FLU

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=210 BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="112f2f02egerdp.jpg"> <div> <A HREF="index.htm" TARGET="_top" TITLE="_"><U><B>RETURN TO HOMEPAGE</B></U></A></div> <div> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="195" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="LEFT" HSPACE="0" VSPACE="0" BGCOLOR=#FFFFFF > <tR> <tD VALIGN=TOP BGCOLOR=#66FFFF HEIGHT= 23 WIDTH="195"><div> <B> </B><A HREF="id91.htm" TARGET="_top" TITLE="BRUCE ROSEMAN, M.D. 330 West 58th Stree"><U><B>CONTACT ME</B></U></A></div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFCC99 HEIGHT= 23 WIDTH="195"><div> <B> </B><A HREF="id17.htm" TARGET="_top" TITLE="office info"><U><B>OFFICE INFO</B></U></A></div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFF99 HEIGHT= 23 WIDTH="195"><div> <B> </B><A HREF="id116.htm" 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ALIGN="bottom" WIDTH="195" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="115f0f03.jpg"> <div> <I>FLU</I></div> <div> The CDC recently set up the following website: </div> <div> <U>www.findaflushot.com</U><FONT SIZE="3" COLOR="#000099" FACE="Arial" > </FONT></div> <div> Patients can enter their zip code to locate pharmacies </div> <div> in their area that carry and administer flu shots. </div> <div> <A HREF="http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm" TARGET="_top" TITLE="http://www.cdc.gov/ncidod/diseases/flu/f"><U>PREVENTION AND CONTROL(CDC)</U></A></div> <div> <A HREF="http://www.tamiflu.com/" TARGET="_top" TITLE="http://www.tamiflu.com/"><U>FLU-NEW TREAT & PREVENTION</U></A></div> <div> <A HREF="id77_flu_shots_for_all_tots.htm" TARGET="_top" TITLE="kids"><U>Flu Shots For All Tots</U></A></div> <div> <A HREF="#classic_signs_and_symptoms_of_influenza" TITLE="FLU"><U>SIGNS AND SYMPTOMS OF FLU</U></A></div> <div> <A HREF="#flu_vs_cold" TITLE="FLU"><U>FLU VS COLD-SIGNS AND SYMPTOMS</U></A></div> <div> <A HREF="#influenza_vaccine_recommendations" TITLE="FLU"><U>WHO SHOULD TAKE THE FLU VACCINE</U></A></div> <div> <A HREF="#adverse_reactions_and_contraindications" TITLE="FLU"><U>FLU VACCINE ADVERSE REACTIONS </U></A></div> <div> <A HREF="#flu_shot_works_best_in_well_rested" TITLE="FLU"><U>Flu Shot Works Best in Well-Rested Individuals </U></A></div> <div> Flu Vaccine may prevent strokes in people over 60</div> <div> <A HREF="id70__beat_the_flu_this_year_with_nasal.htm" TARGET="_top" TITLE="INFECTIOUS DISEASES"><U>Beat the Flu This Year With Nasal Spray </U></A></div> <div> <A HREF="#jama_patient_page" TITLE="FLU"><U>Do You Have The Flu?</U></A></div> <div> <A HREF="#study_suggests_flu_vaccine_didn_t_work" TITLE="FLU"><U>Study Suggests Flu Vaccine Didn't Work Well  in 2003</U></A></div> <div> <A HREF="#flu_shots_may_not_save_lives____study" TITLE="FLU"><U>Flu Shots May Not Save Lives -- Study</U></A></div> <div> <A HREF="#tamiflu_resistanc_and_avian_flu" TITLE="FLU"><U>TAMIFLU RESISTANC AND AVIAN FLU</U></A></div> <div> <A HREF="#flu_vaccines__not_worth_the_trouble_" TITLE="FLU"><U><B>Flu vaccines 'not worth the trouble'</B></U></A></div> <div> <A HREF="#flu_pandemic_may_be_up_to_500000_in" TITLE="FLU"><U><B>flu pandemic may be up to 500,000 in new york alone(</B></U></A><FONT SIZE="3" COLOR="#000099" FACE="Arial" ><A HREF="#flu_pandemic_may_be_up_to_500000_in" TITLE="FLU"><U>June 10, 2009)</U></A></FONT></div> <div> <A HREF="#swine_influenza" TITLE="FLU"><U><B>Swine influenza</B></U></A></div> <div> <A HREF="#2009_h1n1_influenza__vaccine_essentials" TITLE="FLU"><U><B>2009 H1N1 Influenza  Vaccine Essentials</B></U></A><A HREF="#2009_h1n1_influenza__vaccine_essentials" TITLE="FLU"><U>Updated: 10/15/2009</U></A></div> <bR> <div> <U> <A NAME="2009_h1n1_influenza__vaccine_essentials"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></div> <div> <B>2009 H1N1 Influenza  Vaccine Essentials</B></div> <div> John G. Bartlett, MD</div> <div> Published: 09/25/2009; Updated: 10/15/2009</div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="632" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 135 WIDTH="622"><div> <I><B>Editor's Note: This article will be updated frequently, so check back often for new information. On September 30, 2009, updates were added on vaccine supply and vaccine response in children. On October 14, 2009, updates were added on FDA vaccine approval and supply; vaccine types, priorities, dosing, contraindications, and side effects; vaccine interaction and comparative effectiveness; mandates for healthcare workers; influenza vaccine coverage in the United States; and findings of a survey about the public's intent to be vaccinated.</B></I><B> </B></div> </tD> </tR> </TABLE></div> <div> Update on Influenza A (H1N1) 2009 Monovalent Vaccines</div> <bR> <div> The FDA has approved 4 vaccine preparations. The following data highlight relevant issues:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All influenza vaccine preparations in the United States for the 2009-2010 season contain residual egg protein and none contain adjuvant; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children 6 months to 9 years of age who are given influenza A (H1N1) monovalent vaccine should receive 2 doses separated by about 4 weeks; persons = 10 years of age should receive 1 dose; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The influenza A (H1N1) monovalent vaccines were made according to standards used for seasonal and influenza vaccines and have the same age group indications, precautions, and contraindications as vaccines that are FDA-approved for seasonal flu; preliminary data indicate that the safety and efficacy of the 2009 Influenza A (H1N1) monoclonal vaccine is the same as for seasonal flu vaccines; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Side effects, including local pain at the injection site, were reported in 46% of recipients, and systemic reactions (headache, malaise or myalgias) were reported in 45%; the safety profile is consistent with the experience with seasonal flu vaccine; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Influenza activity due to influenza A (H1N1) increased in September 2009 and is expected to continue through fall and winter; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is minimal evidence of significant antigenic change since the first characterization of the virus in April 2009, indicating that the virus continues to be well matched with the vaccine strain; and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The vaccines of the 4 suppliers have some differences that are important to recognize: </div> <div> <B>Table 1. FDA-Approved Influenza A (H1N1) Vaccines</B> </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="641" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="236"><div> <B>Supplier</B> </div> </tD> <tD VALIGN=CENTER WIDTH="210"><div> <B>Vaccine Form</B> </div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Mercury</B> </div> <div> <B>µg/0.5 mL</B> </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="85"><div> <B>Age</B> </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="236"><div> MedImmune</div> <div> (nasal spray)</div> </tD> <tD VALIGN=CENTER WIDTH="210"><div> Live virus 0.2 mL</div> <div> (nasal spray sprayer)</div> </tD> <tD VALIGN=CENTER WIDTH="85"><div> 0</div> </tD> <tD VALIGN=CENTER><NOBR><div> 2-49 yrs<FONT SIZE="1" COLOR="#000099" FACE="Arial" >b</FONT> </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 75 WIDTH="236"><div> Sanofi (IM)<FONT SIZE="1" COLOR="#000099" FACE="Arial" >a</FONT> </div> </tD> <tD VALIGN=CENTER><NOBR><div> Inactivated</div> <div> 0.25 mL prefilled syringe</div> <div> 0.5 mL prefilled syringe</div> <div> 5 mL multidose vial</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="85"><bR> <div> 0</div> <div> 0</div> <div> 25</div> </tD> <tD VALIGN=CENTER><NOBR><bR> <div> 6-35 mos<FONT SIZE="1" COLOR="#000099" FACE="Arial" >b</FONT> </div> <div> > 36 mos<FONT SIZE="1" COLOR="#000099" FACE="Arial" >b</FONT> </div> <div> > 6 mos<FONT SIZE="1" COLOR="#000099" FACE="Arial" >b</FONT> </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="236"><div> Novartis (IM)<FONT SIZE="1" COLOR="#000099" FACE="Arial" >a</FONT> </div> </tD> <tD VALIGN=CENTER><NOBR><div> 5 mL multidose vial</div> <div> 0.5 mL prefilled syringe</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="85"><div> 25</div> <div> < 1.0</div> </tD> <tD VALIGN=CENTER WIDTH="85"><div> = 4 yrs<FONT SIZE="1" COLOR="#000099" FACE="Arial" >b</FONT> </div> <div> > 4 yrs<FONT SIZE="1" COLOR="#000099" FACE="Arial" >b</FONT> </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 ><NOBR><div> CSL Biotherapies, Inc (IM)<FONT SIZE="1" COLOR="#000099" FACE="Arial" >a</FONT> </div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> 0.5 mL prefilled syringe</div> <div> 5.0 mL multidose vial</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="85"><div> 0</div> <div> 24.5</div> </tD> <tD VALIGN=CENTER WIDTH="85"><div> > 18 yrs</div> <div> > 18 yrs</div> </tD> </tR> </TABLE></div> <div> a<FONT SIZE="3" COLOR="#000099" FACE="Arial" >0.5 mL doses contain 15 µg hemagglutinin of the vaccine strain A/California/7/2009 (H1N1)</FONT></div> <div> b<FONT SIZE="3" COLOR="#000099" FACE="Arial" >Two doses separated by 4 weeks for children 2-9 years</FONT></div> <div> (<I>CDC. Update on influenza A (H1N1) monovalent vaccines.</I> MMWR Morb Mortal Wkly Rep. <I>2009;58:1100-1101.)</I> </div> <div> NIH studies show that the 15-µg dose without adjuvant generates an immune response that is expected to be protective in most 10- to 17-year-olds at 8-10 days post-vaccination. Younger children had the expected reduced response and will require 2 doses separated by at least 21 days. Infants younger than 6 months are too young for influenza vaccines.</div> <div> Inactivated Intramuscular Vaccine</div> <div> The inactivated H1N1 vaccine uses killed virus and is intended to prevent 2009 H1N1 (<I>not</I> seasonal flu) and is available in single dose or multidose vials. Some inactivated 2009 H1N1 vaccines contain the preservative thimerosal. (Note that some people have questioned a relationship between thimerosal and autism, but a 2004 review by the Institute of Medicine found no association, and subsequent studies have supported this conclusion. (<I>Immunization Safety Review Committee. Vaccines and Autism. Institute of Medicine. Washington, DC: National Academies Press; 2004. Available at: http://www.nap.edu/catalog.php?record_id=10997 Accessed October 5, 2009</I>.) The H1N1 vaccine will not prevent seasonal flu, and seasonal flu vaccine will not prevent 2009 H1N1 influenza.</div> <div> Children 6 months to 9 years of age should receive 2 doses separated by 3 weeks. Children 10 years and older and adults should receive 1 dose.</div> <div> The following groups should receive the vaccine as soon as it becomes available:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnant women; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">People who live with or care for infants younger than 6 months of age; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Healthcare workers (HCWs) and emergency medical personnel; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons 6 months to 24 years of age; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons 25-64 years of age who have chronic diseases (including immunodeficiency states) that pose risk for influenza. </div> <div> When more vaccine becomes available, the following persons should be vaccinated:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Healthy persons ages 25-64 years; and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adults 65 years of age and older. </div> <div> Patients on the high-priority list should be vaccinated as soon as the vaccine is available. Individuals with the highest priority, as listed above, should be vaccinated first, but stringency of methods to restrict vaccine use is unclear.</div> <div> Contraindications to the inactivated vaccine include:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Previous Guillain-Barré syndrome; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Life-threatening reaction to previous influenza vaccination; and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe illness (a "moderately or severely ill" patient is advised to wait, but a mild upper respiratory infection or other illness is not a contraindication). </div> <div> Note that pregnancy and breastfeeding are not contraindications to receiving the inactivated vaccine. The most common side effect with the killed virus vaccine is soreness at the injection site. Concurrent administration with other vaccines is <I>not</I> contraindicated; seasonal influenza vaccine may be given simultaneously with H1N1 influenza vaccine.</div> <div> Live Attenuated Nasal Spray Vaccine</div> <div> The second vaccine is a live attenuated influenza (LAIV), which is given intranasally. LAIV does not contain thimerosal. It is produced the same way as the LAIV that is used for seasonal flu. It is expected that the LAIV for H1N1 influenza will be as safe and effective as the LAIV for seasonal flu. This vaccine will not prevent seasonal flu, and the seasonal flu vaccine will not prevent 2009 H1N1 influenza.</div> <div> The LAIV for H1N1 is delivered by a nasal spray as a single dose. It is FDA- approved for people 2-49 years of age who do not have contraindications. Groups who should receive the LAIV include:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons 2-24 years of age; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons 25-49 years of age who live with or care for infants younger than 6 months; and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons 25-40 years of age who are HCWs or emergency medical personnel. </div> <div> When more vaccine becomes available it should be offered to healthy persons ages 25-49 years who do not have contraindications to the vaccine.</div> <div> Contraindications to the LAIV include:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe allergy to eggs or other vaccine ingredients; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Age 2 years or younger or 50 years or older; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Immunosuppression; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic medical conditions, including diseases of the heart, lung, kidney, or liver; diabetes, asthma, or blood disease; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children younger than 5 years who have asthma or who have had an episode of wheezing in the past year; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nervous system disease that can cause breathing or swallowing problems; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children and adolescents on long-term aspirin treatment; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any person who has close contact with a person with a severe immunodeficiency; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons with moderate or severe illness should delay use of this vaccine (a mild upper respiratory infection or similar illness is not a contraindication); and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Unlike the inactivated intramuscular vaccine, the 2009 H1N1 LAIV vaccine should <I>not</I> be given with seasonal LAIV because the 2 live virus vaccines must be separated by 1 month. It is permissible to give a killed virus vaccine like the 2009 H1N1 IM vaccine or the seasonal flu IM vaccine with a single LAIV. </div> <div> Risks and side effects of the LAIV:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The most common side effect with the live attenuated nasal spray is nasal congestion in all patients, sore throats in adults, and fever in children 2-6 years. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some children 2-17 years have mild reactions, including nasal congestion, headache, myalgias, fever, wheezing, cough, or gastrointestinal symptoms. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some adults 18-49 years have nasal congestion, cough, fatigue, myalgias, sore throat, or headache. </div> <div> Comparative Efficacy of Live Attenuated Influenza Vaccine and Inactivated (Killed Virus) Influenza Vaccine</div> <div> A double-blind, placebo-controlled trial comparing the LAIV vaccine and the inactivated influenza virus vaccine was conducted in 2007-2008 when influenza A (H3N2) accounted for 91% of influenza cases and type B accounted for 9%. There were 1952 participants ages 18-49 years assigned to receive the inactivated vaccine (or placebo) by IM injection or the live virus vaccine (or placebo) by nasal spray. Efficacy was based on frequency of an influenza-like illness that was confirmed as influenza A or B by culture or PCR. The results showed that absolute efficacy against influenza A was 72% for the killed virus vaccine (IM injection) vs 29% for live virus vaccine (nasal sniff). The investigators concluded that the inactivated vaccine was superior to the LAIV for preventing Influenza A (H3N2) in adults. (<I>Monto A, Ohmit SE, Petrie JG, et al. Comparative efficacy of inactivated and live attenuated influenza vaccines</I>. N Engl J Med. <I>2009;361:1260-1267.)