DOCSLIB.ORG

Influenza Virus-Related Critical Illness: Prevention, Diagnosis, Treatment Eric J

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Influenza Virus-Related Critical Illness: Prevention, Diagnosis, Treatment Eric J Chow et al. Critical Care (2019) 23:214 https://doi.org/10.1186/s13054-019-2491-9 REVIEW Open Access Influenza virus-related critical illness: prevention, diagnosis, treatment Eric J. Chow1,2, Joshua D. Doyle1,2 and Timothy M. Uyeki2* Abstract Annual seasonal influenza epidemics of variable severity result in significant morbidity and mortality in the United States (U.S.) and worldwide. In temperate climate countries, including the U.S., influenza activity peaks during the winter months. Annual influenza vaccination is recommended for all persons in the U.S. aged 6 months and older, and among those at increased risk for influenza-related complications in other parts of the world (e.g. young children, elderly). Observational studies have reported effectiveness of influenza vaccination to reduce the risks of severe disease requiring hospitalization, intensive care unit admission, and death. A diagnosis of influenza should be considered in critically ill patients admitted with complications such as exacerbation of underlying chronic comorbidities, community-acquired pneumonia, and respiratory failure during influenza season. Molecular tests are recommended for influenza testing of respiratory specimens in hospitalized patients. Antigen detection assays are not recommended in critically ill patients because of lower sensitivity; negative results of these tests should not be used to make clinical decisions, and respiratory specimens should be tested for influenza by molecular assays. Because critically ill patients with lower respiratory tract disease may have cleared influenza virus in the upper respiratory tract, but have prolonged influenza viral replication in the lower respiratory tract, an endotracheal aspirate (preferentially) or bronchoalveolar lavage fluid specimen (if collected for other diagnostic purposes) should be tested by molecular assay for detection of influenza viruses. Observational studies have reported that antiviral treatment of critically ill adult influenza patients with a neuraminidase inhibitor is associated with survival benefit. Since earlier initiation of antiviral treatment is associated with the greatest clinical benefit, standard-dose oseltamivir (75 mg twice daily in adults) for enteric administration is recommended as soon as possible as it is well absorbed in critically ill patients. Based upon observational data that suggest harms, adjunctive corticosteroid treatment is currently not recommended for children or adults hospitalized with influenza, including critically ill patients, unless clinically indicated for another reason, such as treatment of asthma or COPD exacerbation, or septic shock. A number of pharmaceutical agents are in development for treatment of severe influenza. Keywords: Influenza, Influenza vaccination, Influenza testing, Antiviral treatment Background have self-limited uncomplicated upper respiratory tract Annual seasonal influenza epidemics of variable severity illness. One study estimated that during 2010–2016, ap- result in significant morbidity and mortality in the proximately 8.3% of the U.S. population experienced United States (U.S.) and worldwide [1–3]. In temperate symptomatic influenza each year [7]. However, compli- climate countries, including the U.S., influenza activity cations may result in severe illness, including fatal out- peaks during the winter months whereas in tropical re- comes. During 2010–2018, an estimated 4.3–23 million gions influenza activity may be more variable [4–6]. medical visits, 140,000–960,000 hospitalizations, and 12, Most persons with symptomatic influenza virus infection 000–79,000 deaths were associated with influenza each year in the U.S. [8]. Another study estimated that 18, * Correspondence: [email protected] 000–96,000 influenza-related intensive care unit (ICU) 2Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-7, 1600 admissions occur annually in the U.S. [9]. There are an Clifton Road, N.E., Atlanta, GA 30329, USA estimated 291,000–646,000 respiratory deaths attributed Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chow et al. Critical Care (2019) 23:214 Page 2 of 11 to seasonal influenza each year worldwide [2]. Here, we Table 2 Groups at high risk for influenza complications* review strategies for prevention, diagnosis, and treat- Risk factors for severe influenza outcomes ment of influenza virus infections in the ICU (Table 1). • Age < 5 years, especially those < 2 years • Age > 65 years Risk factors • Pregnant women Influenza vaccination is the primary method for prevent- • 2 ing influenza and reducing the risk of severe outcomes. Extreme obesity (BMI > 40 kg/m ) In the U.S., the Advisory Committee on Immunization • Native Americans/Alaskan Natives (may also apply to indigenous Practices (ACIP) recommends annual influenza vaccin- people from other countries) ation for all persons aged 6 months and older and priori- • Current or past tobacco use tizes those at higher risk for influenza complications • Children and adolescents receiving aspirin or salicylate-containing [10]. High-risk groups include adults aged > 65 years [11, medications who might be at risk for Reye syndrome 12], children aged < 5 years (particularly those aged < 2 • Underlying chronic medical