H1N1 and other stuff

[Guest guest]

Hi Group:

I promised to tell you guys what happened with the forcing of the h1n1 vaccine

on us that work in my hospital. I personally objected because I dont know how

this vaccine reacts with the DMARDS (biologics). What r they gonna say to me in

10 yrs if something disastrous occurs? Oops, sorry??? Pffffffffft.....anyways:

CDC says there is not enuf research with Enbrel (they emailed me), and my

Rheumy, yesterday, after me waiting for an appt, signed the waiver stating that

she did not recommend it for me, because there is not enuf research with h1n1

and Enbrel, and I am dancing the happy victory dance, cause I one-upped the

mofo's trying to assault me with this vaccine (which I feel is a drug company

ploy to make money), and then, POOF, today my Rheumy emails me with this:

http://www.rheumatology.org/publications/hotline/2009_09_29_h1n1.asp

H1N1 Virus: Implications for Rheumatology

As the fall begins, both rheumatologists and patients are concerned about the

impact of the seasonal influenza virus. This year, there is the additional worry

about the impact of the novel 2009 H1N1 (swine) flu virus. Rheumatologists have

become accustomed to recommending, or administering seasonal, influenza

vaccines, as many of our patients meet the guidelines for annual vaccination.

The guidelines for 2009 H1N1 flu vaccination are similar, but not exactly the

same. This Hotline is intended to provide rheumatologists and their offices with

the most current information on recommendations for management of both seasonal

influenza and 2009 H1N1 flu. The approach to the swine flu, and particularly

vaccination strategies, has been changing rapidly; readers are cautioned to

consult the CDC and FDA Web sites for any updates (see links at the end of this

Hotline).

Seasonal Influenza Vaccines: Seasonal influenza occurs in the U.S. during the

late fall to early spring period, and its associated morbidity and mortality has

led to recommendations to immunize high-risk groups (children < 2 years of age,

adults & #8805; 50, patients with a serious medical condition, and

immunocompromised patients). Groups at risk for transmitting the virus,

including children < 18 years of age, healthcare workers, and household contacts

of high-risk groups, should also be vaccinated. Vaccination is recommended as

soon as the vaccine is available for the season (usually in September each

year), and a single dose is adequate. A live attenuated nasal vaccine is

available, but should not be given to those taking immunosuppressive

medications, or in contact with immunosuppressed persons. The humoral response

to influenza vaccine, while potentially diminished, appears to be adequate for

patients receiving biologic and non-biologic DMARDs. There is also no evidence

that vaccinating patients on these medications leads to complications or

worsening of the underlying disease. Influenza vaccination is appropriate for

patients treated with both biologic and non-biologic DMARDs, and concern over

the level of response should not preclude this.

Novel Influenza (2009 H1N1) Strains: April 2009 brought the first reports of a

novel influenza A (H1N1) virus causing human infections. Termed swine flu

because this virus is endemic in pigs, it is distinct from the human influenza A

(H1N1) viruses previously in circulation. Therefore, most individuals have no

pre-existing antibodies to its key surface epitopes. Several companies are

developing vaccines directed against this novel H1N1 influenza A and these will

be available by mid-October 2009. It appears that a single injection will be

adequate and will confer protection 8-10 days after vaccination. The vaccines

themselves are made using the same process used to produce seasonal influenza

vaccines, so that adverse reactions are not anticipated to be any different.

Seasonal influenza vaccine and H1N1 vaccine may be administered at the same

time. A live, attenuated H1N1 vaccine is expected to be available, but its use

should be subject to the same restrictions as the seasonal live, attenuated

influenza vaccine.

Adverse Effects: Because influenza vaccines are manufactured with chicken eggs,

they are contraindicated in patients with a history of anaphylactic reactions to

eggs or egg proteins. Thimerosal is used as an antibacterial in multidose vials

of influenza vaccine. Single dose vials and LAIV sprays do not contain

thimerosal. Vaccines administered to children <6 months of age are now produced

with significantly reduced amounts of thimerosal, but there is no evidence of

risk to other populations, including pregnant women, aside from local

hypersensitivity reactions. Administration of the swine flu vaccine in 1976 was

associated with an increased frequency of Guillain-Barr & #1104; syndrome.

However, a substantial increase in GBS has not been reported for any of the

seasonal influenza vaccines available since then.