</I> </div> <div> Will People Get the Vaccine?</div> <div> Uptake by priority groups for vaccination is not easily predicted, but it is noteworthy that the current (seasonal) vaccine recommendations apply to 83% of the US population, but only 40% to 44% actually receive a yearly flu vaccine. The group with the highest adherence for having a seasonal influenza immunization is the elderly, a group that is not targeted for the pandemic H1N1 flu vaccine. Persons over 65 years of age have a seasonal flu vaccination rate of 66%; HCWs have an embarrassingly low vaccination rate of 40%-44%. According to a Red Cross telephone survey of 1002 adults, 60% of Americans plan to get the 2009 H1N1 influenza vaccine, and 60% claim that they are not worried about H1N1 influenza A. <I>(American Red Cross. Red Cross survey finds overwhelming majority of public taking steps against H1N1 flu virus. August 27, 2009.</I>)</div> <div> <I>Consumer Reports</I> conducted a nationally representative telephone survey of 1502 adults from September 2 to 7 to determine the demand for 2009 H1N1 vaccine. <I>(Morgan D. Majority of U.S. parents wary about H1N1 vaccine: Poll. Reuters. September 30, 2009.)</I> Results were as follows:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Percentage who want the H1N1 vaccine: 34%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Percentage who are undecided about the H1N1 vaccine: 43%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Percentage who will definitely get their children vaccinated against H1N1: 35%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Percentage who are undecided about getting their children vaccinated against H1N1: 50%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Percentage who had flu vaccine last flu season: 41%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rationale for not getting children vaccinated: desire to have children develop natural immunity and concern for adequacy of the testing; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Factors deemed most important for keeping children healthy in flu season: healthy diet (89%), adequate sleep (83%), keeping children away from sick children (68%). </div> <div> The Associated Press conducted a poll of attitudes on 2009 H1N1 vaccine. In a telephone survey of 1003 adults, they found:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Percentage of parents unlikely to give permission for their children to be vaccinated at school: 38% </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Percentage worried about side effects of vaccine: 72% </div> <div> (<I>GfK Roper Public Affairs and Media. The AP-GfK Poll. October 1-5, 2009. Available at: http://surveys.ap.org/data/GfK/AP-GfK%20Poll%20Final%20FLU%20Topline%20100609.pdf Accessed October 12, 2009.</I>)</div> <div> <B>Vaccine coverage in the United States, 2008-2009.</B> For a historical look at willingness to get influenza vaccine, an analysis of vaccine coverage for the 2008-2009 seasonal influenza vaccine was based on the Behavioral Risk Factor Surveillance System, which represents 3% of the US population. The results showed the following influenza vaccination rates:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">> 65 years: 67%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">50-64 years: 42%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">18-49 years: 32%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5-17 years: 21%; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2-4 years: 32%; and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">6-23 months: 41%. </div> <div> (<I>CDC. Influenza vaccination coverage among children and adults.</I> MMWR Morb Mortal Wkly Rep<I>. 2009;58:1091-1095.)</I> </div> <div> Pregnant Women and Newborns</div> <div> Pregnant women are a high priority for vaccination against both 2009 H1N1 and seasonal influenza. The vaccine is considered safe in pregnancy, and both the mother and the infant are at high risk for complications of influenza. The vaccine to the mother elicits antibody that persists in the infant during the first 6 months when the infant is particularly vulnerable.</div> <div> HCWs</div> <div> The ACIP has identified HCWs as a high priority for influenza vaccine since 1984. <I>(CDC Advisory Committee on Immunization Practices.</I> <I>Prevention and control of influenza.</I> Ann Intern Med<I>. 1984;101:218-222.)</I> This issue has been reviewed and policy recommendations have been provided by the Society for Healthcare Epidemiology of America (SHEA). <I>(Talbot TR, Bradley SE, Cosgrove SE, Ruef C, Siegel JD, Weber DJ. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages.</I> Infect Control Hosp Epidemiol<I>. 2005;26:882-890.)</I> </div> <div> The rationale for immunizing HCWs is to protect both HCWs and patients. The risk to patients is demonstrated by high rates of nosocomial infections due to provider-to-patient transmission, and surveys show that up to 76% of HCWs continue to work when they have a flulike illness. <I>(Weingarten S, Riedinger M, Bolton LB, Miles P, Ault M. Barriers to influenza vaccine acceptance. A survey of physicians and nurses.</I> Am J Infect Control<I>. 1989;17:202-207. Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff.</I> Infect Control Hosp Epidemiol<I>. 2003;24:839-844.)</I> </div> <div> Policy and Legislation for HCW Flu Vaccination</div> <div> Policies for influenza vaccination for HCWs are generally institutionally based, although some states have proposed legislation that would make vaccination mandatory for HCWs unless contraindicated. <I>(Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care workers: seven truths we must accept.</I> Vaccine<I>. 2005;23:2251-2255.)</I> The New York State Review and Planning Council passed a regulation on August 13, 2009 that <I>requires</I> annual influenza vaccinations for all healthcare providers who interact with patients, as well as annual compliance reports. Noncompliance is punishable by a fine of up to $2000. <I>(New York City Department of Health and Mental Hygiene. Prevalence of flu-like illness in New York City: May 2009.</I> American Medical News<I>. August 31, 2009.)</I> </div> <div> New York's policy applies to 522,000 HCWs and is the only statewide mandate. A number of other health systems now require vaccination for HCWs, including Emory Hospital in Atlanta, University of Pennsylvania Hospitals, University of Maryland's 11 hospitals, Loyola Health Systems in Chicago, Virginia Mason Medical Center in Seattle, University of Iowa, MedStar (25,000 HCWs), and the Hospital Corporation of America (273 facilities). (<I>CBS. Health workers protest flu vaccine mandate. CBS Evening News. October 4, 2009. Available at: http://www.cbsnews.com/stories/2009/10/04/eveningnews/main5362636.shtml Accessed October 9, 2009.)</I> </div> <div> Recommendation From SHEA for Increasing Vaccine Adherence in HCWs</div> <div> Targeted education; </div> <div> Provide vaccine at no cost and at convenient locations and times; </div> <div> Require HCWs to receive vaccine, or to sign a declination each year if they refuse vaccination after participating in an educational program or have a medical contraindication; and </div> <div> Maintain facility surveillance. </div> <div> Alternative Plan for Vaccine Allocation</div> <div> An alternative proposal for vaccine priority has been presented by Medlock and Galvani. The authors recommend vaccinations for persons 5-19 years and 30-39 years as the optimal method to control the epidemic and reduce deaths. This would target school-age children and their parents -- the most important vehicles of transmission -- and would be more effective than the CDC plan, which they consider "suboptimal." The potential outcome of the Medlock model compared with the ACIP plan is shown in Table 1. <I>(Medlock J, Galvani AP. Optimizing influenza vaccine distribution.</I> Science<I>. 2009 Aug 20. [Epub ahead of print].)</I> </div> <div> <B>Table 2. Outcome of the ACIP Priorities vs the "Medlock Plan"</B> </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="466" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="88"><div> <B>Plan</B> </div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> <B>Cases</B> </div> </tD> <tD VALIGN=CENTER WIDTH="88"><div> <B>Deaths</B> </div> </tD> <tD VALIGN=CENTER WIDTH="139"><div> <B>Cost</B> </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="88"><div> ACIP</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> 59 million</div> </tD> <tD VALIGN=CENTER WIDTH="88"><div> 139,000</div> </tD> <tD VALIGN=CENTER WIDTH="139"><div> $67 billion</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="88"><div> Medlock</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> 44 million</div> </tD> <tD VALIGN=CENTER WIDTH="88"><div> 108,000</div> </tD> <tD VALIGN=CENTER WIDTH="139"><div> $53 billion</div> </tD> </tR> </TABLE></div> <div> <I>ACIP = Advisory Committee on Immunization Practices</I> </div> <div> From: Medlock J, Galvani AP. Optimizing influenza vaccine distribution. <I>Science</I>. 2009 Aug 20. [Epub ahead of print].</div> <div> Allocation Priorities: HCWs and Influenza Vaccines</div> <div> In the event of inadequate supply, SHEA provides guidance for allocation of vaccine to HCWs. (This is unlikely to be an issue with the seasonal flu vaccine, but it is anticipated for 2009 influenza A H1N1):</div> <div> Nature, degree, and duration of contact: close contact defined as within 3 ft, prolonged is "several minutes" and repeated contact; </div> <div> Degree of contact with patients at high risk for complications; </div> <div> Need to protect essential HCWs and services; </div> <div> Exposure in areas of high patient traffic, such as emergency departments and high-volume clinics; and </div> <div> Areas where HCWs have exposure to patients before they are placed on precautions, including first responders, acute care clinic employees, and emergency department staff. <I>(Talbot TR, Bradley SE, Cosgrove SE, Ruef C, Siegel JD, Weber DJ. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages.</I> Infect Control Hosp Epidemiol<I>. 2005;26:882-890.)</I> </div> <div> Vaccine Response</div> <div> Anthony S. Fauci, Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, reported very promising, early 2009 H1N1 vaccine trial data. The vaccine was well tolerated and induced a "strong immunologic response" when a single, unadjuvanted 15-µg dose was given to healthy adults. The trial data with vaccine from sanofi-aventis showed a response rate of 96% in adults ages 18-64 years and 56% in persons older than 65 years. CSL Biotherapeutics' vaccine showed response rates of 80% in adults ages 18-64 years and 60% in persons older than 65 years. It was acknowledged that vaccine-response rates are expected to be lower in persons older than 65 years. <I>(CNN News. Study: single dose of H1N1 flu vaccine may suffice for adults. September 11, 2009.)</I> </div> <div> <B>Antigenic response to 2009 H1N1 vaccine -- preliminary report, October 9, 2009.</B> The report is based on a trial from CSL Biotherapeutics that used a split virus vaccine in doses of 15 µg or 30 µg in 240 participants aged 18-64 years. The results at 21 days showed antibody titers of > 1:40 in 116/120 (97%) of those given the 15 µg dose and 112/120 (93%) of those given the 30 µg dose. Solicited adverse effects included systemic side effects in 30% (headaches, malaise and myalgia) which subjects attributed to the vaccine. (<I>Greenberg ME, Lai MH, Hartel GF, et al. Response after one dose of a monovalent Influenza A (H1N1) 2009 vaccine -- preliminary report.</I> N Engl J Med. <I>2009 Sep 10.</I> <I>[Epub ahead of print])</I> </div> <div> <B>Vaccine interaction.</B> A widely quoted unpublished study from Canada asserts that people who receive the 2008-2009 seasonal flu vaccine are more prone to acquire pandemic H1N1 influenza. (<I>CBC News. Seasonal flu shot may increase H1N1 risk. September 23, 2009. Available at:</I> <I>http://www.cbc.ca/health/story/2009/09/23/flu-shots-h1n1-seasonal.html Accessed October 13, 2009</I>) The implication is that this year's seasonal flu vaccine should be avoided to prevent this vaccine interaction. However, this interaction has not been found by the CDC or WHO, both of which continue to encourage people to get both vaccines.</div> <div> <B>Vaccine response in children</B>. Dr. Anthony Fauci announced results of the 2009 H1N1 influenza vaccine trials in children. Using doses of 15 µg of Sanofi's killed 2009 H1N1 vaccine, the serologic response rate at 10 days was:</div> <div> <B>Table 3. Antigenic Response to 2009 H1N1 Vaccine (Sanofi) by Age</B> </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="267" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="139"><div> <B>Age Group</B> </div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Response</B> </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="139"><div> 10-17 years</div> </tD> <tD VALIGN=CENTER WIDTH="113"><div> 76%</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="139"><div> 3-9 years</div> </tD> <tD VALIGN=CENTER WIDTH="113"><div> 36%</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="139"><div> 6-35 months</div> </tD> <tD VALIGN=CENTER WIDTH="113"><div> 25%</div> </tD> </tR> </TABLE></div> <bR> <div> These results are similar to the response rate with seasonal flu vaccine. <I>(NIAID, NIH News. Early results: In children, 2009 H1N1 influenza vaccine works like seasonal flu vaccine. September 21, 2009. Available at: http://www3.niaid.nih.gov/news/newsreleases/2009/H1N1PedTrial.htm Accessed September 30, 2009.)</I> </div> <div> <B>Adjuvanted H1N1 vaccine.</B> GSK reported initial results of 130 healthy volunteers vaccinated with the GSK split-virus 2009 H1N1 adjuvanted vaccine. This showed that a single dose of 5.25 µg of adjuvanted vaccine produced a 1:40 seroconversion in 98% of volunteers at 3 weeks. <I>(GlaxoSmithKline. Pandemic (H1N1) 2009 Influenza Update: initial results from first clinical trial of GSK's H1N1 adjuvanted vaccine [press release]. London, United Kingdom: GlaxoSmithKline; September 14, 2009.)</I> </div> <div> <B>Effectiveness and cost-effectiveness of vaccine for pandemic Influenza (H1N1) 2009. </B>Researchers analyzed the effectiveness and cost-effectiveness of the 2009 H1N1 vaccine using epidemiologic models designed to predict the progression of pandemic influenza in a city with a population of 8.3 million. Vaccinating 40% of such a population in October would avert 2051 deaths, gain 69,000 quality-adjusted life-years, and save $469 million. Projected benefits are smaller if the epidemic peaks before mid-October. The study authors concluded that earlier vaccination against pandemic H1N1 influenza prevents more deaths and is more cost-saving. (<I>Khazeni N, Hutton DW, Garber AM, et al.</I> Ann Intern Med. <I>2009;Oct 5. [Epub ahead of print])</I> </div> <div> Vaccine Safety, Purchase, and Payment</div> <div> The US government ordered 250 million doses of pandemic influenza vaccine at a cost of $2 billion. <I>(Stein R. First swine flu vaccine arriving in cities.</I> Washington Post. <I>October 6, 2009.)</I> The first vaccine to be supplied in the United States is FluMIST®, the LAIV that is limited to persons aged 2-49 years who do not have chronic disease and do not have close contact with persons with severe immunodeficiency. <I>(Neergaard L. First swine flu vaccine on the way, still limited. Associated Press. October 2, 2009.)</I> This vaccine may be given at the same time as other injectable vaccines, such as seasonal vaccine or Pneumovax®, with a 3- to 4-week delay between dosing with seasonal LAIV (FluMIST® for seasonal flu) and FluMIST® for pandemic flu. Pandemic flu vaccines (inhaled LAIVs and injectable killed virus vaccine) are provided by the government, but there may be an administrative charge of about $20. <I>(Neergaard L. Q & A about vaccines for swine flu, regular flu. Associated Press. October 6, 2009.)