Compliance and side effects of prophylactic oseltamivir treatment in a school in South West England

Non-Adherence Tree Analysis (NATA)-An adherence improvement framework: A COVID-19 case study

Poor medication adherence is a global phenomenon that has received a significant amount of research attention yet remains largely unsolved. Medication non-adherence can blur drug efficacy results in clinical trials, lead to substantial financial losses, increase the risk of relapse and hospitalisation, or lead to death. The most common methods of measuring adherence are post-treatment measures; that is, adherence is usually measured after the treatment has begun. What the authors are proposing in this multidisciplinary study is a new technique for predicting the factors that are likely to cause non-adherence before or during medication treatment, illustrated in the context of potential non-adherence to COVID-19 antiviral medication. Fault Tree Analysis (FTA), allows system analysts to determine how combinations of simple faults of a system can propagate to cause a total system failure. Monte Carlo simulation is a mathematical algorithm that depends heavily on repeated random sampling to predict the behaviour of a system. In this study, the authors propose a new technique called Non-Adherence Tree Analysis (NATA), based on the FTA and Monte Carlo simulation techniques, to improve adherence. Firstly, the non-adherence factors of a medication treatment lifecycle are translated into what is referred to as a Non-Adherence Tree (NAT). Secondly, the NAT is coded into a format that is translated into the GoldSim software for performing dynamic system modelling and analysis using Monte Carlo. Finally, the GoldSim model is simulated and analysed to predict the behaviour of the NAT. NATA is dynamic and able to learn from emerging datasets to improve the accuracy of future predictions. It produces a framework for improving adherence by analysing social and non-social adherence barriers. Novel terminologies and mathematical expressions have been developed and applied to real-world scenarios. The results of the application of NATA using data from six previous studies in relation to antiviral medication demonstrate a predictive model which suggests that the biggest factor that could contribute to non-adherence to a COVID-19 antiviral treatment is a therapy-related factor (the side effects of the medication). This is closely followed by a condition-related factor (asymptomatic nature of the disease) then patient-related factors (forgetfulness and other causes). From the results, it appears that side effects, asymptomatic factors and forgetfulness contribute 32.44%, 22.67% and 18.22% respectively to discontinuation of medication treatment of COVID-19 antiviral medication treatment. With this information, clinicians can implement relevant interventions and measures and allocate resources appropriately to minimise non-adherence.

Neuropsychiatric events in an adult patient with influenza a (H3N2) treated with oseltamivir (Tamiflu): a case report

Background

Total four influenza pandemics have happened since twentieth century, and currently influenza is in the seasonal epidemic around the world, with a sharp increase in its incidence each year. As an effective treatment of influenza infection, the use of oseltamivir is climbing globally. However, there have been reports of neuropsychiatric events associated with the drug, mainly in young patients and males. To our knowledge, this is the first reported case of oseltamivir-associated neuropsychiatric events occurring in an patient over 50-year-old.

Case presentation

Here we present the case of a 57-year-old Chinese female with H3N2 influenza infection who developed abnormal psychiatric symptoms after administration of high doses of oseltamivir. The patient recovered completely within the cessation of oseltamivir.

Conclusions

We hope that our case report will lead clinicians to be mindful about oseltamivir’s potential neuropsychiatric side effects, and to pay special attention to each patient’s mental state, both in children and adults.

The Effect of Framed Health Messages on Intention to Take Antivirals for Pandemic Influenza: A Vignette-Based Randomised Controlled Trial

During the last influenza pandemic, adherence to antivirals was suboptimal. This study investigated the effect of manipulating the wording of written health messages on intentions to use antivirals as prophylaxis for pandemic influenza. After reading a hypothetical pandemic flu scenario, adult UK residents (N = 216) were randomly allocated to one of the four conditions, defined by a 2 × 2 (agency assignment × attribute framing) factorial design. Each condition presented messages describing the pandemic flu using linguistic expressions that assigned agency to either humans (HA: human agency) or the virus itself (VA: virus agency), whilst describing the antivirals side effects in terms of the chances of either experiencing (NF: negative framing) or not experiencing side effects (PF: positive framing). Intentions to use the antivirals and potential mediating factors were measured. Mean adherence intentions were high in all conditions with no significant differences between them. Higher perceived susceptibility, anticipated regret, self-efficacy, trust, and low response costs were found to predict adherence intentions. The VA messages increased perceived severity, the PF messages increased self-efficacy, whilst VA*PF affected response efficacy. The evidence did not support the hypothesis that the VA and PF framings can increase adherence intentions compared to the HA and NF messages, respectively.

