October 9, 2009 3:30 PM ET

Actions To Take This Flu Season

1. Get Your Seasonal Flu Shot
The best way to prevent seasonal flu is by getting a seasonal flu vaccination each year. As always, CDC recommends that people 65 and older get their regular, or “seasonal,” flu vaccine as soon as it is available. This year is no exception as seasonal flu viruses are expected to circulate along with 2009 H1N1 viruses this flu season. When the 2009 H1N1 vaccine becomes available for people 65 years and older, you should get that vaccine also.

2. Take Everyday Preventive Actions including covering coughs, washing hands often and avoiding people who are sick.

3. Seek medical advice quickly if you develop flu symptoms to see whether you might need medical evaluation or possibly treatment with antiviral medications. People 65 and older are prioritized to get antiviral drugs if they become sick with the flu according to CDC’s guidance. Flu symptoms include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people may also have vomiting and diarrhea. People may be infected with the flu, including 2009 H1N1, and have respiratory symptoms without a fever.
People 65 Years and Older and Seasonal Flu

It has been recognized for many years that older people are at greater risk of serious complications from the flu compared with young, healthy adults. It’s estimated that 90 percent of seasonal flu-related deaths and more than 60 percent of seasonal flu-related hospitalizations in the United States each year occur in people 65 years and older. This is because human immune defenses become weaker with age. So influenza can be a very serious disease for people 65 and older.

People 65 Years and Older and 2009 H1N1 Flu

The new 2009 H1N1 virus does not seem to be affecting people 65 years and older in the same way that seasonal flu usually does. Most people who have gotten sick from this new virus have been younger. In fact, people 65 and older are the group that is least likely to get infected with this new virus. There have been relatively few infections and even fewer cases of serious illness and death with this new virus in people older than 65. Laboratory tests on blood samples indicate that older people likely have some pre-existing immunity to the 2009 H1N1 flu virus. But while people 65 and older are the least likely to be infected with 2009 H1N1 flu, those that do become infected are at greater risk of having serious complications from their illness.
Flu Vaccination

Seasonal Flu Vaccine

People 65 and older are recommended to get seasonal flu vaccine this year, as always.

2009 H1N1 Flu Vaccine

People 65 and older are not in a target group recommended to get the earliest doses of 2009 H1N1 vaccine. This is because people age 65 and older are least likely to get sick with the 2009 H1N1 virus. Because there will be limited amounts of vaccine available at first, the first doses are recommended for those who are most likely to get infected.

The U.S. government has purchased 250 million doses of 2009 H1N1 vaccine, so anyone who wants to get the vaccine will have the opportunity to do so. While people 65 and older are not included in the groups recommended to get the earliest doses of vaccine, they can get the 2009 H1N1 influenza vaccine as soon as the high risk and younger groups have had the opportunity to be vaccinated.
People Age 65 Years and Older and Antiviral Drugs

Influenza antiviral drugs are prescription drugs (pills, liquid, or inhaled powder) that decrease the ability of flu viruses to reproduce. While getting a flu vaccine each year is the first and most important step in protecting against flu, antiviral drugs are a second line of defense in the treatment of flu.

It’s very important that antiviral drugs be used early to treat flu illness in people 65 and older who are very sick (for example people who are in the hospital) and people who are sick with flu and who also have a greater chance of getting serious flu complications (see http://www.cdc.gov/h1n1flu/highrisk.htm).

Although they are the least likely group to be infected with 2009 H1N1 flu, people age 65 and older are at higher risk for influenza related complications. Therefore, they are prioritized for antiviral treatment if they get sick with either seasonal or 2009 H1N1 flu this season.

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One Virus Particle Is Enough To Cause Infectious Disease

ScienceDaily (Mar. 14, 2009) — Can exposure to a single virus particle lead to infection or disease? Until now, solid proof has been lacking. Experimental research with insect larvae at Wageningen University and Simon Fraser University in Canada has shown that one virus particle is theoretically enough to cause infection and subsequent disease.