</I> </div> <div> Monitoring of vaccine safety will be accomplished with standard methods that include the <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Vaccine Adverse Event Reporting System (VAERS)</U></FONT> and the <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Vaccine Safety Data Link (VSD)</U></FONT>.</div> <div> VAERS is a passive reporting system for possible adverse events related to drugs and vaccines, and is monitored by the FDA and the CDC. Signals of concern from VAERS are then further pursued through the VSD, which is a network of managed care organizations that represent 3% of the US population. Additional systematic monitoring is being conducted to detect development of Guillain-Barré syndrome on the basis of experience in 1976. Clinical trials to establish safety and efficacy began in the United States on August 7, 2009, and "there are no red flags yet." <I>(Steenhuysen J. So far, no "red flags" seen in H1N1 vaccine. Reuters. August 21, 2009.)</I> </div> <div> Vaccine Side Effects</div> <div> Concern about the ability to distinguish common medical events (such as myocardial infarction) from rare side effects of the vaccines has been expressed by US health authorities. Weekly rates of common events (which would occur regardless of mass vaccinations) include 25,000 acute myocardial infarctions, 14,000-19,000 miscarriages, and 300 anaphylactic events. Guillain-Barré syndrome is a rare event routinely noted in 1-2/100,000 population. To detect possible associations of these events with the H1N1 flu vaccine:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Using insurance databases for 50 million people, Harvard University will link reasons for post-vaccine physician visits with vaccine administration; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Johns Hopkins University will email 100,000 vaccine recipients to ask how they are feeling; and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CDC will distribute "take-home cards" that instruct vaccine recipients on how to use VAERS. (<I>Neergaard L.Intense tracking for swine flu shot's side effects</I>. <I>Associated Press. September 28, 2009.</I>) </div> <div> Purchase and Payment</div> <div> The government will buy the vaccine supply along with needles, syringes, and alcohol swabs, and provide these items without cost to states according to population. State health departments and some local health departments will be responsible for vaccine distribution. Many will partner with the private sector to ensure efficient and rapid distribution. Presumably, the vaccine will be provided without charge in the public sector, but in the private sector there may be a separate charge for administration; third parties are vague about reimbursement.</div> <div> Vaccine Supply Update</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As of October 12, 2009, 9.8 million H1N1 vaccine doses were available; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Half of the delivered vaccine is now the injectable form; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vaccine is now available in most states, but widespread availability is not expected until the end of October; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vaccine supply can be checked at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>vaccine locator</U></FONT> which shows, for each state, the schools, pharmacies, and hospitals that offer vaccine. </div> <div> Seasonal Flu Vaccine</div> <div> This vaccine is now available and should be promoted by physicians "early and intensely" according to Dr. William Shaffner of Vanderbilt University, Nashville, Tennessee. <I>(Americans urged to get seasonal flu vaccine early.</I> Medical News Today<I>. September 11, 2009.)</I> Efficacy in preventing seasonal flu is reported to be 50%-70% for children 6 months to 8 years of age and 70%-90% in healthy adults under 65 years. <I>(Fiore AE, Shay DK, Broder K, et al; CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009.</I> MMWR Recomm Rep<I>. 2009;58[RR-8]:1-52.)</I> Some states view the seasonal flu vaccine distribution as a dry run for the 2009 H1N1 vaccine. CVS Caremark announced that it will make seasonal influenza available at 500 walk-in <I>Minute Clinics</I> and some drugstores. The plan includes providing free vaccinations to 100,000 unemployed people.</div> <div> Does the Seasonal Flu Vaccine Protect Against H1N1?</div> <div> Analysis of the pandemic influenza strain with strains in the H1N1 vaccine show only 72%-73% amino acid congruence with hemagglutinin; by comparison, the test for seasonal flu shows 97%-98% sequence identity. The CDC concluded that the seasonal flu vaccine will not provide any protection for the pandemic H1N1 influenza strain. This means that 2 entirely different influenza vaccines are required for the 2009-2010 influenza season, the standard seasonal influenza vaccine and a second for pandemic H1N1. <I>(CDC. Serum cross-reactive antibody response to a novel influenza A (H1N1) virus after vaccination with seasonal influenza vaccine.</I> MMWR Morb Mortal Wkly Rep<I>. 2009;58:521-524.)</I> </div> <div> <B>Cross-reactive antibody responses to the 2009 pandemic H1N1 influenza virus.</B> This CDC study reported cross-reactive antibodies to 2009 H1N1 in persons who were blood donors or vaccinated with recent seasonal or 1976 swine influenza vaccines. <I>(Hancock K, Veguilla V, Lu X, et al. Cross-reactive antibody responses to the 2009 pandemic H1N1 influenza virus. N Engl J Med. 2009 Sep 10. [Epub ahead of print].)</I> </div> <div> Pre-existing cross-reaction:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons born after 1980, 4 of 107 (4%); </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons born before 1980, 39 of 115 (34%); and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vaccinated for A/NJ/76 45 of 83 (54%). </div> <div> Four-fold increase after trivalent flu vaccine:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Age 6 months to 9 years, 0; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Age 18-60 years (n = 231), 12%-22%; and </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Age > 60 years (n = 113), = 5%. </div> <div> The conclusion is that recent seasonal flu vaccines produce little or no cross-reactive antibody response, and persons under 30 years of age have little evidence of serologic protection to 2009 H1N1. Vaccination in 1976 substantially boosted cross-reactive antibodies to the 2009 H1N1 virus.</div> <div> Testing of 795 clinical isolates of 2009 H1N1 virus showed that 1 (0.1%) had reduced titers with antisera directed at the vaccine strain A/California/07/2009 (H1N1). The remaining 99.9% are related to the A/California/07/2009 (H1N1) virus. Antigenic characterization of the 2009 H1N1 vaccine strain shows that this virus is antigenically and genetically unrelated to the seasonal influenza (H1N1) viruses. This suggests little or no cross protection. (<I>CDC. FluView. Antigenic characterization. 2008-2009 Influenza Season Week 38 ending September 26, 2009. Available at: http://www.cdc.gov/flu/weekly/ Accessed October 5, 2009.)</I> </div> <div> Resource List</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">American Red Cross. Red Cross survey finds overwhelming majority of public taking steps against H1N1 flu virus. August 27, 2009. Available at: http://www.redcross.org/portal/site/en/menuitem.94aae335470e233f6cf911df43181aa0/?vgnextoid=b78126578c653210VgnV CM10000089f0870aRCRD Accessed September 16, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Americans urged to get seasonal flu vaccine early. Medical News Today. September 11, 2009. Available at: http://www.medicalnewstoday.com/articles/163621.php Accessed September 16, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CBC News. Seasonal flu shot may increase H1N1 risk. September 23, 2009. Available at: http://www.cbc.ca/health/story/2009/09/23/flu-shots-h1n1-seasonal.html Accessed October 13, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CBS. Health workers protest flu vaccine mandate. CBS Evening News, October 4, 2009. Available at: http://www.cbsnews.com/stories/2009/10/04/eveningnews/main5362636.shtml Accessed October 9, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CDC. FluView. Antigenic characterization. 2008-2009 Influenza Season Week 38 ending September 26, 2009. Available at: http://www.cdc.gov/flu/weekly/ Accessed October 5, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CDC Advisory Committee on Immunization Practices. Prevention and control of influenza. Ann Intern Med. 1984;101:218-222. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CDC Advisory Committee on Immunization Practices (ACIP). ACIP recommends H1N1 flu vaccination priorities. July 29, 2009. Available at: http://www.emforum.org/news/09072901.htm Accessed September 16, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CDC. Serum cross-reactive antibody response to a novel influenza A (H1N1) virus after vaccination with seasonal influenza vaccine. MMWR Morb Mortal Wkly Rep. 2009;58:521-524. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Abstract</U></FONT> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CDC. Update on influenza A (H1N1) monovalent vaccines. MMWR Morb Mortal Wkly Rep. 2009;58:1100-1101. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5839a3.htm. Accessed October 14, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CDC. Influenza vaccination coverage among children and adults. MMWR Morb Mortal Wkly Rep. 2009;58:1091-1095. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5839a1.htm Accessed October 14, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CNN News. Study: single dose of H1N1 flu vaccine may suffice for adults. September 11, 2009. Available at: http://edition.cnn.com/2009/HEALTH/09/10/h1n1.vaccine/index.html Accessed September 16, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dormitzer PR, Rappuoli R, Casini D, et al. Adjuvant is necessary for a robust immune response to a single dose of H1N1 pandemic flu vaccine in mice. PloS Curr Influenza. August 31, 2009. Available at: http://knol.google.com/k/philip-r-dormitzer/adjuvant-is-necessary-for-a-robust/uhahw99c63lg/1?collectionId=28qm4 w0q65e4w.1&position=6# Accessed September 16, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">FDA. FDA approves vaccines for 2009 H1N1 influenza virus. FDA News Release. September 15, 2009. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm182399.htm Accessed September 30. 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fiore AE, Shay DK, Broder K, et al; CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep. 2009;58(RR-8):1-52. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">GfK Roper Public Affairs and Media. The AP-GfK Poll. October 1-5, 2009. Available at: http://surveys.ap.org/data/GfK/AP-GfK%20Poll%20Final%20FLU%20Topline%20100609.pdf Accessed October 12, 2009 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">GlaxoSmithKline. Pandemic (H1N1) 2009 Influenza Update: initial results from first clinical trial of GSK's H1N1 adjuvanted vaccine [press release]. London, United Kingdom: GlaxoSmithKline; September 14, 2009. Available at: http://www.gsk.com/media/pressreleases/2009/2009_pressrelease_10087.htm Accessed September 21, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Greenberg ME, Lai MH, Hartel GF, et al. Response after one dose of a monovalent influenza A (H1N1) 2009 vaccine -- preliminary report. N Engl J Med. 2009 Sep 10. [Epub ahead of print]. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hancock K, Veguilla V, Lu X, et al. Cross-reactive antibody responses to the 2009 pandemic H1N1 influenza virus. N Engl J Med. 2009 Sep 10. [Epub ahead of print]. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Immunization Safety Review Committee. Vaccines and Autism. Institute of Medicine. Washington, DC: National Academies Press; 2004. Available at: http://www.nap.edu/catalog.php?record_id=10997 Accessed October 5, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Khazeni N, Hutton DW, Garber AM, et al. Ann Intern Med. 2009; Oct 5. [Epub ahead of print] </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Landers SJ. New York orders health workers to get flu shot. American Medical News. August 31, 2009. Available at: http://www.ama-assn.org/amednews/2009/08/31/prl10831.htm#sb2 Accessed September 16, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol. 2003;24:839-844. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Abstract</U></FONT> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Medlock J, Galvani AP. Optimizing influenza vaccine distribution. Science. 2009 Aug 20. [Epub ahead of print]. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Monto A, Ohmit SE, Petrie JG, et al. Comparative efficacy of inactivated and live attenuated influenza vaccines. N Engl J Med. 2009;361:1260-1267. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Abstract</U></FONT> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Morgan D. Majority of U.S. Parents Wary About H1N1 Vaccine: Poll. Reuters, September 30, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neergaard L. Intense tracking for swine flu shot's side effects. Associated Press. September 27, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neergaard L. First swine flu vaccine on the way, still limited. Associated Press. October 2, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neergaard L. Q & A about vaccines for swine flu, regular flu. Associated Press. October 6, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">New York City Department of Health and Mental Hygiene. Prevalence of flu-like illness in New York City: May 2009. American Medical News. August 31, 2009. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">NIAID, NIH News. Early results: In children, 2009 H1N1 influenza vaccine works like seasonal flu vaccine. September 21, 2009. Available at: http://www3.niaid.nih.gov/news/newsreleases/2009/H1N1PedTrial.htm Accessed September 30, 2009 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Poland GA, Tosh P, Jacobson RM. Requiring influenza </div> <bR> <bR> <bR> <bR> <div> <B> <A NAME="swine_influenza"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Swine influenza</B> is a highly contagious respiratory disease in pigs caused by one of several swine influenza A viruses. In addition, influenza C viruses may also cause illness in swine. Current strategies to control swine influenza virus (SIV) in animals typically include one of several commercially available bivalent swine influenza virus vaccines. </div> <div> Transmission of swine influenza viruses to humans is uncommon. However, the swine influenza virus can be transmitted to humans via contact with infected pigs or environments contaminated with swine influenza viruses. Once a human becomes infected, he or she can then spread the virus to other humans, presumably in the same way as seasonal influenza is spread (ie, via coughing or sneezing).</div> <div> <B>History</B></div> <div> The ability to trace outbreaks of swine flu in humans dates back to investigation of the 1918 Spanish influenza pandemic, which infected one third of the world’s population (an estimated 500 million people) and caused approximately 50 million deaths. In 1918, the cause of human influenza and its links to avian and swine influenza was not understood. The answers did not begin to emerge until the 1930s, when related influenza viruses (now known as H1N1 viruses) were isolated from pigs and then humans.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >1 </FONT></div> <div> In humans, the severity of swine influenza can vary from mild to severe. From 2005 until January 2009, 12 human cases of swine flu were reported in the United States. None were fatal. In 1988, however, a previously healthy 32-year-old pregnant woman in Wisconsin died of pneumonia as a complication of swine influenza.</div> <div> A 1976 outbreak of swine influenza in Fort Dix, New Jersey, involved more than 200 cases, some of them severe, and one death.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >2 </FONT>The first discovered case involved a soldier at Fort Dix who complained of feeling weak and tired. He died the next day.</div> <div> The fear of an influenza pandemic in 1976 led to a national campaign in the United States designed to immunize nearly the entire population. In October, 1976, approximately 40 million people received the A/NewJersey/1976/H1N1 vaccine (ie, swine flu vaccine) before the immunization initiative was halted because of the strong association between the vaccine and Guillain-Barré syndrome (GBS).<FONT SIZE="1" COLOR="#000099" FACE="Arial" >3,4 </FONT>About 500 cases of GBS were reported, with 25 deaths due to associated pulmonary complications.