Influenza A(H1N1) Epidemic Overview

Influenza A(H1N1)Influenza A(H1N1)Epidemic OverviewEpidemic Overview

Texas Oklahoma AIDS Texas Oklahoma AIDS Education & Training CenterEducation & Training Center

Clinical Directors WorkgroupClinical Directors Workgroup

AuthorsAuthors

P Keiser MD; UT Medical Branch, Galveston, TXP Keiser MD; UT Medical Branch, Galveston, TXM Akbar MD; Parkland Health and Hospital System, Dallas, M Akbar MD; Parkland Health and Hospital System, Dallas, TXTXR Andrade MD; Baylor College of Medicine, Houston, TXR Andrade MD; Baylor College of Medicine, Houston, TXL Armas-Kolostroubis MD; Parkland Health and Hospital L Armas-Kolostroubis MD; Parkland Health and Hospital System, Dallas, TXSystem, Dallas, TXF Garcia MD; Valley AIDS Council, Harlingen, TXF Garcia MD; Valley AIDS Council, Harlingen, TXA Khalsa MD; Centro de Salud La Fe; El Paso, TXA Khalsa MD; Centro de Salud La Fe; El Paso, TXL Machado MD; Oklahoma University, Oklahoma City, OKL Machado MD; Oklahoma University, Oklahoma City, OKD Paar MD; UT Medical Branch, Galveston, TXD Paar MD; UT Medical Branch, Galveston, TXD Phillips RN MPH; Parkland Health and Hospital System, D Phillips RN MPH; Parkland Health and Hospital System, Dallas, TXDallas, TX

OutlineOutline

EpidemiologyEpidemiology

Clinical PictureClinical Picture

DiagnosisDiagnosis

TreatmentTreatment

Infection Control measuresInfection Control measures

H1N1 and HIVH1N1 and HIV

Special populationsSpecial populations

EpidemiologyEpidemiology

Swine FluSwine FluRespiratory Illness of pigs Respiratory Illness of pigs infected by infected by Influeza Type AInflueza Type A VirusVirusFlu outbreaks in pigs are Flu outbreaks in pigs are commoncommon30-50% US commercial swine 30-50% US commercial swine have been infected with swine have been infected with swine flufluVaccine available, not 100% Vaccine available, not 100% protectiveprotectiveNo evidence that can be No evidence that can be transmitted through foodtransmitted through foodEating properly handled and Eating properly handled and cooked pork and pork cooked pork and pork products is safeproducts is safe

Influenza A(H1N1)Influenza A(H1N1)

2009 Influenza A(H1N1)2009 Influenza A(H1N1)

Based on genetic analysis “swine flu” is not Based on genetic analysis “swine flu” is not accurateaccurateContains genetic pieces from four different Contains genetic pieces from four different viruses (unusual)viruses (unusual)

North American Swine InfluenzaNorth American Swine InfluenzaNorth American Avian InfluenzaNorth American Avian InfluenzaHuman InfluenzaHuman InfluenzaSwine InfluenzaSwine Influenza

““This virus does not contain markers for This virus does not contain markers for virulence that were seen in Genome of 1918 virulence that were seen in Genome of 1918 Pandemic virus”Pandemic virus”

2009 H1N12009 H1N1

First reported Late March, early April 2009First reported Late March, early April 2009– Central Mexico Central Mexico – TexasTexas– CaliforniaCalifornia

