PANDEMIC INFLUENZA TYPE A H1N1

FACTS FOR CONSIDERATION: PANDEMIC IS NOT THE YEARLY SEASONAL INFLUENZA

BY CAROL WARE DUFF MSN, BA, RN

History of H1N1 Influenza

Viruses use the human cell to reproduce.  A virus has no nucleus and cannot reproduce on its own.  If human cells recognize a virus as an attack of something harmful, the human body will not let the virus invade cells.  This is called immunization and is what vaccines are designed to do.  Without immunization the body does not have the tools to halt the invasion of the virus.

     The H1N1 Influenza virus has had a long history since first being identified in 1918 during what was known as the Spanish influenza pandemic which infected one third of the world’s population of 500 million people.  Roughly 50 million people died during this viral outbreak.  Not until the 1930s were the linked influenza viruses (now known as H1N1 viruses) isolated from pigs and then humans.   

In 1976, an outbreak of influenza occurred at Fort Dix in New Jersey and  affected 200, some severely, with one death of a soldier who experienced feeling tired and weak and was dead the next day. Others during this outbreak were seriously ill.  

The dread of another pandemic influenza outbreak led to a U.S. national campaign to attempt to immunize almost the entire population.  40,000, 000 people received the A/New Jersey/1976/H1N1 vaccine also called the swine flu vaccine.  During this vaccination blitz a strong association developed between the vaccine and Guillain-Barre Syndrome (GBS) (disorder of myelin surrounding nerves, which can cause varying levels of paralysis of the body up to and including difficulty/inability to use muscles required for  breathing).  Five hundred cases were reported with 24 deaths due to complications with the lungs. 

Intense investigation has gone into why GBS occurred after some vaccinations and it is found that the 1976, 1991-1992, and 2004-2005 influenza vaccinations produced antibodies to antiganglioside (anti-GM1).  Further research has tried to discover the connection. An interesting note is that GBS often occurs after viral or bacterial infections.   

There were 12 cases of swine influenza reported in the United States from 2005 till January 2009 with none causing a death.  In 1988 a 32 year old previously healthy female died of pneumonia which is a complication of swine influenza.  

Previously humans have become infected by close contact with infected pigs but the current virus is a novel influenza A (H1N1) virus which has not been previously identified in humans and appears to spread only by human to human contact. 

On March 18, 2009 the first illness (H1N1 influenza A) was reported in Mexico and continued to spread. By May 5, almost 600 more H1N1 influenza cases were confirmed in Mexico and 25 of these people died. Two children were diagnosed in April of 2009 in neighboring counties in southern California with swine influenza A (H1N1), and by April 26th the U.S. Department of Health and Human Services declared a national public health emergency involving H1N1 influenza A.

As of the writing of this article the Center for Disease Control (CDC) states that 37 out of 54 jurisdictions ( includes all 50 states, the District of Columbia, Guam, Puerto Rico, and U.S. Virgin Islands) have reported regional or widespread influenza activity.   There have been 46,329 cases of H1N1 2009 A cases reported with 119 unfluenza related pediatric deaths.    

Between August 30 and September 19 of this year the CDC has noted that  there have been 10,082 hospitalizations and 936 deaths related to influenza syndromes and pneumonia. The annual 2009-2010 Flu season does not even start until October 4, here in the northern hemisphere.  Seasonal (usual yearly influenza vaccines) influenza inoculations offer no protection against the Pandemic H1N1 2009 A.  

According to the World Health Organization (WHO), between April and August of 2009 there were 35,585 reported positive cases of the pandemic flu worldwide.   Do note that not all countries keep accurate records or report in a timely fashion when they have pandemic flu cases.  As of September 1, WHO has reported that there have been over 200,000 confirmed cases in more than 100 countries and at least 2,185 confirmed deaths.

The seasonal (yearly) flu vaccines produce little to no protection against the 2009 H1N1pandmenic virus.  People under 30 have little/no protection from 2009 H1N1 virus but there is evidence that vaccination in 1976 boosted cross-reactive antibodies to the 2009 H1N1 virus.    

