Infuenza A (H1N1) Surveillance Report in a Private Hospital in the

Philippines- The Makati Medical Center Experience

Gelza Mae A. Zabat, M.D.
1
, Salvador M. Abad Santos, M.D.
2
,
Jesus Julio S. Ancheta, M.D.
3
, Michelle G. Vasquez, R.N.
4
,
Maria Princess M. Landicho, M.D.
5
and Benjamin N. Alimurung, M.D.
6
Volume 48 Number 2 July-September, 2010 7
Background: The Influenza Pandemic has made the world
health authorities vigilant for the next pandemic. The First
cases of the Novel Influenza A(H1N1) in Mexico infected
5,000 people in a span of 40 days. On May 22, 2009,
the first case was reported in the Philippines. The rising
incidence of people affected by this disease in several
regi ons of the worl d prompted the WHO to decl are a
pandemic. The mounting number of affected people
in the Philippines lead the Makati Medical Center to start
a surveillance program.
Objective: To describe in an epidemiologic prespective
the cases managed at the MMC.

Design and Methodology: This is a descriptive observational
study of patients with suspected or confirmed influenza
A(H1N1) infection treated at the Makati Medical Center.
The study period was from May 3, 2009 to July 4, 2009.
Patient consults were trended and analyzed. Confirmed
cases were patients with nasopharyngeal throat swab
speci mens that tested posi ti ve for I nfl uenza A (H1N1)
by Real Ti me Reverse Transcri pti on Pol ymerase Chai n
Reaction (PT-PCR). Demographics were presented.
Results: There were 548 patients seen at the MMC who
wer e suspected of bei ng i nf ected wi th I nf l uenza A
(H1N1). Two hundered sixty (47%) were confirmed to be
positive for the Influenza A(H1N1) infection. The reported
cases were distributed in Cities around Makati and near
by provinces. Most patients seen were aged 19 to 49
years. One hundred seventy one (66%) of cases had no
travel history or exposure to patients with known cases of
Influenza A (H1N1). Most common presenting symptoms
are fever, couh, nasal congestion and sore throat. Most
of the cases were treated as outpatient (89%) and only
16% were treated with oseltamivir. Only 1 out of the 260
confirmed cases expired.
Conclusion and Recommendations: There is a heightened
health-awareness among Filipino communities. The Makati
Medical Center cohort shows the value and importance
of multi-sectoral collaboration. The MMC data provided
clinical evidence of a community level transmission. A
great number of patients in the cohort was treated as
out-patient without anti-viral therapy.
Keywords: Makati Medical Center, Pandemic, Influenza
A (H1N1)
Abstract
Introduction
The influenza A virus has circulated the world since the
20
th
century. The 1918 Influenza Pandemic, which was of
the H1N1 subtype, has led to the death of almost 40 million
people worldwide. Two were recent influenza pandemics
the A (H2N2) subtype Asian Flu from 1957 1963 and
A(H3N2) subtype Hongkong flu from 1968 through 197 led
to an estimated 6 million deaths.
1
Because of the potential for
rapid spread of Influenza, the world continues to be vigilant
for the next pandemic.
On April 15 and 17, 2009, two children from Southern
California developed acute respiratory illnesses and soon
afterwere confirmed as infection with a novel Influenza A
(H1N1) virus.
2,3
After 5 days, the Centers for Disease Control
and Prevention (CDC) confirmed the presence of this novel
influenza in more than 5,000 people in Mexico with acute
respiratory illness, and 97 deaths due to this virus by May 29.
4
Evolutionary analysis of this new Influenza A (H1N1) virus
showed that it was a result of reassortment of genes from
avian, swine and human influenza.
5
Animal studies suggested
that domestic pigs serve as mixing vessels, facilitating the
transfer and emergence of the virus among the human
population.
6
This virus still belongs to the H1N1 family of
influenza. However, significant changes in the hemagglutinin
and neuraminidase proteins indicated an antigenic shift,
eventually triggering the pandemic.
7
Similar to seasonal influenza, individuals infected with
Influenza A (H1N1) present with fever, cough and sore
throat.
3
In some population, patients also experienced
gastrointestinal symptoms such as diarrhea and vomiting.
8

Adamantanes notably are ineffective in treating this virus
which remains susceptible to oseltamivir and Zanamivir .
