Public Health Update

David Kirschke, MDMedical Director / Health Officer

Northeast Tennessee Regional Health Office

Notice to Clinicians: Early Reports of pH1N1-Associated Illnesses for 2013-14 Influenza Season

• CDC Health Advisory: December 24, 2013• CDC has received a number of reports of severe

respiratory illness among young and middle-aged adults, many of whom were infected with influenza A (H1N1) pdm09 (pH1N1) virus

• Multiple pH1N1-associated hospitalizations, including many requiring intensive care unit (ICU) admission, and some fatalities have been reported

• If pH1N1 virus continues to circulate widely, illness that disproportionately affects young and middle-aged adults may occur

Influenza-associated Pediatric Death

• 12 year old female• No significant past medical history• Developed influenza-like illness 2 Jan 2014• Seen at urgent care 3 Jan 2014– Rapid influenza test negative

– Provider (NP) prescribed oseltamivir (Tamiflu)

Progression of Illness

• 5 Jan 2014 found collapsed on floor by mother

• Pronounced dead at hospital about 40 minutes later

• Viral panel positive for pH1N1• Autopsy revealed Staph aureus pneumonia

Vaccination History

• Patient had received influenza vaccination in past (2005, 2007, 2010, 2011)

• Did not receive influenza vaccination during 2013-2014 season– Pediatrician

– School-located vaccination

– Pharmacies

2012-13 vs 2013-14 Influenza Seasons

• Last season Influenza A H3N2 predominant– Greater overall hospitalizations and influenza-

related deaths

– Primarily among persons aged 65+ years

• This season Influenza A H1N1 predominant– Increased hospitalizations and deaths among

persons aged 18-64 years

– Moderate number of pediatrics deaths reported

Influenza Surveillance - EIP• 2013-2014 Influenza Season• Among all hospitalizations, 7,941 (92.6%) were associated with

influenza A– 97% were 2009 H1N1

• People 18-64 years accounted for approximately 60% of reported hospitalizations

• Most commonly reported underlying medical conditions among adults were obesity, metabolic disorders, cardiovascular disease, and chronic lung disease (excluding asthma)– ~12% of hospitalized adults had no identified underlying medical

conditions.

– ~43% of hospitalized children had no identified underlying medical conditions

http://gis.cdc.gov/GRASP/Fluview/PedFluDeath.html

Adult Influenza A H1N1 Death

• 41 year old male• Only past medical history GERD• Has never received influenza vaccine• 19 March 2014 developed fever, cough, sore

throat (influenza-like illness or ILI)• Wife and 2 children also ill with same

symptoms

Adult Influenza A H1N1 Death

• Urgent care initiated levofloxacin and ceftriaxone– Influenza test?

– No antivirals

• Admitted to hospital 23 March with respiratory distress– Rapid flu test negative

– Changed antibiotics

– No antivirals

Adult Influenza A H1N1 Death

• Department of Health consulted by IP• Concerned about severe respiratory illness of

unknown origin– Healthcare contact developed respiratory illness

• TDH advised that influenza likely– Antiviral therapy

– Appropriate testing

Adult Influenza A H1N1 Death

• Influenza A H1N1 eventually verified at state lab

• However, treatment was delayed• Patient died after prolonged hospital course• Wife was also hospitalized but recovered

Think Influenza!

Fever

Rapid Flu

Test?Sore Throat

CoughFlu Season

The Princess Bride

• Six-fingered man: “Do you think it might be [flu]?”

• Prince Humperdinck: “I always think everything might be [flu], which is why I'm still alive.”