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >5 </FONT></div> <div> A recent investigation sought to determine the link between GBS and the 1976 swine flu vaccine, since subsequent influenza vaccines did not have this strong association. Nachamkin et al (2008) found that inoculation of the 1976 swine flu vaccine, as well as the 1991-1992 and 2004-2005 influenza vaccines, into mice prompted production of antibodies to antiganglioside (anti-GM1), which are associated with the development of GBS. They proposed that further research regarding influenza vaccine components is warranted to determine how these components elicit antiganglioside effects.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >6 </FONT></div> <bR> <div> <B>Current H1N1 influenza (formerly called swine influenza) outbreak</B></div> <div> Human cases of influenza A (H1N1) have been reported worldwide. In 2009, cases of influenzalike illness were first reported in Mexico on March 18; the outbreak was subsequently confirmed as H1N1 influenza A.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >7 </FONT>Investigation is continuing to clarify the spread and severity of H1N1 influenza (swine flu) in Mexico. Suspected clinical cases had been reported in 19 of the country's 32 states. Although only 97 of the Mexican cases had been laboratory-confirmed as Influenza A/H1N1<FONT SIZE="1" COLOR="#000099" FACE="Arial" >8 </FONT>(12 of them genetically identical to Influenza A/H1N1 viruses from California<FONT SIZE="1" COLOR="#000099" FACE="Arial" >7 </FONT>). As of May 5th, 2009, nearly 600 H1N1 influenza cases had been confirmed in Mexico, including 25 deaths.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >9 </FONT></div> <div> On April 17, 2009, the CDC determined that two cases of febrile respiratory illness in children who resided in adjacent counties in southern California were caused by infection with a swine influenza A (H1N1) virus.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >10 </FONT>By April 26, 2009, the US Department of Health and Human Services declared a national public health emergency involving H1N1 influenza A, citing its significant potential to affect national security.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >11 </FONT>By June 25, 2009, 27,717 lab-defined cases of H1N1 influenza had been confirmed in the United States.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >8,12,13,14 </FONT>As of September 1, 2009, nearly 9,000 hospitalizations and over 550 deaths had been attributed to H1N1 flu in the United States.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >12 </FONT></div> <div> For an updated tally and case counts in specific states, see the CDC's H1N1 Flu (Swine Flu) Web page.</div> <div> On June 11, 2009, WHO raised the pandemic alert level to phase 6 (indicating a global pandemic) because of widespread infection beyond North America to Australia, the United Kingdom, Argentina, Chile, Spain, and Japan.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >8 </FONT>As of September 1, 2009, the World Health Organization (WHO) reported that H1N1 influenza had been confirmed in over 200,000 people in more than 100 countries and that they are aware of at least 2185 confirmed deaths. For an updated tally of affected countries and counts, see WHO's Influenza A (H1N1) Web page.</div> <div> Government and public health officials are monitoring this situation worldwide to assess the threat from H1N1 influenza and to provide guidance to health care professionals and the public. Because the situation is changing rapidly, it is important to check regularly for changes in recommendations as new information becomes available. Online resources for daily guidance include the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and Medscape's H1N1 Influenza A (Swine Flu) Alert Center.</div> <bR> <div> <B>Morbidity and Mortality</B></div> <div> H1N1 influenza (swine flu) tends to cause high morbidity but low mortality rates (1%-4%).</div> <bR> <div> <B>Symptoms</B></div> <div> Manifestations of H1N1 influenza (swine flu) are similar to those of seasonal influenza. Patients present with symptoms of acute respiratory illness, including at least 2 of the following:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fever </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cough </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sore throat </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Body aches </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Headache </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chills and fatigue </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Diarrhea and vomiting (possible)</div> <div> Persons with these symptoms should call their health care provider promptly. If an antiviral agent is warranted, it should ideally be initiated with 48 hours from the onset of symptoms (see Medications). The duration of illness is typically 4-6 days. The infectious period for a confirmed case is defined as 1 day prior to the onset of symptoms to 7 days after onset.</div> <div> In children, signs of severe disease include apnea, tachypnea, dyspnea, cyanosis, dehydration, altered mental status, and extreme irritability.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >15 </FONT></div> <bR> <div> <B>Viral Strain and Testing</B></div> <div> Outbreaks of H1N1 influenza (swine flu) are common in pigs year-round. Historically, when humans have become infected, it is a result of close contact with infected pigs (but not consumption of pork). However, the current virus is a novel influenza A (H1N1) virus not previously identified in humans, and it appears to be spread by human-to-human transmission. The WHO has raised its pandemic alert level for H1N1 influenza to phase 6, which means that community-level outbreaks are in at least one additional country in a different WHO region from phase 5. A global pandemic is under way.</div> <bR> <bR> <div> Phase 6 criteria: In addition to the criteria defined in Phase 5, the same virus has caused sustained community-level outbreaks in at least one other country in another WHO region. Courtesy of the WHO.</div> <div> In the current 2009 outbreak in the United States, preliminary testing has shown that, in all cases, the viruses have the same genetic pattern. The virus is being described as a new subtype of influenza A/H1N1 not previously detected in pigs or humans.</div> <div> Clinicians should consider the possibility of H1N1 influenza virus infections in patients who present with febrile respiratory illness. The CDC criteria for suspected H1N1 influenza are as follows<FONT SIZE="1" COLOR="#000099" FACE="Arial" >16 </FONT>:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Onset of acute febrile respiratory illness within 7 days of close contact with a person who has a confirmed case of H1N1 influenza A virus infection, or </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Onset of acute febrile respiratory illness within 7 days of travel to a community (within the United States or internationally) where one or more H1N1 influenza A cases have been confirmed, or </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute febrile respiratory illness in a person who resides in a community where at least one H1N1 influenza case has been confirmed.</div> <div> If H1N1 flu is suspected, the clinician should obtain a respiratory swab for H1N1 influenza testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact his or her state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.</div> <div> Laboratories should send all influenza A specimens that they are unable to subtype to the Viral Surveillance and Diagnostic Branch of the CDC's Influenza Division as soon as possible for further diagnostic testing.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >17 </FONT></div> <div> <B>Viral tracking and research</B></div> <div> Internationally, scientists have been collaborating on genetic analysis of current animal and human influenza viruses. These researchers have created a human/swine A/H1N1 influenza wiki to facilitate rapid dissemination of the results of this work. The collaboration is producing insights on the origin of the H1N1 virus and should enable scientists to track its evolution as the outbreak spreads around the world. Information from the National Institute of Allergy and Infectious Disease regarding influenza genome sequencing is available to researchers studying how influenza viruses evolve and those developing new and improved ways to prevent, diagnose, and treat influenza disease.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >18,19 </FONT></div> <bR> <div> <B>Treatment Recommendations</B></div> <div>  <A NAME="treatmentrecommendations"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <B>Vaccination campaign</B><FONT SIZE="1" COLOR="#000099" FACE="Arial" ><B>20,21 </B></FONT></div> <div> The 2009 influenza A (H1N1) monovalent vaccine is in production and is expected to be released in mid October. The immunization series consists of 2 doses for children younger than 10 years, consisting of an initial dose and a booster to be administered several weeks later. Adults and children 10 years and older will receive a single dose. Target populations recommended to receive the 2009 H1N1 vaccine include pregnant women, household contacts and caregivers of children younger than 6 months, healthcare and emergency medical services personnel, children aged 6 months to 18 years, young adults aged 19-24 years, and persons aged 25 through 64 years with conditions associated with higher risk of medical complications from influenza.</div> <div> A separate seasonal influenza vaccine will also need to be administered for the 2009/2010 influenza season.</div> <div> <B>Treatment</B></div> <div> Treatment is largely supportive and consists of bedrest, increased fluid consumption, cough suppressants, and antipyretics and analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) for fever and myalgias. Severe cases may require intravenous hydration and other supportive measures. Antiviral agents may also be considered for treatment or prophylaxis (see Medications).</div> <div> Patients should be encouraged to stay home if they become ill, to avoid close contact with people who are sick, to wash their hands often, and to avoid touching their eyes, nose, and mouth. The CDC recommends the following actions when human infection with H1N1 influenza (swine flu) is confirmed in a community<FONT SIZE="1" COLOR="#000099" FACE="Arial" >15 </FONT>:</div> <div> Home isolation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients who develop flulike illness (ie, fever with either cough or sore throat) should be strongly encouraged to self-isolate in their home for 7 days after the onset of illness or at least 24 hours after symptoms have resolved, whichever is longer. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">To seek medical care, patient should contact their health care providers to report illness (by telephone or other remote means) before seeking care at a clinic, physician's office, or hospital. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients who have difficulty breathing or shortness of breath or who are believed to be severely ill should seek immediate medical attention. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If the patient must go into the community (eg, to seek medical care), he or she should wear a face mask to reduce the risk of spreading the virus in the community when coughing, sneezing, talking, or breathing. If a face mask is unavailable, ill persons who need to go into the community should use tissues to cover their mouth and nose while coughing. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">While in home isolation, patients and other household members should be given infection control instructions, including frequent hand washing with soap and water. Use alcohol-based hand gels (containing at least 60% alcohol) when soap and water are not available and hands are not visibly dirty. Patients with H1N1 influenza should wear a face mask when within 6 feet of others at home.</div> <div> Household contacts who are not ill</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Remain home at the earliest sign of illness. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Minimize contact in the community to the extent possible. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Designate a single household family member as caregiver for the patient to minimize interactions with asymptomatic persons.</div> <div> School dismissal and childcare facility closure</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Strong consideration should be given to close schools upon a confirmed case of H1N1 flu or a suspected case epidemiologically linked to a confirmed case. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Decisions regarding broader school dismissal within these communities should be left to local authorities, taking into account the extent of influenzalike illness within the community. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cancelation of all school or childcare related gatherings should also be announced. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Encourage parents and students to avoid congregating outside of the school if school is canceled. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Duration of schools and childcare facilities closings should be evaluated on an ongoing basis depending on epidemiological findings. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Consultation with local or state health departments is essential for guidance concerning when to reopen schools. If no additional confirmed or suspected cases are identified among students (or school-based personnel) for a period of 7 days, schools may consider reopening. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Schools and childcare facilities in unaffected areas should begin preparation for possible school closure.</div> <div> Social distancing</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Large gatherings linked to settings or institutions with laboratory-confirmed cases should be canceled (eg, sporting events or concerts linked to a school with cases); other large gatherings in the community may not need to be canceled at this time. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Additional social distancing measures are currently not recommended. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Persons with underlying medical conditions who are at high risk for complications of influenza should consider avoiding large gatherings.</div> <div> <B>Patient education</B></div> <div> Patients should be referred to the eMedicine Health article Swine Flu.</div> <div> <B>Preventive measures for health care personnel</B></div> <div> The CDC has issued interim recommendations for controlling the spread of H1N1 influenza in health care settings.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >22 </FONT>Recommended measures for care of patients with suspected or confirmed H1N1 influenza include the following:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Place patients in a single-patient room with the door kept closed. An airborne-infection isolation room with negative-pressure air handling can be used, if available. Air can be exhausted directly outside or can be recirculated after filtration by a high efficiency particulate air (HEPA) filter. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Suctioning, bronchoscopy, or intubation should be performed in a procedure room with negative-pressure air handling. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients should wear a surgical mask when outside their room. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Encourage patients to wash their hands frequently and to follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Routine cleaning and disinfection strategies used during influenza seasons can be applied. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Standard, droplet, and contact precautions should be used for all patient care activities and maintained for 7 days after illness onset or until symptoms have resolved. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Health care personnel should wash their hands with soap and water or use hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Personnel providing care to or collecting clinical specimens from patients should wear disposable nonsterile gloves, gowns, and eye protection (eg, goggles) to prevent conjunctival exposure. