COCA Conference Call National Grand Rounds: 2009 H1N1 Influenza and Asthma

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4. Chronic inflammation of the airways Cytokine-mediated over short term Airway remodeling over long term Reversible bronchospasm Wheezing, breathlessness, coughing

5. Public health significance of asthma Inflammation and immune response in asthma Clinical management of asthma 2009 H1N1 Influenza and asthma Data from 2009 H1N1 influenza surveillance Clinical guidelines: prevention and treatment COPD: A high-risk group Conclusions Questions and Answers

8. Current Asthma Prevalence for Youth by Race/Ethnicity, Ages 5-17, 2005-2007

10. Population Disparities in Asthma Current asthma prevalence is higher among children than adults boys than girls women than men Asthma morbidity and mortality is higher among African Americans than Caucasians Low SES, both urban and rural Less access to health care

11. 2009 H1N1 Influenza Virus and Asthma Alkis Togias, MD Asthma, Allergy and Inflammation Branch National Institute of Allergy and Infectious Diseases (NIAID), NIH

13. Airway inflammation and hyperreactivity

14. Asthma and Viral Respiratory Infections

15. Asthma and Viral Respiratory Infections

16. Clinical Management of Asthma Expert Panel Report 3 National Asthma Education and Prevention Program National Heart, Lung and Blood Institute, 2007

18. Asthma Treatment and H1N1 Vaccine Inhaled steroids: mainstay treatment for asthma control Some patients with asthma require high doses of inhaled steroids or even oral steroids Will the 2009 H1N1 influenza vaccine be adequately immunogenic in patients on high doses of inhaled steroids or oral steroids?

19. NIAID/NHLBI Study of the 2009 H1N1 Influenza Vaccine in Patients with Asthma

24. Influenza Vaccination Coverage among People with Asthma

25. 2009 H1N1 and AsthmaHospitalizations 32% of hospitalized with 2009 H1N1 have asthma ICU: 20% with 2009 H1N1 and asthma admitted to ICU Same ICU rate as others (non-asthma) hospitalized with 2009 H1N1

26. ACIP Recommendations Seasonal flu vaccine 2009 H1N1 flu vaccine 6 months to 64 years with lung disease a priority Pneumococcal vaccine Similar recommendations for COPD

28. CDC Guidance http://www.cdc.gov/h1n1flu/asthma_clinicians.htm http://www.cdc.gov/h1n1flu/asthma.htm Asthma Action Plan Asthma should be well-controlled Inhaled corticosteroids are protective

29. CDC Guidance Vaccination 2009 H1N1 and Seasonal Inactivated, injectable only Do not use nasal spray vaccine Pneumococcal Vaccine Prompt treatment Plan for early contact/empiric treatment Oseltamivir (Tamiflu�) started early

30. Treatment Oseltamivir (Tamiflu�) 75 mg po bid for 5 days Weight-based dosing for children http://www.cdc.gov/h1n1flu/asthma_clinicians.htm BEST if started within 48 hours of symptom onset Zanamivir (Relenza�) is not recommended, because of the risk for adverse events, such as bronchospasm

31. Treatment Rapid access to antiviral medications is essential Actions to support treatment initiation Informing patients of signs and symptoms of influenza and need for early treatment Ensuring rapid access to telephone consultation and clinical evaluation Considering empiric treatment of patients based on telephone contact

32. Remember other Chronic Lung Diseases Persons with COPD face similar risk for severe outcome from influenza Recommendations for COPD are similar to those for asthma Asthma and COPD can be comorbidities, particularly in older age groups

34. What is COPD? A common lung disease of smokers and ex-smokers (and some never smokers) who experience difficulty breathing, at rest or on exertion, with or without chronic cough and sputum production. Inflammatory lung disease characterized by airflow limitation that is not fully reversible The term COPD includes: Chronic bronchitis Emphysema

35. COPD Statistics 24 million affected in the U.S. About half do not know they have it Most over age 60 Most have multiple co-morbidities About 15% never smokers >120,000 deaths/year (4th leading cause) Rates rising fastest in women Men and women about equal ~900,000 disabled, working age adults Total cost of $37 billion/year

37. COPD: High Risk For Flu Complications Aging immune system On inhaled and oral steroids Multiple co-morbidities Impaired airway defenses Reduced lung reserve

38. COPD and the Flu Everyone with COPD should routinely be vaccinated against the seasonal flu. Everyone with COPD should have an updated pneumococcal polysaccharide vaccination (PPSV) according to ACIP guidelines. Everyone with COPD should get vaccinated for the 2009 H1N1 influenza as supplies permit, using the shot (injectable) form.

39. COPD and the Flu Persons with COPD should not get the live attenuated nasal spray flu vaccines (i.e., FluMist). The inactivated 2009 H1N1 influenza vaccine can be administered at the same visit as any other vaccine, including the PPSV.

40. Additional Resources Diseases and Conditions Index: COPD: http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html The COPD Learn More Breathe Better Campaign: http://www.nhlbi.nih.gov/health/public/lung/copd/

41. Conclusions Persons with asthma or COPD are at higher-risk of complications from seasonal influenza infection Data available thus far suggest that persons with asthma are at higher-risk of complications from 2009 H1N1 influenza

42. Conclusions Maximize asthma control, including ICS use Vaccinate for primary prevention Seasonal flu vaccine 2009 H1N1 flu vaccine Pneumococcal vaccine Inform patients about the signs and symptoms of 2009 H1N1 influenza Treat empirically with antivirals

43. CDC Interim Guidelines and Updates http://www.cdc.gov/h1n1flu http://www.cdc.gov/h1n1flu/asthma_clinicians.htm

44. Questions

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