Generic Name: Peramivir
Class: Neuraminidase Inhibitors
VA Class: AM800
Chemical Name: 3-[(1S)-1-(Acetylamino)-2-ethylbutyl]-4-[(aminoiminomethyl)amino]-2-hydroxy-cyclopentanecarboxylic acid hydrate
Molecular Formula: C15H28N4O4 • 3H2O
CAS Number: 1041434-82-5
Uses for Rapivab
Treatment of Seasonal Influenza A and B Virus Infections
CDC, US Public Health Service Advisory Committee on Immunization Practices (ACIP), and AAP recommend antiviral treatment of seasonal influenza illness initiated as soon as possible in all individuals with suspected or confirmed influenza who require hospitalization or have severe, complicated, or progressive illness (regardless of vaccination status or underlying illness).105 112 137 144 Early empiric antiviral treatment also recommended in individuals with suspected or confirmed influenza of any severity if they are at high risk of developing influenza-related complications because of age or underlying medical conditions.112 137 144 This includes children <2 years of age, adults ≥65 years of age, individuals of any age with certain chronic medical or immunosuppressive conditions, women who are pregnant or up to 2 weeks postpartum, individuals <19 years of age receiving long-term aspirin therapy, American Indians, Alaskan natives, morbidly obese individuals with body mass index (BMI) ≥40, and residents of any age in nursing homes or other long-term care facilities.112 137 144
CDC, ACIP, and AAP also state empiric antiviral treatment can be considered in previously healthy, symptomatic individuals with suspected or confirmed influenza who are not known to be at increased risk of developing severe or complicated illness if such treatment can be initiated within 48 hours of illness onset.105 112 137 144 Although these individuals typically do not require treatment, early empiric antiviral treatment might provide some benefit (e.g., decreased duration of illness).144
If indicated, initiate antiviral treatment as soon as possible after illness onset (ideally within 48 hours);112 137 144 177 do not delay initiation of treatment while waiting for laboratory confirmation.112 137 144 177
Although manufacturer states use for treatment of influenza only in patients who have been symptomatic for ≤2 days since efficacy not established in those whose symptoms have been present for >48 hours,1 there is some evidence from observational studies evaluating oseltamivir in hospitalized patients that antiviral treatment might still be beneficial when initiated up to 4 or 5 days after illness onset.112 137 144 177 CDC, ACIP, and AAP recommend that antiviral treatment be initiated in all patients with severe, complicated, or progressive illness attributable to influenza and all hospitalized patients and patients at increased risk of influenza complications (either hospitalized or outpatient) who have suspected or confirmed influenza, even if it has been >48 hours since illness onset.112 137 177 Base decisions regarding use of empiric antiviral treatment in outpatients, especially high-risk patients, on disease severity and progression, age, underlying medical conditions, likelihood of influenza, and time since onset of symptoms.137 177 If empiric antiviral treatment considered warranted in previously healthy, symptomatic outpatients not considered at increased risk of influenza complications, initiate within 48 hours after illness onset,112 137 177 but some experts state treatment can be considered in such patients even if it has been >48 hours since illness onset.112
When treatment of suspected or confirmed acute, uncomplicated seasonal influenza indicated, use age-appropriate antiviral (oral oseltamivir, IV peramivir, intranasal zanamivir).112 137 144 177 Oseltamivir usually preferred for hospitalized patients and patients with severe or complicated influenza since data lacking regarding use of peramivir or zanamivir in such patients.112 137 161 Although manufacturer states efficacy of peramivir for treatment of influenza in hospitalized patients not established,1 CDC states that peramivir may be considered for treatment of hospitalized patients with severe influenza† who cannot tolerate or absorb oseltamivir (e.g., because of suspected or known gastric stasis, malabsorption, or GI bleeding).137 161
Consider viral surveillance data available from local and state health departments and CDC when selecting an antiviral for treatment of seasonal influenza.1 137 144 Strains of circulating influenza viruses and the antiviral susceptibility of these strains constantly evolve;1 144 emergence of peramivir-resistant strains may decrease effectiveness of the drug.1 Although influenza A and B viruses circulating in US during last few years generally have been susceptible to peramivir,559 561 562 consult most recent information.1 137 144
CDC issues recommendations concerning use of antivirals for treatment of influenza, and these recommendations are updated as needed during each influenza season.137 144 Information regarding influenza surveillance and updated recommendations for treatment of seasonal influenza are available from CDC at .