A virus population is usually composed of a collection of variants of virus particles. In order to  investigate whether virus particles (virions) can cause an infection independently from each other, and therefore individually, the researchers set up an experiment with two ‘marked’ virus variants. They exposed a population of hosts (caterpillars) to both variants.

The experiment showed that exposure to a low dosage of virus particles resulted in a small number host infections (20%). The majority of these hosts (86%) turned out to be infected by a single virus genotype. In contrast, exposure to a high dosage of virus particles resulted in virtually all the hosts (99%) becoming infected, where most of the hosts were infected by both types of virus. Only 14% were infected by only one of the two variants.

Based on the assumption that every virus particle operates independently from all other virus particles, the researchers set up a probability model. This model predicts how many virus particles have caused an infection and how many different virus genotypes are present in infected hosts, such as plants, insects or people. The results of the infection experiment with the susceptible insects are in agreement with the model predictions. From this it can be derived that the virus particles have an independent effect, and that a single virus particle can indeed cause infection and/or disease.

If there are few virus particles that lead to an infection, the number of virus particles determines the degree of diversity that can be present within the host. This is an important finding because the interactions between virus variants, such as competition and exchanging genetic information, determine the progression of disease and the evolution of the virus.

Until now, it was unclear whether a virus must be seen as an individual that can infect a host independently, or whether a cloud of viruses ‘cooperates’ to cause an infection. It is not yet known if the viruses that affect people can also act individually, but this research shows that it is possible.

The researchers recently published this finding in the Proceedings of the Royal Society B.

Journal reference:

1. Mark P Zwart, Lia Hemerik, Jenny S Cory, J. Arjan G.M de Visser, Felix J.J.A Bianchi, Monique M Van Oers, Just M Vlak, Rolf F Hoekstra, and Wopke Van der Werf. An experimental test of the independent action hypothesis in virus%u2013insect pathosystems. Proc. R. Soc. B, 2009; DOI: 10.1098/rspb.2009.0064..Adapted from materials provided by Wageningen University and Research Centre.

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World Health Organization (WHO)

Is it safe to travel?

Yes. WHO is not recommending travel restrictions related to the outbreak of the influenza A(H1N1) virus. Today, global travel is commonplace and large numbers of people move around the world for business and leisure. Limiting travel and imposing travel restrictions would have very little effect on stopping the virus from spreading, but would be highly disruptive to the global community.

Influenza A(H1N1) has already been confirmed in many parts of the world. The global response now focuses on minimizing the impact of the virus through the rapid identification of cases, and providing patients with appropriate medical care, rather than on stopping its spread internationally.

Although identifying signs and symptoms of influenza in travellers can help track the path of the outbreak, it will not reduce the spread of influenza, as the virus can be transmitted from person to person before the onset of symptoms.

Scientific research based on mathematical modelling shows that restricting travel would be of limited or no benefit in stopping the spread of disease. Historical records of previous influenza pandemics, as well as experience with SARS, validate this.

Does WHO recommend screenings at country entry and exit points to detect if ill people are travelling?

No. We do not believe entry and exit screenings would work to reduce the spread of this disease. However country-level measures to respond to a public health risk are the decision of national authorities, under the International Health Regulations 2005.

Countries that adopt measures that significantly interfere with international traffic (e.g. delaying an airplane passenger for more than 24 hours, or refusing country entry or departure to a traveller) must provide WHO with the public health reasoning and evidence for their actions. WHO will follow up with all of its Member countries on such matters.

Travellers should always be treated with dignity and respect for their human rights.

How can I protect myself from influenza A(H1N1) when I am travelling?

People who are ill should delay travel plans. Returning travellers who become ill should contact their health care provider.

Travellers can protect themselves and others by following simple prevention practices that apply while travelling and in daily life.

Related links

International Health Regulations
See article 32

What can I do?