Recommendations for Vaccination and Management of H1N1: The groups at risk for

H1N1 infection and complications are similar to those at risk with the seasonal

influenza virus, and recommendations for vaccination are correspondingly

similar. Three specific groups likely to be seen by rheumatologists should

receive H1N1 vaccine when available:

Patients with inflammatory arthritis and other systemic inflammatory diseases

Patients receiving immunosuppressive medications, including steroids,

non-biologic and biologic DMARDs

Patients with multiple chronic medical conditions, such as asthma, diabetes,

heart disease, or malignancy, that put them at risk for influenza complications,

including osteoarthritis patients with one of these conditions

In addition, pregnant women, health care and emergency response workers, young

children age >6 months to 18, young adults age 19-24, and those who live with or

care for children < 6 months old are high priority candidates for H1N1

vaccination. Limited availability of H1N1 vaccine is expected by early October

2009, with widespread availability by the end of the month. If enough vaccine is

available, it should be offered to the same individuals who are appropriate to

receive the seasonal influenza vaccine. Vaccination should begin as soon as the

vaccine is available, but vaccination is recommended at any time during the flu

season. Inactivated H1N1 and seasonal influenza vaccines can be given at the

same time, however, LAIV H1N1 and LAIV seasonal vaccines should not be given at

the same time. H1N1 vaccine will be distributed through state health

departments; the CDC Web site has contact information for these offices at

http://www.cdc.gov/h1n1flu/vaccination/statecontacts.htm. The vaccine is

provided free, but practitioners may bill for administration

(http://www.cms.hhs.gov/MLNMattersArticles/downloads/se0920.pdf). The AMA

recently released new CPT codes to bill for the administration of 2009 H1N1

influenza vaccination, effective immediately. See

http://www.ama-assn.org/ama/pub/h1n1/resources/cpt-codes.shtml for details.

Managing Infected Individuals: Persons with suspected 2009 H1N1 influenza or

seasonal influenza who present with an uncomplicated febrile illness generally

do not require treatment. Those who do get sick should be advised to avoid work,

school or travel until 24 hours after they become afebrile without fever

reducing medications. The 2009 H1N1 strain appears to be sensitive to

oseltamivir (Tamiflu®) and zanamivir (Relenza®); either medication may be used,

although zanamivir is not recommended for persons with asthma or underlying

respiratory disease. Antiviral therapy is appropriate for anyone hospitalized

with suspected influenza or anyone at high risk for influenza complications,

including children <5 years of age, adults >65 years of age, pregnant women, and

those with chronic illnesses or receiving immunosuppressive medications. When

the clinical presentation is consistent with influenza, antiviral therapy should

not be delayed by waiting for laboratory confirmation. Antiviral therapy should

be initiated early, preferably within 48 hours of symptoms onset and continued

for five days. Empiric therapy based on telephone contact with high-risk

individuals may be considered. Antiviral therapy for individuals exposed to

someone with confirmed or presumed H1N1 infection may be appropriate for

patients in high-risk groups, but early identification of symptoms and

initiation of antiviral treatment at that time (e.g., watchful waiting) is

another option. Post-exposure prophylaxis should continue for 10 days after the

last known date of exposure.

Further information regarding H1N1 virus and vaccinations is available on the

following Web sites:

www.fda.gov/NewsEvents/PublicHealthFocus/ucm150305.htm - FDA Web page on H1N1

www.cdc.gov/h1n1flu/ - Primary CDC Web site with information on H1N1

www.cdc.gov/h1n1flu/vaccination/acip.htm - CDC H1N1 vaccine recommendations

www.cdc.gov/mmwr/preview/mmwrhtml/rr58e0821a1.htm - MMWR on H1N1 vaccination

www.cdc.gov/h1n1flu/clinicians/ - Information on H1N1 vaccines for health care

professionals treating patients with inflammatory arthritis and related

conditions

www.cdc.gov/h1n1flu/groups.htm - Information on H1N1 vaccines for patients with

inflammatory arthritis and related conditions

Bottom Line:

Keep up to date on the latest information from the CDC and FDA

Recommend vaccination as individually appropriate for your patients as well as

staff

Be aware of the signs and symptoms of disease

Consider antiviral therapy or prophylaxis in high-risk individuals reporting

symptoms or exposure

Hotline Editors: Arthur Kavanaugh, MD, University of California, San Diego and

Ruderman, MD, Northwestern University

Disclosure: The Hotline editors have nothing to disclose.

The ACR Hotline is provided by the ACR Communications and Marketing Committee as

a service to members. This Hotline reflects the views of the author(s) and does

not represent a position statement of the American College of Rheumatology.

Anyways, now i ask my Rheumy if she is revoking my h1n1 pass, and i am awaiting

her response.

Feeling like I am about to be assaulted.

OKD