However, there are reports of oseltamivir-resistant strains of
Influenza A (H1N1).
8
The rapid spread of the infection compelled the World
Health Organization to declare a Public Health Emergency
of International Concern on April 25, 2009.
10
The first infection
in the Western Pacific Region was detected on April 29 in
Original Article Philippine Journal of Internal Medicine
1
Hospital Epidemiologist

2
Consultant, Section of Infectious Disease

3
Fellow, Section of Infectious Diseas
4
Infection Control Nurse

5
Total Quality Officer

6
Medical Director, Makati Medical Center
New Zealand.
11
On May 1, the first case in Asia was reported
in a Mexican, initially asymptomatic, man who arrived in
Hong Kong but who eventually manifested with flu-like
symptoms and later confirmed infected with Influenza A
(H1N1) by real-time Reverse Transcriptase Polymerase Chain
Reaction (RT-PCR).
12
The first documented infection in the Philippines was
in a child returning from USA, confirmed on May 22, 2009.
13

Since these initial infectious, these has been a continuous
increase in the number of cases of Influenza A (H1N1), not
only in the Philippines but in the world. With the increase
in incidence of people in many countries affected by this
disease and based on the revised WHO pandemic scale
14
,
WHO Director General Margaret Chan declared on June 11,
2009 that the world is now at the start of the 2009 influenza
Pandemic.
15
The ri si ng number of affected peopl e i n several
communities in the Philippines necessitated the commitment
of the national government, the Department of Health
(DOH), the public and private hospitals and healthcare
workers to prevent or minimize the spread of this infection.
Makati Medical Center (MMC), a private, 616-bed tertiary
hospital situated at the heart of Makati City, Philippines,
was one of the private institutions who took the challenge
of handling these cases. MMC begun its preparation for
a possi bl e outbreak i n the Phi l i ppi nes si nce the Phase
4 declaration of WHO. The preparedness plan of MMC
included the formation of Pandemic Influenza and Emerging
Diseases Emergency Response (PEDER) Teams that were
initially organized in year 2005, and who were tasked with the
coordination and conduct of various hospital-wide activities
in the event of a pandemic.
Objectives
This paper aims to describe the cases managed at
MMC, in correlation with the events that transpired locally
and internationally. The trend of consults and demographics
of suspected influenza A (H1N1) patients from May 3 to July
4, 2009 (9 weeks of surveillance data) will be described in
an epidemiologic perspective. The demographics of the
confirmed cases of influenza A (H1N1), the level of medical
care and outcome of the reported confirmed cases will be
presented as well.
Design and Methodology
This is a descriptive observational study with samples
consi sti ng of pati ents seen i n Makati Medi cal Center
suspected of Influenza A (H1N1) infection. The patients
included in this study were seen from May 3, 2009 to July 4,
2009. Sources of data included case report forms from DOH,
patients chart and medical records.
Consults were trended and analyzed on a weekly basis
to identify the dates with the highest number consults. This
trend was correlated with the events and declarations of
the WHO and DOH. The consults were described according
8 Volume 48 Number 2 July-September, 2010
to the patient catchment area, age and sex distribution.
The data for the confi rmed cases were extracted
from the total consults. Confirmed cases were patients
with nasopharyngeal specimen which tested positive for
Influenza A (H1N1) based on Real Time Reverse Transcriptase
Pol ymerase Chai n Reacti on (RT-PCR). Thi s test i s onl y
performed in the National Influenza Reference Laboratory of
the Philippines in the Research Institute for Tropical Medicine
(RITM). These were also compared with the Philippines
country-wide statistics. Case detection rates were also
computed for each time period.
Consults were described demographically according
to place of origin, nationality, age, sex and presence of
underlying medical conditions. History of exposure of the
confirmed cases was also expounded based on history
of travel to countries with confirmed influenza A (H1N1)
i nfecti on and/ or hi story of contact wi th a confi rmed
Influenza A (H1N1) case. The different presenting symptoms,
level of medical care, use of antivirals and outcome of these
patients were also described.
Scope and Limitation
This research covers all patients seen and admitted
at the Makati Medical Center from May 3, 2009 to July 4,
2009 only. Patients seen after July 4 were not included in
this study. The duration was limited to the specified dates
because there was a shift in the pandemic management
strategy from containment to mitigation response. DOH
issued a Department Memorandum on June 24, outlining
these guidelines
16
and was implemented in MMC on July 1,
2009. Inclusion of the June 28-July 4 period provides a brief
description of the outcome of this shift in strategy.