Clinical and virological factors associated with gastrointestinal symptoms in patients with acute respiratory infection: a two-year prospective study in general practice medicine

Background

Gastrointestinal (GI) symptoms, such as diarrhea, vomiting, abdominal pain and nausea are not an uncommon manifestation of an acute respiratory infection (ARI).

We therefore evaluated clinical and microbiological factors associated with the presence of GI symptoms in patients consulting a general practitioner (GP) for ARI.

Methods

Nasopharyngeal swabs, stool specimens and clinical data from patients presenting to GPs with an ARI were prospectively collected during two winter seasons (2014-2016). Samples were tested by quantitative real-time PCR for 12 respiratory pathogen groups and for 12 enteric pathogens.

Results

Two hundred and four of 331 included patients (61.6%) were positive for at least one respiratory pathogen. Sixty-nine stools (20.8%) were positive for at least one pathogen (respiratory and/or enteric). GI symptoms were more likely declared in case of laboratory confirmed-enteric infection (adjusted odds ratio (aOR) = 3.2; 95% confidence interval [CI] [1.2–9.9]; p = 0.02) or human coronavirus (HCoV) infection (aOR = 2.7; [1.2–6.8]; p = 0.02). Consumption of antipyretic medication before the consultation seemed to reduce the risk of developing GI symptoms for patients with laboratory-confirmed influenza (aOR = 0.3; [0.1–0.6]; p = 0.002).

Conclusions

The presence of GI symptoms in ARI patients could not be explained by the detection of respiratory pathogens in stools. However, the detection of enteric pathogens in stool samples could explained by the presence of GI symptoms in some of ARI cases. The biological mechanisms explaining the association between the presence of HCoVs in nasopharynx and GI symptoms need to be explored.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2823-9) contains supplementary material, which is available to authorized users.

Efficacy and safety of Re-Du-Ning injection in the treatment of seasonal influenza: results from a randomized, double-blinded, multicenter, oseltamivir-controlled trial

Objective

To assess the efficacy and safety of RDNI in the treatment of seasonal influenza.

Results

1575 participants were screened and 229 completed the study and had a RT-PCR laboratory confirmation of influenza virus infection. Fever alleviation time was 2 and 6 hours, and fever clearance time was 27 and 47 in RDNI and oseltamivir, with significant difference between two groups. Total scores of influenza symptoms descended more in RDNI than oseltamivir on day 2 and day 3. Single symptom such as fever, aversion to cold, sore throat and nasal obstruction score descended more in RDNI than oseltamivir on different days. 20 subjects used aspirin during the trial, and there was no significant difference between two groups.

Materials and Methods

We conducted a randomized, double-blind, double-dummy, oseltamivir controlled clinical trial. Patients with a positive influenza rapid test diagnosis were enrolled and randomized to receive RDNI or oseltamivir. Primary outcome was the median fever alleviation and clearance time. Secondary outcomes were total 8 influenza symptom scores, the single influenza symptom score, and the frequency of aspirin usage.

Conclusions

The effect of RDNI was not worse than oseltamivir on the alleviation of influenza symptoms. RDNI was well tolerated, with no serious adverse events noted during the study period.

Cell Cycle-independent Role of Cyclin D3 in Host Restriction of Influenza Virus Infection

To identify new host factors that modulate the replication of influenza A virus, we performed a yeast two-hybrid screen using the cytoplasmic tail of matrix protein 2 from the highly pathogenic H5N1 strain. The screen revealed a high-score interaction with cyclin D3, a key regulator of cell cycle early G₁ phase. M2-cyclin D3 interaction was validated through GST pull-down and recapitulated in influenza A/WSN/33-infected cells. Knockdown of Ccnd3 by small interfering RNA significantly enhanced virus progeny titers in cell culture supernatants. Interestingly, the increase in virus production was due to cyclin D3 deficiency per se and not merely a consequence of cell cycle deregulation. A combined knockdown of Ccnd3 and Rb1, which rescued cell cycle progression into S phase, failed to normalize virus production. Infection by influenza A virus triggered redistribution of cyclin D3 from the nucleus to the cytoplasm, followed by its proteasomal degradation. When overexpressed in HEK 293T cells, cyclin D3 impaired binding of M2 with M1, which is essential for proper assembly of progeny virions, lending further support to its role as a putative restriction factor. Our study describes the identification and characterization of cyclin D3 as a novel interactor of influenza A virus M2 protein. We hypothesize that competitive inhibition of M1-M2 interaction by cyclin D3 impairs infectious virion formation and results in attenuated virus production. In addition, we provide mechanistic insights into the dynamic interplay of influenza virus with the host cell cycle machinery during infection.