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World Health Organization The main route of transmission of the new influenza A(H1N1) virus seems to be similar to seasonal influenza, via droplets that are expelled by speaking, sneezing or coughing. You can prevent getting infected by avoiding close contact with people who show influenza-like symptoms (trying to maintain a distance of about 1 metre if possible) and taking the following measures: avoid touching your mouth and nose; clean hands thoroughly with soap and water, or cleanse them with an alcohol-based hand rub on a regular basis (especially if touching the mouth and nose, or surfaces that are potentially contaminated); avoid close contact with people who might be ill; reduce the time spent in crowded settings if possible; improve airflow in your living space by opening windows; practise good health habits including adequate sleep, eating nutritious food, and keeping physically active. What about using a mask? What does WHO recommend? If you are not sick you do not have to wear a mask. If you are caring for a sick person, you can wear a mask when you are in close contact with the ill person and dispose of it immediately after contact, and cleanse your hands thoroughly afterwards. When and how to use a mask? If you are sick and must travel or be around others, cover your mouth and nose. Using a mask correctly in all situations is essential. Incorrect use actually increases the chance of spreading infection. How do I know if I have influenza A(H1N1)? You will not be able to tell the difference between seasonal flu and influenza A(H1N1) without medical help. Typical symptoms to watch for are similar to seasonal viruses and include fever, cough, headache, body aches, sore throat and runny nose. Only your medical practitioner and local health authority can confirm a case of influenza A(H1N1). What should I do if I think I have the illness? If you feel unwell, have high fever, cough or sore throat: stay at home and keep away from work, school or crowds; rest and take plenty of fluids; cover your nose and mouth when coughing and sneezing and, if using tissues, make sure you dispose of them carefully. Clean your hands immediately after with soap and water or cleanse them with an alcohol-based hand rub; if you do not have a tissue close by when you cough or sneeze, cover your mouth as much as possible with the crook of your elbow; use a mask to help you contain the spread of droplets when you are around others, but be sure to do so correctly; inform family and friends about your illness and try to avoid contact with other people; If possible, contact a health professional before traveling to a health facility to discuss whether a medical examination is necessary. Should I take an antiviral now just in case I catch the new virus? No. You should only take an antiviral, such as oseltamivir or zanamivir, if your health care provider advises you to do so. Individuals should not buy medicines to prevent or fight this new influenza without a prescription, and they should exercise caution in buying antivirals over the Internet. Warning on purchase of antivirals without a prescription [pdf 35kb] What about breastfeeding? Should I stop if I am ill? No, not unless your health care provider advises it. Studies on other influenza infections show that breastfeeding is most likely protective for babies – it passes on helpful maternal immunities and lowers the risk of respiratory disease. Breastfeeding provides the best overall nutrition for babies and increases their defense factors to fight illness. When should someone seek medical care? A person should seek medical care if they experience shortness of breath or difficulty breathing, or if a fever continues more than three days. For parents with a young child who is ill, seek medical care if a child has fast or labored breathing, continuing fever or convulsions (seizures). Supportive care at home – resting, drinking plenty of fluids and using a pain reliever for aches – is adequate for recovery in most cases. (A non-aspirin pain reliever should be used by children and young adults because of the risk of Reye’s syndrome.) Should I go to work if I have the flu but am feeling OK? No. Whether you have influenza A(H1N1) or a seasonal influenza, you should stay home and away from work through the duration of your symptoms. This is a precaution that can protect your work colleagues and others. Can I travel? If you are feeling unwell or have symptoms of influenza, you should not travel. If you have any doubts about your health, you should check with your health care provider. More on WHO travel recommendations

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April 2009

Key facts

• Influenza is an acute viral infection that spreads easily from person to person.
• Influenza circulates worldwide and can affect anybody in any age group.
• Influenza causes annual epidemics that peak during winter in temperate regions.
• Influenza is a serious public health problem that causes severe illnesses and deaths for higher risk populations.
• An epidemic can take an economic toll through lost workforce productivity, and strain health services.
• Vaccination is the most effective way to prevent infection.

Overview

Seasonal influenza is an acute viral infection caused by an influenza virus.

