AMA -- H1N1 CrRapidly; Predominantly Affects Young Patientsitical Illness Can Occur

[David Farber <dave () farber net>]

Begin forwarded message:

From: "Kevin Gainer" <kgainer () columbus rr com>
Date: October 12, 2009 10:25:25 AM EDT
To: <dave () farber net>, <munsup.seoh () wright edu>
Subject: Distribute to your entire address book so people can protect  
themselves

last several days, we are starting to get an avalanche of medical  
journal articles documenting early experience with the virus. below  
are just a couple from this morning and the news is very bad.

this is a very, very serious situation. the epidemiology does have  
some marked differences compared to "regular" flu including marked  
attack on lung tissue and resulting oxygen deprivation. this is  
detailed in stories below.

the bottom line is deaths in young ARE ALREADY AT ABOUT THE LEVEL SEEN  
IN LAST SEASON FOR ENTIRE YOUNG COHORT AND SEASON HASN'T EVEN STARTED  
YET.

if the vaccine becomes available make sure you get it and particularly  
any youth you know.




H1N1 Critical Illness Can Occur Rapidly; Predominantly Affects Young  
Patients

Source: American Medical Association (AMA)

Newswise — Critical illness among Canadian patients with 2009  
influenza A(H1N1) occurred rapidly after hospital admission, often in  
young adults, and was associated with severely low levels of oxygen in  
the blood, multi-system organ failure, a need for prolonged mechanical  
ventilation, and frequent use of rescue therapies, according to a  
study to appear in the November 4 issue of JAMA. This study is being  
published early online to coincide with its presentation at a meeting  
of the European Society of Intensive Care Medicine.


Infection with the 2009 influenza A(H1N1) virus has been reported in  
virtually every country in the world. The World Health Organization  
declared the first phase six (phase indicating widespread human  
infection) global influenza pandemic of the century on June 11, 2009.  
The largest number of confirmed cases occurred in North America  
between March and July 2009, according to background information in  
the article.


Anand Kumar, M.D., of the Health Sciences Centre and St. Boniface  
Hospital, Winnipeg, Manitoba, Canada, and colleagues with the Canadian  
Critical Care Trials Group H1N1 Collaborative conducted an  
observational study of critically ill patients with 2009 influenza A 
(H1N1) in 38 adult and pediatric intensive care units (ICUs) in Canada  
between April 16 and August 12, 2009. The study focused on the death  
rate at 28 and 90 days, as well as the frequency and duration of  
mechanical ventilation and the duration of ICU stay.


The researchers found that a total of 168 patients had confirmed or  
probable 2009 influenza A(H1N1) infection and became critically ill  
during this time period, and 24 (14.3 percent) died within the first  
28 days from the onset of critical illness. Five more patients died  
within 90 days. The average age of the patients with confirmed or  
probable 2009 influenza A(H1N1) was 32.3 years, 113 were female (67.3  
percent), and 50 were children (29.8 percent).


“Our data suggest that severe disease and mortality in the current  
outbreak is concentrated in relatively healthy adolescents and adults  
between the ages of 10 and 60 years, a pattern reminiscent of the W- 
shaped curve [rise and fall in the population mortality rate for the  
disease, corresponding to age at death] previously seen only during  
the 1918 H1N1 Spanish pandemic,” the authors write.


Patients with 2009 influenza A(H1N1) infection-related critical  
illness experienced symptoms for a median (midpoint) of four days  
before entering the hospital, but worsened rapidly and required care  
in the ICU within one or two days. Shock and multi-system organ  
failure were common, and 136 patients (81 percent) received mechanical  
ventilation, with the median duration being 12 days. The average ICU  
stay was 12 days. Lung rescue therapies included neuromuscular  
blockade, inhaled nitric oxide and high-frequency oscillatory  
ventilation.


“In conclusion, we have demonstrated that 2009 influenza A(H1N1)  
infection-related critical illness predominantly affects young  
patients with few major comorbidities and is associated with severe  
hypoxemic respiratory failure, often requiring prolonged mechanical  
ventilation and rescue therapies,” the authors write. “With such  
therapy, we found that most patients can be supported through their  
critical illness.”

(JAMA. 2009;302(17):doi:10.1001/jama.2009.1496). Available pre-embargo  
to the media at www.jamamedia.org)


Editor’s Note: Please see the article for additional information,  
including other authors, author contributions and affiliations,  
financial disclosures, funding and support, etc.


