influenza update 2009 100109

8/9/2019 Influenza Update 2009 100109

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Influenza Update 2009

Tim Gieseke MD, CMD

Assistant Clinical Professor, UCSF

Multi-facility Medical Director

Associate Medical Director, Sutter VNA Hospice


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Objectives

H1N1 2009 update

LTC Outbreak

Manifestations & Diagnosis Management

Immunization Programs

Patient Education


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H1N1 2009 Pandemic Declared

June 11, 2009

New Influenza A outbreak in Mexico lateMarch 2009

First identified in a Wisconsin, 17 y/o teenager

in 2005 Combination of parts of known Flu viruses

from: Human, Avian, and 2 Swine strains.

> 65 y/o - less impacted then expected

1/3 of > 60 y/o may be partially immuneAs of July 24, 2009, only 4% of hospitalized

cases were in > 65 y/o


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Disaster Preparedness Indicated

Previous Pandemics had initial Spring minor outbreak& then major Winter outbreak.

In Sonoma County as of 9/30/09: 60 hospitalizations (Pneumonia & Dehydration)

9 deaths 3 HCW hospitalized

8 pregnant women hospitalized

In the USA as of 9/3/09: ~ 9,000 Hospitalizations

~ 600 Deaths

If 33% attack rate this winter in Sonoma County: ~ 1,470 Hospitalizations

~ 355 deaths


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High Risk Groups, to Date

Pregnant women 4X > risk of hospitalization

Spontaneous abortion

Pre-term delivery

Obese 2X > risk of hospitalization

Increased mortality

Middle Aged Increased mortality mainly because more susceptible to

getting the flu than > 60 y/o

Young Children (2-9 y/o) 2X more susceptible then older ages


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Presentation

Influenza like illness (IFL): abrupt onset Temp > 100 or 37.8

Cough &/or sore Throat

Absence of alternative cause

Other common symptoms: Malaise

Headaches, Nasal & sinus congestion

Myalgias & arthralgias

Elderly & Children may lack fever H1N1 Distinctive

Nausea & vomiting with dehydration (25-30%)


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Case Definition by CPDH for H1N1

2009

Highly Suspected Case

ILI with lab confirmed influenza A by real-

time RT-PCR

All + specimens have been H1N1

Viral culture sub-typing will only be done for

Fatalities

ICU Cases Index case (s) in HCW (Health Care Worker)


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Lab Testing for H1N1

Rapid Antigen tests have not been reliable

PHD does real-time RT-RCP testing whichidentifies Influenza A.

CPDH requires SNFs to report to countysuspected H1N1 cases Reporting form available on www.calpan.org.

Direct health care workers (HWCs) with IFL

illnesses should be tested. Most outpatients with IFL do not need to be

tested.


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Outbreak of Seasonal Flu Jan 2008

85 y/o with intermediate stage AlzheimerDementia, HBP, Osteoporosis &Diastolic CHF

Sudden onset of lethargy, weakness,cough, low grade fevers, the prior day &had spent the past day in bed

Worse then usual confusion, shortattention span, & reversion to nativeGerman language.


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Assessment

PE 126/80 80 36.7 22 94% on RA

Weak, delirious, but neg. HEENT, Neck, Chest,Cardiac, Abd., Extr., and Skin Exams

Lab: WBC 7.2 Hct 37.4 UA: neg. CXR: neg.

Dx: Possible Influenza, Pertussis, RSV, SARS (Corona

Virus) Other viruses

Pneumonia (D. Pneumo, or Aspiration)


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Outbreak Management

4th IFL illness in facility

Outbreak declared and PHD notified

Oseltamivir (Tamiflu) prescribed

Respiratory Viral Culture of Nose and Naso-pharynx sent to PHD.

Facility Quarantined Canceled: admissions, visitors, activities programs

Residents encouraged to stay in their rooms Meals in rooms on paper plates, etc.

Same staffing for each station (Cohorting)


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Management

Isolation Measures:

Staff wore masks, gowns, gloves

Infected patients wore masks

Spray and Splatter control measures.

