://www.cdc.gov/swineflu/guidance_HIV.htm
Swine Flu-General Information (CDC)
http://www.cdc.gov/swineflu/general_info.htm
Texas information (Texas Department of State Health Services)
http://www.dshs.state.tx.us/swineflu/default.shtm
World health Organization Influenza A(H1N1)
http://www.who.int/csr/disease/swineflu/en/index.html
Special Bulletin: Swine-origin Influenza A (H1N1) Virus (S-OIV)
Infection (Florida/Carribean AETC)
http://www.faetc.org/PDF/Newsletter/Newsletter-Volume102009/HIVCareLink-04-29-09-v10_i7-em-Swineorigin_Influenza_A_Virus.pdf