Four manufacturers are supplying the flu vaccine.  The monovalent inactivated, H1N1 influenza type A vaccine is either delivered by injection into the muscle or through inhaling into the nasal mucosa (live virus).  Both deliveries of the vaccine stimulate active immunity to influenza virus infection by inducing production of specific antibodies. Immunity occurs 10 days from the day of inoculation. 

The main route for the influenza to move from person to person is through large droplets from coughs and sneezing.  The droplets can travel up to six feet or more and are deposited on the mucous membranes, usually the mouth and nose.  Also contamination can be moved by hands touching areas where the virus has been deposited and then placing hands near the mouth or nose. Cover a sneeze or cough, to decrease droplet transfer.  Visit by phone, not in person when one may have a virus.  

Someone who has H1N1 pandemic influenza can pass the illness to others from one day before symptoms show to seven days after the onset of symptoms. The illness will often last between 4 and six days.  Your healthcare provider may determine that you need to take an antiviral agent (discussed later) and this should be done within 48 hours of onset of symptoms.  

Symptoms of the pandemic flu are similar, but usually more severe than seasonal influenza and may include:

• Sudden onset of fever (usually high)
• Cough
• Difficulty with breathing or chest pain
• Bluish coloration of lips, nails
• Confusion
• Sore throat
• Body aches
• Headache
• Chills
• Fatigue
• Possible diarrhea and vomiting.
• Seizures

   Children may have signs of severe disease such as:

• Periods of not breathing
• Rapid breathing
• Turning blue
• Dehydration (urinating less due to lack of liquids)
• Change in mental status (sleepy or excessively irritable)  

Treatment

• Go to bed
•  Increase intake of fluids
• Take antipyretics (Ibuprophen, acetaminophen, non-steroidal anti-inflammatory drugs) to bring down fever, and analgesics (same as list to bring down fever) for aches. Never give asprin or asprin-containing products to children under 18 years because there is a chance of the child getting Reye Syndrome (acute noninflammatory encephalopathy and liver failure). 

Your healthcare provider might place you on an antiviral for prevention or treatment. Intravenous fluids may be needed.  IF YOU ARE HAVING TROUBLE BREATHING, THIS IS AN EMERGENCY AND YOU NEED TO CONTACT YOUR HEALTHCARE PROVIDER IMMEDIATELY. 

Stay home if you are ill until your flu symptoms are gone, avoid being near someone who is sick, wash your hands with soap often, do not touch your face, eyes, nose, or mouth.  Contact your healthcare provider by phone or email to report the illness.  He or she will decide if you need to come to the office or hospital to be checked if you are not following the normal course of getting better. Remember, wherever you go you can spread the virus.

Those who take care of a family member with the flu should:

•  Wash his or her hands frequently with soap and water, use the alcohol-based (at least 60% alcohol) hand sanitizing gels (not as effective as soap and water) when soap and water are not readily available.
• Minimize their contact with the outside world, and it might be best to designate one caregiver for the patient to decrease the chance of spread within the family.
• If face masks are available, the person with the flu should wear one whenever an unaffected person is nearer than six feet from them. 
• Do not attend large gatherings if the H1N1 has been diagnosed in the area. People who have chronic medical conditions such as asthma should avoid large gatherings.   

The physical condition of a person, before getting the flu, is important. In June of 2009, the University of Michigan reported severe complications for 10 patients, average age of 49, who were obese and required ventilation to breath after suffering severe lack of oxygen and adult respiratory distress syndrome (ARDS).  All had pneumonia, some with bacterial pneumonia, and four had pulmonary embolisms (blood clots in lungs).  In general these patients did not do well, with some dying, but to be noted here is that all had the same factor of being obese. 

Most people who get this influenza are able to recover without antiviral (these drugs decrease the release of virus from the infected cells and decrease the spread of the virus) medications.  People with more severe symptoms or who are already ill with another illness may need antiviral medications to help their bodies fight the virus. 

