“낙태권은 보편적 인권으로, 성관계, 임신, 출산, 낙태를 개인이 자유롭고 책임있게 결정할 수 있으며, 낙태와 관련한 정보와 시술 수단에의 접근권, 그 과정에 있어서의 건강과 안전을 보장받는 것을 골자로 한다.”

Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality.

3월 8일 여성의 날에 다시금 여성을 둘러싼 성 건강과 재생산 건강, 그리고 재생산 정의에 대해 성찰하는 기회를 제공할 것이다. 

 ==================================================

‘누구’의 생명을 이야기하고 있는가? 

-재생산 권리의 관점에서 바라보는 낙태 

문현아(건강과대안 연구위원, 젠더와건강팀)

<목차>

1. ‘둘만 낳아 잘 기르자’ 속에 담긴 비밀 아닌 비밀

2. 임신-낙태-출산은 연결되어 있다.  

3. 재생산 권리, 재생산 건강, 재생산 정의 

4. 낙태가 일어나지 않을 수 있는 세상을 바란다. 

초록 및 주요 내용을 요약하였다. 마지막 문단은 원문을 함께 발췌해서 넣었고,

첨부파일로 원문을 첨부했다.

초록

미국의 십대임신율은 지난 20년간 점점 줄었음에도 불구하고 다른 산업화국가들에 비해 여전히 월등히 높다. 응급 피임약은 피임 하지 않은 또는 실패한 성관계 이후120시간 내 사용하였을 때 임신 확률을 낮추며, 24시간이내 사용하였을 때 가장 효율적이다. 응급피임약의 적응증은 성폭력, 피임하지 않은 성관계(unprotected intercourse), 콘돔이 찢어지거나 빠진 경우, 경구피임약을 빼먹거나 늦게 먹은 경우, 자궁내 피임장치가 빠진 경우 등이 있다.  미국 대부분의 주에서 17세 미만의 청소년은 응급피임약을 사려면 의사의 처방전이 필요하다. 모든 주에서 17세 이상의 청소년(남녀모두)들은 처방전 없이 OTC로 응급피임약을 살 수 있다. 이번 정책 성명(policy statement)의 목적은 (1)소아과 의사 및 다른 의사들에 대한 응급 피임법 교육 (2) 십대들이 사용하는 응급피임법들에 대한 안전성, 효율성, 빈도에 대한 자료제공, (3) 보건의료정책 측면에서 십대임신을 줄이기 위한, 일상적인 상담 및 응급피임약 처방의 독려 에 있다. 이 정책은 약물적인 응급피임법을 집중적으로 다루고 있다. 응급피임 약물들에는 FDA 에서 응급피임을 목적으로 승인받은 levonorgestrel과 ulipristal, 그리고 경구피임약의 복합사용(이는 FDA 승인은 받지 않음(off-label)) 법이 있다.

주요 내용

- 가장 최근 자료에 따르면 미국의 15-19세 청소년의 출산율은 1000명당 34.3명이다 : 이 중 57%가 분만하며 27%가 인공임신중절, 16%가 유산이나 사산한다. 십대 임신의80%가 계획되지 않은 임신이다.

- 15-19세 청소년 중 성관계 경험의 비율은 여성은 43%, 남성은 42%이다. (15세는 13% ~ 19세는 70% 로 증가한다)

- 15-19세 청소년 중 성폭력 경험 비율은 10%에 달한다.

- 임신을 피하는 가장 좋은 방법은 금욕 또는 이중피임(콘돔 + 경구피임약/자궁내장치) 이다. 하지만 많은 십대들은 피임 실패의 고위험군이다. 응급피임법은 임신을 예방할 수 있는 중요한 보루(back up method)이다.

- 만약 100명의 청소녀가 그들의 생리주기 중에, 피임하지 않고 성관계를 가진다면 8명이 임신을 할 것이며, 올바른 응급피임법을 사용한다면 이는 2명으로 줄어든다.

- 2002년 조사에 따르면 73%의 십대들이 응급피임법에 대해 알고 있었다. 1996년 44%에 비하면 증가한 것이나, 52% 만이 정확한 사용법을 알고 있었다.

- 응급피임약의 사용의 가장 큰 요인은 콘돔의 실패(찢어짐, 빠짐)이다.

- 응급피임약 처방의 증가는, 응급피임약 사용의 증가와 응급피임약을 사용하기까지의 시간 감소와 상관관계가 있었다. 어떠한 연구에서도 응급피임약 접근권의 증가는 십대들의 성생활(sexual activity) 증가나 일상적인 피임법 사용 빈도의 감소와 관련 없었다.

- 이 AAP 보고서는 경구 복용 제제 응급피임약만 다루고 있다.(자궁내 피임장치는 다루지 않고 있다)

-응급피임약의 적응증은 성폭력, 피임하지 않은 성관계(unprotected intercourse), 콘돔이 찢어지거나 빠진 경우, 경구피임약을 빼먹거나 늦게 먹은 경우, 자궁내 피임장치가 빠진 경우 등이 있다.

- 소아과 의사들은 청소년들이 응급피임의 요구가 있을 때 Plan B, Plan B one-step, Next choice (levonorgestrel 1.5 mg 제제) 를 제공해야 한다. 임신반응검사는 필요치 않다.

- Levonorgestrel 1.5 mg 는 12시간 간격으로 0.75 mg 두번으로 나누어 복용하거나, 1회 복용한다. 두 방법의  효능과 부작용은 차이가 없다.

- 십대들은 Levonorgestrel 1.5 mg 을 120시간 이내에, 그러나 가능한 빨리 복용해야 한다고 복약지도 받아야 한다.

- 응급피임약 복용 3주 이내 정상 생리주기가 없을 경우, 임신 반응 검사를 해보아야 한다.

