Susan M Kellie MD MPH Associate Professor of Medicine Division of Infectious Diseases Hospital Epidemiologist UNMHSC and NMVAHCS Talk outline Current epidemiology Potential surge for inpatient care ID: 912863
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Slide1
Pandemic influenza-focus on inpatient issues
Susan M. Kellie, MD, MPH Associate Professor of MedicineDivision of Infectious DiseasesHospital Epidemiologist, UNMHSC and NMVAHCS
Slide2Talk outline
Current epidemiologyPotential surge for inpatient careSpectrum of disease and complicationsTesting and treatmentInfection control in the hospitalHealthcare worker health issues
Contingency planning
Slide3Slide4Slide5Slide6Number of isolates Influenza A by week 2009-Tricore lab, NM
Slide7Case rate by age group-US data on around 35k confirmed cases
Slide8Hospitalization rates by age group
Slide9Deaths-numbers by age group
Slide10Age distribution of current cases-NM
Tricore requests for virus detection 9/5-9/11/09536 requests, 80 positives3 adenovirus
77 Influenza A-all from previous week confirmed as H1N1
Age # of isolates
0-2: 3
3-5: 12
6-11: 22
12-18: 21
19-64: 15
>65: 4
Slide11FluSurge 2.0 assumptions
No. 1 Average length of non-ICU hospital stay for influenza-related illness is 5 days. No. 2 Average length of ICU stay for influenza-related illness is 10 days. No. 3 Average length of ventilator usage for influenza-related illness is 10 days.
No. 4 Average proportion of admitted influenza patients will need ICU care is 15%.
No. 5 Average proportion of admitted influenza patients will need ventilators is 7.5%.
No. 6 Average proportion of influenza deaths assumed to be hospitalized is 70%.
No. 7 Daily percentage increase in cases arriving compared to previous day is 3%.
4
Slide12Slide13Slide14Slide15Slide16Disease spectrum
Most disease is mild and does not require medical attention
Patients should be educated to do self-care at home
All persons should be aware of the “danger signs”
shortness of breath, either during physical activity or while resting
difficulty in breathing
turning blue
bloody or
coloured
sputum
chest pain
altered mental status
high fever that persists beyond 3 days
low blood pressure.
Slide17Clinical course of more severe disease
WHO states 40% of patients with severe manifestations of pandemic influenza do not have underlying risk factors
Rapid progression to viral pneumonia at the onset of symptoms
Deterioration at day 4-5 of symptoms with viral pneumonia and MODS
Bacterial
superinfection
not described in US severe cases
Some descriptions of bloody mucus plugging requiring therapeutic
bronchoscopy
Slide18Groups at risk of severe disease
Pregnant women and those in the immediate post-partum periodChildren under 4Immunocompromised and those with underlying cardiopulmonary, metabolic, liver, renal conditions
Older children with
neurodevelopmental
delay-only group described so far with substantial rates of bacterial
superinfection
Obesity may be a risk factor? Due to other underlying conditions
Slide19MMWR Dispatch July 10, 2009/58(Dispatch):1-4
Intensive Care patients with Severe Novel Influenza A (H1N1) Virus Infection-Michigan, June 2009
10 patients with H1N1 and ARDS
9 had BMI >30, 7 had BMI>40
Other RF: asthma, asthma plus smoking,
granulomatous
chronic lung disease
5 had PE, 9 had MODS
3 died
DFA for influenza was negative in all 10, viral culture was positive in 2
10 were confirmed by PCR of respiratory specimens
Slide20Complicated or severe influenza
Presentations:
clinical and/or radiological signs of pneumonia,
CNS findings (e.g. encephalopathy),
severe dehydration or secondary complications such as renal failure,
multi‐organ failure, and septic shock.
Other complications can include musculoskeletal (
rhabdomyolysis
) and cardiac (
myocarditis
).
Exacerbation of underlying chronic disease
Any condition requiring hospital admission for clinical management.
Slide21Signs and symptoms of progressive disease
Patients who present initially with uncomplicated influenza may progress to more severe disease. Progression can be rapid.
Indicators include respiratory, CNS deterioration or indicators of severe dehydration, hypotension
i.e. meet criteria for sepsis, SIRS, MODS
Slide22Preventing bacterial pneumonia
Pneumovax is now indicated for all asthmatics and current smokers age 19 and upBe aware of MRSA/ MSSA necrotizing pneumonia following or concurrent with influenzaPresents with severe pleuritic chest pain, purulent bloody sputum, toxic patients
Slide23Slide24Neuro
manifestations of influenza in adults-per Dr. Larry DavisMost common is severe headache, fever, and meningismus mimicking an acute meningitis. However, the CSF is normal with no cells. It is self limited. Myalgias of the posterior neck muscles simulate the meningismus.
