Clinical profile and outcome of patients admitted with swine-origin Influenza A H1N1 virus infection at a tertiary care hospital in Western India

Background: Most of the studies on swine flu H1N1 have been done during the pandemic phase. There was a sudden upsurge in virus activity in 2015 at many centers in India. The present study was designed to assess the current status and pattern of H1N1 infection. The primary objective of this study is to study the clinical profile of patients admitted with Swine-origin influenza A (H1N1) virus infection and Secondary objective is to study the clinical outcome in terms of morbidity and mortality.Methods: This was a retrospective observational study done at a tertiary care centre from March 2015 to April 2016. All admitted and confirmed cases of H1N1 swine flu infection were studied for demographic details, co-existing medical conditions and clinical presentation. Data regarding the course of disease, complications, treatments and outcomes were recorded from the clinical record.Results: Common presenting symptoms were cough and fever (95%). Common findings were fever (62.5%), tachycardia, tachypnea and crepitation on auscultation (58.5%). Associated comorbidities were Diabetes mellitus (19.5%), Chronic kidney disease (17%), immunosuppression (9.8%). Consolidation was seen in nearly half of the patients on radiological imaging. Complications noted in our patients were pneumonia (45%), respiratory failure (31%) and ARDS (14.6%). Seventeen percent of patients required non-invasive and invasive mechanical ventilation. Around 25 percent of cases, required ICU admission while two patients died during the hospital stay.Conclusions: The study emphasizes and restates the morbidities caused by H1N1 swine influenza infection as nearly half of the patients in this study experienced severe illness and complications.

Clinical analysis of nephrotic syndrome combined with H1N1 influenza in 15 children / 临床儿科杂志

Objective To explore the clinical features of nephrotic syndrome combined with H1N1 influenza. Methods The clinical manifestations, laboratory and image examinations, treatment, and prognosis of nephrotic syndrome combined H1N1 influenza were retrospectively analyzed in 15 children with. Results All of 15 children with nephrotic syndrome met the diagnostic criteria of H1N1 influenza. The median age of all children was 4-year-8-month old (2-year-2-month to 6-year-9-month). All children were treated with hormone alone or combined with other immunosuppressive drugs. Three cases were severe and another 5 cases were critically ill. Four cases were complicated with recurrence of nephrotic syndrome, 2 of which suffered from acute renal insufficiency. All children were given oseltamivir as antiviral treatment at admission. Four cases took oseltamivir within 48 hours of onset and showed mild symptoms. Fourteen children with H1N1I influenza were cured, their urinary proteins were significantly decreased or converted to negative, and the median hospital stay was 8 days (1 to 25 days). One child died of acute necrotizing encephalopathy and brain herniation. Conclusions Children with nephrotic syndrome are susceptible to severe or critical H1N1 influenza infections. During the epidemic of H1N1 influenza, the clinical preventive measures should be taken in children with nephrotic syndrome.

Effect of baicalin on apoptosis induced by H1N1 virus in vitro and its mechanism / 中国药理学通报

Aim To investigate the regulatory effects of baicalin on apoptosis induced by virus H1 N1 in hu-man pulmonary carcinoma cell A549 . Methods The chips were used to screen the RNA samples in virus-in-fected A549 cells. Differentially expressed genes were selected in the pathway of apoptosis. The mRNA ex-pressions of caspase-3 and -8 were verified by Real-Time PCR. Results With the DNA microarray, the functions of differentially expressed genes involved in apoptosis biological pathways were analyzed by Kyoto Encyclopedia of Genes and Genomes ( KEGG ) Path-way databases. caspase-3, -7, -8, -10, TRAIL, MYD88 , IL1 A and IL1 B were up-regulated in virus-in-fected group. Oseltamivir could down-regulate gene ex-pressions of caspase-3 ,-4 and-8 . High-dose of baica-lin could down-regulate gene expressions of caspase-3 ,-4,-6 and -8. Except gene expressions of above, low-dose of baicalin could also down-regulate gene expres-sions of IL1RAP and Cn. Real-Time PCR experiments showed that baicalin could significantly decrease mR-NA expression of caspase-3 , -4 , -6 , -8 , IL1 RAP and Cn ( P < 0. 01 ) , compared with the virus-infected group. The results also figured that the interference ef-ficacy of low-dose baicalin was better than that of high-doses. As expected, real-time PCR data were in good agreement with the microarray assay. Conclusions Baicalin can be detected in their suppression effect of caspase-3,-4,-6, and -8 mRNA expression, so it re-sists against the apoptosis to fight against influenza vi-rus in vitro.

Neurological complications after H1N1 influenza vaccination: magnetic resonance imaging findings / Complicações neurológicas após vacinação para H1N1: achados de ressonância magnética.