Avian Influenza A Virus Infections
For treatment of severe, complicated, or progressive avian influenza A infections in hospitalized patients or outpatients, including infections caused by highly pathogenic Asian strain of influenza A (H5N1), other highly pathogenic avian influenza (HPAI) H5 strains, or novel avian influenza A (H7N9), CDC and WHO recommend oseltamivir as drug of choice.104 178 CDC states peramivir may be considered for treatment of hospitalized patients with severe avian influenza A infection† who cannot tolerate or absorb oseltamivir (e.g., because of suspected or known gastric stasis, malabsorption, or GI bleeding).178
For treatment of uncomplicated avian influenza A infections in outpatients, CDC states oseltamivir, zanamivir, or peramivir may be used.178
When antiviral prophylaxis indicated in close contacts of individuals with confirmed or probable infection with avian influenza A virus, CDC recommends oseltamivir or zanamivir.179
Most recent information regarding treatment and prevention of avian influenza A infections is available from CDC at or WHO at .
Most recent influenza pandemic occurred during 2009 and was related to a novel influenza A (H1N1) strain, influenza A (H1N1)pdm09.52 134 144 151 488 In the US, the pandemic was characterized by a substantial increase in influenza activity that peaked in late October and early November 2009 and returned to seasonal baseline levels by January 2010.123 488 During that time, ≥99% of influenza viruses circulating in the US were influenza A (H1N1)pdm09.123 488 In August 2010, the WHO declared that the world was in a post-pandemic period;148 since that time, influenza A (H1N1)pdm09 has become a seasonal influenza virus and continues to circulate with other seasonal viruses.144 551 553 561 562
The spread of the highly pathogenic Asian strain of avian influenza A (H5N1) in poultry in Asia and other countries that has been occurring since 2003 and has caused human infections represents a potential future pandemic threat.50 52 54 55 56 104 147 The novel avian influenza A (H7N9) virus first identified in China in March 2013 that has been causing sporadic human infections also has pandemic potential.50 104 182 555 556
Rapivab Dosage and Administration
For solution compatibility information, see Compatibility under Stability.
Administer by IV infusion.1
Commercially available injection containing 10 mg/mL must be diluted prior to administration.1
Do not mix with or administer simultaneously with other drugs.1
Compatible with materials commonly used for administration (e.g., polyvinyl chloride and polyvinyl chloride-free infusion bags, polypropylene syringes, polyethylene tubing).1
Vials contain no preservatives or bacteriostatic agents and are for single use only.1
Withdraw appropriate dose of peramivir injection containing 10 mg/mL and dilute in 0.9 or 0.45% sodium chloride injection, 5% dextrose injection, or lactated Ringer's injection to achieve a maximum total volume of 100 mL.1
Administer immediately after dilution.1 If not used immediately, diluted solution may be stored for ≤24 hours at 2–8°C.1 Allow refrigerated solution to reach room temperature and administer immediately.1
Discard unused portions of diluted solution 24 hours after dilution.1
Rate of Administration
Administer by IV infusion over 15–30 minutes.1
Treatment of Seasonal Influenza A and B Virus Infections
Treatment of Acute, Uncomplicated Seasonal Influenza A or B Virus InfectionsIV
Single 600-mg dose given within 2 days of symptom onset.1
Clcr ≥50 mL/minute: Usual dosage.1
Clcr 30–49 mL/minute: Single 200-mg dose.1