- 향후 필요성 때문에 미리 처방받기 원하는 청소년에게도 응급피임약을 처방해줘야 한다.

- Levonorgestrel method 에서 통상적으로 항구토제를 처방할 필요는 없다.

- 가장 흔한 부작용은 오심, 구토, 생리혈 증가이다.

- Yuzpe method는 복합경구피임약 2알(각각은 100 µg of ethinyl estradiol,  500 µg of levonorgestrel 이상을 함유해야 한다) 을 한꺼번에 먹는 것이다. 이는 FDA 승인된 적응증은 아니나 1974년 이후로 안전하다고 여겨지고 있다.

- Levonorgestrel method 사용 후 임신율은 1.1%,  Yuzpe method 사용 후 임신율은 3.2%이다. (이는 각각 85%, 57%의 성공률이다.)

- Ulipristal 은 progesterone agonist/antagonist 로 120시간 내에 30mg 복용하면 되면, 2010년 FDA 승인을 받았다.

(우리나라에는 도입되지 않았다.)

- Ulipristal 복용한 후, 정상 생리 주기의 7일 이후까지 생리가 없으면 임신반응 검사를 해야한다.

- Ulipristal 은 연령과 관계없이 처방전이 있어야 구입할 수 있다.  Ulipristal 의 가장 큰 부작용은 두통(18%), 오심 (12%),복통 (12%).이다.

- 모든 청소년들(여성, 남성, 장애인 청소년의 가족) 은 사전에 응급피임법에의 접근 방법과 복용방법에 대해 선행 안내를 받아야 하며, 사전 처방 요구를 할 수 있다.

- 피임법의 상담이 필요한 모든 청소년들은 성매개감염의 예방에 대해서도 상담을 받아야 한다. 응급실이나 진료소, 병원 어디에서건, 피임을 위해 방문하는 순간, 전반적인 상담이 필요하다.)

- 소아과 의사들은 십대들의 응급피임약 구입의 접근성이 높아지는 것(처방전 없이 구입, 보험적용 증가) 을 지지해야 한다.  Pediatricians should advocate for increased nonprescription access to emergency contraception for teens and for insurance coverage of the contraception to reduce cost barriers.

- 개인적, 도덕적 신념으로 (십대의 성관계, 혼외 성관계를 반대하는 등) 응급피임약을 처방하지 않는다면, 응급피임약에 접근 할 수 있는 다른 경로에 대해 안내할 의무( moral obligation) 가 있다. According to the policy, pediatricians have a duty to inform their patients about relevant, legally available treatment options to which they object and have a moral obligation to refer patients to other physicians who will provide and educate about those services. Failure to inform/educate about availability and access to emergency-contraception services violates this duty to their adolescent

미국에서 산모 사망률이 증가하는 이유

연합뉴스 | 입력 2010.05.24 05:35 |
 
(로스앤젤레스=연합뉴스) 최재석 특파원 = 전 세계적으로 감소 추세인 산모 사망률이 선진국 미국에서 오히려 증가하는 것으로 나타나 그 이유에 관심이 쏠린다.

23일 로스앤젤레스타임스(LAT)에 따르면 미국에서는 매일 여성 2명이 임신이나 출산과 관련된 문제로 목숨을 잃고 있다. 더욱이 산모 사망률은 1996년 10만명당 7.6명에서 2006년에 10만명당 13.3명으로 꾸준히 증가하고 있다.

공공보건 수준의 한 척도인 산모 사망률은 통상 후진국에서 높고 선진국에서는 낮지만 유독 미국에서 산모 사망률이 증가하는 것은 이례적이다.

미국은 신생아 출생 1명당 가장 많은 돈을 소비하지만, 산모 사망률은 40개 선진국에서 가장 높다고 이 신문은 전했다. 크로아티아와 헝가리, 마케도니아보다도 높다는 것이다.

미국의 의료 전문가들은 산모 사망률 증가의 원인을 분명히 확정하지 못하고 있지만 몇 가지 가능성을 설명하고 있다.

우선 의료진들은 통상적으로 임신부가 젊고 건강하다고 생각하지만, 미국에서는 그렇지 못한 임신부들이 계속 증가하고 있다고 LAT는 지적했다.

오늘날 임신과 출산 과정에서 합병증 가능성이 많이 증가하는 30, 40대에 출산하는 여성이 갈수록 늘고 있다. 아울러 가임기 여성의 약 25%가 비만상태이기 때문에 당뇨병과 고혈압의 위험이 아주 크다.

그러나 이러한 위험 요소들이 출산할 때 의료진에 의해 충분히 고려되지 않는다고 모성 건강 전문가들이 지적했다.

일부 전문가들은 제왕절개 분만과 약물을 이용한 유도분만이 늘어난 것도 산모사망률 증가와 연관시키고 있다고 이 신문은 밝혔다. 미국에서 제왕절개 분만은 1997년 신생아 5명 중 1명꼴이었으나 현재는 3명 중 1명꼴로 늘었다.

LAT는 또 분만이 이를 뽑는 것보다도 위험하지 않다는 잘못된 신념 때문에 분만과정에 대한 전자모니터링이 무시되는 등의 문제도 있다고 지적했다.

bondong@yna.co.kr

(끝)

2009년 4월~6월, 미국의 신종플루 입원환자 분석

신종플루 증상으로 24시간 이상 입원한 272명 환자의 의료기록 분석.

272명의 환자 중에서 25%는 중환자실(intensive care unit)에 입원. 7% 사망. 18세 이하 청소년 및 영유아는 45%, 65세 이상 노령자는 5%. 87% 환자가 1개 이상의 기저질환(천식, 당뇨, 심장병, 신경질환, 임신)

방사선 촬영을 실시한 249명의 환자 중에서 100명(40%)에서 폐렴 소견 확인. 항바이러스제 투약 실시한 268명의 환자 중에서 200명(75%)는 발병 후 3일 이내에 항바이러스제 투약 시작.
의료기록은 입원환자들에게 초기에 항바이러스제를 투여하는 것은 아주 유용하고 효과적이었음을 암시하고 있음.

