-
The Fourth Horseman:thoughts on influenza, pandemics and
medicineJon Temte, MD/PhD12 November 2009
Professor of Family MedicineUniversity of Wisconsin School of
Medicine and Public HealthVice Chair, CDC Advisory Committee on
Immunization Practices
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The Fourth HorsemenI looked and there before me was a pale
horse! Its rider was named Death to kill by sword, famine and
plague, and by the wild beasts of the earth. Revelations 6:3-4
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Katharine Anne Porter (1890-1980)Her mind tottered and slithered
again, broke from its foundation and spun like a cast wheel in a
ditch... She sank easily through deeps and deeps of darkness until
she lay like a stone at the farthest bottom of life
Pale Horse, Pale Rider, 1939Personal experience withSpanish flu
(H1N1) in 1918
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The Fourth HorsemanThe night air is cool and damp. My initial
irritation at being awake at 2:15 AM is tempered by my familiarity
with the patient I am driving in to admit to the hospital;
well-known, pleasant, but defeated by life, and now hemorrhaging.
As usual, while making my early morning on-call drive, I catch the
BBC World Service on my public radio affiliate. The story deals
with the World Health Organizations efforts to discover the origins
of the latest emergence: influenza A(H1N1) (S-OIV).
(May 1, 2009)
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I know that the tranquility of a Wisconsin spring, and of my
life are in the process of shattering. I have been in cross
training for the last 15 years a family doctor with an interest in
community patterns of infectious disease. I have been a watcher of
influenza, studying its recurrent seasonal spread across my state.
My skills have been in surveillance and communication. Ive
participated over the years with local, state and national pandemic
planning and disaster response. Ive climbed the ladders of
professional society leadership and appointments to national
advisory panels. Influenza is an old familiar friend. I know all
this cold. And I am not ready.
-
The cases will mount. The calls and emails will grow beyond
hope. There will be too much coordination in too many
directions.
Life goes on. I admit my patient, drive home and settle into a
brief and fitful sleep.
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an overviewbasic epidemiologyswine influenzalessons learnedbasic
rules of influenzaresponse
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Basic Influenza Epidemiology
-
Necessary Conditionsfor Epidemicsexposure to
pathogenssusceptible populationsappropriate environmentenhanced
person-to-person contact
-
Exposure to pathogen (spark)immigrant effectremote
communitiesglobal nature of influenzahemispheric
oscillationseasonalityZoonoses (antigenic gift)prevalence in
numerous speciesoccasional interspecific transmission
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Susceptible populations (fuel)role of antigenic driftminor
year-to-year change in antigensrole of antigenic shiftmajor change
in antigenshemaglutinin and neuraminidaseimmunizationbased upon
strains likely to circulatehigh risk population prophylaxis
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NeuraminidaseHemaglutininSource: Dr. Timothy Paustian
www.bact.wisc.edu/ microtextbook
-
Environment (condition)climatictemperaturehumidity
monsoonanthropogeniclong-term trends
-
Seasonal Correlates of Influenza A in Wisconsin( Wisconsin
Influenza Isolates: 7/1/80 through 6/30/05 )
-
Enhanced contact (catalyst)cultural / economicschool
contactsemployment contactsthe commutephysicalconfined spaces
(e.g., air travel)socialholidays
-
Vectors of Respiratory VirusesChildhood illnessschool-aged
children age 5 through 18high attack ratesup to 40%variable
symptomstransmission parents, grandparentssiblingswere
vectorsMonday, December 13, 2004Mom DadVirus culture on December
20, 2006 positive for Influenza A H3N2 California
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Influenza in the Community
-
The role of schoolSeasonality - the year starting in
SeptemberWisconsin: 9/2007 to 8/2008UW Family Medicine Clinical
Data Warehouse
-
1957 Pandemic Kansas Cityattack rate and mortalityInformation
taken from: Serfling et al., Am J Epidemiol 1967;86:433-41Chin et
al., J Public Health Rep 1960; 75:149-58
-
Basic Epidemic Math
-
Nt = NoertNt = the number of cases at time tNo = the number of
cases at time 0 e = the natural exponentialt = the number of
generations
-
A word about rr is the intrinsic rate of growthcan be considered
in terms of how many new cases are caused by each existing case
equal to the natural logarithm of the number of new cases per
existing caser = ln(N1/N0)If 2 cases caused by current case: r =
0.693If 3 cases caused by current case: r = 1.099
-
Example: effect of r
-
This would lead to exponential growth ...