Clcr 10–29 mL/minute: Single 100-mg dose.1
Dosage adjustments based solely on age not needed.1
Cautions for Rapivab
Manufacturer states none.1
Dermatologic and Hypersensitivity Reactions
If hypersensitivity or serious skin reaction occurs or is suspected, initiate appropriate treatment.1
Neuropsychiatric and CNS Effects
Postmarketing cases of delirium and abnormal behavior leading to injury reported in patients with influenza receiving neuraminidase inhibitors, including peramivir.1 Most cases involved children in Japan and generally had abrupt onset and rapid resolution.1 Role of peramivir not established.1
Influenza itself can be associated with a variety of neurologic and behavioral symptoms (e.g., hallucinations, delirium, abnormal behavior) and fatalities can occur.1 Although such events may occur in the setting of encephalitis or encephalopathy, they can occur without obvious severe disease.1
Closely monitor patients with influenza for signs of abnormal behavior.1
When making treatment decisions in patients with suspected influenza, consider possibility of primary or concomitant bacterial infection for which peramivir would be ineffective.1
No evidence of efficacy in illness caused by any organisms other than influenza A or B.1
Although antivirals used for treatment of influenza, including peramivir, may be used concomitantly with or at any time before or after influenza virus vaccine inactivated,1 100 these antivirals may inhibit the vaccine virus contained in influenza vaccine live intranasal.1 100 (See Specific Drugs under Interactions.)
Pregnant women are at increased risk for severe complications from influenza,142 144 which may lead to adverse pregnancy and/or fetal outcomes including maternal death, stillbirths, birth defects, preterm delivery, low birthweight, and small size for gestational age.21
Manufacturer states use peramivir during pregnancy only if clearly needed.1
CDC and ACIP state that pregnancy is not a contraindication to use of antivirals for treatment of influenza;137 142 144 oseltamivir may be preferred when a neuraminidase inhibitor indicated for treatment of influenza in women who are pregnant or up to 2 weeks postpartum.137 142 144
Consider benefits of breast-feeding and importance of peramivir to the woman; also consider potential adverse effects on the breast-fed child from the drug or underlying maternal condition.1
Safety and efficacy not established in pediatric patients <18 years of age.1
During the 2009 influenza A (H1N1)pdm09 pandemic (see Pandemic Influenza under Uses), FDA issued an Emergency Use Authorization (EUA) that temporarily allowed use of peramivir for treatment of serious pandemic influenza virus infection in certain hospitalized patients, including infants and children†.10 11 Although the EUA expired in June 2010,11 some information is available regarding safety and efficacy for treatment of influenza virus infection in pediatric patients†.1 5 9 Data from an open-label study evaluating peramivir for treatment of uncomplicated influenza in infants and children 4 weeks to 16 years of age indicated that the safety profile is similar to that reported in adults.5 Most frequently reported adverse effects in pediatric patients are GI effects (diarrhea, vomiting) and decreased neutrophil counts.1 5 9
Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.1
Not studied in patients with hepatic impairment;1 clinically important alterations in pharmacokinetics not expected since the drug does not undergo clinically important metabolism.1 (See Elimination under Pharmacokinetics.)
