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Ribeiro AF, Pellini ACG, Kitagawa BY, Marques D, Madalosso G, Fred J, Albernaz RKM, Carvalhanas TRMP, Zanetta DMT. Severe influenza A(H1N1)pdm09 in pregnant women and neonatal outcomes, State of Sao Paulo, Brazil, 2009. PLoS One 2018; 13:e0194392. [PMID: 29579099 PMCID: PMC5868799 DOI: 10.1371/journal.pone.0194392] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/02/2018] [Indexed: 11/26/2022] Open
Abstract
To investigate the factors associated with death and describe the gestational outcomes in pregnant women with influenza A(H1N1)pdm09, we conducted a case-control study (deaths and recovered) in hospitalized pregnant women with laboratory-confirmed influenza A(H1N1)pdm09 with severe acute respiratory illness (SARI) in the state of São Paulo from June 9 to December 1, 2009. All cases were evaluated, and four controls that were matched by the epidemiological week of hospitalization of the case were randomly selected for each case. Cases and controls were selected from the National Disease Notification System-SINAN Influenza-web. The hospital records from 126 hospitals were evaluated, and home interviews were conducted using standardized forms. A total of 48 cases and 185 controls were investigated. Having had a previous health visit to a healthcare provider for an influenza episode before hospital admission was a risk factor for death (adjusted OR (ORadj) of 7.93, 95% CI 2.19-28.69). Although not significant in the multiple analysis (ORadj of 2.13, 95% CI 0.91-5.00), the 3rd trimester deserves attention, with an OR = 2.22, 95% CI 1.13-4.37 in the univariate analysis. Antiviral treatment was a protective factor when administered within 48 hours of symptom onset (ORadj = 0.16, 95% CI 0.05-0.50) and from 48 to 72 hours (ORadj = 0.09, 95% CI 0.01-0.87). There was a higher proportion of fetal deaths and preterm births among cases (p = 0.001) and live births with low weight (p = 0.019), compared to control subjects who gave birth during hospitalization. After discharge, control subjects had a favorable neonatal outcome. Early antiviral treatment during the presence of a flu-like illness is an important factor in reducing mortality from influenza in pregnant women and unfavorable neonatal outcomes. It is important to monitor pregnant women, particularly in the 3rd trimester of gestation, with influenza illness for diagnosis and early treatment.
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Affiliation(s)
- Ana Freitas Ribeiro
- Epidemiological Surveillance Center, Sao Paulo State Secretary of Health, São Paulo, São Paulo, Brazil
- Department of Epidemiology, School of Public Health - University of Sao Paulo, São Paulo, São Paulo, Brazil
| | | | - Beatriz Yuko Kitagawa
- Epidemiological Surveillance Center, Sao Paulo State Secretary of Health, São Paulo, São Paulo, Brazil
| | - Daniel Marques
- Epidemiological Surveillance Center, Sao Paulo State Secretary of Health, São Paulo, São Paulo, Brazil
| | - Geraldine Madalosso
- Epidemiological Surveillance Center, Sao Paulo State Secretary of Health, São Paulo, São Paulo, Brazil
| | - Joao Fred
- Epidemiological Surveillance Center, Sao Paulo State Secretary of Health, São Paulo, São Paulo, Brazil
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Ribeiro AF, Pellini ACG, Kitagawa BY, Marques D, Madalosso G, de Cassia Nogueira Figueira G, Fred J, Albernaz RKM, Carvalhanas TRMP, Zanetta DMT. Risk factors for death from Influenza A(H1N1)pdm09, State of São Paulo, Brazil, 2009. PLoS One 2015; 10:e0118772. [PMID: 25774804 PMCID: PMC4361171 DOI: 10.1371/journal.pone.0118772] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 01/06/2015] [Indexed: 11/19/2022] Open
Abstract
This case-control study aimed to assess the risk factors for death from influenza A(H1N1)pdm09 in patients with laboratory confirmation, who had severe acute respiratory illness-SARI and were hospitalized between June 28th and August 29th 2009, in the metropolitan regions of São Paulo and Campinas, Brazil. Medical charts of all the 193 patients who died (cases) and the 386 randomly selected patients who recovered (controls) were investigated in 177 hospitals. Household interviews were conducted with those who had survived and the closest relative of those who had died. 73.6% of cases and 38.1% of controls were at risk of developing influenza-related complications. The 18-to-59-year age group (OR = 2.31, 95%CI: 1.31–4.10 (reference up to 18 years of age)), presence of risk conditions for severity of influenza (OR = 1.99, 95%CI: 1.11–3.57, if one or OR = 6.05, 95%CI: 2.76–13.28, if more than one), obesity (OR = 2.73, 95%CI: 1.28–5.83), immunosuppression (OR = 3.43, 95%CI: 1.28–9.19), and search for previous care associated with the hospitalization (OR = 3.35, 95%CI: 1.75–6.40) were risk factors for death. Antiviral treatment performed within 72 hours of the onset of symptoms (OR = 0.17, 95%CI: 0.08–0.37, if within 48hours, and OR = 0.30, 95%CI: 0.11–0.81, if between 48 and 72 hours) was protective against death. The identification of high-risk patients and early treatment are important factors for reducing morbi-mortality from influenza.