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As per previous recommendations regarding mask and respirator use during influenza pandemics, personnel engaged in aerosol-generating activities (eg, collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy) and/or resuscitation involving emergency intubation or cardiac pulmonary resuscitation should wear a fit-tested disposable N95 respirator. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pending clarification of transmission patterns for the 2009 H1N1 influenza A (swine flu) virus, personnel providing direct patient care for suspected or confirmed cases should wear a fit-tested disposable N95 respirator when entering the patient's room.</div> <div> <B>H1N1 influenza in pregnancy</B></div> <div> As of May 10, 2009, a total of 20 cases of novel influenza A (H1N1) virus (swine flu) infection had been reported among pregnant women in the United States, including 15 confirmed cases and 5 probable cases. Among the 13 women from 7 states for whom data are available, the median age was 26 years (range, 15-39 y); 3 women were hospitalized, one of whom died.</div> <div> Pregnant women with confirmed, probable, or suspected novel influenza A (H1N1) virus infection should receive antiviral treatment for 5 days. Oseltamivir is the preferred treatment for pregnant women, and the drug regimen should be initiated within 48 hours of symptom onset, if possible. Pregnant women who are in close contact with a person with confirmed, probable, or suspected novel influenza A (H1N1) infection should receive a 10-day course of chemoprophylaxis with zanamivir or oseltamivir.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >23 </FONT></div> <div> Jamieson et al summarized cases of H1N1 infection in pregnant women identified in the United States when the outbreak began. The CDC began systematically collecting information in pregnant women as part of their surveillance. Thirty-four confirmed or probable cases of pandemic H1N1 in pregnant women were reported to the CDC from 13 states between April 15 to May 18, 2009. Eleven (32%) women were hospitalized (about 4 times higher than in the general population, 0.32 per 100,000 pregnant women vs 0.076 per 100,000 population). Between April 15 and June 16, 2009, 6 deaths were reported in pregnant women. All the deaths occurred in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation. None of the women who died had received antiviral drugs.</div> <div> Because of the suspected increased risk in pregnant women, the CDC recommends pregnant women be treated promptly with anti-influenza drugs (ie, within 48 h of illness onset). Treatment should be initiated promptly for suspected H1N1 infection in pregnant women, even without confirmation of viral testing.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >24 </FONT></div> <bR> <div> <B>Medication</B></div> <div> Laboratory testing has found the H1N1 influenza A (swine flu) virus susceptible to the prescription antiviral drugs oseltamivir and zanamivir, and the CDC has issued interim guidance for the use of these drugs to treat and prevent infection with swine influenza viruses.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >25,26 </FONT>As part of its preparation for the emergency, the US Department of Homeland Security is releasing 25% of stockpiled antiviral agents (ie, oseltamivir [Tamiflu], zanamivir [Relenza]). </div> <div> The usual vaccine for influenza administered at the beginning of the flu season is not effective for this viral strain. Also, other antiviral agents (eg, amantadine, rimantadine) are not recommended because of recent resistance to other influenza strains documented over the past several years.</div> <div> Basic supportive care (ie, hydration, analgesics, cough suppressants) should be prescribed. Empiric antiviral treatment should be considered for confirmed, probable, or suspected cases of H1N1 influenza. Treatment of hospitalized patients and patients at higher risk for influenza complications should be prioritized.</div> <div> <B>WHO guidelines</B></div> <div> WHO guidelines recommend treating serious cases immediately.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >27 </FONT>The guidelines represent an international panel of experts who reviewed all available studies regarding antiviral agents (with emphasis on oseltamivir and zanamivir). Evidence indicates that oseltamivir, when properly prescribed, significantly decreases risk of pneumonia (a leading cause of death for both pandemic and seasonal influenza) and the need for hospitalization.</div> <div> For patients who initially present with severe illness or whose condition begins to deteriorate, initiate oseltamivir as soon as possible. For patients with severe or deteriorating illness, treatment should be provided even if started later. Where oseltamivir is unavailable or cannot be used for any reason, zanamivir may be given. This recommendation applies to all patient groups, including pregnant women, and all age groups, including young children and infants.</div> <div> For patients with underlying medical conditions that increase the risk of more severe disease, WHO recommends treatment with either oseltamivir or zanamivir. These patients should also receive treatment as soon as possible after symptom onset, without waiting for the results of laboratory tests. Pregnant women are included among groups at increased risk, and WHO recommends that pregnant women receive antiviral treatment as soon as possible after symptom onset.</div> <div> At the same time, the presence of underlying medical conditions will not reliably predict all or even most cases of severe illness. Worldwide, around 40% of severe cases are now occurring in previously healthy children and adults, usually younger than 50 years. Some of these patients experience a sudden and very rapid deterioration in their clinical condition, usually on day 5 or 6 following the onset of symptoms.</div> <div> Clinical deterioration is characterized by primary viral pneumonia, which destroys the lung tissue and does not respond to antibiotics, and the failure of multiple organs, including the heart, kidneys, and liver. These patients require management in intensive care units using therapies in addition to antivirals.</div> <div> <B>Initiate antiviral agents within 48 hours</B></div> <div> Prompt initiation of antiviral agents within 48 hours of symptom onset is imperative for providing treatment efficacy against influenza virus. In studies of seasonal influenza, evidence for benefits of treatment is strongest when treatment is started within 48 hours of illness onset. However, some studies of treatment of seasonal influenza have indicated benefit, including reductions in mortality or duration of hospitalization, even in patients in whom treatment was started more than 48 hours after illness onset. The recommended duration of treatment is 5 days.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >25,26 </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prophylaxis with antiviral agents should also be considered in the following individuals (pre-exposure or postexposure): </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Close household contacts of a confirmed or suspected case who are at high risk for complications (eg, chronic medical conditions, persons >65 y or <5 y, pregnant women) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">School children at high risk for complications who have been in close contact with a confirmed or suspected case </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Travelers to Mexico who are at high risk for complications (eg, chronic medical conditions, persons >65 y or <5 y, pregnant women) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Health care providers or public health workers who were not using appropriate personal protective equipment during close contact with a confirmed or suspected case </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In September 2009, the CDC updated recommendations concerning the use of antiviral medications for prevention because of reported oseltamivir resistance; antivirals should not be used for postexposure chemoprophylaxis in healthy children or adults to manage outbreaks in the community, school, camp, or other settings.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >28 </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reserve antiviral chemoprophylaxis for persons at higher risk for influenza-related complications who have had contact with someone likely to have been infected with influenza.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pre-exposure prophylaxis can be considered in the following persons: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any health care provider who is at high risk for complications (eg, persons with chronic medical conditions, adults >65 y, pregnant women) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Individuals not considered to be at high risk but who are nonetheless traveling to Mexico, first responders, or border workers who are working in areas with confirmed cases</div> <div> <B>Pediatric considerations</B></div> <div> Aspirin or aspirin-containing products (eg, bismuth subsalicylate [Pepto Bismol]) should not be included in the treatment of confirmed or suspected viral infection in persons aged 18 years or younger because of the risk of Reye syndrome. For relief of fever, other antipyretic medications (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) are recommended.</div> <div> <B>Pregnant women</B></div> <div> Oseltamivir and zanamivir are "Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess the safety of these medications in pregnant women.</div> <div> Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, oseltamivir or zanamivir should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus; the manufacturers' package inserts should be consulted. However, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to women who have received oseltamivir or zanamivir.</div> <div> Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Because zanamivir is an inhaled medication and has less systemic absorption, some experts prefer zanamivir over oseltamivir for use in pregnant women, when feasible.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >25,29 </FONT>Others recommend that, because pregnant women may have a decreased ability to inhale zanamivir, they should be given oseltamivir.</div> <div>  <A NAME="1855"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <B>Antiviral Agent</B></div> <div> Drugs indicated for treatment of H1N1 influenza A virus include neuraminidase inhibitors (ie, oseltamivir and zanamivir). </div> <div> Oseltamivir and zanamivir inhibit neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, these agents decrease the release of viruses from infected cells and, thus, viral spread.</div> <div> These antivirals are effective in the treatment of influenza A or B and must be administered within 48 hours of symptom onset to provide optimal treatment. The sooner the drug is administered after symptom onset, the better the likelihood of a good outcome. However, some studies of treatment of seasonal influenza have indicated benefit, including reductions in mortality or duration of hospitalization even for patients whose treatment was started more than 48 hours after illness onset.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >25 </FONT>Antivirals reduce the length of illness by an average of 1.5 days. (In a subgroup of high-risk patients, illness was reduced by 2.5 d.) In addition, the severity of symptoms is also reduced.</div> <div> Oseltamivir (Tamiflu)</div> <div> Inhibits neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, decreases release of viruses from infected cells and thus viral spread. Effective to treat influenza A or B. Start within 40 h of symptom onset. Available as 30-mg, 45-mg, and 75-mg oral capsules and as a powder for suspension that contains 12 mg/mL after reconstitution.</div> <div> <B>Dosing</B></div> <div> <B>Adult</B></div> <div> Treatment for acute illness: 75 mg PO bid for 5 d</div> <div> Prophylaxis: 75 mg PO qd</div> <div> Postexposure prophylaxis for high risk individuals should be initiated within 7 d of exposure and continued for at least 10 days</div> <div> Pre-exposure prophylaxis should be initiated during potential exposure period and continue for 10 days after last known exposure</div> <div> <B>Pediatric</B></div> <div> Treatment for acute illness and age <1 year:</div> <div> <3 months: 12 mg PO bid for 5 d</div> <div> 3-5 months: 20 mg PO bid for 5 d</div> <div> 6-11 months: 25 mg PO bid for 5 d</div> <div> Treatment for acute illness and age <U>></U>1 year:</div> <div> <15 kg: 30 mg PO bid for 5 d</div> <div> 15-23 kg: 45 mg PO bid for 5 d</div> <div> 23-40 kg: 60 mg PO bid for 5 d</div> <div> >40 kg: Administer as in adults</div> <bR> <div> <B>Prophylaxis and age <1 year:</B></div> <div> <3 months: Data limited; not recommended unless situation judged critical</div> <div> 3-5 months: 20 mg PO qd</div> <div> 6-11 months: 25 mg PO qd</div> <div> Prophylaxis and age <U>></U>1 year:</div> <div> <15 kg: 30 mg PO qd for 10 d</div> <div> 15-23 kg: 45 mg PO qd for 10 d</div> <div> 23-40 kg: 60 mg PO qd for 10 d</div> <div> >40 kg: Administer as in adults</div> <div> Interactions</div> <div> None reported</div> <div> Contraindications</div> <div> Documented hypersensitivity</div> <div> Precautions</div> <div> Pregnancy</div> <div> C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus</div> <div> <B>Precautions</B></div> <div> Caution in renal impairment, chronic cardiac or respiratory disease, and breastfeeding; do not use in children <1 y (preclinical trials have demonstrated death in young animals, possibly related to immature blood brain barriers); postmarketing reports (mostly from Japan) of self-injury and delirium in patients with influenza (reports primarily among children), unknown if oseltamivir directly contributes to this behavior (monitor for abnormal behavior throughout treatment period)</div> <div> <B>Zanamivir (Relenza)</B></div> <div> Inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Effective against both influenza A and B. Inhaled through Diskhaler oral inhalation device. Circular foil discs containing 5-mg blisters of drug are inserted into supplied inhalation device.</div> <div> Individuals with asthma or other respiratory conditions that may decrease ability to inhale the drug should be given oseltamivir (eg, asthma, pregnancy). Severe respiratory failure caused by H1N1 influenza has been reported in the southern hemisphere during July and August 2009; therefore, in severely ill patients, the ability to inhale zanamivir may be impaired.</div> <div> <B>Dosing</B></div> <div> Adult</div> <div> Treatment for acute illness: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO q12h for 5 d; initiate within 2 d of symptom onset</div> <div> Prophylaxis of household contact: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO qd for 10 d; initiate within 36 h of exposure</div> <div> Prophylaxis for community outbreak: 10 mg inhaled orally qd for 28 d (initiate within 5 d of outbreak)</div> <div> Pediatric</div> <div> Treatment for acute illness:</div> <div> <7 years: Not established</div> <div> <U>></U>7 years: Administer as in adults</div> <div> Prophylaxis in household contact:</div> <div> <5 years: Not established</div> <div> <U>></U>5 years: Administer as in adults</div> <div> Prophylaxis in community outbreak:</div> <div> Adolescents 12-16 years: Administer as in adults</div> <div> Interactions</div> <div> None reported</div> <div> Contraindications</div> <div> Documented hypersensitivity, obstructive airway disease</div> <div> Precautions</div> <div> Pregnancy</div> <div> C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus</div> <div> Precautions</div> <div> Monitor respiratory status; may cause bronchospasm; caution in breastfeeding</div> <div>  <A NAME="1855_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <B>Vaccines</B></div> <div> Four manufacturers are supplying the H1N1 vaccine. The vaccine is available as an IM injection and as an intranasal product.</div> <div> Influenza A virus vaccine (H1N1)</div> <div> Available as monovalent, inactivated influenza A virus vaccine (H1N1) for IM injection. Indicated for active immunization against influenza caused by pandemic (H1N1) 2009 virus. Stimulates active immunity to influenza virus infection by inducing production of specific antibodies.