H1N1 Resources

OBJECTIVE: To examine 2009 H1N1 influenza illness severity and the effect of antiviral treatment on the severity of illness among pregnant women. METHODS: We abstracted medical records from hospitalized pregnant (n=62) and nonpregnant (n=74) women with laboratory-confirmed 2009 H1N1 influenza in New York City, May through June 2009. We compared characteristics of pregnant and nonpregnant women and of severe and moderate influenza illness among pregnant women, with severe defined as illness resulting in intensive care admission or death. RESULTS: The 2009 H1N1 hospitalization rate was significantly higher among pregnant than nonpregnant women (55.3 compared with 7.7 per 100,000 population). Eight pregnant (including two deaths) and 16 nonpregnant (including four deaths) cases were severe. Pregnant women represented 6.4% of hospitalized cases and 4.3% of deaths caused by 2009 H1N1 influenza. Only 1 in 30 (3.3%) pregnant women who received oseltamivir treatment within 2 days of symptom onset had severe illness compared with 3 of 14 (21.4%) and four of nine (44.4%) pregnant women who started treatment 3–4 days and 5 days or more after symptom onset, respectively (P=.002 for trend). Severe and moderate 2009 H1N1 influenza illness occurred in all pregnancy trimesters, but most women (54.8%) were in the third trimester. Twenty-two women delivered during their influenza hospitalization, and severe neonatal outcomes (neonatal intensive care unit admission or death) occurred among five of six (83.3%) women with severe illness compared with 2 of 16 (12.5%) women with moderate illness (P=.004). CONCLUSION: Our findings highlight the potential for severe illness and adverse neonatal outcomes among pregnant 2009 H1N1 influenza-infected women and suggest the benefit of early oseltamivir treatment. (Obstet Gynecol 2010;115:717–26

BACKGROUND: During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of the patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009.
METHODS: Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase–polymerase-chain-reaction assay.
RESULTS: Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. Forty-five percent of the patients were children under the age of 18 years, and 5% were 65 years of age or older. Seventy-three percent of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early.
CONCLUSIONS: During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.

BACKGROUND: Pandemic H1N1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the first month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak.
METHODS: After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness.
FINDINGS: From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0.32 per 100 000 pregnant women, 95% CI 0.13-0.52 vs 0.076 per 100 000 population at risk, 95% CI 0.07-0.09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation.
INTERPRETATION: Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs.

Background Like previous epidemic and pandemic diseases, 2009 pandemic influenza A (H1N1) may pose an increased risk of severe illness in pregnant women. Methods Statewide surveillance for patients who were hospitalized with or died from 2009 H1N1 influenza was initiated by the California Department of Public Health. We reviewed demographic and clinical data reported from April 23 through August 11, 2009, for all H1N1-infected, reproductive-age women who were hospitalized or died — nonpregnant women, pregnant women, and postpartum women (those who had delivered ≤2 weeks previously). Results Data were reported for 94 pregnant women, 8 postpartum women, and 137 nonpregnant women of reproductive age who were hospitalized with 2009 H1N1 influenza. Rapid antigen tests were falsely negative in 38% of the patients tested (58 of 153). Most pregnant patients (89 of 94 [95%]) were in the second or third trimester, and approximately one third (32 of 93 [34%]) had established risk factors for complications from influenza other than pregnancy. As compared with early antiviral treatment (administered ≤2 days after symptom onset) in pregnant women, later treatment was associated with admission to an intensive care unit (ICU) or death (relative risk, 4.3). In all, 18 pregnant women and 4 postpartum women (total, 22 of 102 [22%]) required intensive care, and 8 (8%) died. Six deliveries occurred in the ICU, including four emergency cesarean deliveries. The 2009 H1N1 influenza–specific maternal mortality ratio (the number of maternal deaths per 100,000 live births) was 4.3. Conclusions 2009 H1N1 influenza can cause severe illness and death in pregnant and postpartum women; regardless of the results of rapid antigen testing, prompt evaluation and antiviral treatment of influenza-like illness should be considered in such women. The high cause-specific maternal mortality rate suggests that 2009 H1N1 influenza may increase the 2009 maternal mortality ratio in the United States.

OBJECTIVE: The objective of the study was to characterize severe illness because of the 2009 pandemic influenza A (H1N1) infection in postpartum women. STUDY DESIGN: We reviewed case reports of infected hospitalized postpartum (
6 months from delivery) women identified through statewide surveillance in California. From April 23 through August 11, 2009, all hospitalizations and/or deaths were reported. After August 11, reporting was limited to cases requiring intensive care or deaths. RESULTS: From April 23 to December 31, 2009, 15 cases were reported; 11 (73%) had symptom onset within 7 days postpartum. Of 10 hospitalized cases reported through August 11, 4 required intensive care, 3 required mechanical ventilation, and 2 died. Of 5 cases requiring intensive care reported after August 11, all required mechanical ventilation and 1 died. Overall, 6 (43%) received antivirals within 48 hours of symptom onset. CONCLUSION: The 2009 H1N1 can cause severe illness in postpartum women, especially in the first week following delivery.