30 sec hand washing( Happy Birthday twice), &/or

Alcohol hand cleansers.

Other measures:

New cases promptly given Tamiflu

Attending physicians notified by faxed letter of

suspected outbreak.


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Whats Changed for H1N1 2009?

Use of goggles if suctioning or delivering Nebulizer Tx.

Use of N 95 masks for all HCWs with direct contactwith known N1H1 cases. May be reused until wet.

Store in brown bag Are effective in preventing Flu, whereas regular surgical

masks are not effective

If N1H1 cases must leave their room, they must: wear reg. mask, wash hands, & give 6 ft. spacing from

others, if possible

Housekeeping protocols to daily (?) cleanse infectedrooms, bathrooms, & door knobs. Use 1:10 diluted bleach & designated stethoscopes.


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Other Changes?

Aerosol Precautions sign on door.

All HCWs hospitalized today had some non-compliance with PPE procedures.

Mandatory hand cleansing prior & immediately aftereach patient physical contact. Patients taught to expect it.

Easy access to Kleenex, Disposable hand towels, &sinks / or Alcohol gels. Quick disposal of kleenix.

Cough or Sneeze into Sleeves or Kleenex,no

t hands. Visitors must use Alcohol Hand Cleanser or Hand

washing on arrival in facility. Education on importance of following hand cleansing protocol.


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Other Changes?

No sick employees or visitors permitted infacility.

Encourage families to call, rather then visit aresident with IFL illness.

Quarantine H1N1 case & facility until 7 dayspost onset of of last case, Unless still still sick, then continue until 24 hrs

asymptomatic.

Direct contact HCWs should keep finger nailswell trimmed Forbid use artificial nails.


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Chemo-Prophylaxis for H1N1 2009

Because of concern about the potential fordeveloping resistance, Chemo-prophylaxisshould be rare, with most use reserved for

those who have become sick enough to behospitalized:

Exceptions: Congregate living facility for frail persons (eg. SNF),

with an outbreak in facility.

Household case, with a child < 6 mo/o.

Exposed person with at risk co-morbid conditions, Start at the first onset of illness symptoms.


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Typing of Influenza

H (Hemaglutinin) Antigen

A surface glycoprotein

Binds to sialic acid residues on the respiratory

epithelium Permits penetration of these cells

N (Neuraminidase) Antigen

Cleaves intracellular viral progeny so they can be

released. Reduces entrapment of the virus in the respiratory

secretions


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High mutation rate of H & N

antigens

Antigenic Drifts Minor changes that produce local outbreaks annually

Antigenic Shifts Are associated with Pandemics

Occur about every 10-30 years

Last pandemic in 1977

Influenza A in humans 3 major subtypes (H1, H2, H3)

Only 2 N subtypes (N1, N2)

Influenza B Much less propensity for antigenic change

Only drifts in H have been described


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Characteristics ofOutbreaks

Almost exclusively in the Winter time in the Northernand Southern Hemispheres Occurs year around in the tropics

Influenza A may occur throughout the year

Attack rates: 10-20% of population in an outbreak

~ 25-50% in a pandemic

Time Course ofOutbreaks: Abrupt onset with multiple cases

Peak incidence by 2-3 weeks

Duration usually 4-8 weeks First indicator usually IFL illness in Children with high

absenteeism from school.


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Morbidity & Mortality of Seasonal

Flu

20-50 K excess deaths annually in USA

Disproportionately effects the elderly (> 64 y/o)and the young (< 5 y/o)

20% increased rate of pneumoniahospitalizations in the winter secondary to Flu.

50% higher mortality for pneumonia occurringin the winter months.

Risk of Pneumonia greatest in the Elderly with: Diabetes, Chronic Pulmonary, Dysphagia, immuno-

compromised or Cardiac diseases.