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Affiliation(s)
- Ana Freitas Ribeiro
- Epidemiological Surveillance Center, Disease Control Coordination, State of São Paulo Department of Health, São Paulo, Brazil
- Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
- * E-mail:
| | | | - Beatriz Yuko Kitagawa
- Epidemiological Surveillance Center, Disease Control Coordination, State of São Paulo Department of Health, São Paulo, Brazil
| | - Daniel Marques
- Epidemiological Surveillance Center, Disease Control Coordination, State of São Paulo Department of Health, São Paulo, Brazil
| | - Geraldine Madalosso
- Epidemiological Surveillance Center, Disease Control Coordination, State of São Paulo Department of Health, São Paulo, Brazil
| | | | - João Fred
- Epidemiological Surveillance Center, Disease Control Coordination, State of São Paulo Department of Health, São Paulo, Brazil
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Almansa R, Bermejo-Martín JF, de Lejarazu Leonardo RO. Immunopathogenesis of 2009 pandemic influenza. Enferm Infecc Microbiol Clin 2013; 30 Suppl 4:18-24. [PMID: 23116788 PMCID: PMC7130369 DOI: 10.1016/s0213-005x(12)70100-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Three years after the pandemic, major advances have been made in our understanding of the innate and adaptive immune responses to the influenza A(H1N1)pdm09 virus and those responses' contribution to the immunopathology associated with this infection. Severe disease is characterized by early secretion of proinflammatory and immunomodulatory cytokines. This cytokine secretion persisted in patients with severe viral pneumonia and was directly associated with the degree of viral replication in the respiratory tract. Cytokines play important roles in the antiviral defense, but persistent hypercytokinemia may cause inflammatory tissue damage and participate in the genesis of the respiratory failure observed in these patients. An absence of pre-existing protective antibodies was the rule for both mild and severe cases. A role for pathogenic immunocomplexes has been proposed for this disease. Defective T cell responses characterize severe cases of infection caused by the influenza A(H1N1)pdm09 virus. Immune alterations associated with accompanying conditions such as obesity, pregnancy or chronic obstructive pulmonary disease may interfere with the normal development of the specific response to the virus. The role of host immunogenetic factors associated with disease severity is also discussed in this review. In conclusion, currently available information suggests a complex immunological dysfunction/alteration that characterizes the severe cases of 2009 pandemic influenza. The potential benefits of prophylactic/therapeutic interventions aimed at preventing/correcting such dysfunction warrant investigation.
