Hini2012 update
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Hini2012 update Presentation Transcript

  • 1. CDC WEB SITE 10/06 : What are the symptoms of seasonal and 2009 H1N1 flu?
    • You may have the flu if you have some or all of these symptoms:
    • Fever*
    • Cough
    • Sore throat
    • Runny or stuffy nose
    • Body aches
    • Headaches
    • Chills
    • Fatigue
    • Sometimes, diarrhea and vomiting
    • *It’s important to note that some people with flu will not have a fever.
  • 2. CDC CASE DEFINITIONS
    • Influenza-like illness (ILI) is defined as fever (temperature of 100ºF [37.8ºC] or greater) with cough and/or sore throat in the absence of a known cause other than influenza
    • A CONFIRMED case of pandemic H1N1 influenza A is defined as an individual with an ILI with laboratory-confirmed H1N1 influenza A virus detection by real-time reverse transcriptase (RT)-PCR or culture.
    • A PROBABLE case of pandemic H1N1 influenza A is defined as an individual with an ILI who is positive for influenza A, but negative for H1 and H3 by RT-PCR
    • Pandemic H1N1 influenza A may be SUSPECTED in an individual who does not meet the definitions of confirmed or probable pandemic H1N1 influenza A, but has an ILI and an EPIDEMIOLOGICAL LINK (eg, likely exposure to a confirmed or probable case within the past seven days). Full case definitions can be found at the CDC's website
  • 3. CDC DEFINITION OF Close Contacts  
    • Having cared for or lived with a person who is a confirmed, probable, or suspected case of pandemic H1N1 influenza A
    • Having been in a setting where there was a high likelihood of contact with respiratory droplets and/or bodily fluids of a confirmed, probable, or suspected case of pandemic H1N1
    • Having had close contact (sharing eating or drinking utensils, physical examination, or any other contact likely to result in exposure to respiratory droplets) with a confirmed, probable, or suspected case of pandemic H1N1 influenza A
    • Close contact does not typically include such activities as walking by an infected individual or sitting across from a symptomatic patient in a waiting room.
  • 4. CDC ADDITION TO “CLOSE CONTACT” 10/16
    • For the purposes of this document (isolation precautions) , close contact is defined as working within 6 feet of the patient or entering into a small enclosed airspace shared with the patient (e.g., average patient room)
    • Apply isolation precautions: Isolation precautions are recommended for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza.
  • 5. INCUBATION PERIOD CDC 10/16
    • In general, the incubation period for influenza is estimated to range from 1 to 4 days with an average of 2 days. 
    • Influenza virus shedding begins the day before illness onset and can persist for 5 to 7 days , although some persons may shed virus for longer periods, particularly young children and severely immunocompromised persons.
    • The amount of virus shed is greatest in the first 2-3 days of illness and appears to correlate with fever, with higher amounts of virus shed when temperatures are highest.
  • 6. Co-Morbidities that predispose patients to Complications from Influenza
    • Chronic pulmonary disease , including ASTHMA (particularly if systemic glucocorticoids have been required during the past year)
    • CHRONIC MEDICAL CONDITIONS
    • -  Cardiovascular disease (except isolated hypertension)       -  Active malignancy       -  Chronic renal insufficiency       -  Chronic liver disease       -  Diabetes mellitus       -  Hemoglobinopathies such as sickle cell disease       - Immunosuppression , including HIV infection (particularly if CD4 <200 cells/microL), organ or hematopoietic stem cell transplantation
    • I nflammatory disorders treated with immunosuppressants
    • Individuals who have any condition that can compromise handling of respiratory secretions (eg, cognitive dysfunction, spinal cord injuries, seizure disorders, neuromuscular disorders, cerebral palsy, metabolic conditions)
  • 7. Complications from 2009 H1N1 causing Severe Maternal Disease
    • VIRAL PNEUMONIA
    • SECONDARY BACTERIAL PNEUMONIA
    • PROGRESSION TO ARDS IF SEVERE DISEASE PERSIST
  • 8. Primary Viral Pneumonia Clinical Presentation  
    • Flu symptoms P ersist and Increase over 24-48 hrs instead of resolving in a patient with acute influenza. Shortness of breath and persistent cough will be the predominant Sx/Sx for those most at risk of severe disease.