=======================================

Volume 361:1935-1944  November 12, 2009  Number 20 

Hospitalized Patients with 2009 H1N1 Influenza in the United States, April–June 2009

Seema Jain, M.D., Laurie Kamimoto, M.D., M.P.H., Anna M. Bramley, M.P.H., Ann M. Schmitz, D.V.M., Stephen R. Benoit, M.D., M.P.H., Janice Louie, M.D., M.P.H., David E. Sugerman, M.D., M.P.H., Jean K. Druckenmiller, B.S., S.M.(N.R.M.), Kathleen A. Ritger, M.D., M.P.H., Rashmi Chugh, M.D., M.P.H., Supriya Jasuja, M.D., M.P.H., Meredith Deutscher, M.D., Sanny Chen, Ph.D., M.H.S., John D. Walker, M.D., Jeffrey S. Duchin, M.D., Susan Lett, M.D., M.P.H., Susan Soliva, M.P.H., Eden V. Wells, M.D., M.P.H., David Swerdlow, M.D., Timothy M. Uyeki, M.D., M.P.H., Anthony E. Fiore, M.D., M.P.H., Sonja J. Olsen, Ph.D., Alicia M. Fry, M.D., M.P.H., Carolyn B. Bridges, M.D., Lyn Finelli, Dr.P.H., for the 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team

출처 : http://content.nejm.org/cgi/content/full/361/20/1935

ABSTRACT

Background During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009.

Methods Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase–polymerase-chain-reaction assay.

Results Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. Forty-five percent of the patients were children under the age of 18 years, and 5% were 65 years of age or older. Seventy-three percent of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early.

Conclusions During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.

——————————————————————————–
On April 15, 2009, and April 17, 2009, the Centers for Disease Control and Prevention (CDC) confirmed the first two cases of human infection with a pandemic influenza A (H1N1) virus in the United States.1 The 2009 H1N1 virus contained a unique combination of gene segments that had not previously been identified in humans or animals.2,3 As of September 20, 2009, human infection with 2009 H1N1 virus had been identified in 191 countries and territories.4
Information on the clinical spectrum of illness and risk factors for severity among persons who are hospitalized for the treatment of 2009 H1N1 influenza is still emerging.5 During peak periods of seasonal influenza, most hospitalizations occur among persons less than 2 years of age or 65 years of age or older and among patients with certain medical conditions.6,7 More than 90% of influenza-related deaths occur in patients in the older age group.8 Underlying medical conditions that have been reported in patients who were hospitalized with seasonal influenza have included diabetes and cardiovascular, neurologic, and pulmonary diseases, including asthma.7,9,10 Frequently reported complications have included pneumonia, bacterial coinfection, and exacerbation of underlying medical conditions, such as congestive heart failure.7,9,10 This report summarizes the clinical findings regarding patients who were hospitalized for the treatment of 2009 H1N1 influenza early in the U.S. epidemic.

Methods

Patients

We describe patients who were hospitalized for at least 24 hours with an influenza-like illness (temperature of 37.8°C [100°F] or higher and cough or sore throat) and who had 2009 H1N1 virus infection, as confirmed by a real-time reverse-transcriptase–polymerase-chain-reaction assay at either the CDC or state health departments. All testing was based on standard CDC-based primers. We identified patients through daily reports regarding case-level information (including hospitalization status) from state health departments to the CDC. State and local public health officials were asked to collect clinical information for each hospitalized patient as part of the public health response to assess the severity of the pandemic; such participation was voluntary.

Study Design

From May 1, 2009, to June 9, 2009, data regarding the first hospitalized patients in each participating state were sequentially reviewed and medical-chart abstractions were performed by infection-control practitioners, physicians, nurses, and epidemiologists at local and state public health departments. The reviewers used a standardized form that included demographic data, influenza-vaccination history for the previous year, underlying medical conditions, clinical signs and symptoms, selected laboratory tests, radiographic findings, and treatment course. All diagnostic testing was clinically driven. For some patients, specimens were sent to the CDC for testing for bacterial infections. The protocol and standardized clinical form were approved by the CDC’s institutional review board.

For time calculations, the day of admission was considered to be hospital day 0. The body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) was calculated, for patients for whom height and weight were available, to determine whether the patient was obese (with obesity defined as a BMI of 30 to 39.9 in adults 18 years of age or older or a BMI percentile of 95 to 100 in children between the ages of 2 and 18 years) or morbidly obese (BMI 40 in adults only); the BMI was not calculated in pregnant women. We performed bivariate analysis to compare the outcomes for patients who were not admitted to an intensive care unit (ICU) and who survived with those for patients who either died or were admitted to an ICU. We used multivariate logistic-regression models to further investigate associations with the severity of illness.

Results

Clinical Characteristics

From May 1, 2009, to June 9, 2009, a total of 13,217 human cases of infection with 2009 H1N1 influenza and 1082 hospitalizations in the United States were reported to the CDC. This report describes the first 272 completed chart abstractions for hospitalized patients with 2009 H1N1 virus infection that were reported to the CDC from 24 states (Figure 1).5 The patients represented 25% of those who were hospitalized with 2009 H1N1 influenza and whose cases were reported to the CDC during the surveillance period that ended on June 9, 2009. Dates of the onset of illness ranged from April 1, 2009, to June 5, 2009. The median age of the patients was 21 years (range, 21 days to 86 years). A majority of the patients were either Hispanic (30%) or non-Hispanic white (27%) (Table 1).