Editorial: Preparing for the Sickest Patients With 2009 Influenza A 
(H1N1)


In an accompanying editorial, Douglas B. White, M.D., M.A.S., and JAMA  
Contributing Editor Derek C. Angus, M.D., M.P.H., of the University of  
Pittsburgh School of Medicine, write that many U.S. hospitals may not  
have adequate numbers of physicians or staffing structures to  
facilitate timely treatment of the most seriously ill patients with  
2009 influenza A(H1N1).


“Hospitals must develop explicit policies to equitably determine who  
will and will not receive life support should absolute scarcity  
occur,” they write. “Any deaths from 2009 influenza A(H1N1) will be  
regrettable, but those that result from insufficient planning and  
inadequate preparation will be especially tragic,” they conclude.

(JAMA. 2009;302(17):doi:10.1001/jama.2009.1539). Available pre-embargo  
to the media at www.jamamedia.org)


Editor’s Note: Please see the article for additional information,  
including financial disclosures, funding and support, etc.


Critical Illness From 2009 H1N1 in Mexico Associated With High  
Fatality Rate

Source: American Medical Association (AMA)

Newswise — Critical illness from 2009 influenza A(H1N1) in Mexico  
occurred among young patients, was associated with severe acute  
respiratory distress syndrome and shock, and had a fatality rate of  
about 40 percent, according to a study to appear in the November 4  
issue of JAMA. This study is being published early online to coincide  
with its presentation at a meeting of the European Society of  
Intensive Care Medicine.


Novel 2009 influenza A(H1N1) was first reported in the southwestern  
United States and Mexico in March 2009. Between March 18 and June 1,  
2009, 5,029 cases and 97 documented deaths occurred in Mexico. The  
population and health care system in Mexico City experienced the first  
and greatest early burden of critical illness, according to background  
information in the article.


Guillermo Domínguez-Cherit, M.D. of Instituto Nacional de Ciencias  
Médicas y Nutrición “Salvador Zubirán,” Mexico City, and colleagues  
conducted an observational study of critically ill patients at six  
hospitals in Mexico that treated the majority of such patients with  
confirmed, probable, or suspected 2009 influenza A(H1N1) between March  
24 and June 1, 2009. The study focused on the death rate, rate of  
critical illness and mechanical ventilation, and length of stay in the  
hospital and the intensive care unit.


Among 899 patients admitted to hospitals with confirmed, probable, or  
suspected 2009 influenza A(H1N1), 58 became critically ill. The  
critically ill patients had a median (midpoint) age of 44 years. Most  
were treated with antibiotics, and 45 patients were treated with anti- 
influenza drugs known as neuraminidase inhibitors, including  
oseltamivir and zanamivir. Fifty-four patients required mechanical  
ventilation.


“Our analysis of critically ill patients with 2009 influenza A(H1N1)  
reveals that this disease affected a young patient group,” the authors  
write. “Fever and respiratory symptoms were harbingers of disease in  
almost all cases. There was a relatively long period of illness prior  
to presentation to the hospital, followed by a short period of acute  
and severe respiratory deterioration.”


By 60 days, 24 of the critically ill patients (41.4 percent) died.  
Nineteen patients died within the first two weeks after becoming  
critically ill.


“Patients who died had greater initial severity of illness, worse  
hypoxemia [abnormally low levels of oxygen in the blood], higher  
creatinine kinase levels, higher creatinine levels, and ongoing organ  
dysfunction,” the authors report.


“Early recognition of disease by the consistent symptoms of fever and  
a respiratory illness during times of outbreak, with prompt medical  
attention including neuraminidase inhibitors and aggressive support of  
oxygenation failure and subsequent organ dysfunction, may provide  
opportunities to mitigate the progression of illness and mortality  
observed in Mexico,” they conclude.

(JAMA. 2009;302(17):doi:10.1001/jama.2009.1536). Available pre-embargo  
to the media at www.jamamedia.org)


Editor’s Note: Please see the article for additional information,  
including other authors, author contributions and affiliations,  
financial disclosures, funding and support, etc.