    • The vast majority of pregnant women will not develop pneumonia or ARDS. Rarely maternal deaths secondary to Viral Pneumonia progressing to ARDS as a complication of 2009 H1N1 Influenza have been reported.
    Lancet 2009; 374: 451–58 N Engl J Med 2009;361
  • 9. INFLUENZA FACILTATES BACTERIAL PNEUMONIA INFECTION
    • Influenza virus alters and damages the lungs in a way that predisposes them to: adherence, invasion, and induction of disease by Streptococcus pneumoniae which is the most common cause( ~50%) of secondary bacterial pneumonia.
    • Secondary bacterial pneumonia causes ~ 25 percent of Influenza A associated deaths
    Clin Microbiol Rev. 2006 July; 19(3): 571 N Engl J Med 2009;361. Morb Mortal Wkly Rep. 2007 Apr 13;56(14):325-9
  • 10. 2009 H1N1 CASES ASSOCIATED WITH BACTERIAL PNEUMONIA
    • Bacterial Coinfection was found in (29%) of lung tissue specimens from 77 deaths associated with 2009 H1N1. Streptococcus pneumoniae was the most common isolated pathogen
    • Community Acquired Methicillin-Resistant Staphylococcus aureus pneumonia IF PRESENT can be associated with high mortality
    MMWR 2009 ;58:749--52. September 29, 2009 BACETRIAL CO-INFECTION WITH H1N1 N Engl J Med 2009;361. Morb Mortal Wkly Rep. 2007 Apr 13;56(14):325-9
  • 11. Secondary Bacterial Pneumonia CLINICAL PRESENTATION
    • Fever may resolve for one to three days after the onset of acute influenza BUT
    • Instead of continuing to improve, the patient with secondary bacterial pneumonia usually relapses with higher fevers ( > 101.5 ) , cough , production of purulent sputum , and CXR evidence of pulmonary infiltrates.
  • 12. Clinical features of severe cases of 2009 H1N1
    • As these bacterial co-infections are more frequent than initially recognized, clinicians stressed the need to consider empiric antimicrobial therapy for community acquired pneumonia as an early treatment.
    • Pneumonia caused by co-infection with bacteria can also contribute to a severe, rapidly progressive illness. Bacteria frequently reported include Streptococcus pneumoniae and Staphylococcus aureus, including methicillin-resistant strains in some cases.
    • In severe cases, patients generally begin to deteriorate around 3 to 5 days after symptom onset . Deterioration is rapid, with many patients progressing to respiratory failure within 24 hours , requiring immediate admission to an intensive care unit.
    WHO 10/16/2009
  • 13. RIVERSIDE OB INTERIM RECOMMENDATIONS 10/26 Triage Evaluation Clinical Management Outpatient Follow up
  • 14. Co-Morbidities that predispose patients to Complications from Influenza
    • Chronic pulmonary disease , including ASTHMA (particularly if systemic glucocorticoids have been required during the past year)
    • CHRONIC MEDICAL CONDITIONS
    • -  Cardiovascular disease (except isolated hypertension)       -  Active malignancy       -  Chronic renal insufficiency       -  Chronic liver disease       -  Diabetes mellitus       -  Hemoglobinopathies such as sickle cell disease       - Immunosuppression , including HIV infection (particularly if CD4 <200 cells/microL), organ or hematopoietic stem cell transplantation
    • I nflammatory disorders treated with immunosuppressants
    • Individuals who have any condition that can compromise handling of respiratory secretions (eg, cognitive dysfunction, spinal cord injuries, seizure disorders, neuromuscular disorders, cerebral palsy, metabolic conditions)
  • 15. Asthma and Pregnancy confer a high risk for Severe Disease with Seasonal Influenza or H1N1
    • Asthmatic pregnant patients may present with what appears to be an asthma exacerbation
    • MAY ACTUALLY HAVE ILI (Seasonal or H1N1)
    • Viral Studies, CXR, “further work up”, with a very low threshold to treat for “ ILI” with Tamiflu & Antibiotics.