A systematic review of factors affecting intended and actual adherence with antiviral medication as treatment or prophylaxis in seasonal and pandemic flu

The aim of this review was to identify factors predicting actual or intended adherence to antivirals as treatment or prophylaxis for influenza. Literature from inception to March 2015 was systematically reviewed to find studies reporting predictors of adherence to antivirals and self‐reported reasons for non‐adherence to antivirals. Twenty‐six studies were included in the review; twenty identified through the literature search and six through other means. Of these studies, 18 assessed predictors of actual adherence to antivirals, whereas eight assessed predictors of intended adherence. The most commonly found predictor of, and self‐reported reason for, non‐adherence was the occurrence of side effects. Other predictors include perceptions surrounding self‐efficacy, response efficacy and perceived personal consequences as well as social influences of others' experiences of taking antivirals. Predictors identified in this review can be used to help inform communications to increase adherence to antivirals in both seasonal and pandemic influenza.

Forsythoside A Controls Influenza A Virus Infection and Improves the Prognosis by Inhibiting Virus Replication in Mice

OBJECTIVE

The objective of this study was to observe the effects of forsythoside A on controlling influenza A virus (IAV) infection and improving the prognosis of IAV infection.

METHODS

Forty-eight SPF C57BL/6j mice were randomly divided into the following four groups: Group A: normal control group (normal con); Group B: IAV control group (V con); Group C: IAV+ oseltamivir treatment group (V oseltamivir; 0.78 mg/mL, 0.2 mL/mouse/day); Group D: IAV+ forsythoside A treatment group (V FTA; 2 μg/mL, 0.2 mL/mouse/day). Real-time fluorescence quantitative PCR (RT-qPCR) was used to measure mRNA expression of the TLR7, MyD88, TRAF6, IRAK4 and NF-κB p65 mRNA in TLR7 signaling pathway and the virus replication level in lung. Western blot was used to measure TLR7, MyD88 and NF-κB p65 protein. Flow cytometry was used to detect the proportion of the T cell subsets Th1/Th2 and Th17/Treg.

RESULTS

The body weight began to decrease after IAV infection, while FTA and oseltamivir could reduce the rate of body weight loss. The pathological damages in the FTA and oseltamivir group were less serious. TLR7, MyD88, TRAF6, IRAK4 and NF-κB p65 mRNA were up-regulated after virus infection (p < 0.01) while down-regulated after oseltamivir and FTA treatment (p < 0.01). The results of TLR7, MyD88 and NF-κB p65 protein consisted with correlative mRNA. Flow cytometry showed the Th1/Th2 differentiated towards Th2, and the Th17/Treg cells differentiated towards Treg after FTA treatment.

CONCLUSIONS

Our study suggests forsythoside A can control influenza A virus infection and improve the prognosis of IAV infection by inhibiting influenza A virus replication.

Efficacy and safety of clearing heat and detoxifying injection in the treatment of influenza: a randomized, double-blinded, placebo-controlled trial

Objective. To evaluate the efficacy and safety of CHDI in the treatment of influenza infection. Method. A randomized double-blind, double dummy trial was conducted. Influenza patients with a positive influenza A rapid test diagnosis were randomized to receive CHDI or oseltamivir. Primary outcome was assessed by the median fever alleviation time and clearance time, and secondary outcome was total scores of influenza symptoms. Results. One hundred thirty-nine participants were screened and 34 had a RT-PCR laboratory confirmation of influenza virus infection. Fever alleviation time was 2.5 and 5 hours in CHDI and oseltamivir, respectively, and fever clearance time was 32.5 and 49 hours. The HR of fever alleviation and clearance time shows no significant difference between two groups. Total scores of influenza symptoms descended significantly in both groups after treatment and descended more in CHDI than oseltamivir on day 2. Similar to total symptoms severity score, fever severity score descend more significantly in CHDI than oseltamivir on day 2, and there were no differences on other symptoms. Conclusions. CHDI have a similar effect to oseltamivir in reducing the duration of influenza illness. CHDI was well tolerated, with no serious adverse events noted during the study period.

