Expert: Be More Alert To H1N1 in Pregnancy

MONTREAL — Prenatal care providers need to take a frontline attitude about novel influenza A (H1N1) because pregnant women are among those at highest risk for infection and serious complications.

“We need to get the message out to the practitioners in the field that they've really got to be thinking about this. They need to recognize that influenza in pregnancy is not trivial, and they should consider early treatment,” said Dr. Deborah Money, president-elect of the Infectious Diseases Society for Obstetrics and Gynecology.

Speaking after chairing an urgent update session on novel H1N1 influenza at the society's annual meeting, Dr. Money said the latest figures on the infection in pregnancy, published in Lancet (doi:10.1016/S0140-6736[09]61304-0) paint a worrisome picture of practitioner's reaction time.

Of 34 pregnant women who contracted the virus, only 50% were treated with oseltamivir, and just 8 (24%) received treatment within 48 hours of symptom onset.

“Antivirals have the best impact within the first 48 hours of treatment and the latest deaths in this population had late starts with oseltamivir treatment,” she said in an interview. Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset, and the latest was 15 days.

The most common presentation was a febrile, influenzalike illness (94% of the patients), which included fever plus cough or sore throat. Vomiting and diarrhea occurred in only 18% and 12% of pregnant patients. Pregnant women were more likely to report shortness of breath (41%) than patients in the general population (15%). Rhinorrhea occurred in 59% of pregnant patients.

Patient awareness also may be an issue, since many pregnant women might not think to call their obstetricians when they come down with the sniffles, she acknowledged.

Dr. Money, an associate professor of obstetrics and gynecology at the University of British Columbia, Vancouver, said prenatal care providers must now make new plans, not only to include influenza patients in their daily schedules, but to ensure that these patients do not put their other patients at risk.

“If the woman really needs to be seen, [providers] need to orchestrate this in a way that is safe for their other patients—either at the end of the day, or in a place with a negative pressure room, or by getting them to wear a mask on entry.”

The drug of choice is oseltamivir, at a dosage of 75 mg twice per day for 5 days (www.cdc.gov/h1n1flu/

“We already have a poor track record with the seasonal influenza. U.S. guidelines have recommended the seasonal influenza vaccine for pregnant women for some time, but despite those recommendations the uptake in studies has been in the 14% range. So given that poor track record, how are we going to manage immunizing women against both seasonal and H1N1 influenza?”

In the Lancet study, 56% of the pregnant women with novel H1N1 influenza had not received the seasonal influenza vaccine, 9% had been vaccinated, and vaccination status was unknown for the remaining 35%.

“The H1N1 vaccine might turn out to be two doses, although that is still to be determined. So, with the addition of the seasonal vaccine we're looking potentially at three doses through the fall and winter of all pregnant women going to care providers, and the logistics start to boggle the mind.”

Discussion at the meeting explored the possibility of setting up influenza vaccination clinics at teaching hospitals to relieve small clinics and private practitioners. However, this plan would still rely on vaccination recommendations from private practitioners.

“Our experience anecdotally is that care providers have been advising against vaccination in pregnancy because they misunderstand which ones you can give in pregnancy and which ones you can't. Our anxiety is that they won't give oseltamivir, and they won't give the vaccine because they are in that mind set. But generally speaking, those of us in academic centers that see complications, end up seeing more complications related to under-treatment rather than overtreatment,” Dr. Money said.

Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset.

Source DR. MONEY

MONTREAL — Prenatal care providers need to take a frontline attitude about novel influenza A (H1N1) because pregnant women are among those at highest risk for infection and serious complications.

“We need to get the message out to the practitioners in the field that they've really got to be thinking about this. They need to recognize that influenza in pregnancy is not trivial, and they should consider early treatment,” said Dr. Deborah Money, president-elect of the Infectious Diseases Society for Obstetrics and Gynecology.

Speaking after chairing an urgent update session on novel H1N1 influenza at the society's annual meeting, Dr. Money said the latest figures on the infection in pregnancy, published in Lancet (doi:10.1016/S0140-6736[09]61304-0) paint a worrisome picture of practitioner's reaction time.

Of 34 pregnant women who contracted the virus, only 50% were treated with oseltamivir, and just 8 (24%) received treatment within 48 hours of symptom onset.

“Antivirals have the best impact within the first 48 hours of treatment and the latest deaths in this population had late starts with oseltamivir treatment,” she said in an interview. Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset, and the latest was 15 days.

The most common presentation was a febrile, influenzalike illness (94% of the patients), which included fever plus cough or sore throat. Vomiting and diarrhea occurred in only 18% and 12% of pregnant patients. Pregnant women were more likely to report shortness of breath (41%) than patients in the general population (15%). Rhinorrhea occurred in 59% of pregnant patients.

Patient awareness also may be an issue, since many pregnant women might not think to call their obstetricians when they come down with the sniffles, she acknowledged.

Dr. Money, an associate professor of obstetrics and gynecology at the University of British Columbia, Vancouver, said prenatal care providers must now make new plans, not only to include influenza patients in their daily schedules, but to ensure that these patients do not put their other patients at risk.