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Affiliation(s)
- Raquel Almansa
- Unidad de Investigación Médica en Infección e Inmunidad (IMI), Investigación Biomédica del Clínico (ibC), Hospital Clínico Universitario, Valladolid, Spain
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Julián-Jiménez A, Gómez-Hernando C, Arrese-Cosculluela MÁ, Estebaran-Martín J. Impacto y carga asistencial durante la pandemia de gripe A (H1N1) en el servicio de urgencias y en un hospital terciario. Enferm Infecc Microbiol Clin 2012; 30:169-70. [DOI: 10.1016/j.eimc.2011.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 10/25/2011] [Indexed: 10/14/2022]
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Rodríguez-Rieiro C, Carrasco-Garrido P, Hernández-Barrera V, López de Andrés A, Jimenez-Trujillo I, Gil de Miguel A, Jiménez-García R. Pandemic influenza hospitalization in Spain (2009): incidence, in-hospital mortality, comorbidities and costs. Hum Vaccin Immunother 2012; 8:443-7. [PMID: 22370516 DOI: 10.4161/hv.18911] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Based on data drawn from the national hospitalization discharge registry, we sought to describe the clinical and epidemiological characteristics of patients hospitalized with pandemic influenza H1N1 in Spain in 2009. Authors calculated national rates of hospitalization stratified by age and analyzed co-morbidities, in hospital mortality, average length of stay and associated medical costs. A total of 11,449 patients were hospitalized (24.9/100,000 inhabitants). Median age was 34 y and 50.28% were male. The highest incidence was observed in the group from 0 to 14 y (42.3/100000 inhabitants), 27.7% of hospitalized women of childbearing age were pregnant and overall in hospital mortality reached 2.46%. The average length of stay was 5 d, median costs per admission was €2,152 and total cost was €35.4 million. Among those patients, 5,791 (50.6%) had an underlying chronic disease: asthma (15.36%), diabetes (9.02%), obesity (8.47%), cancer (4.47%), epilepsy (2.24%), and HIV (2.22%). Suffering a chronic condition was an independent risk factor for dying (OR 13.31 95% for 0-14 y and OR 3.27 for 15-64 y). We conclude that hospitalization was higher in infants and in young adults with associated co-morbidities. Suffering a chronic condition increased the risk of dying as the age decreased. This information will be helpful to prepare vaccination strategies against next pandemic threats.
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Rodríguez A, Alvarez-Rocha L, Sirvent JM, Zaragoza R, Nieto M, Arenzana A, Luque P, Socías L, Martín M, Navarro D, Camarena J, Lorente L, Trefler S, Vidaur L, Solé-Violán J, Barcenilla F, Pobo A, Vallés J, Ferri C, Martín-Loeches I, Díaz E, López D, López-Pueyo MJ, Gordo F, del Nogal F, Marqués A, Tormo S, Fuset MP, Pérez F, Bonastre J, Suberviola B, Navas E, León C. [Recommendations of the Infectious Diseases Work Group (GTEI) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Infections in Critically Ill Patients Study Group (GEIPC) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) for the diagnosis and treatment of influenza A/H1N1 in seriously ill adults admitted to the Intensive Care Unit]. Med Intensiva 2012; 36:103-37. [PMID: 22245450 DOI: 10.1016/j.medin.2011.11.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/20/2011] [Indexed: 02/08/2023]
Abstract
The diagnosis of influenza A/H1N1 is mainly clinical, particularly during peak or seasonal flu outbreaks. A diagnostic test should be performed in all patients with fever and flu symptoms that require hospitalization. The respiratory sample (nasal or pharyngeal exudate or deeper sample in intubated patients) should be obtained as soon as possible, with the immediate start of empirical antiviral treatment. Molecular methods based on nucleic acid amplification techniques (RT-PCR) are the gold standard for the diagnosis of influenza A/H1N1. Immunochromatographic methods have low sensitivity; a negative result therefore does not rule out active infection. Classical culture is slow and has low sensitivity. Direct immunofluorescence offers a sensitivity of 90%, but requires a sample of high quality. Indirect methods for detecting antibodies are only of epidemiological interest. Patients with A/H1N1 flu may have relative leukopenia and elevated serum levels of LDH, CPK and CRP, but none of these variables are independently associated to the prognosis. However, plasma LDH> 1500 IU/L, and the presence of thrombocytopenia <150 x 10(9)/L, could define a patient population at risk of suffering serious complications. Antiviral administration (oseltamivir) should start early (<48 h from the onset of symptoms), with