Objective: To report 4 different neurological complications of H1N1 virus vaccination. Method: Four patients (9, 16, 37 and 69 years of age) had neurological symptoms (intracranial hypertension, ataxia, left peripheral facial palsy of abrupt onset, altered mental status, myelitis) starting 4-15 days after H1N1 vaccination. MRI was obtained during the acute period. Results: One patient with high T2 signal in the cerebellum interpreted as acute cerebellitis; another, with left facial palsy, showed contrast enhancement within both internal auditory canals was present, however it was more important in the right side; one patient showed gyriform hyperintensities on FLAIR with sulcal effacement in the right fronto-parietal region; and the last one showed findings compatible with thoracic myelitis. Conclusion: H1N1 vaccination can result in important neurological complications probably secondary to post-vaccination inflammation. MRI detected abnormalities in all patients. .

Objetivo: Relatar quatro diferentes complicações neurológicas da vacina contra o vírus H1N1. Método: Quatro pacientes (9, 16, 37 e 69 anos) tinham sintomas neurológicos (hipertensão intracraniana, ataxia, paralisia facial esquerda de inicio abrupto, estado mental alterado e mielite) iniciando-se 4 a 15 dias após vacinação contra H1N1. RM foi realizada em quatro pacientes na fase aguda e em um paciente na fase crônica. Resultados: Dos quatro pacientes, um apresentou hipersinal em T2 no cerebelo, interpretado como cerebelite aguda; um, com paralisia facial esquerda, tinha realce dos condutos auditivos internos, maior à direita; um tinha hipersinal em T2 no cortex parieto-occipital direito; um apresentou sinais compatíveis com mielite torácica. Conclusão: A vacinação contra o H1N1 pode resultar em importantes complicações neurológicas, provavelmente secundárias a inflamação pós-vacinal. A RM detectou anormalidades em todos os pacientes. .

Avaliação do perfil dos linfócitos B de pacientes com Imunodeficiência Comun Variável antes a após administração de antígenos protéicos e polissacarídicos / Evaluation of B lymphocyte profile of Common Variable Immunodeficiency patients before and after immunization with protein and polysaccharide antigens

Introdução: A Imunodeficiência Comum Variável (ICV) faz parte de um grupo de imunodeficiências primárias na qual os pacientes apresentam defeitos na maturação e diferenciação dos linfócitos B (LB), resultando em distúrbios funcionais além de alterações na distribuição de seus subtipos. Consequentemente, estes pacientes apresentam hipogamaglobulinemia, susceptibilidade a infecções e ausência de produção de anticorpos a antígenos específicos. Na tentativa de reduzir os episódios de infecções recorrentes, alguns trabalhos têm recomendado a vacinação com patógenos mortos ou subunidades e em trabalho anterior demonstramos a eficácia clínica da vacinação de pacientes com ICV, porém, a experiência com a administração de vacinas em imunocomprometidos é limitada. Objetivos: Avaliar a cinética da distribuição das subpopulações de linfócitos B antes e após a vacinação com antígenos proteicos e polissacarídicos em pacientes com ICV acompanhados no Ambulatório de Imunodeficiências Primárias do Hospital das Clínicas, FMUSP, além da produção de anticorpos específicos aos antígenos vacinais. Pacientes e Métodos: Um grupo de 35 pacientes com ICV e 16 controles foram vacinados contra Influenza, H1N1 e S. pneumoniae. Após as coletas nos tempos pré e pós 1, 3 e 6 meses foram realizados a separação de PBMC e cultura de linfócitos com lisado viral e hemaglutinina de Influenza, além da citometria de fluxo para identificação das subpopulações de LB naive, zona marginal (MZB), memória com troca de isotipo (SMB) e plasmoblastos (PBL). Foram dosados os anticorpos específicos e no grupo dos pacientes foi aplicado um score de sintomas antes e após a imunização. Resultados: Apesar da redução significativa na pontuação do score de sintomas, a maioria dos pacientes não produziu anticorpos específicos para Influenza, H1N1 e S. pneumoniae...

Introduction: Common Variable Immunodeficiency (CVID) is a primary antibody deficiency characterized by defects in B lymphocyte maturation, resulting in disturbed differentiation, distribution and functional variations on its subtypes. As a result , CVID patients have hypogammaglobulinemia and poor antibody response to specific antigens with increased susceptibility to infections. In an effort to minimize the recurrent episodes of infections, some studies have recommended immunization with inactivated pathogens or subunits and in a former study we have shown the clinical improvement determined by immunization in CVID patients, but the experience with vaccines' administration to immunodeficient patients is limited. Objectives: To evaluate the changes in distribution of B cell subtypes before and after vaccination of CVID patients followed at the Division of Clinical Immunology and Allergy of University of São Paulo Medical School with protein and polysaccharide antigens, as well as specific antibody production . Methods: A group of 35 CVID patients and 16 controls were vaccinated against Influenza, H1N1 and S. pneumoniae vaccines. Blood samples were collected before and 1, 3 and 6 months post vaccination. PBMCs were stimulated with Influenza viral lysate and hemagglutinin peptide. Flow cytometry was performed to identify naïve B cells, marginal zone (MZB), switched memory B cells (SMB) and plasmablasts (PBL). Specific antibody production was measured and a symptoms score was applied for clinical evaluation before and after immunization. Results: In spite of the significant reduction in symptoms score after vaccination, most patients didn't produce specific antibodies to Influenza, H1N1 and S. pneumoniae...