-
... except that r rapidly declines after a period of relative
stabilitySusceptible individualsbecome less prevalent In general
population
-
because r declines, a classic epidemic curve emerges
-
This is reflected in the average epidemic curve for
WisconsinFirst CasesTransitionPeakLast Cases
-
Modeling Annual Influenza A Epidemics in Wisconsinr = 0.693;
pre-season immunity = 30%
-
Effect of pre-season immunityon shape and timing of epidemic
curveTime
-
Effect of pre-season immunityon total percent of population
infected
-
Swine Flu and PoohImage: CDC/ C. S. Goldsmith and A. Balish As
the two friends wandered through the snow on their way home, Piglet
grinned to himself, thinking how lucky he was to have a best friend
like PoohPooh thought to himself: If the pig sneezes, hes dead.
-
Novel Influenza A (H1N1)swine-originated influenza virusGenes
fromNA pigsEA pigsHumansTurkeysChickens Rapidly evolving
situationApril 21 case report -2 cases in California Children
-
Doubling Time Global: 1.8 days US: 2.1 days
Chart1
111
222
333
8254
555
6386
40667
81058
651489
10925710
14133111
1606153
2268983
27910853
40314905
64215165
171717
181818
191919
202020
US - CDC
Global - WHO
Day Number
Cases
Sheet1
ProbableConfirmed Cases
DateWisconsinWisconsinUSWORLDDay #
4/20/051
3/21/052
4/22/053
4/23/058254
4/24/055
4/25/05386
4/26/0540667
4/27/051058
4/28/05651489
4/29/05310925710
4/30/0514133111
5/1/05316061512
5/2/0565322689813
5/3/051023279108514
5/4/051195403149015
5/5/051195642151616
5/6/0517
5/7/0518
5/8/0519
5/9/0520
Nt=Noert
Generation Time =2.5days
Global e =0.3988from chart
USA e =0.3359from chart
r (global) =0.997
r (USA) =0.83975
secondary cases (g) =2.71
secondaty cases (u) =2.32
doubling time (g)1.7
doubling time (u)2.1
Sheet1
US - CDC
Global - WHO
Wisconsin
Day Number
Cases
Sheet2
US - CDC
Global - WHO
Day Number
Cases
Sheet3
-
Current Status ReportGlobal (November 1, 2009)482,300 cases
6,071 deaths (case fatality rate = 1.26%)
U.S. (November 6, 2009)17,838 hospitalizations672 deaths
Wisconsin (November 6, 2009)10,685 confirmed or probable cases
20 deaths (case fatality rate = 0.094%)My best guess for case
fatality rate = 0.002 to 0.010%
-
Cumulative Cases of novel H1N1 August 30 - November 6Wisconsin,
by county
-
Cumulative Rates of novel H1N1 August 30 - November 6Wisconsin,
by county
-
Outpatient influenza-like illness visits
-
Pneumonia and influenza death percent
-
Pediatric DeathsHigh Risk Condition Any 67% Neurodevelopmental
61% Multiple ND 36% Chronic Pulmonary28% ND with CPD25% Congenital
Heart 8% Metabolic/Endocrine 6% Immunosuppression 6%
-
H1N1 and pregnancyPregnancy is a significant risk factorWomen of
childbearing age have increased exposureCase rate = 1/100,000
pregnancies four-fold increased rate of hospitalizationCase series:
11 admissions out of 34 cases (32.4%)0.32/100,000 in pregnancy
0.076/100,000 for general population6 deaths (antivirals started
8-15 days post-onset)5 in 3rd trimester (C-section); 1 in first
trimester
-
Signs and Symptoms
-
Basic DemographicsSex Ratiofemale = male Median AgeAll cases =
12 yearsHospitalized cases = 20 yearsDeaths = 37 years
-
1957 Pandemic Kansas Cityattack rate and mortalityInformation
taken from: Serfling et al., Am J Epidemiol 1967;86:433-41Chin et
al., J Public Health Rep 1960; 75:149-58
-
Louie, J. K. et al. JAMA 2009;302:1896-1902.Hospitalization and
