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H1N1 Pandemic Flu 2009: Preparation, Prevention and Treatment
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By Peter Laird, MD America is sending our children back to school with an expected surge in H1N1 influenza cases. At the Centers for Disease Control and Prevention (CDC) H1N1 news briefing, the CDC states that H1N1 is unpredictable but can be a severe disease especially in people with chronic illnesses. To date, the composite Case Fatality Rate (CFR) of the current H1N1 flu pandemic is below 1% with most people infected making a full and complete recovery after a mild illness. However, the H1N1 2009 pandemic flu has many features differing from the usual seasonal flu which forebode the potential for adverse outcomes especially among people with chronic medical conditions including renal disease. In exception to the usual seasonal flu which affects primarily the elderly and chronically ill, the 2009 H1N1 pandemic flu is twenty times more likely in children and young adults ages five to twenty four. H1N1 flu is spreading four times faster than ordinary flu viruses and forty percent of the recorded deaths are in children and young adults who were previously in good health. Pregnant women are at an unusually high risk of death especially during their third trimester. The World Health Organization (WHO) recently issued a warning of a severe form of H1N1 flu that attacks the lung tissues directly whereas seasonal flu is usually harbored only in the upper respiratory tract causing annoying symptoms, but is rarely deadly for healthy individuals. In early unpublished reports from the CDC, people with chronic kidney disease comprised eight percent of the deaths making careful preparation for this flu season mandatory among all people with chronic kidney disease (CKD). Ninety five percent of patients infected with the H1N1 virus will present with fever, cough and sore throat while many commonly have headaches, body aches, fatigue, runny nose and chills as well. Approximately fifteen percent of patients will develop gastrointestinal symptoms including nausea, vomiting and diarrhea. All patients with chronic kidney disease should contact their health care provider immediately if they develop any of these symptoms suggestive of the flu. For patients that progress to more severe symptoms such as difficulty breathing, chest pain, dizziness or signs of dehydration, confusion or discolored or blue lips, they should seek emergency medical attention without any delay. Given the possibility of severe respiratory or gastrointestinal involvement with the H1N1 flu, preparing ahead of time is crucial, especially for those with renal disease. A) Prepare for the worst while hoping for the best: *Plan ahead: Update your home address and emergency contact information with your health care team and prepare alternate transportation options. *Stockpile over the counter cold and flu remedies including anti-nausea and diarrhea agents, replacement electrolyte solutions, pain relievers as well as maintaining all of your prescription medications. *Review emergency diet with your dietician and prepare two weeks of food and water. Dialysis providers should prepare for alternate dialysis schedules if a large number of dialysis personnel call in sick. *Secure basic emergency equipment such as thermometers, flashlights, batteries, garbage bags and toiletries. *Store hand wipes, hand sanitizers, soap and personal hygiene items at home and in your car where they are easily accessible. *Obtain personal protective masks graded as N95 for all members of your household. *For home hemodialysis and peritoneal dialysis patients, gather extra medical supplies through your provider in case of any disruption in resupply that may occur during an extended influenza surge. *Update all usual vaccinations with your doctor including pneumococcal vaccine which helps to prevent pneumonia in high risk patient populations. *Obtain the seasonal flu shot when it is available. Co-infection with H1N1 leads to more severe outcomes. *Talk with family and friends about your preparations especially for patients living alone or with an elderly partner who may also be at risk of illness. B) Preventing H1N1 flu spread at home and at work: Personal Hygiene: *Wash your hands frequently and learn to avoid touching your eyes, mouth and nose which is the most common mode of transmission from inanimate objects contaminated by an infected individual. *Avoid handshakes, kissing and close personal contact. *Keep hand wipes and hand sanitizer available for immediate use at all times. Social Distancing: *Avoid large gatherings where closeness to other people is unavoidable. *Stay home if you develop flu symptoms. For those doing in-center hemodialysis, do not skip dialysis sessions since you will need your renal replacement therapies to overcome an active flu infection. Notify your center ahead of time. *Stay six feet away from other people to avoid infection through respiratory droplets. *Avoid people who are coughing or obviously ill. Medical Masks: * Understand that ordinary surgical masks will protect others from you if you have H1N1 but may not protect you from others with the disease. The CDC recommends individual