    • Have a very low threshold to “admit” or at least observe these patients in the hospital until they improve
    MMWR Morb Mortal Wkly Rep. 2009 May 15;58(18):497-500. N Engl J Med 2009;361
  • 16. Mild ILI Symptoms SEVERE DISEASE NOT LIKELY
      • 1) NO Co-morbidity (Consider BMI > or = to 40 also)
      • 2) NO difficulty breathing while: performing routine physical activity, child care, talking, etc. NO SOB while laying down flat. Basically NO complaints of SOB and the patient feels well.
      • 3) NO c/o &quot;green/yellow sputum&quot; or &quot;severe coughing&quot;
      • 4) Patient has no dehydration. They are tolerating liquids/food with no problem and they do not have severe diarrhea &/or vomiting.
      • 5) No CNS symptoms eg disorientation, confusion, Seizure
      • 6) No chest pain/pressure.
      • 7) No difficulty getting 10 fetal movements in 2 hours
  • 17. MILD ILI SYMPTON ONSET > 72 HOURS No Treatment with Tamiflu , NO culture, No Observation
    • M ore than 72 hours has elapsed since the patient developed Sx Sx of ILI and she has started to improve with a decrease in her symptoms and currently feels better.
    • No significant lower respiratory tract symptoms (No persistent cough and not short of breath)
    • No Co-morbidities
    • No culture, No further evaluation ,No Tamiflu treatment.
    • General recommendations & RN follow up only
    • RN case manager will call for 3 days
  • 18. MILD ILI SYMPTON ONSET < 72 HOURS Treat with Tamiflu & Release NO culture No Observation
    • No Co-Morbidities
    • No Shortness of Breath No CXR
    • RR < or = 20 No CXR
    • Normal Chest Exam by Auscultation No CXR
    • No or minimal clear productive cough No CXR
    • SaO2 96 % or higher on RA while awake No CXR
    • Temperature < 101.5
    • No: Dehydration, persistent vomiting, confusion or disorientation, chest pain, dizziness, or difficulty tolerating PO. Patient feels well & desires to go home.
    • NST Reactive for EGA
    • Tamiflu 75 mg BID X 5 days & General Guidelines
    • Case manager RN follow up for 3 days
  • 19. Concerning ILI Signs & Symptoms Warrant further Evaluation, Tamiflu Tx, Culture & Observation
    • Co-Morbidities present
    • Shortness of Breath CXR
    • RR > or = to 22 CXR
    • Positive Chest Exam by Auscultation CXR
    • SaO2 < or = to 95 % on RA CXR
    • Positive CXR - Add Ceftriaxone / Azithromycin
    • Temperature > or equal to 101.5
    • Complains of any one: Dehydration, persistent vomiting, confusion or disorientation, chest pain, dizziness, or difficulty tolerating PO.
  • 20. Evaluation for Concerning ILI
    • Viral Studies
    • (see current protocols for specific Viral studies & infection Control)
    • CXR / Continuous Pulse Oximetry
    • Document MRSA status ( pos, neg, unknown / risk ie pos family member)
    • ALT / AST ( > 2X upper limit of normal in 16% & 18% respectively )
    • CBC in patients with H1N1
    • 20 % WBC < 5K
    • 18 % WBC > 11K
    • CONSIDER FURTHER EVALUATION FOR
    • BUN, Creatinine, Lytes, (if suspect dehydration)
    • Blood Culture ( If Temp > or equal 101.5 )
    • Sputum Culture & Gram Stain (if productive cough)
    • Consider ABG based on SaO2 / CXR
    • Consider Streptococcus pneumoniae urine antigen for positive CXR
    N Engl J Med 2009;361 (10.1056/NEJMoa0906695) Obstet & Gynecol VOL. 114, NO. 4, 2009
  • 21. Consider Viral Studies, Tamiflu, Observation WITH No FEVER HOWEVER CLINICALLY CONCERNING ILI Sx/Sx AND
    • 1) HIGH RISK Co-Morbidities (Asthma, Pre-Gestational Diabetes , Immunosuppression , etc)
    • 2) HAVE A SIGNIFICANT EXPOSURE eg. family member or close contact treated or with classic ILI
    • 3) You are concerned about their Sx/Sx and/or suspect pneumonia
  • 22. ILI of Concern Further Workup & Treatment Indicated
    • Patient symptoms have progressed over the preceding 24-72 hours. ( suspect viral pneumonia)
    • Patient symptoms initially improved in the first 24-96 hours ; However they have developed a progression of respiratory symptoms and/or return of high fever
    • (suspect secondary bacterial pneumonia)
    • Treat with Tamiflu 75 mg bid for ten doses
    • Add IV antibiotics to Tamiflu
    • If posititve CXR or bacterial pneumonia Treat with
    • IV Ceftriaxone 2 G Q 24 hours
    • IV Azithromycin 500mg Q 24 hours
            • N Engl J Med 2009;361.