This study is also limited to the patients whose specimens
were taken in MMC and if not seen in MMC, whose Influenza
A (H1N1) status were disclosed to their attending physicians.
The data is limited to that gathered from the case report
forms, patient charts and medical records, which covers
the period from date of admission to discharge from the
institution.
Results and Discussion
Consults Due to Influenza A (H1N1) in Makati Medical
Center
The WHO decl ar ati on of Pandemi c Phase 5 l ast
April 29, 2009
17
prompted DOH to allow private medical
facilities to handle suspected Influenza A (H1N1) patients.
Makati Medi cal Center i s one of the pri vate hospi tal s
i n the Phi l i ppi nes that handl ed cases of thi s emergi ng
infection. With the activation of the MMC PEDER Teams
and the directive of the Medical Director, MMC started
seeing patients suspected of this disease and obtaining
nasopharyngeal specimen for RT-PCR on May 3, 2009. Nine
weeks after the first consult, MMC has treated a total of 548
patients suspected or confirmed with Influenza A (H1N1)
infection.
Influenza A (H1N1) Surveillance Report Zabat GM A, et al
The first confirmed case of Influenza A (H1N1) in the
Phi l i ppi nes was detected on May 22.
13
Soon after, an
exponential rise in the number of consults due to flu like
symptoms was observed in from that declaration the weeks
that followed. An abrupt increase in consults was detected
during the period of May 31 to June 6 (from 11 the previous
week to 54 consults). It was during this period that the first
case from a school in Manila was confirmed (June 3, 2009).
18

. The declaration of Phase 6 by WHO on June 11
15
and the
1
st
community level transmission in the Philippines in Jaen,
Nueva Ecija on June 15
19
also led to a marked increase in
the number of consults.
The first death complicated by Influenza A (H1N1)
was identified on June 22
20
, which was followed by the
decl arati on of a communi ty l evel outbreak i n Mani l a,
Philippines on June 23
21
. This incidence consults due to flu
like symptoms (from 129 the previous week to 228 consults)
peaked during the week of June 21 to 27, accounting for 42%
of the total number of identified consults due to Influenza A
(H1N1) seen at MMC.
The exponentially rise in number of patients presenting
with this emerging disease in the whole Philippines prompted
DOH to i ni ti ate a country-wi de i mpl ementati on of a
mitigation strategy.
16
Implemented from July 1, 2009 onward
in MMC, this shift in strategy was immediately associated
with a decline in the incidence of daily consults (from 228
to 34 consults) that were subjected to confirmation RT-PCR
test for the novel Influenza virus.
Demographics of Consults
Catchment Area
At the heart of Makati City with a population of less
than hal f a mi l l i on, MMC i s very accessi bl e for Makati
residents who comprised 35% of the total number of MMC
consults suspected of Influenza A (H1N1). This was followed
by residents from the neighboring cities of Manila (8%),
Paranaque (7%), Quezon City (6%), Taguig (4%), Pasay
(3%) and Pasig (3%). The rest of the patients came from
more distant cities and provinces: Laguna, Rizal, Cavite,
Mandaluyong, San Juan, Muntinlupa, Caloocan, Las Pinas,
Bul acan, Batangas, Mal abon, Val enzuel a, Pampanga,
Magallanes and Marikina.
Age Distribution
Most patients who sought consult during this 9-week
period were among the age group of 19 to 49 years old,
comprising 59% of the observed cohort. This was followed
by patients of school age, with 18% belonging to the 13 to
18 year-old age range, and 10% among 5-12 year-old age
range. The median age of patients seeking consult was 24
years old (Range= 6 months to 84 years old).
Gender Distribution
Of the 548 consults on Influenza A (H1N1), 295 (54%)
Volume 48 Number 2 July-September, 2010 9
Influenza A (H1N1) Surveillance Report Zabat GM A, et al
Figure 1. MMC weekly census of consults on Infuenza A (H1N1) from May 3 to July 4, 2009.
Figure 2. Real Time RT-PCR Results of Suspected
Infuenza A (H1N1) Patients seen in MMC.