“If the woman really needs to be seen, [providers] need to orchestrate this in a way that is safe for their other patients—either at the end of the day, or in a place with a negative pressure room, or by getting them to wear a mask on entry.”

The drug of choice is oseltamivir, at a dosage of 75 mg twice per day for 5 days (www.cdc.gov/h1n1flu/

“We already have a poor track record with the seasonal influenza. U.S. guidelines have recommended the seasonal influenza vaccine for pregnant women for some time, but despite those recommendations the uptake in studies has been in the 14% range. So given that poor track record, how are we going to manage immunizing women against both seasonal and H1N1 influenza?”

In the Lancet study, 56% of the pregnant women with novel H1N1 influenza had not received the seasonal influenza vaccine, 9% had been vaccinated, and vaccination status was unknown for the remaining 35%.

“The H1N1 vaccine might turn out to be two doses, although that is still to be determined. So, with the addition of the seasonal vaccine we're looking potentially at three doses through the fall and winter of all pregnant women going to care providers, and the logistics start to boggle the mind.”

Discussion at the meeting explored the possibility of setting up influenza vaccination clinics at teaching hospitals to relieve small clinics and private practitioners. However, this plan would still rely on vaccination recommendations from private practitioners.

“Our experience anecdotally is that care providers have been advising against vaccination in pregnancy because they misunderstand which ones you can give in pregnancy and which ones you can't. Our anxiety is that they won't give oseltamivir, and they won't give the vaccine because they are in that mind set. But generally speaking, those of us in academic centers that see complications, end up seeing more complications related to under-treatment rather than overtreatment,” Dr. Money said.

Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset.

Source DR. MONEY

MONTREAL — Prenatal care providers need to take a frontline attitude about novel influenza A (H1N1) because pregnant women are among those at highest risk for infection and serious complications.

“We need to get the message out to the practitioners in the field that they've really got to be thinking about this. They need to recognize that influenza in pregnancy is not trivial, and they should consider early treatment,” said Dr. Deborah Money, president-elect of the Infectious Diseases Society for Obstetrics and Gynecology.

Speaking after chairing an urgent update session on novel H1N1 influenza at the society's annual meeting, Dr. Money said the latest figures on the infection in pregnancy, published in Lancet (doi:10.1016/S0140-6736[09]61304-0) paint a worrisome picture of practitioner's reaction time.

Of 34 pregnant women who contracted the virus, only 50% were treated with oseltamivir, and just 8 (24%) received treatment within 48 hours of symptom onset.

“Antivirals have the best impact within the first 48 hours of treatment and the latest deaths in this population had late starts with oseltamivir treatment,” she said in an interview. Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset, and the latest was 15 days.

The most common presentation was a febrile, influenzalike illness (94% of the patients), which included fever plus cough or sore throat. Vomiting and diarrhea occurred in only 18% and 12% of pregnant patients. Pregnant women were more likely to report shortness of breath (41%) than patients in the general population (15%). Rhinorrhea occurred in 59% of pregnant patients.

Patient awareness also may be an issue, since many pregnant women might not think to call their obstetricians when they come down with the sniffles, she acknowledged.

Dr. Money, an associate professor of obstetrics and gynecology at the University of British Columbia, Vancouver, said prenatal care providers must now make new plans, not only to include influenza patients in their daily schedules, but to ensure that these patients do not put their other patients at risk.

“If the woman really needs to be seen, [providers] need to orchestrate this in a way that is safe for their other patients—either at the end of the day, or in a place with a negative pressure room, or by getting them to wear a mask on entry.”

The drug of choice is oseltamivir, at a dosage of 75 mg twice per day for 5 days (www.cdc.gov/h1n1flu/

“We already have a poor track record with the seasonal influenza. U.S. guidelines have recommended the seasonal influenza vaccine for pregnant women for some time, but despite those recommendations the uptake in studies has been in the 14% range. So given that poor track record, how are we going to manage immunizing women against both seasonal and H1N1 influenza?”

In the Lancet study, 56% of the pregnant women with novel H1N1 influenza had not received the seasonal influenza vaccine, 9% had been vaccinated, and vaccination status was unknown for the remaining 35%.

“The H1N1 vaccine might turn out to be two doses, although that is still to be determined. So, with the addition of the seasonal vaccine we're looking potentially at three doses through the fall and winter of all pregnant women going to care providers, and the logistics start to boggle the mind.”

Discussion at the meeting explored the possibility of setting up influenza vaccination clinics at teaching hospitals to relieve small clinics and private practitioners. However, this plan would still rely on vaccination recommendations from private practitioners.

“Our experience anecdotally is that care providers have been advising against vaccination in pregnancy because they misunderstand which ones you can give in pregnancy and which ones you can't. Our anxiety is that they won't give oseltamivir, and they won't give the vaccine because they are in that mind set. But generally speaking, those of us in academic centers that see complications, end up seeing more complications related to under-treatment rather than overtreatment,” Dr. Money said.

Among the six women who died, the earliest initiation of oseltamivir was 6 days after symptom onset.

Source DR. MONEY