INFLUENZA UPDATE

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INFLUENZA UPDATE Tuesday 9/22/09
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Global Updates

• The US is reporting increased activity,
  especially in the southeast and southwest.
• European activity remains stable, except for
  increases in France.
• Much of South and Southeast Asia reports
  widespread activity.
• In the temperate Southern Hemisphere influenza
  activity continues to decline.
• Sporadic cases (now 26) of oseltamivir
  resistance continue to be reported.
• WHO H1N1 vaccine production will likely be
  substantially less than the 4.9 billion doses
  originally forecast.
• The US announced that 10 (19.5 million doses)
  of its H1N1 vaccine supply will be shared with
  other countries through the WHO. Australia,
  Brazil, France, Italy, New Zealand, Norway,
  Switzerland, and Britain made similar
  announcements.

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Global Updates

• Australian researchers are reporting that
  pregnant women who became severely ill with
  pandemic H1N1 had low levels of IgG2.
• Severe cases had IgG2 levels about one-third of
  those detected in moderately ill patients.
• Three of four critically ill patients treated
  with immune globulin survived.
• The team looked at health pregnant women and
  found that about 60 were mildly deficient in
  IgG2.
• The data were recently presented at the ICAAC
  annual meeting of the American Society for
  Microbiology, and should be considered
  preliminary and unreplicated.
• Peramivir, a new antiviral drug under
  development, is a neuraminidase inhibitor (like
  oseltamivir) but is administered intravenously.
  It is currently in Phase II studies.

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• H1N1 Vaccine Early Results from a Child
  Clinical Trial
• Preliminary results from a child clinical trial
  demonstrate that after a single 15 microgram dose
  of H1N1 vaccine
• a protective immune response was achieved in 76
  of 25 children 10 -17 years
• 36 of 25 children aged 3-9 years old had a
  protective immune response
• 25 of 20 children aged 6 35 months had a
  protective immune response.
• If sustained, these results will likely lead to
  a recommendation that children 10 17 years of
  age need only a single dose of H1N1 vaccine for
  the majority to become immune, whereas younger
  children would need an initial dose followed by a
  booster dose.

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World Activity by Outbreak Severity
http//upload.wikimedia.org/wikipedia/commons/0/0c
/H1N1_map.svg
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World Activity by Outbreak Size
http//en.wikipedia.org/wiki/FileH1N1_map_by_conf
irmed_cases.svg
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Global Updates

• Recent news headlines
• Belatedly, Egypt Spots Flaws in Wiping Out
  Pigs
• Finland reports clusters in school
• India Death toll reaches 240
• Russia registers first swine flu death
• Tasmania hospitals overstretched to capacity
  last 3 months
• Hong Kong update 717 new cases in 24 hours
• Kenyan high school reports 11 more cases of
  swine flu
• Mozambique reports first two deaths of A/H1N1
  flu
• France Peak expected in four to eight weeks
• UK Case rates doubling, may indicate 2nd wave
  underway
• Brazil registers 899 swine flu deaths
• KwaZulu Natal doctor succumbs to H1N1

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Global Updates

• CDC Briefing 9.18.09
• the flu season has begun. It's begun early,
  and nearly all of the influenza that we're seeing
  is this novel H1N1 virus.children and young
  adults are still being hit the hardest
  Influenza is being reported in all 50 states.
• Circulating H1N1 is still a good match for the
  strain selected for the vaccine. Susceptibility
  to oseltamivir remains almost universal. No
  increased virulence has been observed.
• 54 million doses of seasonal vaccine have been
  distributed, roughly half of the anticipated
  production.
• The FDA has licensed H1N1 vaccine from 4 of the
  5 manufacturers. The government has ordered 195
  million doses. Initially, we anticipate that
  about 3.4 million doses of vaccine will be
  available. They then anticipate 20 million
  doses/week through December, distributed to
  states by population.

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Global Updates

• The initial release of H1N1 vaccine may
  primarily be the intranasal spray, which is a
  live attenuated virus vaccine. If this is the
  case, it is important to remember that many
  populations typically should not receive a live
  attenuated virus influenza vaccine (eg, children
  younger than 2 years, adults over 50, pregnant
  women, children younger than 5 with asthma,
  people with potential respiratory impairment from
  neuromuscular illnesses, immunosuppressed
  patients, children or adolescents on long-term
  aspirin treatment, and people with predisposing
  chronic medical conditions). These populations
  should wait for the injectable inactivated-virus
  vaccine.
• Multi-dose vials of both vaccines will contain
  thimerisol as a preservative. Single-dose units
  and the intranasal preparation will not.