There are three types of seasonal influenza – A, B and C. Type A influenza viruses are further typed into subtypes according to different kinds and combinations of virus surface proteins. Among many subtypes of influenza A viruses, currently influenza A(H1N1) and A(H3N2) subtypes are circulating among humans. Influenza viruses circulate in every part of the world. Type C influenza cases occur much less frequently than A and B. That is why only influenza A and B viruses are included in seasonal influenza vaccines.

Signs and symptoms

Seasonal influenza is characterized by a sudden onset of high fever, cough (usually dry), headache, muscle and joint pain, severe malaise (feeling unwell), sore throat and runny nose. Most people recover from fever and other symptoms within a week without requiring medical attention. But influenza can cause severe illness or death in people at high risk (see below). The time from infection to illness, known as the incubation period, is about two days.

Who is at risk?

Yearly influenza epidemics can seriously affect all age groups, but the highest risk of complications occur among children younger than age two, adults age 65 or older, and people of any age with certain medical conditions, such as chronic heart, lung, kidney, liver, blood or metabolic diseases (such as diabetes), or weakened immune systems.

Transmission

Seasonal influenza spreads easily and can sweep through schools, nursing homes or businesses and towns. When an infected person coughs, infected droplets get into the air and another person can breath them in and be exposed. The virus can also be spread by hands infected with the virus. To prevent transmission, people should cover their mouth and nose with a tissue when coughing, and wash their hands regularly.

Treatment

Antiviral drugs for influenza are available in some countries and effectively prevent and treat the illness. There are two classes of such medicines, 1) adamantanes (amantadine and remantadine), and 2) inhibitors of influenza neuraminidase (oseltamivir and zanamivir). Some influenza viruses develop resistance to the antiviral medicines, limiting the effectiveness of treatment. WHO monitors antiviral susceptibility in the circulating influenza viruses.

Seasonal epidemics

Influenza epidemics occur yearly during autumn and winter in temperate regions. Illnesses result in hospitalizations and deaths mainly among high-risk groups (the very young, elderly or chronically ill). Worldwide, these annual epidemics result in about three to five million cases of severe illness, and about 250 000 to 500 000 deaths. Most deaths associated with influenza in industrialized countries occur among people age 65 or older. In some tropical countries, influenza viruses circulate throughout the year with one or two peaks during rainy seasons.

Disease effects

Influenza can cause serious public health and economic problems. In developed countries, epidemics can result in high levels of worker absenteeism and productivity losses. In communities, clinics and hospitals can be overwhelmed when large numbers of sick people appear for treatment during peak illness periods. While most people recover from a bout of influenza, there are large numbers of people who need hospital treatment and many who die from the disease every year. Little is known about the effects of influenza epidemics in developing countries.

Prevention

The most effective way to prevent the disease or severe outcomes from the illness is vaccination. Safe and effective vaccines have been available and used for more than 60 years. Among healthy adults, influenza vaccine can prevent 70% to 90% of influenza-specific illness. Among the elderly, the vaccine reduces severe illnesses and complications by up to 60%, and deaths by 80%.

Vaccination is especially important for people at higher risk of serious influenza complications, and for people who live with or care for high risk individuals.

WHO recommends annual vaccination for (in order of priority):

• nursing-home residents (the elderly or disabled)
• elderly individuals
• people with chronic medical conditions
• other groups such as pregnant women, health care workers, those with essential functions in society, as well as children from ages six months to two years.

Influenza vaccination is most effective when circulating viruses are well-matched with vaccine viruses. Influenza viruses are constantly changing, and the WHO Global Influenza Surveillance Network (GISN), a partnership of National Influenza Centres around the world, monitors the influenza viruses circulating in humans. WHO annually recommends a vaccine composition that targets the three most representative strains in circulation.

WHO response

WHO, with its partners, monitors influenza globally, annually recommends a seasonal influenza vaccine composition, and supports Member States efforts to develop prevention and control strategies. WHO works to strengthen national and regional influenza diagnostic capacities, disease surveillance, outbreak responses, and increase vaccine coverage among high-risk groups.