conditions: years) [13, 14], pregnant women (up to 2 weeks post- ○ Pulmonary partum) [15–18], persons with certain chronic medical ○ Cardiovascular 1 conditions, Native Americans/Alaska Natives, and resi- ○ Renal dents of nursing homes and other long-term care facil- ○ Hepatic ities (Table 2). Studies have specifically highlighted that ○ those with chronic pulmonary, cardiovascular, renal, Neurologic hepatic, neurologic, hematologic or metabolic disorders, ○ Hematologic immunocompromised persons, children and adolescents ○ Metabolic receiving aspirin- or salicylate-containing medications ○ Immunocompromised state and who might be at risk for experiencing Reye syn- *From the U.S. Centers for Disease Control and Prevention Advisory drome with influenza virus infection, and those who are Committee on Immunization Practices extremely obese (BMI > 40) are at increased risk for influenza-related complications [10, 19–23]. influenza patients [24, 29]. In children, independent risk Many studies evaluated risk factors for severe influenza factors for influenza A(H1N1)pdm09-related mortality in- during the 2009 H1N1 influenza pandemic. Adult ICU pa- cluded chronic neurologic condition or immune com- tients with influenza A(H1N1)pdm09 virus infection were promise, acute myocarditis or encephalitis, and early primarily non-elderly, were obese [24–28], and had higher presumed MRSA co-infection of the lung [30]. Female odds of death, invasive mechanical ventilation, acute re- gender was also identified as a risk factor; however, there spiratory distress syndrome (ARDS), septic shock, and was no gender difference in overall mortality. Bacterial co- multi-lobar pneumonia when compared with seasonal infection was identified in approximately one third of fatal influenza A(H1N1)pdm09 cases in the largest autopsy Table 1 Key points: care of patients with severe influenza case series [31]. Bacterial co-infections in the inter- Key Points pandemic period are also common in critically ill influ- • There are an estimated 291,000–646,000 seasonal influenza-associated enza patients [32]. One study identified past or current to- respiratory deaths every year worldwide. bacco use as a risk factor associated with ICU admission • Annual influenza vaccination is the primary method of preventing [33]. A recent multicenter cohort study reported that influenza and influenza-related complications, especially in high-risk persons. mortality was higher in immunosuppressed patients with influenza A(H1N1)pdm09 than in immunocompetent pa- • Influenza molecular diagnostic testing is recommended for all patients requiring hospitalization with suspected influenza. tients [34]. Severity of influenza seasons varies from year- • Influenza antiviral treatment should be started as soon as possible in to-year based on the predominant influenza viruses, and hospitalized patients with suspected influenza, including critically ill between seasonal and pandemic influenza [35, 36]. One patients, and should not be delayed while awaiting results of influenza study reported that patients with influenza A(H1N1) diagnostic tests. pdm09 had higher odds of severe disease than patients • Enterically administered oseltamivir is recommended for influenza with either influenza A(H3N2) or influenza B virus infec- patients except for those with contraindications (e.g., gastric stasis, ileus, malabsorption). tions [37]. However, influenza B virus infection has been shown to increase the odds of in-hospital mortality in chil- • Repeat virologic testing in lower respiratory tract specimens may be required to determine therapeutic
Load more

Recommended publications
  • Antiviral Agents Active Against Influenza a Viruses
    REVIEWS Antiviral agents active against influenza A viruses Erik De Clercq Abstract | The recent outbreaks of avian influenza A (H5N1) virus, its expanding geographic distribution and its ability to transfer to humans and cause severe infection have raised serious concerns about the measures available to control an avian or human pandemic of influenza A. In anticipation of such a pandemic, several preventive and therapeutic strategies have been proposed, including the stockpiling of antiviral drugs, in particular the neuraminidase inhibitors oseltamivir (Tamiflu; Roche) and zanamivir (Relenza; GlaxoSmithKline). This article reviews agents that have been shown to have activity against influenza A viruses and discusses their therapeutic potential, and also describes emerging strategies for targeting these viruses. HXNY In the face of the persistent threat of human influenza A into the interior of the virus particles (virions) within In the naming system for (H3N2, H1N1) and B infections, the outbreaks of avian endosomes, a process that is needed for the uncoating virus strains, H refers to influenza (H5N1) in Southeast Asia, and the potential of to occur. The H+ ions are imported through the M2 haemagglutinin and N a new human or avian influenza A variant to unleash a (matrix 2) channels10; the transmembrane domain of to neuraminidase. pandemic, there is much concern about the shortage in the M2 protein, with the amino-acid residues facing both the number and supply of effective anti-influenza- the ion-conducting pore, is shown in FIG. 3a (REF. 11). virus agents1–4. There are, in principle, two mechanisms Amantadine has been postulated to block the interior by which pandemic influenza could originate: first, by channel within the tetrameric M2 helix bundle12.