10 Volume 48 Number 2 July-September, 2010
Influenza A (H1N1) Surveillance Report Zabat GM A, et al
Figure 3. MMC weekly census of confrmed cases of Infuenza A (H1N1) from May 3 to July 4, 2009.
Figure 4. Infuenza A (H1N1) Case detection Rate in MMC.
Figure 5. Confrmed cases seen in MMC vs. country-wide report of confrmed Infuenza A (H1N1) cases.
were females and 253 (46%) were males.
Confirmed Cases of Influenza A (H1N1) in Makati Medical
Center
Within 9 weeks, MMC managed 548 patients suspected
of Influenza A (H1N1) infection. Of these, 47% (260) were
confirmed to be positive for the novel Influenza A (H1N1), 1%
(4) were positive for Influenza A but negative for the novel
H1N1 subtype and 49% (266) were negative for Influenza A.
The remaining samples (1%, 5 patients) were either still being
processed and awaiting results or the results were either
unknown or not reported to MMC (2%, 13).
The first 8 weeks (May 3 to June 27) of surveillance
corresponded with the containment strategy phase as
mandated by the DOH
22
and recommended by WHO. During
this period, nasopharyngeal specimens of all patients who
consulted in the Emergency Room exhibiting influenza-like
illness and with history of travel and/or close contact with
a confirmed case of Influenza A (H1N1) were taken for
confirmatory verification using RT-PCR. Analysis of the data
from the 1
st
detected case in MMC to the period before the
mitigation strategy (May 30 to June 27) revealed a linear
increase in case detection rates (slope=0.13), consistent
with the ongoing transmission of the virus and increase in
the number of affected individuals. This peaked during the
period of June 21 to June 27 at 61%, when DOH declared
a community-level outbreak in Metro Manila. During the
last week of observation, the shift to mitigation phase
was associated with a marked decline in the number of
confirmatory tests done in MMC, which were limited to high
risk patients.
16
Case detection rate was still high during this
period at 68%.
The graph above depicted the increasing trend of
confirmed cases in the Philippines along with the confirmed
cases seen in MMC. As of July 4, 2009, MMC managed 15%
(260 out of 1709
23
) of the total confirmed influenza A (H1N1)
cases in the Philippines.
Demographics of Confirmed Cases
Place of Origin
Of the 260 confirmed cases seen in MMC, 38% (99) were
residents from the Makati area, 10% (26) from Manila, 8% (20)
from Paranaque, 5% (12) from Pasay, 5% (12) Quezon City
and 4% (10) from Taguig. The rest of the confirmed cases
were more distant cities and provinces: Laguna, Pasig,
Cavite, Rizal, Mandaluyong, San Juan, Bulacan, Batangas,
Muntinlupa, Malabon, Valenzuela, Las PInas, Marikina and
Magallanes.
Nationality
Most of the patients who sought consult in MMC and
who were found to be positive were Filipinos (90%, 235).
However, MMC also took care of confirmed patients who
were of other nationalities: Japanese, Korean, American,
Australian, German, Malaysian, Finnish and British.
Age Distribution
Volume 48 Number 2 July-September, 2010 11
Influenza A (H1N1) Surveillance Report Zabat GM A, et al
Table I. Age Distribution of confrmed Infuenza A (H1N1) cases
seen in MMC

Age Range Female Male Total %
0-1 year old 3 1 4 1.5%
2-5 years old 1 4 5 1.9%
6-12 years old 20 19 39 15.0%
13-18 years old 35 33 68 26.2%
19-49 years old 65 59 124 47.7%
50-65 years old 2 7 9 3.5%
>65 years old 0 0 0 0.0%
No information 5 6 11 1.5%
TOTAL 131 129 260 1.5%
Cumulatively, 89% (231) of the confirmed Influenza A
(H1N1) cases seen in MMC, were of the healthy school age
range and the reproductive age group. Majority, 47.7% (124)
of the confirmed cases seen in MMC, belonged to the 19
to 49 years old group, representing the adult reproductive
age. This was followed by 26.2% (68) from the 13-18 years
old group and 15% (39) from the 6-12 years old group. These
age ranges represent the previously healthy pediatric school
age- high/ secondary school and primary/ elementary
school respectively. The median age of the confirmed cases
is 24 years old (range=6 months to 56 years old).