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• US Updates
• CDC Activity Report for 8/30/09 9/12/09 in 39
  of 56 states and territories

U.S. Influenza and Pneumonia-Associated
Hospitalizations and Deaths 8/30/09 - 9/5/09

• Twenty-one states are reporting widespread
  influenza activity at this time (including NM) 9
  states and Puerto Rico report regional activity.
• 99 of all subtyped influenza A viruses were
  pandemic H1N1.

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• US Updates
• The proportion of outpatient visits for ILI was
  above the national baseline.
• The CDC has updated its Interim Recommendations
  for Obstetric Health Care Providers Related to
  Use of Antiviral Medications in the Treatment and
  Prevention of Influenza for the 2009-2010 Season.
  The update is attached to the email.
• The American College Health Association reports
  the following college data for the week of
  September 5-11
• 6,432 new cases of influenza-like illness from
  210 institutions
• no reported deaths
• new case rate of 21.5 per 10,000 (up 3.7)
• New Mexico reports an unchanged attack rate of
  3.1 per 10,000, with 8 new cases for the week
  ending September 11
• The highest activity rate remains in the
  Northwest.

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• US Updates
• Federal health officials reported last Friday
  that 3.4 million doses of H1N1 vaccine would be
  available the first week of October.
• The New York State Health Department has adopted
  emergency regulations mandating seasonal and H1N1
  vaccination for all hospital, home health and
  hospice workers.
• According to the NY Times, Only two hospital
  groups in the country, Virginia Mason in Seattle
  and BJC HealthCare in St. Louis, now make all
  their employees get flu shots or face dismissal.
• A BMJ article reports that over half of Hong
  Kong healthcare workers would not be vaccinated.
  Another BMJ article reported that a poll of NHS
  nurses showed that a third would reject
  vaccination. A survey by Israels ministry of
  health found that at least 25 of the population
  is not willing to be vaccinated.

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• US Updates
• The CDC recommends that for children with
  asthma
• Everyone with asthma who is older than 6 months
  should get a shot every year to protect against
  the seasonal flu.Children aged 6 months to 8
  years who never have had a seasonal flu shot will
  need two doses the first time. Children who have
  had a seasonal flu shot in the past only need one
  shot. Persons with asthma should not use the
  inhaled "FluMist" vaccine.
• Everyone with asthma who is aged 6 months to 64
  years should get the 2009 H1N1 flu shot when it
  becomes available. The 2009 H1N1 flu shot is not
  the same as the shot for seasonal flu. If the
  H1N1 flu vaccine is in short supply, some persons
  may not be able to get the shot right away.
• Antiviral drugs (e.g., oseltamivir) should be
  considered.
• Aspirin-containing products (including
  Pepto-Bismol) should not be given (because of the
  risk of Reyes syndrome).

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http//www.cdc.gov/h1n1flu/updates/us/
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Percentage of Visits for Influenza-like Illness
Reported by the U.S. Outpatient ILI Surveillance
Network (ILINet), National Summary 2008-2009 and
Previous Two Seasons (Posted 9/11/09, for Week
Ending 9/12/09)
http//www.cdc.gov/h1n1flu/updates/us/
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CDC Guillain-Barré Syndrome and Influenza
Vaccines

• Guillain-Barré syndrome (GBS) is a rare disease
  in which the body damages its own nerve cells,
  causing muscle weakness and sometimes paralysis.
  It is not fully understood why some people
  develop GBS, but it is believed that stimulation
  of the bodys immune system may play a role in
  its development. Infection with the bacterium
  Campylobacter jejuni, which can cause diarrhea,
  is one of the most common risk factors for GBS.
  People can also develop GBS after having the flu
  or other infections (such as cytomegalovirus and
  Epstein Barr virus). On very rare occasions, they
  may develop GBS in the days or weeks following
  receiving a vaccination.
• In 1976, there was a small risk of GBS
  following influenza (swine flu) vaccination
  (approximately 1 additional case per 100,000
  people who received the swine flu vaccine). That
  number of GBS cases was slightly higher than what
  is normally seen in the population, whether or
  not people were vaccinated. Since then, numerous
  studies have been done to evaluate if other flu
  vaccines were associated with GBS. In most
  studies, no association was found, but two
  studies suggested that approximately 1 additional
  person out of 1 million vaccinated people may be
  at risk for GBS associated with the seasonal
  influenza vaccine. FDA and CDC will be closely
  monitoring reports of serious problems following
  the 2009 H1N1 influenza vaccines, including GBS.