Second most common is pt with high fever, headache, myalgias, and confusion
looking like an acute encephalopathy. MRI is normal. Self limited, improves quickly
The third most common is seizures
. Any high fever can trigger a seizure and influenza can. In those from Mexico, consider underlying neurocysticercosis.
Uncommon but does occur are patients with Reye’s syndrome
Another group is the influenza ADEM
where the encephalopathy has focal neurologic signs, and the MRI shows patchy white matter lesions.
Finally is the influenza patient with focal myositis.
The muscle is painful and biopsies have shown actual fiber necrosis and inflammation. CPK is elevated
Slide25H1N1 2009 influenza virus during pregnancy in the USA-Lancet online July 29, 2009
From April 15-May 18, 2009, 34 confirmed or probable cases of H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) were admitted to hospital.
Rate of admission was 0.32 per 100,000 pregnant women at risk
vs
0.076 per 100,000 general population
6 of 45 deaths from April 15 to June 16 were in pregnant women. As more deaths accrued over the following week, this ratio dropped to 7 out of 87 deaths.
Slide26Recent case at UNM
21 year old woman with only PMHx recent pregnancy and C-section-not within last month4 days of coryza, cough and fever
Presented to another ED
hypotensive
and hypoxemic
Intubated
, flown to UNMH.
Died after 11 days in ICU with refractory ARDS
Slide27Emerging complications
Pulmonary embolisms in non-hospitalized and hospitalized patientsRespiratory decompensation in ventilated patients due to plugging with bloody mucus
Myositis
Slide28Figure 3. Distribution of Guillain-Barre syndrome episodes in 90-day intervals around the date of influenza-like illness, UK 1990-2005. Stowe et al. Am J Epidemiol 2009; 169: 382-8
Influenza
causes GBS
Slide29Testing/surveillance
As disease activity increases, it is 30-70% likely that influenza-like illness (i.e. fever plus sore throat and/or cough) is influenza-more sensitive the younger the patient is.
Influenza H1N1 is almost 100% of circulating strains
Testing should be limited to hospitalized patients
Specific PCR testing for “H1N1” will be performed at state lab on admitted patients for epidemiologic purposes
Slide30Exact mechanics of testing still to be decided
Currently Tricore forwards all positives to SLD for PCR-requires extensive form to be filled outState now wants all negative swabs also-will match to admission list for respiratory diseases (?)
No feedback loop to infection control on previously unidentified cases (rapid
neg
, PCR positive)-these are called to provider/patient
Tricore
now validating independent PCR with SLD
Slide31Test all patients admitted with or developing while in hospital…
NMDOH : All hospitalized patients meeting any of the following criteria are considered by NMDOH to be possible influenza cases and should have a specimen sent to SLD for influenza PCR testing, regardless of whether other influenza testing has been ordered (e.g., a rapid influenza diagnostic test):
*Influenza or rule-out influenza
*Influenza-like illness (i.e., fever 100º degrees Fahrenheit or higher, and cough, and/or sore throat)
*Pneumonia or rule-out pneumonia
*
Bronchiolitis
*Exacerbation of underlying pulmonary disease (e.g., asthma, cystic fibrosis, COPD)
*Fever of unknown origin
*Cough
*
Dyspnea
/shortness of breath/respiratory distress
*CHF, or CHF exacerbation, associated with fever or with unclear etiology
Added by SK_ARDS, respiratory failure
*Any of the following testing/treatment events:
*Any influenza test ordered on an inpatient
*Any influenza antiviral medication/s {e.g.,
Tamiflu
(
oseltamavir
),
Relenza
(
zanamavir
),
Symmetrel
(
amantadine
),
Flumadine
(
rimantadine
)} ordered for an inpatient
Slide32Oseltamivir
New Mexico has 350,000 coursesEnough to treat 1/3 to 1/2 of those who might become illPrioritize those admitted to hospital with severe/complicated influenzaPersons at high risk of complications of influenza-young children, pregnant women and those with underlying conditions
Prophylax persons at high risk post-exposure
Slide33WHO classification
Uncomplicated influenza – Influenza‐like illness symptoms: fever, cough, sore throat, rhinorrhea, headache, muscle pain, malaise, but no shortness of breath, no dyspnoea. Patients may present with some or all of these symptoms. – Gastrointestinal illness may also be present, such as diarrhoea and/or vomiting, especially in children, but without evidence of dehydration.
Slide34Signs and symptoms of progressive disease
Patients who present initially with uncomplicated influenza may progress to more severe disease. Progression can be rapid.