Most H1N1 Patients With Respiratory Failure Treated With Oxygenating  
System Survive Illness

Source: American Medical Association (AMA)

Newswise — Despite the severity of disease and the intensity of  
treatment, most patients in Australia and New Zealand who experienced  
respiratory failure as a result of 2009 influenza A(H1N1) and were  
treated with a system that adds oxygen to the patient’s blood survived  
the disease, according to a study to appear in the November 4 issue of  
JAMA. This study is being published early online because of its public  
health importance.


The influenza A(H1N1) pandemic affected Australia and New Zealand  
during the 2009 southern hemisphere winter, causing an epidemic of  
critical illness. Some patients developed severe acute respiratory  
distress syndrome (ARDS) and were treated with extracorporeal membrane  
oxygenation (ECMO), according to background information in the article.


ARDS is a lung condition that leads to respiratory failure due to the  
rapid accumulation of fluid in the lungs. ECMO is a type of life  
support that circulates blood through a system that adds oxygen. ECMO  
was used for the patients in this study because they developed very  
low blood oxygen levels that developed rapidly despite standard  
ventilator (or respirator) settings. ECMO is generally used for a  
limited time because of the risks of bleeding, clotting, infection,  
and organ failure.


The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ  
ECMO) Influenza Investigators in collaboration with the Australian and  
New Zealand Intensive Care Research Centre at Monash University in  
Melbourne, conducted an observational study of patients with 2009  
influenza A(H1N1)-associated ARDS treated with ECMO in 15 intensive  
care units (ICUs) in Australia and New Zealand between June 1 and  
August 31, 2009. The researchers looked at incidence, clinical  
features, the degree of lung dysfunction, technical characteristics,  
the duration of ECMO, complications, and survival.


The study found that 68 patients with severe influenza-associated ARDS  
were treated with ECMO, including 53 with confirmed 2009 influenza A 
(H1N1). An additional 133 patients with influenza A received  
mechanical ventilation, but not ECMO, in the same ICUs. The 68  
patients who received ECMO had a median (midpoint) age of 34.4 years  
and half were men.


“Affected patients were often young adults, pregnant or postpartum,  
obese, had severe respiratory failure before ECMO, and received  
prolonged mechanical ventilation and ECMO support,” the authors write.


The median duration of ECMO support was ten days. At the time of  
reporting, 54 of the 68 patients had survived and 14 (21 percent) had  
died. Six patients remained in ICU, including two who were still  
receiving ECMO. Sixteen patients were still hospitalized, but out of  
ICU, and 32 had been discharged from the hospital.


“Despite their illness severity and the prolonged use of life support,  
most of these patients survived,” the authors conclude. “This  
information should facilitate health care planning and clinical  
management for these complex patients during the ongoing pandemic.”

(JAMA. 2009;302(17):doi:10.1001/JAMA.2009.1535. Available pre-embargo  
to the media at www.jamamedia.org)


Editor’s Note: Please see the article for additional information,  
including other authors, author contributions and affiliations,  
financial disclosures, funding and support, etc.


H1n1 Flu Sweeping U.S.: Ut Health Science Center at Houston Experts  
Available

Source: University of Texas Health Science Center at Houston

Newswise — Waiting rooms are full, physician phone lines are  
overwhelmed and questions are running rampant as federal health  
officials say the H1N1 flu virus is spreading quickly.

"Emergency departments are experiencing increasing patient loads as  
the epidemic progresses. Fortunately, most patients are not seriously  
ill, though many certainly feel terrible,” said Brent King, M.D.,  
professor and chair of the Department of Emergency Medicine at The  
University of Texas Medical School at Houston. “But, unfortunately,  
there is little we can do for these patients that they cannot do for  
themselves. Resting, maintaining hydration and judiciously using  
medications to treat fever are the mainstays of managing influenza.”

However, King added that a very small number of people have developed  
serious respiratory symptoms in association with H1N1 influenza.  
“People who are concerned that they might be seriously ill should  
contact their personal physician and follow her or his advice  
regarding further treatment. As always, emergency physicians are  
available to evaluate and treat those who are very concerned about  
their symptoms,” King said.

Pediatric neurologists at the UT Medical School at Houston say they  
expect possible neurological complications, including seizures, from  
the virus and clinicians should look for H1N1-associated  
encephalopathy in children. “We expect to see the same problems with  
H1N1 that we do with seasonal flu. We’re telling our residents to look  
for meningitis, encephalitis, myositis and peripheral neuritis,” said  
Ian Butler, M.D., professor and chief of the Division of Child  
Neurology at the medical school.