Fatality Rates and Case-Fatality Proportion Among Reported
Hospitalized Cases California, April 23 Through August 11, 2009
-
Age Distribution of Hospitalizations
-
Hospitalization Rates (per 100,000)
*Based on confirmed cases for whom these data are available at
time of report
-
Percent of Hospitalized Patientswith underlying medical
conditions
-
Lessons learned: Imagine an iceberg
-
Seasonal Influenza36,000 deaths200,000 hospitalizations
-
Pandemic influenza672 deaths 17,838 hospitalizations
-
Influenza Isolates WisconsinApril 26 October 3, 2009
-
Influenza Isolates Wisconsin(excluding 2009 H1N1) April 26
October 3, 2009
-
Chart1
2.30094959822.3009495982
1.64504903511.6450490351
0.52417006410.5241700641
0.78902229850.7890222985
0.49941245590.4994124559
1.61943319841.6194331984
1.58394931361.5839493136
1.06082036781.0608203678
1.74757281551.7475728155
0.46701692940.4670169294
0.40816326530.4081632653
1.06382978721.0638297872
0.09643201540.0964320154
0.36496350360.3649635036
1.03519668741.0351966874
0.95419847330.9541984733
0.52219321150.5221932115
0.21067415730.2106741573
0.4477611940.447761194
1.04166666671.0416666667
0.61162079510.6116207951
0.45045045050.4504504505
0.34364261170.3436426117
1.31578947371.3157894737
0.31948881790.3194888179
0.53191489360.5319148936
0.52910052910.5291005291
0.35335689050.3533568905
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
all states
staes with at least 1 death
State by State Incidence (cases/100,000)
Case Fatality Rate (%)
y = -0.0018x + 0.4794R2 = 0.0049
y = -3E-05x + 0.8518R2 = 0.0053
Sheet1
StatecasespopulationdeathsCFR%incidence/100,000deaths/100,000
New York273819306000632.3014.180.33
California316136458000521.658.670.14
Texas515123508000270.5221.910.11
Florida291518090000230.7916.110.13
Illinois340412832000170.5026.530.13
Utah9882550000161.6238.750.63
Arizona9476166000151.5815.360.24
New Jersey14148725000151.0616.210.17
Michigan5151009600091.755.100.09
Connecticut1713350500080.4748.870.23
Pennsylvania19601244100080.4115.750.06
Washington658639600071.0610.290.11
Wisconsin6222555700060.10111.970.11
Massachusetts1370643700050.3621.280.08
North Carolina483885700051.045.450.06
Oregon524370100050.9514.160.14
Maryland766561600040.5213.640.07
Hawaii1424128500030.21110.820.23
Minnesota670516700030.4512.970.06
Rhode Island192106800021.0417.980.19
Virginia327764300020.614.280.03
Georgia222936400010.452.370.01
Indiana291631400010.344.610.02
Missouri76584300011.321.300.02
Nebraska313176800010.3217.700.06
Ohio1881147800010.531.640.01
Oklahoma189357900010.535.280.03
Tennessee283603900010.354.690.02
Alabama477459900000.0010.370.00
Alaska27267000000.0040.600.00
Arkansas131281100000.004.660.00
Colorado171475300000.003.600.00
Delaware38185300000.0044.670.00
Idaho166146600000.0011.320.00
Iowa165298200000.005.530.00
Kansas204276400000.007.380.00
Kentucky143420600000.003.400.00
Louisiana232428800000.005.410.00
Maine145132200000.0010.970.00
Mississippi252291100000.008.660.00
Montana9494500000.009.950.00
Nevada467249600000.0018.710.00
New Hampshire247131500000.0018.780.00
New Mexico232195500000.0011.870.00
North Dakota6363600000.009.910.00
South Carolina244432100000.005.650.00
South Dakota4578200000.005.750.00
Vermont5962400000.009.460.00
Washington, D.C.4558200000.007.730.00
West Virginia243181800000.0013.370.00
Wyoming11151500000.0021.550.00