Neuraminidase inhibitors for influenza: a review and public health perspective in the aftermath of the 2009 pandemic

OBJECTIVES

The objectives of this study were to: (1) reflect on key stages in the discovery, development and pre-pandemic use of neuraminidase inhibitors (NAIs), (2) summarise the evidence of NAI effectiveness for treatment and prophylaxis of seasonal influenza prior to the 2009 pandemic, and (3) summarise the evidence base generated during the 2009 pandemic period.

DESIGN

A rapid systematic review of evidence published to June 2010 was conducted where existing high-quality systematic reviews formed a baseline and were supplemented with data from other reviews, randomised controlled trials (RCTs) and observational studies.

MAIN OUTCOME MEASURES

Severity and duration of symptoms; rates of severe illness, complications and death following treatment for influenza or influenza-like illness; rates of influenza and influenza-like illness following long-term prophylaxis or post-exposure prophylaxis of household contacts.

RESULTS

Prior to the 2009 pandemic, evidence from RCTs conducted in seasonal influenza epidemics indicated that NAIs used to treat laboratory-confirmed influenza in healthy adults reduced the duration of illness by one day. NAIs provide high levels of protective efficacy in adults when given long-term or in household-based post-exposure prophylaxis for seasonal influenza. Several 2009 pandemic period observational studies suggest that early treatment may reduce rates of hospitalisation and in-hospital mortality, but data from that period do not substantially increase the evidence base on prophylaxis, although they confirm effectiveness.

CONCLUSIONS

NAIs should be deployed during a future pandemic for either post-exposure prophylaxis or treatment depending on national policy considerations and logistics. The existing evidence base on effectiveness against severe outcomes requires supplementation.

Prevention of influenza in healthy children

Healthy children are high transmitters of influenza and can experience poor influenza outcomes. Many questions remain about the efficacy and impect of preventive measures because most existing studies report imprecise proxies of influenza incidence, do not follow subjects throughout the entire influenza season and across multiple influenza seasons, or do not control for important factors such as timing of implementation and social contact patterns. Modeling and simulation are key methodologies to answer questions regarding influenza prevention. While vaccination may be the most efficacious existing intervention, variations in circulating strains and children's immune systems keep current vaccines from being fully protective, necessitating further clinical and economic studies and technology improvements. Hand hygiene appears to be an important adjunct but improving compliance, standardizing regimens and quantifying its impact remain challenging. Future studies should help better define the specific indications and circumstances for antiviral use and the role of nutritional supplements and nonpharmaceutical interventions.

Compliance to oseltamivir among two populations in Oxfordshire, United Kingdom affected by influenza A(H1N1)pdm09, November 2009--a waste water epidemiology study

Antiviral provision remains the focus of many pandemic preparedness plans, however, there is considerable uncertainty regarding antiviral compliance rates. Here we employ a waste water epidemiology approach to estimate oseltamivir (Tamiflu®) compliance. Oseltamivir carboxylate (oseltamivir's active metabolite) was recovered from two waste water treatment plant (WWTP) catchments within the United Kingdom at the peak of the autumnal wave of the 2009 Influenza A (H1N1)pdm09 pandemic. Predictions of oseltamivir consumption from detected levels were compared with two sources of national government statistics to derive compliance rates. Scenario and sensitivity analysis indicated between 3-4 and 120-154 people were using oseltamivir during the study period in the two WWTP catchments and a compliance rate between 45-60%. With approximately half the collected antivirals going unused, there is a clear need to alter public health messages to improve compliance. We argue that a near real-time understanding of drug compliance at the scale of the waste water treatment plant (hundreds to millions of people) can potentially help public health messages become more timely, targeted, and demographically sensitive, while potentially leading to less mis- and un-used antiviral, less wastage and ultimately a more robust and efficacious pandemic preparedness plan.

