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2020: the Year of the Respiratory Viruses a Primer on Influenza and COVID-19

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2020: the Year of the Respiratory Viruses a Primer on Influenza and COVID-19 2020: The Year of the Respiratory Viruses A Primer on Influenza and COVID-19 Marilyn N. Bulloch PharmD, BCPS, FCCM Associate Clinical Professor and Director of Strategic Operations Harrison School of Pharmacy Auburn University Objectives • Review the pathophysiology of influenza and COVID-19 • Compare and contrast symptoms of influenza and COVID-19 • Describe pharmacologic options for the treatment and prevention of influenza • Identify treatment strategies for patients diagnosed with COVID-19 • Discuss pipeline agents being developed for the prevention and/or treatment of influenza and/or COVID-19 Disclosures • Speaker’s Bureau - Xofluza (Baloxavir) • Pharmacy Times – contributor • PowerPak – author (sleep medicine) None of these disclosures will impact the content of my presentation today Glenn Ridenour MD, Infectious Disease Specialist Charleston, West Virginia A Brief History of Influenza 1st (Documented) Pandemic Advance in Lab Research Reason for Earlier pandemics • 1931 – discovery that influenza can Pandemics are likely, but were grow in eggs not recognized or • 1932 – human influenza isolated Identified documented for • 1935 – 1st egg-based vaccine historic purposes developed Antigenic shift studied 1173 1580 1700’s 1930’s 1940’s 1950’s Initial Recognition Term “Influenza” Growth of Knowledge Influenza as a disease is Coined • Vaccine given to U.S military known to be at least 6,000 members during WWII years old, but was first • 1946 – discovery of antigenic drift classified as a disease in the 12th century http://www.medicalecology.org/diseases/influenza/influenza.htm#sect2.1 (Accessed 11 Mar 2015) Shope RE. Public Health Reports. 1958;73:165-179 Potter CW. J Applied Microbiol. 2001;91:572-579 Kilbourne ED. History of Vaccine Development. How Influenza is Named Antigenic Type •A, B, or C Host of Origin •I.E. Swine, Chicken, Equine, ect •No host of origin given if human origin City of Geographic Origin Strain Number •Unique Year of Isolation For Influenza A strains •Hemagglutinin and neuraminidase description in parentheses •I.E. H3N2 http://www.cdc.gov/flu/about/viruses/types.htm Source: www.medicalecology.com 2019-20 Flu Season Burden 410,000-740,000 39-56 Million Influenza 18-26 Million Medical Visits 24,000-62,000 Deaths Illnesses Hospitalizations https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm Source: Cruz D. How does the flu change over time? http://spotlight.vitals.com/2015/01/how-does-the-flu-change-over-time/ (Accessed 24 Mar 2015) History of COVID-19 Photo courtesy of Creative Commons CCO: https://www.researchgate.net/figure/Timeline-showing-the-most-important-events-occurred-in-the-world-from-novel- coronavirus_fig2_342840258 Which is a symptom of COVID-19, but not a symptom of Influenza? A. Fever B. Nausea C. Body aches D. Loss of smell Symptoms of Influenza Symptoms vary WIDELY Headache by patient Fever (Usually high) Chills Patients may not have all or even Congestion or runny nose most of the known symptoms Cough (usually non-productive) Sore throat Symptoms appear 1-4 days after Shortness of breath or exposure difficulty breathing People are contagious ~ 1 day Fatigue before symptoms appear Muscle or body aches Most contagious in first 3-4 days, but remain contagious ~ 7 days (up to 2 weeks in children and immunocompromised GI symptoms more common in Nausea Vomiting children and with Influenza B Diarrhea Cough and fatigue may last > 2 weeks Symptoms may have abrupt onset https://www.cdc.gov/flu/symptoms/symptoms.htm Symptoms of COVID-19 Symptoms vary WIDELY by Headache patient Fever (may be low grade) Chills Patients may not have all or even most Loss of smell of the known symptoms Congestion or runny nose Symptoms vary even among those in the same household Cough Loss of taste Sore throat Symptoms appear 2-14 days after Shortness of breath or exposure (average 5 days) difficulty breathing 97.5% of people who develop symptoms develop them within 11.5 days of exposure Fatigue Muscle or body aches Symptom severity and duration vary widely by patient People are contagious ~ 2 days before Nausea symptoms appear and remain for 10 days Vomiting Diarrhea Some patients never exhibit any signs or symptoms https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html Luaer et al. Ann Intern Med. 2020 COVID-19 and Hypercoagulability Proposed Pathophysiology Some patients Laboratory Abnormalities Complications Treatment • Inpatient DVT develop • DVT/PE • Largely unknown at this time prophylaxis • • Microvascular clots in toes hypercoagulable Thrombocytopenia (mild) • May be due to inflammatory • Unclear if treatment • • Catheter clotting state Increased D-dimer**** activation of coagulation dose anticoagulation • Increased ferritin and fibrinogen • STEMI pathway. should be used. • Prolonged PT • Large vessel stroke. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#clinical-management-treatment%3C https://www.covid19treatmentguidelines.nih.gov/adjunctive-therapy/antithrombotic-therapy/ Patients at High Risk of Complications Influenza COVID-19 < 2 weeks post- Age ≥ 65 years Age < 2 years Pregnancy partum Increaseing Age Cancer CKD Diabetes and other Chronic lung Immunocompromised endocrine disorders disease COPD Immunocompromised BMI ≥ 30 Hematologic Heart Disease Neurologic Diseases (I.E. Asthma and Stroke Conditions Sickle Cell Serious Heart Disease) Sickle Cell Disease Diabetes Disease Children on Kideny Disease Liver disease BMI ≥ 40 long-term salicylates American Alaskan Natives LTC facilities Indians https://www.cdc.gov/flu/highrisk/index.htm https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html Patients Who May Be at Increased Risk for COVID-19 Complications Moderate-Severe Cerebrovascular Cystic Fibrosis Hypertension Immunocompromised Asthma Disease Steroid or other Neurologic Conditions immunosuppressive Liver Disease Pregnancy Pulmonary Fibrosis (e.g. dementia) medications Children with congenital Smokers Thalassemia Type 1 Diabetes cardiovascular, Type A Blood Type neurologic, genetic, or metabolic conditions More to come https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/evidence-table.html Potential Complications of COVID-19 Pneumonia Respiratory (often ARDS failure bilateral) Cardic events Multiple-organ Sepsis (e.g. MI, failure Stroke) Worseing of Secondary chronic Inflammation bacteria disease infections https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm#anchor_1595599580 An ounce of prevention gives a glimmer of hope Flu Vaccine Effectiveness Overall Influenza Vaccine Vaccine Effectiveness 2019-20 Effectiveness 2010-2020 Flu Season 80% 50% 39% 42% 60% 33% 37% 35% 37% 48% 52% 49% 47% 40% 60% 39% 38% 40% 29% 30% 40% 19% 20% 20% 10% 0% 0% All 6 mos-8 9-17 18-49 50-64 65 years years years years years and older Vaccine Effectiveness for Circulating Strains 2019-20 Flu Season 60% 45% 44% 38% 39% 39% 38% 42% 31% 29% 40% 22% 28% 20% 4% 0% All 6 mos - 8 years 9-17 years 18-49 years 50-64 years 65 years and older H1N1 B/Victoria https://www.cdc.gov/flu/vaccines-work/2019-2020.html https://www.cdc.gov/flu/vaccines-work/effectiveness-studies.htm Vaccine Prevented Burdens 2017-18 Flu Season 2016-17 Flu Season Averted Averted Medical Averted Averted Averted Flu Averted Medical Averted Averted Age Group Age Group Flu Cases Visits Hospitalizations Deaths Cases Visits Hospitalizations Deaths All 6,160,213 3,180,360 90,904 5,747 All 5,283,410 2,651,757 72,303 5,217 0-4 years 1,721,215 1,153,214 15,139 68 0-4 years 615,907 412,658 4,294 32 5-17 years 1,151,025 598,533 4,275 110 5-17 years 2,234,364 1,161,869 6,126 43 18-49 years 1,044,837 386,590 6,534 226 18-49 years 528,273 195,461 2,965 78 50-64 years 1,647,176 708,286 16,792 808 50-64 years 1,422,737 611,777 15,088 722 ≥ 65 years 595,961 333,738 48,163 4,536 ≥ 65 years 482,130 269,993 43,830 4,341 2015-16 Flu Season 2014-15 Flu Season Averted Averted Medical Averted Averted Averted Flu Averted Medical Averted Averted Age Group Age Group Flu Cases Visits Hospitalizations Deaths Cases Visits Hospitalizations Deaths All 5,348,579 2,655,362 69,506 6,413 All 1,408,009 702,400 38,776 3,657 0-4 years 1,059,354 709,767 7,385 87 0-4 years 140,406 94,072 979 17 5-17 years 1,521,776 791,324 4,173 32 5-17 years 357,179 185,733 979 23 18-49 years 1,579,966 584,588 8,868 295 18-49 years 247,680 91,642 1,390 28 50-64 years 733,122 315,243 7,775 362 50-64 years 309,102 132,914 3,278 203 ≥ 65 years 454,360 254,442 41,305 5,637 ≥ 65 years 353,641 198,039 32,149 3,386 https://www.cdc.gov/flu/vaccines-work/burden-averted.htm 2020-21 Influenza Vaccine Components A/Guangdong- A/Hawaii/70/2019(H1N1) Maonan/SWL1536/2019(H1 pdm09-like virus N1)pdm09-like virus A/Hong A/Hong Kong/45/2019 Kong/2671/2019(H3N2)-like (H3N2)-like virus virus B/Washington/02/2019 B/Washington/02/2019 (B/Victoria lineage)-like virus (B/Victoria lineage)-like virus B/Phuket/3073/2013-like Cell – or B/Phuket/3073/2013-like Egg-Based (Yamagata lineage) virus Recombinant - (Yamagata lineage) virus Vaccines Based Vaccines https://www.cdc.gov/flu/season/faq-flu-season-2020-2021.htm CDC Recommendations on Immunization During COVID19 Patients should continue to receive recommended vaccinations All essential workers need a flu vaccine All patients at increased risk for severe COVID-19 need a flu vaccine All patients at increased risk for influenza complications need a flu vaccine Defer vaccination in patients with suspected or confirmed COVID19 until out of isolation Screen all patients for COVID19 symptoms Wear masks and use other precautions • Patient – cloth • Immunizer – medical (N-95 not required, even for intranasal vaccine because it is not aerosol- generating) Immunizers in areas of high community transmission (e.g.
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