OBJECTIVE: The objective of the study was to characterize severe illness because of the 2009 pandemic influenza A (H1N1) infection in postpartum women. STUDY DESIGN: We reviewed case reports of infected hospitalized postpartum (6 months from delivery) women identified through statewide surveillance in California. From April 23 through August 11, 2009, all hospitalizations and/or deaths were reported. After August 11, reporting was limited to cases requiring intensive care or deaths. RESULTS: From April 23 to December 31, 2009, 15 cases were reported; 11 (73%) had symptom onset within 7 days postpartum. Of 10 hospitalized cases reported through August 11, 4 required intensive care, 3 required mechanical ventilation, and 2 died. Of 5 cases requiring intensive care reported after August 11, all required mechanical ventilation and 1 died. Overall, 6 (43%) received antivirals within 48 hours of symptom onset. CONCLUSION: The 2009 H1N1 can cause severe illness in postpartum women, especially in the first week following delivery.

CLINICAL COMMENTARY: Among healthy persons, two groups are notable for increased risk of serious illness and hospitalization with influenza infection: healthy women in pregnancy and their healthy infants (aged 0 to 6 months). Inactivated influenza vaccine has been used in pregnant women since the 1960s in both the United States and Canada; however, currently, only 15% of pregnant women receive the vaccine. A randomized, controlled trial has shown influenza immunization of pregnant women reduced influenza-like illness by more than 30% in both the mothers and the infants and reduced laboratory-proven influenza infections in 0- to 6-month-old infants by 63%. Physicians caring for pregnant women should be aware of the risks of influenza and of the availability of an effective and cost-saving intervention.

An "In The Trenches" article (no formal abstract). Two cases of very severe maternal H1N1 illness are presented. This is followed by proposed guidelines for evaluation and treatment of H1N1 in pregnancy with extensive discussion in a Q&A format.

BACKGROUND: Young infants and pregnant women are at increased risk for serious consequences of influenza infection. Inactivated influenza vaccine is recommended for pregnant women but is not licensed for infants younger than 6 months of age. We assessed the clinical effectiveness of inactivated influenza vaccine administered during pregnancy in Bangladesh.
METHODS: In this randomized study, we assigned 340 mothers to receive either inactivated influenza vaccine (influenza-vaccine group) or the 23-valent pneumococcal polysaccharide vaccine (control group). Mothers were interviewed weekly to assess illnesses until 24 weeks after birth. Subjects with febrile respiratory illness were assessed clinically, and ill infants were tested for influenza antigens. We estimated the incidence of illness, incidence rate ratios, and vaccine effectiveness.
RESULTS: Mothers and infants were observed from August 2004 through December 2005. Among infants of mothers who received influenza vaccine, there were fewer cases of laboratory-confirmed influenza than among infants in the control group (6 cases and 16 cases, respectively), with a vaccine effectiveness of 63% (95% confidence interval [CI], 5 to 85). Respiratory illness with fever occurred in 110 infants in the influenza-vaccine group and 153 infants in the control group, with a vaccine effectiveness of 29% (95% CI, 7 to 46). Among the mothers, there was a reduction in the rate of respiratory illness with fever of 36% (95% CI, 4 to 57).
CONCLUSIONS: Inactivated influenza vaccine reduced proven influenza illness by 63% in infants up to 6 months of age and averted approximately a third of all febrile respiratory illnesses in mothers and young infants. Maternal influenza immunization is a strategy with substantial benefits for both mothers and infants.

Comprehensive Website for California-specific information.
PREVENTION: Provides general information and access to posters and brochures.
VACCINATION: Information about the status of California's vaccine supply.
WHATS NEW: H1N1 (2009) Influenza Data and Statistics Update with reported hospitalized, ICU, and fatal cases of H1N1 (2009) influenza virus infections in California.
GUIDANCE: In the box section on the right, there is a section for California-specific guideline updates from CDPH.

Provides up to date links to a variety of good resources. Includes information for pregnant women and parents; information for clinicians and health officials, general H1N1 and seasonal flu information.

This is a great discussion about key issues in H1N1 and pregnancy. Good for mothers and for providers. It is a YouTube video that is an hour long (scroll down the list of archived Webcasts to August 27, 2009). An important discussion on newborn isolation is at minute 34:40. This emphasizes clinical judgment for the need to isolate the baby after birth: if the mother is very ill then the baby is isolated. However, if the mother is on treatment and doing well then the need for isolation is not well established. This has not yet been put into writing as a formal recommendation by the CDC but is what many practitioners are doing in clinical practice.