Gender Distribution
Both genders were equally affected. There were 131
(50.4 %) females and 129 (49.6%) males.
Underlying Medical Conditions
The surveillance included identification of the presence
of underlying medical conditions of the patients. This would
determine if a patient was high risk for development of
severe disease and a potential need for more intensive
care. Of the 260 confirmed cases, 16 patients (6.3%) had
pre-existing hypertension, 12 (4.7%) had asthma and 2 (0.8%)
had diabetes. One patient each disclosed that they had
Crohns disease and an undetermined heart disease. One
patient also had a history of open heart surgery as a neonate
and another with history of generalized seizures. There were
2 pregnant patients seen in MMC, one at 16 weeks another
at 32-33 weeks Age of Gestation, who were confirmed with
Influenza A (H1N1) infection.
History of Exposure
During the containment management strategy phases
of the disease in the Philippines, DOH issued guidelines on
case detection which required that all individuals exhibiting
flu-like symptoms and who had a history of recent travel to
countries with known cases of Influenza A (H1N1) should
undergo confirmation examination with RT-PCR of infection
of this new virus.
22
From the MMC surveillance data, a total of
41 patients had history of travel to an affected country prior
to consult. Fifteen (15) of these cases had history of travel
to the United States, 5 travelled to Canada, 4 to Taiwan, 6
to Singapore, 3 to Japan and 3 to Australia. Other places
of travel included China, Finland, Hong Kong, France, India,
Korea and Thailand. Only one of these patients with travel
history also had history of close contact with a known case
of Influenza A (H1N1).
Close contact with no history of travel was reported in
48 individuals (19%) confirmed with the disease. Of these, 16
were students with exposure in their schools and 2 patients
disclosed exposure in their offices. This is consistent with
the experience in Europe where transmission of the virus is
seeded in closed community settings by returning travelers.
Thi s l i kel y i ncreased the vi ral reservoi r i n communi ti es,
eventually leading to community outbreaks.
24
However,
there were 5 healthcare workers (HCWs) who were confirmed
with Influenza A (H1N1) infection; 4 of whom were exposed
while performing their duties in the hospital and one was
exposed in the community. This suggest that virus transmission
may occur both in the healthcare and community settings.
25
However, majority of the cases could not recall any
known exposure to the virus. There were 171 confirmed cases
of Influenza A (H1N1), representing 66% of the 260 confirmed
cases, who had not travelled to an affected country as well
as unknown history of close contact with a confirmed case.
The absence of known exposure from these patients further
supports the declaration of DOH of sustained human-to-
human transmission and community-level outbreak in the
Philippines.
19, 21
Presenting Symptoms
Fever was the most common symptom of Influenza A
(H1N1), present in 83% of the confirmed patients seen in
MMC. This was followed by cough in 75%, nasal congestion
in 50%, sore throat in 38%, muscle ache in 14%, colds in
10% and headache in 5%. These constitutional symptoms
were si mi l ar to the typi cal mani festati ons of seasonal
i nf l uenza i nf ect i on. However , a var yi ng per cent of
patients with Influenza A (H1N1) among some populations
al so experi enced gastroi ntesti nal symptoms whi ch are
uncommon in patients with seasonal flu. Reports from the US
and Mexico documented vomiting and diarrhea in 25% of
their patients.
26
However, among the MMC cohort, only few
patients experienced these symptoms, with 4% complained
of nausea, 3% had episodes of vomiting, 2% had diarrhea
and 1% experienced abdominal pain.
Level of Medical Care
Since majority of the patients manifested with mild
symptoms, 89% (233) of the confirmed cases of Influenza A
(H1N1) of the MMC were managed on an outpatient basis.
They were sent home on supportive care, with specific
instruction on WHO and DOH guidelines on standard and
droplet precautions and self imposed home quarantine.
There were 25 patients (10%) who were treated as inpatients
and quarantined in regular individual rooms for closer
Influenza A (H1N1) Surveillance Report Zabat GM A, et al
12 Volume 48 Number 2 July-September, 2010
Figure 7. Presenting symptoms of confrmed cases ofInfuenza A (H1N1) in MMC.
Figure 6. History of Exposure of Confrmed
Infuenza A (H1N1) cases.
monitoring, These included the two pregnant women since
pregnancy is a recognized risk marker for potential sever
influenza-related complications.
