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ACIP Recommendations for the Use of Antiviral Medications Morbidity and Mortality Weekly Report Recommendations and Reports / Vol. 60 / No. 1 January 21, 2011 Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP) Hemagglutinin Neuraminidase M2 Ion Channel RNP U.S. Department of Health and Human Services Centers for Disease Control and Prevention Recommendations and Reports CONTENTS Introduction ............................................................................................................1 Methods ....................................................................................................................2 Primary Changes and Updates in the Recommendations .....................2 Influenza Virus Transmission .............................................................................3 Clinical Signs and Symptoms of Influenza ...................................................3 Role of Laboratory Diagnosis ............................................................................4 Antiviral Agents for Influenza ...........................................................................6 Antiviral Drug Resistance Among Influenza Viruses .............................6 Use of Antivirals ..................................................................................................7 Dosage ................................................................................................................ 14 Adverse Events ................................................................................................ 17 Drug Interactions ........................................................................................... 18 Emergency Use Authorization ................................................................... 18 Additional Information ..................................................................................... 18 On the cover: This illustration depicts the influenza A virus. Graphic created by Dan J. Higgins, Division of Communication Services, CDC. The MMWR series of publications is published by Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested Citation: Centers for Disease Control and Prevention. [Title]. MMWR 2011;60(No. RR-#):[inclusive page numbers]. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director Harold W. Jaffe, MD, MA, Associate Director for Science James W. Stephens, PhD, Office of the Associate Director for Science Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office MMWR Editorial and Production Staff Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist Christine G. Casey, MD, Deputy Editor, MMWR Series Malbea A. LaPete, Julia C. Martinroe, Teresa F. Rutledge, Managing Editor, MMWR Series Stephen R. Spriggs, Terraye M. Starr Visual Information Specialists David C. Johnson, Lead Technical Writer-Editor Quang M. Doan, MBA, Phyllis H. King Jeffrey D. Sokolow, MA, Project Editor Information Technology Specialists MMWR Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN Patricia Quinlisk, MD, MPH, Des Moines, IA Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patrick L. Remington, MD, MPH, Madison, WI David W. Fleming, MD, Seattle, WA Barbara K. Rimer, DrPH, Chapel Hill, NC William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN Deborah Holtzman, PhD, Atlanta, GA Anne Schuchat, MD, Atlanta, GA John K. Iglehart, Bethesda, MD Dixie E. Snider, MD, MPH, Atlanta, GA Dennis G. Maki, MD, Madison, WI John W. Ward, MD, Atlanta, GA Recommendations and Reports Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP) Prepared by Anthony E. Fiore, MD Alicia Fry, MD David Shay, MD Larisa Gubareva, PhD Joseph S. Bresee, MD Timothy M. Uyeki, MD Influenza Division, National Center for Immunization and Respiratory Diseases Summary This report updates previous recommendations by CDC’s Advisory Committee on Immunization Practices (ACIP) regarding the use of antiviral agents for the prevention and treatment of influenza (CDC. Prevention and control of influenza: recom- mendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2008;57[No. RR-7]).This report contains information on treatment and chemoprophylaxis of influenza virus infection and provides a summary of the effectiveness and safety of antiviral treatment medications. Highlights include recommendations for use of 1) early antiviral treatment of suspected or confirmed influenza among persons with severe influenza (e.g., those who have severe, complicated, or progressive illness or who require hospitalization); 2) early antiviral treatment of suspected or confirmed influenza among persons at higher risk for influenza complications; and 3) either oseltamivir or zanamivir for persons with influenza caused by 2009 H1N1 virus, influenza A (H3N2) virus, or influenza B virus or when the influenza virus type or influenza A virus subtype is unknown; 4) antiviral medications among children aged <1 year; 5) local influenza testing and influenza surveillance data, when available, to help guide treatment decisions; and 6) consideration of antiviral treatment for outpatients with confirmed or suspected influenza who do not have known risk factors for severe illness, if treatment can be initiated within 48 hours of illness onset. Additional information is available from CDC’s influenza website at http://www.cdc.gov/flu, including any updates or supplements to these recommenda- tions that might be required during the 2010–11 influenza season. Health-care providers should be alert to announcements of recommendation updates and should check the CDC influenza website periodically for additional information. Recommendations related to the use of vaccines for the prevention of influenza during the 2010–11 influenza season have been published previ- ously (CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices [ACIP], 2010. MMWR 2010;59[No. RR-8]). Introduction illness and death are highest among persons aged ≥65 years, children aged <2 years, and persons of any age who have medical conditions In the United States, annual epidemics of influenza occur typically that place them at increased risk for complications from influenza during the late fall through early spring. Influenza viruses can cause (3,4). In addition, data from epidemiologic studies conducted during disease among persons in any age group, but rates of illness are highest the 2009 influenza A (H1N1) pandemic indicated that the risk for among children (1,2). During most influenza seasons, rates of serious influenza complications was also increased among persons who are morbidly obese (body-mass index [BMI] ≥40) and American Indians/ Alaska Natives (5–8). Influenza illness caused by 2009 pandemic The material in this report originated in the National Center for influenza A (H1N1) (2009 H1N1) virus is expected to occur during Immunization and Respiratory Diseases, Anne Schuchat, MD, winter influenza seasons in the Northern and Southern hemispheres. Director, and the Influenza Division, Nancy Cox, PhD, Director. The extent of influenza activity caused by strains of the two seasonal Corresponding preparer: Timothy Uyeki, MD, Influenza Division, influenza A virus subtypes (seasonal H1N1 and H3N2) that have National Center for Immunization and Respiratory Diseases, CDC, 1600 Clifton Road, N.E., MS A-20, Atlanta, GA 30333. Telephone: cocirculated since 1977 and influenza B virus strains is unpredictable, 404-639-3747; Fax: 404-639-3866; E-mail: [email protected]. although seasonal H1N1 virus strains have been detected very rarely MMWR / January 21, 2011 / Vol. 60 / No. 1 1 Recommendations and Reports worldwide since 2009. In the postpandemic period, 2009 H1N1 Methods virus strains now are considered to be the predominant seasonal influenza A (H1N1) virus strains. CDC’s Advisory Committee on Immunization Practices (ACIP) On the basis of epidemiologic studies of seasonal influenza or 2009 provides annual recommendations for the prevention and control H1N1, persons at higher risk for influenza complications include: of influenza. The ACIP Influenza Work Group* meets monthly • children aged <5 years (especially those aged <2 years); throughout the year to discuss newly published studies, review current • adults aged ≥65 years; guidelines, and consider potential revisions to the recommendations. • persons with chronic pulmonary (including asthma), cardiovas- As they review the annual recommendations for consideration of the cular (except hypertension alone), renal, hepatic, hematologic full ACIP, members of the Work Group consider a variety of issues, (including sickle cell disease), metabolic disorders (including dia- including burden of influenza illness, vaccine efficacy and effective- betes mellitus) or neurologic and neurodevelopment conditions ness, safety and coverage in groups recommended for vaccination, (including disorders of the brain, spinal cord, peripheral nerve, feasibility, cost-effectiveness, and anticipated
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