Scroll down to see many useful charts and maps that can be easily swept into PPT presentations. Maps for prior weeks (for comparison) can be found at the very bottom of the page.

Great site for a large variety of PDFs of education materials for general use, parents, pregnant women, vaccine, and anti-flu drugs. Many are also in Spanish and a few in Chinese.

Multiple topics covered including: general questions, Thimerosal, Guillain-Barre, Adjuvants, Testing and Monitoring, and Adverse Effects Monitoring.

OVERVIEW: The single best place to visit for connections to a wide variety of resources (some of which we have individually indexed).
KEY STEP: Visit here often for updates.

Clinician Outreach Communication Activity (COCA) Conference Calls are designed to serve as the venue for timely education and two-way communication with CDC Subject Matter Experts (SME).
FIND: Scroll to the September 29, 2009 date.
CONTENTS: Transcript and MP3 audio recording that go with the Slide Set (Slides are in the CMQCC H1N1 Documents area (below) or can be directly downloaded from this same site). The presentation is broken into 5 areas: Overview of influenza; Infection control guidance; Testing and treatment; Vaccination; and The Atlanta experience.

This guideline represents a tweaking of the CDC/Emory evaluation algorithm to be pregnancy specific. It is an excellent summary of current thinking.

Patient information sheet that covers signs and symptoms, prevention, what to do if you think you have the flu, and safety of flu vaccines.

SUMMARY: This document has been developed to provide guidance for prevention and management of novel H1N1 flu infection in inpatient and out-patient obstetric settings. Severe illnesses among pregnant woman and infants have been reported in this outbreak, although the epidemiology and spectrum of illness among pregnant woman and infants are not fully understood at this time and are under investigation. Prevention of infection with novel influenza A (H1N1) virus in pregnant women and infants is the highest priority message in this guidance. Healthy pregnant women should have access to prenatal care and labor and delivery services in settings where they can be separated from persons who are ill or potentially ill with novel H1N1 flu infection. In addition, a cautious approach to the management of neonates with ill mothers is recommended which includes isolation and close observation. Recommendations are interim, based on current knowledge of the novel H1N1 flu outbreak in the United States, and may be revised as more information becomes available.
COMMENT: It is widely anticipated that this document will be revised shortly, particularly the sections on isolation.

Released on 9/17/09: Pregnant women are at higher risk for severe complications and death from influenza, including both 2009 H1N1 influenza and seasonal influenza. Treatment with oseltamivir (Tamiflu®) or zanamivir (Relenza®) is recommended for pregnant women with suspected or confirmed influenza and can be taken during any trimester of pregnancy. The duration of antiviral treatment is 5 days. See Table 1 (below) for dosing information. Oseltamivir and zanamivir are "Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. However, the available risk-benefit data indicate pregnant women with suspected or confirmed influenza should receive prompt antiviral therapy. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Treatment should be initiated as early as possible because studies show that treatment initiated early (i.e., within 48 hours of illness onset) is more likely to provide benefit. Treatment should not wait for laboratory confirmation of influenza because laboratory testing can delay treatment and because a negative rapid test for influenza does not rule out influenza. The sensitivity of rapid tests can range from 10 % to 70%. View information on the use of rapid influenza diagnostic tests.

SUMMARY: This is the required CDC Vaccine information statement for all patients who receive the inactivated 2009 H1N1 vaccine. A Spanish translation is also available.

SUMMARY: very comprehensive set of Q+A for clinicians about the use of H1N1 vaccine in pregnancy.

SUMMARY: Likely the best and most comprehensive vaccine Q+A sheet for pregnant women.

SUMMARY: Comprehensive set of Q+A for clinicians about the Nasal Spray Vaccine (aka: Live Attenuated Influenza Vaccine or LAIV). While this vaccine is contraindicated for pregnant women on theoretical grounds, it is safe and recommended for post-partum mothers, mothers who are breast-feeding, and for partners and others living with pregnant women.

SUMMARY: This is the required CDC Vaccine information statement in SPANISH for all patients who receive the inactivated 2009 H1N1 vaccine.

SUMMARY: Q+A for issues around infection control measures for inpatient H1N1 infections (goes with the Guidelines that were releases the same day). It does not address L&D, Postpartum and Nursery issues.

REVISIONS FROM EARLIER GUIDANCE INCLUDE: criteria for identification of suspected influenza patients; recommended time away from work for healthcare personnel; changes to isolation precautions based on tasks and anticipated exposures; expansion of information on the hierarchy of controls which ranks preventive interventions in the following order of preference: elimination of exposures, engineering controls, administrative controls, and personal protective equipment; and changes to guidance on use of respiratory protection.