Common Adverse Effects
Interactions for Rapivab
Not a substrate for and does not inhibit P-glycoprotein (P-gp).1
Oral contraceptives containing ethinyl estradiol and levonorgestrel: No interactions1
Influenza virus vaccines
Influenza virus vaccine inactivated: No specific studies1
Influenza vaccine live intranasal: Do not administer the live vaccine until at least 48 hours after peramivir discontinued;1 100 do not administer peramivir until at least 2 weeks after the vaccine, unless medically necessary;1 if peramivir is administered within 2 weeks after the vaccine, ACIP recommends revaccination ≥48 hours after antiviral dose;100 alternatively, if peramivir given 2 days before to 14 days after the vaccine, revaccinate using parenteral inactivated vaccine or parenteral recombinant vaccine100
Linear relationship between dose and exposure parameters (peak plasma concentrations, AUC).1
Well distributed within extracellular fluid spaces, including nose and throat, following IV administration.6
Crosses placenta in animals.1
Plasma Protein Binding
Does not undergo clinically important metabolism.1
Not a substrate for and does not affect CYP isoenzymes.1
Following IV administration, approximately 90% of dose eliminated unchanged in urine, principally by glomerular filtration.1
Removed by hemodialysis.1
Approximately 20 hours following single 600-mg IV dose.1
Renal Impairment: AUC increased by 28, 302, or 412% in patients with Clcr of 50–79, 30–49, or <30 mL/minute, respectively, compared with individuals with normal renal function.1 Systemic exposure decreased by 73–81% in patients undergoing hemodialysis.1
Hepatic impairment: Pharmacokinetics not studied, but substantial alterations not expected since the drug does not undergo clinically important metabolism.1
Geriatric individuals: Pharmacokinetics similar to that in younger adults.1
Solution for IV Use
20–25°C (may be exposed to 15–30°C).1
For information on systemic interactions resulting from concomitant use, see Interactions.
Ringer’s injection, lactated
Sodium chloride 0.45 or 0.9%
Actions and Spectrum
Active in vitro against both influenza A and B viruses.1 2 3 6 137 Majority of seasonal influenza A (H3N2), influenza A (H1N1)pdm09, and influenza B viruses circulating during recent influenza seasons have been susceptible to neuraminidase inhibitors (oseltamivir, peramivir, zanamivir) in vitro;551 552 557 559 561 562 resistance reported rarely.123 144 163 167 551 552 557 559 561 562
Influenza viruses with decreased susceptibility to peramivir have been produced in vitro and observed rarely in clinical isolates.1 181 6 Clinical importance of decreased in vitro susceptibility not known.1
Cross-resistance between peramivir and other neuraminidase inhibitors (e.g., oseltamivir, zanamivir) reported in influenza A and B viruses.1 6 21 172 173 175 181 However, because oseltamivir, peramivir, and zanamivir bind to different sites on the neuraminidase enzyme or interact differently with binding sites, cross-resistance among the drugs is variable.173 175 Some influenza A or B strains have reduced in vitro susceptibility to peramivir and/or oseltamivir, but are susceptible to zanamivir;1 144 163 167 181 552 562 other strains have reduced in vitro susceptibility to zanamivir, but are susceptible to peramivir and/or oseltamivir.1 21 181 562 Reduced in vitro susceptibility to all 3 drugs (oseltamivir, peramivir, zanamivir) reported in some influenza A and B strains with certain resistance-associated neuraminidase substitutions.1 21 562 To date, influenza A (H1N1)pdm09 isolates with the H275Y mutation are cross-resistant to oseltamivir and peramivir, but susceptible to zanamivir in vitro.172 174 181 559 562
Advice to Patients
Advise patients of the risk of serious skin reactions and importance of immediately contacting a clinician if a skin reaction occurs.1
Advise patients of the risk of neuropsychiatric reactions in patients with influenza and importance of immediately contacting a clinician if they experience signs of abnormal behavior after receiving peramivir.1
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.1
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Injection, for IV use
AHFS DI Essentials. © Copyright, 2016, American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.
Date published: August 11, 2015
Last reviewed: August 11, 2015
Date modified: February 08, 2016
1. BioCryst Pharmaceuticals, Inc. Rapivab (peramivir) injection for intravenous use prescribing information. Durham, NC: 2014 Dec.