respirators rated as N95 masks for maximal self protection. You may find them at medical supply stores as well as paint supply and hardware stores. Look for the N95 designation. *Utilize medical masks during transport to dialysis centers to protect your drivers. They are your life line to continued dialysis during an overwhelming flu surge and will be more likely to place themselves at risk if you do your part in protecting them as well. *Do not reuse disposable masks as this reduces their ability to protect you and others. H1N1 Flu Vaccine: *The United States has contracted with five companies to provide H1N1 flu shots for health care workers and those at high risk but production is slower than expected. *Forty-five million doses are expected by mid-October with twenty million doses per week after that. *You will need two shots of the H1N1 vaccination at an interval of 21-28 days to obtain adequate protective antibodies two weeks after the second injection is completed. *Discuss with your provider when and where you can obtain this vaccine series as well as the seasonal flu vaccine for a total of at least two shots this year. (Medicare will pay/reimburse for the N1H1 vaccination) Antiviral Prophylaxis: *There are four antiviral medications approved for treatment and prophylaxis of the flu in the United States. Rimantadine and Amantadine have a high rate of resistance leaving Oseltamivir (Tamiflu) and Zanamivir (Relenza) the drugs of choice. *Tamiflu and Relenza are effective in preventing influenza in at risk groups during an extensive outbreak. Discuss with your provider under what circumstances you should consider taking these medications and what are the potential side effects that you may encounter. C) Treating H1N1 Flu in the CKD population: *All CKD patients who develop symptoms of H1N1 influenza should immediately contact their health care provider due to an increased risk of adverse complications in the renal disease population no matter what modality of renal replacement therapy utilized. *Oseltamivir (Tamiflu) dose reduction is needed for all CKD patients. Zanamivir (Relenza) has a low bioavailability and no dose reduction is recommended for CKD patients. * Treatment needs to start with in the first 48 hours that the patient is symptomatic to be effective. *One excellent study on bioavailability of Tamiflu in the CKD population offers guidance to providers: The pharmacokinetics and tolerability of oseltamivir suspension in patients on haemodialysis and continuous ambulatory peritoneal dialysis Nephrol Dial Transplant (2006) 21: 2556–2562 Advance Access publication 24 June 2006 Richard Robson, Adrian Buttimore, Kelvin Lynn, Mike Brewster and Penelope Ward “The results of the present study suggest that 30 mg oseltamivir in suspension can be given weekly (to CAPD patients) or after alternate HDs (to HD patients), to provide effective treatment for, or prophylaxis against, influenza illness. HD patients should take 30 mg after alternate HD sessions over a 5 day period. For prophylaxis, our results indicate that administration of 30 mg oseltamivir once a week after CAPD and 30 mg after each alternate HD session are well-tolerated when administered over a 6 week period, and further dose reductions need not be made in either of these patient populations. Administration over a 6 week period would normally be sufficient to provide protection for the duration of a local influenza outbreak.” During any extended flu outbreak, you should continue with your regular provision of renal replacement therapy unless directed differently by your medical team. Interruption of hemodialysis, peritoneal dialysis or immunosuppressive medications can put you at risk of adverse outcomes. Protect the care takers and other people in your home by avoiding close contact with those who are ill (especially face to face contact), provide adequate air ventilation, throw away paper towels and contaminated tissues immediately, and wash your hands frequently. The H1N1 influenza pandemic of 2009 is likely to be the most challenging flu season that anyone of this generation will have lived through to date. Understanding the basic principles of preparation, prevention and treatment for the H1N1 virus can help you to reduce your risk of severe illness. Learning about the H1N1 flu virus from reputable sources will help give you and your family members hope even in these trying times. You may learn more about the H1N1 virus at the following websites: Centers for Disease Control and Prevention: 2009 H1N1 Flu (Swine Flu) World Health Organization: Pandemic (H1N1) 2009 Dialysis From the Sharp End of the Needle http://www.billpeckham.com/from_the_sharp_end_of_the/pandemic/
CMS Vaccine PDF
About the Author
Dr. Peter Laird is a renal disease patient who started on hemodialysis in 2007 who is also an experienced internal medicine physician which gives him a unique perspective on renal related issues from that of a physician and at the same time as a patient. Dr. Laird is currently on an expanded dose of home hemodialysis with the NxStage System One and he is also a regular contributor on the renal issues blog - Dialysis from the sharp end of the needle.
Last Updated September 2009
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