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Pandemic H1 N1 Influenza

Pandemic H1 N1 Influenza






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    Pandemic H1 N1 Influenza Pandemic H1 N1 Influenza Presentation Transcript

    • Pandemic 2009 H1N1 Influenza
      PeteyLaohaburanakit, MD, FCCP
      Intensive Care Unit
      Rogue Valley Medical Center
      October 8, 2009
    • Outline
      Global experiences with 2009 H1N1
      Southern hemisphere
      Published cohorts
      Hospital management
      Case identification
      Infection control and prevention
      Disaster preparedness, triage, and allocation of scarce resources
    • 2009 H1N1 Influenza A
      Quadruple re-assortment of RNAs from two swine strains, one human strain and one avian strain
      First recognized in March-April 2009 in Mexico
      Phase 6 pandemic status by June 2009
      Currently named 2009 H1N1 Influenza by CDC
    • 2009 H1N1 Influenza A
      1976 – present
      2009 H1N1
    • The Big Deal
      Novel virus to humans
      Sustained human-to-human transmission
      Causes severe, fatal illnesses in unusual populations
      May re-assort with seasonal flu (H3N2) or avian flu (H5N1)
      Unknown interactions with seasonal flu
    • Risk Groups for Seasonal Flu
      Chronic lung disease
      Cardiac disease
      Diabetes mellitus
      Chronic kidney disease
    • Risk Groups for 2009 H1N1
      Same as seasonal flu risk groups PLUS
      Age 6 months to 24 years old*
      Highest illness rates
      Second highest mortality rates
      Age 25 to 64 years old*
      Highest mortality rates
    • Is the mortality rate higher than seasonal flu?
      Study from Australia and New Zealand
      NEJM 2009 October
    • Experiences with 2009 H1N1
      Data from Southern hemisphere
      Published cohorts
      Mexico city
      Local experience at RVMC
    • 2009 H1N1 in Southern Hemisphere
      Reports from Argentina, Australia, Chile, New Zealand, and Uruguay
      Viral strain similar to the U.S. strain
      Similar at-risk groups
      Highest mortality in adults 25-64 years of age
      47-60% with known risk factors for severe disease
      Increased risks of complications in pregnant women
      Assessment of 2009 Influenza A (H1N1) Pandemic on Selected Countries in the Southern Hemisphere. Department of Health and Human Services. August 26, 2009.
    • 2009 H1N1 in Southern Hemisphere
      About 6-7 week ascent to peak followed by rapid decline
      Community mitigation measures
      School closures
      Cancellation of mass gatherings
      Isolation, quarantine, other social distancing
      Healthcare systems experienced stress
      Geographically isolated
      Relatively short-lived
    • Good news or Bad news?
      During Spring/Summer, hospitalization rates in the U.S. is 2.6 per 100,000 population (as opposed to 7.8 to 21.7 for the Southern hemisphere).
      Schools open in the fall.
      Our flu season officially starts October 4th 2009.
    • Second Waves
      Miller MA et al. New England J Med
      2009 ; 360:2595-2598.
    • Mexico City
      488 with influenza-like illness (ILI)
      114 confirmed by PCR
      22 observed in ER
      33 hospitalized for more than 24 hours.
      13 (39.3%) required non-invasive ventilation.
      9 (27%) required mechanical ventilation; average time on MV was 7 days (range 1-25 days).
      Data courtesy of Dr. Guillermo
    • Mexico City
    • Mexico City
    • Mexico City
    • Mexico City
    • Mexico City
    • Mexico City
      * Some patients required both non-invasive and invasive ventilation.
    • Mexico City
    • Mexico City
    • Spain
      Rello J, et al. Crit Care 2009;13:R148.
    • Spain
    • Spain
    • Spain
    • Spain
    • Michigan
      Intensive Care Patients With Severe Novel
      Influenza (H1N1) Virus Infection – Michigan
      MMWR. June 2009
    • Michigan
    • RVMC – All cases
      Fourteen cases of confirmed H1N1 (as of October 6)
      Average age 17 years (range 35 days-42 years)
      Male : Female = 1.2:1
      Average hospital length of stay 6.5 days
      Excluding ICU patients, hospital LOS 2 days
      Two patients expired.
    • RVMC – ICU cases
      4 admitted to ICU
      Age 25-34 years old
      3/4 developed severe ARDS.
      All ARDS patients required high-frequency oscillator.
      Two deaths, one transferred to a long-term acute care facility on mechanical ventilation, one discharged from hospital after 3 days
      Average hospital/ICU LOS is 16 days (range 3-52 days)
    • RVMC – ICU Cases
    • Common Themes
      Severe disease found in younger patients (pooled mean is 40 years old).
      The majority of ICU admits required prolonged invasive mechanical ventilation.
      Non-invasive ventilation not effective.
      Significant portion required HFOV or ECMO.
    • Common Themes
      Spain and Michigan reported range of 4-8 days from onset to first antiviral dose.
      ICU mortality rates varied from 28 to 45% (Mexico City, Spain, and Michigan).
