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Outline. Current Outbreak. Brief review of Influenza structure & subtypes. Transmission and Prevention. Available Testing. Treatment. Prophylaxis – PowerPoint PPT presentation

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Title: Influenza

  • Peggy Beeley, MD
  • Best Practice 1/15/14

  • Current Outbreak
  • Brief review of Influenza structure subtypes
  • Transmission and Prevention
  • Available Testing
  • Treatment
  • Prophylaxis

Signs Symptoms
  • Fever
  • Cough
  • Sore throat
  • Coryza or nasal congesting
  • Headache
  • Myalgias and fatigue
  • Nausea and vomiting may occur
  • Illness occurs during influenza season
  • Abrupt onset
  • Primary viral pneumonia
  • Secondary Bacterial Pneumonia
  • Croup
  • Exacerbation of Chronic Pulm Dz
  • Otitis Media
  • Sinusitis
  • Myositis
  • Cardiac Complications
  • Toxic Shock Syndrome
  • Reyes Syndrome

Most Recent Surveillance from CDC
UNMH Admissions for 2013-2014 Influenza Season
Courtesy Dr. Meghan Brett
Characteristics of Admitted Patients with
  • Average age 36.7 years
  • Range 0 64 years
  • Sex 53 Female
  • 47 Males
  • Admitted from
  • 71 from ED
  • 29 from Clinics
  • All positive for Influenza A

Courtesy Dr. Meghan Brett
  • RNA viruses Orthomyxoviradae
  • Influenza A
  • Most morbidity mortality
  • Pandemic
  • Influenza B
  • gt 60 Yamagata
  • gt 30 Victoria
  • Influenza C

Structure of Virus
  • Glycoprotein's.
  • Hemagglutinin(HA)
  • attaches to sialic acid residues on host cells
  • Neuraminidase (NA)
  • glycoproteins attach to host cells and releases
    viral progeny
  • Once infected, direct necrotic effects on human
    cells as virus begins to use host cell machinery
    for replication

Mandell, 2010
National Data for Influenza 2013-2014
Tricore Report
  • Respiratory Virus Detection by
  • DFA, RESPAN and the FLURSV Assay Methods
  • 889 requests with 418 positive(s)
  • Influenza A H1 (2009) 109
  • Influenza A H3 1
  • Influenza A 108
  • Influenza B 1

Transmission Prevention
  • Transmission
  • Person to Person Large particle respiratory
    droplet (cough or sneeze) within 6 ft or less
  • Indirect contact via hand transfer of
    virus-contaminated surfaces or objects to mucosal
    surfaces of the face
  • All respiratory secretions, bodily fluids,
    including diarrheal stools are potentially
  • Airborne transmission via small particle aerosols
    may occur
  • Procedures
  • Prevention
  • Vaccinations
  • Good hand hygiene
  • Cough etiquette
  • Wear mask if sick and on clinical service
  • Wear mask if unable to get vaccinated

UNMs Vaccine
  • Efficacy for Influ A 70-90
  • Fluzone
  • Split-virus vaccine
  • Contains H3N2, H1N1, B
  • Trivalent vs. Quadravalent
  • Standard dosing vs High dose for Patients gt 65 yo
  • Flublok
  • Egg free, grown in cell culture
  • Early vaccination of inpatients

Influenza Vaccination by Group at UNMH, Influenza
Season 2013-2014
  Compliant Total Number of Employees
UNMH 99.4 6,099
UNM Residents 65.6 633
CRTC 76.8 323
UNM MG 58.4 351
UNMH Cred Providers 100.0 245
UNM Cred Providers 74.4 1,102
Date of Report 1.10.14
Courtesy Dr. Meghan Brett
Influenza Vaccination Rates by Dept,
1.10.2014Courtesy Dr. Meghan Brett
Department Percent Compliant
Radiology 97.4
Emergency Medicine 95.2
Anesthesiology Critical Care Medicine 88.9
Family Community Medicine 87.7
Internal Medicine 74.8
Obstetrics Gynecology 73.7
Pediatrics 72.1
Psychiatry 66.7
Orthopedics Rehabilitation 64.9
Neurology 64.3
Dental Medicine 62.5
Surgery 52.6
Pathology 50.9
Dermatology 50.0
Neurosurgery 47.4
Laboratory Testing
  • Tricore runs all tests
  • No clinic Ag testing
  • 3 types of tests available
  • DFA
  • Coinfections 10
  • Usually rhinovirus and flu or RSV
  • 1 Influenza A B

Anti-flu therapy and prophylaxis
  • Neuraminidase Inhibitors
  • oseltamivir (Tamiflu)
  • zanamivir (Relenza)
  • Japan has two others
  • laninamivir
  • peramivir, IV form
  • Adamantanes
  • Amantadine
  • Rimantadine
  • Ribavirin

