Viral Pneumonia: much more than what is diagnosed Filipe Froes

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1 Viral Pneumonia: much more than what is diagnosed Filipe Froes Centro Hospitalar Lisboa Norte Directorate-General of Health - ICU Influenza Surveillance Network 27 de Fevereiro de 2014

2 The perpetual challenge of infectious diseases NEJM 2012;366:454-61

3 Leading causes of death from infectious diseases NEJM 2012;366: Pneumonia the forgotten killer Mostly bacteria. Viral?

4 How many pathogens can infect Humans? 2008: 1400 pathogens are known to infect humans. From 1940 to 2004: 335 Emerging Infectious Diseases (EID) events: - events caused by newly evolved strains (e.g., VRSA) - pathogens newly entered human population (e.g., HIV, SARS) ± 70% animal origin (zoonotic) Significant impact on global health and economcis Jones K. Nature 2008;451: > 2004: H5N1, Pandemic influenza, MERS-CoV, H7N9, never ending story!

5 What is the role of virus? From 1940 to 2004: Virus and prions pathogens represent 25,4% of EID events Lung involvement: - frequent - related to severity Nature 2008

6 Clear and present danger... World experiencing emergence of two exceptional new virus infections: - avian influenza A (H7N9) - novel coronavirus MERS-CoV Unusual global situation: - unrelated, highly pathogenic - potential to evolve and spread No comparable situation since SARS, H5N1 (Avian flu) and pandemic flu

7 Middle East Respiratory Syndrome Coronavirus (MERS-CoV) New virus emerged Spring 2012 as a cause of SARI/ARDS in humans. Virus of animal origin, most likely primordial source is bats ( morcegos ). Possibly circulating in camels for a decade or more. Limited human-to-human spread.

8 Middle East Respiratory Syndrome Coronavirus (MERS-CoV) As of 21 Jan 2014: laboratory confirmed cases median age: 52 years including 76 deaths 62% male - 19 possible cases - 70 primary cases (no history of exposure to other human cases) with CFR 53% secondary cases (>50% associated with healthcare settings) with CFR 27% - all cases have a link to the Middle East (Jordan, Kuwait, Oman, Qatar, Saudi Arabia and UAE) - reported cases: France, Germany, Italy & UK (Spain?) - most cases presented with severe primary viral penumonia, few with mild disease.

9 Avian Influenza A (H7N9) Since February 2013, 355 confirmed cases and 112 deaths. First notification to OMS at the end of March Most cases from infected animals (live animal markets). No sustained human-to-human transmission to date.

10 Avian Influenza A (H7N9) As of 17 Feb 2014: laboratory confirmed cases including 112 deaths - Case Fatality Rate 31,5% - less cases during Summer median age: 58 years 67% male - most cases: rapidly progressive severe pneumonia - severe illness is more likely to occur in older persons with underlying chronic conditions - several cases with oseltamivir resistance - sistemic high dose corticosteroids in severe ill patients has been reported to be harmful

11 MERS-CoV & Avian Influenza A (H7N9) &... MERS-CoV & A (H7N9): - few cases in Europe - no cases in Portugal NEW PARADIGMA (> 2009 Pandemic Flu) Virus: greater impact (quantitative) severe disease (qualitative)

12 Viral pneumonia after pandemic influenza Recent advances in molecular virology have led to the discovery of previously unrecognized respiratory virus (hmpv, PIV, HCoV) - Virus: - sole cause of pneumonia (viral pneumonia) - present as co-infection (virus-bacteria, virus-virus) - predisposing factor to facilitate or worsen bacterial pneumonia - Hospitalized adults with CAP: - respiratory virus are detected in 15 to 54% - coinfection virus-bacteria in 4 to 30% Pavia A. Infect Dis Clin N Am 2013;27:

13 Virus associated with pneumonia Pavia A. Infect Dis Clin N Am 2013;27:

14 Virus associated with pneumonia Serious medical conditions, immunocompromised and closed settings RSV: 4-7% adults with CAP (RSV seasons), more common and severe in older adults. Adenovirus: 2005 a new variant serotype 14 emerged as a cause of severe LRTI in community and military. Rhinovirus: cause of CAP or coinfection facilitate second virus or bacteria infection? Pavia A. Infect Dis Clin N Am 2013;27:

15 Admissions for CAP and influenza activity (Portugal) Taxa de hospitalização por PAC / hab (GDH-ACSS) Taxa de incidência de síndroma gripal por ha, (Médicos Sentinela) Admissions for CAP and ILI incidence by week ( ) Semana (hospitalização/início dos sintomas) CAP in Adults a 10-Year Retrospective Study in the Hospital Setting in Mainland Portugal F Froes, A Diniz, M Mesquita, M Serrado, B Nunes (in submission)

16 Portuguese Influenza Surveillance Network in ICU ( ) - started (6 ICU 8 patients) (16 ICU 95 patients) (20 ICU 93...) ICU ICU participants in the surveillance network Flu Season : - 16 ICU - 95 patients confirmed (RT-PCR) - median age 56,7 years 51,6% with years 51% male 76,8% A(H1N1) % not vaccinated 75,8% at least 1 risk factor: obesity (BMI >30) 33,7% chronic heart disease 27,4% diabetes mellitus 17,9% imunossupression 13,7% DGS data

17 Portuguese Influenza Surveillance Network in ICU ( ) weekly distribution of influenza cases % of patientes admitted with flu to ICU 13.3% 10% DGS data

18 Portuguese Influenza Surveillance Network in ICU ( ) - implemented (6 ICU 8 patients) (16 ICU 95 patients) (20 ICU 93...) ICU Flu Season : - 95 patients confirmed (RT-PCR) - Outcomes: 83 (87,3%) mechanical ventilation 12 (12,6%) ECMO 3 zanamivir IV 27 (28,4%) died: median age of 59 years 44,4% age years MV: 27 (32,5%) ECMO: 4 (33,3%) ICU participants in the surveillance network DGS data

19 Viral Pneumonia: much more than what is diagnosed without any doubt! (bacterial) pneumonia: the old man s friend. W. Osler (viral) pneumonia: the (not so) old man s underdiagnosed enemy? F. Froes, G. Translate

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