</div> <div> Dosing</div> <div> Adult</div> <div> IM injection: 0.5 mL IM in deltoid muscle of upper arm (1 dose)</div> <div> Pediatric</div> <div> IM injection (Sanofi Pasteur vaccine)</div> <div> 6-35 months: 0.25 mL IM; administer 2 injections approximately 4 wk apart</div> <div> 3-9 years: 0.5 mL IM; administer 2 injections approximately 4 wk apart</div> <div> 10-17 years: Administer as in adults</div> <bR> <div> IM injection (Novartis vaccine)</div> <div> 4-9 years: 0.5 mL IM; administer 2 injections approximately 4 wk apart</div> <div> 10-17 years: Administer as in adults</div> <bR> <div> Administer IM injection in anterolateral aspect of thigh for infants, and administer in deltoid muscle of upper arm in toddlers and children</div> <div> Avoid gluteal region or areas with major nerve trunk</div> <div> Interactions</div> <div> Do not mix with other vaccine in same syringe or vial; immunosuppressive therapies may decrease immune response to vaccine</div> <div> Contraindications</div> <div> Hypersensitivity to eggs or chicken protein, neomycin, or polymyxin; life-threatening reaction to previous influenza vaccination</div> <div> Precautions</div> <div> Pregnancy</div> <div> C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus</div> <div> Precautions</div> <div> Guillain-Barré syndrome has occurred within 6 wk of previous influenza vaccination; immunocompromised persons may have a diminished immune response to vaccine; common injection site adverse effects (=10%) include tenderness, pain, redness, and swelling; common systemic adverse effects (=10%) include headache, malaise, and myalgia; multidose vial contains thimerosal, a mercury derivative</div> <div> Influenza A virus vaccine (H1N1), intranasal</div> <div> Available as monovalent live virus vaccine for intranasal administration. Indicated for active immunization against influenza caused by pandemic (H1N1) 2009 virus. Stimulates active immunity to influenza virus infection by inducing production of specific antibodies.</div> <div> Dosing</div> <div> Adult</div> <div> Intranasal (10-49 years): 0.2 mL/dose (0.1 mL per nostril) intranasally (1 dose)</div> <div> Pediatric</div> <div> Intranasal (MedImmune vaccine)</div> <div> 2-9 years: 0.2 mL/dose (0.1 mL per nostril) intranasally; administer 2 doses approximately 4 wk apart</div> <div> >9 years: Administer as in adults</div> <div> Interactions</div> <div> None reported</div> <div> Contraindications</div> <div> Hypersensitivity, especially anaphylactic reactions, to eggs, egg proteins, gentamicin, gelatin, or arginine; life-threatening reaction to previous influenza vaccination; do not administer intranasal vaccine (live virus) to children or adolescents receiving aspirin, or to immunocompromised individuals</div> <div> Precautions</div> <div> Pregnancy</div> <div> C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus</div> <div> Precautions</div> <div> Guillain-Barré syndrome has occurred within 6 wk of previous influenza vaccination; adverse effects include rhinitis, nasal congestion, fever >100°F in children aged 2-6 y, and sore throat in adults; administer intranasal vaccine with caution to individuals with asthma or recurrent wheezing; intranasal vaccine has potential for viral transmission to immunocompromised household contacts</div> <div> Multimedia</div> <bR> <bR> <div> References</div> <div> Taubenberger JK, Morens DM. 1918 Influenza: the mother of all pandemics. <I>Emerg Infect Dis</I>. Jan 2006;12(1):15-22. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>.</div> <div> Bresee J. CDC Podcasts: Swine Flu. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www2a.cdc.gov/podcasts/player.asp?f=11226</U></FONT>. Accessed April 28, 2009.</div> <div> Roan S. Swine flu 'debacle' of 1976 is recalled. <I>LA Times</I>. April 27, 2009;Health: Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.latimes.com/features/health/la-sci-swine-history27-2009apr27,0,967115.story</U></FONT>.</div> <div> CDC. Swine Flu - Vaccine Safety and Emergency Preparedness. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/vaccinesafety/emergency/swineflu.htm</U></FONT>. Accessed April 29, 2009.</div> <div> Vellozzi C, Burwen DR, Dobardzic A, Ball R, Walton K, Haber P. Safety of trivalent inactivated influenza vaccines in adults: background for pandemic influenza vaccine safety monitoring. <I>Vaccine</I>. Mar 26 2009;27(15):2114-20. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>.</div> <div> Nachamkin I, Shadomy SV, Moran AP, Cox N, Fitzgerald C, Ung H, et al. Anti-ganglioside antibody induction by swine (A/NJ/1976/H1N1) and other influenza vaccines: insights into vaccine-associated Guillain-Barré syndrome. <I>J Infect Dis</I>. Jul 15 2008;198(2):226-33. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>.</div> <div> World Health Organization. Influenza-like illness in the United States and Mexico. WHO Epidemic and Pandemic Alert and Response. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.who.int/csr/don/2009_04_24/en/index.html</U></FONT>. Accessed April 27, 2009.</div> <div> WHO. Influenza A (H1N1): Special Highlights. World Health Organization. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.who.int/en/</U></FONT>. Accessed September 1, 2009.</div> <div> McNeil DG Jr. U.S. Declares Public Health Emergency Over Swine Flu. <I>New York Times</I>. April 27, 2009;A: 1. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.nytimes.com/2009/04/27/world/27flu.html?th&emc=th</U></FONT>.</div> <div> Swine Influenza A (H1N1) infection in two children--Southern California, March-April 2009. <I>MMWR Morb Mortal Wkly Rep</I>. Apr 24 2009;58(15):400-2. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Full Text]</U></FONT>.</div> <div> U.S. Department of Health and Human Services. Determination that a Public Health Emergency Exists. U.S. Department of Health and Human Services. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.hhs.gov/secretary/phe_swh1n1.html</U></FONT>. Accessed April 27, 2009.</div> <div> CDC. Swine Influenza (Flu). Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/h1n1flu/</U></FONT>. Accessed September 1, 2009.</div> <div> Dawood FS, Jain S, Finelli L, Shaw MW, Lindstrom S, Garten RJ, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. <I>N Engl J Med</I>. Jun 18 2009;360(25):2605-15. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>.</div> <div> Centers for Disease Control and Prevention (CDC). Update: novel influenza A (H1N1) virus infections - worldwide, May 6, 2009. <I>MMWR Morb Mortal Wkly Rep</I>. May 8 2009;58(17):453-8. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>.</div> <div> CDC. Interim Guidance for Clinicians on the Prevention and Treatment of Swine-Origin Influenza Virus Infection in Young Children. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/swineflu/childrentreatment.htm</U></FONT>. Accessed April 30, 2009.</div> <div> CDC. Interim Guidance on Specimen Collection and Processing for Patients with Suspected Swine Influenza A (H1N1) Virus Infection. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/swineflu/specimencollection.htm</U></FONT>. Accessed April 28, 2009.</div> <div> CDC. Guidance for Clinicians & Public Health Professionals. http://www.cdc.gov/swineflu/guidance/. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/swineflu/guidance/</U></FONT>. Accessed April 27, 2009.</div> <div> National Center for Biotechnology Information. Influenza Virus Resource. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.ncbi.nlm.nih.gov/genomes/FLU/SwineFlu.html</U></FONT>. Accessed May 4, 2009.</div> <div> NIAID. NIAID and 2009 H1N1 influenza. National Institute of Allergy and Infectious Diseases. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www3.niaid.nih.gov/topics/Flu/understandingFlu/2009h1n1.htm</U></FONT>. Accessed May 4, 2009.</div> <div> CDC 2009 H1N1 vaccination campaign planning checklist. August 31, 2009. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/H1N1flu/vaccination/statelocal/planning_checklist.htm</U></FONT>. Accessed September 1, 2009.</div> <div> CDC. Novel H1N1 vaccination recommendations. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/h1n1flu/vaccination/acip.htm</U></FONT>. Accessed September 1, 2009.</div> <div> CDC. Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/swineflu/guidelines_infection_control.htm</U></FONT>. Accessed April 29, 2009.</div> <div> CDC. Novel influenza A (H1N1) virus infections in three pregnant women - United States, April-May 2009. <I>MMWR Morb Mortal Wkly Rep</I>. May 15 2009;58(18):497-500. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Full Text]</U></FONT>.</div> <div> Jamieson DJ, Honein MA, Rasmussen SA, Williams JL, Swerdlow DL, Biggerstaff MS, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. <I>Lancet</I>. Aug 8 2009;374(9688):451-8. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>.</div> <div> CDC. Interim Guidance on Antiviral Recommendations for Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection and Close Contacts. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/swineflu/recommendations.htm</U></FONT>. Accessed April 28, 2009.</div> <div> CDC. Update: drug susceptibility of swine-origin influenza A (H1N1) viruses, April 2009. <I>MMWR Morb Mortal Wkly Rep</I>. May 1 2009;58(16):433-5. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Full Text]</U></FONT>.</div> <div> WHO guidelines for pharmacological management of pandemic (H1N1) 2009 influenza and other influenza viruses. August 20, 2009. World Health Organization. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.who.int/csr/resources/publications/swineflu/h1n1_use_antivirals_20090820/en/index.html Accessed September 1, 2009</U></FONT>. Accessed September 1, 2009.</div> <div> Oseltamivir-resistant 2009 pandemic influenza A (H1N1) virus infection in two summer campers receiving prophylaxis--North Carolina, 2009. <I>MMWR Morb Mortal Wkly Rep</I>. Sep 11 2009;58(35):969-72. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Medline]</U></FONT>.</div> <div> CDC. Interim Guidance - Pregnant women and swine influenza: considerations for clinicians. Centers for Disease Control and Prevention. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.cdc.gov/swineflu/clinician_pregnant.htm</U></FONT>. Accessed April 29, 2009.</div> <div> CDC. Swine Flu: CDC Offers Clinical Guidance, WHO Raises Alert Level Again. Physician First Watch – Journal Watch. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://firstwatch.jwatch.org/cgi/content/full/2009/430/1</U></FONT>. Accessed April 30, 2009.</div> <div> Hospitalized Patients with Novel Influenza A (H1N1) Virus Infection --- California, April--May, 2009. <I>MMWR</I>. May 2009;58:1-5. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>[Full Text]</U></FONT>.</div> <div> WHO. Swine Influenza Frequently Asked Questions. World Health Organization. Available at <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>http://www.who.int/csr/swine_flu/swine_flu_faq_26april.pdf</U></FONT>. Accessed April 27, 2009.</div> <div> Keywords</div> <div> H1N1 influenza, H1N1 flu, swine flu, swine influenza, swine influenza virus, swine influenza A (H1N1) virus, human swine flu, influenza A, influenza (H1N1), SIV, swine flu symptoms, swine flu diagnosis, swine flu treatment, swine flu antiviral, swine flu pandemic, swine flu outbreak, H1N1 flu symptoms, H1N1 flu diagnosis, H1N1 flu treatment, H1N1 flu antiviral, H1N1 flu pandemic, H1N1 flu outbreak</div> <div> Contributor Information and Disclosures</div> <div> Author</div> <div> <B>Michael Stuart Bronze, MD,</B> Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center</div> <div> Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation </div> <div> Disclosure: Nothing to disclose.</div> <div> Pharmacy Editor</div> <div> <B>Mary L Windle, PharmD,</B> Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine</div> <div> Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner</div> <div> Chief Editor</div> <div> <B>Russell W Steele, MD,</B> Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine</div> <div> Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association </div> <div> Disclosure: None None None</div> <div> <B>Further Reading</B> </div> <div> © 1994-2009 by Medscape.</div> <div> All Rights Reserved</div> <div> (http://www.medscape.com/public/copyright)</div> <bR> <bR> <div> <B> <A NAME="flu_pandemic_may_be_up_to_500000_in"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>flu pandemic may be up to 500,000 in new york alone(</B><FONT SIZE="3" COLOR="#000099" FACE="Arial" >June 10, 2009)</FONT></div> <bR> <div> Published: June 10, 2009 </div> <div> New York City officials on Wednesday reported the deaths of three more people with <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>swine flu</U></FONT>, and estimated that more than half a million New Yorkers may have become sick from the virus.</div> <bR> <div> The latest deaths bring the city’s total to 12 since the outbreak began in late April. The city health department said that one of the latest victims was 30 to 39 years old, one was 50 to 59 years old and one was over 65.</div> <div> The city also announced 102 new hospitalizations since its last report on Monday, bringing the total hospitalizations to 530.</div> <div> Dr. Don Weiss, director of surveillance for the Bureau of Communicable Disease, said that what looked like a spike in hospitalizations actually represented catching up from a lag in reporting over the weekend. He said that hospitalizations were running at the rate of 35 to 40 a day, and “don’t appear to be going up or down appreciably.”</div> <div> Health officials said that in a telephone poll of New Yorkers, 6.9 percent of those surveyed reported having flulike illness, like <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>fever</U></FONT> and <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>cough</U></FONT> or a <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>sore throat</U></FONT>, between May 1 and May 20.</div> <div> Extrapolated to the general population, that would mean that about 550,000 people could have become sick with the virus. The 500 who have been hospitalized make up a tiny proportion — about one-tenth of 1 percent — of those who became ill, an indication of how mild the virus generally has been, officials said.</div> <div> “The findings don’t tell us exactly how many New Yorkers have had H1N1 <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>influenza</U></FONT>,” Dr. Thomas A. Farley, the city’s new health commissioner, said in a statement. “But they suggest it has been widespread and mild in most people.”</div> <div> The survey of 1,005 households found that the prevalence of flulike illness was highest in Queens, where the outbreak began, with 9.4 percent, and lowest in Manhattan and the Bronx with just below 4 percent.</div> <div> Officials cautioned that some of those who reported flulike symptoms may have had seasonal <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>flu</U></FONT>, <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>strep throat</U></FONT> or similar illnesses.</div> <div> In an ordinary flu season, Dr. Weiss said, 5 to 20 percent of the population becomes ill, and using a conservative estimate of 10 percent of the population, that would be 800,000 people.</div> <div> The city’s descriptions of those with swine flu who have died have become progressively vaguer, dropping information like exact age, sex and home borough. By Wednesday, the city had stopped saying if victims had an underlying health problem that put them at more risk from the virus.</div> <div> Jessica Scaperotti, a health department spokeswoman, said the city had become less specific to guard patient confidentiality, but also because the disease had become so widespread that officials were more interested in the big picture. “We’re not really focused on individual cases,” she said.