Similar symptoms as in human influenzaSimilar symptoms as in human influenza

WHO Pandemic Influenza PhasesWHO Pandemic Influenza Phases

http://www.who.int/csr/disease/avian_influenza/phase/en/index.html

Mexico Ministry of Health as of Mexico Ministry of Health as of 5/01/095/01/09

Number of confirmed cases:Number of confirmed cases: 312312

Discharged:Discharged: 300300

Deaths:Deaths: 12 12

http://portal.salud.gob.mx/contenidos/noticias/influenza/estadisticas.html

Enhanced SurveillanceEnhanced Surveillance

MMWR Dispatch; Vol. 58 / April 30, 2009

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

TexasTexas

CountyCounty # Confirmed Cases# Confirmed Cases DeathsDeaths

CameronCameron 11

ComalComal 11

DallasDallas 66

DentonDenton 11

Fort BendFort Bend 11

GuadalupeGuadalupe 99

HarrisHarris 11 1*1*

StarrStarr 22

TarrantTarrant 55

TotalTotal 2727 11

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

Clinical PictureClinical Picture

Clinical Symptoms of A(H1N1) FluClinical Symptoms of A(H1N1) Flu

Similar to regular human seasonal influenza:Similar to regular human seasonal influenza:– Fever (temp > 102)Fever (temp > 102)– Body aches and muscle achesBody aches and muscle aches– HeadachesHeadaches– ChillsChills– FatigueFatigue– LethargyLethargy– Lack of appetite Lack of appetite – Coughing and sneezingCoughing and sneezing– Runny nose and sore throatRunny nose and sore throat– Nausea, vomiting and diarrhea.Nausea, vomiting and diarrhea.

Important FactsImportant Facts

76% of influenza A(H1N1) exhibitors tested had 76% of influenza A(H1N1) exhibitors tested had antibody evidence of influenza A(H1N1) flu infection antibody evidence of influenza A(H1N1) flu infection but no serious illnesses were detected but no serious illnesses were detected Severity from mild to severe. Severity from mild to severe. Severe disease Severe disease – Pneumonia Pneumonia – Respiratory failure Respiratory failure – Death Death – Particularly in people with chronic medical conditions. Particularly in people with chronic medical conditions.

Bacterial infections may occur at the same time as or Bacterial infections may occur at the same time as or after infection with influenza viruses and lead to after infection with influenza viruses and lead to pneumonias, ear infections, or sinus infectionspneumonias, ear infections, or sinus infections

Recommendations for Possible Recommendations for Possible Influenza A(H1N1) SymptomsInfluenza A(H1N1) Symptoms

Check with health care provider for:Check with health care provider for:– Accurate diagnosisAccurate diagnosis– TreatmentTreatment– Chemoprophylaxis Chemoprophylaxis

General careGeneral care– Stay home for 7 days after the start of illness and fever is gone Stay home for 7 days after the start of illness and fever is gone – Get plenty of rest Get plenty of rest – Drink clear fluids to keep from being dehydrated Drink clear fluids to keep from being dehydrated – Cover coughs and sneezesCover coughs and sneezes– Clean hands with soap and water or an alcohol-based hand rub Clean hands with soap and water or an alcohol-based hand rub

often and especially after using tissues and after coughing or often and especially after using tissues and after coughing or sneezing into hands. sneezing into hands.

Be watchful for emergency warning signs Be watchful for emergency warning signs Over-the-counter cold and flu medications may help lessen Over-the-counter cold and flu medications may help lessen some symptoms such as cough and congestion some symptoms such as cough and congestion

DiagnosisDiagnosis

Influenza A (H1N1) Virus (S-OIV) Influenza A (H1N1) Virus (S-OIV) Case DefinitionsCase Definitions

Confirmed caseConfirmed case Is defined as a person with an Is defined as a person with an acute febrile respiratory illness acute febrile respiratory illness with laboratory confirmed infection with laboratory confirmed infection at CDC by one or more of the at CDC by one or more of the following tests: following tests:

– real-time RT-PCR real-time RT-PCR

– viral culture viral culture

Probable caseProbable caseIs defined as a person with an Is defined as a person with an acute febrile respiratory illness acute febrile respiratory illness who is positive for influenza A, but who is positive for influenza A, but negative for H1 and H3 by negative for H1 and H3 by influenza RT-PCR influenza RT-PCR

Suspected caseSuspected case Person with acute febrile Person with acute febrile respiratory illness respiratory illness

Onset within 7 days of close Onset within 7 days of close contact with a person who is a contact with a person who is a confirmed case of infection, or confirmed case of infection, or

Within 7 days of travel to Within 7 days of travel to community either within the United community either within the United States or internationally where States or internationally where there are one or more confirmed there are one or more confirmed cases of infection, or cases of infection, or

Resides in a community where Resides in a community where there are one or more confirmed there are one or more confirmed cases of infection. cases of infection.