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ScienceDaily (May 5, 2009) — As the swine flu continues its global spread, researchers from the Children’s Hospital of Philadelphia have discovered important clues about why influenza is more severe in some people than it is in others.

In their research study published online in the Journal of Leukocyte Biology, the scientists show that the influenza virus can actually paralyze the immune systems of otherwise healthy individuals, leading to severe secondary bacterial infections, such as pneumonia. Furthermore, this immunological paralysis can be long-lived, which is important to know when developing treatment strategies to combat the virus.

According to Kathleen Sullivan, M.D., Ph.D., the senior researcher involved in the study and Chief of the Division of Allergy and Immunology at the Children’s Hospital of Philadelphia, “We have a very limited understanding of why some people who get influenza simply have a bad cold and other people become very sick and even die. The results of this study give us a much better sense of the mechanisms underlying bacterial infections arising on top of the viral infection.”

Sullivan and colleagues recruited pediatric patients with severe influenza and examined the level of cytokines, which serve as the first line initiators of immune response, in the blood plasma. Although they found elevated levels of cytokines, they also found a decreased response of toll-like receptors, which activate immune cell responses as a result of invading microbes. This suggests that the diminished response of these receptors may be responsible for the paralysis of the immune system, leading to secondary bacterial infections.

The influenza patients were compared with patients with moderate influenza, respiratory syncytial virus, and a control group of healthy individuals. The immune paralysis appeared to be specifically a result of influenza infection and was not seen in patients with respiratory syncytial virus. This process might explain why one quarter of children who die from influenza, die from a bacterial infection occurring on top of the virus.

“Despite major medical advances since the devastating flu outbreak of 1918 and 1919, influenza virus infection remains a very serious threat,” said John Wherry, Ph.D., Deputy Editor of the Journal of Leukocyte Biology, “and the current swine flu outbreak is a grim reminder of this fact. The work by Dr. Sullivan and colleagues brings us a step closer to understanding exactly what goes wrong in some people who get the flu, so, ultimately, physicians can develop more effective treatment strategies.”

Journal reference:

1. Meredith L. Heltzer, Susan E. Coffin, Kelly Maurer, Asen Bagashev, Zhe Zhang, Jordan S. Orange, and Kathleen E. Sullivan. Immune dysregulation in severe influenza. Journal of Leukocyte Biology, 2009; DOI: 10.1189/jlb.1108710

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Influenza And Bacterial Pneumonia Make For Harmful Super-infection

ScienceDaily

Influenza, or flu, is an unpleasant affair with fever, cough, as well as head and body ache.
When this illness is further complicated by a
bacterialpneumonia, a harmful super-infection develops. Until now, researchers thought
that the flu facilitates an infection with pneumonia bacteria because it leads
to a decrease of immune cells in the blood and thus impairs the body's
defenses.
A joint venture from researchers from the Helmholtz-Centre for Infection
Research (HZI) in Braunschweig, the Otto-von-Guericke-University in Magdeburg,
and the Karolinska institute in Sweden have taken an in-depth look at the
connection between flu infection and pneumonia. Their results have disproven a
common theory about flu-like pneumonia.

Some viral infections trigger a decrease of immune cells in the blood – a
so-called "lymphopenia". The reasons behind it and whether this is
the case with influenza are unknown. To investigate the latter, HZI researchers
infected mice with flu viruses and measured the amount of immune cells in the
animal's blood every day. Some days later, flu-infected mice received a dosage
of pneumonia bacteria usually harmless for healthy mice. While the flu-infected
mice did develop a superinfection & subsequently died, surprisingly, they
were not suffering from lymphopenia. The healthy, non-flu-infected mice
defeated the bacteria successfully and recovered.

To discover whether a lack of immune cells encourages an infection with
pneumonia bacteria in general, an artificial drug-induced lymphopenia was
established in the mice. Without infecting these lymphopenic mice with flu
viruses, they received pneumonia bacteria. Despite a severe lack of immune
cells, the mice recovered completely.