</div> <bR> <div> <B>from the TIMES OF LONDON</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="246" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 133 WIDTH="242"><div> <B> <A NAME="flu_vaccines__not_worth_the_trouble_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Flu vaccines 'not worth the trouble'</B></div> <bR> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="246" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 115 WIDTH="242"><div> FLU vaccines may be far less effective at combating seasonal outbreaks than previously thought, researchers say, adding that they may not be worth the cost and effort required to produce them. </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="242"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="242" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="242"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="242" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 802 WIDTH="242"><div> According to a review published today, there is little clinical evidence that the vaccines reduce deaths significantly, hospital stays and time off work among those most at risk from seasonal flu, including the over-65s and those with chronic heart and lung conditions. </div> <div> Public policy worldwide recommends the use of inactivated influenza vaccines — those that contain dead viruses and are given with a needle in the arm — to prevent outbreaks. More than 15 million doses of vaccine have been ordered for use this winter in Britain. </div> <div> But according to Tom Jefferson, a vaccines expert, vaccines given to children under 2 have the same effect as if they were given a dummy drug. He is calling for an urgent re-evaluation of vaccination campaigns. </div> <div> Writing in the <I>British Medical Journal</I>, he says that because influenza viruses mutate and vary from year to year, it is difficult for scientists to study the precise effects of vaccines and that most existing studies are of poor quality. </div> <div> Responding to Dr Jefferson’s comments, David Salisbury, director of immunisation at the Department of Health, said: “In older people, protection against infection may be less, but there is good evidence showing that immunisation reduces broncho- pneumonia, hospital admissions and mortality.”</div> </tD> </tR> </TABLE></div> <bR> <bR> <div>  <A NAME="tamiflu_resistanc_and_avian_flu"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>TAMIFLU RESISTANC AND AVIAN FLU</div> <bR> <div> By Steven Reinberg</div> <div> HealthDay ReporterWed Dec 21,11:48 PM ET</div> <bR> <div> WEDNESDAY, Dec. 21 (HealthDay News) -- One of the few drugs known to be effective against the potentially pandemic avian flu is the antiviral drug Tamiflu, but a new report finds further evidence that some patients may develop resistance to it.</div> <bR> <div> A report issued last October outlined one such case in Vietnam. Now, a new article gives more details on two Vietnamese patients who were resistant to Tamiflu (oseltamivir) and died from the H5N1 avian flu virus despite treatment with the drug.</div> <bR> <div> According to the report, six surviving patients who were also treated with the drug appeared to respond well to the therapy, which was associated with a rapid decline of viral load to undetectable levels in the blood.</div> <bR> <div> The report appears in the Dec. 22 issue of The New England Journal of Medicine.</div> <bR> <div> A research team from the Oxford University Clinical Research Unit and Hospital for Tropical Diseases, in Ho Chi Minh City, believes the failed cases show that in some H5N1-infected patients, the recommended dose of Tamiflu is unable to stop the virus from replicating.</div> <bR> <div> In these cases, not only does the virus spread, but a viral resistance to Tamiflu may develop.</div> <bR> <div> The study's lead author, Dr. Menno D. de Jong, said the resistance is unsurprising, but added, "this does not automatically extrapolate to the situation in the event of an influenza pandemic."</div> <bR> <div> "While our study shows that the drug seems to be effective in suppressing viral replication in at least some patients, it also clearly shows that oseltamivir resistance in H5N1 can develop, and if this happens it may render the drug not effective," de Jong said.</div> <bR> <div> "The availability of alternative antiviral drugs, which remain active against oseltamivir-resistant virus, is important," de Jong said. "One such drug is zanamivir. In addition, strategies to prevent or delay resistance development, for example, higher dosing or combination therapy needs to be explored."</div> <bR> <div> "My advice to patients is to remain calm," de Jong added. "High resistance rates have been observed in human flu as well, generally without detrimental clinical effects."</div> <bR> <div> The reasons for Tamiflu's ineffectiveness in some patients is unclear, however. The researchers speculated that the virus may be replicating too fast for the drug to stop it, or somehow the drug becomes altered in these patients.</div> <bR> <div> One expert believes, however, that Tamiflu resistance may not be the reason the two patients died. Instead, their deaths could be due to the virulence of the particular virus.</div> <bR> <div> "There is no telling that the development of resistance has anything to do with the fatal outcome of these patients," said Dr. Arnold S. Monto, a professor of epidemiology at the University of Michigan School of Public Health, Ann Arbor. "We do not suspect that with this virus that we are going to get 100 percent cure."</div> <bR> <div> Monto noted that the H5N1 virus may not be able to spread easily, since it seems to take a very large amount of the virus to move from birds and then infect people. "This virus is somewhat lacking in fitness -- its ability to infect and transmit [to people]," he said. "On a population basis, this virus might not take off."</div> <bR> <div> According to Monto, a new report about to be issued shows that Japan, where Tamiflu is widely used, has not seen an emergence of a resistant flu virus. "Appropriate use of Tamiflu in treating seasonal influenza should not be inhibited because you are worried that you may be enhancing the emergence of a resistant virus," he said.</div> <bR> <div> Despite this, Monto believes that other antiviral drugs to treat the flu are needed. "It's an unhealthy situation to have the whole world dependent on one drug for treating a very important infection," he said. "We can't ensure that this resistance will not emerge. We need to be sure that we have a backup if it does."</div> <bR> <div> Faced with the growing fear of a pandemic of deadly avian flu, the number of requests by patients for prescriptions for Tamiflu has increased dramatically. In increasing numbers, patients have been asking their doctors for Tamiflu so they can be sure they have a supply should an outbreak occur.</div> <bR> <div> One expert, writing in the same journal issue, cautions doctors not to let patients stockpile Tamiflu as a way of being prepared for an outbreak of avian flu.</div> <bR> <div> Physicians are receiving requests by patients to give them prescriptions for Tamiflu, and in many cases, doctors are acceding to these requests, because it's easier than arguing with patients, said Dr. Allan S. Brett, a professor of medicine at the University of South Carolina School of Medicine, Columbia.</div> <bR> <div> "Physicians should not yield to requests for Tamiflu, when the purpose is personal stockpiling," Brett said. "The patient is asking it for some hypothetical event in the future that may or may not even come," he said.</div> <bR> <div> Brett also cautioned that allowing patients to have the drug may encourage them to take it when they think they have the flu, but only have a bad cold. "People may say, 'This could be influenza, so I'll just start taking the drug,' and then it becomes a real waste," he said. "In addition, widespread unnecessary use will increase the chance of resistant virus."</div> <bR> <div> Another expert, writing in the journal, agreed with Brett.</div> <bR> <div> "I focus on the issue of the development of resistance in influenza to Tamiflu," said Dr. Anne Moscona, a professor in the departments of pediatrics and microbiology and immunology at the Weill Medical College of Cornell University in New York City. "This means that the influenza may develop to [a point] where it is no longer able to be killed, to be treated by Tamiflu."</div> <bR> <div> Moscona isn't surprised that resistance to Tamiflu is developing in the H5N1 virus. "We expected resistance to develop," she said. "Resistance is developing in seasonal flu and now resistance is developing in avian flu."</div> <bR> <div> "There is no pandemic flu right now," Moscona said. "Really, Tamiflu remains an effective and important drug in seasonal influenza. Physicians should not be prescribing Tamiflu to people who just want to stockpile it. We should use these drugs to treat people who are sick."</div> <bR> <div> More information</div> <bR> <div> For moe on avian flu, head to the U.S. Centers for Disease Control and Prevention.</div> <bR> <div> <B><U> <A NAME="flu_shots_may_not_save_lives____study"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Flu Shots May Not Save Lives -- Study</U></B></div> <bR> <bR> <div> CHICAGO (Reuters) - The flu vaccinations that doctors hoped would save the lives of fragile elderly people have apparently failed to lower death rates, U.S. researchers said on Monday.</div> <bR> <div>       </div> <div> More people whose health could be put at risk by influenza have heeded the call to get vaccinated before flu season, but the death rate during the winter flu season remained the same rather than declining, they said.</div> <bR> <div> Based on U.S. mortality rates from 1968 to 2001, the study by the National Institute of Allergy and Infectious Diseases (news - web sites) found no correlation between increasing vaccination rates after 1980 and declining death rates in any age group.</div> <bR> <div> "We conclude, therefore, that there are not enough influenza-related deaths to support the conclusion that vaccination can reduce total winter mortality among the U.S. elderly population by as much as half," study author Lone Simonsen wrote in The Archives of Internal Medicine (news - web sites).</div> <bR> <div> Previous studies have estimated that vaccine programs have cut mortality rates among the elderly by about half.</div> <bR> <div> While the vaccination rate in 2001 rose to 65 percent among elderly Americans from around 20 percent before 1980, the rate of excess winter deaths has remained flat instead of declining by an expected 40 percent.</div> <bR> <div> Because deaths spiked in some years when a virulent form of flu was epidemic, the findings may not be conclusive, the researchers said.</div> <bR> <div> The report suggested earlier observational studies may have had skewed data. For one thing, influenza sufferers may have died from secondary complications brought on by flu after their symptoms had passed, it said. In addition, vaccines often fail to activate antibodies in the elderly.</div> <bR> <div> Further evidence may come after this flu season since an initial U.S. shortage of flu vaccine should have an effect on mortality rates, one way or the other, the report said.</div> <bR> <div> "Either way, this vast disconnect between conclusions from different studies must be sorted out," it said.</div> <bR> <bR> <bR> <div> <B><U> <A NAME="study_suggests_flu_vaccine_didn_t_work"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Study Suggests Flu Vaccine Didn't Work Well  </U></B><FONT SIZE="1" COLOR="#0000FF" FACE="Verdana" > </FONT></div> <div> Thu Jan 15, 4:10 PM ET  Add Health - Reuters to My Yahoo! </div> <div>  </div> <bR> <div> By Maggie Fox, Health and Science Correspondent </div> <bR> <div> WASHINGTON (Reuters) - The influenza vaccine that many Americans clamored for this year was not very good at protecting people against influenza, colds and similar viruses, a preliminary report published on Thursday shows. </div> <bR> <bR> <div> The study is the first attempt to show whether the vaccine that many sought after a flu scare this autumn and winter actually worked. </div> <bR> <bR> <div> The study of hospital workers in Colorado, a state that was hit early and hard by influenza, showed the vaccine had "no or low effectiveness against influenza-like illness," the U.S. Centers for Disease Control and Prevention (news - web sites) said in its report. </div> <bR> <bR> <div> Many experts did not expect the vaccine to work well, although the CDC had hoped it would at least prevent some of the worst illnesses caused by this year's strain of influenza. </div> <bR> <bR> <div> The vaccine is only meant to protect against true influenza. Without a test, it is often difficult to distinguish between influenza and other, similar viruses. </div> <bR> <bR> <div> CDC spokesman Tom Skinner said that for this reason the report only shows part of the story. </div> <bR> <bR> <div> "This is the first of a number of studies that we are going to do to try to answer the question, 'did this year's vaccine offer protection against flu?' This study in and of itself does not answer this question," he said in a telephone interview. </div> <bR> <bR> <div> However, the study shows that people who were vaccinated against influenza came down with colds, flu and similar viruses at the same rate as people who were not vaccinated. This would presumably include true influenza. </div> <bR> <bR> <div> The vaccine is formulated each year in February or March, at the end of the northern hemisphere's flu season, and did not include the Fujian strain of influenza, a new, mutated strain that turned out to be the predominant type of flu in the United States and several other countries this year. </div> <bR> <bR> <div> The epidemic appears to be on the wane -- this past week only 2.8 percent of hospital visits were for influenza-like illnesses, compared to 5.5 percent the week before. </div> <bR> <bR> <div> News coverage of the early start to the flu season sent many people rushing to get vaccinated. There were shortages in some places and the U.S. government bought 625,000 doses of flu vaccine from makers Chiron and Aventis . </div> <bR> <bR> <div> It also negotiated a discount price for states to buy up to 3 million unsold doses of Wyeth and MedImmune's FluMist vaccine, which is given nasally. </div> <bR> <bR> <div> Experts knew the vaccines did not include the Fujian strain, but they did contain the related Panama strain, which they hoped would provide at least some protection. </div> <bR> <bR> <div> The study, done among hospital workers at the Children's Hospital in Denver, suggests it did not. </div> <bR> <bR> <div> Of the 1,000 people vaccinated before Nov. 1, 149 developed influenza-like illness, or just under 15 percent. Of the 402 people who were not vaccinated, 68 got a flu-like illness, or just under 17 percent. </div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <div> <B> <A NAME="jama_patient_page"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>JAMA Patient Page:</B></div> <div> <B>Do You Have The Flu? </B></div> <div> The common cold and influenza (commonly called flu) are both respiratory infections caused by viruses. But the flu is considered more serious because of more severe symptoms that can lead to pneumonia and even death in persons who have other chronic diseases. </div> <div> With both the cold and flu, you may experience a stuffy nose, sore throat, and sneezing. Tiredness, fever, chills, headache, and major aches and pains may mean you have the flu. Neither the common cold nor flu need to be treated with antibiotics. Consult your doctor if your symptoms get worse or persist for more than a few days. </div> <div> One of the best ways to prevent flu infection is to get a flu vaccine from your doctor. A study in the March 10, 1999, issue of <I>The Journal of the American Medical Association</I> shows that the vaccine is 88 percent effective in preventing influenza type A infection and 89 percent effective in preventing influenza type B infection. A second study in the same issue shows that it may be especially advisable for certain groups of people, such as women younger than age 65 with certain chronic medical conditions, to get an annual flu vaccine. </div> <div> <B>Who Should Get a Flu Shot?