View larger version (38K): [in this window] [in a new window]

Figure 1. Distribution of the 272 Patients in the Study, as Compared with the Total Number of Patients Hospitalized for 2009 H1N1 Influenza, as Reported by the States to the CDC as of June 9, 2009. States that had any reported hospitalizations of patients with 2009 H1N1 influenza during the study period are indicated in blue (states in orange had no reported hospitalizations). The number shown for each state is the proportion of patients from that state who were included in the study, as compared with the total number of hospitalized patients with confirmed 2009 H1N1 influenza that was reported by the state. Thus, the number 1 indicates that all hospitalized patients in that state were included in the study, and 0 indicates that none of the hospitalized patients were included in the study. States with 0 had no more than 5 hospitalized patients, except for Florida, which had 20; New Jersey, which had 36; and Virginia, which had 10. The study focused on approximately 25% of patients who were hospitalized, because of the availability of complete data concerning the patients’ clinical characteristics.

View this table: [in this window] [in a new window]   Table 1. Characteristics of 272 Hospitalized Patients Who Were Infected with the 2009 H1N1 Virus in the United States (April–June 2009).

Symptoms at presentation included fever and cough (Table 1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). Diarrhea or vomiting was reported in 39% of patients, including 42% of children (i.e., patients under the age of 18 years) and 37% of adults (those 18 years). The median time from the onset of illness to hospital admission was 3 days (range, 0 to 18). Of the 272 patients, 198 (73%) had an underlying medical condition, including 60% of children and 83% of adults; 32% had at least two such conditions (Table 2, and Table 1 in the Supplementary Appendix). Among patients 65 years of age or older, 100% had an underlying medical condition. Asthma was the most common condition seen in both children (29%) and adults (27%). Neurocognitive, neuromuscular, or seizure disorders were seen in both groups (14%) but were more common among children (20%) than among adults (9%). A total of 18 patients (7%) were pregnant, of whom 6 (33%) had another underlying medical condition (asthma in 4 patients and diabetes in 2 patients). Of the 18 pregnant patients, 2 (11%) were in the first trimester, 3 (17%) were in the second trimester, and 12 (67%) were in the third trimester; the gestational duration of 1 patient was not known.

View this table: [in this window] [in a new window]

Table 2. Underlying Medical Conditions among the Patients, According to Age Group.

Height and weight were available for 161 of 231 patients (70%) over the age of 2 years (with the exclusion of pregnant women). Of 100 adults, 29 (29%) were obese, and 26 (26%) were morbidly obese; 26 of the obese patients (90%) and 21 of the morbidly obese patients (81%) had an underlying medical condition. Of 61 children, 18 were obese (30%); of the obese children, 12 (67%) had an underlying medical condition (Table 1 in the Supplementary Appendix).

Diagnostic Findings

On admission, 50 of 246 patients who were tested (20%) had leukopenia, 87 of 238 (37%) had anemia, and 33 of 234 (14%) had thrombocytopenia (Table 3).11 Three of 182 patients had positive blood cultures: a 78-year-old man with Escherichia coli urosepsis, a 55-year-old woman with Streptococcus pneumoniae and group A streptococcus infection and a lung-tissue specimen that was positive for S. pneumoniae (as identified by immunohistochemical and molecular assays performed at the CDC), and a 17-year-old boy with pneumonia who had blood and endotracheal-aspirate cultures that were positive for methicillin-resistant Staphylococcus aureus. Bacterial infections that were identified from sources aside from blood samples included group A streptococcus, which was identified by means of immunohistochemical and molecular assays performed at the CDC, in a pleural-biopsy specimen from a 23-month-old boy with pleural empyema, and S. pneumoniae in two patients: a 57-year-old woman with pneumonia who had a positive urinary antigen test and a 58-year-old woman with pneumonia who had a positive culture obtained from bronchoalveolar-lavage fluid.

View this table: [in this window] [in a new window]

Table 3. Selected Laboratory Abnormalities in the Patients.

Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings that were consistent with pneumonia; the median age of these patients was 27 years (range, 1 month to 86 years), and 66% had an underlying medical condition. Radiographic findings included bilateral infiltrates (in 66 patients), an infiltrate limited to one lobe (in 26), and multilobar infiltrates limited to one lung (in 6); data were not available for 2 patients.

Treatment

Of the 268 patients for whom data were available regarding the use of antiviral drugs, 200 (75%) received such drugs (Table 1 in the Supplementary Appendix). Of these patients, 188 received oseltamivir, and 19 received zanamivir; 13 patients received combination therapy with amantadine plus oseltamivir, and 14 received combination therapy with rimantadine plus oseltamivir. The median time from the onset of illness to the initiation of antiviral therapy was 3 days (range, 0 to 29); 39% of patients received antiviral therapy within 48 hours after the onset of symptoms. Among 195 patients for whom the date of the initiation of antiviral therapy was available, such therapy was started before admission in 18 patients (9%), on admission in 86 patients (44%), within 48 hours after admission in 61 patients (31%), and more than 48 hours after admission in 30 patients (15%).

Of 260 patients for whom data were available regarding antibiotic therapy, 206 (79%) received antibiotics. Of 198 patients for whom the date of initiation of antibiotics was available, such therapy was started before admission in 30 patients (15%), on admission in 117 patients (59%), within 48 hours after admission in 44 patients (22%), and more than 48 hours after admission in 7 patients (4%). Patients received a median of two antibiotics (range, one to seven); 70% of the patients received more than one antibiotic. Commonly used antibiotics included ceftriaxone (in 94 patients), azithromycin (in 84 patients), vancomycin (in 56 patients), and levofloxacin (in 47 patients). Seventy-three percent of patients who had radiographic findings that were consistent with pneumonia were treated with antiviral drugs, and 97% were treated with antibiotics.