Recommended Tests:Recommended Tests:Real-time RT-PCR for influenza A, B, H1, H3 at a State Real-time RT-PCR for influenza A, B, H1, H3 at a State Health Department Laboratory Health Department Laboratory

Currently, influenza A (H1N1) virus will test positive for Currently, influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-influenza A and negative for H1 and H3 by real-time RT-PCRPCR

Confirmation as influenza A (H1N1) virus is performed at Confirmation as influenza A (H1N1) virus is performed at CDC CDC

Testing for Influenza A (H1N1) VirusTesting for Influenza A (H1N1) Virus

Other influenza tests Other influenza tests Rapid influenza antigen test*Rapid influenza antigen test*

(*(*these tests have unknown sensitivity and specificity to detect these tests have unknown sensitivity and specificity to detect human infection with swine-origin influenza A (H1N1) virus in clinical human infection with swine-origin influenza A (H1N1) virus in clinical specimensspecimens))

Immunofluorescence (DFA or IFA)* Immunofluorescence (DFA or IFA)* (*(*It can distinguish between influenza A It can distinguish between influenza A and B viruses; and B viruses; It is not possible to differentiate from seasonal influenza It is not possible to differentiate from seasonal influenza A viruses)A viruses)

Viral culture* Viral culture* (*Isolation of swine-origin influenza A (H1N1) virus is diagnostic of (*Isolation of swine-origin influenza A (H1N1) virus is diagnostic of

infection, but may not yield timely results for clinical management) infection, but may not yield timely results for clinical management)



Preferred respiratory specimensPreferred respiratory specimens::

nasopharyngeal swab/aspirate or nasopharyngeal swab/aspirate or

nasal wash/aspiratenasal wash/aspirate

If these specimens cannot be collected:If these specimens cannot be collected:

a combined nasal swab with an oropharyngeal swab is acceptable a combined nasal swab with an oropharyngeal swab is acceptable

For patients who are intubated, an endotrachealFor patients who are intubated, an endotracheal

aspirate should also be collectedaspirate should also be collected

Specimens should be placed into sterile viral transport media (VTM) and immediately placed on ice or 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 laboratorycold packs or at 4°C (refrigerator) or transport to the laboratory

TreatmentTreatment

Treatment for Influenza A (H1N1) VirusTreatment for Influenza A (H1N1) Virus

Antiviral treatment should be considered for confirmed, Antiviral treatment should be considered for confirmed, probable or suspected cases of influenza A(H1N1) flu.probable or suspected cases of influenza A(H1N1) flu.

Hospitalized patients and those at higher risk for Hospitalized patients and those at higher risk for influenza complications should be prioritized.influenza complications should be prioritized.

Antiviral treatment should be initiated within 48 hours of Antiviral treatment should be initiated within 48 hours of symptom onset, but even those treated after 48 hours symptom onset, but even those treated after 48 hours may have reduced morbidity and mortality.may have reduced morbidity and mortality.

Recommended duration of treatment is 5 days.Recommended duration of treatment is 5 days.

www.cdc.gov.swineflu/recommendations

Chemoprophylaxis Influenza A (H1N1)Chemoprophylaxis Influenza A (H1N1)

RecommendedRecommended

Close household contacts who are at high-risk Close household contacts who are at high-risk for complications of influenza of a confirmed or for complications of influenza of a confirmed or probable case.probable case.

Health care workers or public health workers Health care workers or public health workers who were not using appropriate personal who were not using appropriate personal protective equipment during close contact with protective equipment during close contact with an ill confirmed, probable, or suspect case an ill confirmed, probable, or suspect case during the case’s infectious period.during the case’s infectious period.


Chemoprophylaxis for Influenza A (H1N1)Chemoprophylaxis for Influenza A (H1N1)

ConsiderConsider

Close household contacts who are at high-risk for Close household contacts who are at high-risk for complications of influenza of a suspected case.complications of influenza of a suspected case.

Children attending school or daycare who are at high-risk Children attending school or daycare who are at high-risk for complications of influenza and who had close contact for complications of influenza and who had close contact with a confirmed, probable, or suspected case.with a confirmed, probable, or suspected case.

Health care workers who are at high-risk for Health care workers who are at high-risk for complications of influenza who are working in an area complications of influenza who are working in an area housing confirmed cases or who are caring for patients housing confirmed cases or who are caring for patients with any acute febrile respiratory illness.with any acute febrile respiratory illness.