Oseltamivir and inhaled zanamivir as influenza prophylaxis in Thai health workers: a randomized, double-blind, placebo-controlled safety trial over 16 weeks

OBJECTIVES

Long-term chemoprophylaxis using neuraminidase inhibitors may be needed during influenza epidemics but safety data are limited to several weeks. We sought to assess the tolerability of oseltamivir and zanamivir as primary prophylaxis over 16 weeks.

METHODS

We conducted a parallel group, double blind, 2 (active drug) :1 (placebo) randomized trial of oral oseltamivir/placebo or inhaled zanamivir/placebo over 16 weeks in healthy, Thai hospital professionals at two Bangkok hospitals. The primary endpoint was study withdrawal due to drug-related (possibly, probably, definitely) serious or adverse events (AEs) graded ≥ 2.

RESULTS

Recruited subjects numbered 129 oseltamivir/65 placebo and 131 zanamivir/65 placebo. A total of 102 grade ≥ 2 AEs were reported or detected in 69 subjects: 23/129 (17.8%) versus 15/65 (23.1%) (P=0.26), and 23/131 (17.6%) versus 8/65 (12.3%) (P=0.28). Intercurrent infections/fevers [26/102 (25.5%)], abnormal biochemistry [25/102 (24.5%)] and gastrointestinal symptoms [18/102 (17.6%)] were the most frequently reported AEs. There were no drug-related study withdrawals. Eight serious AEs were all due to intercurrent illnesses. Laboratory, lung function and ECG parameters were similar between drugs and placebos.

CONCLUSIONS

Oseltamivir and zanamivir were well tolerated in healthy hospital professionals. Both drugs can be recommended for primary influenza prophylaxis for up to 16 weeks.

School closures and influenza: systematic review of epidemiological studies

OBJECTIVE

To review the effects of school closures on pandemic and seasonal influenza outbreaks.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE and EMBASE, reference lists of identified articles, hand searches of key journals and additional papers from the authors' collections.

STUDY SELECTION

Studies were included if they reported on a seasonal or pandemic influenza outbreak coinciding with a planned or unplanned school closure.

RESULTS

Of 2579 papers identified through MEDLINE and EMBASE, 65 were eligible for inclusion in the review along with 14 identified from other sources. Influenza incidence frequently declined after school closure. The effect was sometimes reversed when schools reopened, supporting a causal role for school closure in reducing incidence. Any benefits associated with school closure appeared to be greatest among school-aged children. However, as schools often closed late in the outbreak or other interventions were used concurrently, it was sometimes unclear how much school closure contributed to the reductions in incidence.

CONCLUSIONS

School closures appear to have the potential to reduce influenza transmission, but the heterogeneity in the data available means that the optimum strategy (eg, the ideal length and timing of closure) remains unclear.

Oseltamivir adherence and tolerability in health care workers treated prophylactically after occupational influenza exposure

This survey of health care workers who were prescribed oseltamivir prophylaxis after occupational exposure to 2009 pandemic influenza A (H1N1) documents their adherence, adverse effects, development of influenza-like illness, and knowledge and beliefs about the treatment and transmission of influenza. Adverse effects occurred in 15 of 36 participants evaluated (41.6%). The majority of the participants understood that influenza is highly infective and would take oseltamivir again, although 40.5% (15 of 37) thought they had not been given sufficient information about adverse effects.

Influenza outbreaks in Singapore: epidemiology, diagnosis, treatment and prevention

With the recent influenza A/H1N1 2009 pandemic still spreading through global populations, there has been an increased focus on optimizing the prevention, diagnosis and treatment of influenza infections, as well as the epidemiology of the virus. Clinical and epidemiological data on influenza infections in tropical countries have been relatively sparse until fairly recently, and it is the aim of this review to close some of these gaps by examining the behavior of influenza viruses in the tropical Singaporean population.

Safety and tolerability of a 6-week course of oseltamivir prophylaxis for seasonal influenza in children

Please cite this paper as: Reisinger et al. Safety and tolerability of a 6‐week course of oseltamivir prophylaxis for seasonal influenza in children. Influenza and Other Respiratory Viruses DOI: 10.1111/j.1750‐2659.2012.00367.x.