Of 239 patients for whom data were available regarding the use of corticosteroids, 86 (36%) received such drugs, with oral administration in 44 patients, intravenous administration in 24 patients, and both oral and intravenous administration in 15 patients; data were not available for 3 patients. Of the patients who received corticosteroids, 76% had an underlying medical condition; the most common conditions were asthma or chronic obstructive pulmonary disease (COPD) (in 48%), immunosuppression (in 19%), and cardiovascular disease (in 15%).

ICU Admissions

Of the 272 patients we evaluated, 67 (25%) were admitted to an ICU; 19 died. The median age of those who were admitted to an ICU was 29 years (range, 1 to 86). Of the 67 patients who were admitted to an ICU, 45 (67%) had an underlying medical condition, including asthma or COPD (in 28%), immunosuppression (in 18%), and neurologic diseases (in 18%); 6 patients (9%) were pregnant. Of the 67 patients who were admitted to an ICU, 42 required mechanical ventilation, 24 had the acute respiratory distress syndrome (ARDS), and 21 had a clinical diagnosis of sepsis; 56 of 65 patients (86%) received antiviral drugs, and 62 of 65 patients (95%) received antibiotics. Among these patients, the median time from the onset of illness to the initiation of antiviral therapy was 6 days (range, 0 to 24); 23% of patients received antiviral drugs within 48 hours after the onset of illness.

Outcomes

Of the 272 hospitalized patients, 253 (93%) were discharged. Nineteen patients (7%) died; all 19 had been admitted to an ICU and required mechanical ventilation. The median age of patients who died was 26 years (range, 1.3 to 57); the median time from the onset of illness to death was 15 days (range, 4 to 52). Thirteen patients who died (68%) had an underlying medical condition, including neurologic disease (in 21%), asthma or COPD (in 16%), and pregnancy (in 16%). Of the 19 patients who died, 90% received antiviral drugs, and all received antibiotics. The median time from the onset of illness to the initiation of antiviral therapy was 8 days (range, 3 to 20); none of the patients who died received antiviral therapy within 48 hours after the onset of symptoms.

Patients who were admitted to an ICU and those who died were more likely than patients who were not admitted to an ICU to have shortness of breath, a neurologic disorder, radiographically confirmed pneumonia, ARDS, or sepsis; they were also more likely to have received antimicrobial agents or corticosteroids (Table 4, and Table 2 in the Supplementary Appendix). In addition, patients who were admitted to an ICU and those who died were older, were less likely to have been vaccinated for influenza during the 2008–2009 season, and had a longer time between the onset of illness and the initiation of antiviral therapy, as compared with patients who were not admitted to an ICU. In a multivariable model that included age, admission within 2 days or more than 2 days after the onset of illness, initiation of antiviral therapy within 2 days or more than 2 days after the onset of illness, and influenza-vaccination status, the only variable that was significantly associated with a positive outcome was the receipt of antiviral drugs within 2 days after the onset of illness.

View this table: [in this window] [in a new window]   Table 4. Characteristics of Hospitalized Patients Who Were Not Admitted to an Intensive Care Unit (ICU) and Survived and Patients Who Were Admitted to an ICU or Died.

Discussion

We report on a large U.S. case series of hospitalized patients with 2009 H1N1 virus infection during the first 2 months of the pandemic. The pandemic strain of H1N1 virus caused severe illness, including pneumonia and ARDS, and resulted in ICU admissions in 25% of patients and death in 7%. Although underlying medical conditions were common in the 272 patients we evaluated, we also identified severe illness from H1N1 virus infection among young, healthy persons. Antiviral drugs were administered to most patients, but such therapy was started more than 48 hours after the onset of illness in a majority of the patients. Delayed initiation of antiviral therapy may have contributed to an increased severity of illness.

In contrast to peak periods of seasonal influenza, when influenza hospitalizations are more common among persons 65 years of age or older and those under the age of 5 years,7 during the period of our study, almost half the hospitalizations involved persons under the age of 18 years; more than one third of the patients were between the ages of 18 and 49 years, and only 5% were 65 years of age or older. Possible explanations for this phenomenon include the fact that children are more likely to be exposed in schools, the young have a greater susceptibility to the virus (as compared with persons >60 years of age, on the basis of serologic studies12,13,14), and young, febrile patients are more likely to be tested, since older adults with influenza often do not have fever.15

The clinical features of patients who were hospitalized with 2009 H1N1 influenza were generally similar to those reported during peak periods of seasonal influenza and past pandemics with an acute onset of respiratory illness.15,16,17,18 Whereas diarrhea or vomiting have occasionally been reported in children and in less than 5% of adults during peak periods of seasonal influenza,15 these symptoms were reported in 39% of patients in our study, with no significant difference between children and adults. Studies are ongoing to determine whether the transmission of the 2009 H1N1 virus can occur from exposure to virus shed in stool.

In a pattern that was similar to that in patients with seasonal influenza, the patients in our study had a high prevalence of underlying medical conditions (73%). Eighty-two percent of the patients would be considered at increased risk for influenza-related complications on the basis of age (<5 years or 65 years) or the presence of an underlying medical condition. The proportion of children who had an underlying condition (60%) was higher than proportions that have been reported for children who were hospitalized with seasonal influenza (31 to 43%).9,19,20 In published studies and unpublished CDC data, 44 to 84% of adults who were hospitalized with seasonal influenza had an underlying condition.21,22,23 The upper end of this range is similar to the proportion of hospitalized adults in our study who had an underlying condition (83%).