total436932994030003020.0714.590.10
estimated10000000.03334.00
Sheet1
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
all states
staes with at least 1 death
State by State Incidence (cases/100,000)
Case Fatality Rate (%)
y = -0.0018x + 0.4794R2 = 0.0049
y = -3E-05x + 0.8518R2 = 0.0053
Sheet2
Sheet3
-
Telephone Call VolumeSep 7Sep 14Sep 21Sep 28Oct 5Oct 12
-
Basic Rules of Influenza(1) Human influenza viruses are
transmitted person-to-person
Children are effective vectors. Social distancingmaintaining
distance between susceptible persons and casesis a uniformly
effective measure that will prevent transmission.
-
Basic Rules of Influenza(2) Influenza viruses are primarily
transmitted by respiratory droplets formed from respiratory
secretions and propelled forth by a cough or sneeze.
Deflecting or containing respiratory droplets will prevent
transmission. Face masks, used by infected or susceptible persons,
can be effective in preventing transmission.
-
Basic Rules of Influenza(3) Influenza viruses prefer cool, dry
air. Influenza is a highly seasonal virus with most transmission
limited to late fall and winter across temperate latitudes.
Transmission can occur at other times, but is far less
efficient. When novel viruses (such as H1N1 influenza) emerge,
transmission can occur at unusual times because of the absence of
immunity.
-
Basic Rules of Influenza(4) Influenza viruses target respiratory
mucosa. The potentially "exposed" respiratory mucosa covers the
nasal passages, nasopharynx, conjunctiva, pharynx, larynx, trachea,
bronchi, bronchioles, and alveoli.
Protection of respiratory mucosa from droplets and/or direct
contact will prevent transmission. Contaminated hands can provide
direct contact. Hand-washing reduces direct contact.
-
Basic Rules of Influenza(5) Once exposed, there is a fairly
predictable incubation period for influenza viruses. Clinical
illness will appear within 24 to 72 hours following infection.
The lack of clinical illness following exposure signifies no
infection, adequate immunity, or subclinical infection.
-
Basic Rules of Influenza(6) Once infected, there is a fairly
predictable period of virus shedding and transmissibility. Peak
shedding of the virus occurs during day two to three of clinical
illness, generally corresponding to the period of peak
symptoms.
Sick persons are less likely to move through the community.
Medical systems, however, often require sick persons to present to
the community. After five to six days of illness, an individual is
unlikely to transmit influenza.
-
Basic Rules of Influenza(7) Once infected, a pathway leading to
immunity is triggered within the influenza host. The immune
response leads to some of influenza's symptoms.
Infection and recovery produce lasting immunity to that
particular strain of influenza, provided that the host's immune
system is intact. People who successfully avoid H1N1 influenza will
be susceptible in the future and should be vaccinated.
-
Basic Rules of Influenza(8) Infection leads to recovery and
immunity, or death.
The propensity towards host death depends on strain and host
factors. In general, influenza mortality is highest in very young
and very old, and in the most immunocompromised persons.
-
Basic Rules of Influenza(9) Immunity may be acquired via
infection or via immunization.
