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Zanamivir Use During Transmission of Amantadine-Resistant Influenza A in a Nursing Home

  • Christine Lee (a1), Mark Loeb (a2), Anne Phillips (a3), Judy Nesbitt (a4), Karen Smith (a4), Margaret Fearon (a5), Margaret A. McArthur (a1), Tony Mazzulli (a1), Yan Li (a6) and Allison McGeer (a1)...

To describe the use of zanamivir during an influenza A outbreak.


Residents of a 176-bed long-term-care facility for the elderly in Newmarket, Ontario, Canada, 90% of whom received influenza vaccine in the fall of 1998.


When respiratory illness due to influenza A was confirmed, infection control measures and amantadine prophylaxis were initiated. Despite these measures, transmission of influenza A continued.


Zanamivir inhalations, 10 mg daily for prophylaxis and 10 mg twice daily for treatment of influenza.


There were 13 definite and 66 probable outbreak-associated cases of influenza A. Twelve (15%) cases developed pneumonia, 7 (9%) were hospitalized, and 2 (2.6%) died. All 12 culture-positive cases yielded influenza A/Sydney/H3N2/05/97-like virus, a 1998/99 vaccine component. The three isolates obtained prior to the initiation of amantadine were amantadine-susceptible; all nine obtained after prophylaxis was instituted were amantadine-resistant. One hundred twenty-nine (92%) of 140 residents who were offered zanamivir accepted it and were able to attempt inhalations. Of these 129, 78% (100) had no difficulty in complying with inhalations. Difficulty with inhalations was associated with decreased functional and mental status. Fifteen (58%) of 26 residents fully dependent in activities of daily living had difficulty compared to 14 (14%) of 100 others (P<.001). Twenty-two (45%) of 49 residents not oriented to person, place, or time had difficulty compared to 7 (10%) of 77 others (P<001). In the 2 weeks after zanamivir prophylaxis, only 2 new cases of respiratory illness occurred, neither confirmed as influenza. No side effects were identified in 128 zanamivir-treated residents.


A minority of nursing home residents have difficulty following instructions for zanamivir inhalations. Zanamivir was well tolerated, and its use was temporally associated with termination of an outbreak that amantadine had failed to control.