In an open‐label study, 49 children aged 1–12 years received oseltamivir (30–75 mg once daily depending on bodyweight) for 6 weeks for influenza prophylaxis. Seventeen participants reported 22 adverse events (AEs); in three participants, AEs were considered probably drug related (nausea or vomiting). No serious AEs were reported. The tolerability profile was similar to pooled safety data from treatment studies (duration of 5 days) in children.

Characteristics of hospitalized children with 2009 pandemic influenza A (H1N1): a multicenter study in Korea

The majority of Korean patients with pandemic influenza A (H1N1) during the 2009 epidemic were under 20 yr of age. The limited data on the clinical characteristics of these children led us to conduct a case note-based investigation of children admitted to 6 university hospitals with 2009 H1N1 influenza. A total of 804 children was enrolled. The median age was 5 yr; 63.8% were males; and 22.4% had at least one chronic underlying disease. Ninety-five of the patients (11.8%) were critically ill and they suffered more from shortness of breath, dyspnea and lymphopenia than the other patients. Among all the patients, 98.8% were treated with antivirals and 73% received treatment within 48 hr of illness onset. All the enrolled patients are alive and appear to have had good outcomes, probably due to the early intervention and antiviral treatment. This study deals with hospitalized children whose diagnoses of influenza A (H1N1) were confirmed, and therefore provides important new information about the clinical patterns of children with influenza A (H1N1) in Korea.

Effects of influenza antivirals on individual and population immunity over many epidemic waves

Antivirals are an important defence against novel strains of influenza. However, the impact of widespread drug usage on strain circulation across multiple epidemic waves - via their impact on host immunity - is unknown despite antivirals having the likelihood of extensive use during a pandemic. To explore how drug usage by individuals affects population strain dynamics, we embedded a two-strain model of within-host dynamics within an epidemic model. We found that when 40% of hosts took drugs early during the infectious period, transmission was reduced by 30% and average levels of immunity by 2·9-fold (comparable to antibody concentrations), relative to 14% and 1·5-fold reductions when drugs were taken late. The novel strain was more successful relative to the resident strain when drugs were not taken, and an intermediate level of drug coverage minimized incidence in subsequent waves. We discuss how drug regimens, coverage and R 0 could impact pandemic preparedness.

A systematic review to identify areas of enhancements of pandemic simulation models for operational use at provincial and local levels

BACKGROUND

In recent years, computer simulation models have supported development of pandemic influenza preparedness policies. However, U.S. policymakers have raised several concerns about the practical use of these models. In this review paper, we examine the extent to which the current literature already addresses these concerns and identify means of enhancing the current models for higher operational use.

METHODS

We surveyed PubMed and other sources for published research literature on simulation models for influenza pandemic preparedness. We identified 23 models published between 1990 and 2010 that consider single-region (e.g., country, province, city) outbreaks and multi-pronged mitigation strategies. We developed a plan for examination of the literature based on the concerns raised by the policymakers.

RESULTS

While examining the concerns about the adequacy and validity of data, we found that though the epidemiological data supporting the models appears to be adequate, it should be validated through as many updates as possible during an outbreak. Demographical data must improve its interfaces for access, retrieval, and translation into model parameters. Regarding the concern about credibility and validity of modeling assumptions, we found that the models often simplify reality to reduce computational burden. Such simplifications may be permissible if they do not interfere with the performance assessment of the mitigation strategies. We also agreed with the concern that social behavior is inadequately represented in pandemic influenza models. Our review showed that the models consider only a few social-behavioral aspects including contact rates, withdrawal from work or school due to symptoms appearance or to care for sick relatives, and compliance to social distancing, vaccination, and antiviral prophylaxis. The concern about the degree of accessibility of the models is palpable, since we found three models that are currently accessible by the public while other models are seeking public accessibility. Policymakers would prefer models scalable to any population size that can be downloadable and operable in personal computers. But scaling models to larger populations would often require computational needs that cannot be handled with personal computers and laptops. As a limitation, we state that some existing models could not be included in our review due to their limited available documentation discussing the choice of relevant parameter values.

CONCLUSIONS

To adequately address the concerns of the policymakers, we need continuing model enhancements in critical areas including: updating of epidemiological data during a pandemic, smooth handling of large demographical databases, incorporation of a broader spectrum of social-behavioral aspects, updating information for contact patterns, adaptation of recent methodologies for collecting human mobility data, and improvement of computational efficiency and accessibility.