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Morbidity & Mortality

During Flu season, >

hospitalization rates for acute cardiopulmonary

events

Mortality

Mortality in Pandemics

Illness Severity index:

10X > for 1918 strain, then H1N1 2009

20-50 million deaths worldwide in 1918

~ 50% of deaths occur in low risk groups, since:

more susceptible with high dIsease prevalence


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Usual Illness Clinical Course

Contagious from:

1 day prior to illness onset

Until 24 hrs afebrile Incubation Time: 1-4 days

Viral Shedding (?): < 7 days

Duration of illness: 2-5 days Post Influenza Asthenia: 1-6 weeks


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Transmission

Viral replication only occurs in the respiratorytract

Transmitted by droplet and aerosolized:

Coughing Sneezing Talking Survives on surfaces for hours

Viral shedding: Peaks at 24-48 hrs

Rapidly becomes negligible by day 6 May still shed in the Elderly, High risk patients, or

Children for up to 5 weeks


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Complications

Pneumonia is most common complication High Risk patients have greatest risk

Primary Pneumonia may be diffuse and

severe (ARDS) Secondary Bacterial Pneumonia

25% of all Influenza deaths Strep Pneumonia in 48%

Staph (19%, MRSA)

Suspect when exacerbation of fever & resp.symptoms occur days after initial clinicalimprovement.


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Complications

Dehydration

Myositis predominantly in children

CNS

Encephalitis, Aseptic meningitis, Reyes Syndrome

Transverse myelitis

Guillian-Barre syndrome

Other Myocarditis & pericarditis

MI & Strokes


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Diagnosis

In SNF Outbreaks, cultures of nose and nasal-pharynxfor virus to PHD Real-time RT-PCR

Culture takes 48-72 hrs, but report may take 1 wk.

In outbreaks, IFL illness highly predictive of Flu

For usual seasonal outbreak, rapid diagnostic tests Quick-vue A & B test (Clia waiver)

~ 75% sensitivity

Many other similar test kits

Rapid: 15-30 min.

Not recommended this year, since not reliable for H1N12009


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Mode of Spread

Cough and Spray of large droplets Aerosolizes up to 3-4 feet

Keep > 6 foot away from other residents &

roommate (s). Consider chemo-prophylaxis for roommates.

Virus may survive on surfaces for hours

Hands spread it to eyes, nose, and mouth &may precipitate illness. Discourage this habit.

Clean surfaces with 1/10 diluted bleach.


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Treatment (Supportive measures)

Isolation measures Spray & Splatter Control

Fever & pain control (Tylenol or Advil) Avoid Aspirin to reduce risk Reyes Syndrome & GI Bleed.

Pulmonary supportive measures O2, O2 Sats, Suction, HOB elevation > 15 degrees

Dysphagia measures Diet consistency appropriate?

Swallow therapy Evaluation

Fall risk & Delirium management Hydration measures considerIV fluids

Acute hospitalization? (Advanced Directives, POLST)


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Neuraminidase Inhibitors

Work by reducing rate of Viral Shedding

from Respiratory cells

Most effective when given within 30 hrsof symptom onset or for prophylaxsis.

Reduce duration of illness by 2-3 days

Reduce severity of illness &

hospitalization rate

Effective for H1N1 2009


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Neuraminidase Inhibitors

Side Effects Oseltamivir (Tamiflu)

Nausea (rarely vomiting), but is rarely severe enough tostop it

Zanamivir (Relenza) has been associated with Broncho-spasm

Decline in respiratory function in patients with Asthma

Contraindicated in Asthmatics

Acute Illness Dosing Oseltamivir: 75 mg bid X 5 days

Zanamivir: 10 mg (2 puffbid) X 5 days


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Chemo-Prophylaxis in 2009

Zanamivir (Relenza) Household contacts: 10 mg daily X 10 days

Only if < 6 mo/o or severe immuno-compromised person

SNF Community Outbreak: Start within 48 hrs of identified outbreak Continue until 7 days post onset of last case in facility.

Oseltamivir (Tamiflu) 75 mg daily X 10 days or 7 days post last case.

