This document summarizes information about the 2009 H1N1 influenza pandemic presented by Professor Jim Bishop. It provides an overview of the epidemiology and severity of the 2009 H1N1 virus, its impact on transplant recipients, and the current global situation. Some key points are that the 2009 H1N1 virus resulted in over 37,000 cases and 191 deaths in Australia, with higher rates of hospitalization and ICU admission compared to seasonal influenza. It also resulted in significant illness in transplant recipients, though antiviral treatment reduced complications. Currently, influenza activity is low in both the Northern and Southern Hemispheres.

1. 2010 TSANZ ANNUAL
SCIENTIFIC MEETING
pH1N1 Influenza in
Transplantation
Professor Jim Bishop AO
Chief Medical Officer
Australian Government Department of Health and
Ageing
Thursday 24 June 2010
PANDEMIC (H1N1) 2009

2. Overview
 Epidemiology of Pandemic H1N1 09 Influenza
 Severity indices
 Influenza in Transplantation
 Current Global Situation

3. The Australian Health Management Plan for
Pandemic Influenza (AHMPPI)
• The AHMPPI (2008): third edition
of the national health management
plan
• Exercise Cumpston 06
recommended
– AHMPPI revision: policy gaps
– Streamlined decision making
– More flexible policy
PANDEMIC POLICIES
and PLANNING

4. Pandemic H1N1
2009 Timeline
WHO announces novel human influenza24 Apr
WHO moves to Pandemic phase 427 Apr
Australia moves to Pandemic DELAY28 Apr
WHO moves to Pandemic phase 529 Apr
Australia moves to Pandemic CONTAIN22 May
Victoria moves to MODIFIED SUSTAIN3 Jun
WHO moves to Pandemic phase 611 Jun
Australia moves to Pandemic PROTECT17 Jun

5. H1N1 Influenza 09
Pandemic Phases
ALERT (pre 24 April 09)
DELAY (24 April 09)
CONTAIN (22 May 09)
SUSTAIN
Victoria moved to a MODIFIED
SUSTAIN on 3 June 2009
CONTROL
RECOVER
PROTECT
17 June 2009
Evidence supports focusing
efforts on protecting the
‘vulnerable’
Australia's response is continual informed
by the emerging evidence around the virus
and effectiveness of control measures
H1N1
Influenza 09,
mild in most
and severe in
some (the
vulnerable)

6. KEY ELEMENTS OF
THE PROTECT PHASE
 Identifying the vulnerable
 Early treatment of those identified as vulnerable
 Voluntary home isolation for those who are sick
 Controlling outbreaks in special settings
 Limited school action, limiting ILI
 A re-focus of testing to the vulnerable, severe
 Public Communications Plan

7. Laboratory confirmed cases of
pandemic (H1N1) 2009 and total
influenza in Australia

8. OVERALL STATISTICS
Australia 2009
 37,000 laboratory confirmed cases, underestimate
 4,500 hospitalisations
 13% of laboratory confirmed cases, higher in ATSI
 700 ICU admissions
 336 cases of viral pneumonia (around 57 per year usually)
 13% of hospitalisations were admitted to ICU
 1/3 had no known risk factor
 61 patients treated using ECMO, 2/3 survived
 191 deaths
 Median age 53 years (83 years usually)
 1/3 of deaths occurred in people with no known risk
 Deaths reduced by:
- Older Australians spared
- Use of ECMO

9. Summary of
severity indicators
AUSTRALIAN INFLUENZA SURVEILLANCE REPORT. No. 22, 2010, 29 May 2010 – 4 June 2010

10. Rate of deaths classified as
influenza and pneumonia (NSW)

11. SEVERITY INDICES
p H1N1 2009
 Hospitalisations
- Chronic underlying medical condition
- Higher proportion of Indigenous Australians (20%)
- Over 50% admitted within 48 hours of onset
 Higher rate of ICU admissions than expected
 The clinical syndrome in intensive care was diffuse viral
pneumonitis associated with severe hypoxemia

12. Clinical
Presentation
Chest Radiograph and Computed Tomogram of 2 Patients Successfully Treated
With ECMO for Confirmed 2009 Influenza A(H1N1)
Extracorporeal Membrane Oxygenation for 2009 Influenza
A(H1N1) Acute Respiratory Distress Syndrome.
JAMA. 2009;302(17):1888-1895

13. Pathological
Features
 Consistent histopathological findings
- diffuse alveolar damage
- hyaline membranes
- septal oedema
- necrotizing bronchiolitis.
 The 2009 H1N1 virus targets alveolar lining cells (type I
and II pneumocytes) as well as upper airway lining cells
Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza,
Clinical Aspects of Pandemic 2009 Influenza A (H1N1) Virus Infection
N Engl J Med 2010 362: 1708-1719

14. KEY FINDINGS
FROM ANZICS
 Infants and younger adults 25-64 predominated
 Risk of death increased with age
 Underlying risk factors were pregnancy, chronic
lung disease, Indigenous or obese
 1/3 had no pre-existing risk factors
Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand. The ANZIC Influenza Investigators
N Engl J Med 2009;361:1925-34.