Pandemic response lessons from influenza H1N1 2009 in Asia

During April 2009, a novel H1N1 influenza A virus strain was identified in Mexico and the USA. Within weeks the virus had spread globally and the first pandemic of the 21st Century had been declared. It is unlikely to be the last and it is crucial that real lessons are learned from the experience. Asia is considered a hot spot for the emergence of new pathogens including past influenza pandemics. On this occasion while preparing for an avian, highly virulent influenza virus (H5N1 like) originating in Asia in fact the pandemic originated from swine, and was less virulent. This discrepancy between what was planned for and what emerged created its own challenges. The H1N1 pandemic has tested national health-care infrastructures and exposed shortcomings in our preparedness as a region. Key health challenges include communication throughout the region, surge capacity, access to reliable information and access to quality care, health-care worker skills, quality, density and distribution, access to essential medicines and lack of organizational infrastructure for emergency response. Despite years of preparation the public health and clinical research community were not ready to respond and opportunities for an immediate research response were missed. Despite warm words and pledges efforts to engage the international community to ensure equitable sharing of limited resources such as antivirals and vaccines fell short and stockpiles in the main remained in the rich world. This manuscript with authors from across the region describes some of the major challenges faced by Asia in response to the pandemic and draws lessons for the future.

Compliance to oseltamivir and subsequent occurrence of self-reported adverse drug reactions among nursery and primary school children following exposure to Influenza A(H1N1)v

During the containment phase of Influenza A(H1N1)v, a nursery, a primary school and an afterschool club were closed after two pupils were found confirmed cases. Classmates were prescribed postexposure oseltamivir. Compliance was expected to be low. The objective of this study was to assess compliance, the number of children developing adverse drug reactions (ADRs) and the reasons for stopping the course prematurely. We conducted a survey among parents of all classmates of the two cases. Parents were asked about compliance and adverse drug events in a questionnaire or underwent a telephone interview. Response was high, 88%. Seventy-nine percent of the children were compliant to the prescribed dose of oseltamivir. One in four children experienced at least one ADR. Children who took a higher daily dose (treatment dose) developed significantly more often ADRs. No children developed Influenza A(H1N1)v. We found that a high overall compliance to prescribed oseltamivir can be achieved in very young children (1-11 years). The proportion of children developing ADRs was much lower than described in two other recent UK investigations. Possibly, this is related to the socioeconomic status of the population under investigation.

Recommendations for and compliance with social restrictions during implementation of school closures in the early phase of the influenza A (H1N1) 2009 outbreak in Melbourne, Australia

Background

Localized reactive school and classroom closures were implemented as part of a suite of pandemic containment measures during the initial response to influenza A (H1N1) 2009 in Melbourne, Australia. Infected individuals, and those who had been in close contact with a case, were asked to stay in voluntary home quarantine and refrain from contact with visitors for seven days from the date of symptom onset or exposure to an infected person. Oseltamivir (Tamiflu^®) was available for treatment or prophylaxis.

Methods

We surveyed affected families through schools involved in the closures. Analyses of responses were descriptive. We characterized recommendations made to case and contact households and quantified adherence to guidelines and antiviral therapy.

Results

Of the 314 respondent households, 51 contained a confirmed case. The prescribed quarantine period ranged from 1-14 days, reflecting logistic difficulties in reactive implementation relative to the stated guidelines. Household-level compliance with the requirement to stay at home was high (84.5%, 95% CI 79.3,88.5) and contact with children outside the immediate family infrequent.

Conclusions

Levels of compliance with recommendations in our sample were high compared with other studies, likely due to heightened public awareness of a newly introduced virus of uncertain severity. The variability of reported recommendations highlighted the difficulties inherent in implementing a targeted reactive strategy, such as that employed in Melbourne, on a large scale during a public health emergency. This study emphasizes the need to understand how public health measures are implemented when seeking to evaluate their effectiveness.