Early treatment with an antiviral may be considered for those who are at higher risk for complications.  These groups are children younger than 2, people who are 65 or older, pregnant women (women who are pregnant or think they might be pregnant should consult their obstetrician or healthcare provider regarding recommended treatment), people with some chronic medical or immunosuppressive conditions, and people under 19 who receive long term aspirin therapy. 

Laboratory testing has found that the H1N1 influenza A (swine flu) virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir, and the CDC maintains weekly status to make sure these antiviral drugs are still working against the H1N1.  If it is noted that oseltamivir-resistant seasonal H1N1 viruses become more common or are identified in community outbreaks, zanamivir or a combination of oseltamivir and rimantadine or amantadine should be considered for use for patients who might have oseltamivir-resistant influenza.   

On August 25, 2009, the President’s Council of Advisors predicted that the virus would infect up to one half of the U.S. population with hospitalizations of 1.8 million and deaths of between 30,000 and 90,000.  This council also estimated that 60-120 million will seek medical care and 300,000 would be hospitalized in intensive care units (ICU) which may fill all ICU beds in most hospitals. 

Australia and New Zealand, in the Southern Hemisphere, have just had their winter and experience with the H1N1 Influenza A. Medical records and observation of diseases of this area of the globe resemble those of the U.S., so it is expected that what happened there  is a good predictor of what the U.S. may expect during its upcoming flu season.

The numbers of influenza cases give a picture of how this influenza has created more visits to healthcare provider. In Australia/New Zealand the rate of 50 to 249 influenza illness per every 100,000 people per week is average for a normal flu season.  Rates greater than 400/100,000 equal epidemic levels.  The highest rate during this past flu season was 287 medical visits/100,000 for July 13-19, 2009 which is three times the peak rate of 95/100,000 seen in 2008. The northern hemisphere has now entered its prime time for influenza cases, although during the summer months there have been more cases diagnosed than are ever seen during the warmer months. 

Studies for safety are part of the ongoing trials and there is significant assumption of safety because the vaccine is created using methods equal to those which have been used for seasonal influenza for the past 40 years.  Current products do not contain thimerosal.  Two methods are used to monitor the safety of the vaccine.  The Vaccine Adverse Event Reporting System (VAERS) and the Vaccine Safety Data Link (VSD).   

Additional methodical monitoring is being conducted to detect development of Guillain-Barre syndrome due to experiences in 1976. Clinical trials to establish safety and efficacy began in the U.S. on August 7, 2009 and so far there are no “red flags”. (Steenhuysen J. So far, no “red flags” seen in H1N1 vaccine. Reuters. August 21, 2009.)

  REFERENCES

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Bresee J. CDC Podcasts: Swine Flu. Centers for Disease Control and Prevention. Available at http://www2a.cdc.gov/podcasts/player.asp?f=11226. Retrieved April 28, 2009.

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Centers for Disease Control and Prevention, 2009. Interim Guidance for Clinicians on the Prevention and Treatment of Swine-Origin Influenza Virus Infection in Young Children. Available at http://www.cdc.gov/swineflu/childrentreatment.htm. Retrieved October 1, 2009

Centers for Disease Control and Prevention, 2009. Interim Guidance on Antiviral Recommendations for Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection and Close Contacts. Available at http://www.cdc.gov/swineflu/recommendations.htm. Retrieved October 1, 2009

Centers for Disease Control and Prevention, 2009. Swine Flu – Vaccine Safety and Emergency Preparedness. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vaccinesafety/emergency/swineflu.htm. Retrieved October 1, 2009

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Carol Duff graduated from Nursing School at Riverside White Cross in Columbus, Ohio. She has a BA from Bowling Green University in History and Literature and a Masters of Science in Nursing as a Nurse Educator from the University of Toledo College of Nursing.

She has traveled extensively and has written on military history, veterans health issues and related subjects. She is the mother of several children and 10 cats and 1 guinea pig.

She can be reached via email at: Thehertz@aol.com

Carol Duff

Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master’s of Nursing Science Degree as an Educator.

She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen – one daughter-in-law; Katie – two granddaughters; Isabella Marianna and Zoe Olivia – and one grandson, Alexander Paul. She also shares her life with her husband Gordon Duff, many cats, and two rescues.

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