Indicators include respiratory, CNS deterioration or indicators of severe dehydration, hypotension
i.e. meet criteria for sepsis, SIRS, MODS
Slide35Treatment
Treat serious /hospitalized cases immediatelyOseltamivir can significantly reduce the risk of pneumonia (a leading cause of death for both pandemic and seasonal influenza) and the need for hospitalization. (usual dose 75mg
po
bid for 5 days, reduce by 50% for
creatinine
clearance under 30ml/min)
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.
Patients with underlying medical conditions that increase the risk of more severe disease, should also receive treatment as soon as possible after symptom onset, without waiting for the results of laboratory tests.
Children under4
Pregnant women or those in the immediate post-partum period
All patients with underlying conditions
ALSO PROPHYLAX THIS GROUP AND EXPOSED HCWs
Prophylaxis dose –
oseltamivir
75mg
po
qd
for 10 d
Slide36Treatment in severe disease
In ventilated patients, some clinicians have used double dose oseltamivir 150mg po bid Based on H5N1 experience and fear that diarrhea will interfere with absorption
Duration of treatment can be longer-no data in severely ill patients
Investigational drug:
peramivir
-Dr.
Goade
is PI,
Intravenous neuraminidase inhibitor, final criteria for study pending, open label
Slide37Employee health
Employees with influenza-like illness must call supervisor and stay off work for either 7 days or 24 hours afebrile off all antipyretics, whichever is longerDoctor’s note will not be requiredVacation time will not be taken
Treatment will be dispensed to employees at higher risk of complications-send in family with your ID.
Lobocare clinic will be site of care for sick UNM employees and referral site for UH employees
No work restrictions are advised for employees at higher risk e.g. pregnant workers
Slide38Infection control-see WHO checklist
HICPAC recommendations:
Standard and droplet (surgical mask) precautions will be used.
N95 masks will be reserved for the following aerosol-generating procedures on patients with ILI:
Intubation/
extubation
CPR with emergency intubation and/or chest compressions
Open suction
Bronchoscopy
Slide39Infection control in 1918
Basic respiratory hygiene and droplet precaution measures“None of my classmates died and very few became ill. Perhaps the masks, gowns and handwashing did more to protect us than we had a right to expect. Certainly, with death all around us, we had every encouragement to be as careful as we could, but we were so busy and so tired that we forgot about precautions, and patient after patient coughed into our faces as we tended to their needs.”
Starr. Influenza in 1918: recollections of the epidemic in Philadelphia. Ann Intern Med 2006: 145:138-40.
Slide40Visitors: Some restrictions apply
Before entering the room:
Hand Hygiene
Don Surgical Mask
Don
Gown, Gloves and Eye Protection
depending on task and risk of exposure to body fluids
Expanded Precautions indicated for aerosol generating procedures – turn sign over
On exit from room:
Remove and Discard PPE
Hand Hygiene
Disinfect all shared equipment.
Droplet Precautions
Please see a nurse for instructions before entering the room.
Surgical
mask required with hand hygiene on entry and exit. Protective equipment is not available for children <12 years.
Alternatives: Cone-style surgical mask or ear-loop procedure mask
(N-95 respirators are NOT required)
Slide41Aerosol Generating
Procedure in Progress
Use Expanded Precautions:
Visitors are restricted for 1 hour
Essential Healthcare Workers ONLY
Don N-95 Respirator Mask or PAPR
Don Gown, Gloves and Eye Protection
Keep Door Closed
(Negative Pressure Room preferred)
On exit from room:
Remove and Discard PPE
Hand Hygiene
Disinfect all shared equipment.
Discontinue Expanded Precautions
1 hour after aerosol generating procedure is completed
Slide42Other measures
Restriction of visitationScreening of all visitorsImmunization of healthcare workers-walk-in starting October 8.One seasonal, one (?) pandemic injection
Slide43Emergency coordination
UNM, UNMHSC and VA have all activated their emergency operations centersFrees up resources and communication to create greater flexibility and responsiveness
Homeland Security will be running Joint Information Center for State to coordinate all public and healthcare communication
Slide44Surge capacity/limitations to services
Early on, employee and employee family illness may be major cause of absenteeism and interfere with usual delivery of careVA/UNM are prepared to open alternate site of care near ED to render care to overflow ILI patients and if necessary, employees
Supervisors/division chiefs need to consider continuation of operations plans with significant staff absenteeism
Slide45Other critical infrastructure
Ethics training at state and facility level for allocation of scarce resourcesECMOVentsDaily reporting of all beds, oseltamivir, masks etc now
being monitored by DOH
Slide46Essential resources
www.flu.gov link from CDC-patient education, personal preparedness
CDC website
www.cdc.gov
, current
recs
NMDOH website, DOH symposium Oct 2-at UNM CE
Free materials on
www.idsociety.org
www.nejm.com
,
www.thelancet.com