Denise Nicole Thomas RNBSN Auburn University Nurse Practitioner Student

1. Influenza: Is Pregnancy an Infection Risk? Denise Nicole Thomas RNBSNAuburn University Nurse Practitioner Student

2. Goals of Presentation • Identify the impact pregnancy has on influenza infection risk/complications • List prevention and control strategies for influenza in pregnant population

3. What is Influenza? • Influenza is a very significant acute upper respiratory tract infection caused by influenza viruses. Influenza can occur year round but usually occurs in winter and spring.

4. Pathology of Influenza • Virus attaches to and penetrates respiratory epithelial cells in trachea and bronchi • Virus replicates and destroys host cell • Symptoms occur but viremia absent • Virus shed in respiratory secretions for 5-10 days, runs course in 2 weeks.

5. Signs and Symptoms of Influenza • IMMEDIATE onset of muscle aches, fatigue and high fever. Also includes cough, sore throat, headache, chills, nonproductive cough, conjunctivitis, runny nose. • In children, diarrhea and seizures

6. Definition of Close Contact • Close contacts are defined as persons within approximately 6 feet (2 meters) or within the room or care area of a confirmed or probable H7N9 case patient for a prolonged period of time, or with direct contact with infectious secretions (such as being directly in the path of a sneeze) while the patient was likely to be infectious (beginning 1 day prior to onset of signs and/or symptoms and continuing until resolution of illness). CDC – 2013-2014

7. Influenza Transmission – Close Contact • Coughing, sneezing into air • Inhaling infected air • Kissing or sharing handkerchiefs/tissues • Sharing eating utensils/sharing food • Touching contaminated smooth surfaces (door knobs, handles, telephones)

8. High Risk Groups • Groups at high risk for complications secondary to influenza are those with: Chronic lung disease, diabetes mellitus, chronic renal failure, cardiac disease, immunosuppressed, those in residential homes and long term care facilities

9. Morbidity/Mortality • 2006 through 2013 – Annual influenza related hospitalizations = 226,000 • 2006 through 2013 – Annual influenza associated deaths = 24,000/year • 2006-2013 – Annual influenza associated deaths = 36,000/year (8,000 due to influenza associated pneumonia)

10. Pandemic versus Epidemic Influenza

11. Pandemic Influenza • Pandemic occurs when: • new influenza type-A virus emerges (antigenic shift) - no immunity in population - virus spreads efficiently between humans - results in worldwide outbreaks of disease

12. Recent Pandemics • 1889- Pandemic • 1918- 1919 Spanish pandemic (influenza virus type H1) • 1957- subtype H2N2 • 1968- 1969 Hong Kong H2N2 • 1977- Russian subtype H1N1 • 2009- H1N1 • 2013- H3N2

13. Epidemic Influenza • Type A or B influenza virus appearing in groups or clusters • Virus is not new virus • Vaccine usually available • Post exposure prophylaxis available

14. Influenza Virus Vaccines • Inactivated influenza virus vaccine - Prepared annually - No live virus in vaccine - Injectable - 2 doses for children with zero prior influenza vaccination

15. Live attenuated virus vaccine (LAV) • Live weakened flu vaccine • Intranasal administration • Limited to healthy individuals • Not administered to children under 2 years old. • Two doses for children with zero prior influenza vaccination • Vaccine for 2 years and younger Thimerosol- free

16. Influenza and Pregnancy

17. 19 flu seasons- 4,300 women of child bearing age- Pregnant women 5 times more likely than post-partum patients to require hospitalization- (Harvard Health, 2010) • 1970’s- 3 flu seasons rates of medical visits for acute respiratory disease more than twice as high in pregnant vs. non-pregnant. (CDC, 2012)

18. Routine Vaccines for Pregnant Patients • Hepatitis A & B • Influenza (inactivated) • Tetanus/Diphtheria or T dap (2nd or 3rd trimester) • Meningococcal • Rabies ACIP Guidelines- February 2013

19. Why does pregnancy appear to increase risk of influenza complications? • Mechanical & hormonal changes associated with pregnancy • Decreased lung capacity • Changes in the cardiovascular system

20. Altered immune response due to pregnancy---shift away from cell mediated immunity • Hospitalization for women 37-42 weeks gestation= 5 fold compared to women one to six months post partum • Greatest risk in 3rdtrimester!!!

21. Use of Antiviral • Start anti-viral treatment immediately if influenza suspected. • Antivirals MOST effective when given within 48 hours of symptoms • BUT, start ASAP even if beyond 48 hours.

22. Prophylaxis during Pregnancy • No evidence of adverse effects of antiviral use (Tamiflu) in pregnant female. • Better to treat than risk increased illness in pregnant female. CDC 2013

23. Influenza and the Neonate • Flu vaccine risk to infants quite low • Some studies show vaccine protects mother and infant (NEJM- 2013) • Virus does not appear to pass through placenta • Neonatal problems associated with maternal inflammatory process & fever (Int J Dev Neuroscience- 2013)

24. 2013 H1N1 Influenza Lessons Learned • Number of new cases declined with vaccine, prevention strategies and post- exposure management. • 99% of serotype Influenza type A were H1N1 • H1N1 vaccine supply started below expected level but increased mid-season

25. Lessons Learned cont’d. • Ongoing surveillance did not reveal unusual adverse effects associated with vaccine • Child deaths from H1N1 in otherwise healthy children associated with co-infection with bacteria, usually Staphylococcus or Pneumococcal pneumonia.

26. 2012-2013 Seasonal Vaccine Recommendation Changes • Recommends 6 month and older (previously 19-49 years old.) • Vaccine dose (under 8 year old) related to # vaccine doses received in 2011. • 2012-2013 vaccine includes 2 A viruses and one B virus. (H1N1 included). (CDC, 2013)

27. Conclusions • Influenza is a seasonal viral infection that affect males and females, young & old, pregnant and non pregnant. • Influenza vaccine should be taken by all eligible consumers • Implement prevention/control policies including hand hygiene, including pets • Avoid close contact with infected • Administer antivirals following exposure

28. Preventing Influenza • Hand hygiene • Vaccine • Post-exposure prophylaxis for all exposed including pregnant • Home quarantine in epidemics • ER/MD office segregation sick/pregnant

29. Questions?

30. Hot Topic’s In 2013-2014