As in patients with seasonal influenza, asthma and COPD were the most common underlying conditions in the patients we studied.9,19,20,21,22,23 Although few patients had neurocognitive or neuromuscular disorders, children in our study were disproportionately affected by these conditions and were at increased risk for severe influenza. The 7% prevalence of pregnancy in our study was higher than the expected prevalence in the general population (1%).24 During periods of seasonal influenza and past pandemics, pregnant women have been at higher risk for influenza-associated morbidity and mortality.24,25,26,27,28

Although data regarding height and weight were available for only 70% of patients in our study, 45% of these patients (including 18 children) were either obese or morbidly obese. A majority of these patients (81%) had an underlying condition associated with an increased risk of influenza-related complications. The prevalence of obesity among the adults in our study (29%) was similar to that in the adult U.S. population (27%).29 However, the prevalence of morbid obesity (26%) was higher than the estimated 5% in the adult U.S. population.29 Although obesity has not been linked to an increased risk of influenza-related complications, further investigation is warranted.

Few bacterial coinfections were detected, but bacterial diagnostic tests were not performed in all patients; most patients received antibiotics near the time of culture collection, which could have reduced the diagnostic sensitivity. Data on pediatric mortality associated with influenza in the United States have shown an increase in the rate of bacterial coinfection, from 6 to 24% between 2004–2005 and 2006–2007; the majority of these infections were caused by methicillin-resistant S. aureus.30 The implications of such trends for 2009 H1N1 influenza are not yet clear.

In our study, a significant proportion of hospitalized patients had findings on chest radiography that were consistent with pneumonia, and the majority had bilateral infiltrates. Although it is difficult to precisely determine the cause of pneumonia from radiographs, during the 1957–1958 influenza pandemic, Louria et al.18 reported findings of diffuse bilateral infiltrates in patients with primary influenza viral pneumonia, whereas lobar infiltrates were seen in patients with secondary bacterial infections. Better studies are needed to correlate radiographic findings with the cause of pneumonia during influenza outbreaks. In our study, only 73% of patients with radiographic evidence of pneumonia received antiviral drugs, whereas 97% received antibiotics. In the absence of accurate diagnostic methods, patients who are hospitalized with suspected influenza and lung infiltrates on chest radiography should be considered for treatment with both antibiotics and antiviral drugs.10

The majority of 2009 H1N1 viruses that have been tested at the CDC to date have been susceptible to two neuraminidase inhibitors, oseltamivir and zanamivir, and resistant to two adamantanes, amantadine and rimantadine.2,3,31 Recent guidelines from the Infectious Diseases Society of America recommended the use of antiviral drugs in adults and children who are hospitalized with seasonal influenza, regardless of the underlying illness or influenza-vaccination status.10 Current interim CDC guidelines for pandemic and seasonal influenza recommend the use of either oseltamivir or zanamivir for hospitalized patients with suspected or confirmed influenza and for outpatients who are at high risk for complications.32 Although the evidence of a benefit of antiviral therapy is strongest when treatment is initiated within 48 hours after the onset of illness, a prospective cohort study of oseltamivir therapy in hospitalized patients with influenza indicated a reduction in mortality, even when such therapy was initiated more than 48 hours after illness onset.23 Recent data from Thailand also showed that oseltamivir therapy was associated with survival in hospitalized patients with influenza pneumonia.33 Under an Emergency Use Authorization, the FDA recently approved oseltamivir therapy for 2009 H1N1 infection even if it is initiated more than 48 hours after the onset of illness and also approved its use in children under the age of 1 year.32

Data from our study suggest that the use of antiviral drugs is beneficial, especially when initiated early, since patients who were admitted to an ICU or died were less likely to have received such therapy within 48 hours after the onset of symptoms. Despite the absence of definitive data regarding clinical effectiveness, treatment with antiviral drugs should be initiated in hospitalized patients with suspected 2009 H1N1 infection, even if such therapy is initiated more than 48 hours after the onset of symptoms, especially in patients with pneumonia and outpatients who are at increased risk for complications, including pregnant women.

Our study has several limitations. The patients we evaluated represented 25% of total hospitalizations for 2009 H1N1 infection that were reported to the CDC during the surveillance period that ended on June 9, 2009, and they represented most of the states with substantial influenza outbreaks during that period. Participation in the study was voluntary and was therefore subject to reporting bias. We evaluated only patients with confirmed 2009 H1N1 infection, so the group may not be representative of hospitalized patients who may not have been tested. All diagnostic testing was clinically driven, and tests were not obtained in a standardized fashion. Finally, despite the use of a standardized data-collection form, not all information was collected for all patients.

Clinicians should consider influenza, including 2009 H1N1 infection, in the differential diagnosis for patients presenting with fever and respiratory illness or pneumonia. Empirical antiviral treatment for hospitalized patients with suspected influenza or pneumonia and for outpatients who have underlying medical conditions or who are pregnant should be considered. The benefits of treatment are probably greatest when such therapy is started early, but antiviral drugs should not be withheld if patients present more than 48 hours after the onset of symptoms. As the 2009 H1N1 pandemic evolves, continued investigation is needed to better define the clinical spectrum of disease and risk factors for an increased severity of illness, which will allow for improvements in treatment guidance.

Supported by the Influenza Division and Office of Workforce and Career Development at the CDC.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the CDC.

No potential conflict of interest relevant to this article was reported.

* Members of the 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team are listed in the Appendix.

Source Information

The authors’ affiliations are listed in the Appendix.

This article (10.1056/NEJMoa0906695) was published on October 8, 2009, at NEJM.org.

Address reprint requests to Dr. Jain at the Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, MS A-32, Atlanta, GA 30333, or at bwc8@cdc.gov.

1. Swine influenza A (H1N1) infection in two children — Southern California, March-April 2009. MMWR Morb Mortal Wkly Rep 2009;58:400-402. [Medline]
   
2. Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med 2009;360:2605-2615. [Erratum, N Engl J Med 2009;361:102.] [Free Full Text]
   
3. Garten RJ, Davis CT, Russell CA, et al. Antigenic and genetic characteristics of swine-origin 2009 A (H1N1) influenza viruses circulating in humans. Science 2009;325:197-201. [Free Full Text]
   
4. Pandemic (H1N1) 2009 — update 67. Geneva: World Health Organization. (Accessed October 19, 2009, at http://www.who.int/csr/don/2009_09_25/en/index.html.)
   