    [Show full text]
  • Treatment and Prevention of Pandemic H1N1 Influenza
    Annals of Global Health VOL. 81, NO. 5, 2015 ª 2015 The Authors. Published by Elsevier Inc. ISSN 2214-9996 on behalf of Icahn School of Medicine at Mount Sinai http://dx.doi.org/10.1016/j.aogh.2015.08.014 REVIEW Treatment and Prevention of Pandemic H1N1 Influenza Suresh Rewar, Dashrath Mirdha, Prahlad Rewar Rajasthan, India Abstract BACKGROUND Swine influenza is a respiratory infection common to pigs worldwide caused by type Ainfluenza viruses, principally subtypes H1N1, H1N2, H2N1, H3N1, H3N2, and H2N3. Swine influenza viruses also can cause moderate to severe illness in humans and affect persons of all age groups. People in close contact with swine are at especially high risk. Until recently, epidemiological study of influenza was limited to resource-rich countries. The World Health Organization declared an H1N1 pandemic on June 11, 2009, after more than 70 countries reported 30,000 cases of H1N1 infection. In 2015, incidence of swine influenza increased substantially to reach a 5-year high. In India in 2015, 10,000 cases of swine influenza were reported with 774 deaths. METHODS The Centers for Disease Control and Prevention recommend real-time polymerase chain reaction as the method of choice for diagnosing H1N1. Antiviral drugs are the mainstay of clinical treatment of swine influenza and can make the illness milder and enable the patient to feel better faster. FINDINGS Antiviral drugs are most effective when they are started within the first 48 hours after the clinical signs begin, although they also may be used in severe or high-risk cases first seen after this time.
    [Show full text]
  • Influenza: Diagnosis and Treatment
    Influenza: Diagnosis and Treatment David Y. Gaitonde, MD; Cpt. Faith C. Moore, USA, MC; and Maj. Mackenzie K. Morgan, USA, MC Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia Influenza is an acute viral respiratory infection that causes significant morbidity and mortality worldwide. Three types of influ- enza cause disease in humans. Influenza A is the type most responsible for causing pandemics because of its high susceptibility to antigenic variation. Influenza is highly contagious, and the hallmark of infection is abrupt onset of fever, cough, chills or sweats, myalgias, and malaise. For most patients in the outpatient setting, the diagnosis is made clinically, and laboratory con- firmation is not necessary. Laboratory testing may be useful in hospitalized patients with suspected influenza and in patients for whom a confirmed diagnosis will change treatment decisions. Rapid molecular assays are the preferred diagnostic tests because they can be done at the point of care, are highly accurate, and have fast results. Treatment with one of four approved anti-influenza drugs may be considered if the patient presents within 48 hours of symptom onset. The benefit of treatment is greatest when antiviral therapy is started within 24 hours of symptom onset. These drugs decrease the duration of illness by about 24 hours in otherwise healthy patients and may decrease the risk of serious complications. No anti-influenza drug has been proven superior. Annual influenza vaccination is recommended for all people six months and older who do not have contraindications. (Am Fam Physician. 2019; 100:online. Copyright © 2019 American Academy of Family Physicians.) Published online November 11, 2019 BEST PRACTICES IN INFECTIOUS DISEASE Influenza is an acute respiratory infection caused by a negative-strand RNA virus of the Orthomyxoviridae fam- Recommendations from the Choosing ily.