Groups at High Risk for Groups at High Risk for Complications from InfluenzaComplications from Influenza

Children less than 5 years old.Children less than 5 years old.Persons aged 50 years or older.Persons aged 50 years or older.Children and adolescents (6 months – 18 years) who are Children and adolescents (6 months – 18 years) who are receiving long-term aspirin therapy (risk of Reye’s receiving long-term aspirin therapy (risk of Reye’s Syndrome).Syndrome).Pregnant women.Pregnant women.Adults and children who have chronic pulmonary, Adults and children who have chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders.neuromuscular, or metabolic disorders.Adults and children who have immunosuppression Adults and children who have immunosuppression (including HIV).(including HIV).Residents of nursing homes and other chronic-care Residents of nursing homes and other chronic-care facilitiesfacilities

Treatment Options for Influenza A (H1N1)Treatment Options for Influenza A (H1N1)

Susceptible to Susceptible to – Oseltamivir (Tamiflu)Oseltamivir (Tamiflu)– Zanamivir (Relenza) Zanamivir (Relenza)

Resistant to Resistant to – AmantadineAmantadine– RimantadineRimantadine

Additional antibacterial agents at the discretion of the Additional antibacterial agents at the discretion of the clinician given the patient’s clinical presentationclinician given the patient’s clinical presentationHospitalized patients with severe community-acquired Hospitalized patients with severe community-acquired pneumonia requiring intensive care unit admission, pneumonia requiring intensive care unit admission, suspect MRSA infection and treat empirically if suspect MRSA infection and treat empirically if – Necrotizing or cavitary infiltrates Necrotizing or cavitary infiltrates – EmpyemaEmpyema

www.cdc.gov/swineflu/identifyingpatients

Oseltamivir and Zanamivir Treatment Oseltamivir and Zanamivir Treatment and Chemoprophylaxis Dosagesand Chemoprophylaxis Dosages

Table 1. Influenza A(H1N1) antiviral medication dosing recommendations.(Table extracted from IDSA guidelines for seasonal influenza.)

Agent, group Treatment Chemoprophylaxis

Oseltamivir

AdultsAdults 75 mg capsule twice per 75 mg capsule twice per day for 5 daysday for 5 days

75 mg capsule once per 75 mg capsule once per dayday

ChildrenChildren (age, 12 months (age, 12 months or older), weight:or older), weight:

15 kg or less15 kg or less 60 mg per day divided into 60 mg per day divided into 2 doses2 doses 30 mg once per day30 mg once per day

15–23 kg15–23 kg 90 mg per day divided into 90 mg per day divided into 2 doses2 doses 45 mg once per day45 mg once per day

24–40 kg24–40 kg 120 mg per day divided 120 mg per day divided into 2 dosesinto 2 doses 60 mg once per day60 mg once per day

>40 kg>40 kg 150 mg per day divided 150 mg per day divided into 2 dosesinto 2 doses 75 mg once per day75 mg once per day

Zanamivir

AdultsAdultsTwo 5 mg inhalations (10 Two 5 mg inhalations (10

mg total) twice per mg total) twice per dayday

Two 5 mg inhalations (10 Two 5 mg inhalations (10 mg total) once per daymg total) once per day

ChildrenChildren

Two 5 mg inhalations (10 Two 5 mg inhalations (10 mg total) twice per mg total) twice per day (age, 7 years or day (age, 7 years or older)older)

Two 5 mg inhalations (10 Two 5 mg inhalations (10 mg total) once per day mg total) once per day (age, 5 years or older)(age, 5 years or older)www.cdc.gov.swineflu/recommendations

Treatment with Oseltamivir* for Treatment with Oseltamivir* for Children < 1 year of ageChildren < 1 year of age

Table 2. Dosing recommendations for antiviral treatment of children younger Table 2. Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir.than 1 year using oseltamivir.

Age Age Recommended treatment dose for 5 daysRecommended treatment dose for 5 days

<3 months<3 months 12 mg twice daily12 mg twice daily

3-5 months3-5 months 20 mg twice daily20 mg twice daily

6-11 months6-11 months 25 mg twice daily25 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.

Chemoprophylaxis with Oseltamivir* Chemoprophylaxis with Oseltamivir* for Children < 1 year of agefor 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.

Special Considerations for ChildrenSpecial Considerations for Children

Aspirin or aspirin-containing products (e.g. Pepto Bismol) Aspirin or aspirin-containing products (e.g. Pepto Bismol) should notshould not be administered to any confirmed or be administered to any confirmed or suspected case of influenza A(H1N1) influenza virus suspected case of influenza A(H1N1) influenza virus infection aged 18 years old and younger due to risk of infection aged 18 years old and younger due to risk of Reye’s Syndrome.Reye’s Syndrome.