Corresponding author
Room 1460, Department of Microbiology, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario M5G 1X5, Canada
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1.Stevenson CG, McArthur MA, Zivnickova H, Naus M, Abraham E, McGeer A. Progress in the control of influenza and pneumococcal disease in long term care facilities: where do we stand? Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections; March 5-9, 2000; Atlanta, GA.
2.Henry B. Summary report of the Ontario influenza 1998/9 season. Public Health and Epidemiology Report. Ontario. 1999;10:144159.
3.Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48:(RR-4):128.
4.Statement on influenza vaccination for the 2000-2001 season. An Advisory Committee Statement (ASC). National Advisory Committee on Immunization. Can Commun Dis Rep 2000;26:116.
5.Aoki FY. Amantadine and rimantadine. In: Nicholson KG, Webster RG, Hay AJ, eds. Textbook of Influenza. Oxford, England: Blackwell Science, Ltd; 1998:457476.
6.Atkinson WL, Arden NH, Patriarca PA Leslie N, Lui KJ, Gohd R. Amantadine prophylaxis during an institutional outbreak of type A (H1N1) influenza. Arch Intern Med 1986;146:17511756.
7.Mast EE, Harmon MW, Gravenstein S, Wu SP, Arden NH, Circo R, et al. Emergence and possible transmission of amantadine-resistant viruses during nursing home outbreaks of influenza A (H3N2). Am J Epidemiol 1991;134:988997.
8.Degelau J, Somani SK Cooper SL, Guay DR, Crossley KB. Amantadine-resistant influenza A in a nursing facility. Ardi Intern Med 1992;152:390392.
9.Houck P, Hemphill M, LaCroix S, Hirsh D, Cox N. Amantadine-resistant influenza A in a nursing homes. Identification of a resistant virus prior to drug use. Arch Intern Med 1995;155:533537.
10.Hayden FG, Osterhaus AD, Treanor JJ, Fleming DM, Aoki FY, Nicholson KG, et al. Efficacy and safety of the neuraminidase inhibitor zanamivir in the treatment of influenzavirus infections. GG167 Influenza Study Group. N Engl J Med 1997;337:874880.
11.Randomised trial of the efficacy and safety of inhaled zanamivir in treatment of influenza A and B virus infections. The MIST (Management of Influenza in the Southern Hemisphere Trialists) Study Group. Lancet 1998;352:18771881.
12.Monto AS, Robinson DP, Herlocher ML, Hinson JM Jr, Elliott MJ, Crisp A Zanamivir in the prevention of influenza among healthy adults: a randomized controlled txial. JAMA 1999;282:3135.
13.Schilling M, Povinelli L, Krause P, Gravenstein M, Ambrozaitis A Jones HH, et al. Efficacy of zanamivir for chemoprophylaxis of nursing home outbreaks. Vaccine 1998;16:17711774.
14.McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991;19:17.
15.Katz S, Downs TD, Cash HR, Frotz RD. Progress in the development of the index of ADL. Gerontologist 1970;10:2030.
16.KUmov AI, Rocha E, Hayden FG, Schult RA, Roumillat LF, Cox NJ. Prolonged shedding of amantadine-resistant influenza A viruses by immunodeficient patients: detection by polymerase chain reaction-restriction analysis. J Infect Dis 1995;172:13521355.
17.Li Y. 1998-1999 influenza season: Canadian laboratory diagnoses and strain characterization. Can Commun Dis Rep 1999;25-21:177181.
18.Patriarca PA Weber JA Parker RA Hall WN, Kendal AP, Bregman DJ, et al. Efficacy of influenza vaccines in nursing homes. Reduction in illness and complications during an influenza A (H3N2) epidemic. JAMA 1985;253:11361139.
19.Arden NH, Patriarca PA Kendal AP. Experiences in the use and efficacy of inactivated influenza vaccine in nursing homes. Options for the Control of Influenza. New York, NY: Alan R. Liss; 1986:155168.
20.Potter J, Stott DJ, Roberts MA Elder AG, O'Donnell B, Knight PV, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces mortality of elderly patients. J Infect Dis 1997;175:16.
21.Carman WF, Elder AG, Wallace LA, McAulay K, Walker A Murray GD, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000;355:9397.
22.Goevart TM, Thijs CT, Masurel N, Sprenger JJ, Dinant GJ, Knottnerus JA The efficacy of influenza vaccination in elderly individuals. A randomized double-blind placebo-controlled trial. JAMA 1994;272:16611665.
23.Gross PA Hermogenes AW, Sacks HS, Lau J, Levandowski RA The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature. Ann Intern Med 1995;123:518527.
24.Strassburg MA, Greenland S, Sondilo FJ, Lieb LE, Habel LA Influenza in the elderly: report of an outbreak and a review of vaccine effectiveness reports. Vaccine 1986;4:3844.
25.Ohmit SE, Arden NH, Monto AS. Effectiveness of inactivated influenza vaccine among nursing home residents during an influenza type A (H3N2) epidemic. J Am Geriatr Soc 1999;47:165–71.
26.Staynor K, Foster G, McArthur M, McGeer A Petric M, Simor AE. Influenza A outbreak in a nursing home: the value of early diagnosis and the use of amantadine hydrochloride. Can J Infect Control 1994;9:109111.
27.Dolin R, Reichman RC, Madore HP, Maynard R, Linton PN, Webber-Jones J. A controlled trial of amantadine and rimantadine in the prophylaxis of influenza A infection. N Engl J Med 1982;307:580584.
28.Hayden FG. Antivirals for pandemic influenza. J Infect Dis 1997;176(suppl 1):S56S61.
29.Arden NH, Patriarca PA, Fasano MB, Lui KJ, Harmon MW, Kendal AP, et al. The roles of vaccination and amantadine prophylaxis in controlling an outbreak of influenza A (H3N2) in a nursing home. Arch Intern Med 1988;148:865868.
30.Peters NL, Oboler S, Hair C, Laxson L, Kost J, Meiklejohn G. Treatment of an influenza A outbreak in a teaching nursing home. Effectiveness of a protocol for prevention and control. J Am Geriatr Soc 1989;37:210218.
31.Centers for Disease Control and Prevention. Control of influenza A outbreaks in nursing homes: amantadine as an adjunct to vaccine—Washington, 1989-90. MMWR 1991;40:841844.
32.Hayden HG, Belshe RB, Clover RD, Hay AJ, Oakes MJ, Soo W. Emergence and apparent transmission of rimantadine-resistant influenza A virus in families. N Engl J Med 1989;321:16961702.
33.Hayden FG, Atmar RL, Schilling M, Johnson C, Poretz D, Paar D, et al. Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza. N Engl J Med 1999;341:13361343.
34.Lee W, McArthur M, Kam A Friedman R Phillips A Simor A et al. Use of zanamivir to control an outbreak of influenza A in a nursing home. Presented at the Community and Hospital Infection Control Association of Canada; May 29-31, 2000; Toronto, Ontario, Canada. Abstract 11.
35.Gubareva LV, Kaiser L, Hayden FG. Influenza virus neuraminidase inhibitors. Lancet 2000;355:827835.
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Infection Control & Hospital Epidemiology
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  • EISSN: 1559-6834
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