    [Show full text]
  • Development and Effects of Influenza Antiviral Drugs
    molecules Review Development and Effects of Influenza Antiviral Drugs Hang Yin, Ning Jiang, Wenhao Shi, Xiaojuan Chi, Sairu Liu, Ji-Long Chen and Song Wang * Key Laboratory of Fujian-Taiwan Animal Pathogen Biology, College of Animal Sciences (College of Bee Science), Fujian Agriculture and Forestry University, Fuzhou 350002, China; [email protected] (H.Y.); [email protected] (N.J.); [email protected] (W.S.); [email protected] (X.C.); [email protected] (S.L.); [email protected] (J.-L.C.) * Correspondence: [email protected] Abstract: Influenza virus is a highly contagious zoonotic respiratory disease that causes seasonal out- breaks each year and unpredictable pandemics occasionally with high morbidity and mortality rates, posing a great threat to public health worldwide. Besides the limited effect of vaccines, the problem is exacerbated by the lack of drugs with strong antiviral activity against all flu strains. Currently, there are two classes of antiviral drugs available that are chemosynthetic and approved against influenza A virus for prophylactic and therapeutic treatment, but the appearance of drug-resistant virus strains is a serious issue that strikes at the core of influenza control. There is therefore an urgent need to develop new antiviral drugs. Many reports have shown that the development of novel bioactive plant extracts and microbial extracts has significant advantages in influenza treat- ment. This paper comprehensively reviews the development and effects of chemosynthetic drugs, plant extracts, and microbial extracts with influenza antiviral activity, hoping to provide some refer- ences for novel antiviral drug design and promising alternative candidates for further anti-influenza drug development.
    [Show full text]
  • Influenza Antiviral Medications: Summary for Clinicians
    Influenza Antiviral Medications: Summary for Clinicians The information on this page should be considered current for the 2014-2015 influenza season for clinical practice regarding the use of influenza antiviral medications. This page contains excerpts from Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP). PDF Version[1 MB, 28 pages] Antiviral medications with activity against influenza viruses are an important adjunct to influenza vaccine in the control of influenza. Influenza antiviral prescription drugs can be used to treat influenza or to prevent influenza. Four licensed prescription influenza antiviral agents are available in the United States. o Two FDA-approved influenza antiviral medications are recommended for use in the United States during the 2014-2015 influenza season: oral oseltamivir (Tamiflu®) and inhaled zanamivir (Relenza®). Oseltamivir and zanamivir are chemically related antiviral medications known as neuraminidase inhibitors that have activity against both influenza A and B viruses. o Amantadine and rimantadine are antiviral drugs in a class of medications known as adamantanes. These medications are active against influenza A viruses, but not influenza B viruses. As in recent past seasons, there continues to be high levels of resistance (>99%) to adamantanes among influenza A (H3N2) and influenza A (H1N1) pdm09 ("2009 H1N1") viruses. Therefore, amantadine and rimantadine are not recommended for antiviral treatment or chemoprophylaxis of currently circulating influenza A viruses. Antiviral resistance to oseltamivir and zanamivir among circulating influenza viruses is currently low, but this can change. Also, antiviral resistance can emerge during or after treatment in some patients (e.g., immunosuppressed).