For relief of fever, other anti-pyretic medications such as For relief of fever, other anti-pyretic medications such as acetaminophen or NSAIDS are recommendedacetaminophen or NSAIDS are recommended

The safest care for flu symptoms in children younger than 2 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 years of age is using a cool-mist humidifier and a suction bulb to help clear away mucus. help clear away mucus.


Adverse Reactions and Drug Interactions Adverse Reactions and Drug Interactions associated with Oseltamivir and Zanamivirassociated with Oseltamivir and Zanamivir

Nausea and vomiting are the primary side-effects of Nausea and vomiting are the primary side-effects of oseltamivir (can be reduced by administration with food).oseltamivir (can be reduced by administration with food).

Decline in FEV1 in patients with underlying asthma who Decline in FEV1 in patients with underlying asthma who are treated with zanamivir (zanamivir is not licensed for are treated with zanamivir (zanamivir is not licensed for patients with underlying asthma or cardiac disease).patients with underlying asthma or cardiac disease).

No known drug interactions with zanamivir.No known drug interactions with zanamivir.

Oseltamivir and metabolite are excreted in the urine by Oseltamivir and metabolite are excreted in the urine by glomerular filtration and tubular secretion therefore co-glomerular filtration and tubular secretion therefore co-administration with other agents (e.g. probenicid) may administration with other agents (e.g. probenicid) may result in increased plasma levels of oseltamivir.result in increased plasma levels of oseltamivir.

www.cdc.gov/flu/professionals/antivirals/side-effects

Recommendations to Go to the HospitalRecommendations to Go to the Hospital

Difficulty breathing or chest pain Difficulty breathing or chest pain

Vomiting and unable to keep liquids down Vomiting and unable to keep liquids down

Signs of dehydrationSigns of dehydration– Dizziness when standing Dizziness when standing – Absence of urinationAbsence of urination– In infants, a lack of tears when they cry In infants, a lack of tears when they cry

Less responsive than normal or confused Less responsive than normal or confused

Infection ControlInfection Control

Infection Control: Infection Control: For All Persons with Signs/Symptoms For All Persons with Signs/Symptoms

of Respiratory Infectionof Respiratory Infection

Cover the nose/mouth when coughing or sneezingCover the nose/mouth when coughing or sneezing

Use tissues to contain respiratory secretions and Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after dispose of them in the nearest waste receptacle after useuse

Perform hand hygiene (e.g., hand washing with non-Perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash) after having contact with antiseptic handwash) after having contact with respiratory secretions and contaminated respiratory secretions and contaminated objects/materials. objects/materials.

http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

Infection Control:Infection Control:

Healthcare personnelHealthcare personnel

Healthcare personnel should not report to work if they have a febrile Healthcare personnel should not report to work if they have a febrile respiratory illness.respiratory illness.

In communities where influenza A (H1N1) virus transmission is occurring, In communities where influenza A (H1N1) virus transmission is occurring, healthcare personnel should be monitored daily for signs and symptoms of healthcare personnel should be monitored daily for signs and symptoms of febrile respiratory illnessfebrile respiratory illness

In communities where influenza A(H1N1) influenza virus transmission is In communities where influenza A(H1N1) influenza virus transmission is occurring, healthcare personnel who develop a febrile respiratory illness occurring, healthcare personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.whichever is longer.

In communities where influenza A(H1N1) influenza virus transmission is not In communities where influenza A(H1N1) influenza virus transmission is not occurring, healthcare personnel who develop febrile respiratory illness and occurring, healthcare personnel who develop febrile respiratory illness and have not been in areas of the facility where influenza A(H1N1) influenza have not been in areas of the facility where influenza A(H1N1) influenza patients are present should follow facility guidelines on returning to work.patients are present should follow facility guidelines on returning to work.

http://www.cdc.gov/swineflu/guidelines_infection_control.htm

Infection Control:Infection Control: Items forItems for Healthcare FacilitiesHealthcare Facilities

Provide tissues and no-touch receptacles for used tissue Provide tissues and no-touch receptacles for used tissue disposal. disposal.

