Occurrence of Influenza A(H1N1)v Virus in Western Romania in Relationship to International Travel

Abstract

Epidemiological and clinical characteristics of the first cases of infection with the novel influenza A (H1N1) variant virus [A(H1N1)v] admitted to a reference hospital in Western Romanian from mid-June to mid-July 2009 are overviewed. Of 74 suspected cases, 7 were laboratory confirmed. All patients were either Romanian citizens, or people originating from Romania and established overseas. The median age was 13 years and the mean length of hospital stay was 7.7 days. Cough (n = 6) and fever (n = 4) were the most commonly reported symptoms, and all cases made complete recovery. Early diagnosis and management of H1N1 flu was not problematic for the infectious disease specialists. Because many Romanians established overseas come yearly to visit their relatives, special attention must be addressed to the international flight passengers.

Introduction

A ll three genera of influenza virus (A, B, and C) produce human infections, but only A is responsible for the disease on pandemic scale (Watts 2009). After the three major pandemics that occurred in the past century (1918 [Spanish Flu], 1957, and 1968), in March 2009 a new influenza A (H1N1) variant virus [A(H1N1)v] emerged in Mexico (Narain and Bhatia 2009). This new virus, which was found to be a mixture of avian, porcine, and human influenza RNA, is highly transmissible, but its virulence and clinical picture of the illness are comparative to seasonal influenza (Fitzgerald 2009, Narain and Bhatia 2009). The clinical picture may vary broadly from asymptomatic forms to severe pneumonia leading to fatality. Additionally, gastrointestinal symptoms like nausea, vomiting, and diarrhea may occur (Narain and Bhatia 2009).

As of 25 August, 253,169 cases and 2572 fatalities were reported worldwide (Institute of Public Health Bucharest—National Center of Communicable Diseases Prevention and Control 2009). In Romania, the first case was found on 27 May (The Romanian Academy—Stefan S Nicolau Institute of Virology 2009), and as of 25 August, 284 cases were laboratory confirmed. All patients had history of international travel or reported contact with infected persons. No indigenous cases and no fatalities have been reported up to date (Institute of Public Health Bucharest—National Center of Communicable Diseases Prevention and Control 2009). Timisoara, the largest city in western Romania, is situated in proximity to the Serbian and Hungarian borders. Timisoara's international airport, Traian Vuia, is the main gateway of Western Romania to many European metropolises. Overseas travel is accessible via Germany or Austria.

As of 3 August, 74 individuals were suspected of influenza A(H1N1)v virus infection by the Institute of Public Health in Timisoara. Finally, only seven of them were laboratory confirmed and consequently treated at Victor Babes Hospital of Infectious Diseases in Timisoara.

This study aimed to present the epidemiological and clinical characteristics of the first cases of novel influenza A(H1N1)v admitted to Victor Babes Hospital of Infectious Diseases in Timisoara—the reference hospital for infectious diseases in Western Romania. To our knowledge, this is the first international report on Romanian patients found to have influenza A(H1N1)v virus.

Materials and Methods

The medical documents, available at Institute of Public Health and Victor Babes Hospital of Infectious Diseases in Timisoara, Romania, were the main sources of information for the present report. The following data were abstracted from the medical charts of the hospitalized patients: registration number, age, sex, residence, date and length of hospitalization, travel history, diagnosis, symptoms, pathological laboratory test results, and specific therapy. Diagnosis was confirmed by testing pharyngeal exudates with real-time reverse transcription (RT)-polymerase chain reaction at the national influenza reference laboratory located at Cantacuzino Institute in Bucharest, Romania.

Case Reports

The first patient (Table 1) found to have the infection in Timisoara in June 2009 was an 8-year-old girl established in Canada who traveled together with her great grandmother in Romania. Symptomatology developed in the first part of the travel, during the flight Toronto–Vienna, with fever and sore throat. The next day after arriving at the final destination, fever (38.4°C) occurred again and the family doctor prescribed an antibiotic, an analgesic, and an antipyretic. The following day the temperature continued to increase (39.6°C) and the patient began to cough. The family notified the Public Health Services about the presence of the disease in the context of positive travel history. The pharyngeal exudate gave a positive result for influenza A(H1N1)v virus and the patient was admitted to Victor Babes Hospital of Infectious Disease in Timisoara for isolation and administration of specific therapy. After 5 days the symptoms remitted and the control pharyngeal exudate was negative for influenza A(H1N1)v virus.

Table 1.