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• US Updates
• Recent news headlines
• Colorado schools suffering 20 absenteeism
• Florida coach Urban Meyer in panic mode over
  teams flu bug
• H1N1 virus hits Portland OR Metro grade
  schools
• Lubbock TX schools report early influenza
• NC Gaston Memorial flooded with flu-like
  cases
• WI Dozens on Badgers football team ignored flu
  symptoms
• GA Swine flu claims 4 lives in Ga. in past
  week
• WA 13 WSU Cougars football players among those
  infected with flu
• New Jersey Is Expected to Require Flu Shots for
  Preschoolers
• First family to follow rules on flu vaccine

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New Mexico Updates

• CDC has advanced New Mexico from regional to
  widespread influenza activity.
• The NM Department of Health has begun releasing
  weekly media updates on influenza in New Mexico.
  From this weeks report
• To date there have been four H1N1-related deaths
  in New Mexico a 45-year-old female from Sierra
  County with end stage liver disease, a
  52-year-old female from Bernalillo County with
  chronic pulmonary disease, a 48-year-old female
  from McKinley County with asthma and diabetes,
  and a 21-year-old female from Los Alamos County
  without chronic medical conditions.
• DOH is tracking 22 clinics. For the week ending
  September 12th, 4 of patients at those clinics
  had ILI, an increase of 1.

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New Mexico Updates

• DOH weekly report excerpts, continued
• As of Sept. 15, 2009, there have been 48
  hospitalizations related to H1N1 influenza. The
  hospitalizations by county are as follows
  Bernalillo County (6), Chaves County (1), Cibola
  County (1), Doña Ana County (5), Eddy County (1),
  Lea County (1), McKinley County (4), Otero County
  (1), Roosevelt County (2), San Juan County (2),
  Sandoval County (1), Santa Fe County (3), and
  Sierra County (4) and 16 cases not yet
  determined.
• As noted previously, CDC has advanced New
  Mexicos influenza activity to widespread.
• Local pharmacies are reporting shortages of
  oseltamivir.
• Tricore Lab respiratory virus isolates typed as
  Influenza A have essentially been doubling
  weekly, most recently at 77 isolates for the week
  of 9/5-9/11/09. 96 of respiratory virus
  positives were Influenza A (almost certain to be
  H1N1).

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UNM Updates

• Influenza-like illness continues in low numbers
  amongst UNM students and staff, UNMH employees,
  and UNMH patients. No clinical surges have been
  noted as yet.
• Ambulatory services and the ER are receiving an
  increasing number of inquiries about vaccine
  availability.
• UNM Student Health Counseling has prepared an
  H1N1 informational handout for students and staff
  (attached to email).
• Residence Life and SHAC have prepared
  handwashing signage.
• UNMH Pharmacy is dispensing oseltamivir from the
  Strategic National Stockpile supply.
  Distribution to ambulatory and inpatient sites is
  anticipated later this week or next week.
• The Starting Gate recently provided guidelines
  for hand sanitizer stations.

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UNM Updates

• UNMH is working with MMRS and DOH to coordinate
  hospital visitation policies among local area
  hospitals.
• Delivery of the UNMH seasonal influenza vaccine
  order is imminent hopefully this week,
  guaranteed by 9/30.
• Clinical guidance documents are being updated to
  reflect CDC and DOH updates.
• The Influenza COG is meeting more frequently, in
  anticipation of increased activity.
• ER leaders, ambulatory leaders, and influenza
  planners have been meeting to enhance our ability
  to handle clinical surges.
• Several clinical Departments have held recent
  meetings to review and develop clinical surge
  plans.
• Inpatient Medical Directors will be briefed
  9/22.
• The UNM and UNMH websites have been updated.

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UNM Updates

• NB I will be on leave for the next two
  Tuesdays. Brief situational updates will still
  be forthcoming on those days, and I will resume
  these updates upon my return. In my absence, Dr.
  David Pitcher will be the EOC incident commander.
  Other specific questions may be directed as
  follows
• UNM Emergency Management Byron Piatt
• UNMH Emergency Management Cynde Tagg
• Influenza-related clinical questions Susan
  Kellie, Pam Iwamoto.
• Vaccination programs Quentin Jones, Karen
  Ellingboe
• Thanks. Bob Bailey