UPDATES INCLUDE: 1. Clarify treatment and chemoprophylaxis considerations for persons vaccinated with the 2009 H1N1 and seasonal influenza vaccines. 2. Include women up to 2 weeks postpartum at higher risk for complications from 2009 H1N1 influenza. 3. Provide additional oseltamivir dosing instructions for children younger than 1 year of age. 4. Review adverse events and contraindications associated with oseltamivir and zanamivir.

SUMMARY: Good general information for patients about H1N1 and pregnancy including prevention, symptoms, medications and a little about the vaccine.

NOTE: This interim guidance has been updated to replace previously posted guidance entitled “Considerations Regarding Novel H1N1 Flu Virus in Obstetric Settings”, dated July 6, 2009. This document clarifies clinical considerations related to management of suspected or confirmed maternal infection with 2009 H1N1 influenza virus infection within labor and delivery, postpartum, and newborn care settings in hospitals. A cautious approach to the management of ill mothers and their newborns is still recommended, but several options are provided based on hospital configuration, staffing, and surge capacity.
SUMMARY: Pregnant women who enter the hospital setting with illness from suspected or confirmed 2009 H1N1 influenza virus infection represent a special population warranting clinical management that considers the specific risks that 2009 H1N1 virus exposure poses to the newborn infant. The location of the mother and newborn should be considered based on postpartum and/or newborn ward configuration and existing infection control policies. As clinically indicated providers should consider a TWO-STEP process to manage postpartum and newborn care.
ONE: Providers should consider temporarily separating the infected mother from the newborn within her room (in an isolette) or in separate rooms until the risk of infectious transmission is reduced, defined as having met ALL of the following criteria: * The mother has received antiviral medications for at least 48 hours and; * The mother is without fever for 24 hours without antipyretics and; * The mother can control cough and respiratory secretions. Once these criteria are met, the mother and infant can initiate close contact throughout the postpartum period with droplet precautions and the mother can begin infant feedings.
TWO: Once the mother and infant are able to initiate close contact, the following guidance is offered for mothers immediately prior to feeding and handling the infant in order to protect the newborn from droplet exposure: * The mother should wash her hands with soap and water; * The mother should put on a face mask; * The mother should observe all respiratory hygiene/ cough etiquette guidelines. These precautions should be followed for 7 days after symptom onset or 24 hours after resolution of symptoms, whichever is longer. Healthy term newborns of infected mothers with suspected or confirmed 2009 H1N1 should be considered exposed, rather than infected, if they are born in the hospital setting following infection control guidelines. These infants should be observed for signs of infection. Unless clinically indicated, these newborns should be cared for with standard precautions whether they are cared for in the mother’s room or in the term newborn nursery setting.

SUMMARY: This is an algorithm developed by the Emory School of Medicine and used widely on the East Coast. ACOG has adopted it with minor modifications for use in telephone triage for OB's offices. Teo key elements for OB's are: 1) be sure the patient knows to call back and seek care if she worsens or does not improve, and 2) there needs to be a clear plan and site for evaluation other than the OB's office.

Slide set (55 slides) discussing the latest CDC guidelines with some background. Largely replaces the earlier CDC COCA slides.

SUMMARY : Since 2006, California law [Health and Safety Code Section 124172 subdivision (a)] has stated that vaccines containing specific levels of mercury cannot be administered to pregnant women and young children, except under certain circumstances. The Secretary of the California Health and Human Services Agency has granted an exemption to this restriction for Influenza A (H1N1) 2009 Monovalent Vaccine in children younger than 3 years of age and pregnant womenfrom October 12, 2009 – November 30, 2009. The exception is being granted because of the present dangers posed by pandemic (H1N1) influenza and because there are insufficient supplies of thimerosal-free influenza A (H1N1) 2009 monovalent influenza vaccine to comply with the law. The need for an extension of the exemption will be assessed over this period.

A good general slide set made for OB Grand Rounds or Nursing Education. Covers epidemiology, pregnancy risks, triage assessment, treatment and prophylaxis, vaccine issues, and isolation/visitor policies.

Clinician Outreach Communication Activity (COCA) Conference Calls are designed to serve as the venue for timely education and two-way communication with CDC Subject Matter Experts (SME).
SLIDE SET: broken into 5 areas: Overview of influenza; Infection control guidance; Testing and treatment; Vaccination; and The Atlanta experience. Note that this slide set is in.pps format so that it is not editable.
TRANSCRIPT AND AUDIO TAPE: can be obtained using the citation noted in Web Resources with the same authors.