5. Hospitalized patients with novel influenza A (H1N1) virus infection — California, April-May 2009. MMWR Morb Mortal Wkly Rep 2009;58:536-541. [Medline]
   
6. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep 2008;57:1-60. [Medline]
   
7. Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA 2004;292:1333-1340. [Free Full Text]
   
8. Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289:179-186. [Free Full Text]
   
9. Schrag SJ, Shay DK, Gershman K, et al. Multistate surveillance for laboratory-confirmed, influenza-associated hospitalizations in children: 2003-2004. Pediatr Infect Dis J 2006;25:395-400. [CrossRef][Web of Science][Medline]
   
10. Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children — diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2009;48:1003-1032. [CrossRef][Web of Science][Medline]
    
11. Custer JW, Rau RE, eds. The Harriet Lane handbook. 18th ed. Philadelphia: Elsevier Mosby, 2009.
    
12. Hancock K, Veguilla V, Lu X, et al. Cross-reactive antibody responses to the 2009 pandemic H1N1 influenza virus. N Engl J Med 2009;361:1945-1952. [Free Full Text]
    
13. Cate TR, Kasel JA, Couch RB, Six HR, Knight V. Clinical trials of bivalent influenza A/New Jersey/76-A/Victoria/75 vaccines in the elderly. J Infect Dis 1977;136:Suppl:S518-S525. [Web of Science][Medline]
    
14. Dolin R, Wise TG, Mazur MH, Tuazon CU, Ennis FA. Immunogenicity and reactogenicity of influenza A/New Jersey/76 virus vaccines in normal adults. J Infect Dis 1977;136:Suppl:S435-S442. [Web of Science][Medline]
    
15. Nicholson KG. Clinical features of influenza. Semin Respir Infect 1992;7:26-37. [Medline]
    
16. Cox NJ, Subbarao K. Influenza. Lancet 1999;354:1277-1282. [CrossRef][Web of Science][Medline]
    
17. Moore DL, Vaudry W, Scheifele DW, et al. Surveillance for influenza admissions among children hospitalized in Canadian immunization monitoring program active centers, 2003-2004. Pediatrics 2006;118:e610-e619. [Free Full Text]
    
18. Louria DB, Blumenfield HL, Ellis JT, Kilbourne ED, Rogers DE. Studies on influenza in the pandemic of 1957-1958. II. Pulmonary complications of influenza. J Clin Invest 1959;38:213-265. [Web of Science][Medline]
    
19. Keren R, Zaoutis TE, Bridges CB, et al. Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection. JAMA 2005;294:2188-2194. [Free Full Text]
    
20. Ampofo K, Gesteland PH, Bender J, et al. Epidemiology, complications, and cost of hospitalization in children with laboratory-confirmed influenza infection. Pediatrics 2006;118:2409-2417. [Free Full Text]
    
21. Walsh EE, Cox C, Falsey AR. Clinical features of influenza A infection in older hospitalized persons. J Am Geriatr Soc 2002;50:1498-1503. [CrossRef][Web of Science][Medline]
    
22. Neuzil KM, Maynard C, Griffin MR, Heagerty P. Winter respiratory viruses and health care use: a population-based study in the northwest United States. Clin Infect Dis 2003;37:201-207. [CrossRef][Web of Science][Medline]
    
23. McGeer A, Green KA, Plevneshi A, et al. Antiviral therapy and outcomes of influenza requiring hospitalization in Ontario, Canada. Clin Infect Dis 2007;45:1568-1575. [CrossRef][Web of Science][Medline]
    
24. Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009;374:451-458. [CrossRef][Web of Science][Medline]
    
25. Dodds L, McNeil SA, Fell DB, et al. Impact of influenza exposure on rates of hospital admissions and physician visits because of respiratory illness among pregnant women. CMAJ 2007;176:463-468. [Free Full Text]
    
26. Neuzil KM, Reed GW, Mitchel EF, Simonsen L, Griffin MR. Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol 1998;148:1094-1102. [Free Full Text]
    
27. Freeman DW, Barno A. Deaths from Asian influenza associated with pregnancy. Am J Obstet Gynecol 1959;78:1172-1175. [Web of Science][Medline]
    
28. Harris JW. Influenza occurring in pregnant women. JAMA 1919;72:978-980. [Free Full Text]
    
29. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295:1549-1555. [Free Full Text]
    
30. Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics 2008;122:805-811. [Free Full Text]
    
31. FluView: a weekly influenza surveillance report prepared by the Influenza Division. Atlanta: Centers for Disease Control and Prevention. (Accessed October 19, 2009, at http://www.cdc.gov/flu/weekly/.)
    
32. Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009-2010 season. Atlanta: Centers for Disease Control and Prevention. (Accessed October 19, 2009, at http://www.cdc.gov/h1n1flu/recommendations.htm.)
    
33. Hanshaoworakul W, Simmerman JM, Narueponjirakul U, et al. Severe human influenza infections in Thailand: oseltamivir treatment and risk factors for fatal outcome. PLoS One 2009;4(6):e6051.