Oseltamivir-resistant influenza A(H1N1) pdm09 virus: first reported case from India.

Background: Recent studies on antiviral susceptibiliy from South-East Asia, Europe and the United States have shown sporadic neuraminidase inhibitor (NAI) resistance in A(H1N1)pdm09 viruses. We undertook a study to evaluate NAI resistance in these viruses isolated in India. Methods: Pandemic influenza viruses, isolated from 2009 to 2013, along with clincal samples were genetically analysed for known resistance markers in the neuraminidase (NA) gene. Clinical samples (n=1524) were tested for H275Y (N1 numbering; H274Y in N2 numbering) mutation by real time reverse transcriptase PCR (rRT-PCR). One hundred and ten randomly selected resistant and sensitive viruses were analysed by phenotypic assay. Results: All but one of the 2013 A(H1N1)pdm09 isolates were sensitive to oseltamivir. Genetic analysis of this isolate as well as the original clinical material showed that the presence of H275Y mutation was responsible for reduced susceptibility to oseltamivir in the patient. This was confirmed by phenotypic assay. Conclusion: The emergence of a pandemic influenza strain resistant to oseltamivir emphasizes the need for monitoring antiviral resistance as part of the National Influenza Programme in India.

Pandemic influenza A (H1N1) 2009: epidemiological analysis of cases in a tropical/semi-arid region of Brazil

Introduction The year 2009 marked the beginning of a pandemic caused by a new variant of influenza A (H1N1). After spreading through North America, the pandemic influenza virus (H1N1) 2009 spread rapidly throughout the world. The aim of this study was to describe the clinical and epidemiological characteristics of cases of pandemic influenza in a tropical/semi-arid region of Brazil. Methods A retrospective study analyzed all suspected cases of pandemic influenza (H1N1) 2009 reported in the Ceará State through the National Information System for Notifiable Diseases during the pandemic period between 28 April, 2009 and November 25, 2010. Results A total of 616 suspected cases were notified, 58 (9.4%) in the containment phase and 558 (90.6%) in the mitigation phase. Most cases were of affected young people resident in the City of Fortaleza, the largest urban center in the State of Ceará. The most frequent symptoms presented by the cases with confirmed infection were fever, cough, myalgia, arthralgia, and nasal congestion. Mortality rate was 0.0009/1,000 inhabitants and lethality was 5.6%. Deaths were observed only in the mitigation phase. Mortality rates were similar for both sexes but were higher in the age group under 5 years. Conclusions The study suggests that the influenza A (H1N1) pandemic in this tropical/semi-arid region had a lower magnitude when compared to states in the Southern and Southeastern regions of Brazil. .

Clinical presentation of patients with seasonal influenza and pandemic influenza A (H1N1-2009) requiring hospitalisation.

Background. A sudden increase in the number of novel influenza A virus (pH1N1-2009) infection prompted us to compare the clinical presentation and outcomes of patients infected with pH1N1-2009 and seasonal influenza A virus during the postpandemic phase. Methods. During the period August 13 to September 27, 2010, case records of 106 patients with severe influenza like illness (ILI) and respiratory complications who underwent diagnostic testing by real-time polymerase chain reaction (RT-PCR) for confirmation of pH1N1-2009 were retrospectively studied. Results. Nineteen (17.9%) patients were tested positive for pH1N1-2009 and 78 (73.6%) were tested positive for seasonal influenza A virus. The mean age of patients infected with pH1N1-2009 was 45.2±15.3 years (range of 22 to 80 years). Common presenting symptoms included fever in 17 (89.4%), cough in 16 (84.2%), myalgia in 15 (78.9%) and breathlessness in 10 (52.6%) patients. The most common comorbidities included bronchial asthma/bronchitis/chronic obstructive pulmonary disease (COPD) in 4 (21%); followed by hypertension in 3 (15.8%) and diabetes in 3 (15.8%) patients. Overall, of the 97 influenza infected patients, 9 (9.3%) needed hospitalisation to the intensive care unit (ICU); one patient with COPD died due to multi-organ failure. Conclusions. Both the pandemic and seasonal strains were found to be co-circulating in the community. Patients with severe hypoxia, hypertension, acute respiratory distress syndrome and shock required ICU care.

Surveillance of influenza A H1N1 2009 among school children during 2009 and 2010 in São Paulo, Brazil / Vigilância de influenza A H1N1 2009 entre crianças em idade escolar durante os anos de 2009 e 2010 em São Paulo, Brasil

INTRODUCTION: Influenza A H1N1 2009 is associated with a high morbidity rate among children around the world, including Brazil. This survey was conducted on samples of symptomatic children (< 12 years) to investigate the influenza virus as the etiological agent of respiratory infections in a day care school in a health facility during the first and second pandemic wave of H1N1 (2009-2010) in São Paulo, Brazil. METHODS: Influenza infections were determined by real-time PCR in 34% (47/137) of children with a median age of 5 years (8 months - 12 years), from June to October 2009 and in 16% (14/85) of those with median age of 6 years (1-12 years), from March to November 2010. RESULTS: In general, most positive cases (64%) occurred in children aged 5-12 years, this age group was significantly the most affected (39.8%, p = 0.001, OR = 8.3, CI 95% 1.9-36.9). Wheezing was reported by 31% (19/61) and dyspnea by 23% (14/61) of the studied patients. An outbreak of influenza H1N1 with an attack rate of 35.7% among children (median age 6 years) was documented in April 2010, before the vaccination campaign against the pandemic virus was extended for children up to 5 years in Brazil. CONCLUSIONS: Therefore, the study reinforces the recommendation to immunize school children to reduce the incidence of the disease.

