H1N1 flu update
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Posts: 6,651
Here is the latest of the weekly H1N1 updates we get at work, in case anyone's interested:
Pandemic H1N1 update 10/13/09
Global
- Northern Hemisphere influenza rates suggest an unusually early start to the fall/winter influenza season in many countries.
- The US and Mexico are reporting elevated influenza rates.
- Europe and Central/Western Asia report increasing and early virus transmission rates.
- Japan continues to report elevated influenza activity.
- High-intensity activity is reported in Columbia, Cuba, and El Salvador.
- Transmission has largely declined or subsided in Chile, Argentina, South Africa, and Australia.
- All antigenically-typed strains continue to resemble the vaccine strain.
- Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada. Kumar et al. JAMA Online http://jama.ama-assn.org/cgi/content/full/2009.1496
o A prospective observational study of 168 critically ill patients with H1N1 in 38 adult and pediatric ICUs in Canada between April 16 and August 12, 2009.
o Among the 168 patients with confirmed or probable H1N1, the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%).
o Overall mortality among critically ill patients at 28 days was 14.3%.
o 43 patients were aboriginal Canadians (25.6%).
o The median time from Sx onset to admission was 4 days and from hospitalization to ICU admission was 1 day. Shock and nonpulmonary acute organ dysfunction were common.
o Neuraminidase inhibitors were administered to 152 patients (90.5%).
o All patients were severely hypoxemic at ICU admission.
o Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days and ICU stay was 12 days.
o Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%).
o Overall mortality among critically ill patients at 90 days was 17.3%.
o Conclusion: Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.
- Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Mexico. Dominquez-Cherit et al. JAMA Online http://jama.ama-assn.org/cgi/content/full/2009.1536
o Observational study of 58 critically ill patients with H1N1at 6 hospitals between March 24 and June 1, 2009.
o Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital.
o Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese.
o Time from hospital to ICU admission was short (median, 1 day) and all patients but 2 received mechanical ventilation for severe ARDS and refractory hypoxemia .
o By 60 days, 24 patients had died (41.4%).
o Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction.
o After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 7.4; 95% confidence interval, 1.8-31.0).
o Conclusion: Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate.
- Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers. Loeb et al. JAMA Online
http://jama.ama-assn.org/cgi/content/full/2009.1466
o Context: Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance.
o Objective: To compare the surgical mask with the N95 respirator in protecting health care workers against influenza.
o Design, Setting, and Participants: Noninferiority randomized controlled trial of 446 nurses in emergency departments, medical units, and pediatric units in 8 tertiary care Ontario hospitals.
o Intervention: Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season.
o Results: Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group.
o Conclusion: Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza.
- Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. Aust/NZ ECMO investigators. JAMA Online http://jama.ama-assn.org/cgi/content/full/2009.15635
o 68 patients with severe influenza-associated ARDS were treated with ECMO. The 68 patients who received ECMO had a median age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support.
o The median duration of ECMO support was 10 (7-15) days.
o At the time of reporting, 48 of the 68 patients (71%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO.
o [NB: UNM is already utilizing ECMO when indicated.]
- Recent News Headlines
o UK: "Nervous passenger thrown off aircraft for suspected swine flu"
o UK: "14 in hospital as second wave of swine flu starts"
o India: "Four swine flu deaths take India's toll to 389"
o Vietnam: " A/H1N1 flu cases rise to 9,789"
o TX: "Houston Health Care Workers Are Overworked"
o VA: "Local boy, 9, dies in wake of flu outbreak"
o Washington Post: "H1N1 Deaths Among Youths Rise as Epidemic Spreads"
o KY: "School Closures Related to Influenza-Like Illness"
o NE: "State cancels/delays employee flu clinics - Can't get the H1N1 vaccine"
o "CDC confirms 76 deaths in US children, 19 in past week"
o "Arizona confirms 31st death in state, in 40s man"
o IL: "School closes after 100 show signs of flu"
USA
- Thirty-seven states are reporting widespread influenza activity (including New Mexico and surrounding states).
- Of typed viruses, almost all are 2009 Influenza A/H1N1.