27
Duri ng the observati on peri od, two pati ents (1%)
required confinement in critical care units due to severe
respiratory distress and encephalopathy respectively. These
patients were triaged for intensive care and very closely
monitored because of the severity of their conditions.
Use of Antivirals
Drug suscepti bi l i ty testi ng showed that the novel
Influenza A (H1N1) remains susceptible to the antiviral
drugs neuraminidase inhibitors zanamivir and oseltamivir
9
.
However, the only available antiviral drug in the Philippines
is oseltamivir. The effectivity of antivirals is highest when
given within 48 hours from symptom onset. Based on previous
studies of other influenza strains, treatment with oseltamivir
reduces respiratory complications and length of hospital
stay in both previously healthy and at-risk individuals.
28,29
There were 41 patients (16%) who received Oseltamivir
in MMC. All admitted patients in the regular rooms and
critical care units, aside from the pregnant patients, received
antivirals. Some patients treated on an outpatient basis, were
also given Oseltamivir if they were considered high risk of
severe influenza complications.
There is very limited data on the safety and efficacy of
antivirals during pregnancy.
30,31
There are also conflicting
r ecommendati ons on whi ch anti vi r al (osel tami vi r or
Zanamivir) to administer for these patients.
32,33
In the light of
available evidence, the two pregnant patients admitted
in MMC did not receive any antiviral drugs. They were very
closely monitored for the duration of their illness and both
patients recovered fully with supportive care and were
discharged well.
Antivirals were not prescribed to 240 (92%) confirmed
cases exhibiting mild symptoms and were managed on
an outpatient basis. These patients were provided with
supportive home care, which led to rapid improvement
of their symptoms. This highlights the known usual quick
recovery of mild cases of Influenza A (H1N1) infection even
without antiviral medications.
Outcome
Of the 260 confirmed cases, 259 patients are alive.
However, unfortunately there was one mortality among
the MMC cohort due to concomitant bacterial pneumonia
complicated to respiratory arrest.
Conclusions and Recommendations
The trend of consults in relation to the events that
transpired with Influenza A (H1N1) pandemic shows the
enhanced health-awareness behavior of communities,
particularly Filipinos. Individuals are more aware of the
implications of the pandemic and seek prompt medical
care. This poses a substantial surge in patients visits to
the ER and a sudden strain on health care facilities, thus
emphasizing the importance of partnership between the
public and private sectors. The magnitude of the confirmed
cases seen within a brief period of time at Makati Medical
Center is proof of the success of this partnership.
The MMC surveillance data cohort shows that those in
the adult reproductive age group of 19 to 49 years old were
more frequently affected by the disease. This was closely
followed by those belonging in the school age group of 5 to
18 years old. There was also no predilection to any gender.
The MMC data provi ded evi dence of communi ty
outbreak since most of its confirmed cases did not have
any travel history and with no known history of contact
with a confirmed case. Infection control practices were
also effective in the workplace in MMC, given that only 4
healthcare workers had suspected exposure in the clinical
setting.
This novel virus seems to manifests generally as a mild
disease, presenting with similar symptoms as the seasonal flu
(fever, cough, nasal congestion, sore throat). There were only
a few patients with documented gastrointestinal symptoms,
unlike the reported from Mexico and the US. This mild nature
of the disease allowed outpatient care for a majority of the
patients.
Most pati ents who were confi rmed to have been
infected with Influenza A (H1N1) did not receive antivirals
but recovered fully with brief clinical course of the illness.
The severe cases which include the documented mortality
had other co-existing medical conditions such as asthma
and bacterial pneumonia.
Although there was a rapid decline in the number of
confirmed cases after June 28, this likely under-estimated
the number of affected individuals. As such, a heightened
alertness and vigilance should continue, because of the
potential re-emergence and mutation of this virus, and the
appearance of a more virulent and severe disease. In the
second and third wave, which were well documented in
previous influenza pandemics in the 20th century.
Volume 48 Number 2 July-September, 2010 13
Influenza A (H1N1) Surveillance Report Zabat GM A, et al
Figure 8. Level of Medical Care of Confrmed
Infuenza A (H1N1) cases in MMC.
Addendum
In the course of writing this article, four more severe
patients were admitted in Makati Medical Center. Here is a
summary of the four critical cases managed in MMC.