INTRODUÇÃO: Influenza A H1N1 2009 está associado com uma alta taxa de morbidade entre crianças ao redor do mundo, incluindo o Brasil. Esta pesquisa foi realizada em amostras de crianças sintomáticas (< 12 anos) em uma creche escola para filhos de funcionários do hospital durante a primeira e segunda onda pandêmica (2009-2010) em São Paulo, Brasil. MÉTODOS: Infecções pelo vírus influenza foram determinadas por PCR em tempo real em 34% (47/137) em crianças com idade mediana de 5 anos (8 meses -12 anos), entre junho e outubro de 2009 e em 16% (14/85) daquelas com mediana de idade de 6 anos (1-12 anos), de março a novembro de 2010. RESULTADOS: Em geral, a maioria dos casos positivos (64%) ocorreu em crianças com idade entre 5-12 anos, esta faixa etária foi significativamente a mais afetada (39,8%, p = 0,001, OR = 8,3, CI 95%: 1,9-36,9). Chiado foi relatado em 31% (19/61) e dispnéia em 23% (14/61) dos pacientes estudados. Um surto de gripe H1N1 com uma taxa de ataque de 35,7% entre as crianças (mediana de idade de 6 anos) foi documentado em abril de 2010, antes da extensão da campanha de vacinação contra o vírus pandêmico para crianças até 5 anos no Brasil. CONCLUSÕES: Portanto, neste estudo reforça a recomendação para imunizar crianças em idade escolar para reduzir a incidência da doença.

Clinical analysis of early predictors of patients with 2009 H1N1 pneumonia / 中华急诊医学杂志

Objective To explore the early predictors of patients with 2009 H1N1 pneumonia by analyzing the clinical features.Methods The 2009 H1 N1 pneumonia patients,admitted to our emergency intensive care unit (EICU) from October 2009 to January 2010,were retrospectively analyzed. The 86patients were divided into died and survival groups. The chi-square test and T test were used to examine the difference between groups.Results Of the 86 patients we studied,15 ( 17.4％ ) cases died and 12 cases received mechanical ventilation. All patients underwent chest radiography on admission and the findings were consistent with pneumonia in all cases.The median duration of symptoms before admission was 3.2 days.The first laboratory test results indicated the average total number of white blood cell (WBC) was (6358 ±483) /mm3.Of the 86 patients,47 (54.7％ ) showed a reduction in WBC.Of the 71 patients who survived,35 (49.3％) had leucopenia and12 (80％) in died group (x2 =4.71,P ＜ 0.05).In survival group,39 (54.9％) had lymphopenia and 13 (86.7％) in died group (x2 =5.22,P ＜0.05).Of 72 patients had T-lymphocyte subsets results,CD4 + T cell counts on average was (424.8 ±231.6 ) /mm3 in57 survival cases and (242.5 ±99.1) /mm3 in 15 died cases (t=2.14,P ＜ 0.05).On admission,serum creatine kinase (CK) in died group was (794.5 ± 85.1 ) U/L,higher than (632.3 ±47.9) U/L in survival group (t =2.25,P ＜ 0.05).Elevated CK was found in 14 (93.3％)of 15 died cases and 50 (70.4％) in survival group (x2 =5.87,P ＜ 0.05). Serum lactate dehydrogenase (LDH) in died group was (1028.6 ± 97.3) U/L,higher than (832.3 ± 56.1 ) U/L in survival group (t =2.31,P ＜ 0.05). According to the criterion of body mass index (BMI) ≥25 kg/m2,33 (38.4％) cases were obesity,in which 13 (86.7％ ) in died group and 20 (28.2％) in survival group ( x2 =17.92,P ＜ 0.01 ),The mortality was increasing along with the BMI was increasing ( r =0.37,P =0.048). Conclusions SOFA,MEDS,CURB-65 score used in emergency room as the risk stratification methods can not effectively predict the 2009 H1N1 pneumonia patients. Peripheral blood lymphocyte counts,serum creatine kinase and lactate dehydrogenase,body mass index in the early course may be factors associated with outcomes of 2009 H1N1 pneumonia patients.