    [Show full text]
  • Use of Vaccines and Antivirals During Influenza Pandemics
    WHO Guidelines on the Use of Vaccines and Antivirals during Influenza Pandemics Department of Communicable Disease Surveillance and Response WHO Global Influenza Programme WHO Guidelines on the Use of Vaccines and Antivirals during Influenza Pandemics World Health Organization Department of Communicable Disease Surveillance and Response © World Health Organization 2004 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. WHO Guidelines on the Use of Vaccines and Antivirals during Influenza Pandemics WHO/CDS/CSR/RMD/2004.8 CONTENTS 1. Introduction ..............................................................................................................................................2
    [Show full text]
  • Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008
    Morbidity and Mortality Weekly Report www.cdc.gov/mmwr Early Release July 17, 2008 / Vol. 57 Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008 depardepardepartment of health and human servicesvicesvices Centers for Disease Control and PreventionPrevention Early Release CONTENTS The MMWR series of publications is published by the Coordinating Center for Health Information and Service, Centers for Disease Introduction......................................................................... 1 Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Methods .............................................................................. 3 Suggested Citation: Centers for Disease Control and Prevention. Primary Changes and Updates in the Recommendations ..... 3 [Title]. MMWR Early Release 2008;57[Date]:[inclusive page numbers]. Background and Epidemiology ............................................ 4 Influenza Vaccine Efficacy, Effectiveness, and Safety ............ 8 Centers for Disease Control and Prevention Julie L. Gerberding, MD, MPH Recommendations for Using TIV and LAIV During the Director 2008–09 Influenza Season .............................................. 25 Tanja Popovic, MD, PhD Chief Science Officer Additional Information About Vaccination of Specific James W. Stephens, PhD Populations ...................................................................... 26 Associate Director for Science Recommendations for Vaccination Administration
    [Show full text]
  • Therapeutic Class Overview Antivirals: Influenza
    Therapeutic Class Overview Antivirals: Influenza Therapeutic Class • Overview/Summary: Influenza epidemics are a major cause of respiratory illness in the United States.1 The most effective way to minimize the negative impact of influenza is through prophylaxis, by administration of the influenza vaccine.1 Guidance for the 2014-2015 season follows the recommendations from the 2013-2014 influenza season. Interim guidance continues to recommend annual influenza vaccination for all persons six months of age and older in the United States.2 It is specifically recommended annually for older persons (≥65 years of age), young children, pregnant women and individuals considered high risk, including immunocompromised persons and those with comorbidities such as chronic pulmonary, cardiovascular and chronic metabolic diseases, or any disorder interfering with respiratory function. The general population should be vaccinated once the above populations have had the opportunity to be vaccinated. The use of chemotherapeutic agents for the prophylaxis and treatment of influenza is an important adjunct for disease control during outbreaks among unvaccinated individuals, or for individuals at risk for whom the vaccine is contraindicated or ineffective.1 The neuraminidase inhibitors and the adamantanes are the two classes of drugs available for the prophylaxis and treatment of influenza. The neuraminidase inhibitors, oseltamivir and zanamivir are Food and Drug Administration (FDA)-approved for the treatment and prophylaxis of influenza A and B.3,4 Neuraminidase
    [Show full text]
  • Clinical and Cross-Discipline Team Leader Review
    Clinical and Cross Discipline Team Leader Review Clinical and Cross-Discipline Team Leader Review Date January 20, 2021 From Peter Miele, MD Subject Clinical and Cross-Discipline Team Leader Review NDA/BLA # and Supplement# NDA 206426/S-007 Applicant BioCryst Pharmaceuticals, Inc. Date of Submission July 29, 2020 PDUFA Goal Date January 29, 2021 Proprietary Name Rapviab® Established or Proper Name Peramivir Dosage Form(s) 200 mg in 20 mL (10 mg/mL) single use vials Treatment of acute uncomplicated influenza in Applicant Proposed patients 6 months and older who have been Indication(s)/Population(s) symptomatic for no more than two days Adults and adolescents (13 years and older): 600 mg Applicant Proposed Dosing single dose Regimen(s) Pediatric patients (6 months to 12 years): 12 mg/kg (up to 600 mg) single dose Recommendation on Regulatory Approval Action Recommended Same as proposed by Applicant Indication(s)/Population(s) (if applicable) Recommended Dosing Same as proposed by Applicant Regimen(s) (if applicable) 1 Reference ID: 4738132 Clinical and Cross Discipline Team Leader Review 1. Benefit-Risk Assessment Benefit-Risk Assessment Framework Benefit-Risk Integrated Assessment Children younger than 5 years old, and especially those younger than 2 years, are at increased risk of serious influenza and its related complications, which can result in hospitalization and death. The U.S. Centers for Disease Control and Prevention (CDC) recommends prompt initiation of antiviral drugs in young children with suspected or confirmed influenza of any severity. Currently, the only antiviral drug approved in the U.S. for use in children younger than 2 years is oseltamivir (Tamiflu®), an oral neuraminidase inhibitor (NAI) prodrug that is administered twice daily for 5 days and widely used for the treatment of influenza.