Health officials are encouraging pregnant women—at any point in their  
pregnancy—to be vaccinated for the seasonal flu and the H1N1  
influenza. “The seasonal influenza vaccine is already available, so  
pregnant women should receive it now. The H1N1 vaccine can be given as  
soon as it is available in your community,” said Pamela Berens, M.D.,  
associate professor of obstetrics and gynecology at the UT Medical  
School at Houston. “If the expectant mother has not yet been  
vaccinated, both vaccines can actually be given the same day but  
should be given in different sites. The vaccine should also be given  
to women who have recently delivered to reduce their chance of  
becoming ill and possibly passing the illness on to their young child.”

Berens said changes during pregnancy may result in more severe  
complications for pregnant women than for other groups. “During  
pregnancy there is an increase in your heart rate and the amount of  
blood that your heart pumps. There is also an increased consumption of  
oxygen and your lungs may not expand as well due to the increasing  
size of the uterus and baby. Changes in your body's ability to respond  
to infection also occur. All of these changes together likely play a  
role in the risk of influenza in pregnancy,” Berens said. “Any  
pregnant women who suspects that she has influenza symptoms should  
contact her OB to discuss possible treatment and should notify them if  
they experience any difficulty with breathing.”

Robert Emery, Dr.PH, associate professor of occupational health at The  
University of Texas School of Public Health, says prevention needs to  
be the main focus. “Although there is a lot of attention being focused  
on shots for the seasonal and H1N1 flu, individuals and businesses  
need to remember the power of prevention and adhere to the basic  
practices of frequent hand washing and cough control to help prevent  
the spread of the virus,” Emery said.

Experts who are available for interviews to discuss H1N1 flu include:

•Brent King, M.D., can provide information about H1N1 flu, hospital  
plans for responding to this infectious disease and how to best  
protect children. He is chairman of the Department of Emergency  
Medicine at The University of Texas Medical School at Houston and  
provides emergency medical care to both children and adults at  
Memorial Hermann-Texas Medical Center, Children's Memorial Hermann  
Hospital and Lyndon B. Johnson General Hospital.

•Richard N. Bradley, M.D., chief of the Division of EMS and Disaster  
Medicine at The University of Texas Medical School at Houston, can  
discuss how Americans and emergency departments are being affected.

•Pamela Berens, M.D., associate of obstetrics and gynecology at The  
University of Texas Medical School at Houston, can answer questions  
about concerns facing women who are pregnant. She is able to discuss  
questions about the vaccine and what pregnant women should do if they  
think they are infected.

•Ian Butler, M.D., professor and chief of the Division of Child  
Neurology at The University of Texas Medical School at Houston, can  
discuss neurological complications in children that can result from  
H1N1 and seasonal flu.

•Galit Holzmann-Pazgal, M.D, assistant professor of pediatrics in the  
Division of Pediatric Infectious Disease at The University of Texas  
Medical School at Houston, is available for interviews to discuss  
prevention and treatment of the swine flu as it related to children.  
Holzmann-Pazgal is also medical director of infection control for  
Children’s Memorial Hermann Hospital.

•Gloria Heresi, M.D, professor and interim director of the Division of  
Pediatric Infectious Disease at The University of Texas Medical School  
at Houston, is available for interviews with Spanish-language media.  
She can discuss prevention and treatment of H1N1 as it relates to  
children.

•Richard Castriotta, M.D., professor and director of the Division of  
Pulmonary, Critical Care and Sleep Medicine at The University of Texas  
Medical School at Houston, can discuss the flu's leading causes of  
death, which are respiratory failure and/or pneumonia. Castriotta sees  
patients at Memorial Hermann-Texas Medical Center, Lyndon B. Johnson  
General Hospital and the UT Pulmonary Medicine clinic.

•John Halphen, M.D., assistant professor of medicine in the Division  
of Geriatric and Palliative Medicine at The University of Texas  
Medical School at Houston, can discuss how flu-like illnesses affect  
the elderly, including the danger of dehydration, the risk of  
secondary bacterial infections and potential complications for  
patients who may be on medications such as diuretics. He coordinates  
geriatric services at Lyndon B. Johnson General Hospital, part of the  
Harris County Hospital District.