Isolation and characterization of a pandemic H1N1 influenza virus in pigs in Brazil / Isolamento e caracterização do vírus da influenza pandêmico H1N1 em suínos no Brasil

Influenza A virus (IAV) infections are endemic in pork producing countries around the world. The emergence of the pandemic 2009 human H1N1 influenza A virus (pH1N1) raised questions about the occurrence of this virus in Brazilian swine population. During a 2009-2010 swine influenza virus research project at Embrapa Swine and Poultry (CNPSA), an outbreak of a highly transmissible H1N1 influenza A virus disease was detected in a pig herd in Santa Catarina State, Brazil. The virus caused a mild disease in growing pigs and sows without mortality. Three clinically affected piglets were euthanized. Gross lesions included mild to moderate consolidation of cranioventral areas of the lung. Microscopically, the lesions were characterized by necrotizing obliterative bronchiolitis and bronchointerstitial pneumonia. Immunohistochemistry using a monoclonal antibody against type A influenza virus nucleoprotein revealed positive staining in the nuclei of the bronchiolar epithelial cells. Lung tissue from three piglets and nasal swabs from five sows and four piglets were positive for influenza A by RT-PCR. Influenza virus was isolated from one lung, later confirmed by the hemagglutination test (HA titer 1:128) and RT-PCR. Sequence analyses of Hemmaglutinin (HA) and Matrix (M) genes revealed that the virus was consistent with the pandemic (A/H1N1) 2009 influenza virus strain that circulated in humans. This is the first report of an outbreak of pandemic A/H1N1 influenza virus in pigs in Brazil.

A infecção causada pelo vírus Influenza A (IAV) é endêmica em suínos no mundo inteiro. O surgimento da pandemia de influenza humana pelo vírus A/H1N1 (pH1N1) em 2009 levantou dúvidas sobre a ocorrência deste vírus em suínos no Brasil. Durante o desenvolvimento de um projeto de pesquisa do vírus de influenza suína em 2009-2010, na Embrapa Suínos e Aves (CNPSA), foi detectado em um rebanho de suínos em Santa Catarina, Brasil, um surto de influenza altamente transmissível causado pelo subtipo viral H1N1. Este vírus causou uma doença leve em suínos em crescimento e em fêmeas adultas, sem mortalidade. Tres leitões clinicamente afetados foram eutanasiados. As lesões macroscópicas incluiam consolidação leve a moderada das áreas cranioventrais do pulmão. Microscopicamente, as lesões foram caracterizadas por bronquiolite necrosante obliterativa e pneumonia broncointersticial. A imunohistoquímica, utilizando um anticorpo monoclonal contra a nucleoproteína do vírus influenza A, revelou marcação positiva no núcleo das células epiteliais bronquiolares. O tecido pulmonar de três leitões e os suabes nasais de cinco fêmeas e quatro leitões foram positivos para influenza A pela RT-PCR. O vírus influenza foi isolado de um pulmão, mais tarde sendo confirmado pelo teste de hemaglutinação (título HA 1:128) e por RT-PCR. A análise das seqüências de nucleotídeos dos genes da hemaglutinina (HA) e proteína da matriz (M) revelou que o vírus isolado foi consistente com o vírus pandêmico A/H1N1/2009 que circulou em humanos no mesmo período. Este é o primeiro relato de um surto de influenza causado pelo vírus pandêmico A/H1N1 em suínos no Brasil.

Factores asociados a mortalidad en la pandemia de influenza H1N1 2009 en Paraguay / Factors associated to mortality in the influenza H1N1 pandemic in Paraguay in 2009

La presencia de condiciones médicas pre-existentes se ha asociado con la mortalidad relacionada al virus de influenza A (H1N1). El objetivo de este estudio fue determinar los factores asociados a mortalidad en personas con sospecha de infección con influenza A (H1N1) en Paraguay. Los datos clínicos y epidemiológicos fueron obtenidos a través del sistema de vigilancia para la infección por influenza A(H1N1) establecido en el país por el Ministerio de Salud Pública y Bienestar Social a partir del 28 de abril de 2009. Hasta el 30 de enero de 2010, fueron notificados a la Dirección General de Vigilancia de la Salud, 8303 casos con sospecha de Influenza A (H1N1). Tanto el análisis bivariado como el multivariado identificaron los siguientes factores de riesgo de mortalidad: obesidad (p=0,022; OR:13,5), embarazo (p<0,001; OR:11,0), Diabetes mellitus (p= 0,006; OR:5,7), enfermedad cardiovascular (p=0,002; OR: 4,6), sexo masculino (p <0,0001, OR: 3,0), edad mayor a 60 años (p =0,008; OR: 2,9) y no haber sido vacunado contra el virus de influenza estacional en el periodo 2009 (p<0,023; OR: 2,6). El embarazo como factor de riesgo de mortalidad ya había sido observado en las otras pandemias; no así la obesidad, la cual recién en la última pandemia, ha sido relacionada, por varios países, con complicaciones graves de infección por el virus A (H1N1). Esta asociación amerita el desarrollo de investigaciones que permitan un mejor abordaje promocional, preventivo y terapéutico de las personas con obesidad.

