LETTERS Clinical outcomes of pandemic (H1N1) 2009 influenza (swine flu) in adults with cystic fibrosis Patients with cystic fibrosis (CF) suffer recurrent bacterial pulmonary infections, but viral infections can also cause acute clinical deterioration. 1 Certain patient groups suffer increased morbidity following pandemic (H1N1) 2009 influenza (swine flu), 2 but there are few previous reports of outcomes in individuals with CF. 34 The West Midlands, along with Greater London, has had the highest incidence of H1N1 influenza in the UK. 5 We therefore examined the outcomes of patients diagnosed with H1N1 influenza at the West Midlands Adult CF Centre. From June 2009 to April 2010 all adults with CF at our regional centre with potential H1N1 influenza had nasopharyngeal swabs tested by PCR. PCR testing was instituted in patients with fever >388C together with one or more of the following: sore throat, rhinorrhoea, loose bowel motions, myalgia and headache. We documented clinical management, as well as lung function and body mass index (BMI) at the visit prior to their febrile illness and at their subsequent clinic visit. We used paired and unpaired Student t test and ManneWhitney U test as indicated. Out of our total patient population of 325 adults with CF, 45 patients had nasopha- ryngeal swabs tested by PCR over the study period. Thirteen patients (4% of our patient population) tested positive (‘H1N1 +ve’ group) and 32 patients (9.8%) tested nega- tive for H1N1 influenza (‘H1N1 Àve group’). In three of the ‘H1N1 Àve’ group, PCR was positive for alternative viruses (1 adenovirus, 1 parainfluenza type 4, and 1 herpes simplex type 1). There were no statistically significant differences in baseline clinical characteristics between the two groups (table 1). Presenting symptoms in the ‘H1N1 +ve’ group were: fever >388C (13/13 patients), increased sputum production (13/13), sore throat (8/ 13), myalgia (5/13), nausea/vomiting (5/13) and headache (2/13). Fever, increased sputum production, nausea/vomiting and headaches were similarly common in the ‘H1N1 Àve group’; however, none of the patients in the ‘H1N1 Àve group complained of sore throat or myalgia. Blood test results showed a trend towards lower total white cell count and C-reactive protein (CRP) in the ‘H1N1 +ve’ group compared with the ‘H1N1 Àve’ group. All patients initially received antibiotics and oseltamivir, and in ‘H1N1 +ve’ patients oseltamivir was continued for a median of 10 days. Nine of the 13 patients in the ‘H1N1 +ve group’ required hospital admission, but there were no differences in duration of hospital admission or requirement for antibiotics between the two groups. There were no statistically significant differences in clinical outcomes between the ‘H1N1 +ve’ and ‘H1N1 Àve’ groups. In both the ‘H1N1 +ve’ and ‘H1N1 Àve’ groups there was a non- significant decrease in FEV 1 (forced expira- tory volume in 1 s) % predicted, FVC (forced vital capacity) % predicted (table 1) and BMI. None of the patients in the ‘H1N1 +ve’ group had new changes on their chest radiograph or required ventilatory support. In our experience, adults with CF have generally experienced a relatively mild illness as a result of the first influenza pandemic of the 21st century. However, the CF commu- nity is well aware of the potential implica- tions of a subsequent more virulent pandemic in future years. Edward F Nash, Richard Whitmill, Bethan Barker, Rifat Rashid, Joanna L Whitehouse, David Honeybourne West Midlands Adult Cystic Fibrosis Centre, Heartlands Hospital, Birmingham, UK Correspondence to Edward F Nash, West Midlands Adult Cystic Fibrosis Centre, Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK; edward. nash@heartofengland.nhs.uk Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. Accepted 26 June 2010 Published Online First 6 September 2010 Thorax 2011;66:259. doi:10.1136/thx.2010.140822 REFERENCES 1. Wat D, Gelder C, Hibbitts S, et al. The role of respiratory viruses in cystic fibrosis. J Cyst Fibros 2008;7:320e8. 2. Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients with 2009 H1N1 influenza in the United States, AprileJune 2009. N Engl J Med 2009;361:1935e44. 3. Whitaker P, Etherington C, Denton M, et al. A/H1N1 and other viruses affecting cystic fibrosis. BMJ 2009;339:b3958. 4. France MW, Tai S, Masel PJ, et al. The month of July: an early experience with pandemic influenza (H1N1) in adults with cystic fibrosis. BMC Pulm Med 2010;10:8. 5. Pandemic (H1N1) 2009 in England: an overview of initial epidemiological findings and implications for the second wave, 2009. http://www.hpa.org.uk/web/ HPAwebFile/HPAweb_C/1258560552857. Immunogenicity and safety profile of the monovalent A/H1N1 MF59-adjuvanted vaccine in patients affected by cystic fibrosis Viral respiratory tract infections may deter- mine lung function deterioration in patients affected by cystic fibrosis (CF). Viruses may have a synergistic action with bacteria to damage the respiratory tract; they may also promote airway bacterial colonisation. 1 Influenza virus infection has been described to increase the number of CF pulmonary exacerbations and the incidence of hospital- isation. 2 For this reason, vaccination is strongly recommended annually. The immunogenic effect and safety of influenza vaccines in CF children are comparable with that of healthy individuals. 3 The reported adverse events after vaccination are mild and not persisting. In 2009, a novel swine pandemic influenza A virus (A/H1N1) was identified. To date, the outcome of H1N1 infection has been described only in CF adults, 4 and no data are available about the safety and immunogenicity of the A/H1N1 vaccine administered to CF patients. The aim of our study was to evaluate safety and immunogenicity of the monovalent A/H1N1 MF59-adjuvanted surface antigen vaccine administered to CF patients. All CF patients aged 6 months to 26 years and followed at the referral Centre of the Bambino Gesù Children’s Hospital (Rome, Italy) were assessed for eligibility. Exclusion criteria were a contraindication for the influenza vaccine or a previous documented H1N1 virus infection. All subjects received one dose of Table 1 Patient characteristics and lung function data Age, median (range) Male, n (%) Chronic Pseudomonas airway infection, n (%) CF-related diabetes, n (%) CF liver disease, n (%) Transplant recipient, n (%) FEV 1 % predicted prior to presenting illness, mean±SD FEV 1 % predicted following presenting illness, mean±SD FVC % predicted prior to presenting illness, mean±SD FVC % predicted following presenting illness, mean±SD ‘H1N1 +ve’ group (n¼13) 22 (17e48) years 6 (46.2%) 13 (100%) 7 (53.8%) 6 (46.2%) 3 (23.1%) 51.4618.3% 46.5616.7% 67.4617.9% 64.0619.9% ‘H1N1 Àve’ group (n¼32) 26 (15e59) years 15 (46.9%) 31 (96.9%) 24 (75%) 6 (18.8%) 3 (9.4%) 50.7620.9% 49.8619.5% 66.4623.4% 65.0620.9% CF, cystic fibrosis; FEV 1 , forced expiratory volume in 1 s; FVC, forced vital capacity. Thorax March 2011 Vol 66 No 3 259 PostScript group.bmj.com on March 6, 2011 - Published by thorax.bmj.com Downloaded from