    • Hospital Management
      Case identification
      Clinical diagnosis
      Laboratory confirmation
      Infection control and Prevention
      Treatment of suspected cases
      Disaster preparedness, triage, and allocation of scarce resources
    • Case Identification
      Symptoms and signs
      Diarrhea and vomiting*
      Laboratory findings
      Leucopenia or lymphopenia
      Elevated serum lactate dehydrogenase (LD)
    • Case Identification
      Laboratory confirmation
      Priority groups
      Those require hospitalization
      Those at risk of developing complications
      Nasopharyngeal swabs or aspirate
      Nasal swab plus throat swab
      Nasal wash
      Tracheal aspirate
    • Sampling
      Use personal protective equipment while swabbing.
      Swab horizontally, away from nasal septum.
      Samples need to be placed in viral transport media and placed on ice or cold packs or at 4 ºC for transport.
    • Diagnostic Tests
      Rapid antigen detection
      Nucleic acid testing : rRT-PCR
      Viral culture
      Antibody testing
      Acute sample
      Convalescent sample
    • Diagnostic Tests
      Beigel JH. Crit Care Med 2008;36:2660-2666.
    • Diagnostic Tests
      Send two swabs in one viral transport media for both rapid antigen detection and rRT-PCR for 2009 H1N1
      If 2009 H1N1 continues to predominate
      Positive rapid antigen leads to treatment with Oseltamivir or Zanamivir
      If seasonal flu becomes co-dominant with 2009 H1N1
      Positive rapid antigen may indicate combination treatment with Oseltamivir and Amantadine OR Zanamivir as single agent
      Negative rapid antigen test does not exclude influenza infection!
    • Infection Control and Prevention
      Droplet and standard precautions
      Surgical mask
      Eye protection
      Close contact is < 6 feet
      CDC recommends isolation until symptoms resolved or > 7 days after onset, whichever is longer.
      RVMC recommends isolation until hospital discharge.
    • Infection Control and Prevention
      Fit-tested N95 masks for aerosol generating procedureslisted in the WHO infection control recommendations
      Aspiration of respiratory tract
    • Infection Control and Prevention
      Hand hygiene
      Cough etiquette
      Self-quarantine and social distancing
    • Why personal hygiene is important
    • Infection Control and Prevention
      N95 masks? - Pros
      McIntyre R et al. (unpublished data)
      1936 healthcare workers in China
      Randomized to surgical masks or N95
      N95 group had 75% reduction in influenza-like illness, 75% reduction in confirmed influenza
      Surgical mask had no efficacy
      Other details unavailable
      What’s the control group?
      Usage and compliance?
      Other preventive measures?
    • Infection Control and Prevention
      N95 masks? - Cons
      Loeb M et al. JAMA 2009;302(17):e-pub ahead of print Oct 1, 2009.
      446 nurses in 8 Ontario hospitals
      Randomized to either surgical masks or fit-tested N-95 masks
      23.6% of surgical masks group and 22.9% of N-95 group developed laboratory confirmed influenza
    • Infection Control and Prevention
      Problems with N95
      Evidence to support the use is not very strong.
      Inadequate supply, especially in outpatient settings
      Requires fit testing
      Not practical for prolonged, day-to-day use
      Difficult to maintain compliance
    • What should we do?
      CDC, AMA, and IOM recommend the use of fit-tested N95.
      IDSA, APIC and SHEA recommend surgical masks.
      RVMC Infection Control recommends
      Droplet/contact precautions plus eye protection
      N95 for aerosol-generating procedures
    • Treatment
      Supportive care
      Oxygen therapy
      Intravenous hydration
      Symptomatic relief
      Critical care needs : ventilator, hemodynamic support, etc.
      Antiviral therapy
      Adjunct therapies – Not generally recommended
      Prophylactic antibiotics
    • Antiviral Therapy
      2009 H1N1 is resistant to Amantadine and Rimantadine.
      Susceptible to neuraminidase inhibitors
    • Antiviral Therapy
      Benefits of antiviral therapy
      Shortens the duration of symptoms
      Decreases the risks of complicated disease
      Decreases viral shedding
      Best results if initiated < 48 hours after onset
      May still help after 48 hours if symptoms are severe or in pregnant patients
    • Oseltamivir
      Oral formulation
      75 mg po bid for 5 days
      150 mg po bid for 10 days for the critically ill
      Side effects/practical issues
      Neuropsychiatric side effects
      Oseltamivir resistance
      Poor GI absorption
    • Zanamivir
      Inhalation via Diskhaler®
      Report of intravenous use (unlabeled)
      Kidd IM et al. Lancet 2009;374;1036.
      Two inhalations (10 mg total) twice a day for 5 days
      Side effects/practical issues
      Cough and bronchospasm
      Not appropriate in children < 7 years old
      Not administrable via ventilator circuit
    • Oseltamivir resistance
      Risk factors
      Prior exposure to Oseltamivir (prophylaxis or treatment)
      Immunocompromised patients
      Treatment options in suspected resistance
      Zanamivir when appropriate
      Oseltamivir plus Rimantadine or Amantadine
      Oseltamivir, Rimantadine plus Ribavirin
    • Antiviral Prophylaxis
      CDC guidance – September 22, 2009
      Close contact in high risks of complications
      Close unprotected contact in healthcare workers, first responders
      An alternative is to treat early if symptoms occur after a suspected exposure.