Previous infection with other strains and/or immunization does
not guarantee immunity. Host factors and poor vaccine match can
significantly reduce immunity. As an H1N1 influenza vaccine becomes
available, physicians will need to immunize patients according to
recommendations.
-
Basic Rules of Influenza(10) Influenza epidemics follow
predictable patterns over time. This general behavior can be
modeled using estimates of immunity, transmissibility, and
generation time.
Many of the parameters needed to model epidemics are difficult
to obtain; models work best in retrospect. Many excellent regional
and national surveillance systems exist which can guide appropriate
practice.
-
Basic Rules of Influenza(11) There is a delicate interplay
between the infectivity of a virus and the population's level of
pre-existing immunity. For transmission to occur, susceptible
persons in the exposed population are needed. Reducing the
likelihood of contact with a susceptible person reduces the
infectivity of a virus.
Novel influenza viruses are unconstrained by factors of immunity
and achieve high infectivity potential. As late fall and winter
return, H1N1 influenza may become significantly worse.
-
Basic Rules of Influenza(12) "All living things contain a
measure of madness that moves them in strange, sometimes
inexplicable ways.*" Any of these rules may be broken at any time;
influenza viruses have a high potential for mutation, genomes may
be recombined, and population patterns are not fixed.
Whereas basic rules can set the conversation for planning
activities, ongoing surveillance and modification of response are
necessary for influenza prevention and control efforts. *Yann
Martel, Life of Pi 2003
-
responding toinfluenza
-
HandwashingRespiratory Protective Equipment
6/06
Faculty Documentation Form for Evidence-Based CME Clinical
Content
Complete this form for each topic seeking AAFP EB CME
designation and submit with the CME application. Please print
supporting evidence for each practice recommendation from the
approved source web site. Submit only the page(s) where the
evidence is cited. This page must show the specific web page
address. No more than three recommendations are needed for each
credit.
Learners must be informed in writing of 1) the approved practice
recommendation, 2) the AAFP-approved EBM source used, 3) the
specific URL where that information can be found, and 4) the
strength of the sited evidence.
Date of Submission: July 14, 2006
Activity Title: 2006 AAFP Scientific Assembly, Annual Lecture
Series
Topic Title: Pandemic Influenza: What You Need to Know Now
Date (if applicable): September 27 - October 1, 2006
Author/Speaker: Jonathan L. Temte, MD, PhD
Number of EB CME credits requested: 1
In the past year, has this topic been approved for AAFP EB CME
designation? FORMCHECKBOX Yes FORMCHECKBOX No
________________________________________________________________________________________________
Handwritten recommendations cannot be accepted for review. A
sample practice recommendation can be found at the end of this
form.
# 1 PRACTICE RECOMMENDATION (a statement of clinical guidance,
supported by evidence, that learners can use within their
practice.)
Handwashing can reduce trasmission or respiratory viruses,
including (potentially) influenza H5N1
Name of AAFP-approved source of systematic evidence review:
Bandolier
Specific webpage address citing the evidence supporting the
recommendation from the approved source (not the sources home
page):
http://www.jr2.ox.ac.uk/bandolier/band91/b91-4.html
Strength of evidence (narrative and/or grade with explanation of
what the grade means as provided by the approved source):
Frequent handwashers have fewer self-reported respiratory
illness than infrequent handwashers [OR = 1.5 (95% CI: 1.2 to
2.8)]
Infrequent handwashers have significantly more hospital
admissions [OR = 11 (95% CI: 2.7 to 46 )]
________________________________________________________________________________________________
# 2 PRACTICE RECOMMENDATION (a statement of clinical guidance,
supported by evidence, that learners can use within their
practice.)
The use of respiratory protective equipment, for example a
particulate filter mask, is indicated when exposure to a
significant respiratory pathogen is possible.