    [Show full text]
  • Influenza Treatment and Prophylaxis Guidelines for The
    Interim recommendations for the selection of antiviral treatment using laboratory test results and viral surveillance data, United States, 2008-09 season‡ (from CDC.gov) NOTE: In Nebraska, influenza A (H1N1) has been predominant. Oseltamivir should not be used as monotherapy unless influenza A (H3N2) or Influenza B is identified. Rapid antigen or other Predominant virus(es) in Preferred medication(s) Alternative (combination antiviral treatment) laboratory test community Not done or H1N1 or unknown Zanamivir Oseltamivir + Rimantadine* negative, but clinical suspicion for influenza Not done or H3N2 or B Oseltamivir or None** negative, but clinical suspicion Zanamivir for influenza Positive A H1N1 or unknown Zanamivir Oseltamivir + Rimantadine* Positive A H3N2 or B Oseltamivir or None** Zanamivir Positive B Any Oseltamivir or None** Zanamivir Positive A+B*** H1N1 or unknown Zanamivir Oseltamivir + Rimantadine* Positive A+B*** H3N2 or B Oseltamivir or None** Zanamivir *Amantadine can be substituted for rimantadine but has increased risk of adverse events. Human data are lacking to support the benefits of combination antiviral treatment of influenza; however, these interim recommendations are intended to assist clinicians treating patients who might be infected with oseltamivir-resistant influenza A (H1N1) virus. ** The adamantanes (amantadine and rimantadine) should not be used for H3N2 or B viruses. *** Positive A+B indicates a rapid antigen test that cannot distinguish between influenza A and influenza B viruses. ‡ Influenza antiviral medications used for treatment are most beneficial when initiated within the first two days of illness. Clinicians should consult the package insert of each antiviral medication for specific dosing information, approved indications and ages, contraindications/warnings/precautions, and adverse effects.
    [Show full text]
  • Influenza: Developing Drugs for Treatment And/Or Prophylaxis
    Guidance for Industry Influenza: Developing Drugs for Treatment and/or Prophylaxis U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER) April 2011 Clinical Antimicrobial Guidance for Industry Influenza: Developing Drugs for Treatment and/or Prophylaxis Additional copies are available from: Office of Communications, Division of Drug Information Center for Drug Evaluation and Research Food and Drug Administration 10903 New Hampshire Ave., Bldg. 51, rm. 2201 Silver Spring, MD 20993-0002 Tel: 301-796-3400; Fax: 301-847-8714; E-mail: [email protected] http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER) April 2011 Clinical Antimicrobial TABLE OF CONTENTS I. INTRODUCTION............................................................................................................. 1 II. BACKGROUND ............................................................................................................... 2 III. DEVELOPMENT PROGRAM ....................................................................................... 4 A. General Considerations .................................................................................................................4 1. Nonclinical and Early Phase Clinical Development Considerations ..............................................4 a. Phase 2A: Challenge trials .......................................................................................................5
    [Show full text]
  • Downloaded from Manchesterhive.Com at 10/03/2021 01:08:52AM Via Free Access Pandemic Flus and Vaccination Policies in Sweden 261 Was Limited
    10 Pandemic flus and vaccination policies in Sweden Britta Lundgren and Martin Holmberg Introduction During the summer of 2010, unexpected reports of narcolepsy in Swedish children and adolescents after vaccination with the pandemic influenza vaccine Pandemrix came to the attention of the Medical Prod- ucts Agency (MPA). The main features of this condition are excessive daytime sleepiness, sudden loss of voluntary muscle tone (cataplexy) that may be triggered by strong emotions, vivid dreamlike images/ hallucinations (hypnagogic hallucinations), and paralysis during sleep onset or when waking (sleep paralysis). Vaccination of the entire popu- lation had been recommended by the National Board of Health and Welfare as a preventive measure to stop the spread and mitigate the feared consequences of the A(H1N1) pandemic that began in the summer of 2009. Over 60 per cent of people living in Sweden were vaccinated during the fall of 2009 with a new vaccine. This was the single largest public health intervention in response to an outbreak in Swedish history. Five different vaccines were developed during the pandemic and were approved by the European Medicines Agency (EMA) and the EU commission in a special fast-track procedure.1 Sweden had signed a contract with one of the producers of the vaccine Pandemrix (Glaxo- SmithKline). This vaccine contained a new formulation for the adju- vant, the component of a vaccine that enhances the immune response to the included antigen. Since the pandemic vaccines were approved under exceptional circumstances, information on possible side effects Britta Lundgren and Martin Holmberg - 9781526110916 Downloaded from manchesterhive.com at 10/03/2021 01:08:52AM via free access Pandemic flus and vaccination policies in Sweden 261 was limited.
    [Show full text]