Epidemiological and Clinical Features of the Study Group

Patient	Age	Sex	Residence	Aircraft travel route	Hospitalization period (2009)	Comorbidities	Clinics	Pathological laboratory findings	Specific therapy
1	8 years	F	Toronto, Canada	Toronto–Vienna–Timisoara	June 13–18	Poststreptoccocal syndrome	Fever Sore throat Dry cough	L = 3840 cells/mm³ ASOT = 400 IU/mL	Oseltamivir 2 × 75 mg/day for 5 days
2	30 years	M	Timisoara, Romania	Return flight: Timisoara–Vienna–Koln	June 16–22	None	Fever Sore throat Harsh voice Wet cough Watery rhinorrhea	None	Oseltamivir 2 × 75 mg/day for 7 days
3	9 months	F	Hickory, North Carolina	North Carolina–New York–Dusseldorf–Timisoara	June 24–July 2	Acute enterocolitis with group D Salmonella Acute dehydration syndrome Anemia	Nasal catarrh Wet cough Rhinorrhea Congested pharynx Diarrhea	Hb = 11 g/dL Coproculture positive for group D Salmonella	Oseltamivir 2 × 75 mg/day (dissolved in liquid) for 5 days
4	13 years	M	Hickory, North Carolina	North Carolina–New York–Dusseldorf–Timisoara	June 24–July 1	Acute vomiting syndrome	Dry cough Nausea Vomiting	None	Oseltamivir 2 × 75 mg/day for 6 days
5	6 years	M	Hickory, North Carolina	North Carolina–New York–Dusseldorf–Timisoara	June 24–July 1	None	Fever Sore throat Wet cough	ESR = 15 mm/1 h and 30 mm/2 h hFb = 3.7 g%	Oseltamivir 2 × 75 mg/day (dissolved in liquid) for 6 days
6	25 years	F	Timisoara, Romania	Orlando–New York–Dusseldorf–Timisoara	July 7–18	None	Watery rhinorrhea Sneeze Shivers	None	Oseltamivir 2 × 75 mg/day for 10 days
7	15 years	M	Timisoara, Romania	Honolulu–Los Angeles–London–Budapest	July 11–18	Nasal carriage of Staphylococcus aureus	Fever Dry cough Headache Congested pharynx Laterocervical adenopathy	L = 3130 cells/mm³ Nasal exudate positive for S. aureus	Oseltamivir 2 × 75 mg/day for 7 days

ASOT, antistreptolysin O titer; ESR, erythrocyte sedimentation rate; F, female; M, male; Fb, fibrinogen; Hb, hemoglobin; L, leukocyte count.

Patient 2 (Table 1), a 30-year-old man, acquired the infection during a 2-day business travel to Köln, Germany. Before departure he had an underlying respiratory condition manifested by sore throat and harsh voice. Two days after returning home, his status worsened with productive cough, mild fever (37.8°C), and watery rhinorrhea. He was also announced by the travel agency that a passenger in the same flight was found to have the influenza A(H1N1)v virus. Consequently, he presented at the hospital where an exudate sample was collected and sent to the reference institute; the infection with the novel influenza was confirmed. After a 6-day hospitalization period, a new pharyngeal exudate was analyzed and the result was negative.

The following three patients (Table 1) were siblings: an infant (patient 3) and two children (patients 4 and 5) established in North Carolina, who traveled together with their parents in Romania. During the flight from New York to Düsseldorf, they came in contact with a person established later to be infected with influenza A(H1N1)v virus. Diagnosis was confirmed in all three cases and they were hospitalized in Timisoara. Their parents were negative for the novel influenza virus. The control pharyngeal exudates tested for influenza A(H1N1)v virus were negative after 1 week of hospitalization and treatment.

Patient 6 (Table 1) was a young adult who traveled from the United States to Romania. She came in contact with an infected couple during the flight from New York to Düsseldorf. After the onset of the flu symptoms and confirmation of the infection with influenza A(H1N1)v virus, she was hospitalized in Timisoara. Although during the hospital stay she was afebrile and asymptomatic, the pharyngeal exudate was positive after 7 days of specific therapy. She continued the treatment with oseltamivir for another 3 days. Finally, the result of the exudate was negative.

Patient 7 (Table 1) was an adolescent who spent his holiday in Hawaii. Symptoms occurred 2 days after his return, and ibuprofen was administered. The symptomatology persisted for the next 2 days; therefore, he consulted an infectious disease specialist, who recommended hospitalization. His mother accepted the hospitalization only after the infection with influenza A(H1N1)v virus was laboratory confirmed. The patient had a favorable evolution after 7 days of therapy. The second pharyngeal exudate was negative for influenza A(H1N1)v virus.

Discussion and Conclusions

All patients were either Romanian citizens or people originating from Romania and established overseas. The median age of our patients was 13 years, similar to a Japanese study performed in Osaka in which the median age of the three studied groups was 16, 11, and 15 years, respectively (Komiya et al. 2009). Most of the patients (n = 5) were children, and the eldest patient was 30 years old. Four out of seven patients acquired the disease possibly because of contact with infected passengers on a flight connecting New York and Düsseldorf. The mean length of hospital stay was 7.7 days, twice longer than in a French surveillance (3 days) (Influenza A(H1N1)v investigation teams 2009) and an Italian surveillance (3.4 days) (Rizzo et al. 2009). The most commonly reported symptoms were cough (n = 6) and fever (n = 4), similar to other studies (Castro-Jimenez et al. 2009, Ciblak et al. 2009, Influenza A(H1N1)v investigation teams 2009). All patients had a mild clinical course and favorable outcome. The presence of comorbidities (n = 4) did not worsen the course of the disease. Routine laboratory investigations were not significantly changed in these patients.

In conclusion, although the early diagnosis and management of H1N1 flu was not problematic for the infectious disease specialists in Timisoara, they must focus on the influenza season and apply different methods, including the coming influenza A(H1N1)v vaccine to avoid severe cases. A special attention must be given to the international flight passengers, especially to the overseas visitors. Many Romanians who left the country and established in the United States and Canada come yearly to visit their relatives. Accordingly, these individuals maintain the risk of importation of new cases, as it happened in four out of seven cases reported above. Mass media campaigns regarding early detection of the infection and preventive measures are essential in the confrontation with the novel influenza virus. The population must understand the importance of timely presentation at an infectious diseases hospital in case of self-detecting flu-like symptoms to receive proper therapy, avoid the complications, and limit the transmission of the infection.

Footnotes

Disclosure Statement

No competing financial interests exist.

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