    Obstet & Genecol VOL. 114, NO. 4, 2009
  • 23. SEVERE ILI Stabilization & Consider Delivery
    • SaO2 < or = to 90 % on RA
    • RR > 30
    • ABG Ph < 7.35
    • Sepsis Syndrome
    • Temp > or = 103
    • BUN > 30
    • Disoriented, confused, or seizures
  • 24. Complications & 2009 H1N1
    • Viral pneumonia may be rapidly progressive in 24 – 48 hours
    • Evaluate for complications : Secondary Bacterial Pneumonia ,DVT and/or PE, ARDS, Renal failure, MODS, CNS involvement ( Seizures, Disorientation).
    • Consider Evaluation for exacerbation of underlying medical Co-Morbidities
    • EGA dependent for NST / Continuous EFM
    • Continuous SaO2
    • Serial CBC , Chest Exam , Temperature, Vital Signs
    • Accurate I & O
    • F/U CXR , ABG , dependent on above.
  • 25. TREATMENT WITH TAMIFLU Requires Approval By (…..) in Comments Section
    • The CDC has recommended that symptomatic pregnant women be treated with oseltamivir (TAMIFLU) Pregnant women who meet current case definitions for confirmed, probable, or suspected pandemic H1N1 influenza A infection should receive antiviral therapy with
    • Treat-Tamiflu 75 mg Q 12 HOURS FOR FIVE DAYS
    • CXR positive or secondary bacterial pneumonia -Treatment with Ceftriaxone 2 G IV Q 24 & Azithromycin 500 mg IV Q 24
  • 26. PREGNANCY HI RISK
    • Pregnant women:   Pregnancy increases the risk of complications, hospitalization, and severe disease. (Lancet. 2009;374:451-458).
    • While oseltamivir and zanamivir are &quot;Pregnancy Category C&quot; available data suggest pregnant women with suspected or confirmed influenza should receive prompt antiviral therapy, and pregnancy should not be considered a contraindication to treatment with oseltamivir or zanamivir.
    • Oseltamivir is preferred for treatment of pregnant women because of its systemic activity. Anecdotal reports suggest postpartum women, similar to pregnant women, might be at increased risk for severe complications and death from 2009 H1N1 influenza. 
    • The transition to normal immune, cardiac, and respiratory function occurs quickly, but not immediately after delivery.  Therefore, the increased risk associated with pregnancy should be considered to extend for 2 weeks postpartum regardless of the outcome of the pregnancy (including live birth, premature birth, termination of pregnancy, miscarriage, fetal death). 
    • Prompt empiric antiviral treatment is indicated for suspected or confirmed 2009 H1N1 influenza in women who are up to 2 weeks postpartum regardless of how the pregnancy ended.