Renal Dosing required forOseltamivir Cr.Cl. 30-60: 75 mg daily X 5 days for acute illness

Cr.Cl. < 30 not defined ask SC PHD


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Seasonal Flu Vaccines

Development

Based on Worldwide Flu surveillance by theCDC and the WHO

Vaccine chosen to cover the 3 most prevalentstrains anticipated for the coming season Targets are H & N proteins

Future targets of more conserved viral proteins likeMatrix Protein 2 & the Intersubunit of Hemaglutinin

Production starts about in Jan or Feb withdelivery of manufactured vaccine in lateSeptember

Similar manufacturing process for H1N1 2009


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2009-2010 Seasonal Flu Vaccine for

Northern Hemisphere

4 Manufacturers of Inactivated vaccine

Only 1 manufacturer of the live

attenuated vaccine Contains following virus strains:

A/Brisbane/59/2007-like virus (H1N1)

A/Brisbane/10/2007-like virus (H3N2)

B/Brisbane/60/2008(only change this yr)


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Vaccine Types same for Seasonal

and H1N1 2009

TIV (Trivalent Inactivated Vaccine) Dead can not cause influenza

IM route only

Whole virus form not available in USA Split virus ( subvirion components) fewer adverse

reactions in children The only TIV available in USA

Only vaccine for < 2 y/o & > 50 y/o

Side effects Soreness at injection site

Myalgias and sl. fever ~ 12-36 hr < 5% of vaccinated


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FluMist = LAIV (Live Attenuated

Vaccine) - Intranasal

Approved for 2-49 y/o who do not have Asthma

HCW may receive it if: not taking care of severely immuno-compromised patients

Stored 2-8 degrees C and thawed just prior to use

Less protective then TIV in 2007-2008 season.

Side Effects: Runny nose, nasal congestion, HA, and sore throat < 12-36 hr

No anaphylaxis, GB Syndrome, Asthma or Bells palsy yet


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Efficacy of Seasonal Vaccine

Greatest in < 65 y/o

~ 80% protected if good vaccine match

~ 60% poor

Protective Vaccine levels > 4 mo. aftervaccination in most Seniors

Probably reduces mortality in frail Seniors

especially in Seniors annually vaccinated

TIV safe in all phases of Pregnancy

Pregnancy is a high risk state for Mom / baby


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Vaccination & Herd Effect

If most of population vaccinated, the risk of an

outbreak is much less.

When elementary students vaccinated,

Household adults had less missed work that winter.

When Acute Hospital HCWs vaccinated (51%

vs. 5%)

Acute Hospital Mortality was reduced significantly

(13.6 vs. 22.4%) over the next 6 months.


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Seasonal Vaccine Indicated for:

> 50 y/o (29% with one or more high risk conditions)

< 5 y/o (increased morbidity)

SNF Direct HCWs

Women pregnant during influenza season Adults with serious co-morbid chronic illnesses:

Chronic Pulm dz, CV dz, CRD, Liver dz, D.M., Asplenia,Immunosuppression, CNS disorders (Seizures, Dementia,Neuromuscular disorders with dysphagia)

Consider forspouses and all visitors to SNFs


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Who shouldnt have it?

Acute illness more then trivial URI or medicallyunstable

Serious Allergies to eggs Grown on egg medium

Egg intolerance is not a contraindication

New vaccine grown on insect media in development

Allergy to preservative Thimersol Commonly used Mercury preservative in eye drops

Omitted in vaccine given to < 3 y/o and pregnant women

Previous Guillian-Barre syndrome


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2009 Vaccine Recommendations

Give usual Trivalent seasonal vaccine as soon asavailable this September. TIV may given simultaneously with H1N1, but not LAV.

Give H1N1 2009 vaccine (TIV or LAIV forms) when it

becomes available in Mid-October per CDC guidelines A.California/07/2009 mono-valent vaccine

Not initially available for SNF residents.

Initially give 1 dose for > 10 y/o, & 2nd dose 4 weeks later if

influenza update 2009 100109

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