1. Public Health Update David Kirschke, MD Medical Director / Health Officer Northeast Tennessee Regional Health Office

2. 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

3. 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)

4. 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

5. 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

6. 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

8. 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

10. 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

11. 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

12. 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

13. 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

14. Think Influenza! Fever Rapid Flu Test? Sore Throat Cough Flu Season

15. 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.”