2. Kohno S, Kida H, Mizuguchi M et al. Efficacy and safety of intravenous peramivir for treatment of seasonal influenza virus infection. Antimicrob Agents Chemother. 2010; 54:4568-74. [PubMed 20713668]
3. Kohno S, Yen MY, Cheong HJ et al. Phase III randomized, double-blind study comparing single-dose intravenous peramivir with oral oseltamivir in patients with seasonal influenza virus infection. Antimicrob Agents Chemother. 2011; 55:5267-76. [PubMed 21825298]
4. de Jong MD, Ison MG, Monto AS et al. Evaluation of intravenous peramivir for treatment of influenza in hospitalized patients. Clin Infect Dis. 2014; 59:e172-85. [PubMed 25115871]
5. Sugaya N, Kohno S, Ishibashi T et al. Efficacy, safety, and pharmacokinetics of intravenous peramivir in children with 2009 pandemic H1N1 influenza A virus infection. Antimicrob Agents Chemother. 2012; 56:369-77. [PubMed 22024821]
6. US Food and Drug Administration. Center for Drug Evaluation and Research. Application number: 206426Orig1s000: Medical review(s). From FDA website.
7. Kohno S, Kida H, Mizuguchi M et al. Intravenous peramivir for treatment of influenza A and B virus infection in high-risk patients. Antimicrob Agents Chemother. 2011; 55:2803-12. [PubMed 21464252]
9. Hata A, Akashi-Ueda R, Takamatsu K et al. Safety and efficacy of peramivir for influenza treatment. Drug Des Devel Ther. 2014; 8:2017-38. [PubMed 25368514]
10. US Food and Drug Administration. Emergency use authorization of peramivir IV fact sheet for health care providers. From FDA website.
11. Food and Drug Administration. Peramivir emergency use authorization disposition letter and question and answer attachment. June 22, 2010. From FDA website. Accessed 2015 Feb 25.
13. McKimm-Breschkin JL, Williams J, Barrett S et al. Reduced susceptibility to all neuraminidase inhibitors of influenza H1N1 viruses with haemagglutinin mutations and mutations in non-conserved residues of the neuraminidase. J Antimicrob Chemother. 2013; 68:2210-21. [PubMed 23759505]
14. Kamali A, Holodniy M. Influenza treatment and prophylaxis with neuraminidase inhibitors: a review. Infect Drug Resist. 2013; 6:187-98. [PubMed 24277988]
21. Genentech, Inc. Tamiflu (oseltamivir phosphate) capsules and for oral suspension prescribing information. South San Francisco, CA: 2014 Nov.
50. Centers for Disease Control and Prevention. Information on avian influenza. From CDC website. Accessed 2015 June 19.
52. World Health Organization. WHO guidelines for pharmacological management of pandemic influenza A (H1N1) 2009 and other influenza viruses. Revised February 2010. Part I. Recommendations. From WHO website. Accessed 2014 Feb 4.
54. Longini IM Jr, Nizam A, Xu S et al. Containing pandemic influenza at the source. Sciencexpress. 2005 Aug 3.
55. Tsang KWT, Eng P, Liam CK et al. H5N1 influenza pandemic: contingency plans. Lancet. 2005; 366:533-4. Editorial. [PubMed 16099278]
56. Ferguson NM, Cummings DAT, Cauchemez S et al. Strategies for containing an emerging influenza pandemic in Southeast Asia. Nature. Published online at Nature.com on 3 August 2005.
64. Moscona A. Neuraminidase inhibitors for influenza. N Engl J Med. 2005; 353:1363-73. [IDIS 540075] [PubMed 16192481]
100. Influenza Division, National Center for Immunization and Respiratory Diseases, CDC. Prevention and control of seasonal influenza with vaccines. MMWR Recomm Rep. 2013; 62(RR-07):1-43. [PubMed 24048214]
104. World Health Organization. Avian influenza. From WHO website. Accessed 2015 Feb 16.
105. American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
112. Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2014-2015. Pediatrics. 2014; :. [PubMed 25246619]
114. Centers for Disease Control and Prevention. Update: Swine influenza A (H1N1) infections–California and Texas, April 2009. MMWR Morb Mortal Wkly Rep. 2009; 58:435-7.
