Influenza A(H1N1) Epidemic Overview

1. Influenza A(H1N1)Epidemic Overview Texas Oklahoma AIDS Education & Training Center Clinical Directors Workgroup

2. 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

3. Outline • Epidemiology • Clinical Picture • Diagnosis • Treatment • Infection Control measures • H1N1 and HIV • Special populations

4. Epidemiology

5. 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

6. Influenza A(H1N1)

7. 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”

8. 2009 H1N1 • First reported Late March, early April 2009 • Central Mexico • Texas • California • Similar symptoms as in human influenza

9. WHO Pandemic Influenza Phases http://www.who.int/csr/disease/avian_influenza/phase/en/index.html

11. Mexico Ministry of Health as of 5/01/09 • Number of confirmed cases: 312 • Discharged: 300 • Deaths: 12 http://portal.salud.gob.mx/contenidos/noticias/influenza/estadisticas.html

12. Enhanced Surveillance MMWR Dispatch; Vol. 58 / April 30, 2009

13. http://www.cdc.gov/h1n1flu/

14. Texas * Child from Mexico City http://www.dshs.state.tx.us/swineflu/default.shtm

15. Clinical Picture

16. 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.

17. 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

18. 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

19. Diagnosis

20. 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. Influenza A (H1N1) Virus (S-OIV) Case Definitions

21. 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 RT-PCR • Confirmation as influenza A (H1N1) virus is performed at CDC

22. 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)

23. 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

24. Treatment

25. 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

26. 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

27. 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 high-risk 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

28. 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

29. 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

30. Oseltamivir and Zanamivir Treatment and Chemoprophylaxis Dosages www.cdc.gov.swineflu/recommendations

31. Treatment with Oseltamivir* for Children < 1 year of age *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

32. Chemoprophylaxis with Oseltamivir* for Children < 1 year of age *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

33. 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

34. 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 co-administration with other agents (e.g. probenicid) may result in increased plasma levels of oseltamivir. www.cdc.gov/flu/professionals/antivirals/side-effects

35. 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

36. Infection Control

37. 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 non-antimicrobial 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

38. 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

39. Infection Control:Items forHealthcare Facilities • Provide tissues and no-touch receptacles for used tissue disposal. • Provide conveniently located dispensers of alcohol-based 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

40. 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

41. Healthcare worker (wearing protective equipment) screens patient entering facility for symptoms of influenza Example of Institutional Procedures - 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 Hospitalization required (consider patient potentially infectious) Hospitalization required No Hospitalization required -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 -Instruct patient to return home and provide hand-out 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 -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) 772-3192 (phone) or (409) 643-3133 (pager) At UT medical Branch in Galveston this is their recommended procedure as of 4/30/09.Courtesy of Dr Philip Keiser

42. Special Populations

43. 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

44. 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

45. 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

46. 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

47. Breastfeeding • Reports of viremia with seasonal influenza are rare • Donor Human Milk from a HMBANA- certified milk bank • Antiviral treatment or chemoprophylaxis not a contrainidication for breastfeeding

48. 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

49. 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

50. Recent SUSPECTED Cases: Mexico Border Area The only confirmed case to date is in Antiguo Morelos where one person died as a result of Influenza A(H1N1)