Name of AAFP-approved source of systematic evidence review:
National Guideline Clearinghouse (NGC)
Specific webpage address citing the evidence supporting the
recommendation from the approved source (not the sources home
page):
http://www.guideline.gov/summary/summary.aspx?doc_id=5069
Strength of evidence (narrative and/or grade with explanation of
what the grade means as provided by the approved source):
Grade D - Directly based on category IV evidence, or
extrapolated recommendation from category I, II or III evidence
_______________________________________________________________________________________________________________________________________
# 3 PRACTICE RECOMMENDATION (a statement of clinical guidance,
supported by evidence, that learners can use within their
practice.)
Neuraminidase inhibitors are recommended for treatment of
influenza, and can possibly be of benefit for influenza A (H5N1).
Recommendations are provided for adults and children
Name of AAFP-approved source of systematic evidence review:
Cochrane Database of Systematic Reviews
Specific webpage address citing the evidence supporting the
recommendation from the approved source (not the sources home
page):
http://www.cochrane.org/reviews/en/ab001265.html
http://www.cochrane.org/reviews/en/ab002744.html
Strength of evidence (narrative and/or grade with explanation of
what the grade means as provided by the approved source):
For Adults:
NIs were 74% effective (95% CI: 50%-87%) in preventing
clinically defined influenza
NIs were 60% effective (95% CI: 76%-33%) in preventing cases of
laboratory confirmed influenza
NIs shorten the duration of symptoms by one day (95% CI: 1.3 to
-0.6).
For Children:
Oseltamivir reduced the median duration of illness by 26% (36
hours) in previously healthy children with laboratory confirmed
influenza (p < 0.0001) and by 17% (21 hours) for
intention-to-treat population (p = 0.0002).
Zanamivir reduced the median duration of illness by 24% (1.25
days) in previously healthy children with laboratory confirmed
influenza (p < 0.001) and by 10% (0.5 days) for
intention-to-treat population (p = 0.011).
________________________________________________________________________________________________
# 4 PRACTICE RECOMMENDATION (a statement of clinical guidance,
supported by evidence, that learners can use within their
practice.)
Influenza vaccine--if availble--is recommended to prevent
influenza A (H5N1). Recommendations are provided for both adults
and children.
Name of AAFP-approved source of systematic evidence review:
Cochrane Database of Systematic Reviews
Specific webpage address citing the evidence supporting the
recommendation from the approved source (not the sources home
page):
http://www.cochrane.org/reviews/en/ab001269.html
http://www.cochrane.org/reviews/en/ab004879.html
Strength of evidence (narrative and/or grade with explanation of
what the grade means as provided by the approved source):
For Adults: LAIV reduced cases of serologically confirmed
influenza by 48% (95% CI: 24% to 64%) and clinical influenza cases
by 15% (95% CI: 8% to 21%). TIV had a vaccine efficacy of 70% (95%
CI: 56% to 80%) for of serologically confirmed influenza and of 25%
(95% CI: 13% to 35%) for clinical I influenza cases.
For Children: LAIV showed an efficacy of 79% (95% CI: 48% to
92%) and an effectiveness of 33% (95% CI: 28% to 38%). TIV had a
vaccine efficacy of 59% (95% CI: 41% to 71%) and an effectiveness
of 36% (95% CI: 24% to 46%)
________________________________________________________________________________________________
EMBED MSPhotoEd.3
_1111835904.bin
-
Oops... evidence encounters dogma
-
Antiviral MedicationVaccine
# 3 PRACTICE RECOMMENDATION (a statement of clinical guidance,
supported by evidence, that learners can use within their
practice.)
Neuraminidase inhibitors are recommended for treatment of
influenza, and can possibly be of benefit for influenza A (H5N1).