116. Harper SA, Bradley JS, Englund JA et al. Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009; 48:1003-32. [PubMed 19281331]
118. Centers for Disease Control and Prevention. Swine-origin influenza A (H1N1) virus infection in a school–New York City, April 2009. MMWR Morb Mortal Wkly Rep. 2009; 58 (Dispatch):1-3. [PubMed 19145219]
119. Centers for Disease Control and Prevention. Outbreak of swine-origin influenza A (H1N1) virus infection–Mexico, March-April 2009. MMWR Morb Mortal Wkly Rep. 2009; 58 (Dispatch):1-3. [PubMed 19145219]
123. Centers for Disease Control and Prevention (CDC). Update: influenza activity - United States, August 30, 2009-March 27, 2010, and composition of the 2010-11 influenza vaccine. MMWR Morb Mortal Wkly Rep. 2010; 59:423-30. [PubMed 20395936]
124. Centers for Disease Control and Prevention. Update: drug susceptibility of swine-origin influenza A (H1N1) viruses, April 2009. MMWR Morb Mortal Wkly Rep. 2009; 58:433-4. [PubMed 19407738]
132. Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team, Dawood FS, Jain S et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med. 2009; 360:2605-15. [PubMed 19423869]
134. Centers for Disease Control and Prevention. The 2009 H1N1 pandemic: summary highlights, April 2009–April 2010. From CDC website. Accessed 28 Oct 2010.
137. Centers for Disease Control and Prevention. Influenza antiviral medications: summary for clinicians. From CDC website. Accessed 2015 Jan 13.
142. Centers for Disease Control and Prevention. Recommendations for obstetric health care providers related to use of antiviral medications in the treatment and prevention of influenza. From CDC website. Accessed 2015 Feb 6.
144. Fiore AE, Fry A, Shay D et al. Antiviral agents for the treatment and chemoprophylaxis of influenza --- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011; 60:1-24. [PubMed 21248682]
147. . Summary of human infection with highly pathogenic avian influenza A (H5N1) virus reported to WHO, January 2003-March 2009: cluster-associated cases. Wkly Epidemiol Rec. 2010; 85:13-20. [PubMed 20095108]
148. World Health Organization. Global alert and response (GAR). WHO recommendations for the post-pandemic period. From WHO website. Accessed Sep 29, 2010.
151. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza, Bautista E, Chotpitayasunondh T et al. Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. N Engl J Med. 2010; 362:1708-19. [PubMed 20445182]
161. Centers for Disease Control and Prevention. Intravenous influenza antiviral medications and CDC considerations related to investigational use of intravenous zanamivir for 2014–2015 influenza season. From CDC website. Accessed 2015 Feb 3.
163. . Recommended composition of influenza virus vaccines for use in the 2011-2012 northern hemisphere influenza season. Wkly Epidemiol Rec. 2011; 86:81-91.
167. . Review of the 2010-2011 winter influenza season, northern hemisphere. Wkly Epidemiol Rec. 2011; 86:221-32. [PubMed 21661270]
172. Okomo-Adhiambo M, Fry AM, Su S et al. Oseltamivir-Resistant Influenza A(H1N1)pdm09 Viruses, United States, 2013-14. Emerg Infect Dis. 2015; 21:136-41. [PubMed 25532050]
173. Mishin VP, Hayden FG, Gubareva LV. Susceptibilities of antiviral-resistant influenza viruses to novel neuraminidase inhibitors. Antimicrob Agents Chemother. 2005; 49:4515-20. [PubMed 16251290]
174. Takashita E, Ejima M, Itoh R et al. A community cluster of influenza A(H1N1)pdm09 virus exhibiting cross-resistance to oseltamivir and peramivir in Japan, November to December 2013. Euro Surveill. 2014; 19:. [PubMed 24434172]
175. Gubareva LV, Webster RG, Hayden FG. Comparison of the activities of zanamivir, oseltamivir, and RWJ-270201 against clinical isolates of influenza virus and neuraminidase inhibitor-resistant variants. Antimicrob Agents Chemother. 2001; 45:3403-8. [PubMed 11709315]
177. Centers for Disease Control and Prevention Health Alert Network. CDC health update regarding treatment of patients with influenza with antiviral medications. CDCHAN-0375. January 9, 2015. From CDC website.