a dose of 75 mg every 12h, and with a duration of at least 7 days or until clinical improvement is observed. Early antiviral administration is associated to improved survival in critically ill patients. New antiviral drugs, especially those formulated for intravenous administration, may be the best choice in future epidemics. Patients with a high suspicion of influenza A/H1N1 infection must continue with antiviral treatment, regardless of the negative results of initial tests, unless an alternative diagnosis can be established or clinical criteria suggest a low probability of influenza. In patients with influenza A/H1N1 pneumonia, empirical antibiotic therapy should be provided due to the possibility of bacterial coinfection. A beta-lactam plus a macrolide should be administered as soon as possible. The microbiological findings and clinical or laboratory test variables may decide withdrawal or not of antibiotic treatment. Pneumococcal vaccination is recommended as a preventive measure in the population at risk of suffering severe complications. Although the use of moderate- or low-dose corticosteroids has been proposed for the treatment of influenza A/H1N1 pneumonia, the existing scientific evidence is not sufficient to recommend the use of corticosteroids in these patients. The treatment of acute respiratory distress syndrome in patients with influenza A/H1N1 must be based on the use of a protective ventilatory strategy (tidal volume <10 ml / kg and plateau pressure <35 mmHg) and positive end-expiratory pressure set to high patient lung mechanics, combined with the use of prone ventilation, muscle relaxation and recruitment maneuvers. Noninvasive mechanical ventilation cannot be considered a technique of choice in patients with acute respiratory distress syndrome, though it may be useful in experienced centers and in cases of respiratory failure associated with chronic obstructive pulmonary disease exacerbation or heart failure. Extracorporeal membrane oxygenation is a rescue technique in refractory acute respiratory distress syndrome due to influenza A/H1N1 infection. The scientific evidence is weak, however, and extracorporeal membrane oxygenation is not the technique of choice. Extracorporeal membrane oxygenation will be advisable if all other options have failed to improve oxygenation. The centralization of extracorporeal membrane oxygenation in referral hospitals is recommended. Clinical findings show 50-60% survival rates in patients treated with this technique. Cardiovascular complications of influenza A/H1N1 are common. Such problems may appear due to the deterioration of pre-existing cardiomyopathy, myocarditis, ischemic heart disease and right ventricular dysfunction. Early diagnosis and adequate monitoring allow the start of effective treatment, and in severe cases help decide the use of circulatory support systems. Influenza vaccination is recommended for all patients at risk. This indication in turn could be extended to all subjects over 6 months of age, unless contraindicated. Children should receive two doses (one per month). Immunocompromised patients and the population at risk should receive one dose and another dose annually. The frequency of adverse effects of the vaccine against A/H1N1 flu is similar to that of seasonal flu. Chemoprophylaxis must always be considered a supplement to vaccination, and is indicated in people at high risk of complications, as well in healthcare personnel who have been exposed.
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Affiliation(s)
- A Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII, IISPV - URV - CIBER Enfermedades Respiratorias, Tarragona, España.
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Gripe A, ¿seguirá mutando? Med Intensiva 2012; 36:64. [DOI: 10.1016/j.medin.2011.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 11/12/2011] [Indexed: 11/23/2022]
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Nin N, Sánchez-Rodríguez C, Ver L, Cardinal P, Ferruelo A, Soto L, Deicas A, Campos N, Rocha O, Ceraso D, El-Assar M, Ortín J, Fernández-Segoviano P, Esteban A, Lorente J. Lung histopathological findings in fatal pandemic influenza A (H1N1). Med Intensiva 2012; 36:24-31. [DOI: 10.1016/j.medin.2011.10.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 10/18/2011] [Accepted: 10/19/2011] [Indexed: 11/28/2022]
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Rello J, Balcells J. El retorno de la gripe: liderazgo, trabajo en equipo y anticipación. Med Intensiva 2011; 35:460-2. [DOI: 10.1016/j.medin.2011.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 05/20/2011] [Accepted: 05/24/2011] [Indexed: 11/27/2022]
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