Appendix
The authors’ affiliations are as follows: the Influenza Division, National Center for Immunization and Respiratory Diseases (S.J., L.K., A.M.B., D.E.S., T.M.U., A.E.F., S.J.O., A.M.F., C.B.B., L.F.), the Infectious Diseases Pathology Branch, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (A.M.S.), the Division of Emergency Preparedness and Response, National Center for Public Health Informatics (S.R.B.), the Epidemic Intelligence Service, Office of Workforce and Career Development (D.S., M.D., S.C.), and the Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases (M.D.) — all at the Centers for Disease Control and Prevention, Atlanta; the California Department of Public Health, Richmond (J.L.); San Diego County Health and Human Services, San Diego, CA (D.S.); the Wisconsin Division of Public Health, Madison (J.K.D.); the Chicago Department of Public Health, Chicago (K.A.R.), DuPage County Health Department, Wheaton (R.C.), and Cook County Department of Public Health, Oak Park (S.J.) — all in Illinois; the Arizona Department of Public Health, Phoenix (S.C.); the Texas Department of State Health Services, Austin (J.D.W.); Public Health–Seattle and King County, Seattle (J.S.D.); the Massachusetts Department of Health, Jamaica Plain (S.L., S.S.); and the Michigan Department of Community Health, Lansing (E.V.W.).

The members of the 2009 Pandemic Influenza A (H1N1) Hospitalizations Investigation Team are as follows: Centers for Disease Control and Prevention (asterisks indicate members of the Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta): E. Barzilay, M. Biggerstaff, D.M. Blau,* L. Brammer, J. Bresee, Y. Brown, A. Cohn, N. Cox, K. Date,* F. Dawood,* N. Dharan,* S. Doshi,* J. Finks,* G. Fischer, M. Fischer, A. Fowlkes, G. Grant, D. Gross, G. Han,* L. Hicks, F. Husain,* C. Kent, J. Jaeger,* D. Jernigan, E. Lutterloh,* T. Mallick,* E. Meites,* M. Menon, M. Moore, C. Nielsen, R. Novak, M. Nowell, E. Piercefield,* C. Reed,* C. O’Reilly, M. Patel,* P. Peters, E. Staples, C. VanBeneden, S. Zaki; Adventist Glen Oaks Hospital (IL): S. Gorman; Advocate Good Samaritan Hospital (IL): O. Jegede, S. Pur; Adventist Hinsdale Hospital (IL): B. Kratochvil; Alexian Brothers Medical Center (IL): J. Daniel; Arizona Department of Public Health: R. Sunenshine; Banner Desert Medical Center (AZ): M. Reich; Barren River District Health Department (KY): S. Ray, S. Seshadri; California Department of Public Health: M. Acosta, S. Gilliam, K. Winter; Cameron County Department of Health and Human Services (TX): O. Fritzler; Cape Girardeau County Public Health Center (MO): V. Landers; Carolinas Medical Center (NC): G. Butler; Central DuPage Hospital (IL): B. Kruse, S.J. Rivera; Chicago Department of Public Health: S. Gerber; Children’s Hospital of Wisconsin: M. Rotar; City of El Paso Department of Health (TX): Y. Vasquez; City of St. Louis Department of Health: S. Alexander; Colorado Department of Public Health and Environment: T. Gosh, K. Gershman; Cook County Department of Public Health (IL): P. Linchangco, S. Nelson, M.T. Patel, M. Vernon; Corpus Christi–Nueces County Public Health District (TX): L. Simmons; Delaware Division of Public Health: P. Eggers; Denton County Health Department (TX): D. O’Brien; DuPage County Health Department (IL): M. Lally, C. Petit, J. Vercillo; Edward Hospital and Human Services (IL): M. Anderson; Elmhurst Memorial Healthcare (IL): J. Allen, A. Schmocker, J. Lahvic; Georgia Department of Public Health: K. Arnold, C.L. Drenzek; Illinois Department of Public Health: C. Conover; Imperial County Public Health Department (CA): P. Kriner; Indian Health Services (AZ): M. Bell; Ingalls Memorial Hospital (IL): J. Gomez, R. Jain; Kansas Department of Public Health: I. Garrison, D.C. Hunt, D. Neises; Kentucky Department of Public Health: D. Thoroughman; Louisiana Department of Public Health: E. Stanley; Maricopa County Correctional Health Services (AZ): E. Shopteese, C. Wilson; Massachusetts Department of Health: N. Cocoros, M. Crockett, L. Madoff; Michigan Department of Community Health: S. Bohm, J. Collins, R. Sharangpani; Minnesota Department of Public Health: K. Como-Sabetti, S. Lowther, R. Lynfield, C. Morin, L. Triden; Missouri Department of Health and Senior Services: K.S. Oo, S. Patrick, G. Turabelidze; Nevada Department of Public Health: I. Azzam; New York City Department of Health and Mental Hygiene: Swine Flu Investigation Team; New York State Department of Health: N. Spina; North Carolina Department of Health and Human Services: D. Bergmire-Sweat, Z. Moore; Northwest Community Hospital (IL): M. Moore; Oklahoma State Department of Health: K.K. Bradley; Oregon Department of Health: M. Vandermeer; Palos Community Hospital (IL): M. Giglio; Pennsylvania Department of Health: T. Berezansky; Philadelphia Department of Public Health: C. Burke; San Diego County Health and Human Services (CA): M. Ginsberg; St. Alexius Medical Center (IL): A. Lucey; St. Catherine Hospital (IN): J. Seabrook; St. Luke’s South Hospital (KS): K. Hall-Meyer; St. Louis County Health: K. Howell; Public Health–Seattle and King County, Seattle: T. Kwan-Gett, S. McKiernan, L. Serafin, R.L. Smith; Snohomish Health District (WA): S. Patton; Tacoma–Pierce County Health Department (WA): S. Reinsvold; Tennessee Department of Health: A. Craig, T.F. Jones, M. Kainer; Texas Department of State Health Services: S. Damon, M. Davis, V.P. Fonseca, A. Martinez, J. Mireles, J.L. Smit; United States Air Force School of Aerospace Medicine (TX): K.W. Ma; Utah Department of Health: J. Coombs, R. Rolfs; Vanderbilt University School of Medicine (TN): W. Schaffner; Washington State Department of Health: C. DeBolt, A Marfin.