The first critical patient, a 7-year old girl presented
initially with fever and dry cough 5 days prior to admission.
Her symptoms worsened as she experienced difficulty of
breathing prompting ER consult and subsequent admission
to the Pediatric Intensive Care Unit on June 20, 2009. She
was dyspneic with severe hypoxia, progressing to acute
respiratory failure requiring mechanical ventilation. Chest
X-ray findings showed bilateral infiltrates and consolidation,
with pleural effusion. Nasopharyngeal swab of the patient
tested positive for Influenza A (H1N1). She was treated with
intravenous antibiotics, oseltamivir and corticosteroids.
Resolution of symptoms and chest x-ray findings were seen
on the 7
th
hospital day, and weaning from mechanical
venti l ator was i ni ti ated. On the 11
th
hospi tal day, she
became hypotensive, with marked oxygen desaturation.
Pneumothor ax was confi r med on chest x-r ay and a
thoracostomy was done. However, the patient developed
a cardiorespiratory arrest and resuscitation efforts failed to
revive the patient.
The second patient, a 5-year old girl with history of
meni ngi ti s one year earl i er. She presented wi th fever,
cough and colds 4 days prior to admission. One day prior to
confinement, he exhibited behavioral changes, restlessness,
and irritability with seizure episodes. Electroencephalogram
showed generalized encephalopathic pathology and MRI
studies showed focal areas consistent with viral encephalitis.
A chest x-ray showed early bronchopneumonia. Admitted
on July 2, 2009 in the Pediatric Intensive Care Unit, patient
was GCS 6- with no eye movement and verbal response
but with decorticate posturing to painful stimuli. Lumbar
tap was negative for bacteriologic and fungal studies.
Nasopharyngeal specimen was positive for Influenza A
(H1N1). She was treated with antibiotics and oseltamivir.
Within 5 days patients level of consciousness markedly
improved.
The third patient was a 23-year old obese, female
student with history of diabetes and hypertension. She
presented wi th a 6-day hi story of fever and cough.
Nasopharyngeal specimen taken prior to confinement
was positive for Influenza A (H1N1). Because of progressive
respiratory distress she was promptly admitted to the Medical
Intensive Care Unit on July 6, 2009. She subsequently required
intubation and mechanical ventilation. Chest x-ray showed
bilateral lung infiltrates. Patient was treated with antibiotics,
oseltamivir and corticosteroids. She gradually improved and
recovered fully.
The fourth critical patient was a 44-year old obese,
school teacher with history of asthma and hypertension.
She presented with a 3-week history of fever, cough and
shortness of breath, severe progressive hypoxemia. She
was admitted to the Medical Intensive Care Unit on July 6,
2009. Chest x-ray showed bilateral infiltrates and pulmonary
congestion. Nasopharyngeal specimen was positive for
Influenza A (H1N1). She was treated with antimicrobials,
oseltamivir and corticosteroids. She gradually improved and
had fully recovered.
Acknowledgements
The authors grateful l y acknowl edge the tremendous
contributions of the following:
Dr. Johnny Sinon, Dr. Farah Modesto, Dr. Arnie Syquia
and Dr. Dan Luchangco of the Emergency Department
who were first responders for most of the patient cohort
and diligently filled up case report forms and tracked
the RT-PCR test results performed at RITM
Dr. Thelma E. Tupasi, Dr. Ma. Tarcela Gler, Dr. Dennis
Garcia and Dr. Carmenchu Echiverri, Infectious Disease
consultants and fellow who patiently provided vital
information regarding their patients.
Dr. Sheila Rose Ann Mendoza-Ugalino, Dr. Christine
Joy Tanteo, Dr. Gallo, pediatric residents who were
kind enough to provide us with clinical abstracts of the
critical patients
Mr. Alex Mendoza and Ms. Gold Francisco, Infection
Control Nurses who ably assisted in the collection and
completion of case report forms and isolation ward data
of discharged patients
The nurses in the 8
th
wing isolation ward (where patients
who di d not requi re cri ti cal care were admi tted),
Medi cal and Pedi atri c I ntensi ve Care Uni ts, who
consi stentl y exerci sed stri ct pati ent i sol ati on and
quarantine protocols I the care of influenza A (H1N1)
patients.
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