The presence of pre-existing medical conditions has been associated with mortality related to influenza A virus (H1N1). Our objective was to determine the risk factors associated to mortality in suspected cases of influenza A (H1N1) in Paraguay. Clinical and epidemiological data were obtained through the surveillance system of influenza A (H1N1) established in the country by the Ministry of Public Health and Social Welfare on April 28, 2009. Up to January 30, 2010, 8,303 suspected cases of influenza A (H1N1) were reported to the Dirección General de Vigilancia de la Salud. Bivariate as well as the multivariate analyses identified the following mortality risk factors: obesity (p<0.022, OR:13.5), pregnancy (p <0.001, OR: 11.0), diabetes mellitus (p= 0.006; OR:5.7); cardiovascular disease (p = 0.002; OR:4.6), male sex (p<0.0001, OR:3.0); age older than 60 years (p <0.008, OR:2.9), not been vaccinated against seasonal influenza virus during 2009 (p<0.023; OR:2.6). Pregnancy as a mortality risk factor for viral influenza infections was seen in other influenza pandemics, but no obesity, which has been reported by several countries as a risk factor for severe complication of A (H1N1) virus infection in the last pandemic. This association deserves the development of research studies that allow a better promotional, preventive and therapeutical approach of obese people.

Variations in Number of Hospitalized Patients with Cardiopulmonary Diseases Associated with 2009 H1N1 Pandemic Influenza in a Tertiary Teaching Hospital - Comparison with Seasonal Influenza / 감염과화학요법

BACKGROUND: The world encountered the global outbreak of an H1N1 influenza pandemic in 2009. Influenza has accounted for grave outcomes, not only through infectious complications, but also through the exacerbation of underlying chronic diseases. A substantial number of confirmed or probable cases of influenza had been reported during the 2009 H1N1 pandemic in South Korea, but a review of the development of influenza-related complications or the exacerbation of underlying chronic diseases has been absent. This study aims to understand the influence of the 2009 pandemic on the exacerbation of existing cardiopulmonary diseases. MATERIALS AND METHODS: We surveyed the number of hospitalized patients with a diagnosis of pneumonia, asthma, chronic obstructive pulmonary disease, acute myocardial infarctions, and heart failure during the period of the 2009 H1N1 influenza pandemic in a 950-bed teaching hospital in Korea. Three influenza seasons from 2007 to 2009 were compared via a medical records review. Data collection included the number of hospitalizations, patient age, number of deaths from all causes, and underlying medical conditions of fatal patients. RESULTS: The weekly number of cardiopulmonary hospitalizations showed no differences between the 2009 pandemic influenza period and seasonal influenza epidemics (53 and 56 on average, respectively), but the total number of hospitalized patients during the pandemic influenza period was 1481, whereas there were 625 on average for seasonal influenza. The hospitalization rate for patients under five years of age exceeded that of the patients sixty years of age or older in pandemic influenza, and the hospitalization rate of patients twentyfive to fifty-nine during pandemic influenza was significantly higher than that of seasonal influenza outbreaks (P=0.012). On the other hand, the hospitalization rate of the patients sixty years of age or older during the pandemic influenza period significantly fell short of that in past seasonal influenza periods (P<0.001). However, the patients sixty years of age or older had the highest case fatality rate during both periods. The total number of deaths among hospitalized patients with cardiopulmonary diseases in pandemic influenza and seasonal influenza epidemics was 87 and 46 on average, respectively. Weekly fatal cases were 3 and 4. CONCLUSIONS: The cardiopulmonary hospitalization rate during the pandemic period outnumbered that of preceding seasonal influenza epidemics by its extended length. But, the virulence or disease severity of the 2009 H1N1 and seasonal influenza seems to be little different. A larger-scale epidemiological investigation is necessary.

Desfecho dos casos de influenza pandêmica (H1N1) 2009 em mulheres em idade fértil durante a pandemia, no município do Rio de Janeiro / Outcomes of pandemic Influenza (H1N1) 2009 in women of childbearing age, in the city of Rio de Janeiro

Objetivo: avaliar a letalidade entre mulheres em idade fértil durante a pandemia de Influenza Pandêmica (H1N1) 2009, tendo a presença de gravidez como exposição, no município do Rio de Janeiro. Metodologia: foram selecionados, a partir do Sistema Nacional de Agravos de Notificação (Sinan), do Ministério da Saúde, os casos confirmados de influenza pandêmica para comparação entre gestantes e não-gestantes, sendo incluídas 633 mulheres residentes no MRJ, estando 233 gestantes (37 por cento). Resultados: sete gestantes e 22 não gestantes faleceram no episódio de gripe, não se evidenciando um risco maior de óbito entre as gestantes (Risco relativo=0,53 [IC95 por cento: 0,22-1,27]). Conclusão: apesar de não ter sido evidenciada associação entre gestação e óbito, a infecção pelo vírus (H1N1) em gestantes deve ser acompanhada cuidadosamente, principalmente na presença de fatores de risco.

Objective: to compare the death rate among women of childbearing age during the Pandemic Influenza (H1N1) 2009 in Rio de Janeiro considering pregnancy exposure. Methodology: confirmed cases were selected from the National Disease Reporting System (SinanWeb) of Brazil’s Ministry of Health, and pregnant were compared to non-pregnant women. 633 patients were included and 233 of them (37 percent) were pregnant when reported. Results: seven pregnant and 22 non-pregnant women died during the flu episode, but we failed to elicit a greater risk of death among those who were pregnant (Relative Risk=0.53 [95 percent CI 0.22-1.27]). Conclusion: although no evidence of association of pregnancy and death was found, pregnant women with the new flu should be followed carefully, especially in the presence of known risk factors.