  • 27. SEVERE ILI Stabilization in the ICU
    • SaO2 < or = to 90 % on RA
    • RR > 30
    • ABG Ph < 7.35
    • Sepsis Syndrome
    • Temp > or = 103
    • BUN > 30
    • Disoriented, confused, or seizures
  • 28. Who to treat CDPH
    • Treatment of Confirmed or Suspected Influenza
    • Who to treat
    • Prompt empiric treatment is recommended for persons with suspected or confirmed influenza and:
    • Illness requiring hospitalization
    • Progressive, severe, or complicated illness, regardless of previous health status, and/or 
    • Patients at risk for severe disease pregnqncy and up to 2 weeks psopstpartum(see below for groups at high risk)
    • How to treat
    • Antiviral drugs: oseltamivir (oral), zanamivir (inhaled)
    • Initiate treatment as early as possible after onset of symptoms
    • Treat empirically before diagnostic test results are reported
    • When definitive diagnosis is indicated, request definitive diagnostic tests (rRT-PCR*, viral culture) rather than rapid tests (RIDT*, DFA*)
    • * rRT-PCR: real-time reverse transcriptase polymerase chain reaction; RIDT:  rapid influenza diagnostic test, DFA: direct immunofluorescence assay
  • 29. TREATMENT VS PROPHYLAXIS
    • 75 mg twice daily FOR 5 DAYS IS TRAETMENT75 mg once daily
    • 75 MG ONCE DAILY FOR 10 DAYS IS PROPHYLAXIS
  • 30. TAMIFLU INFORMATION
    • Oseltamivir - The neuraminidase inhibitor oseltamivir formulated as capsules or oral suspension (Tamiflu®) is FDA-approved for the treatment of uncomplicated acute influenza in patients 1 year and older who have been symptomatic for no more than 2 days.
    •  
    • In addition, the CDC authorizes treatment of patients symptomatic with 2009 H1N1 influenza for more than 2 days and patients sick enough to require hospitalization (see www.cdc.gov/h1n1flu/eua/tamiflu.htm). 
  • 31. IV THERAPY RECOMMENDED
    • Peramivir - A third neuraminidase inhibitor peramivir formulated for intravenous (IV) administration is an investigational product currently being evaluated in clinical trials.  As of October, 2009, safety and/or efficacy data from 1,891 patients with acute uncomplicated seasonal influenza A has been submitted to the FDA
    • Even though the data are insufficient to allow FDA approval, the FDA issued an EUA for treatment with peramivir of hospitalized patients with 2009 H1N1 influenza who have potentially life-threatening suspected or laboratory confirmed infection.
    • Peramivir IV is available through the CDC upon request of a licensed physician. Under the EUA, treatment of adult patients with IV peramivir is approved only if:  (1) the patient has not responded to either oral or inhaled antiviral therapy; (2) drug delivery by a route other than IV is not expected to be dependable or is not feasible; or (3) the clinician judges IV therapy is appropriate due to other circumstances.  Treatment of pediatric patients is approved if either of the first two criteria apply.
  • 32. INHALATION THERAPY
    • Zanamivir is administered by inhalation using a proprietary “Diskhaler” device distributed together with the medication. 
    • Zanamivir is a dry powder, not an aerosol, and should not be administered using nebulizers, ventilators, or other devices typically used for administering medications in aerosolized solutions.
    • Zanamivir is not recommended for persons with chronic respiratory diseases such as asthma or chronic obstructive pulmonary disease that increase the risk of bronchospasm.
  • 33. MEDICAL COMPLICATIONS
    • Pregnant women: 2 weeks postpartum regardless of the outcome of the pregnancy (including live birth, premature birth, termination of pregnancy, miscarriage, fetal death). 
    • Adults aged 65 years and older:
    • Asthma
  • 34. MEDICAL COMPLICATIONS HIGH RISK FOR ADVERSE OUTCOME
    • Chronic  lung disease   (such as chronic obstructive pulmonary disease  [COPD] and cystic fibrosis)
    • Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease)  
    • Blood disorders (such as sickle cell disease)
    • Endocrine disorders (such as diabetes mellitus)
    • Kidney disorders
    • Liver disorders
    • Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
    • Weakened immune system due to disease or medication (such as people with HIV or AIDS, or cancer, or those on chronic steroids)
    • People younger than 19 years of age who are receiving long-term aspirin therapy