Monday, October 26, 2009

H1N1 Flu Challenges Heart and Lung Transplants

By Michael Smith, North American Correspondent, MedPage Today

The pandemic H1N1 flu poses special problems for people getting heart and lung transplants, according to an advisory from the International Society for Heart and Lung Transplantation.

The pandemic virus "highlights unique aspects of transplant care that will require heightened vigilance in coming months," according to Lara Danziger-Isakov, MD, of the Cleveland Clinic Children's Hospital, and colleagues.

"Aggressive diagnosis and early treatment" will need to be paired with active preventive measures to lessen the impact of the pandemic on the transplant population, she and colleagues wrote online in the Journal of Heart and Lung Transplantation.

Among the key elements:
  • Transplant patients should get both the seasonal trivalent inactivated flu vaccine and the H1N1 vaccine as soon as possible.

  • Avoid using live, attenuated seasonal trivalent vaccine (FluMist nasal spray) with transplant candidates and recipients, as well as their care providers.

  • Both seasonal and flu vaccines can be given soon after transplant, but caregivers should be aware that vaccination soon after transplantation may only be partly protective.

  • Potential donors should have nasopharyngeal and throat swabs for the H1N1 virus before the organs are harvested.

  • The preferred test for all flu infections, including the pandemic virus, is real-time reverse transcriptase-polymerase chain reaction (rRT-PCR).

  • A negative result on a rapid influenza detection assay does not exclude diagnosis of pandemic flu infection.
The turnaround time for rRT-PCR is up to 48 hours, plus travel time in some cases, the researchers said.

Especially when it comes to evaluating donors -- where time is of the essence -- the long turnaround is "a concern" and highlights the need for faster tests, they said.

Aside from vaccination, Danziger-Isakov and colleagues said, caregivers can also consider postexposure prophylaxis and prolonged seasonal prophylaxis, both with oseltamivir (Tamiflu).

In the case of prolonged prophylaxis, caregivers should be aware that oseltamivir resistance in the H1N1 flu is rare, but cases have been identified, many in immunocompromised patients.

If a potential donor dies of confirmed H1N1 flu, Danziger-Isakov and colleagues said, neither the lungs nor heart should be used for transplantation.

In some cases, a donor with confirmed H1N1 flu might die of another cause, they said. In those cases, the lungs should not be used, but the heart may be, at the discretion of the transplanting medical team.

The same is true for potential donors with suspect cases of the pandemic flu, they said.

On the other hand, both the lungs and heart of a donor with a history of the H1N1 flu who received at least five days of treatment can be used, they said.

Primary source: The Journal of Heart and Lung Transplantation
Source reference:
Danziger-Isakov LA, et al "The Novel 2009 H1N1 influenza virus pandemic: Unique considerations for programs in cardiothoracic transplantation" J Heart Lung Transpl 2009; DOI: 10.1016/j.healun.2009.10.001.

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