O vírus influenza H1N1 e os trabalhadores da suinocultura: uma revisão / H1N1 influenza virus and workers in swine farms: an overview

Considerando-se o grande impacto midiático e populacional da recente epidemia pelo vírus Influenza H1N1, em função do seu risco potencial de alta letalidade, decidimos realizar esta revisão, de forma a melhor compreender as relações entre a exposição aos suínos e a possível contaminação laboral. A influenza, também conhecida como gripe, é uma doença viral adquirida através do contato humano com animais domesticados. Os suínos são importantes hospedeiros do vírus Influenza H1N1 (swine-like Influenza A) e susceptíveisàs infecções por vírus Influenza de origem aviária e humana. Os suínos possuem importante papel na transmissão viral entre espécies e na epidemiologia da influenza humana. A epidemia por Influenza A H1N1/2009 representou um grande desafio para as autoridades públicas e setores privados da saúde, no que se refere às medidas de planejamento e execução de ações de prevenção e tratamento. Estima-se que 89 milhões de pessoas tenham sido contaminadas por este vírus, com até 403 mil casos de hospitalização e 18.300 óbitos até abril de 2010. Embora estejamos em período pós-pandemia, acredita-se que o vírus H1N1 tenha atualmente um comportamento semelhante ao vírus de gripe sazonal, causando focos infecciosos localizados e com níveis ainda significativos de transmissão. Destaca-se a preocupação com a saúde dos trabalhadores diretamente ligados à suinocultura, já que essa atividade produtiva apresenta uma situação de risco aos trabalhadores envolvidos e também à comunidade.

Given the global impact of the recent H1N1 virus epidemic, due to the occurrence of fatal cases of influenza and the public response to the outbreak, we reviewed the literature considering the possibility of contamination from swine to humans. Influenzais a viral disease that might be acquired through human contact with domesticated animals. Swines are important hosts of influenza virus H1N1 (swine-likeinfluenza A) and susceptible to infections caused by influenza viruses from avian and human origin, and play an important role in interspecies transmission and inepidemiology of human influenza. The 2009 H1N1 Influenza epidemic represented a major challenge for public authorities and private health sector. By April 2010, a total of 89 million cases, with 403.000 cases of hospitalization and 18.300 deaths with 2009 H1N1 have been estimated worldwide. In the present post-pandemic period, the H1N1 virus circulates very likely as seasonal flu virus and causes local outbreaks, indicating yet significant levels of transmission. Among the measures of prevention, workers in swine farms are of concern because they are at high risk of a zoonotic influenza infection, as well as the community involved.

Pandemic influenza A(H1N1) 2009 outbreak in a residential school at Panchgani, Maharashtra, India.

Background & objectives: An outbreak of influenza was investigated between June 24 and July 30, 2009 in a residential school at Panchgani, Maharashtra, India. The objectives were to determine the aetiology, study the clinical features in the affected individuals and, important epidemiological and environmental factors. The nature of public health response and effectiveness of the control measures were also evaluated. Methods: Real time reverse transcriptase polymerase chain reaction was performed on throat swabs collected from 82 suspected cases to determine the influenza types (A or B) and sub-types [pandemic (H1N1) 2009, as well as seasonal influenza H1N1, H3N2]. Haemagglutination inhibition assay was performed on serum samples collected from entire school population (N = 415) to detect antibodies for pandemic (H1N1) 2009, seasonal H1N1, H3N2 and influenza B/Yamagata and B/Victoria lineages. Antibody titres ≥ 10 for pandemic (H1N1) 2009 and ≥ 20 for seasonal influenza A and B were considered as positive for these viruses. Results: Clinical attack rate for influenza-like illness was 71.1 per cent (295/415). The attack rate for pandemic (H1N1) 2009 cases was 42.4 per cent (176/415). Throat swabs were collected from 82 cases, of which pandemic (H1N1) 2009 virus was detected in 15 (18.3%), influenza type A in (6) 7.4 per cent and influenza type B only in one case. A serosurvey carried out showed haemagglutination inhibition antibodies to pandemic (H1N1) 2009 in 52 per cent (216) subjects in the school and 9 per cent (22) in the community. Interpretation & conclusion: Our findings confirmed an outbreak of pandemic (H1N1) 2009 due to local transmission among students in a residential school at Panchgani, Maharashtra, India.