    • Secondary Bacterial Infection
      Retrospective pathologic review suggested secondary bacterial infection was a common cause of death in Pandemic H1N1 in 1918.
      Occurs several days after onset.
      Staphylococcus aureusincluding MRSA
      Necrotizing pneumonia
      Gram negative bacteria
    • Influenza-like Illness
      Need for hospital admission
      Risk factors for complicated disease
      • Isolation/self quarantine
      • Send samples for rRT-PCR ± Rapid antigen
      • Start empiric antiviral treatment
      Supportive care ± follow up
    • Influenza-like Illness
      Need for hospital admission
      Risk factors for complicated disease
      • Isolation/self quarantine
      • Send samples for rRT-PCR ± Rapid antigen
      • Start empiric antiviral treatment
      High risks for disease acquisition/spread
      Consider antiviral treatment
      Supportive care ± follow up
    • Disaster Preparedness, Triage and Allocation of Resources
      At a given time, most hospitals operate at over 90% capacity.
      Does not take much to overwhelm healthcare resources.
      Hospitals, practitioners, hospital staff need to prepare for a surge in patient load.
    • What NOT to do
    • Disaster Preparedness
      Be prepared
      “Know your enemies and know yourself, you will be victorious a hundred times in a hundred battles…”
      Sun Tzu’s The Art of War
    • Disaster Preparedness
      Educate yourself
      CDC guidance
      Flu.gov or Flu.oregon.gov
      American Medical Association
      Society of Critical Care Medicine
      New England Journal of Medicine H1N1 Center
    • Disaster Preparedness
      Protect yourself
      Personal hygiene
      Protective equipments
      Self quarantine
      Social distancing if needed
    • Disaster Preparedness
      Maximize staffing
      Tiered staffing model
      Physicians, mid-level practitioners, RNs, RTs, and pharmacists
      Maximize hospital facility
      Outpatient surgery, short stay unit
      Alternate care site (ACS)
    • Tiered Staffing
    • Definition of Triage
      “Scarce resources are used to provide the maximum benefit to the population at large, even if it means that other victims who might have been saved under usual circumstances cannot be treated optimally…”
      Christian M et al. Critical care during a pandemic: report from Ontario Health Plan for an influenza pandemic (OHPIP) working group on admission/discharge triage. 2006
    • Triage
      Every practitioner performs triage every single day, knowingly or unknowingly.
      Prioritization of patients with semi-objective risk calculation or eyeballing
      When resources are available, trials of treatment are reasonable.
      When resources are limited, trial of treatment may exhaust extensive resources and cause others to die.
    • The Scenario
      One ventilator
      Three H1N1 patients
      34-year-old single mother of 2
      82-year-old man who is a big donor to hospital foundation with severe emphysema and depends on home oxygen
      18-year-old male with drug abuse history
      How do we decide who gets the ventilator?
    • Ethical Principles in Triage
      Responsibility toward
      the common good
      Individual needs
      Available resources
    • Response Thresholds
      Christian M et al. Critical care during a pandemic: report from OHPIP working group on admission/discharge triage. 2006
    • Opportunities for Triage
    • Mortality Prediction for Triage
      Sequential organ failure assessment (SOFA) score
      Christian MD et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006; 175:1377-1381.
    • SOFA Score
    • Modified SOFA Score
    • Utah Hospitals and Health Systems Association. Utah Pandemic Influenza Hospital and ICU Triage Guidelines. January 10, 2009.
    • Exclusion Criteria for Admission
      Utah Hospitals and Health Systems Association. Utah Pandemic Influenza Hospital and ICU Triage Guidelines. January 10, 2009.
    • The Scenario
      One ventilator
      Three H1N1 patients
      34-year-old single mother of 2
      82-year-old man who is a big donor to hospital foundation with severe emphysema and depends on home oxygen
      18-year-old male with drug abuse history
      How do we decide who gets the ventilator?
    • Who Gets the ICU Bed and Ventilator?
    • Multi-modality Model
      White DB et al. Ann Intern Med 2009;150:132-138.
    • Palliative Care Services
      Those triaged to non-critical care must be treated nonetheless.
      Simple treatment measures may be provided if resources are available (e.g. oxygen, medications).
      Patients should be ensured adequate symptom relief and palliative care expertise.
    • Take Home Messages
      Recognize high-risk groups for severe 2009 H1N1 disease
      Most hospitalized patients are younger and could become critically ill quickly.
      High index of suspicion
      Isolate early and sufficiently.
      Protect yourself and your patients.
    • Take Home Messages
      Treat early and adequately
      Treatment most effective within 48 hours
      Treatment beyond 48 hours warranted in pregnancy and those with persistent, severe symptoms
      Double dose, double duration for severe cases
      Be informed, educated and prepared.