178. Centers for Disease Control and Prevention. Interim guidance on the use of antiviral medications for treatment of human infections with novel influenza A viruses associated with severe human disease. From CDC website. Accessed 2015 Jun 19.
179. Centers for Disease Control and Prevention. Interim guidance on follow-up of close contacts of persons infected with novel influenza A viruses associated with severe human disease and on the use of antiviral medications for chemoprophylaxis. From CDC website. Accessed 2015 Jun 19.
180. Centers for Disease Control and Prevention Health Alert Network. Bird infections with highly-pathogenic avian influenza A (H5N2), (H5N8), and (H5N1) viruses: recommendations for human health investigations and responses. CDCHAN-00378. June 2, 2015. From CDC website.
181. Takashita E, Meijer A, Lackenby A et al. Global update on the susceptibility of human influenza viruses to neuraminidase inhibitors, 2013-2014. Antiviral Res. 2015; 117:27-38. [PubMed 25721488]
182. Tan KX, Jacob SA, Chan KG et al. An overview of the characteristics of the novel avian influenza A H7N9 virus in humans. Front Microbiol. 2015; 6:140. [PubMed 25798131]
183. United States Department of Agriculture. Avian influenza. From the USDA website. Accessed 2015 Jun 29.
488. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 12th ed. Washington DC: Public Health Foundation; 2012 May. Updates may be available at CDC website.
551. Centers for Disease Control and Prevention (CDC). Influenza activity--United States, 2012-13 season and composition of the 2013-14 influenza vaccine. MMWR Morb Mortal Wkly Rep. 2013; 62:473-9. [PubMed 23760189]
552. . Recommended composition of influenza virus vaccines for use in the 2013–2014 northern hemisphere influenza season. Wkly Epidemiol Rec. 2013; 88:101-14. [PubMed 23544236]
553. World Health Organization (WHO). Standardization of terminology of the pandemic A(H1N1)2009 virus. October 2011. From WHO website. Accessed 2013 Jul.
555. Centers for Disease Control and Prevention (CDC). Emergence of avian influenza A(H7N9) virus causing severe human illness - China, February-April 2013. MMWR Morb Mortal Wkly Rep. 2013; 62:366-71. [PubMed 23657113]
556. Gao HN, Lu HZ, Cao B et al. Clinical findings in 111 cases of influenza A (H7N9) virus infection. N Engl J Med. 2013; 368:2277-85. [PubMed 23697469]
557. Epperson S, Blanton L, Kniss K et al. Influenza activity - United States, 2013-14 season and composition of the 2014-15 influenza vaccines. MMWR Morb Mortal Wkly Rep. 2014; 63:483-90. [PubMed 24898165]
559. . Recommended composition of influenza virus vaccines for use in the 2014-2015 northern hemisphere influenza season. Wkly Epidemiol Rec. 2014; 89:93-104. [PubMed 24707514]
561. Appiah GD, Blanton L, D'Mello T et al. Influenza activity - United States, 2014-15 season and composition of the 2015-16 influenza vaccine. MMWR Morb Mortal Wkly Rep. 2015; 64:583-90. [PubMed 26042650]
562. . Recommended composition of influenza virus vaccines for use in the 2015–2016 northern hemisphere influenza season. Wkly Epidemiol Rec. 2015; 90:97-108. [PubMed 25771542]
563. Jhung MA, Nelson DI, Centers for Disease Control and Prevention (CDC). Outbreaks of avian influenza A (H5N2), (H5N8), and (H5N1) among birds--United States, December 2014-January 2015. MMWR Morb Mortal Wkly Rep. 2015; 64:111. [PubMed 25654614]