Recommendations are provided for adults and children
Name of AAFP-approved source of systematic evidence review:
Cochrane Database of Systematic Reviews
Specific webpage address citing the evidence supporting the
recommendation from the approved source (not the sources home
page):
http://www.cochrane.org/reviews/en/ab001265.html
http://www.cochrane.org/reviews/en/ab002744.html
Strength of evidence (narrative and/or grade with explanation of
what the grade means as provided by the approved source):
For Adults:
NIs were 74% effective (95% CI: 50%-87%) in preventing
clinically defined influenza
NIs were 60% effective (95% CI: 76%-33%) in preventing cases of
laboratory confirmed influenza
NIs shorten the duration of symptoms by one day (95% CI: 1.3 to
-0.6).
For Children:
Oseltamivir reduced the median duration of illness by 26% (36
hours) in previously healthy children with laboratory confirmed
influenza (p < 0.0001) and by 17% (21 hours) for
intention-to-treat population (p = 0.0002).
Zanamivir reduced the median duration of illness by 24% (1.25
days) in previously healthy children with laboratory confirmed
influenza (p < 0.001) and by 10% (0.5 days) for
intention-to-treat population (p = 0.011).
________________________________________________________________________________________________
# 4 PRACTICE RECOMMENDATION (a statement of clinical guidance,
supported by evidence, that learners can use within their
practice.)
Influenza vaccine--if availble--is recommended to prevent
influenza A (H5N1). Recommendations are provided for both adults
and children.
Name of AAFP-approved source of systematic evidence review:
Cochrane Database of Systematic Reviews
Specific webpage address citing the evidence supporting the
recommendation from the approved source (not the sources home
page):
http://www.cochrane.org/reviews/en/ab001269.html
http://www.cochrane.org/reviews/en/ab004879.html
Strength of evidence (narrative and/or grade with explanation of
what the grade means as provided by the approved source):
For Adults: LAIV reduced cases of serologically confirmed
influenza by 48% (95% CI: 24% to 64%) and clinical influenza cases
by 15% (95% CI: 8% to 21%). TIV had a vaccine efficacy of 70% (95%
CI: 56% to 80%) for of serologically confirmed influenza and of 25%
(95% CI: 13% to 35%) for clinical I influenza cases.
For Children: LAIV showed an efficacy of 79% (95% CI: 48% to
92%) and an effectiveness of 33% (95% CI: 28% to 38%). TIV had a
vaccine efficacy of 59% (95% CI: 41% to 71%) and an effectiveness
of 36% (95% CI: 24% to 46%)
________________________________________________________________________________________________
-
Influenza H1N1Priority Group 1Pregnant women Household
contacts/caregivers of infants younger than 6 months Healthcare
personnel and EMS Children and adolescents6 months to 18 years 78
millionhigh incidence of infection & potent influenza
spreadersYoung adults age 19-24 years Adults aged 25-64 years with
certain medical conditionsImage: CDC/ C. S. Goldsmith and A. Balish
Image: CDC/ Dr. Terrence Tumpey
-
Aggregate doses H1N1 vaccine shipped as of 11/04/09: 26,248,100
(10.5%)
-
Parents Efforts to Get H1N1 Flu VaccineHarvard Opinion Research
Program, Harvard School of Public Health, October 30-November 1,
2009.% Among ParentsTried to get H1N1 vaccine for childrenGot H1N1
vaccine for childrenCould NOT Get H1N1 vaccine for children% Among
Parents who Tried to Get VaccineDid NOT try to get H1N1 vaccine for
children
- High Priority Adults* Efforts to Get H1N1 Flu VaccineHarvard
Opinion Research Program, Harvard School of Public Health, October
30-November 1, 2009.% Among High Priority AdultsTried to get H1N1
vaccineGot H1N1 vaccineCould NOT Get H1N1 vaccine% Among High
Priority Adults who Tried to Get VaccineDid NOT try to get H1N1
vaccine*High priority adults include: pregnant women, health care
or emergency health personnel, adults who live with/care for
child
-
Personal Reactions in Trying to Get H1N1 Flu Vaccine% Among
Those Who Tried but Could Not Get H1N1 VaccineVery