Clinical Characteristic of Respiratory Tract Infections in Children during Pandemic Influenza (H1N1 2009) in Korea / 감염과화학요법

BACKGROUND: Since initial emergence on pandemic influenza (H1N1 2009) in Mexico on March 2009, the first case of pandemic influenza (H1N1 2009) occured on 2 May 2009 in Korea. We describe the clinical characteristics of childhood patients from pandemic influenza (H1N1 2009) and other concurrent respiratory pathogens during early phase of the pandemic influenza in Korea. MATERIALS AND METHODS: We have retrospectively studied 959 patients under age of 15 years who have visited Department of Emergency Medicine for a diagnostic test of pandemic influenza (H1N1 2009) or treatment of flu-like illness between May and September of 2009. The pandemic influenza (H1N1 2009) was detected via real-time RT-PCR and other respiratory viruses were detected via multiplex RT-PCR. RESULTS: A total of 959 patients visited Department of Emergency Medicine at Severance Hospital. Of them, 562 were tested; 124 (12.7%) were positive for pandemic influenza (H1N1 2009). Confirmed patients of pandemic influenza (H1N1 2009) were relatively older than non-H1N1 patients (7.5 years of age vs 4.6 years, P<0.001). Among histories or symptoms of patients with flu-like illness, contact history (80%) with another patient with pandemic influenza (H1N1 2009) was an important clue of the infection in early phase of pandemic. Comparing with hospitalized patients with respiratory tract infections due to other causes, lower ESR (32.9+/-23.5 mm/hour vs 11.5+/-9.2 mm/hour), hyperkalemia (4.2+/-0.3 mmol/L vs 5.2+/-3 mmol/L) and hyponatremia (137.2+/-2.5 mmol/L vs 124+/-40.5 mmol/L) were significant laboratory finding and higher cholesterol and GTP were noticed in pandemic influenza (H1N1 2009). Ten confirmed patients with pandemic influenza (H1N1 2009) were hospitalized due to pneumonia and all of them were resolved without any complication. CONCLUSIONS: Respiratory tract infections were caused not only by pandemic influenza (H1N1 2009) virus but also various respiratory viruses. Hospitalized patients, confirmed as pandemic influenza (H1N1 2009), showed a good prognosis. Age and contact history were distinct features and could be an important clue to differentiate causes in patients with febrile respiratory symptoms.

Laboratory Confirmatory Rate of Pandemic Influenza (H1N1 2009) Virus in Korean Households with Index Case / 감염과화학요법

BACKGROUND: Influenza transmission in households a subject of renewed interest especially in pandemic situation. We performed this study to investigate the laboratory-confirmatory rate in household contacts with index cases of pandemic influenza (H1N1 2009). MATERIALS AND METHODS: For three months from 1 September and 29 November 2009, people who had a history of close contact with confirmed cases of pandemic influenza (index case) were recruited. The information on the study participants was collected using a standardized questionnaire. Presence of the pandemic influenza (H1N1 2009) infection was confirmed by real-time reverse-transcription polymerase chain reaction (RT-PCR). RESULTS: A total of 113 index cases and 141 household contacts were investigated. One hundred and four index cases (92.0%) were younger than 20 years. The median age of household contacts was 40 years. Twenty eight household contacts (19.8%) had acute respiratory illness (ARI). Overall, 10.6% of enrolled household contacts were positive in RT-PCR for pandemic influenza (H1N1 2009). The positive rate of household contacts with ARI was 25.0% and it was 7.1% in household contacts without ARI. The positive rate was significantly higher in children and young adults under 30 years (28.3%) compared with that in household contacts older than 30 years (8.3%). CONCLUSIONS: This results showed a significant role of mild symptomatic or asymptomatic pandemic influenza (H1N1 2009) patients as a virus carriers in households.

A Case of Oseltamivir-Resistant Pandemic Influenza (H1N1 2009) in a Patient with Acute Myeloid Leukemia / 감염과화학요법

Oseltamivir is the drug of choice for patients with pandemic influenza (H1N1 2009). However, sporadic cases of oseltamivir resistance have been described worldwide. Up to March 2010, a total of 11 strains (2.2% of tested isolates) of oseltamivir-resistant pandemic influenza (H1N1 2009) have been discovered in South Korea. We report a case of 46-year-old man with acute myeloid leukemia in whom an oseltamivir-resistant pandemic (H1N1) 2009 virus was isolated. Despite high dose oseltamivir therapy for 10 days he had persistent symptoms and showed positive results in repeated real-time RT-PCR for pandemic influenza (H1N1 2009) virus from nasopharyngeal specimen. The patient improved eventually after oseltamivir was replaced by zanamivir inhalation.

Early Extracorporeal Membrane Oxygenation in a Patient with Pandemic Influenza (H1N1 2009) and Acute Respiratory Distress Syndrome / 감염과화학요법

Despite advanced technologies in intensive care, pandemic influenza (H1N1 2009) can rapidly progress to acute respiratory distress syndrome (ARDS) and cause death in a small subset of patients. Extracorporeal membrane oxygenation (ECMO) is expected to provide adequate gas exchange, to reduce ventilator-induced lung injury and, eventually, to improve outcome in these patients. A previously healthy, young female received mechanically ventilatory support because of rapidly progressive respiratory failure caused by 2009 H1N1 influenza. As she failed to respond to high ventilatory support, ECMO was instituted at 6 hours after admission. We describe detailed course of case and literature review on ECMO, helping physicians make a decision to initiate ECMO in patients with influenza-related ARDS.