</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All people aged 65 years or older </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">People of any age with chronic diseases of the heart, lung or kidneys, diabetes, compromised immune systems, severe forms of anemia, or asthma </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Residents of nursing homes and other facilities where patients with chronic medical conditions live </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children or teenagers who are receiving long-term aspirin therapy and who therefore may be at risk for developing Reye syndrome (a neurologic disorder characterized by brain or liver damage) after a flu infection </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women who will be in the second or third trimester of pregnancy during the flu season </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Health care professionals and volunteers who work with high-risk patients </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">People who live in a household with a person who fits into any of the categories above </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="575" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=3 HEIGHT= 38 ><NOBR><div> <B>LEADING CAUSES OF DEATH, UNITED STATES, 1995:</B></div> <bR> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="168"><div> 1</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> Heart disease</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 737,563</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="168"><div> 2</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> Cancer</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 538,455</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="168"><div> 3</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> Cerebrovascular disease</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 157,991</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="168"><div> 4</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> Chronic obstructive lung disease</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 102,899</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="168"><div> 5</div> </tD> <tD VALIGN=CENTER><NOBR><div> Unintentional injury</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="219"><div> 93,320</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="168"><div> 6</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> <B>Pneumonia and influenza</B></div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> <B>82,923</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="168"><div> 7</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> Diabetes</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 59,254</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="168"><div> 8</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> HIV and AIDS</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 43,115</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="168"><div> 9</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> Suicide</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 31,284</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="168"><div> 10</div> </tD> <tD VALIGN=CENTER WIDTH="168"><div> Chronic liver diseases</div> </tD> <tD VALIGN=CENTER WIDTH="219"><div> 25,222</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=3 HEIGHT= 29 WIDTH="561"><div> <B>Sources: National Foundation for Infectious Diseases, 1996-97, and Injury Chartbook, Hyattsville, Maryland, 1997</B></div> </tD> </tR> </TABLE></div> <div> <B>What to Expect:</B> </div> <div> The flu shot contains no live virus, so you cannot get the flu from the shot. In the United States, flu season usually occurs from about November to April, and the best time to get the vaccine is between September and mid-November. Flu viruses continually change, so it is important that you receive the flu vaccine every year. Most people do not experience side effects from the flu vaccine; however, some people may feel sore at the vaccination site, and other minor, uncommon side effects include headache or low-grade fever for about a day after vaccination. </div> <div> <B>What is Influenza?</B> </div> <div> <B>Influenza</B> is a highly contagious respiratory infection. It is spread person-to-person through infectious droplets, such as when an infected person coughs or sneezes. It causes symptoms that include headache, chills, and dry cough, followed by body aches, fever, nasal congestion and sore throat. Symptoms usually appear within two days to four days days of being infected, and a person is considered contagious for another three days to four days after symptoms appear. There are three types of influenza viruses (types A, B and C), with type A being the most prevalent and associated with the most serious epidemics. </div> <div> <B>For More Information:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">National Institute of Allergy and Infectious Diseases</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Building 31, Room 7A50</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">31 Center Drive, MSC 2520</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bethesda, MD 20892-2520</div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">http://www.niaid.nih.gov</U><FONT SIZE="3" COLOR="#000099" FACE="Verdana" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">American Lung Association</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">(800) LUNG-USA</div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">http://www.lungusa.org</U><FONT SIZE="3" COLOR="#000099" FACE="Verdana" > </FONT></div> <div> <B>Additional Sources:</B> National Center for Infectious Diseases, National Institute for Allergy and Infectious Diseases, Food and Drug Administration, <I>AMA's Encyclopedia of Medicine</I> </div> <div> <I>Mi Young Hwang, Writer</I></div> <div> <I>Richard M. Glass, Editor</I></div> <div> <I>Jeff Molter, Director of Science News</I> </div> <div> (<I>JAMA</I>. 1999; 281:962) </div> <div> Published in <I>JAMA</I>: March 10, 1999 </div> <div> The JAMA Patient Page is a public service of <I>The Journal of the American Medical Association</I> and the American Medical Association. The information and recommendations appearing on this page are appropriate in most instances; but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, <I>JAMA</I> and AMA suggest that you consult your physician. This page may be reproduced noncommercially by physicians and other health care professionals to share with patients. Any other reproduction is subject to AMA approval. </div> <DIV ALIGN="LEFT"></DIV> <div> © Copyright 1999 American Medical Association</div> <div> All rights reserved.</div> <div> <I><B>This article is provided by Medem, Inc. All rights reserved.</B></I></div> <bR> <bR> <div> <B><U> <A NAME="flu_shot_works_best_in_well_rested"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Flu Shot Works Best in Well-Rested Individuals </U></B></div> <div> Tue Sep 24, 5:38 PM ET </div> <div> <I>By Charnicia E. Huggins</I> </div> <div> NEW YORK (Reuters Health) - <FONT SIZE="3" COLOR="#000099" FACE="arial" >An annual vaccination may be the best way to protect against the influenza bug, but to guarantee its effectiveness, people should also be sure to get a good night's sleep before they get their flu shot, new study findings show. </FONT></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="12" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="4"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="4" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> "Getting your flu shot after not having enough sleep may not offer the same protection as getting it when well-rested," study author Dr. Eve Van Cauter of the University of Chicago in Illinois told Reuters Health. </div> <div> "Chronic partial sleep loss, as experienced by millions of Americans today, has an adverse effect on immune function," she added. </div> <div> To investigate, Van Cauter and her team studied 25 healthy young men. Eleven had their sleep restricted to just 4 hours a night on 6 nights of the week, followed by 12 hours of sleep per night for a full week. They were vaccinated against the flu on the morning of the fifth day during their sleep-deprived week. The remaining 14 men maintained their usual bedtimes before they were vaccinated. </div> <div> At follow-up, 10 days after the vaccinations, the investigators found that the men who were immunized while sleep-deprived had an immune response to the flu that was less than half of that shown by their better-rested peers. </div> <div> At both the 3- and 4-week follow-ups, however, there were no great differences in immune response between the two groups, the researchers note. Their findings are published in a letter to the editor in the September 25th issue of The Journal of the American Medical Association ( <FONT SIZE="3" COLOR="#0000FF" FACE="arial" ><U>news</U></FONT> - <FONT SIZE="3" COLOR="#0000FF" FACE="arial" ><U>web sites</U></FONT>). </div> <div> "These findings add to a growing body of evidence indicating that sleep curtailment has adverse health effects," such as making people more prone to colds and other illnesses, Van Cauter said. </div> <div> The study was partially funded by grants from the National Institutes of Health ( <FONT SIZE="3" COLOR="#0000FF" FACE="arial" ><U>news</U></FONT> - <FONT SIZE="3" COLOR="#0000FF" FACE="arial" ><U>web sites</U></FONT>). </div> <div> SOURCE: The Journal of the American Medical Association 2002;288:1471-1472. </div> <bR> <div> <B><U> <A NAME="classic_signs_and_symptoms_of_influenza"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Classic signs and symptoms of influenza</U></B></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="424" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 241 WIDTH="414"><div> Rapid onset of symptoms </div> <div> Fever (temperature usually > 37.7°C [100°F]) </div> <div> Nonproductive cough </div> <div> Headache </div> <div> Myalgia </div> <div> Chills and/or sweats </div> <div> Sore throat </div> <div> Potentially severe, persistent malaise </div> <div> Substernal soreness, photo-phobia, and ocular problems </div> </tD> </tR> </TABLE></div> <div> From Cox NJ, Fukuda K. Infect Dis Clin North Am. 1998.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >[6]</FONT></div> <bR> <div> <B><U> <A NAME="flu_vs_cold"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>     </U></B><B><U>FLU VS COLD</U></B></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="540" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="105"><div> <B>Signs and symptoms</B></div> </tD> <tD VALIGN=TOP WIDTH="225"><div> <B>Influenza</B></div> </tD> <tD VALIGN=TOP WIDTH="190"><div> <B>Cold</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="105"><div> Onset</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Sudden</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Gradual</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="105"><div> Fever</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Characteristically high, lasting 3 or 4 days</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Uncommon</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="105"><div> Cough</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Frequent, early in onset, often marked, sometimes mucoid</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Less frequent, less severe, later in onset</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="105"><div> Headache</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Prominent</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Common but usually not disabling</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="105"><div> Myalgia</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Usual, often severe</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Slight</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="105"><div> Fatigue or weakness</div> </tD> <tD VALIGN=TOP><NOBR><div> May last up to 2 to 3 weeks</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="190"><div> Mild</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="105"><div> Extreme exhaustion</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Early and prominent</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Rare</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="105"><div> Chest discomfort</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Common</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Uncommon</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="105"><div> Stuffy nose</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Sometimes</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Hallmark symptom</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="105"><div> Sneezing</div> </tD> <tD VALIGN=TOP WIDTH="225"><div> Sometimes</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Hallmark symptom</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 ><NOBR><div> Sore throat</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="225"><div> Sometimes</div> </tD> <tD VALIGN=TOP WIDTH="190"><div> Sore or scratchy throat typically first symptom noted</div> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> <B><U> <A NAME="influenza_vaccine_recommendations"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Influenza Vaccine Recommendations</U></B></div> <div> The most important control measure for the prevention of influenza outbreaks in any population is annual vaccination with the influenza vaccine. The Advisory Committee on Immunization Practices (ACIP) has prioritized target groups for influenza vaccination.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >[1]</FONT> People who are included in the highest priority group are those most at risk for complications of influenza (see Table 1). This group includes: (1) persons aged 65 years or older; (2) residents of nursing homes and other facilities where people with chronic illnesses reside; (3) adults and children who have chronic disorders, especially pulmonary or cardiovascular illness, chronic metabolic diseases (eg, diabetes), renal dysfunction, hemoglobinopathies, or immunosuppression such as HIV; (4) children and teenagers who receive long-term aspirin therapy and are therefore at risk for Reye syndrome following an influenza infection; and (5) women who will be in their second or third trimester of pregnancy during the influenza season. </div> <div> People who are between the ages of 50 and 64 years are also included in the ACIP's recommendation for vaccination, because this age group has a high prevalence of chronic medical conditions. People who have close contact with at-risk individuals (eg, healthcare workers, family caregivers) should also be vaccinated. Finally, any healthy person who wishes to be protected from influenza should receive an annual vaccine. Since many office workers are at risk for a worksite epidemic, employers often encourage them to be vaccinated. The vaccination of apparently healthy children may also be warranted because encephalitis and encephalopathy have been reported with increased frequency among children who have an influenza infection.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >[8]</FONT> </div> <bR> <div> <U>The Influenza Vaccine</U></div> <div> <B><U>Vaccine Protection</U></B></div> <div> Protection from influenza is dependent on how closely the strains approximate the circulating strains of the virus. Elderly and immunocompromised people may not be as protected as younger adults because their postvaccination antibody titers tend to be lower.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >[4]</FONT> Protective antibody levels are achieved in 70% to 90% of immunized healthy adults younger than 65 years of age.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >[9]</FONT> The antibody titer begins to decline within 7 months, and, therefore, annual vaccination is needed. The vaccine may reduce the severity and complications that follow the onset of influenza. Therefore, vaccine protection can decrease the risks of illness, hospitalization, and death. </div> <bR> <div> <B><U> <A NAME="adverse_reactions_and_contraindications"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Adverse Reactions and Contraindications</U></B></div> <div> Local reactions, which occur in approximately one third of recipients, include pain, erythema, and induration at the vaccine site. For the first 2 days after the intramuscular injection, the recipient may experience systemic reactions consisting of fever, malaise, and myalgia. Because influenza virus is killed during the manufacturing process, people cannot get influenza from the vaccine. Guillain-Barré syndrome has not been associated with the vaccine since the 1976 swine influenza vaccine. However, Wyeth Laboratories recommends that the vaccine not be administered to persons with a history of Guillain-Barré syndrome.<FONT SIZE="1" COLOR="#000099" FACE="Arial" >[7]</FONT> Although the vaccine can be given to people with minor illnesses, persons with acute febrile illnesses should not receive it. Because animal reproduction studies have not been conducted to determine fetal harm from the vaccine, caution should be used when making decisions to give the vaccine to pregnant women. The vaccine contains a small amount of egg protein and therefore is contraindicated for individuals with a severe anaphylactic sensitivity to eggs. </div> <div> Chemoprophylaxis With Antiviral Compounds</div> <bR> <bR> </td> </tr></table></body>