Targets of Antivirals
Itzstein, M Nature Review of Drug discovery, vol
6 2007
  • Trade name Relenza
  • Higher affinity to the NA binding site than does
    native sialic acid.
  • Poorly absorbed in GI tract and thus delivered as
    an inhaled agent
  • Only 15 of drug deposits within lower
    respiratory tract
  • Can precipitate bronchospasm
  • in pts with pulm dz
  • cant be used in mechanical ventilation
  • Clinical trials for optimal dosing for IV form,
    compassionate use.
  • RX10 mg inhaled twice daily for 5 days (approved
    for gt 7 yr old)
  • Prophylaxis is given once daily for 10 days (up
    to28 days) agegt 5
  • Higher activity for influenza B H1N1 strains
    than oseltamivir, less activity against H3N2
  • Doesnt have the H275Y neuraminidase mutation
  • N294S (N295S) neuraminidase mutation seen in
    immunocompromised causes decreased sensitivity to

  • Trade name Tamiflu
  • Prodrug converted in liver to active form
  • Dosing based on weight and renal function
  • Most common side effect is GI upset, improved
    with food
  • Neurologic side effects reported in children
    mostly in Japan
  • No IV admin
  • Resistance can occur

Combination Therapy
  • zanamivir and oseltamivir has been studied but
    showed no benefit and greater viral loads
    (competition for site)
  • Triple combination of oseltamivir, amantadine and
    ribavirin are being studied
  • In vitro study (Hoopes, et al) looked promising
  • Nguyen et al looked at TCAD in murine model
  • 90 survival with TCAD vs 20 with single agent
  • Korean study (Kim et al)
  • showed 24 pts, at 14 days 17 mortality for TCAD
    compared with 35 oseltamivir alone
  • low powered, no difference in 90 d mortality

Moscona A. N Engl J Med 2009 360 (10) 953-6
Who Gets Treated
  • Antiviral treatment is recommended as early as
    possible for any patient with confirmed or
    suspected influenza who
  • is hospitalized
  • has severe, complicated, or progressive illness
  • is at higher risk for influenza complications.
    This list includes
  • children aged younger than 2 years
  • adults aged 65 years and older
  • persons with chronic pulmonary (including
    asthma), cardiovascular (except hypertension
    alone), renal, hepatic, hematological (including
    sickle cell disease), metabolic disorders
    (including diabetes mellitus), or neurologic and
    neurodevelopment conditions (including disorders
    of the brain, spinal cord, peripheral nerve, and
    muscle such as cerebral palsy, epilepsy seizure
    disorders, stroke, intellectual disability
    mental retardation, moderate to severe
    developmental delay, muscular dystrophy, or
    spinal cord injury)
  • persons with immunosuppression, including that
    caused by medications or by HIV infection
  • women who are pregnant or postpartum (within 2
    weeks after delivery)
  • persons aged younger than 19 years who are
    receiving long-term aspirin therapy
  • American Indians/Alaska Natives
  • persons who are morbidly obese (i.e., body-mass
    index is equal to or greater than 40) and
  • residents of nursing homes and other chronic-care
  • Consider in healthy individuals based on severity
    at presentation and how soon they present.

  • Neuraminidase Inhibitors
  • Close household contacts of persons with
    influenza who have not received the vaccine and
    who have comorbidities that could lead to
  • HCW who had not practiced proper precautions
  • Person living in NH or LT care facilities
  • Adamantanes class (amantidine and rimantidine)
    are rarely used due to resistance

Summary Points
  • Vaccinating health care workers is vital
  • Vaccinate patients on admission when possible
  • FLURSV has quickest turn around time, may be
  • If influenza is suspected, start oseltamivir or
    zanamivir (if available) before test results are
  • Avoid Adamantanes as all circulating flu is
    resistant this year

Boltz A, Drugs
2010 70 (11) 1349-1362 CDC Health Alert
Network, December 24, 2013 CDC Web site Ginsberg
J et al, Detecting Influenza epidemics using
search engine query data Nature 2009 457 Groom
A, Pandemic Influenza Preparedness and Vulnerable
Populations in Tribal Communities American
Journal of Public Health 2009 99, No S2
271-277 Harper S, et al IDSA Clinic Practice
Guidelines Seasonal Influenza in Adults and
Children CID 200948 1003-1032 H1N1 hitting
young and middle-aged adults ACP Hospitalist
Weekly, Jan 8 2014 Kamali A, Holodniy M,
Infection and drug Resistance Nov18 20136
187-198 Polgreen P, et al Using Internet Searches
for Influenza Surveillance, CID 2008
47 Prevention and control of Seasonal Influenza
with Vaccines, ACIP, MMWR 9/20/201362 No7
Nature Reviews Drug Discovery 6, 967-974
(December 2007) Useful web sites http//www.cdc.g
ov/flu/ http// www.tricore.or