Provide conveniently located dispensers of alcohol-Provide conveniently located dispensers of alcohol-based hand rubbased hand rub

Where sinks are available, ensure that supplies for hand Where sinks are available, ensure that supplies for hand washing (i.e., soap, disposable towels) are consistently washing (i.e., soap, disposable towels) are consistently available available

http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

Infection ControlInfection Control

Common senseCommon sense

Panic and massive hysteria controlPanic and massive hysteria control

Contact your institution’s officialsContact your institution’s officials

Report any suspected caseReport any suspected case

Contact your County’s Health DepartmentContact your County’s Health Department

Contact your State Health DepartmentContact your State Health Department

Follow CDC, WHO recommendationsFollow CDC, WHO recommendations

+ POCT

Healthcare worker (wearing protective equipment) screens patient entering facility for symptoms of influenza

-Place surgical mask on patient-Escort patient into private exam room and close door

+ screen - screen

Patient enters clinic as usual

-Clinical evaluation-Influenza point-of-care test (POCT) administered

- POCT

-Collect sample from nose/oropharynx for viral culture-Place in viral transport media-Send to UTMB Clinical Micro Lab

-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)

-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

No Hospitalization required

Hospitalization required

-Send viral culture if the patient:•had contact with someone with influenza•has traveled to Mexico within the past 7 days•requires hospitalization

-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

Hospitalization required(consider patient potentially infectious)

No hospitalization required

At UT medical Branch in Galveston this is their recommended procedure as of 4/30/09.Courtesy of Dr Philip Keiser

Example of Institutional Procedures

Special PopulationsSpecial Populations

HIV and Influenza A(H1N1)HIV and Influenza A(H1N1)

Initial presentation is typical acute Initial presentation is typical acute respiratory illnessrespiratory illnessHIV with low CD4 counts HIV with low CD4 counts – May progress rapidlyMay progress rapidly– May complicate with secondary bacterial May complicate with secondary bacterial

infections, including pneumoniainfections, including pneumonia

If suspected, should get testedIf suspected, should get testedTreatment and general recommendations Treatment and general recommendations are no different than non-HIVare no different than non-HIV

http://www.cdc.gov/h1n1flu/guidance_HIV.htm

Pregnant WomenPregnant Women

Initial presentation is typical acute respiratory Initial presentation is typical acute respiratory illnessillness

If suspected, should get testedIf suspected, should get tested

Treatment or chemoprophylaxis with Oseltamivir Treatment or chemoprophylaxis with Oseltamivir or Zanamivir (Pregnancy Category C) likely or Zanamivir (Pregnancy Category C) likely outweigh the theoretical risks of antiviral useoutweigh the theoretical risks of antiviral use

Because Zanamivir is inhaled Because Zanamivir is inhaled less systemic less systemic absorption but careful in those at risk for absorption but careful in those at risk for respiratory problemsrespiratory problems

http://www.cdc.gov/h1n1flu/clinician_pregnant.htm

Pregnant WomenPregnant Women

Maternal hyperthermia in first trimester Maternal hyperthermia in first trimester – Doubles the risk of neural tube defectsDoubles the risk of neural tube defects– Associated with other birth defects and adverse outcomesAssociated with other birth defects and adverse outcomes

Maternal fever during labor:Maternal fever during labor:– Risk factor for adverse neonatal and developmental oucomesRisk factor for adverse neonatal and developmental oucomes

Neonatal SeizuresNeonatal SeizuresEncephalopathyEncephalopathyCerebral PalsyCerebral PalsyNeonatal deathNeonatal death

Fever in pregnant women should be treatedFever in pregnant women should be treated– AcetaminophenAcetaminophen


BreastfeedingBreastfeedingInfants who are not breastfeeding are Infants who are not breastfeeding are more susceptiblemore susceptible– HIV infection contra-indicates HIV infection contra-indicates

breastfeedingbreastfeeding

If If non-HIVnon-HIV infected infected encourage early encourage early and frequent breastfeeding so infant and frequent breastfeeding so infant can receive maternal antibodiescan receive maternal antibodies– Even if woman is illEven if woman is ill


BreastfeedingBreastfeeding

Reports of viremia with seasonal Reports of viremia with seasonal influenza are rareinfluenza are rareDonor Human Milk from a HMBANA- Donor Human Milk from a HMBANA- certified milk bankcertified milk bankAntiviral treatment or Antiviral treatment or chemoprophylaxis not a chemoprophylaxis not a contrainidication for breastfeedingcontrainidication for breastfeeding

Influenza A(H1N1) in Correctional Influenza A(H1N1) in Correctional Facilities as of 4/30/09Facilities as of 4/30/09

There are still no reported cases of H1N1 There are still no reported cases of H1N1 flu in correctional facilities. flu in correctional facilities.