With these results, the researchers could show that influenza facilitates
and intensifies an infection from pneumonia bacteria, while disproving the
common idea that this is caused by a lack of immune cells. "This result
was an enormous surprise for us because it directly contradicts widespread
assumptions", says Sabine Stegemann, researcher in the groups "Immune
regulation" at the HZI and "Molecular Immunology" at the
Otto-von-Guericke-University in Magdeburg.

"Now we want to understand the reasons for the increased
susceptibility", says Matthias Gunzer, head of the group in Magdeburg.
"It could be interplay of weakened mucous membranes and scavenger cells
that induce ideal conditions for pneumonia bacteria to create a deadly lung infection.
Another reason may be a reaction of the host immune system: It disables
hyperactive flu-fighting immune cells to inhibit destruction of healthy lung
tissue. "The immune system keeps itself under control and that makes it
easy for pneumonia bacteria to infect the lung", says Gunzer.
Increased Susceptibility for Superinfection with Streptococcus pneumoniae
during Influenza Virus Infection Is Not Caused by TLR7-Mediated Lymphopenia 2009; 

Adapted from materials provided by Helmholtz Association of German Research Centres,
via EurekAlert!, a service of AAAS.

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ScienceDaily (Mar. 30, 2009) — For some people it is a certainty: as soon as the annual flu season gets underway, they are sure to go down with it. It is little comfort to know that there are other people who are apparently resistant to flu or overcome the illness after just a couple of days. It is this phenomenon that is now being investigated by researchers at the Helmholtz Center for Infection Research, using various strains of mice.

“Where there are many scientific works dealing solely with the flu virus, we have investigated how the host reacts to an infection,” says Klaus Schughart, head of the Experimental Mouse Genetics research group. In infection experiments the researchers have now discovered that an excessive immune response is responsible for the fatal outcome of the disease in mice. This overreaction has genetic roots.

For their investigations the researchers injected seven different inbred mouse strains with the same quantity of type Influenza A flu viruses. All of the animals within one mouse strain are genetically identical, like identical twins. However, one strain differs from another just like different individuals in the human population. To their surprise, the researchers were able to identify strong differences in the progression of the influenza between the seven strains. In five of the strains the illness was mild: the animals lost weight, recovering completely after seven to eight days. However, in two of the mouse strains the animals lost weight rapidly and died after just a few days.

The researchers looked for reasons for these differences: they investigated how the immune system of the animals responds to the virus. “The mice die from their own immune defences, which are actually supposed to protect them against the virus. The immune system produces too many messengers, which have a strong activating effect on the immune cells. These cells then kill tissue cells in the lungs that are infected with the virus,” says Schughart. At the same time, these overactive cells also destroy healthy lung tissue. In mice that died the researchers also found one hundred times more viruses than in animals that survived. “It appears that the animals have specific receptors on their cells that make them more receptive to a severe viral infection.” Flu infections in humans could take a similar course, here too, genetic factors could favour a severe progression of the illness. “It is only now that we are beginning to understand the role played by the genetic factors of the host and what increased receptiveness means in the case of influenza,” says Schughart.

Every year between 10,000 and 30,000 people in Germany die from influenza, the majority via pathogens of the Influenza A type. There are various sub-types of the main type A, in which the composition of the virus envelope differs. H1N1 and H3N2 are the most widely-distributed flu strains amongst humans, H5N1 the familiar avian flu virus. The H stands for the protein haemagglutinin, with which the virus latches onto the cells of the airways, infecting them. In order for the newly-created flu viruses to leave the host cells, in turn, they require neuraminidase (N). To evade an immune response the virus changes the H and N characteristics constantly. Sometimes light, sometimes heavy: the result is a completely new virus type with a new number, with the consequences generally a severe global flu pandemic.

Journal reference:

1. Srivastava et al. Host Genetic Background Strongly Influences the Response to Influenza A Virus Infections. PLoS ONE, 2009; 4 (3): e4857 DOI: 10.1371/journal.pone.0004857

Adapted from materials provided by Helmholtz Association of German Research Centres, via EurekAlert!, a service of AAAS.

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