Clinical and epidemiological characteristics of patients with influenza A (H1N1) 2009 attended to at the emergency room of a children's hospital

In June 2009, the first influenza pandemic of the twenty-first century, due to the swine origin influenza A (H1N1) 2009 virus, was declared. This study aimed to describe the epidemiological and clinical features, complications, lethality and risk factors for hospital admission of microbiologically confirmed cases of influenza A (H1N1) 2009 infection seen at the emergency department of a children's hospital. All cases of children with influenza A (H1N1) 2009 viral infection, confirmed microbiologically by real-time reverse transcription polymerase chain reactions and treated in the emergency room between July and December 2009, were prospectively included. Patients were compared according to admission requirement to study variables associated with the risk of hospitalisation. Oseltamivir was the antiviral used for the treatment and its safety was analysed. Four hundred and twelve patients with influenza A (H1N1) 2009 infection were included. The most frequent symptoms were: fever (96%), cough (95%) and coryza (90%). Eighty-five patients (20.6%) were admitted: three to the paediatric intensive care unit and two died. Hospitalised children were younger than those not admitted (median age 5 vs 8 years; p = 0.001). Age under 1 year (OR 6.01; CI 95% 2.77-13.05), pneumonia (OR 7.99; CI 95% 3.50-18.22) and haemoglobinopathy or underlying blood disorders (OR 5.99; CI 95% 1.32-27.30) were statistically significant risk factors for admission. No differences were observed regarding onset of antiviral treatment among admitted and non-admitted patients. Treatment with oseltamivir was well tolerated. In conclusion, the incidence of severe cases and lethality of influenza A (H1N1) 2009 infection were low in our setting, even in a population with risk factors for developing complications.

2009 pandemic influenza: a review

PURPOSE OF REVIEW

A review of influenza is particularly relevant this year due to the ongoing novel H1N1 influenza pandemic.

RECENT FINDINGS

Surveillance and clinical data including risk factors for infection and complications due to the current H1N1 pandemic are reviewed. New evidence on the safety of antiviral agents in children and studies on interventions to reduce community transmission of influenza are included. Influenza vaccine efficacy and improving immunization coverage have also been addressed by recent studies.

SUMMARY

These studies from the early phase of the pandemic identify the population that are at high risk for complications, and affirm that active surveillance and prevention are important aspects of a public health response. Appropriate use of antiviral agents and improving influenza immunization coverage for all ages continue to be a challenge. Further studies are underway to improve the public health response, and the pandemic H1N1 strain is being incorporated into the 2010 seasonal influenza vaccine.

Early clinical experiences with the new influenza A (H1N1/09)

BACKGROUND

Because of ongoing person-to-person transmission of the disease, the World Health Organization has declared a phase 6 pandemic alert for the new type of influenza A (H1N1/09). This means that the spread of the disease must be closely monitored.

METHODS

At the Düsseldorf University Hospital, patients with flu-like symptoms and their contacts have been tested for the new type of influenza A since April 2009.

RESULTS

The first patients that tested positive for H1N1/09 were treated on 20 May 2009. By mid-September, 3372 persons underwent PCR testing of a sample obtained by deep nasal swabbing, and the results were positive in 450 (13.3%). 379 of these 450 infections, or 84.2%, had been contracted abroad. Most patients came to the hospital with flu-like symptoms within three days of becoming ill. An analysis of the first 60 patients revealed a median core temperature of 37.8 degrees C and a mildly elevated C-reactive protein concentration. All patients were treated with oseltamivir. Most of the initially symptomatic patients were asymptomatic again within 3 days; the median duration of treatment was 5 days. The median time to the first negative deep nasal swab was 4 days. No oseltamivir resistance has been found to date in our patient collective.

CONCLUSION

The clinical manifestations of the new type of influenza were still mild in the patient population that we studied up to mid-September 2009. At that time, the second wave of the pandemic had not yet begun in Germany. At present, however, the number of cases acquired within the country is on the rise.

Guidelines on management of human infection with the novel virus influenza A (H1N1)--a report from the Hospital das Clínicas of the University of São Paulo

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July, 2009. Since then, 9.249 cases were confirmed in Brazil, most of them concentrated in São Paulo. The Hospital das Clínicas of the University of São Paulo is a reference center for H1N1 cases in São Paulo. The purpose of this review is to analyze the evidence concerning diagnosis, prevention, and treatment of novel influenza A (H1N1) infection. In addition, we propose guidelines for the management of this pandemic emphasizing Hospital das Clínicas "bundles" for the control of the pandemic novel influenza A (H1N1).