The Indiana Department of Corrections The Indiana Department of Corrections has now suspended visitation as a has now suspended visitation as a precautionary measure. precautionary measure.

ACA Flu Bulletin 4/30/09ACA Flu Bulletin 4/30/09

Impact in US/Border AreaImpact in US/Border Area

Death of a 23 m/o baby from Mexico City who Death of a 23 m/o baby from Mexico City who crossed US/MX Border at Brownsville early Aprilcrossed US/MX Border at Brownsville early AprilAdditional 3 Suspect cases identified in the Lower Additional 3 Suspect cases identified in the Lower Rio Grande Valley Rio Grande Valley Pharmacists across the region have struggled to Pharmacists across the region have struggled to keep face masks, hand sanitizer and flu medications keep face masks, hand sanitizer and flu medications on the shelves. on the shelves. In the South of the border, U.S. citizens has bought In the South of the border, U.S. citizens has bought medications in pharmacies in Reynosa and Nuevo medications in pharmacies in Reynosa and Nuevo Progreso to stock up on the drug even if they didn't Progreso to stock up on the drug even if they didn't have a prescriptionhave a prescription

Recent SUSPECTED Cases: Recent SUSPECTED Cases: Mexico Border AreaMexico Border Area

The only confirmed case to date is in Antiguo Morelos where one person died as a result of Influenza A(H1N1)The only confirmed case to date is in Antiguo Morelos where one person died as a result of Influenza A(H1N1)

CityCity # Suspected Cases# Suspected Cases

ReynosaReynosa 1717

MatamorosMatamoros 33

Nuevo LaredoNuevo Laredo 11

Rio BravoRio Bravo 33

HidalgoHidalgo 11

Soto La MarinaSoto La Marina 22

VictoriaVictoria 11

TampicoTampico 33

MaderoMadero 77

ManteMante 22

Nuevo MorelosNuevo Morelos 55

Antiguo MorelosAntiguo Morelos 44

ManteMante 22

Influenza A(H1N1) Flu Influenza A(H1N1) Flu Helpful LinksHelpful Links

Interim Guidance—HIV-Infected Adults and Adolescents: Interim Guidance—HIV-Infected Adults and Adolescents: Considerations for Clinicians Regarding Swine-Origin Influenza Considerations for Clinicians Regarding Swine-Origin Influenza A (H1N1) Virus A (H1N1) Virus (CDC) (CDC) http://http://www.cdc.gov/swineflu/guidance_HIV.htmwww.cdc.gov/swineflu/guidance_HIV.htmSwine Flu-General Information (CDC) Swine Flu-General Information (CDC) http://http://www.cdc.gov/swineflu/general_info.htmwww.cdc.gov/swineflu/general_info.htmTexas information (Texas Department of State Health Services) Texas information (Texas Department of State Health Services) http://www.dshs.state.tx.us/swineflu/default.shtmhttp://www.dshs.state.tx.us/swineflu/default.shtmWorld health Organization Influenza A(H1N1)World health Organization Influenza A(H1N1)

http://www.who.int/csr/disease/swineflu/en/index.html http://www.who.int/csr/disease/swineflu/en/index.html Special Bulletin: Swine-origin Influenza A (H1N1) Virus (S-OIV) Special Bulletin: Swine-origin Influenza A (H1N1) Virus (S-OIV) Infection (Florida/Carribean AETC) Infection (Florida/Carribean AETC) http://www.faetc.org/PDF/Newsletter/Newsletter-Volume10-2009http://www.faetc.org/PDF/Newsletter/Newsletter-Volume10-2009/HIVCareLink-04-29-09-v10_i7-em-Swine-origin_Influenza_A_Vir/HIVCareLink-04-29-09-v10_i7-em-Swine-origin_Influenza_A_Virus.pdfus.pdf

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Influenza A(H1N1) Epidemic Overview