15. ANZICS
Data
Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand. The ANZIC Influenza Investigators
N Engl J Med 2009;361:1925-34.

16. ECMO
Study

17. Influenza in
Transplant Recipients
 Infection in transplant recipients
- Harder to recognize as signs and symptoms may
be diminished
- Fever may result from allograft rejection [1].
 Influenza
- is a common infection in solid organ transplant
recipients
- is associated with higher morbidity (viral
pneumonia, secondary bacterial pneumonia)
and mortality than in immunocompetent hosts [2].
1. Jay Fishman New England Med 357, 25 Dec 2007
2. Ison, MG, Hayden, FG. Viral infections in immunocompromised patients: what's new with respiratory viruses?.
Curr Opin Infect Dis 2002; 15:355.

18. Influenza in Lung
Transplant Patients
 Influenza causes significant morbidity and mortality,
including obliterative bronchiolitis
 Neuraminidase inhibitors shorten the duration of symptoms,
virus shedding and fewer antibiotic complications
 In lung transplant recipients
- Oseltamivir is well tolerated
- Infection resolved in all patients and there were no
deaths
- None of the patients had persistent abnormalities noted
on chest imaging and most did not show significant
changes on pulmonary function testing
Ison, M. G., A. Sharma, et al. (2008).
"Outcome of Influenza Infection Managed With Oseltamivir in Lung Transplant Recipients."
The Journal of Heart and Lung Transplantation 27(3): 282-288.

19. REVIEW of pH1N1
in TRANSPLANTATION
 115 Adult and paediatric solid organ transplants
 76 adults (median age, 49 years) 39 children
(median age, 8 years)
 38 kidney, 23 liver, 22 heart, 18 lung, and 14 other
 median time since transplant was 3.8 years
( 2 - 21.9 years)
American Transplant Congress (ATC) 2010: Abstract 5. Presented May 2, 2010
From http://www.medscape.com/viewarticle/721412

20. REVIEW of pH1N1
in TRANSPLANTATION
OUTCOMES:
 91% received anti-viral therapy
 65.2% of patients were hospitalized
 61.1% of patients were lymphopenic
 25.2% experienced pneumonia
 13.0% were admitted into the intensive
care unit (ICU)
 One death
American Transplant Congress (ATC) 2010: Abstract 5. Presented May 2, 2010
From http://www.medscape.com/viewarticle/721412

21. A mulitvariate analysis with hospitalization more likely
with:
- fever (P < .001),
- recent antilymphocyte globulin therapy (P = .04)
- or delayed antiviral therapy (P = .03)
Antiviral treatment within 48 hours of symptom onset
- Less likely to be admitted to the ICU — 0 of 36
compared with 15 of 67 patients (22.4%) who
received late antiviral treatment (P = .005)
American Transplant Congress (ATC) 2010: Abstract 5. Presented May 2, 2010
From http://www.medscape.com/viewarticle/721412
REVIEW OF pH1N1 in
TRANSPLANTATION

22. World Transplant
Games
 Held in Queensland -20 – 30 August 2009
 2000 transplant recipients from 50 countries
 At a single campus
 No reported cases
 No hospitalisations
 No fatalities

23. GUIDANCE FOR
TRANSPLANT RECIPIENTS
Endorsed by the American Society of Transplantation
(ABT), The Transplantation Society (TSS) and the
Canadian Society of Transplantation (CST):
 Diagnosis
 Treatment
 Chronoprophylaxis
 Recommendations for patients and family
 Recommendations for health care workers
Kumar D et al
American Journal of Transplantation 2010; 10: 18-25

24. 0
10
20
30
40
50
60
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53
Week
RateofILIper1,000consultations
ASPREN 2007
ASPREN 2008
ASPREN + NT + VIDRL 2009
ASPREN + VIDRL 2010
First case of
Pandemic
(H1N1) 2009
reported in
Australia
Weekly rate of ILI GP surveillance
systems - 1 January 2007 to 6 June 2010

25. Currently
 Australia has low pH1N1 activity with no increase
in Influenza A levels
 Following first wave natural immunity 15-25% of the
population
 Vaccination induced immunity is high:
- 9 Million pandemic vaccine does (41%)
- 5 Million + seasonal vaccine doses (23%)

26. WHO Update
May 30 2010
Northern Hemisphere
– Overall pandemic influenza activity remains low
– Active but declining p H1N1 in the Caribbean and
Southeast Asia
– Seasonal influenza type B viruses in China
Southern Hemisphere
– Pandemic and seasonal influenza activity is low
– ILI remains low in Australia and New Zealand
– Limited pandemic influenza virus in Chile.
– Low levels of H3N2 viruses in Kenya and Tanzania.
WHO Summary as at 30 May 2010