- Visits to doctors for influenza in 122 reporting cities continue to increase and are higher than expected for this time of year.
- Nineteen pediatric influenza-related deaths were reported during the past week. A total of 76 H1N1-confirmed pediatric deaths have been reported to CDC since April.
- States have ordered 3.7 million doses of H1N1 vaccine. A total of 6.8 million doses are anticipated to be available for order. Deliveries of small initial quantities have begun. Delivery of "substantial quantities" is anticipated by mid-November.
- A recent Harvard Public School of Health poll found that only 50% of Americans plan to get vaccinated.
- Hospitalized Patients with 2009 H1N1 Influenza in the United States, April - June 2009. Jain et al.
NEJM http://content.nejm.org/cgi/content/full/NEJMoa0906695
. Background: During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of the patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009.
. Methods: Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase PCR assay.
. Results: Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. 45% of the patients were children under the age of 18 years, and 5% were 65 years of age or older. 73% of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early.
. Conclusions: During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.
. Other data from the article:
. Median age = 21 years
. Median days from onset of illness to admission = 3 days
. Commonest clinical symptoms (present > 50%): fever, cough, SOB
. Commonest underlying medical conditions were asthma and obesity
. Mortality rate 7%
. Factors differentiating hospitalized non-ICU and ICU patients
. Age: median age 19 vs 29 years
. Presenting symptoms:
. SOB: 51% vs 87%
. Chills: 36% vs 51%
. CXR at admission consistent with pneumonia: 28% vs 73%
. ARDS, sepsis at admission :1% vs 45%
- CDC MMWR 10/9/09 - Update on Influenza A (H1N1) 2009 Monovalent Vaccines
. The vaccines contain no adjuvants.
. Children aged 6 months - 9 years should receive two doses ~ 4 weeks apart.
. The multi-dose vials contain thimerosol; the other forms do not.
. FDA age of approval varies from 6 months to 18 years depending upon manufacturer and preparation.
. All of the approved vaccines contain residual egg protein (so recipients should be screened for allergy to egg protein).
. Immunogenicity and safety are similar to those of seasonal vaccines. No unusual side-effects or safety issues were observed.
Pandemic H1N1 update 10/13/09
Global
- Northern Hemisphere influenza rates suggest an unusually early start to the fall/winter influenza season in many countries.
- The US and Mexico are reporting elevated influenza rates.
- Europe and Central/Western Asia report increasing and early virus transmission rates.
- Japan continues to report elevated influenza activity.
- High-intensity activity is reported in Columbia, Cuba, and El Salvador.
- Transmission has largely declined or subsided in Chile, Argentina, South Africa, and Australia.
- All antigenically-typed strains continue to resemble the vaccine strain.
- Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada. Kumar et al. JAMA Online http://jama.ama-assn.org/cgi/content/full/2009.1496
o A prospective observational study of 168 critically ill patients with H1N1 in 38 adult and pediatric ICUs in Canada between April 16 and August 12, 2009.
o Among the 168 patients with confirmed or probable H1N1, the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%).
o Overall mortality among critically ill patients at 28 days was 14.3%.
o 43 patients were aboriginal Canadians (25.6%).
o The median time from Sx onset to admission was 4 days and from hospitalization to ICU admission was 1 day. Shock and nonpulmonary acute organ dysfunction were common.
o Neuraminidase inhibitors were administered to 152 patients (90.5%).
o All patients were severely hypoxemic at ICU admission.
o Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days and ICU stay was 12 days.
o Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%).
o Overall mortality among critically ill patients at 90 days was 17.3%.
o Conclusion: Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.
- Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Mexico. Dominquez-Cherit et al. JAMA Online http://jama.ama-assn.org/cgi/content/full/2009.1536
o Observational study of 58 critically ill patients with H1N1at 6 hospitals between March 24 and June 1, 2009.
o Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital.
o Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese.
o Time from hospital to ICU admission was short (median, 1 day) and all patients but 2 received mechanical ventilation for severe ARDS and refractory hypoxemia .
o By 60 days, 24 patients had died (41.4%).
o Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction.
o After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 7.4; 95% confidence interval, 1.8-31.0).
o Conclusion: Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate.
- Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers. Loeb et al. JAMA Online
http://jama.ama-assn.org/cgi/content/full/2009.1466
o Context: Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance.
o Objective: To compare the surgical mask with the N95 respirator in protecting health care workers against influenza.
o Design, Setting, and Participants: Noninferiority randomized controlled trial of 446 nurses in emergency departments, medical units, and pediatric units in 8 tertiary care Ontario hospitals.
o Intervention: Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season.
o Results: Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group.
o Conclusion: Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza.
- Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. Aust/NZ ECMO investigators. JAMA Online http://jama.ama-assn.org/cgi/content/full/2009.15635
o 68 patients with severe influenza-associated ARDS were treated with ECMO. The 68 patients who received ECMO had a median age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support.
o The median duration of ECMO support was 10 (7-15) days.
o At the time of reporting, 48 of the 68 patients (71%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO.
o [NB: UNM is already utilizing ECMO when indicated.]
- Recent News Headlines
o UK: "Nervous passenger thrown off aircraft for suspected swine flu"
o UK: "14 in hospital as second wave of swine flu starts"
o India: "Four swine flu deaths take India's toll to 389"
o Vietnam: " A/H1N1 flu cases rise to 9,789"
o TX: "Houston Health Care Workers Are Overworked"
o VA: "Local boy, 9, dies in wake of flu outbreak"
o Washington Post: "H1N1 Deaths Among Youths Rise as Epidemic Spreads"
o KY: "School Closures Related to Influenza-Like Illness"
o NE: "State cancels/delays employee flu clinics - Can't get the H1N1 vaccine"
o "CDC confirms 76 deaths in US children, 19 in past week"
o "Arizona confirms 31st death in state, in 40s man"
o IL: "School closes after 100 show signs of flu"
USA
- Thirty-seven states are reporting widespread influenza activity (including New Mexico and surrounding states).
- Of typed viruses, almost all are 2009 Influenza A/H1N1.
- Visits to doctors for influenza in 122 reporting cities continue to increase and are higher than expected for this time of year.
- Nineteen pediatric influenza-related deaths were reported during the past week. A total of 76 H1N1-confirmed pediatric deaths have been reported to CDC since April.
- States have ordered 3.7 million doses of H1N1 vaccine. A total of 6.8 million doses are anticipated to be available for order. Deliveries of small initial quantities have begun. Delivery of "substantial quantities" is anticipated by mid-November.
- A recent Harvard Public School of Health poll found that only 50% of Americans plan to get vaccinated.
- Hospitalized Patients with 2009 H1N1 Influenza in the United States, April - June 2009. Jain et al.
NEJM http://content.nejm.org/cgi/content/full/NEJMoa0906695
. Background: During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of the patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009.
. Methods: Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase PCR assay.
. Results: Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. 45% of the patients were children under the age of 18 years, and 5% were 65 years of age or older. 73% of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early.
. Conclusions: During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.
. Other data from the article:
. Median age = 21 years
. Median days from onset of illness to admission = 3 days
. Commonest clinical symptoms (present > 50%): fever, cough, SOB
. Commonest underlying medical conditions were asthma and obesity
. Mortality rate 7%
. Factors differentiating hospitalized non-ICU and ICU patients
. Age: median age 19 vs 29 years
. Presenting symptoms:
. SOB: 51% vs 87%
. Chills: 36% vs 51%
. CXR at admission consistent with pneumonia: 28% vs 73%
. ARDS, sepsis at admission :1% vs 45%
- CDC MMWR 10/9/09 - Update on Influenza A (H1N1) 2009 Monovalent Vaccines
. The vaccines contain no adjuvants.
. Children aged 6 months - 9 years should receive two doses ~ 4 weeks apart.
. The multi-dose vials contain thimerosol; the other forms do not.
. FDA age of approval varies from 6 months to 18 years depending upon manufacturer and preparation.
. All of the approved vaccines contain residual egg protein (so recipients should be screened for allergy to egg protein).
. Immunogenicity and safety are similar to those of seasonal vaccines. No unusual side-effects or safety issues were observed.
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