•Robert Emery, Dr.PH, vice president of safety, health, environment  
and risk management at The University of Texas Health Science Center  
at Houston, is available to discuss flu prevention, as well as  
protective equipment for health care professionals. Emery, who has a  
faculty appointment at The University of Texas School of Public  
Health, also can discuss emergency preparedness and business  
continuity plans in coordination with the U.S. Centers for Disease  
Control and Prevention and the World Health Organization.

•George Delclos, M.D. is a professor of occupational medicine at The  
University of Texas School of Public Health. Dr. Delclos is able to  
advise on H1N1 flu-related work life issues such as working from home  
if you feel ill or what employers should look for in their employees.

•Charles Ericsson, M.D., can discuss H1N1 flu and measures to protect  
yourself during travel. He is professor and head of clinical  
infectious disease at The University of Texas Medical School at  
Houston. He also is the director of the university's Travel Medicine  
clinic and sees patients at UT Physicians clinics, Lyndon B. Johnson  
General Hospital and Memorial Hermann-Texas Medical Center.

•Luis Z. Ostrosky, M.D., can discuss the infectious nature of H1N1 flu  
and can provide details on what patients can do to reduce their risk  
of becoming infected or spreading it to others. He is available for  
interviews in both English and Spanish. Ostrosky is associate  
professor of medicine and epidemiology in the Division of Infectious  
Diseases at The University of Texas Medical School at Houston. He also  
is medical director for epidemiology at Memorial Hermann-Texas Medical  
Center.

•Herbert DuPont, M.D. is a professor of infectious disease and  
director of the Center for Infectious Diseases at The University of  
Texas School of Public Health. With over 30 years of experience in  
infectious disease and travel medicine, DuPont can speak on the  
development of swine flu, symptoms, how to reduce the risk of becoming  
infected and how to keep yourself safe if you are traveling.

•Susan P. Fisher-Hoch, M.D. is a professor of epidemiology at The  
University of Texas School of Public Health Brownsville Regional  
Campus. Fisher-Hoch is one of the world's leading virologists. She is  
able to discuss any topic related to the H1N1 flu.

•Kristy Murray, D.V.M, Ph.D., a former Epidemic Intelligence Service  
Officer for the Centers for Disease Control and Prevention, is  
assistant professor of epidemiology at The University of Texas School  
of Public Health. She is able to discuss transmission of the virus  
from animal to human and how to reduce your risk of becoming infected  
or spreading it to others.

•John Herbold, D.V.M, Ph.D., is associate professor of epidemiology  
and director of the Center for Biosecurity and Public Health  
Preparedness at The University of Texas School of Public Health San  
Antonio Regional Campus. As a veterinarian, Herbold can discuss the  
origin of influenza viruses in humans and the role of animals in a flu  
outbreak. He can also discuss why H1N1 flu passed from human to human  
unlike the bird/avian flu. In addition, Herbold can address the  
importance of clinicians, veterinarians and public health workers  
joining together to stabilize and fight the outbreak.

•C. Ed Hsu, Ph.D., MPH, is associate professor of public health  
informatics at The University of Texas School of Health Information  
Sciences at Houston and associate director of health informatics at  
the Center for Biosecurity and Public Health Preparedness at The  
University of Texas School of Public Health. In Hsu's Preventive  
Health Informatics and Spatial Analysis laboratory, he is using public  
health informatics to address critical public health challenges,  
including global health surveillance and emergency preparedness.

•Elda Ramirez, Ph.D., RN, is available to do interviews in both  
English and Spanish. She can describe symptoms of H1N1 flu and discuss  
when it is appropriate to consult a primary care provider or seek  
medical attention at an emergency room. Ramirez is assistant professor  
in The University of Texas Health Science Center at Houston School of  
Nursing and emergency medicine nurse practitioner in The University of  
Texas Medical School at Houston.

•Susan Parnell, RN, a nursing instructor at The University of Texas  
Health Science Center at Houston School of Nursing, is available to  
discuss infection control and explain how cases of influenza or other  
outbreaks are investigated.

•Victor Cardenas, M.D., Ph.D., is an associate professor of  
epidemiology at The University of Texas School of Public Health El  
Paso Regional Campus. He is able to discuss first-hand experience in  
influenza A outbreaks in several countries, including Mexico and  
Colombia.





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