frustratedSomewhat frustratedWill try again this yearWill not try
again this yearHarvard Opinion Research Program, Harvard School of
Public Health, October 30- November 1, 2009.Not Very frustratedNot
frustrated
-
Other concerns
-
Other VaccinesSeasonal Influenza Vaccine (TIV or
LAIV)Pneumococcal VaccineAge over 65AsthmaCigarette SmokersChronic
lung disease Chronic cardiovascular diseasesDiabetes
mellitusChronic liver diseasesChronic renal failure or nephrotic
syndromeFunctional or anatomic asplenia Immunocompromising
conditionsCochlear implants Cerebrospinal fluid leaks
-
Diagnosing InfluenzaClinical SymptomsPPV for fever and (cough or
sore throat) = 80%Seasonal influenza When influenza is
circulatingOver the age of 4 yearsRapid antigen tests for
influenzaSensitivity for H1N1 from 40% to 69%Dependent on viral
titerSpecificity is goodPCRGold standard, but too slow for
ambulatory care
-
Targets for Antiviral Medicationany severe Lower Respiratory
Infection hospitalized patientschildren younger than 5 years of
ageadults 65 and older people with chronic pulmonary,
cardiovascular, renal, hepatic, hematological, neurologic,
neuromuscular, or metabolic disorders people with
immunosuppressionpregnant womenpeople < 19 years on long-term
aspirin therapy
-
Treatment of Influenza H1N1Neuraminidase inhibitors Oseltamivir
Oral Treatment from age 1Chemoprophylaxis from age
1ZanamivirInhaled powerTreatment from age 7Chemoprophylaxis from
age 5Start within 48 hours of symptomsLate initiation may benefit
hospitalized patients
-
Early use of antiviral enhances benefitAoki FY, et al. J
Antimicrob Chemother. 2003;51:123-129.Reduction in duration
(days)Time to treatment (hours)Impaired activityImpaired
healthFever612243602468
-
Antiviral Resistance
-
When all else failsyou can count on the legislatureA member of
the State Legislature in Wisconsin has introduced a resolution to
stop state agencies and their employees from using the term Swine
Flu.
-
When all else fails novel approaches for novel
influenzahttp://www.youtube.com/watch?v=CVTFxYMhwiA
-
The fourth horseman revisited The night air has warmed with the
advance of spring. The baby robins in the nest built in our
castaway Christmas tree, propped against the garage, are nearly
fledged. It has been 29 days since a previous call night; I am
finally returning home after again admitting a number of patients,
including one from last time who is still defeated by life, and now
suffers from a bout of severe nausea and vomiting. To my dismay,
the admission requires a gown, a pair of gloves, a respirator and
eye protection, as she had a cough influenza A(H1N1). (May 21,
2009)
-
As I drive through the Wisconsin night I again catch the BBC
World Service. This time the story is on the Chelsea Flower Show
and the banning of gnomes from garden displays. I am bemused.
The tranquility of our springtime was indeed shattered. I
witnessed a very prompted and vigorous response to a newly emerged
threat. Practitioners, however, were buried in a sea of emails,
webcasts, clinical guidances, and updates that were mostly
uncoordinated, often conflicting, and poorly presented for the busy
clinician.
-
The value of the primary care in the ambulatory practice was
largely ignored. Early on came the chorus of infectious disease
end-timers, predicting the millions of casualties. As the
relatively benign influenza virus emerged, we seemed powerless to
accept this, unwilling to stand down. On a brief trip to New York
for CDC business, I exerted myself to note that the air grid was
still under an orange threat level. Seeing this, I got a cup of
coffee and read the paper.
-
Influenza is an old familiar friend. After a month, I recognize
its patterns and settle in for the coming months. I am ready.
Life goes on. As I drive home for a brief sleep I wonder if
garden gnomes need droplet precaution.
-
AcknowledgementsWisconsin Division of Public HealthBureau of
Communicable DiseasesWisconsin State Laboratory of HygieneCenters
for Disease Control World Health Organization